Abstract
OBJECTIVES:
To evaluate the clinical outcomes and identify the predictors of mortality in elderly patients undergoing peritoneal dialysis.
METHODS:
We conducted a retrospective study including all incident peritoneal dialysis cases in patients ≥65 years of age treated from 2001 to 2014. Demographic and clinical data on the initiation of peritoneal dialysis and the clinical events during the study period were collected. Infectious complications were recorded. Overall and technique survival rates were analyzed.
RESULTS:
Fifty-eight patients who began peritoneal dialysis during the study period were considered for analysis, and 50 of these patients were included in the final analysis. Peritoneal dialysis exchanges were performed by another person for 65% of the patients, whereas 79.9% of patients preferred to perform the peritoneal dialysis themselves. Peritonitis and catheter exit site/tunnel infection incidences were 20.4±16.3 and 24.6±17.4 patient-months, respectively. During the follow-up period, 40 patients were withdrawn from peritoneal dialysis. Causes of death included peritonitis and/or sepsis (50%) and cardiovascular events (30%). The mean patient survival time was 38.9±4.3 months, and the survival rates were 78.8%, 66.8%, 50.9% and 19.5% at 1, 2, 3 and 4 years after peritoneal dialysis initiation, respectively. Advanced age, the presence of additional diseases, increased episodes of peritonitis, the use of continuous ambulatory peritoneal dialysis, and low albumin levels and daily urine volumes (<100 ml) at the initiation of peritoneal dialysis were predictors of mortality. The mean technique survival duration was 61.7±5.2 months. The technique survival rates were 97.9%, 90.6%, 81.5% and 71% at 1, 2, 3 and 4 years, respectively. None of the factors analyzed were predictors of technique survival.
CONCLUSIONS:
Mortality was higher in elderly patients. Factors affecting mortality in elderly patients included advanced age, the presence of comorbid diseases, increased episodes of peritonitis, use of continuous ambulatory peritoneal dialysis, and low albumin levels and daily urine volumes (<100 ml) at the initiation of peritoneal dialysis.
Peritoneal Dialysis; Elderly; Mortality
INTRODUCTION
The total number of elderly patients initiating dialysis regimens is expected to
increase due to rising life expectancies around the world. Data from the US Renal
Data System (USRDS) indicate that the number of patients older than 80 who initiated
dialysis increased from 7,054 in 1996 to 13,577 in 2003 11. Kurella M, Covinsky KE, Collins AJ, Chertow GM. Octogenarians and
nonagenarians starting dialysis in the United States. Ann Intern Med
2007-146(3)-177-83,
http://dx.doi.org/10.7326/0003-4819-146-3-200702060-00006.
http://dx.doi.org/10.7326/0003-4819-146-...
. In France, peritoneal dialysis (PD) is commonly
used among elderly patients, and more than one-half of all PD patients are >70
years old. In Hong Kong, 80% of all dialysis patients are on PD, and the median age
of these patients is 62 years 22. Brown EA. Should older patients be offered peritoneal
dialysis? Perit Dial Int. 2008;28(5)-444-8..
In Canada, the majority of patients starting dialysis are older than 65 years 33. Jassal SV, Trpeski L, Zhu N, Fenton S, Hemmelgarn B. Changes in
survival among elderly patients initiating dialysis from 1990 to 1999. CMAJ.
2007;177(9)-1033-8, http://dx.doi.org/10.1503/cmaj.061765.
http://dx.doi.org/10.1503/cmaj.061765...
.
PD in elderly patients is increasingly important due to the rapid growth of this
population. PD has several advantages and disadvantages in the elderly. Elderly
patients have a higher incidence of intestinal complications, including
diverticulosis, bowel perforations, and constipation. Moreover, many elderly
patients have undergone previous abdominal surgeries, which increases the risk of
adhesions and abdominal wall leaks. Older patients on dialysis also often have
multiple comorbidities, including diabetes mellitus, hypertension and cardiovascular
and cerebrovascular diseases 44. Dimkovic NB, Prakash S, Roscoe J Brissenden J, Tam P, Bargman J,
et al. Chronic peritoneal dialysis in octogenarians. Nephrol Dial Transplant.
2001;16(10)-2034-40, http://dx.doi.org/10.1093/ndt/16.10.2034.
http://dx.doi.org/10.1093/ndt/16.10.2034...
.
The under-utilization of PD in elderly patients is linked to the inability of the
patient to perform PD exchanges due to functional impairments or cognitive
dysfunction. Older age may frequently be associated with contraindications for
peritoneal dialysis 55. Jager KJ, Korevaar JC, Dekker FW Krediet RT, Boeschoten EW;
Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD) Study Group.
The effect of contraindications and patient preference on dialysis modality
selection in ESRD patients in the Netherlands. Am J Kidney Dis.
2004;43(5)-891-9, http://dx.doi.org/10.1053/j.ajkd.2003.12.051.
http://dx.doi.org/10.1053/j.ajkd.2003.12...
. Therefore,
dialysis decisions in elderly patients must incorporate geriatric principles with an
emphasis on an accurate assessment of patient autonomy, disabilities, and
comorbidities 66. Shien Wen SG,Chan CM. The Elderly Patient with End-stage Renal
Disease- Is Dialysis the Best and Only Option? Proceedings of Singapore
Healthcare. 2012;21(2)-125-31..
There is no clear consensus concerning the optimal form of renal replacement therapy for elderly patients. Furthermore, little is known regarding the results of PD therapy in elderly patients. Thus, the aim of this study is to provide information regarding the clinical outcomes and survival rates of elderly patients treated with PD.
MATERIALS AND METHODS
Records of 58 elderly patients (>65 years and older) in our PD unit who began PD therapy between June 2001 and January 2014 due to end-stage renal disease (ESRD) were evaluated retrospectively. Eight patients were excluded from the study because their PD history was less than 90 days. The data from the remaining 50 patients were collected and evaluated. Neither open-label research nor questionnaires were used in our study. Moreover, ethical committee approval was not sought because of the retrospective nature of the study.
