Renal function decline and optimized planning for kidney replacement therapy

Chronic Kidney disease (CKD) is an increasing health problem world-wide, and the prevalence increases with age. CKD is a life-threatening condition, with high risk of cardiovascular disease and mortality. Patients with advanced CKD often need Kidney Replacement Therapy, (KRT), this includes transplantation, dialysis or conservative care. Education and follow-up of patients with advanced CKD is often referred to as predialysis care. This increases patient knowledge and enables more individualized treatment choices. Research on the natural course, and prognosis of CKD is necessary to be able to offer our patients best possible care. This thesis studies the influence of kidney progression rate on prognosis, planning for KRT, vascular access and patient survival. All studies were observational cohort studies. Patients were included from the Swedish Renal Registry, (SRR), SRR-CKD, SRR-Access and Stockholm CREAtinin Measurement (SCREAM) during 2005-2020. Study I described the impact of progression rate and age on the absolute risk for KRT and death. We used an unselected nephrology- referred CKD population, (n=8,771) with at least two creatinine measurements within a year. We used competing risk models and compared fast to slow progressors with regard to outcomes. Fast progression was associated to increased KRT risk in all ages and CKD stages, but the prognosis was affected by the age and eGFR of the patient. Study II studied the progression rate following access creation, comparing Arteriovenous (AV) to peritoneal dialysis (PD) access placement in patients with severe CKD. Data were collected at 100 days before and after surgery, (n=744). We used linear mixed models with random intercept and slope. Access surgery was associated to a slower progression rate, but without any significant differences in AV compared to PD accesses. This study emphasizes the importance of predialysis care, but the need for dialysis remains the main determinant for access creation. Study III compared the influence of open surgical versus endovascular intervention for AV access thrombosis on time to access abandonment and next intervention, (n=904). We also compared several categories of each intervention. The outcome; time to access abandonment were described in Kaplan-Mayer curves and compared with log-rank statistics. There was a statistically significant benefit of endovascular intervention on both short- and long-term access survival, albeit small in absolute terms Study IV evaluated the use of Kidney Failure Risk Equation, (KFRE) versus eGFR15 as a threshold for optimized timing of AV access creation. We used cumulative incidences to describe the outcomes of KRT, death and test diagnostics. KFRE>40% had superior specificity and positive predictive value compared to eGFR15 and were superior to predict KRT initiation and death. To summarize, an individualized predialysis care considering progression rate and age is important to optimize the plan for future care. We found no evidence of a specific effect of AV access creation on the eGFR decline, and endovascular methods for vascular access thrombosis were shown to increase the proportion of people with a functioning access after 3-6 months. The use of KFRE>40% could be a valuable tool to improve the proportion of patients starting hemodialysis with a working access

Treatment practices and outcomes in incident peritoneal dialysis patients : The Swedish Renal Registry 2006-2015

Background: Therapeutic developments have contributed to markedly improved clinical outcomes in peritoneal dialysis (PD) during the 1990s and 2000s. We investigated whether recent advances in PD treatment are implemented in routine Swedish care and whether their implementation parallels improved patient outcomes. Methods: We conducted an observational study of 3122 patients initiating PD in Sweden from 2006 to 2015. We evaluated trends of treatment practices (medications, PD-related procedures) and outcomes [patient survival, major adverse cardiovascular events (MACEs), peritonitis, transfer to haemodialysis (HD) and kidney transplantation] and analysed associations of changes of treatment practices with changes in outcomes. Results: Over the 10-year period, demographics (mean age 63 years, 33% women) and comorbidities remained essentially stable. There were changes in clinical characteristics (body mass index and diastolic blood pressure increased), prescribed drugs (calcium channel blockers, non-calcium phosphate binders and cinacalcet increased and the use of renin-angiotensin system inhibitors, erythropoietin and iron decreased) and dialysis treatment (increased use of automated PD, icodextrin and assisted PD). The standardized 1- and 2-year mortality and MACE risk did not change over the period. Compared with the general population, the risk of 1-year mortality was 4.1 times higher in 2006-2007 and remained stable throughout follow-up. However, the standardized 1- and 2-year peritonitis rate decreased and the incidence of kidney transplantation increased while transfers to HD did not change. Conclusions: Over the last decade, treatment advances in PD patients were accompanied by a substantial decline in peritonitis frequency and an increased rate of kidney transplantations, while 1- and 2-year survival and MACE risk did not change

Availability of assisted peritoneal dialysis in Europe: call for increased and equal access

