Dear All Suppose you have the choice to give a cadaveric kidney (donor is 67 years old, hypertensive, eGFR before retrieval is 63 mls/min) to one of 2 potential recipients. Both are similar to in comorbidities and the same age, but one oh HD and the other on PD. Which one would you select? The one on HD or the one in PD and why?
I will give it to HD patient as he is at higher risk for cardiovascular disease, dialysis access failure and many other HD complications that increase the more time he spend on HD but PD PD patients had less complications and the longevity of PD time might not affect the out come of TX
This cadaveric kidney is considered an ECD kidney (equivalent to high KDPI). The one- and 2-years allograft survival is markedly lower for this allograft category, as illustrated in the attached figure (1). Therefore, I will try to avoid the additional higher risk of DGF noted with recipients on haemodialysis. DGF has a negative impact on the kidney allograft outcome.
I would recommend offering this allograft to the PD patient if he accepts to receive a marginal kidney.
I would choose the PD patient. The PD patient had lower incidence of DGF and had better residual kidney function. Also I would consider dual kidney transplantation.
A PD patient would be better choice due to decreased rate of DGF (as the donor is marginal one, the chances of DGF are high and it could further rise in HD patient). A dual kidney transplant would be a better option.
I will select the patient on PD as the provided graft is from a marginal donor and in PD patient there is a lower rate of DGF( which is a common problem with marginal kidneys) as compared to HD patients, better volume status on PD patients, better patient and graft survival on PD patients, still dual kidney transplantation is an option if the patient accept the idea and if his anatomical and surgical condition allow.
This donor is considered a marginal donor ( ECD ) so inorder to improve outcomes and decrease incidence of DGF , I would prefer to give him to the PD patient
I will offer the kidney to patient on PD.
the justification for my choice:
both patients have similar comorbidities so nothing preferred one patient over the other regarding the choice.
patient on PD do well post transplant and having less post transplant events in comparison to patients on maintenance HD ( apart from risk of serious infection like Peritonitis which is more encountered in Rx treated with PD in pre-transplant period).
the only thing that may change my decicision to offer the kidney to the patient on maintenance HD is that patient on PD has more life expectancy and waiting length than HD patient, in other words PD patient can wait more than HD patient.
I will choose the PD patient
because the donor already have marginal kidney and choosing HD patient will lead to increase the risk of graft failure
PD patient will have better graft outcomes and patient survival
It is difficult for me to make a decision and select between them only based on being on HD or on PD. I will consider other factors in both of them, such as duration of stay on HD or PD, presence of access failure or any problem with catheters, and the adequacy of dialysis.
If the situation is exactly similar between them and there isn’t any urgency or emergency for kidney transplantation, I will select patient on PD, because of lower risk of DGF and better patient survival.
Based on the comorbidities of the donor, kidneys are considered from the expanded criteria donor. The decision is not easy. In the context of high risk of delayed graft function, given the donation of marginal cadaveric kidney, I will consider patient with less additional risks for DGF. But in this old age we have to take into account the risk of catheter infection/peritonitis, allograft thrombosis and their outcomes especially in the postoperative period. In the settings of same age and comorbidities, I would discuss the risks and benefits of marginal kidneys with the patients, and If both are accepting the risk I would offer it to the PD patient, but both are still candidates.
This is DD transplant with marginal donor by age and comorbid with the current GFR , in this case there is high risk of DGF anyway for both with increased chance infection in case of use of PD catheter post transplantaion as access for dialysis , in that case may be logical such marginal donor will go to HD recipient as his survival rate on waiting list will be lower compaired to PD Patient with preserved kidney function
To the HD patient as he is at higher risk for CVD and dialysis related complications with poorer outcome in comparison with PD patient , while the other patient being on PD modality may indicate better residual kidney function than the HD patien , also as the transplanted graft is a marginal graft ( ECD) and the risk of graft thrombosis is higher in PD patients , thus itis better to give it to the HD patient.
Dear All Thank you very much for your reflection. This question represents a grey area in transplantation. It depends on your justifications. I do not feel (no enough evidence) regarding the thombogenicity of PD.
I will chose the PD patient for the following reasons (all mentioned)
PD patient has residual functioning can tolerate a protracted course of DGF which is quite expected from this marginal kidney. The patient most properly passing urine and helps to protect his against fluid overload
His residual function also may contribute the function of the newly transplanted kidney initially. The first few weeks post-transplantation are very crucial.
HD who is old may suffer a complicated postoperative course if this kidney did not work straight away (expected to have high DGF rate).
PD patients has better outcomes with DGF .. and residual kidney function.
This considered marginal kidney doner so we dual tx must be in consideration .
I would select PD one .
Due to :
1- Better preservation of residual kidney functions on PD.
2- Better patient survival who is predominately on PD prior to transplantation.
3- Expenditure is less in PD than HD.
4- Risk of TB and chronic hepatitis C in 90 days after TX those who are on HD prior to TX.
5- Better graft outcomes in patient predominant on PD prior to TX.
6-DGF is less likely with PD due to daily PD provide patients with less likely to be hyperkalaemic , overloaded or need additional treatment prior to TX.