Age, gender, educational level, socio-demographic characteristics, the availability of someone to administer PD (e.g., themselves, their children or other persons, such as healthcare workers), and the nature of the use of PD (patient preference or a compulsory choice) were investigated in-depth using patient records. We noted whether the patient had previously received hemodialysis, and if so, the history of the hemodialysis treatment was recorded. The etiology of the ESRD and the presence of comorbid systemic diseases, such as hypertension, cardiovascular disease (CVD), cerebrovascular events, and malignancy, were recorded.
Systolic and diastolic blood pressure measurements, daily urine volumes, daily mean ultrafiltration (UF) amounts, and cardiothoracic indices were recorded for all patients at the beginning and at the end of the study.
Serum urea, creatinine, calcium, phosphorus, albumin, intact parathyroid hormone (iPTH), hemoglobin, transferrin saturation and ferritin values were recorded at the beginning of the PD treatment and at the final monitoring appointment. Initiation of PD for continuous ambulatory peritoneal dialysis (CAPD) refers to the time when the patient started to use the PD solutions effectively, which generally refers to performing 2-liter exchanges 4 times per day. Initiation of PD for automated peritoneal dialysis (APD) refers to when the patient started PD at the necessary exchange volumes, which typically takes approximately 2-3 weeks after PD catheter insertion to occur.
Incidences of infectious complications, including peritonitis and exit site/tunnel infections, were determined. Factors associated with mortality as well as patient and technique survival rates were analyzed. Technique failure was defined as the requirement for patient transfer to HD due to peritonitis, inadequate ultrafiltration, exit site and/or tunnel infections, or mechanical problems.
Statistical analyses were performed using the Statistical Package for the Social Sciences software (version 11.0; SPSS Inc., Chicago, IL, USA). χ2 tests were used to assess nonparametric variables. Independent sample t-tests were used to analyze clinical and biochemical parameters. Patient survival rates and technique survival rates were calculated using Kaplan-Meier analysis. Risk factors and calculated hazard ratios (HRs) for patient mortality and PD technique failure were also analyzed using backward logistic regression models based on the Cox proportional hazards method. Differences were considered statistically significant if the p-value was less than 0.05.
RESULTS
Of the 367 patients who began PD during the study period, 58 met our inclusion criteria. Eight patients with a PD history of less than 90 days were excluded from our analysis. The mean age of the remaining 50 patients (including 31 females) at the time of the initiation of PD was 71.8±4.9 years. The mean PD duration was 26.5±20.2 months. The patient demographic data are presented in Table 1.
A total of 64% (n=32) of the patients performed PD with the help of another person, including their child, their spouse or another person, such as a healthcare worker. Fifty-eight percent of patients (n=29) made a compulsory choice to begin PD due to vascular access or social problems. Histories of HD use were present in 24% of the patients, and the mean period of HD therapy prior to PD was 62.3±43.9 (3-144) months.
Etiologies of renal failure included diabetic nephropathy (56%), chronic glomerulonephritis (18%), polycystic kidney disease (8%), chronic pyelonephritis (8%), amyloidosis (2%) and unknown causes (8%). In addition to diabetes, comorbid diseases included hypertension (12%), cerebrovascular accidents (10%), coronary artery disease (7%), chronic obstructive pulmonary disease (8%), malignancies (4%) and visual defects due to diabetic retinopathy (10%).
The clinical and laboratory data at the initiation of PD and at the final visit are presented in Table 2. The incidence of peritonitis was 20.4±16.3 patient-months; the incidence of infections at the catheter exit site/tunnel was 24.6±17.4 patient-months.
The PD modality was CAPD in 74% of patients (n=37); 3 of these patients eventually required a transfer to APD (n=16). The mean following time of APD therapy was 19.8-12.9 months. When compared with patients treated with APD, the hemodialysis duration was longer in patients receiving CAPD treatment (p=0.024). In patients receiving CAPD treatment, initial and final UF amounts were greater and systolic blood pressures and urine volume levels were lower than in patients treated with APD (p=0.014, <0.001, 0.008 and 0.023, respectively). In 80% of the APD group and 50% of the CAPD group, the procedure was performed by someone other than the patient (p=0.04). Factors that similarly affected CAPD and APD patients (p>0.05) included age, gender, etiology, educational status, nature of the PD decision, and incidences of peritonitis and catheter exit site/tunnel infections.
During the follow-up period, only 10 patients continued to receive PD treatments. None of the patients received kidney transplants (Table 3), and 30 patients died. Of the patients who died, 10 were treated with APD and 20 were treated with CAPD. The mortality rate was higher in patients treated with CAPD (p<0.001). Most of these deaths were caused by cardiovascular events (30%) and peritonitis and/or sepsis (50%). The underlying causes of peritonitis and/or sepsis were Gram-negative bacteria (Escherichia Coli, Enterobacter and Pseudomonas species) in 6 patients, Klebsiella and Acinetobacter species in 4 patients, and fungi in 1 patient. The causative microorganisms could not be isolated in 4 patients. In total, 10 patients were transferred to HD because of infectious complications associated with PD (50%), PD insufficiency (30%), and malnutrition (20%). Severe peritonitis with Gram-negative bacteria (Escherichia coli, Enterobacter and Pseudomonas species) in 4 patients and frequent peritonitis in 1 patient warranted mandatory transfers to HD.
The mean survival time for all patients was 38.9±4.3 months based on the Kaplan-Meier analysis. The survival rates were 78.8%, 66.8%, 50.9% and 19.5% at 1, 2, 3, and 4 years, respectively. No significant difference was observed in the survival rates between the two PD groups (log rank: 0.609) (Figures 1A and 1B). Patient age, nature of the PD decision (self vs. mandatory), administration form (self vs. by someone else), HD history status, history of additional systemic diseases, PD treatment modality (CAPD and APD), pretreatment urine volume (>100 ml/day vs. <100 ml/day), incidence of peritonitis and catheter exit site/tunnel infections, pretreatment serum albumin levels, systolic (SBP) and diastolic (DBP) blood pressures, and UF volumes were analyzed using Cox proportional hazard models and backward stepwise likelihood ratios (LRs) to identify independent risk factors for patient mortality. Predictors of increased mortality included advanced age, the presence of additional systemic diseases, increased episodes of peritonitis, CAPD modality, and low serum albumin levels and daily urine volumes (<100 ml) at the initiation of PD (Table 4).