International audienceBackground Availability of assisted PD (asPD) increases access to dialysis at home, particularly for the increasing numbers of older and frail people with advanced kidney disease. Although asPD has been widely used in some European countries for many years, it remains unavailable or poorly utilized in others. A group of leading European nephrologists have therefore formed a group to drive increased availability of asPD in Europe and in their own countries. Methods Members of the group filled in a proforma with the following headings: personal experience, country experience, who are the assistants, funding of asPD, barriers to growth, what is needed to grow and their top three priorities. Results Only 5 of the 13 countries surveyed provided publicly funded reimbursement for asPD. The use of asPD depends on overall attitudes to PD, with all respondents mentioning the need for nephrology team education and/or patient education and involvement in dialysis modality decision making. Conclusions and call to action Many people with advanced kidney disease would prefer to have their dialysis at home, yet if the frail patient chooses PD most healthcare systems cannot provide their choice. AsPD should be available in all countries in Europe and in all renal centres. The top priorities to make this happen are education of renal healthcare teams about the advantages of PD, education of and discussion with patients and their families as they approach the need for dialysis, and engagement with policymakers and healthcare providers to develop and support assistance for PD

Assisted peritoneal dialysis across Europe: Practice variation and factors associated with availability

Background: In Europe, the number of elderly end-stage kidney disease patients is increasing. Few of those patients receive peritoneal dialysis (PD), as many cannot perform PD autonomously. Assisted PD programmes are available in most European countries, but the percentage of patients receiving assisted PD varies considerably. Hence, we assessed which factors are associated with the availability of an assisted PD programme at a centre level and whether the availability of this programme is associated with proportion of home dialysis patients. Methods: An online survey was sent to healthcare professionals of European nephrology units. After selecting one respondent per centre, the associations were explored by χ2 tests and (ordinal) logistic regression. Results: In total, 609 respondents completed the survey. Subsequently, 288 respondents from individual centres were identified; 58% worked in a centre with an assisted PD programme. Factors associated with availability of an assisted PD programme were Western European and Scandinavian countries (OR: 5.73; 95% CI: 3.07–10.68), non-academic centres (OR: 2.01; 95% CI: 1.09–3.72) and centres with a dedicated team for education (OR: 2.87; 95% CI: 1.35–6.11). Most Eastern & Central European respondents reported that the proportion of incident and prevalent home dialysis patients was 30% for both incident and prevalent home dialysis patients. Availability of an assisted PD programme was associated with a higher incidence (cumulative OR: 1.91; 95% CI: 1.21–3.01) and prevalence (cumulative OR: 2.81; 95% CI: 1.76–4.47) of patients on home dialysis. Conclusions: Assisted PD was more commonly offered among non-academic centres with a dedicated team for education across Europe, especially among Western European and Scandinavian countries where higher incidence and prevalence of home dialysis patients was reported

Assisted peritoneal dialysis across Europe: Practice variation and factors associated with availability

Background: In Europe, the number of elderly end-stage kidney disease patients is increasing. Few of those patients receive peritoneal dialysis (PD), as many cannot perform PD autonomously. Assisted PD programmes are available in most European countries, but the percentage of patients receiving assisted PD varies considerably. Hence, we assessed which factors are associated with the availability of an assisted PD programme at a centre level and whether the availability of this programme is associated with proportion of home dialysis patients. Methods: An online survey was sent to healthcare professionals of European nephrology units. After selecting one respondent per centre, the associations were explored by χ2 tests and (ordinal) logistic regression. Results: In total, 609 respondents completed the survey. Subsequently, 288 respondents from individual centres were identified; 58% worked in a centre with an assisted PD programme. Factors associated with availability of an assisted PD programme were Western European and Scandinavian countries (OR: 5.73; 95% CI: 3.07–10.68), non-academic centres (OR: 2.01; 95% CI: 1.09–3.72) and centres with a dedicated team for education (OR: 2.87; 95% CI: 1.35–6.11). Most Eastern & Central European respondents reported that the proportion of incident and prevalent home dialysis patients was 30% for both incident and prevalent home dialysis patients. Availability of an assisted PD programme was associated with a higher incidence (cumulative OR: 1.91; 95% CI: 1.21–3.01) and prevalence (cumulative OR: 2.81; 95% CI: 1.76–4.47) of patients on home dialysis. Conclusions: Assisted PD was more commonly offered among non-academic centres with a dedicated team for education across Europe, especially among Western European and Scandinavian countries where higher incidence and prevalence of home dialysis patients was reported