Multicenter Registry Analysis of Center Characteristics Associated with Technique Failure in Patients on Incident Peritoneal Dialysis

Abstract

Background and objectives: Technique failure is a major limitation of peritoneal dialysis. Our study aimed to identify center- and patient-level predictors of peritoneal dialysis technique failure.

Design, setting, participants, & measurements: All patients on incident peritoneal dialysis in Australia from 2004 to 2014 were included in the study using data from the Australia and New Zealand Dialysis and Transplant Registry. Center- and patient-level characteristics associated with technique failure were evaluated using Cox shared frailty models. Death-censored technique failure and cause-specific technique failure were analyzed as secondary outcomes.

Results: The study included 9362 patients from 51 centers in Australia. The technique failure rate was 0.35 (95% confidence interval, 0.34 to 0.36) episodes per patient-year, with a sevenfold variation across centers that was mainly associated with center-level characteristics. Technique failure was significantly less likely in centers with larger proportions of patients treated with peritoneal dialysis (>29%; adjusted hazard ratio, 0.83; 95% confidence interval, 0.73 to 0.94) and more likely in smaller centers (<16 new patients per year; adjusted hazard ratio, 1.10; 95% confidence interval, 1.00 to 1.21) and centers with lower proportions of patients achieving target baseline serum phosphate levels (<40%; adjusted hazard ratio, 1.15; 95% confidence interval, 1.03 to 1.29). Similar results were observed for death-censored technique failure, except that center target phosphate achievement was not significantly associated. Technique failure due to infection, social reasons, mechanical causes, or death was variably associated with center size, proportion of patients on peritoneal dialysis, and/or target phosphate achievement, automated peritoneal dialysis exposure, icodextrin use, and antifungal use. The variation of hazards of technique failure across centers was reduced by 28% after adjusting for patient-specific factors and an additional 53% after adding center-specific factors.

Conclusions: Technique failure varies widely across centers in Australia. A significant proportion of this variation is related to potentially modifiable center characteristics, including peritoneal dialysis center size, proportion of patients on peritoneal dialysis, and proportion of patients on peritoneal dialysis achieving target phosphate level.

Keywords: Anti-Bacterial Agents; Australia; Glucans; Glucose; Hemoglobins; Humans; New Zealand; Peritonitis; Phosphates; Registries; hospitalization; icodextrin; peritoneal dialysis; renal dialysis.

Figure 1.

Forest plot showing the association between center-level characteristics and technique failure after adjusting for age, sex, race, body mass index, smoking status, primary renal disease, diabetes mellitus, cardiovascular disease, chronic lung disease, late nephrology referral, initial modality of peritoneal dialysis, initial modality of RRT, socioeconomic position, and era of peritoneal dialysis commencement. For each variable, the reference group is the middle category (combined second and third quartiles). APD, automated peritoneal dialysis; 95% CI, 95% confidence interval; HR, hazard ratio.

Figure 2.

Variation in hazard of technique failure across 51 Australian peritoneal dialysis centers during the period of 2004–2014 in unadjusted (green diamonds), patient-level adjusted (red triangles), and patient- and center-level adjusted (blue circles) models with SEMs. Dialysis centers are ranked by hazard of technique failure.

Figure 3.

Forest plot showing the association between center-level characteristics and death-censored technique failure after adjusting for age, sex, race, body mass index, smoking status, primary renal disease, diabetes mellitus, cardiovascular disease, chronic lung disease, late nephrology referral, initial modality of peritoneal dialysis, initial modality of RRT, socioeconomic position, and era of peritoneal dialysis commencement. For each variable, the reference group is the middle category (combined second and third quartiles). APD, automated peritoneal dialysis; 95% CI, 95% confidence interval; HR, hazard ratio.