The mean technique survival duration was 61.7±5.2 months based on Kaplan-Meier analysis. The technique survival rates were 97.9%, 90.6%, 81.5%, and 71% at 1, 2, 3, and 4 years, respectively. Technique survival rates were similar between the two PD modalities (log rank: 0.788) (Figures 2A and 2B). Patient age, nature of the PD decision, administration form (self vs. by someone else), HD history, history of additional systemic diseases, pretreatment urine volume, incidence of peritonitis and catheter exit site/tunnel infections, PD treatment modality (CAPD and APD), pretreatment serum albumin levels, SBP, DBP, and UF volumes were analyzed using Cox proportional hazard models and backward stepwise LRs to identify independent risk factors affecting the technique survival rates. None of the factors, including PD modality, were significant predictors of technique survival.
DISCUSSION
In this study, advanced age, presence of comorbid systemic diseases, increased episodes of peritonitis, CAPD modality, low serum albumin levels and low daily urine volumes at the initiation of PD were poor predictors of patient survival in elderly PD patients. Infectious complications and cardiovascular events were the main causes of death, whereas the most significant factor in warranting patient transfer to HD was the presence of peritonitis and/or sepsis.
Dialysis for older patients with ESRD is a significant challenge for healthcare
providers. These individuals are often referred to nephrologists during the later
stages of the disease. Moreover, these patients tend to have more comorbidities such
as cardiovascular diseases, malnutrition, and hearing and visual impairments 7. Valderraban F, Jofre R, Lopez-Gomez JM. Quality of life in end
stage renal disease patients. Am J Kidney Dis. 2001;38(3)-443-64,
http://dx.doi.org/10.1053/ajkd.2001.26824.
http://dx.doi.org/10.1053/ajkd.2001.2682...
7,88. Joly D, Anglicheau D, Alberti C, Nguyen AT, Touam M,
Grünfeld JP, et al. Octogenarians reaching end stage renal disease- cohort
study of decision making and clinical outcomes. J Am Soc Nephrol.
2003;14(4)-1012-21,
http://dx.doi.org/10.1097/01.ASN.0000054493.04151.80.
http://dx.doi.org/10.1097/01.ASN.0000054...
. All of these factors are problematic for any dialysis modality. The
prevalence of elderly patients requiring renal replacement therapy has also been
increasing in recent years. Genestier et al. reported that 15% of the PD population
was elderly and projected that this proportion would increase to 40-41% in the
future 99. Genestier S, Meyer N, Chantrel F, Alenabi F, Brignon P, Maaz M,
et al. Prognostic survival factors in elderly renal failure patients treated
with peritoneal dialysis- a nıne year retrospective study. Perit Dial Int.
2009;30(2)-218-26, http://dx.doi.org/10.3747/pdi.2009.00043.
http://dx.doi.org/10.3747/pdi.2009.00043...
. The elderly PD
population in our study accounted for 15.8% of all PD patients at our facility.
As the proportion of the older population increases, the number of older PD patients
will also increase. Mortality rates in elderly PD patients are not favorable. In our
study, the mean survival time was 38.9 months, and the mean survival rates were
78.8%, 66.8%, and 50.9% at 1, 2, and 3 years, respectively. Mortality rates in the
present study were higher than observed in a previous study of ours that evaluated
all of our PD patients between 2001 and 2010 1010. Unsal A, Koc Y, Basturk T, Sakaci T, Ahbap E, Sinangil A, et al.
Clinical outcomes and mortality in peritoneal dialysis patients- a 10-year
retrospective analysis in a single center. Clinical Nephrology.
2013;80(4)-270-9, http://dx.doi.org/10.5414/CN107711.
http://dx.doi.org/10.5414/CN107711...
. Different results are observed in other centers
and other countries. One of the reasons for some of the discrepancies in the reports
is the lack of a standard definition of “elderly patient.” Some
authors, including us, consider patients over 65 years of age as elderly, but
heterogeneity regarding this definition exists between studies.
Elderly patients on PD can attain favorable outcomes: the 2- and 5-year survival rates of patients over 65 years of age in Hong Kong were reported to be 88% and 56%, respectively 1111. Li PK, Law MC, Chow KM, Leung CB, Kwan BC, Chung KY, et al. Good patient and technique survival in elderly patients on continuous ambulatory peritoneal dialysis. Perit Dial Int. 2007;27(2)-196-201.. A study evaluating patients over 80 years of age reported a 12-month survival rate of 83% and a 24-month survival rate of 41%. These numbers are higher than those of other similar studies, which is most likely due to the presence of fewer comorbid conditions in the patients included in their study.
Most reports of dialysis outcomes in elderly patients are retrospective and use
varying definitions of elderly. The North Thames Dialysis Study 1313. Lamping DL, Constantinovici N, Roderick P, Normand C, Henderson
L, Harris S, et al. Clinical outcomes, quality of life, and costs in the North
Thames Dialysis Study of elderly people on dialysis- a prospective cohort study.
Lancet. 2000;356(9241)-1543-50,
http://dx.doi.org/10.1016/S0140-6736(00)03123-8.
http://dx.doi.org/10.1016/S0140-6736(00)...
was a large prospective study
that defined elderly as 70 years of age or older when starting dialysis. In this
study, survival was assessed in 125 patients (age 70-86 years), and the overall
1-year survival rate was 71%. De Vecchi et al. 1414. De Vecchi AF, Maccario M, Braga M, Scalamogna A, Castelnovo C,
Ponticelli C. Peritoneal dialysis in nondiabetic patients older than 70 years-
comparison with patients aged 40 to 60 years. Am J Kidney Dis. 1998;
31(3)-479-90,
http://dx.doi.org/10.1053/ajkd.1998.v31.pm9506685.
http://dx.doi.org/10.1053/ajkd.1998.v31....
compared the outcomes of 63 consecutive
non-diabetic patients older than 70 years who were treated with CAPD with the
outcomes of 86 non-diabetic patients aged 40-60 years who were treated over the same
period. The 2-year patient survival rate was, not surprisingly, lower in the older
group (68% vs. 82%, p < 0.001). Kadambi et al. 1515. Kadambi P, Troidle L, Gorban-Brennan N, Kliger AS, Finkelstein
FO. APD in the elderly. Semin Dial. 2002;15(6)-430-3,
http://dx.doi.org/10.1046/j.1525-139X.2002.00106.x.
http://dx.doi.org/10.1046/j.1525-139X.20...
compared the outcomes of three groups of patients
of different ages (<50 years, 50-64 years, and >65 years); over 90% of the
patients were receiving APD. This was a large retrospective study of 493 patients,
192 of whom were older than 65 years. The authors found that patients over 65 years
of age had a higher mortality rate than the group of younger patients.
