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Advancing Dialysis Recent Findings: PD first ... what's next?

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Advancing Dialysis Recent Findings: PD first ... what's next?

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Advancing Dialysis Recent Findings: PD first ... what's next?

  1. 1. AdvancingDialysis.org Peritoneal Dialysis Transitions to Hemodialysis Summarized findings of outcomes after patients transition to hemodialysis and interventional considerations Kansal SK, Morfin JA, Weinhandl ED. Survival And Kidney Transplant Incidence On Home Versus In- center Hemodialysis, Following Peritoneal Dialysis Technique Failure. Perit Dial Int. 2019 39:25-34.
  2. 2. AdvancingDialysis.org Background • Peritoneal dialysis utilization has increased since Medicare reimbursement changes in 2009 • Percentage of patients initiating peritoneal dialysis from 2009 – 2016 has grown from 6.4% to 10%1 1USRDS 2018 Annual Data Report. Reference table D1: Percentages & counts of reported ESRD patients: by treatment modality 85% 90% 95% 100% 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Incident Dialysis Patients by Modality PD HD
  3. 3. AdvancingDialysis.org Number of Patients Initiating Peritoneal Dialysis 6,939 6,771 6,525 6,602 7,141 7,755 8,345 9,601 10,733 11,264 11,864 12,095 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 OVER 12,000 PERITONEAL DIALYSIS STARTS IN 2016 1USRDS 2018 Annual Data Report. Reference table D1: Percentages & counts of reported ESRD patients: by treatment modality
  4. 4. AdvancingDialysis.org High Peritoneal Dialysis Therapy Attrition Rates Commonly Reported 1Guo A, Mujais S. Patient and technique survival on peritoneal dialysis in the United States: evaluation in large incident cohorts. Kidney Int Suppl 2003; (88):S3–12. 2Afolalu B, Troidle L, Osayimwen O, Bhargava J, Kitsen J, Finkelstein FO. Technique failure and center size in a large cohort of peritoneal dialysis patients in a defined geographic area. Perit Dial Int 2009; 29(3):292–6. 3Weinhandl ED, Collins AJ. Trend in peritoneal dialysis technique failure in incident dialysis patients. American Society of Nephrology, San Diego, CA, 2018. Therapy Attrition Studies Year Sample Size Findings Guo and Mujais1 2003 >30,000 patients First-year technique failure rates between 18.7% and 20.5% from 1999 to 2001 Afolalu et al.2 2009 5,003 patients 15.6% and 11.9% among large and small centers, respectively, in a regional cohort from 2001 to 2005 Weinhandl ED, Collins AJ3 2016 22,197 patients 19.5 and 20.8 events per 100 patient-years from 2005 to 2009 18.1 and 18.9 events per 100 patient-years from 2010 to 2012
  5. 5. AdvancingDialysis.org 7,016 7,320 7,250 7,274 7,589 7,894 8,493 9,307 10,109 10,675 11,949 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 1Analysis of United States Renal Data System Standard Analysis Files. PD technique failure defined by at least 30 days of HD immediately following PD. MORE ATTENTION NEEDED TO KEEP PATIENTS HOME IN 2015 – NEARLY 12,000 PERITONEAL DIALYSIS PATIENTS TRANSITIONED TO HEMODIALYSIS1
  6. 6. AdvancingDialysis.org • Peritonitis • Catheter failure • Ultrafiltration failure • Inadequate solute clearance • Psychosocial factors • Abdominal complications • Malnutrition Common Complications Resulting in Peritoneal Dialysis Technique Failure1,2 1Kolesnyk I, Dekker FW, Boeschoten EW, Krediet RT. Time-dependent reasons for peritoneal dialysis technique failure and mortality. Perit Dial Int 2010; 30(2):170–7. 2Kansal SK, Morfin JA, Weinhandl ED. Survival And Kidney Transplant Incidence On Home Versus In- center Hemodialysis, Following Peritoneal Dialysis Technique Failure. Perit Dial Int. 2019 39:25-34. Home Dialysis Continuation needing to transition to hemodialysis, transitioned to home hemodialysis2 >4% of patients
  7. 7. AdvancingDialysis.org Planned Transitions to Hemodialysis may Improve Outcomes • Fewer “crashes” into hemodialysis1 • Improvements in fistula placement2 • Less occurrence of fluid overload3 • Reduced hospitalizations and fewer hospitalization days1 • Improved survival and lower risk of death1 1Kansal SK, Morfin JM, Weinhandl ED. Survival and Kidney Transplant Incidence on Home versus In-Center Hemodialysis, Following Peritoneal Dialysis Technique Failure. Perit Dial Int. January-February 2019 vol. 39 no. 1 25-34. 2Boissinot L, et al. Is transition between peritoneal dialysis and hemodialysis really a gradual process? Perit Dial Int 2013; 33(4):391–7. 3Bakris GL, et al. Intensive hemodialysis, blood pressure, and antihypertensive medication use. Am J Kidney Dis2016; 68(5s1):S15–23.
