Abstract

INTRODUCTION

Chronic kidney disease (CKD) is defined as structural or functional abnormalities of the kidney, present for >3 months, with implications for health. It is a major cause of death and disability, reaching epidemic proportions in recent years: an estimated 1.37 million people worldwide suffered from chronic kidney failure (CKD stage ≥3) in 2011. Three methods exist for renal replacement therapy (RRT), indicated when glomerular filtration rate (GFR) falls to ≤15 mL/min/1.73 m², stage 5 CKD or end-stage renal disease (ESRD): globally, some 940,000 (68%) of patients are treated with hemodialysis, while some 315,000 (23%) have received kidney transplants, and 120,000 (9%) receive peritoneal dialysis.[¹1. Kramer A, Stel V, Zoccali C, Heaf J, Ansell D, Grönhagen-Riska C, et al. An update on renal replacement therapy in Europe: ERA-EDTA Registry data from 1997 to 2006. Nephrol Dial Transplant. 2009 Dec;24(12):3557–66.,²2. McDonald SP, Marshall MR, Johnson DW, Polkinghorne KR. Relationship between dialysis modality and mortality. J Am Soc Nephrol. 2009 Jan;20(1):155–63. 3. Popovich RP, Moncrief JW. Kinetic modeling of peritoneal transport. In: Treviño Becerra A, Boen FST editors. Today’s Art of Peritoneal Dialysis. Basel (CH): S. Karger Pub; 1979 Sep. p. 59–83.]

Peritoneal dialysis was described by Popovich in 1976,[3] and two years later the first results were published.[⁴4. Moncrief JW, Popovich RP, Nolph KD. The history and current status of continuous ambulatory peritoneal dialysis. Am J Kidney Dis. 1990 Dec;16(6):579–84.] Its use, still relatively low worldwide, is increasing because of the good outcomes obtained, including better quality of life for patients and reduced family stress, owing in large part to home-based treatment and low costs observed in developed countries.[⁵5. Remón Rodríguez C, Quirós-Ganga PL. La evidencia actual demuestra una equivalencia de resultados entre las técnicas de diálisis. Nefrología. 2011 May 20;31(5):520–7. Spanish. 6. Portolés J, Remón C. En busca de la eficiencia y la sostenibilidad del tratamiento sustitutivo renal integrado. Nefrología. 2010;1(Suppl 1):S2–7. Spanish. 7. Alvarez-Ude F, Vicente E, Badía X. La medida de la calidad de vida relacionada con la salud en los pacientes en programa de hemodiálisis y diálisis peritoneal continua ambulatoria de Segovia. Instituto de Salud Pública de Cataluña. Nefrología. 1995 Jun 13;15(6):572–80. Spanish.–⁸8. Ponz E, Sató J, García García M, Mañé N, Ramirez Vaca J, García Morales M, et al. Análisis de la gestión económica de un programa de diÁlisis peritoneal. Comparación con el programa de hemodiálisis. Unidad de Nefrología. Servicio de Medicina. Consorcio Hospitalario del Parc Tauli. Sabadell. Nefrología. 1997;17(2):152–61. Spanish.]

The term peritoneal dialysis means replacement therapy that uses the peritoneum as the dialysis membrane. The method consists essentially in instilling a solution with controlled electrolytes and osmolarity into the peritoneal cavity through a catheter specifically designed for this purpose (Tenckhoff catheter). The instilled fluid remains in the abdominal cavity for four to six hours and is then drained. During dwell time, water and solutes diffuse from peritoneal capillaries into the dialysis fluid through the peritoneum, a biological membrane with a large surface area and high vascularity lining the abdominal cavity, producing an exchange of water and solutes between plasma and intracavitary fluid.[⁹9. Grapsa E, Oreopoulos D. Chronic peritoneal dialysis in the elderly. In: Khanma R, Krediet RT, editors. Textbook of peritoneal dialysis. New York: Springer; 2009. p. 737–55. 10. Mehrotra R, Chiu YW, Kalantar-Zadeh K, Bargman J, Vonesh E. Similar outcomes with hemodialysis and peritoneal dialysis in patients with end-stage renal disease. Arch Intern Med. 2011 Jan 24;171(2):110–8.–¹¹11. Weinhandl ED, Foley RN, Gilbertson DT, Arneson TJ, Snyder JJ, Collins AJ. Propensity-matched mortality comparison of incident hemodialysis and peritoneal dialysis patients. J Am Soc Nephrol. 2010 Mar;21(3):499–506.]