The reasons underlying the different survival rates may be multifactorial in elderly
patients. Recent data indicate that age and the presence of comorbid conditions play
a significant role in dialysis mortality 16. Collins AJ, Hao W, Xia H, Ebben JP, Everson SE, Constantini EG,
et al. Mortality Risks of Peritoneal Dialysis and Hemodialysis. Am J Kidney Dis.
1999;34(6)-1065-74,
http://dx.doi.org/10.1016/S0272-6386(99)70012-0.
http://dx.doi.org/10.1016/S0272-6386(99)...
17. Vonesh EF, Snyder JJ, Foley RN, Collins AJ. The differential
impact of risk factors on mortality in hemodialysis and peritoneal dialysis.
Kidney Int. 2004;66(6)-2389-2401,
http://dx.doi.org/10.1111/kid.2004.66.issue-6.
http://dx.doi.org/10.1111/kid.2004.66.is...
18. Vonesh EF, Snyder JJ, Foley RN, Collins AJ. Mortality studies
comparing peritoneal dialysis and hemodialysis- What do they tell us?
Kidney Int Suppl. 2006;(103)-S3-11,
http://dx.doi.org/10.1038/sj.ki.5001910.
http://dx.doi.org/10.1038/sj.ki.5001910...
19. McDonald S, Marshall M, Johnson DW, and Polkinghorne K.
Relationship between Dialysis Modality and Mortality. J Am Soc Nephrol.
2009;20(1)-155-63, http://dx.doi.org/10.1681/ASN.2007111188.
http://dx.doi.org/10.1681/ASN.2007111188...
16-2020. 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;21(3)-499-506,
http://dx.doi.org/10.1681/ASN.2009060635.
http://dx.doi.org/10.1681/ASN.2009060635...
. Demographic characteristics
of patients (age, presence of diabetes, number of comorbid diseases, presence of
malnutrition, low residual renal function, presence of hemodialysis history) were
generally different in all of these study populations 16. Collins AJ, Hao W, Xia H, Ebben JP, Everson SE, Constantini EG,
et al. Mortality Risks of Peritoneal Dialysis and Hemodialysis. Am J Kidney Dis.
1999;34(6)-1065-74,
http://dx.doi.org/10.1016/S0272-6386(99)70012-0.
http://dx.doi.org/10.1016/S0272-6386(99)...
21. Cueto-Manzano AM, Quintana-Piãa E, Correa Rotter R.
Long-term CAPD survival and analysis of mortality risk factors- 12-year
experience of a single Mexican center. Perit Dial Int.
2001;21(2)-148-53.22. Avram MM, Mittman N, Bonomini L, Chattopadhyay J, Fein P.
Markers for survival in dialysis- a seven-year prospective study. Am J Kidney
Dis.1995;26(1)-209-19,
http://dx.doi.org/10.1016/0272-6386(95)90176-0.
http://dx.doi.org/10.1016/0272-6386(95)9...
16,21-2323. Johnson JG, Gore SM, Firth J. The effect of age, diabetes, and
other comorbidity on the survival of patients on dialysis- a systematic
quantitative overview of the literature. Nephrol Dial Transplant. 1999;
14(9)-2156-164, http://dx.doi.org/10.1093/ndt/14.9.2156.
http://dx.doi.org/10.1093/ndt/14.9.2156...
. In the Cox proportional hazard model used in our study,
advanced age, the presence of comorbid systemic diseases, increased episodes of
peritonitis, CAPD modality, and low serum albumin levels and low daily urine volumes
at the initiation of PD were predictors of poor patient survival. Weinhandle et al.
also observed increased survival of PD in patients less than 65 years of age without
comorbid conditions 2020. 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;21(3)-499-506,
http://dx.doi.org/10.1681/ASN.2009060635.
http://dx.doi.org/10.1681/ASN.2009060635...
. Kurella et
al. observed a decreasing mean survival rate after dialysis initiation in the older
dialysis population, with a result of 24.9 months in patients aged 65 to 79 years,
15.6 months in patients aged 80 to 84 years, 11.6 months in patients aged 85 to 89
years and 8.4 months in patients aged 90 years and older 11. Kurella M, Covinsky KE, Collins AJ, Chertow GM. Octogenarians and
nonagenarians starting dialysis in the United States. Ann Intern Med
2007-146(3)-177-83,
http://dx.doi.org/10.7326/0003-4819-146-3-200702060-00006.
http://dx.doi.org/10.7326/0003-4819-146-...
. The authors also showed that the dialysis
population had a substantially lower average life expectancy of 48 to 89 months
compared with the age-matched general population 11. Kurella M, Covinsky KE, Collins AJ, Chertow GM. Octogenarians and
nonagenarians starting dialysis in the United States. Ann Intern Med
2007-146(3)-177-83,
http://dx.doi.org/10.7326/0003-4819-146-3-200702060-00006.
http://dx.doi.org/10.7326/0003-4819-146-...
.
Dialysis may not confer a survival benefit in elderly patients with significant
comorbidities. As expected, the survival of patients receiving PD was affected by
comorbidities. In addition, comorbidities were associated with the mortality risk of
patients receiving PD in an age-independent manner 24. Couchoud C, Savoye E, Frimat L Ryckelynck JP, Chalem Y, Verger
C, et al. Variability in case mix and peritoneal dialysis selection in
fifty-nine French districts. Perit Dial Int. 2008;28(5)-
509-17.24,2525. Vrtovsnik F, Porcher R, Michel C Hufnagel G, Queffeulou G,
Mentré F, et al. Survival of elderly patients on peritoneal dialysis-
retrospective study of 292 patients, from 1982 to 1999. Perit Dial Int.