  8. 8. AdvancingDialysis.org Reported Outcomes in Patients that Transitioned from Peritoneal Dialysis to Hemodialysis1 1Kansal SK, Morfin JM, Weinhandl ED. Survival and Kidney Transplant Incidence on Home versus In-Center Hemodialysis, Following Peritoneal Dialysis Technique Failure. Perit Dial Int. January-February 2019 vol. 39 no. 1 25-34 Transplantation Incidence (4-year follow-up) Survival (4-year follow-up) Hospitalization Days Hemodialysis Setting Study Population 33,452 peritoneal dialysis patients transitioned to hemodialysis 521 patients to Home HD (3.8%) 9.1 hospitalization days during transition 70.1% survived 28.8% transplanted 32,931 patients to In-center HD (96.2%) 18.5 hospitalization days during transition 62.4% survived 22.4% transplanted
  9. 9. AdvancingDialysis.org • 24% lower risk of death in transitions to home hemodialysis vs. in-center hemodialysis • Risk of death varied significantly based on Medicare coverage: ‒ 43% lower risk of death in non- Medicare patients ‒ 8% lower risk of death in Medicare patients • ESRD duration at the time of PD therapy attrition was 1.4 years greater in home hemodialysis patients with vs. without Medicare Lower Risk of Death in Transitions to Home Hemodialysis1 Hazard ratios of death for home hemodialysis versus matched in-center hemodialysis patients. HHD = home hemodialysis; IHD = in-center hemodialysis. Hazard ratio 0.76 (0.65–0.90) 1Kansal SK, Morfin JM, Weinhandl ED. Survival and Kidney Transplant Incidence on Home versus In-Center Hemodialysis, Following Peritoneal Dialysis Technique Failure. Perit Dial Int. January-February 2019 vol. 39 no. 1 25-34
  10. 10. AdvancingDialysis.org 62.4% 70.1% • 4-year survival differences between home hemodialysis and in-center were 7.7% overall • Survival differences varied by Medicare coverage: ‒ 12.5 point improvement 4-year survival in non-Medicare patients ‒ 4.0 point improvement 4-year survival in Medicare patients • ESRD duration at the time of PD therapy attrition was 1.4 years greater in home hemodialysis patients with vs. without Medicare Improved Survival in Transitions to Home Hemodialysis1 Survival in non-Medicare peritoneal dialysis patients transitioned to home hemodialysis and In-center hemodialysis. 1Kansal SK, Morfin JM, Weinhandl ED. Survival and Kidney Transplant Incidence on Home versus In-Center Hemodialysis, Following Peritoneal Dialysis Technique Failure. Perit Dial Int. January-February 2019 vol. 39 no. 1 25-34
  11. 11. AdvancingDialysis.org • Transplantation incidence differences between home hemodialysis and in- center were 6.4% overall • The likelihood of transplant was 36% higher with home hemodialysis versus in-center, and varied greatly by Medicare coverage ‒ 86% higher likelihood of transplantation in non-Medicare patients ‒ No statistical difference in likelihood in Medicare patients Improved Transplantation Incidence in Transitions to Home Hemodialysis1 Cumulative incidence of kidney transplant among home hemodialysis and matched in-center hemodialysis patients following peritoneal dialysis technique failure 1Kansal SK, Morfin JM, Weinhandl ED. Survival and Kidney Transplant Incidence on Home versus In-Center Hemodialysis, Following Peritoneal Dialysis Technique Failure. Perit Dial Int. January-February 2019 vol. 39 no. 1 25-34 22.4% 28.8%
  12. 12. AdvancingDialysis.org Planning for Transitions to Hemodialysis: Proposed Clinical Indicators When the Peritoneal Dialysis to Home Hemodialysis Therapy Transition Makes Sense. Multidisciplinary, Quality Improvement Team Final Report on file. 2014. Accelerate education and intervention Waning Adequacy Hospitalizations Physical Appearance Qualitative Concerns Medical Complications Vintage Malnutrition
  13. 13. AdvancingDialysis.org Transition Planning Overview When the Peritoneal Dialysis to Home Hemodialysis Therapy Transition Makes Sense. Multidisciplinary, Quality Improvement Team Final Report. 2014. Stage 1 Healthy PD Adjustment Prepare for the future even as they begin home dialysis Educate on modality options, create Life Plan Stage 2 PD @ Risk Re-evaluation Closely monitor for signs of decline as the journey continues Re-assess if therapy is meeting needs, re-educate on modality options Stage 3 PD Decline Imminent Transition Proactively plan to keep them at home, if that’s what they want Establish access, train on chosen modality
  14. 14. AdvancingDialysis.org Recommended Indicators to Manage Planned Patient Transitions to Hemodialysis Stage 1: Healthy PD Stage 2: PD @ Risk Stage 3: PD Decline Adjustment • Peritonitis episode • Albumin level < 3.5 • Life-changing events (family, change in social support, depression) • PD vintage > 5 years • Transplant waiting list > 2 years When the Peritoneal Dialysis to Home Hemodialysis Therapy Transition Makes Sense. Multidisciplinary, Quality Improvement Team Final Report. 2014.