Hemodialysis and peritoneal dialysis began use as RRT in Cuba in the 1960s. Unlike hemodialysis, which in Cuba has kept pace with international technological advances, peritoneal dialysis has not developed at the rate we would have liked: we have over 40 years’ experience with peritoneal dialysis, but with the intermittent version of the procedure, which has fallen into virtual disuse internationally.[¹²12. Sociedad Española de Nefrología [Internet]. Barcelona: Sociedad Española de Nefrología; c2009. Registro Espanol de Enfermos Renales. Informe de Diálisis y Trasplante; 2010 [cited 2013 Oct 18]; [about 30 screens]. Available from: http://www.senefro.org/modules.php?name=webstructure&idwebstructure=128. Spanish.
http://www.senefro.org/modules.php?name=... ] It was not until December 20, 2007, that continuous ambulatory peritoneal dialysis (CAPD) was introduced in the country by the Nephrology Institute (INEF) in Havana. Months later, automated peritoneal dialysis was introduced (this uses a dialysis machine also known as a cycler, to which the patient is connected from 9 to 12 hours a day).

Home peritoneal dialysis is becoming not only an alternative for Cuban patients but also a necessity for many due to increased survival rates on hemodialysis—annual mortality on hemodialysis dropped from 32% in 2004 to 25% in 2010[¹³13. Pérez Oliva J. Programa enfermedad Renal Crónica, Diálisis y Trasplante. Centro Coordinador. Instituto de Nefrología. Havana: Institute of Nephrology (CU); 2012. p. 7–52. Spanish.]—indicating more patients require home peritoneal dialysis once their vascular capacity has been exhausted.

Our research objective was to analyze the clinical course of patients in INEF’s Home Peritoneal Dialysis Program during its first five years of operation, including assessment of response to this therapy.

METHODS

This was a retrospective descriptive study based on administrative records. The universe comprised the 40 INEF patients who underwent treatment with home peritoneal dialysis (32 with CAPD and 8 with automated peritoneal dialysis) from December 20, 2007 to December 20, 2012.

Variables

Table 1 lists study variables and descriptions.

Analysis

Relative and absolute frequencies were calculated for each category of variables. Survival of the peritoneum as thedialysis membrane and patient survival were assessed using the Kaplan-Meier curve. Small sample size ruled out analysis by type of home peritoneal dialysis.

Ethics

Before beginning treatment with home peritoneal dialysis, all patients received detailed information on the therapy and provided written consent for inclusion in the study. The research was approved by INEF’s scientific council.

RESULTS

Of the 40 patients, 23 were men and 17 women; the majority (22.6%) were aged 40–59 years. The most frequent cause of chronic kidney failure was hypertension, in 17 patients (42.5%), followed by glomerulopathies and diabetes mellitus, in 9 patients each (22.5%).

A total of 103 complications occurred. Of these, etiology was infectious in 68 (66%) and noninfectious in 35 (34%). The most frequent infectious cause was peritonitis, in 45 (66.2%), while the most frequent non-infectious complication was catheter displacement, in 13 (37.1%) (Table 2). There was one episode of peritonitis every 27.9 months/patient over the 5-year study period.

In all, seven patients left the program: three died, two lost peritoneal dialyzing capacity, one received a kidney transplant and one recovered kidney function (Table 3). Survival at 5 years was 89.2%. Figures 1 and 2 show patient survival and survival of peritoneal membrane dialysis capacity.

DISCUSSION

Home peritoneal dialysis was introduced as RRT for advanced chronic kidney failure in Cuba on December 20, 2007.[1¹⁴14. Alfonzo Guerra J. Diálisis peritoneal. In: Historia de la Nefrología en Cuba. Havana: ECIMED; 2013. p. 107–14. Spanish.] Inclusion of patients in the program increased gradually: from 2007 to 2012, 40 patients were included, a small proportion of patients enrolled in the National Hemodialysis Program (some 2600). This is true, despite the fact that home peritoneal dialysis is capable not only of keeping patients alive but also of facilitating their ability to carry out normal daily activities. [⁹9. Grapsa E, Oreopoulos D. Chronic peritoneal dialysis in the elderly. In: Khanma R, Krediet RT, editors. Textbook of peritoneal dialysis. New York: Springer; 2009. p. 737–55.–¹¹11. Weinhandl ED, Foley RN, Gilbertson DT, Arneson TJ, Snyder JJ, Collins AJ. Propensity-matched mortality comparison of incident hemodialysis and peritoneal dialysis patients. J Am Soc Nephrol. 2010 Mar;21(3):499–506.]