2002;22(1)-73-81. A
study conducted in London by Murtagh et al. also demonstrated a survival benefit for
dialysis treatment in the elderly (>75 years) 2626. Murtagh FE, Marsh JE, Donohoe P, Ekbal NJ, Sheerin NS, Harris
FE. Dialysis or not? A comparative survival study of patients over 75 years
with chronic kidney disease stage 5. Nephrol Dial Transplant.
2007;22(7)-1955-62, http://dx.doi.org/10.1093/ndt/gfm153.
http://dx.doi.org/10.1093/ndt/gfm153...
. However, in patients with ischemic heart disease
or significant comorbidities (score=2 in the comorbidity scoring system by Davies et
al.) 2727. Davies SJ, Phillips L, Naish PF, Russell GI. Quantifying
comorbidity in peritoneal dialysis patients and its relationship to other
predictors of survival. Nephrol Dial Transplant. 2002;17(6)-1085-92,
http://dx.doi.org/10.1093/ndt/17.6.1085.
http://dx.doi.org/10.1093/ndt/17.6.1085...
, no survival benefit was
observed for dialysis treatment. In our study, we found that the presence of
comorbid conditions negatively affected patient survival.
Malnutrition is common in ESRD patients and is a powerful predictor of morbidity and
mortality. In general, elderly patients on any type of dialysis have poor
nutritional status. Studies comparing nutritional statuses of PD and HD patients are
scant, but there is no clear evidence that nutritional status is worse in elderly PD
patients despite the potential for protein loss in the effluent 2828. Dimkovic N, Oreopoulos DG. Chronic peritoneal dialysis in the
elderly. Semin Dial. 2002;15(2)-94-7,
http://dx.doi.org/10.1046/j.1525-139X.2002.00038.x.
http://dx.doi.org/10.1046/j.1525-139X.20...
. PD patients may be severely
hypoalbuminemic at the initiation of dialysis 2929. Chung SH, Lindholm B, Lee HB. Is malnutrition an independent
predictor of mortality in dialysis patients? Nephrol Dial Transplant.
2003;18(10)-2134-40, http://dx.doi.org/10.1093/ndt/gfg318.
http://dx.doi.org/10.1093/ndt/gfg318...
and may remain at higher risk of malnutrition due
to constant protein loss in the effluent. Moreover, malnutrition may be
significantly higher among high peritoneal transporter patients and in patients
experiencing peritonitis. We suspect that this effect accounts for the decreased
survival rate in patients with lower serum albumin levels at the initiation of
PD.
Peritonitis is a major complication in patients receiving PD. Peritonitis is the
major cause of technique failure and represents a significant cause of morbidity and
mortality 3030. Davenport A. Peritonitis remains the major clinical complication
of peritoneal dialysis- the London, U.K., peritonitis audit 2002-2003. Perit
Dial Int. 2009;29(3);297-302.. The reported rates
of peritonitis in elderly patients have varied in the literature. Rates have been
reported to be higher than, similar to, or lower than the rates observed in younger
patients 14. De Vecchi AF, Maccario M, Braga M, Scalamogna A, Castelnovo C,
Ponticelli C. Peritoneal dialysis in nondiabetic patients older than 70 years-
comparison with patients aged 40 to 60 years. Am J Kidney Dis. 1998;
31(3)-479-90,
http://dx.doi.org/10.1053/ajkd.1998.v31.pm9506685.
http://dx.doi.org/10.1053/ajkd.1998.v31....
15. Kadambi P, Troidle L, Gorban-Brennan N, Kliger AS, Finkelstein
FO. APD in the elderly. Semin Dial. 2002;15(6)-430-3,
http://dx.doi.org/10.1046/j.1525-139X.2002.00106.x.
http://dx.doi.org/10.1046/j.1525-139X.20...
31. Pérez-Contreras J, Miguel A, Sánchez J, Rivera F,
Olivares J. A prospective multicenter comparison of peritonitis in peritoneal
dialysis patients aged above and below 85. Levante PD Multicenter group. Adv
Perit Dial. 2000;16-267-70.32. Valente J, Rappaport W. Continuous ambulatory peritoneal
dialysis associated with peritonitis in older patients. Am J Surg.
1990;159(6)-579-81,
http://dx.doi.org/10.1016/S0002-9610(06)80070-X.
http://dx.doi.org/10.1016/S0002-9610(06)...
33. Suh H, Wadhwa NK, Cabralda T, Sokunbi D, Solomon M. Peritoneal
dialysis in elderly end-stage renal disease patients. Adv Perit Dial.
1993;9-134-7.34. Holley JL, Bernardini J, Perlmutter JA, Piraino B. A comparison
of infection rates among older and younger patients on continuous peritoneal
dialysis. Perit Dial Int. 1994;14(1)-66-9.35. Szeto CC, Kwan BC, Chow KM. Peritonitis risk for older patients
on peritoneal dialysis. Perit Dial Int 2008;28(5)-457-60.14,15,31-3636. Taveras AE, Bekui AM, Gorban-Brennan N, Raducu R, Finkelstein
FO. Peritoeal dialysis in patients 75 years of age and older-a 22-year
experience. Adv Perit Dial. 2012;28-85-8.. Elderly patients could be more susceptible to peritonitis
because of functional impairments, immunodeficiency and diverticulitis. Our results
showed that the incidence of peritonitis was similar to the ISPD Guidelines target
3737. Li PK, Szeto CC, Piraino B, Bernardini J, Figueiredo AE, Gupta
A, et al. International Society for Peritoneal Dialysis. Peritoneal
dialysis-related infections recommendations- 2010 update. Perit Dial Int.
2010;30(4)-393-423, http://dx.doi.org/10.3747/pdi.2010.00049.
http://dx.doi.org/10.3747/pdi.2010.00049...
. The higher peritonitis
incidence in our patients was probably due to the high rate of administration of PD
by someone other than the patient.
