Current evidence shows that survival outcomes are equivalent for dialysis techniques.

Studies that have analyzed survival between hemodialysis and peritoneal dialysis have showed heterogeneous outcomes for both techniques, and often confusing, also dependent on many factors. For this reason, it is necessary to know if there are real differences between the two treatments, to put the scientific evidence as a fundamental pillar in the choice of treatment, along with the clinical circumstances of individual patients, preferences and lifestyle of these. A comparative review of survival among dialysis techniques cannot avoid a basic methodological characteristics or attributes, such as appropriate designs such as observational studies with large cohorts, with incidents and no prevalent populations, with "intent to treat analysis "survival analysis and multivariate analysis with adjustments to the main comorbidity. We studied the nine classical main studies (incidents before 2002), presenting similar conclusions: there are no major differences between the techniques outcomes. When performing a stratification and adjustment for comorbidities, peritoneal dialysis has a equivalent or better prognosis in the nondiabetic group, less comorbidity and younger, almost all the publications, and hemodialysis in diabetics, older and more comorbid groups. The recent studies (including incidents after 2002), concluding a similar behavior for the survival HD: DP. Similarly, age and comorbidity influence the patient's outcomes almost identical to previous studies. In the last decade has seen an improvement in the prognosis of patients on dialysis, more pronounced in PD patients, both in the U.S., and Europe, Australia and in Spain (Andalusia analysis also). Finally, by multivariate analysis, we can show that patient survival on dialysis is much more influenced by conditions at the beginning of the treatment, as age, presence of diabetes or cardiovascular disease, rather than the type of technique of dialysis.  

Recovering activity and illusion: the nephrology day care unit.

Day Care Units are an alternative to hospital care that improves more efficiency. The Nephrology, by its technical characteristics, would be benefit greatly from further development of this care modality. The objectives of this study are to present the process we have developed the Nephrology Day Care Unit in the Puerto Real University Hospital (Cádiz, Spain). For this project we followed the Deming Management Method of Quality improvement, selecting opportunities, analyzing causes, select interventions, implement and monitor results. The intervention plan includes the following points: 1) Define the place of the Day Care Unit in the organization of our Clinical Department of Nephrology, 2) Define the Manual of organization, 3) Define the structural and equipment resources, 4) Define the Catalogue of services and procedures, 5) Standards of Care Processes. Protocols and Clinical Pathways; and 6) Information and Registration System. In the first 8 months we have been performed nearly 2000 procedures, which corresponds to an average of about 10 procedures per day, and essentially related to Hemodialysis in critical or acute patients, the Interventional Nephrology, the Clinical Nephrology and Peritoneal Dialysis. The development of the Nephrology Day Care Units can help to increase our autonomy, our presence in Hospitals, recover the progressive loss of clinical activity (diagnostic and therapeutic skills) in the past to the benefit of other Specialties. It also contributes to: Promote and develop the Diagnostic and Interventional Nephrology; improve the clinical management of patients with Primary Health Level, promote the Health Education and Investigation, collaborate in the Resources Management, and finally, to make more attractive and exciting our Specialty, both for nephrologists to training specialists.

La evidencia actual demuestra una equivalencia de resultados entre las técnicas de diálisis / Current evidence shows that survival outcomes are equivalent for dialysis techniques

Los estudios que han analizado la supervivencia entre hemodiálisis y diálisis peritoneal han sido hasta ahora heterogéneos, con resultados a favor de una u otra técnica, y en muchos casos, confusos, lo que depende también de numerosos factores. Por dicho motivo, es necesario conocer si existen diferencias reales entre las dos modalidades, para situar a la evidencia científica como pilar fundamental en la elección del tratamiento, junto con las circunstancias clínicas de los pacientes concretos, sus preferencias y estilo de vida. Una revisión comparativa de la supervivencia entre técnicas de diálisis no puede eludir unas características o atributos metodológicos básicos, como ser de diseños adecuados, como los estudios observacionales de registros con grandes cohortes, con poblaciones incidentes y no prevalentes, con análisis por intención de tratar, análisis de supervivencia y análisis multivariantes con ajustes de las principales comorbilidades. Se han revisado los nueve estudios clásicos (poblaciones incidentes previas al año 2002) principales, que presentan unas conclusiones similares: globalmente no existen grandes diferencias entre las técnicas, con un comportamiento similar tanto en los grandes registros como en las cohortes prospectivas. Cuando se realizan una estratificación y un ajuste por comorbilidades, la diálisis peritoneal presenta un pronóstico equivalente o mejor en los grupos de pacientes no diabéticos, menos comórbidos y más jóvenes, prácticamente en todas las publicaciones, y la hemodiálisis en los diabéticos, de mayor edad y más comórbidos. De la misma forma, se detallan los resultados de los estudios recientes (que incluyen poblaciones incidentes posteriores al 2002), que llegan a la conclusión de que existe un comportamiento similar para la supervivencia entre hemodiálisis y diálisis peritoneal. De igual manera, la edad y la comorbilidad del paciente influyen en los resultados de forma casi idéntica a lo publicado en los estudios anteriores. En la última década hemos asistido en una mejora del pronóstico vital de los pacientes tratados en diálisis, más importante en los pacientes en diálisis peritoneal, tanto en EE.UU. como en Europa, Australia y también en España (análisis propio en Andalucía). Finalmente, y por medio de análisis multivariantes propios, podemos afirmar que la supervivencia del paciente en diálisis se ve mucho más influida por las condiciones al inicio de la técnica, como la edad, la presencia de diabetes o la enfermedad cardiovascular, que por el tipo de técnica en sí (AU)