The predominance of men and of the 40–59 year-old age group in our program are consistent with the EPICRE study (Spanish epidemiological study of chronic kidney failure) with regard to sex, but not to age; the EPICRE study had more patients aged >64 years.[¹⁵15. Rodríguez CR, Quirós PL, Cunquero JM, Ruiz SR, Fosalba NA, Fernández AR, et al. Diez años de diálisis peritoneal en Andalucía (1999–2008): datos epidemiológicos, tipos de tratamiento, peritonitis, comorbilidad y supervivencia de pacientes y técnica. Nefrología. 2010;30(1):46–53. Spanish.] CKD is a disease of aging; it is the final common endpoint of many vascular diseases, and thus its frequency increases proportionally with age.

Generally, the disease that most frequently causes chronic kidney chronic is diabetes mellitus, followed by hypertension.[¹⁶16. Quirós-Ganga PL, Remón-Rodríguez C. Logrando mejores resultados para la diálisis peritoneal en los últimos años. Servicio de Nefrología. Hospital Universitario Puerto Real. Cádiz. Nefrología. 2012 Sep 26;32(5):587–96. Spanish.–¹⁹19. Verde E, Sanz Guajardo D, Luño J. Epidemiología de la enfermedad renal crónica y su tratamiento sustitutivo. Indicaciones, contrain-dicaciones y opciones terapéuticas. In: Jofre R, López Gómez JM, Luno J, Pérez García R, Rodríguez Benítez P, editors. Tratado de Hemodiálisis. 2nd. ed. Barcelona: Editorial Médica Jims; 2006. p. 39–54. Spanish.] In our study, however, hypertension was the leading cause and glomerulopathies gave rise to as many cases as diabetes, although the small sample size limits inferences from these results. Quirós-Ganga, in a study of 1464 incident peritoneal dialysis patients, found that diabetic nephropathy and glomerular pathology were the most prevalent primary renal diseases.[¹⁶16. Quirós-Ganga PL, Remón-Rodríguez C. Logrando mejores resultados para la diálisis peritoneal en los últimos años. Servicio de Nefrología. Hospital Universitario Puerto Real. Cádiz. Nefrología. 2012 Sep 26;32(5):587–96. Spanish.] Other authors report similar findings.[¹⁷17. Arrieta J, Rodríguez-Carmona A, Remón C, Pérez-Fontán M, Ortega F, Sánchez Tornero JA, et al. La diálisis peritoneal es la mejor alternativa costo-efectiva para la sostenibilidad del tratamiento con diálisis. Nefrología (Madr). 2011;31(5):505–13. Spanish. 18. Boulanger E. Peritoneal and systemic inflammation: the benefits of using biocompatible peritoneal dialysis fluids. Perit Dial Int. 2008 Jan-Feb;28(1):28–31.–¹⁹19. Verde E, Sanz Guajardo D, Luño J. Epidemiología de la enfermedad renal crónica y su tratamiento sustitutivo. Indicaciones, contrain-dicaciones y opciones terapéuticas. In: Jofre R, López Gómez JM, Luno J, Pérez García R, Rodríguez Benítez P, editors. Tratado de Hemodiálisis. 2nd. ed. Barcelona: Editorial Médica Jims; 2006. p. 39–54. Spanish.]

Infections are relatively common in peritoneal dialysis patients, since normal skin barriers are broken and the patient has a depressed immune system. Infections may be located at the catheter exit site or in the tunnel created during its placement. They can be more severe if the infection reaches the peritoneum (peritonitis).[²⁰20. Fenton SSA. Peritonitis-related deaths among CAPD patients. Perit Dial Bull. 1983 Jul-Sep;3 Suppl:S9–11.]