Cardiovascular disease is prevalent in CKD patients. In fact, it is the most frequent
cause of death in CKD patients, accounting for approximately 50% of all deaths 3838. Culleton BF, Hemmelgarn BR. Is chronic kidney disease a
cardiovascular disease risk factor? Semin Dial. 2003;16(2)-95-100,
http://dx.doi.org/10.1046/j.1525-139X.2003.16024.x.
http://dx.doi.org/10.1046/j.1525-139X.20...
. A report from a Far-Eastern
country suggested that the most significant causes of death in CKD patients were
infections (61%) and cardiovascular events (39%) 3939. Shiao CC, Kao TW, Hung KY, Chen YC, Wu MS, Chu TS, et al.
Seven-year follow-up of peritoneal dialysis patients in Taiwan. Perit Dial Int.
2009;29(4)-450-7.. These data correlate well with our study, as we
also found that the most frequent causes of death were infections (peritonitis
and/or sepsis) and cardiovascular events.
Inter-study variability exists regarding the definition of technique failure. Many
studies, including the present study, define technique failure as a requirement for
transfer to HD 40. Churchill DN, Thorpe KE, Nolph KD, Keshaviah PR, Oreopoulos DG,
Pagé D; The Canada-USA (CANUSA) Peritoneal Dialysis Study Group. Increased
peritoneal membrane transport is associated with decreased patient and technique
survival for continuous peritoneal dialysis patients. J Am Soc Nephrol.
1998;9(7)-1285-92.40,4141. Szeto CC, Law MC, Wong TY, Leung CB, Li PK. Peritoneal transport
status correlates with morbidity but not longitudinal change of nutritional
status of continuous ambulatory peritoneal dialysis patients- a 2-year
prospective study. Am J Kidney Dis. 2001;37(2)-329-36,
http://dx.doi.org/10.1053/ajkd.2001.21298.
http://dx.doi.org/10.1053/ajkd.2001.2129...
. However, some authors define technique
failure as death or a requirement for transfer to HD 4242. Wu CH, Huang CC, Huang JY, Wu MS, Leu ML. High flux peritoneal
membrane is a risk factor in survival of CAPD treatment. Adv Perit
Dial.1996;12-105-9.. In addition to the differences between
definitions, technique survival rates may differ between countries or even between
clinics in the same country 39. Shiao CC, Kao TW, Hung KY, Chen YC, Wu MS, Chu TS, et al.
Seven-year follow-up of peritoneal dialysis patients in Taiwan. Perit Dial Int.
2009;29(4)-450-7.40. Churchill DN, Thorpe KE, Nolph KD, Keshaviah PR, Oreopoulos DG,
Pagé D; The Canada-USA (CANUSA) Peritoneal Dialysis Study Group. Increased
peritoneal membrane transport is associated with decreased patient and technique
survival for continuous peritoneal dialysis patients. J Am Soc Nephrol.
1998;9(7)-1285-92.39,40,4343. Chung SH, Heimbürger O, Lindholm B, Lee HB. Peritoneal
dialysis patient survival- a comparison between a Swedish and a Korean centre.
Nephrol Dial Transplant. 2005;20(6)-1207-13,
http://dx.doi.org/10.1093/ndt/gfh772.
http://dx.doi.org/10.1093/ndt/gfh772...
. The most common causes of transfers from PD to HD were
PD-related infections and inadequate dialysis 3939. Shiao CC, Kao TW, Hung KY, Chen YC, Wu MS, Chu TS, et al.
Seven-year follow-up of peritoneal dialysis patients in Taiwan. Perit Dial Int.
2009;29(4)-450-7.. Similarly, infections (peritonitis and/or
sepsis) and inadequate dialysis were the most important causes of technique failure
in our study. The mean technique survival duration was 61.7±5.2 months, and the
technique survival rates were 97.9%, 90.6%, 81.5% and 71% at 1, 2, 3 and 4 years,
respectively. These data are consistent with similar studies from the literature
1414. De Vecchi AF, Maccario M, Braga M, Scalamogna A, Castelnovo C,
Ponticelli C. Peritoneal dialysis in nondiabetic patients older than 70 years-
comparison with patients aged 40 to 60 years. Am J Kidney Dis. 1998;
31(3)-479-90,
http://dx.doi.org/10.1053/ajkd.1998.v31.pm9506685.
http://dx.doi.org/10.1053/ajkd.1998.v31....
. We could not find any
significant risk factors with effects on technique survival, which was probably
because of the small size of the study population that was transferred to HD.
In conclusion, although different survival rates in PD patients have been reported in different studies, mortality was high in elderly PD patients in our study. The factors affecting mortality and survival rates in our elderly patients are advanced age, the presence of comorbid systemic diseases, increased episodes of peritonitis, and low serum albumin levels and diastolic blood pressures at initiation of PD. Transfers to HD and death were the most common causes of withdrawal from PD. Infectious complications and cardiovascular events were the main causes of death, whereas peritonitis and/or sepsis and inadequate dialysis were the most prevalent reasons for transferring to HD.
REFERENCES
-
1Kurella M, Covinsky KE, Collins AJ, Chertow GM. Octogenarians and nonagenarians starting dialysis in the United States. Ann Intern Med 2007-146(3)-177-83, http://dx.doi.org/10.7326/0003-4819-146-3-200702060-00006.
» http://dx.doi.org/10.7326/0003-4819-146-3-200702060-00006 -
2Brown EA. Should older patients be offered peritoneal dialysis? Perit Dial Int. 2008;28(5)-444-8.
-
3Jassal SV, Trpeski L, Zhu N, Fenton S, Hemmelgarn B. Changes in survival among elderly patients initiating dialysis from 1990 to 1999. CMAJ. 2007;177(9)-1033-8, http://dx.doi.org/10.1503/cmaj.061765.
» http://dx.doi.org/10.1503/cmaj.061765 -
4Dimkovic NB, Prakash S, Roscoe J Brissenden J, Tam P, Bargman J, et al. Chronic peritoneal dialysis in octogenarians. Nephrol Dial Transplant. 2001;16(10)-2034-40, http://dx.doi.org/10.1093/ndt/16.10.2034.