Studies that have analyzed survival between hemodialysis and peritoneal dialysis have showed heterogeneous outcomes for both techniques, and often confusing, also dependent on many factors. For this reason, it is necessary to know if there are real differences between the two treatments, to put the scientific evidence as a fundamental pillar in the choice of treatment, along with the clinical circumstances of individual patients, preferences and lifestyle of these. A comparative review of survival among dialysis techniques cannot avoid a basic methodological characteristics or attributes, such as appropriate designs such as observational studies with large cohorts, with incidents and no prevalent populations, with "intent to treat analysis "survival analysis and multivariate analysis with adjustments to the main comorbidity. We studied the nine classical main studies (incidents before 2002), presenting similar conclusions: there are no major differences between the techniques outcomes. When performing a stratification and adjustment for comorbidities, peritoneal dialysis has a equivalent or better prognosis in the nondiabetic group, less comorbidity and younger, almost all the publications, and hemodialysis in diabetics, older and more comorbid groups. The recent studies (including incidents after 2002), concluding a similar behavior for the survival HD: DP. Similarly, age and comorbidity influence the patient's outcomes almost identical to previous studies. In the last decade has seen an improvement in the prognosis of patients on dialysis, more pronounced in PD patients, both in the U.S., and Europe, Australia and in Spain (Andalusia analysis also). Finally, by multivariate analysis, we can show that patient survival on dialysis is much more influenced by conditions at the beginning of the treatment, as age, presence of diabetes or cardiovascular disease, rather than the type of technique of dialysis (AU)

Diez años de diálisis peritoneal en Andalucía (1999-2008): datos epidemiológicos, tipos de tratamiento, peritonitis, comorbilidady supervivencia de pacientes y técnica / Peritoneal dialysis outcome. The Andalusian Registry Peritoneal Dialysis: 1999-2008

En este estudio presentamos todos los resultados derivados del procesamiento de los datos del registro de los pacientes de diálisis peritoneal que iniciaron tratamiento sustitutivo en Andalucía entre enero de 1999 y diciembre de 2008. Toda la información procede del Sistema de Información de la Coordinación Autonómica de Trasplante de Andalucía (SICATA). Se presentan datos demográficos, distribución por provincias, las causas de insuficiencia renal y motivo de elección de la diálisis peritoneal como técnica de tratamiento renal sustitutivo, la situación con respecto al trasplante, datos en relación con el catéter y técnica de diálisis peritoneal, las salidas del programa y sus causas, las peritonitis del año 2008, su evolución y resultado de los cultivos. Presentamos también en el informe datos evolutivos 1999-2008 en cuanto a inclusiones, diabetes, tratamiento con diálisis peritoneal automática e incidencia de peritonitis. Analizamos, por otra parte, la supervivencia global de los pacientes y de la técnica diálisis peritoneal, la comorbilidad al inicio del tratamiento y su impacto en la supervivencia (AU)

In this study we show the results derived from the processing of the data of the Registry of the patients on peritoneal dialysis that initiated renal replacement therapy in Andalucía between January of 1999 and December of2008. All the information comes from the base of the Registry of Renal Patients of the Andalucia´s Health Service. The results show demographic data, distribution by provinces, etiology of the end stage renal disease, reason for election of the peritoneal dialysis, inclusion or not in list of renal transplant, catheter data, with draws and their causes, and peritonitis data of 2008. We also analyze in the report, from 1999-2008: anual incidence, diabetes, automatic peritoneal dialysis and peritonitis incidence. Finally we have studied patient and technique survival and factors affecting mortality on peritoneal dialysis, the initial comorbid conditions and its impact in the patient´s survival (AU)

Indicaciones para el inicio de técnicas de depuración extrarrenal / No disponible

A falta de evidencia científica que nos apoye el inicio de laTRS a partir de una determinada cifra de filtrado glomerular,se pueden extraer ciertas conclusiones cuya aplicaciónen la práctica clínica pueden ser de utilidad. Las recomendaciones que podríamos realizar son:• El inicio programado de la TRS se asocia a un mejor pronóstico del paciente (Fuerza de Recomendación B).• Debe preverse el inicio de la TRS para que el paciente pueda decidir libremente la técnica de TRS (Grado de Recomendación B).• Si el paciente inicia HD con acceso vascular definitivo, su evolución será mejor (Fuerza de Recomendación B).• Cuando el paciente presente alguna indicación clínica de iniciar TRS, esta no debe posponerse (Fuerza de Recomendación A).• El filtrado glomerular es la mejor forma de valoración de la función renal (Fuerza de recomendación B).• En los pacientes con filtrados glomerulares menor de 15ml/min y alguna sintomatología asociada a la uremia no corregible con tratamiento convencional, debería de valorarse el inicio de la TRS (Fuerza de Recomendación C).• Pacientes con filtrado glomerular menor de 6-8 ml/min deberían iniciar TRS aunque estuvieran minimamentes intomáticos (Fuerza de Recomendación C).• Los pacientes con más comorbilidades o de edades extremas(niños, ancianos, diabéticos, cardiópatas,...) podrían beneficiarse del inicio de la TRS antes que otro tipo de pacientes (Fuerza de Recomendación C).• Algunos pacientes, por patologías asociadas, podrían incluso beneficiarse del inicio de la TRS con cifras de filtrado glomerular superiores a 15 ml/min (Fuerza de Recomendación C) (AU)

