Epidemiology of peritoneal dialysis outcomes

Abstract

Peritoneal dialysis (PD) is an important home-based treatment for kidney failure and accounts for 11% of all dialysis and 9% of all kidney replacement therapy globally. Although PD is available in 81% of countries, this provision ranges from 96% in high-income countries to 32% in low-income countries. Compared with haemodialysis, PD has numerous potential advantages, including a simpler technique, greater feasibility of use in remote communities, generally lower cost, lesser need for trained staff, fewer management challenges during natural disasters, possibly better survival in the first few years, greater ability to travel, fewer dietary restrictions, better preservation of residual kidney function, greater treatment satisfaction, better quality of life, better outcomes following subsequent kidney transplantation, delayed need for vascular access (especially in small children), reduced need for erythropoiesis-stimulating agents, and lower risk of blood-borne virus infections and of SARS-CoV-2 infection. PD outcomes have been improving over time but with great variability, driven by individual and system-level inequities and by centre effects; this variation is exacerbated by a lack of standardized outcome definitions. Potential strategies for outcome improvement include enhanced standardization, monitoring and reporting of PD outcomes, and the implementation of continuous quality improvement programmes and of PD-specific interventions, such as incremental PD, the use of biocompatible PD solutions and remote PD monitoring.

Fig. 1. Hierarchy of importance of peritoneal dialysis outcomes to patients, caregivers and clinicians.

The Standardized Outcomes in Nephrology in Peritoneal Dialysis (SONG-PD) initiative identified a hierarchy of PD outcomes according to their level of importance to stakeholder groups. The outcomes in the top tier are critically important to all stakeholder groups, those in the middle tier are critically important to some stakeholder groups and those in the bottom tier are important to some or all stakeholder groups. Adapted with permission from ref., Elsevier.

Fig. 2. Correlates of fatigue in kidney failure.

The onset of fatigue in patients with kidney failure is multidimensional and multifactorial, with bidirectional and circular associations leading to substantial social, mental and physical disability. CRP, C-reactive protein; Hb, haemoglobin; KRT, kidney replacement therapy. Adapted with permission from Artom et al., Elsevier.