Peritonitis is the complication most feared by patients and nephrologists and is the main reason for transfer to hemodialysis. [²¹21. Montenegro J. Peritonitis bacteriana. In: Tratado de Diálisis Peritoneal. 3ra ed. Barcelona: Elsevier España S.L; 2009. p. 283–320. Spanish.] In the period studied, the 45 episodes of peritonitis occurred in 21 patients. Peritonitis from Staphylococcus aureus is, in general, the most severe peritoneal infection caused by grampositive organisms and occurs in nasal carriers of the organism and patients with skin and hand colonization, and is also related to catheter exit site colonization and infection.[²²22. De Sousa E, Bajo Rubio MA, Del Peso G, Castro MJ, Celadilla O, Selgas Gutiérrez R. Experiencia de 30 años en una unidad de diálisis peritoneal: supervivencia a largo plazo. Nefrología. 2013;33(4):546–51. Spanish.,²³23. Li PK, Szeto CC, Piraino B, Bernardini J, Figueiredo AE, Gupta A, et al. Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int. 2010 Jul-Aug;30(4):393–423.]

Incidence rates of peritonitis in this study are consistent with quality standards for peritoneal dialysis units in the Practical Clinical Guidelines for Peritoneal Dialysis of the Spanish Nephrology Society, which defines as acceptable fewer than 0.6 episodes/patient/year, equivalent to one episode every 24 months/patient,[²⁴24. Arrieta J, Bajo Rubio MA, Caravaca F, Coronel F, García Pérez H, González Parra E, et al. Guías de Práctica Clínica en Diálisis Peritoneal. Nefrología. 2006;26 Suppl 4. Spanish.] a rate higher than that found in our series.

In recent years, prognosis for survival has improved more in peritoneal dialysis than in hemodialysis, even though this has not led to an increase in its use. Comorbidities and associated factors have the greatest influence on mortality, with similar outcomes for both techniques over the long term.[¹³13. Pérez Oliva J. Programa enfermedad Renal Crónica, Diálisis y Trasplante. Centro Coordinador. Instituto de Nefrología. Havana: Institute of Nephrology (CU); 2012. p. 7–52. Spanish.,²⁵25. Montenegro J, Olivares J. Peritonitis bacteriana en diálisis peritoneal. In: Montenegro J, Olivares J, editors. La Diálisis Peritoneal. 2nd ed. Barcelona: Ed. DIBE, SL; 2003. p. 307–59. Spanish.] The main cause of death is cardiovascular complications; hence the need for early diagnosis of cardiovascular morbidities in the interest of achieving greater patient survival.[²⁶26. Brown EA. Peritoneal dialysis for older people, overcoming the barriers. Kidney Int Suppl. 2008 Apr;(108):S68–71.]

Peritoneal dialysis programs lose patients. The most fortunate withdrawals are due to kidney transplants or the rare case of recovery of renal function; in our series, we had one case of each. Negative reasons for withdrawal from the program are failure of the technique—obliging patients to switch to hemodialysis—and death. Over the course of our five-year research, few patients were withdrawn from the program for either of these reasons. While it is clear that this is a small sample, the withdrawal rate is similar to that of several dialysis centers in Japan, which documented an annual all-cause withdrawal rate of 10%.[²²22. De Sousa E, Bajo Rubio MA, Del Peso G, Castro MJ, Celadilla O, Selgas Gutiérrez R. Experiencia de 30 años en una unidad de diálisis peritoneal: supervivencia a largo plazo. Nefrología. 2013;33(4):546–51. Spanish.,²⁶26. Brown EA. Peritoneal dialysis for older people, overcoming the barriers. Kidney Int Suppl. 2008 Apr;(108):S68–71.]

Peritoneal dialysis, both in our country and throughout the world, has improved its outcomes for patients in recent years (unlike hemodialysis, where results have remained essentially the same). Technological improvements have enabled lower rates of peritonitis, as well as fewer alterations of the peritoneum, thanks to more biocompatible dialysis solutions.[¹⁶16. Quirós-Ganga PL, Remón-Rodríguez C. Logrando mejores resultados para la diálisis peritoneal en los últimos años. Servicio de Nefrología. Hospital Universitario Puerto Real. Cádiz. Nefrología. 2012 Sep 26;32(5):587–96. Spanish.]

Limitations of this study include small size of the series and short evaluation time. It does allow us, however, to recommend increasing the number of patients who could benefit from this therapy, and expanding its use to all of Cuba’s 51 nephrology services.

CONCLUSIONS

In our study, home peritoneal dialysis had outcomes similar to those attained internationally, making it a potentially promising RRT, which, along with hemodialysis and kidney transplant, can help prolong the life of patients with ESRD.

REFERENCES

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