Opportunities to improve the management of anemia in peritoneal dialysis patients: lessons from a national study in routine clinical practice.

Background: Current guidelines establish the same hemoglobin (Hb) and iron biomarkers targets for hemodialysis (HD) and peritoneal dialysis (PD) in patients receiving erythropoiesis-stimulating agents (ESAs) even though patients having PD are usually younger, more active and less comorbid. Unfortunately, specific renal anemia [anemia in chronic kidney disease (aCKD)] trials or observational studies on PD are scanty. The aims of this study were to describe current aCKD management, goals and adherence to clinical guidelines, identifying opportunities for healthcare improvement in PD patients. Methods: This was a retrospective, nationwide, multicentre study including patients from 19 PD units. The nephrologists collected baseline data, demographics, comorbidities and data related to anemia management (laboratory values, previously prescribed treatments and subsequent adjustments) from electronic medical records. The European adaptation of KDIGO guidelines was the reference for definitions, drug prescriptions and targets. Results: A total of 343 patients (mean age 62.9 years, 61.2% male) were included; 72.9% were receiving ESAs and 33.2% iron therapy [20.7% intravenously (IV)]. Eighty-two patients were receiving ESA without iron therapy, despite 53 of them having an indication according to the European Renal Best Practice guidelines. After laboratory results, iron therapy was only started in 15% of patients. Among ESA-treated patients, 51.9% had an optimal control [hemoglobin (Hb) 10-12 g/dL] and 28.3% between 12-12.9 g/dL. Seventeen patients achieved Hb >13 g/dL, and 12 of them remained on ESA after overshooting. Only three patients had Hb <10 g/dL without ESAs. Seven patients (2%) met criteria for ESA resistance (epoetin dose >300 IU/kg/week). The highest tertile of erythropoietin resistance index (>6.3 UI/kg/week/g/dL) was associated with iron deficiency and low albumin corrected by renal replacement therapy vintage and hospital admissions in the previous 3 months. Conclusion: Iron therapy continues to be underused (especially IV). Low albumin, iron deficiency and prior events explain most of the ESA hyporesponsiveness. Hb targets are titrated to/above the upper limits. Thus, several missed opportunities for adequate prescriptions and adherence to guidelines were identified.

Association of Prescription With Body Composition and Patient Outcomes in Incident Peritoneal Dialysis Patients.

Objective: The nutritional status of patients on peritoneal dialysis (PD) is influenced by patient- and disease-related factors and lifestyle. This analysis evaluated the association of PD prescription with body composition and patient outcomes in the prospective incident Initiative for Patient Outcomes in Dialysis-Peritoneal Dialysis (IPOD-PD) patient cohort. Design and Methods: In this observational, international cohort study with longitudinal follow-up of 1,054 incident PD patients, the association of PD prescription with body composition was analyzed by using the linear mixed models, and the association of body composition with death and change to hemodialysis (HD) by means of a competing risk analysis combined with a spline analysis. Body composition was regularly assessed with the body composition monitor, a device applying bioimpedance spectroscopy. Results: Age, time on PD, and the use of hypertonic and polyglucose solutions were significantly associated with a decrease in lean tissue index (LTI) and an increase in fat tissue index (FTI) over time. Competing risk analysis revealed a U-shaped association of body mass index (BMI) with the subdistributional hazard ratio (HR) for risk of death. High LTI was associated with a lower subdistributional HR, whereas low LTI was associated with an increased subdistributional HR when compared with the median LTI as a reference. High FTI was associated with a higher subdistributional HR when compared with the median as a reference. Subdistributional HR for risk of change to HD was not associated with any of the body composition parameters. The use of polyglucose or hypertonic PD solutions was predictive of an increased probability of change to HD, and the use of biocompatible solutions was predictive of a decreased probability of change to HD. Conclusion: Body composition is associated with non-modifiable patient-specific and modifiable treatment-related factors. The association between lean tissue and fat tissue mass and death and change to HD in patients on PD suggests developing interventions and patient counseling to improve nutritional markers and, ultimately, patient outcomes. Study Registration: The study has been registered at Clinicaltrials.gov (NCT01285726).

High-permeability alternatives to current dialyzers performing both high-flux hemodialysis and postdilution online hemodiafiltration.