» http://dx.doi.org/10.1093/ndt/16.10.2034 -
5Jager KJ, Korevaar JC, Dekker FW Krediet RT, Boeschoten EW; Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD) Study Group. The effect of contraindications and patient preference on dialysis modality selection in ESRD patients in the Netherlands. Am J Kidney Dis. 2004;43(5)-891-9, http://dx.doi.org/10.1053/j.ajkd.2003.12.051.
» http://dx.doi.org/10.1053/j.ajkd.2003.12.051 -
6Shien Wen SG,Chan CM. The Elderly Patient with End-stage Renal Disease- Is Dialysis the Best and Only Option? Proceedings of Singapore Healthcare. 2012;21(2)-125-31.
-
7Valderraban F, Jofre R, Lopez-Gomez JM. Quality of life in end stage renal disease patients. Am J Kidney Dis. 2001;38(3)-443-64, http://dx.doi.org/10.1053/ajkd.2001.26824.
» http://dx.doi.org/10.1053/ajkd.2001.26824 -
8Joly D, Anglicheau D, Alberti C, Nguyen AT, Touam M, Grünfeld JP, et al. Octogenarians reaching end stage renal disease- cohort study of decision making and clinical outcomes. J Am Soc Nephrol. 2003;14(4)-1012-21, http://dx.doi.org/10.1097/01.ASN.0000054493.04151.80.
» http://dx.doi.org/10.1097/01.ASN.0000054493.04151.80 -
9Genestier S, Meyer N, Chantrel F, Alenabi F, Brignon P, Maaz M, et al. Prognostic survival factors in elderly renal failure patients treated with peritoneal dialysis- a nıne year retrospective study. Perit Dial Int. 2009;30(2)-218-26, http://dx.doi.org/10.3747/pdi.2009.00043.
» http://dx.doi.org/10.3747/pdi.2009.00043 -
10Unsal A, Koc Y, Basturk T, Sakaci T, Ahbap E, Sinangil A, et al. Clinical outcomes and mortality in peritoneal dialysis patients- a 10-year retrospective analysis in a single center. Clinical Nephrology. 2013;80(4)-270-9, http://dx.doi.org/10.5414/CN107711.
» http://dx.doi.org/10.5414/CN107711 -
11Li PK, Law MC, Chow KM, Leung CB, Kwan BC, Chung KY, et al. Good patient and technique survival in elderly patients on continuous ambulatory peritoneal dialysis. Perit Dial Int. 2007;27(2)-196-201.
-
12Otowa T, Sakurada T, Nagasava M, Shimizu S, Yokoyama T, Kaneshiro N, et al. Clinical outcomes in elderly (more than 80 years of age) peritoneal dialysis patients- five years experience at two centers. Adv Perit Dial. 2013;29-43-5.
-
13Lamping DL, Constantinovici N, Roderick P, Normand C, Henderson L, Harris S, et al. Clinical outcomes, quality of life, and costs in the North Thames Dialysis Study of elderly people on dialysis- a prospective cohort study. Lancet. 2000;356(9241)-1543-50, http://dx.doi.org/10.1016/S0140-6736(00)03123-8.
» http://dx.doi.org/10.1016/S0140-6736(00)03123-8 -
14De Vecchi AF, Maccario M, Braga M, Scalamogna A, Castelnovo C, Ponticelli C. Peritoneal dialysis in nondiabetic patients older than 70 years- comparison with patients aged 40 to 60 years. Am J Kidney Dis. 1998; 31(3)-479-90, http://dx.doi.org/10.1053/ajkd.1998.v31.pm9506685.
» http://dx.doi.org/10.1053/ajkd.1998.v31.pm9506685 -
15Kadambi P, Troidle L, Gorban-Brennan N, Kliger AS, Finkelstein FO. APD in the elderly. Semin Dial. 2002;15(6)-430-3, http://dx.doi.org/10.1046/j.1525-139X.2002.00106.x.
» http://dx.doi.org/10.1046/j.1525-139X.2002.00106.x -
16Collins AJ, Hao W, Xia H, Ebben JP, Everson SE, Constantini EG, et al. Mortality Risks of Peritoneal Dialysis and Hemodialysis. Am J Kidney Dis. 1999;34(6)-1065-74, http://dx.doi.org/10.1016/S0272-6386(99)70012-0.
» http://dx.doi.org/10.1016/S0272-6386(99)70012-0 -
17Vonesh EF, Snyder JJ, Foley RN, Collins AJ. The differential impact of risk factors on mortality in hemodialysis and peritoneal dialysis. Kidney Int. 2004;66(6)-2389-2401, http://dx.doi.org/10.1111/kid.2004.66.issue-6.
» http://dx.doi.org/10.1111/kid.2004.66.issue-6 -
18Vonesh EF, Snyder JJ, Foley RN, Collins AJ. Mortality studies comparing peritoneal dialysis and hemodialysis- What do they tell us? Kidney Int Suppl. 2006;(103)-S3-11, http://dx.doi.org/10.1038/sj.ki.5001910.
» http://dx.doi.org/10.1038/sj.ki.5001910 -
19McDonald S, Marshall M, Johnson DW, and Polkinghorne K. Relationship between Dialysis Modality and Mortality. J Am Soc Nephrol. 2009;20(1)-155-63, http://dx.doi.org/10.1681/ASN.2007111188.
» http://dx.doi.org/10.1681/ASN.2007111188 -
20Weinhandl 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;21(3)-499-506, http://dx.doi.org/10.1681/ASN.2009060635.
» http://dx.doi.org/10.1681/ASN.2009060635 -
21Cueto-Manzano AM, Quintana-Piãa E, Correa Rotter R. Long-term CAPD survival and analysis of mortality risk factors- 12-year experience of a single Mexican center. Perit Dial Int. 2001;21(2)-148-53.
-
22Avram MM, Mittman N, Bonomini L, Chattopadhyay J, Fein P. Markers for survival in dialysis- a seven-year prospective study. Am J Kidney Dis.1995;26(1)-209-19, http://dx.doi.org/10.1016/0272-6386(95)90176-0.
» http://dx.doi.org/10.1016/0272-6386(95)90176-0 -
23Johnson JG, Gore SM, Firth J. The effect of age, diabetes, and other comorbidity on the survival of patients on dialysis- a systematic quantitative overview of the literature. Nephrol Dial Transplant. 1999; 14(9)-2156-164, http://dx.doi.org/10.1093/ndt/14.9.2156.