In view of the lack of scientific evidence to support the initiation of KRT from a specific filtration rate, certain conclusions can be drawn whose application in clinical practice may be useful. There commendations we could make are:• Scheduled initiation of KRT is associated with a better patient prognosis (Strength of Recommendation B).• KRT should be planned in advance so that the patient can freely choose the technique for KRT (Strength of Recommendation B).• If the patient starts HD with a permanent vascular access, his/her course will be better (Strength of Recommendation B).• When the patient has any clinical indication for initiating KRT, this should not be postponed (Strength of Recommendation A).• Glomerular filtration rate is the best way to assess kidney function (Strength of Recommendation B).• Patients with a glomerular filtration rate less than 15 ml/min and any symptom associated with uremia not correctable by conventional treatment should be assessed for the initiation of KRT (Strength of Recommendation C).• Patients with a glomerular filtration rate less than 6-8 ml/min should initiate KRT even if they are minimally symptomatic(Strength of Recommendation C).• Patients with more comorbidities or more extreme ages (children, elderly, diabetics, heart disease patients,...) could benefit from the initiation of KRT before other types of patients(Strength of Recommendation C).• Some patients with associated comorbid conditions could even benefit from the initiation of KRT with glomerular filtration rates above 15 ml/min (Strength of Recommendation C) (AU)

[Indications for starting kidney replacement therapy]. / Indicaciones para el inicio de tecnicas de depuracion extrarrenal.

In view of the lack of scientific evidence to support the initiation of KRT from a specific filtration rate, certain conclusions can be drawn whose application in clinical practice may be useful. The recommendations we could make are: - Scheduled initiation of KRT is associated with a better patient prognosis (Strength of Recommendation B). - KRT should be planned in advance so that the patient can freely choose the technique for KRT (Strength of Recommendation B). - If the patient starts HD with a permanent vascular access, his/her course will be better (Strength of Recommendation B). - When the patient has any clinical indication for initiating KRT, this should not be postponed (Strength of Recommendation A). - Glomerular filtration rate is the best way to assess kidney function (Strength of Recommendation B). - Patients with a glomerular filtration rate less than 15 ml/min and any symptom associated with uremia not correctable by conventional treatment should be assessed for the initiation of KRT (Strength of Recommendation C). - Patients with a glomerular filtration rate less than 6-8 ml/min should initiate KRT even if they are minimally symptomatic (Strength of Recommendation C). - Patients with more comorbidities or more extreme ages (children, elderly, diabetics, heart disease patients,...) could benefit from the initiation of KRT before other types of patients (Strength of Recommendation C). - Some patients with associated comorbid conditions could even benefit from the initiation of KRT with glomerular filtration rates above 15 ml/min (Strength of Recommendation C).

[Guidelines of the Spanish Society of Nephrology. Clinical practice guidelines for peritoneal dialysis]. / Guías Sociedad Española de Nefrología. Guías de práctica clínica en diálisis peritoneal.

In Spain and in each of its autonomous communities, the dialysis treatment of chronic renal disease stage 5 is totally covered by public health. Peritoneal dialysis, in any of its modalities, is established as the preferred home dialysis technique and is chosen by high percentage of patients as their choice in dialysis treatment. The Spanish Society of Nephrology has promoted a project of creation of performance guides in the field of peritoneal dialysis, entrusting a work group composed of members of the Spanish Society of Nephrology a with the development of these guides. The information offered is based on levels of evidence, opinion and clinical experience of the most relevant publications of the topic. In these guides, after defining the concept of << peritoneal dialysis>>, the obligations and responsibilities of the sanitation team of the peritoneal dialysis unit are determined, and protocols and performance procedures that try to include all the aspects that concern the patient with chronic renal disease in substitute treatment with this technique are developed. They propose prescription objectives based on available clinical evidence and, lacking this, on the consensus of the experts' opinions. The final aim is to improve the care and quality of the of the patient in peritoneal dialysis, optimizing in this way the survival of the patient and of the technique. In Spain, as in other neighbouring countries, peritoneal dialysis has an incidence and prevalence that is much lower than that of hemodialysis, ranging in the last evaluation by the Spanish Society of Nephrology between 5 and 24% in the different autonomous communities. The great majority of peritoneal dialysis units form part of the public network of the Spanish state, with special representation as a Satellite Unit or Concerted Center related to the public hospital of reference, on which it must depend.