Most high-flux dialyzers can be used in both hemodialysis (HD) and online hemodiafiltration (OL-HDF). However, some of these dialyzers have higher permeability and should not be prescribed for OL-HDF to avoid high albumin losses. The aim of this study was to compare the safety and efficacy of a currently used dialyzer in HD and OL-HDF with those of several other high permeability dialyzers which should only be used in HD. A prospective, single-center study was carried out in 21 patients. Each patient underwent 5 dialysis sessions with routine dialysis parameters: 2 sessions with Helixone (HD and postdilution OL-HDF) and 1 session each with steam sterilized polyphenylene, polymethylmethacrylate (PMMA), and medium cut-off (MCO) dialyzers in HD treatment. The removal ratios (RR) of urea, creatinine, ß2 -microglobulin, myoglobin, prolactin, α1 -microglobulin, α1 -acid glycoprotein, and albumin were compared intraindividually. A proportional part of the dialysate was collected to quantify the loss of various solutes, including albumin. Urea and creatinine RRs with the Helixone-HDF and MCO dialyzers were higher than with the other 3 dialyzers in HD. The ß2 -microglobulin, myoglobin and prolactin RRs with Helixone-HDF treatment were significantly higher than those obtained with all 4 dialyzers in HD treatment. The ß2 -microglobulin value obtained with the MCO dialyzer was also higher than that obtained with the other 3 dialyzers in HD treatment. The myoglobin RR with MCO was higher than those obtained with Helixone and PMMA in HD treatment. The prolactin RR with Helixone-HD was significantly lower than those obtained in the other 4 study sessions. The α1 -microglobulin and α1 - acid glycoprotein RRs with Helixone-HDF were significantly higher than those obtained with Helixone and PMMA in HD treatment. The albumin loss varied from 0.54 g with Helixone-HD to 3.3 g with polyphenylene. The global removal score values ((UreaRR + ß2 -microglobulinRR + myoglobinRR + prolactinRR + α1 -microglobulinRR + α1 -acid glycoproteinRR - albuminRR )/6) were 43.7% with Helixone-HD, 47.7% with PMMA, 54% with polyphenylene, 54.8% with MCO and 59.6% with Helixone-HDF, with significant differences. In conclusion, this study confirms the superiority of OL-HDF over HD with the high-flux dialyzers that allow both treatments. Although new dialyzers with high permeability can only be used in HD, they are in an intermediate position and some are very close to OL-HDF.

Diálisis peritoneal automática adaptada: un método de prescripción eficaz, eficiente y seguro / Adapted automated peritoneal dialysis: an effective, efficient and safe prescription method

El objetivo del trabajo es analizar los resultados obtenidos tras la introducción de la modalidad de diálisis peritoneal automática adaptada, usando bicarbonato puro como agente tampón, en un grupo de pacientes en programa de diálisis peritoneal automática convencional. Estudio de diseño cuasi experimental, que se realizó entre los meses de febrero y diciembre de 2013, en la unidad de diálisis peritoneal del Hospital Clínic de Barcelona. Los sujetos de estudio fueron 12 pacientes, 7 mujeres y 5 hombres, de dicha unidad en modalidad de diálisis peritoneal automática convencional. Edad media 58±12 años (rango: 34-71). El estudio consistió en comparar dos modalidades de diálisis peritoneal automática. Se inició el estudio con prescripción de diálisis convencional, durante tres meses, para cambiar a modalidad de diálisis adaptada durante el mismo intervalo de tiempo. Y finalizarlo, con tres meses de pauta de diálisis convencional. Se prescribió el mismo volumen total de líquido de diálisis y tiempo de sesión, para cada paciente en ambas modalidades, variando los volúmenes y tiempos de permanencia en función de la modalidad. Se utilizó solución de diálisis con bicarbonato puro y glucosa 1,5%. Todos los pacientes, con día seco. Se monitorizaron las variables al inicio del estudio, y en cada cambio de prescripción. Los resultados obtenidos en diálisis convencional: Kt/v=2,3±0,2, aclaramiento de creatinina=63±8litros/semana, y ultrafiltración=842±110ml. En diálisis adaptada, Kt/v=2,8±0,2, aclaramiento de creatinina=74±9litros/semana, y ultrafiltración=982±123ml. La diálisis adaptada permite obtener una adecuada eficacia de tratamiento, mejora los parámetros de adecuación de diálisis y ultrafiltración; siendo segura y cómoda para el paciente (AU)

The aim of this study is to analyze results obtained following the introduction of the adapted automated peritoneal dialysis, in a group of patients in conventional automated peritoneal dialysis program using bicarbonate-buffered dialysate. Design trial in experimental phase, which was conducted in the months from February and December 2013, in the unit of peritoneal dialysis in the Hospital Clinic of Barcelona. Study subjects were 12 patients, 7 women and 5 men, in conventional automated peritoneal dialysis modality. Mean age 58±12 years (range: 34-71). The study assessed two automated peritoneal dialysis prescriptions. This study was started with conventional dialysis for three months. Then, dialysis prescription was modified, and adapted was applied during same interval of time. And finally, conventional dialysis for three months. The same total volume of dialysate, the same duration, and the same 1,5% glucose bicarbonate-buffered dialysate, were prescribed in both modalities. Only dwell time and fill volume were modified, when dialysis modality was changed. All patients, on dry day. Variables at the beginning of the study, and at each change of prescription were seldom monitored. Outcomes for conventional dialysis: Kt/v=2,3±0,2, creatinine clearance=63±8l/week, and ultrafiltration=842±110ml. For dialysis adapted, Kt/v=2,8±0,2, creatinine clearance=74±9l/week, and ultrafiltration=982±123ml. Adapted dialysis allows appropriate treatment efficiency, improves adequacy of dialysis and ultrafiltration parameters; being safe and comfortable for the patient (AU)