Patient-reported advantages and disadvantages of peritoneal dialysis: results from the PDOPPS

Abstract

Background: Patient-reported measures are increasingly recognized as important predictors of clinical outcomes in peritoneal dialysis (PD). We sought to understand associations between patient-reported perceptions of the advantages and disadvantages of PD and clinical outcomes.

Methods: In this cohort study, 2760 PD patients in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) completed a questionnaire on their PD experience, between 2014 and 2017. In this questionnaire, PDOPPS patients rated 17 aspects of their PD experience on a 5-category ordinal scale, with responses scored from - 2 (major disadvantage) to + 2 (major advantage). An advantage/disadvantage score (ADS) was computed for each patient by averaging their response scores. The ADS, along with each of these 17 aspects, were used as exposures. Outcomes included mortality, transition to hemodialysis (HD), patient-reported quality of life (QOL), and depression. Cox regression was used to estimate associations between ADS and mortality, transition to HD, and a composite of the two. Logistic regression with generalized estimating equations was used to estimate cross-sectional associations of ADS with QOL and depression.

Results: While 7% of PD patients had an ADS < 0 (negative perception of PD), 59% had an ADS between 0 and < 1 (positive perception), and 34% had an ADS ≥1 (very positive perception). Minimal association was observed between mortality and the ADS. Compared with a very positive perception, patients with a negative perception had a higher transition rate to HD (hazard ratio [HR] = 1.67; 95% confidence interval [CI]: 1.21, 2.30). Among individual items, "space taken up by PD supplies" was commonly rated as a disadvantage and had the strongest association with transition to HD (HR = 1.28; 95% CI 1.07, 1.53). Lower ADS was strongly associated with worse QOL rating and greater depressive symptoms.

Conclusions: Although patients reported a generally favorable perception of PD, patient-reported disadvantages were associated with transition to HD, lower QOL, and depression. Strategies addressing these disadvantages, in particular reducing solution storage space, may improve patient outcomes and the experience of PD.

Keywords: Depression; Patient selection; Patient-reported measures; Peritoneal dialysis; Quality of life; Surveys and questionnaires; Technique survival.

Fig. 1

Distribution of responses to 17 questions regarding “To what extent do you feel the following aspects of your peritoneal dialysis treatments are an advantage or disadvantage?” *Indicates the aspects the authors had expected to be disadvantages of peritoneal treatment

Fig. 2

Distribution of ADS, by country. Patient responses are coded −2 (major disadvantage) to + 2 (major advantage). A higher score, calculated from this Likert scale, reflects a more favorable perception of PD. “I do not know” was treated the same as “neither advantage nor disadvantage”

Fig. 3

Associations (adjusted HRs and 95% CIs) between the ADS and: a all-cause mortality, transition to HD, and the composite outcome (mortality or transition to HD); and (b) measures of poor QOL and depression symptoms. The ADS was computed for each patient, where patient responses are coded − 2 (major disadvantage) to + 2 (major advantage). A higher ADS reflects a more favorable perception of PD. PCS and MCS scores were derived from the SF-12, with lower scores indicating worse QOL, and depressive symptoms were assessed by the 10-item version of the CES-D, where CES-D ≥ 10 was a positive screen for depressive symptoms. All models adjusted for the following potential confounders: age, sex, BMI, time on PD, 13 summary comorbid conditions (Table 1), serum albumin, 24-h urine volume, and previous HD treatment. Models for: a were stratified by country and US LDO; and for (b) were additionally adjusted for country and US LDO

Fig. 4

Association between the reporting of an item as a disadvantage and: a subsequent hazard of death, HD transition, or both; and (b) measures of poor QOL and depression for each of the eight items, in which more than 10% of patients scored that item as a disadvantage of PD. The reference group consisted of patients who reported the item as an advantage or neutral. PCS and MCS scores were derived from the SF-12, with lower scores indicating worse QOL, and depressive symptoms were assessed by the 10-item version of the CES-D, where CES-D ≥ 10 was a positive screen for depressive symptoms. All models adjusted for the following potential confounders: age, sex, BMI, time on PD, 13 summary comorbid conditions (Table 1), serum albumin, 24-h urine volume, and previous HD treatment. Models for: a were stratified by country and US LDO; and for (b) were additionally adjusted for country and US LDO. Abbreviations: ADS advantage/disadvantage score, BMI body mass index, CES-D Center for Epidemiological Studies Depression Screening Index, CI confidence interval, HD hemodialysis, HR hazard ratio, LDO large dialysis organization, MCS mental component summary, PCS physical component summary, PD peritoneal dialysis, QOL quality of life, SF short form, US United States