» http://dx.doi.org/10.1093/ndt/14.9.2156 -
24Couchoud C, Savoye E, Frimat L Ryckelynck JP, Chalem Y, Verger C, et al. Variability in case mix and peritoneal dialysis selection in fifty-nine French districts. Perit Dial Int. 2008;28(5)- 509-17.
-
25Vrtovsnik F, Porcher R, Michel C Hufnagel G, Queffeulou G, Mentré F, et al. Survival of elderly patients on peritoneal dialysis- retrospective study of 292 patients, from 1982 to 1999. Perit Dial Int. 2002;22(1)-73-81
-
26Murtagh FE, Marsh JE, Donohoe P, Ekbal NJ, Sheerin NS, Harris FE. Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrol Dial Transplant. 2007;22(7)-1955-62, http://dx.doi.org/10.1093/ndt/gfm153.
» http://dx.doi.org/10.1093/ndt/gfm153 -
27Davies SJ, Phillips L, Naish PF, Russell GI. Quantifying comorbidity in peritoneal dialysis patients and its relationship to other predictors of survival. Nephrol Dial Transplant. 2002;17(6)-1085-92, http://dx.doi.org/10.1093/ndt/17.6.1085.
» http://dx.doi.org/10.1093/ndt/17.6.1085 -
28Dimkovic N, Oreopoulos DG. Chronic peritoneal dialysis in the elderly. Semin Dial. 2002;15(2)-94-7, http://dx.doi.org/10.1046/j.1525-139X.2002.00038.x.
» http://dx.doi.org/10.1046/j.1525-139X.2002.00038.x -
29Chung SH, Lindholm B, Lee HB. Is malnutrition an independent predictor of mortality in dialysis patients? Nephrol Dial Transplant. 2003;18(10)-2134-40, http://dx.doi.org/10.1093/ndt/gfg318.
» http://dx.doi.org/10.1093/ndt/gfg318 -
30Davenport A. Peritonitis remains the major clinical complication of peritoneal dialysis- the London, U.K., peritonitis audit 2002-2003. Perit Dial Int. 2009;29(3);297-302.
-
31Pérez-Contreras J, Miguel A, Sánchez J, Rivera F, Olivares J. A prospective multicenter comparison of peritonitis in peritoneal dialysis patients aged above and below 85. Levante PD Multicenter group. Adv Perit Dial. 2000;16-267-70.
-
32Valente J, Rappaport W. Continuous ambulatory peritoneal dialysis associated with peritonitis in older patients. Am J Surg. 1990;159(6)-579-81, http://dx.doi.org/10.1016/S0002-9610(06)80070-X.
» http://dx.doi.org/10.1016/S0002-9610(06)80070-X -
33Suh H, Wadhwa NK, Cabralda T, Sokunbi D, Solomon M. Peritoneal dialysis in elderly end-stage renal disease patients. Adv Perit Dial. 1993;9-134-7.
-
34Holley JL, Bernardini J, Perlmutter JA, Piraino B. A comparison of infection rates among older and younger patients on continuous peritoneal dialysis. Perit Dial Int. 1994;14(1)-66-9.
-
35Szeto CC, Kwan BC, Chow KM. Peritonitis risk for older patients on peritoneal dialysis. Perit Dial Int 2008;28(5)-457-60.
-
36Taveras AE, Bekui AM, Gorban-Brennan N, Raducu R, Finkelstein FO. Peritoeal dialysis in patients 75 years of age and older-a 22-year experience. Adv Perit Dial. 2012;28-85-8.
-
37Li PK, Szeto CC, Piraino B, Bernardini J, Figueiredo AE, Gupta A, et al. International Society for Peritoneal Dialysis. Peritoneal dialysis-related infections recommendations- 2010 update. Perit Dial Int. 2010;30(4)-393-423, http://dx.doi.org/10.3747/pdi.2010.00049.
» http://dx.doi.org/10.3747/pdi.2010.00049 -
38Culleton BF, Hemmelgarn BR. Is chronic kidney disease a cardiovascular disease risk factor? Semin Dial. 2003;16(2)-95-100, http://dx.doi.org/10.1046/j.1525-139X.2003.16024.x.
» http://dx.doi.org/10.1046/j.1525-139X.2003.16024.x -
39Shiao CC, Kao TW, Hung KY, Chen YC, Wu MS, Chu TS, et al. Seven-year follow-up of peritoneal dialysis patients in Taiwan. Perit Dial Int. 2009;29(4)-450-7.
-
40Churchill DN, Thorpe KE, Nolph KD, Keshaviah PR, Oreopoulos DG, Pagé D; The Canada-USA (CANUSA) Peritoneal Dialysis Study Group. Increased peritoneal membrane transport is associated with decreased patient and technique survival for continuous peritoneal dialysis patients. J Am Soc Nephrol. 1998;9(7)-1285-92.
-
41Szeto CC, Law MC, Wong TY, Leung CB, Li PK. Peritoneal transport status correlates with morbidity but not longitudinal change of nutritional status of continuous ambulatory peritoneal dialysis patients- a 2-year prospective study. Am J Kidney Dis. 2001;37(2)-329-36, http://dx.doi.org/10.1053/ajkd.2001.21298.
» http://dx.doi.org/10.1053/ajkd.2001.21298 -
42Wu CH, Huang CC, Huang JY, Wu MS, Leu ML. High flux peritoneal membrane is a risk factor in survival of CAPD treatment. Adv Perit Dial.1996;12-105-9.
-
43Chung SH, Heimbürger O, Lindholm B, Lee HB. Peritoneal dialysis patient survival- a comparison between a Swedish and a Korean centre. Nephrol Dial Transplant. 2005;20(6)-1207-13, http://dx.doi.org/10.1093/ndt/gfh772.
» http://dx.doi.org/10.1093/ndt/gfh772
Publication Dates
-
Publication in this collection
May 2015
History
-
Received
8 Jan 2015 -
Reviewed
20 Feb 2015 -
Accepted
20 Feb 2015