  15. 15. AdvancingDialysis.org Recommended Indicators to Manage Planned Patient Transitions to Hemodialysis Stage 1: Healthy PD Stage 2: PD @ Risk Stage 3: PD Decline Re-evaluation • Declining or loss of Residual Renal Function • Albumin level <3.0 ‒ or decrease of .2 every 2 months • 3 or more infections within a year ‒ Ex. peritonitis, ES, tunnel ‒ 1 very severe episode (fungal, sclerosing) • <1 L/day of UF combined with residual and therapy • Increasing number of exchanges • Use of Icodextrin • Declining adequacy ‒ Kt/V<1.7 after Rx adjustments • Decline in physical appearance and or abilities When the Peritoneal Dialysis to Home Hemodialysis Therapy Transition Makes Sense. Multidisciplinary, Quality Improvement Team Final Report. 2014.
  16. 16. AdvancingDialysis.org Recommended Indicators to Manage Planned Patient Transitions to Hemodialysis Stage 1: Healthy PD Stage 2: PD @ Risk Stage 3: PD Decline Imminent Transition • 3 or more indicators, plus the following: • Medical complications • Ex. cardiovascular decline, fractures, hernias, leaks • >3 hospitalizations in 1 year (ICU) When the Peritoneal Dialysis to Home Hemodialysis Therapy Transition Makes Sense. Multidisciplinary, Quality Improvement Team Final Report. 2014.
  17. 17. AdvancingDialysis.org Key Takeaways FINDING1 • Keeping patients on a home home modality offers better outcomes • PD patients transitioning to hemodialysis already are accustomed to managing treatment at home RECOMMENDATION1 • Planning modality transitions, with the aim of keeping patients home, should be a core strategy as the dialysis patient population grows • Leverage patient knowledge of chronic disease, self-management at home ‒ Previously trained to manage supplies, interface with a dialysis cycler and aseptic techniques and supplies When the Peritoneal Dialysis to Home Hemodialysis Therapy Transition Makes Sense. Multidisciplinary, Quality Improvement Team Final Report. 2014.
  18. 18. AdvancingDialysis.org Broader context as summarized by Dr. José Morfín: UC Davis School of Medicine • Increased hemodialysis treatment frequency may be particularly important for peritoneal patients, particularly after transitioning to hemodialysis • Transiting to more frequent home hemodialysis may be especially helpful for patients with: ‒ Deteriorating cardiac status (due to volume expansion) ‒ Rising blood pressure ‒ Worsening left ventricular hypertrophy • The most practical setting that conforms to increased treatment frequency is home • Encouraging the transition from peritoneal dialysis to home hemodialysis is an evidence-based approach and we have 12,000 (or more) chances each year to make this transition happen Dr. José Morfín is an Associate Professor at UC Davis School of Medicine and is the Medical Director of Home Dialysis Services at Satellite Wellbound in Sacramento, California. Dr. Morfín launched his first home program in 2009 and in 2017, launched Optimal Transitions™—A first-of-its-kind program that provides dialysis patients and their families the time, support and resources needed to select the right dialysis therapy for them. Dr. Morfín is a member of NxStage Medical’s Scientific Advisory Board.
  19. 19. AdvancingDialysis.org About this presentation This presentation is one in an ongoing series focused on recent articles, clinical findings or guidelines related to issues affecting dialysis patients. AdvancingDialysis.org is dedicated to providing clinicians and patients with better access to and more awareness of the reported clinical benefits and improved quality of life made possible with home dialysis, including more frequent, solo, more intensive, and nocturnal therapy schedules. For more information, visit AdvancingDialysis.org AdvancingDialysis.org is a project of NxStage Medical, Inc.
  20. 20. AdvancingDialysis.org Risk and Responsibility All forms of hemodialysis, including treatments performed in-center and at home, involve some risks. When vascular access is exposed to more frequent use, infection of the site, and other access related complications may also be potential risks. In addition, there are certain risks unique to treatment in the home environment. Patients differ and not everyone will experience the reported benefits of more frequent hemodialysis. Certain risks associated with hemodialysis treatment are increased when performing solo home hemodialysis because no one is present to help the patient respond to health emergencies. Certain risks associated with hemodialysis treatment are increased when performing nocturnal therapy due to the length of treatment time and because therapy is performed while the patient and care partner are sleeping.
  21. 21. AdvancingDialysis.org www.AdvancingDialysis.org © 2019 NxStage Medical, Inc.

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