It’s better for both to receive kidney transplantation even ECD as renal transplantation has better survival and quality of life than those who still in waiting list .
i will prefer to give this kidney for PD pt , as he has lower rate of DGF, CV complications also there is residual kidney function which will help the transplanted kidney….
This donor becomes ECD (expanded criteria donor). I would prefer to give this ECD to patient on PD as they would better tolerate the DGF which is anticipated after transplant as they would have better native urine output and less immunogenic as compared to HD patients lowering the further risk of immune activation
i will choose the reciepient who was on PD . because this graft has high risk of delayed graft function and the patients on HD also has higher risk foe delayed graft function compared to HD .
PD patients having residual kidney function ;making PD a reasonable option
Akram Abdullah
3 years ago
Pre-emptive kidney transplantation is the best option and is associated with the best patient and graft survival. All patients with CKD will need renal replacement therapy at some point in time. Adequate, counseling is needed regarding the type of dialysis PD vs HD and also in the mean time referral to transplant center for the best option for him. Peritoneal dialysis has many advantages and it can be done at home. It reserves residual renal functions, avoidance of recurrent hospital visits, least interference with cardiac status, less microinflammation, and serves as the best bridge therapy before transplantation. Data from USRDS in 2015 suggest that HD patients have higher mortality as compared to PD. Overall survival probability is better in PD after 3 years of PD initiation as compared to HD. With regards to the hospitalization rates for PD and HD, HD patients have higher initial hospitalization rates as compared to PD patients, who get admitted later due to catheter-related Peritonitis. In the Pre transplant period, PD is always better as it is associated with lower costs as compared to HD . In terms of DGF: HD patients will be dialyzed before Transplant and some form of volume depletion may contribute to decreasing perfusion pressure of transplant kidney. Graft thrombosis may be higher in PD patients as compared to HD patients. In PD patients their hypercoagulable state is unmasked and it is revealed only at the time of transplant. Overall PD patients have a lower risk of hospitalizations, a lower risk of infection as compared to HD. PD patients and incenter HD have the same mortality as per studies from the USRDS data. However, in terms of post-transplant outcomes, PD patients have better graft and overall survival with less incidences of DGF.
Mohammed Sobair
3 years ago
Abstract
The population of patients with end stage renal disease (ESRD) is increasing,
lengthening waiting lists for kidney transplantation. Majority of the patients are not able
to receive a kidney transplant in timely manner even though it is well established that
patient survival and quality of life after kidney transplantation is far better when
compared to being on dialysis. A large number of patients who desire a kidney transplant
ultimately end up needing some form of dialysis therapy. Most of incident ESRD patients
choose hemodialysis (HD) over peritoneal dialysis.
Introduction:
transplantation is the ideal form of RRT in patients ESRD.
Preemptive kidney transplantation is ideal for many, as it is associated with lower rates
of acute rejection, increased allograft and patient survival.
. However, a preemptive kidney transplant (17% overall) is not always possible for many
patient.
ESRD DEMOGRAPHICS:
As per the United Network for Organ Sharing, in 2017, there
were 94897 patients on the waiting list.
ESRD OUTCOMES :
In recent times, success of PD technique has improved and risk of peritonitis had
dwindled. Review of the data also suggests that as per the USRDS.
Delayed graft function for kidney transplant:
DGF defined as need of dialysis within seven days of kidney transplantation, occurred in 21.3% of patients .
Numerous studies have investigated DGF rates and have found mostly similar to lower
rates of DGF in PD versus HD patients.
Thrombosis of the allograft:
Comparing prior HD to PD In contrast to DGF, thrombosis of the graft may be
surprisingly higher in the PD .
Risk of infection and diabetes mellitus after transplantation
Patients receive multiple immunosuppressive medications in post-transplant period
which increases the risk of infections. Infectious complications related with PD catheter
after transplantation remain a concern also PTDM common with PD.
Mohamed Essmat
3 years ago
Introduction:–Kidney transplantation is the ideal form of renal replacement therapy in patients with end-stage renal disease . -Preemptive kidney transplantation is associated with lower rates of acute rejection and increased allograft and patient survival. -A lot of patients are removed from a waiting list for renal transplant due to death or decline in medical condition. -The average time on the waitlist for a deceased donor is quite variable depending on age, blood group, panel reacting antibodies, history of prior transplantation. – According to several studies PD is better as a transient therapy to renal transplantation than HD . ESRD demographics -In the USA, In –center HD is the most common modality of renal therapy than PD while in other countries like Qatar, Mexico, New Zealand, Thailand PD is more used than HD. -PD is the a better form of RRT than HD because of its flexibility, autonomy, care satisfaction, better preservation of renal function, better hypertension control, lower intradialytic hypotension episodes, low risk of dementia, slower cognitive decline, better anemia management, and lower proportion of patient needing erythropoietin. -Expenditure of PD is better than HD but much higher than the cost for transplant patients and the overall adjusted survival probability of incident patients on PD better than patients on HD. -HD and PD patients have similar hospitalization rates but almost double those of patients with kidney transplantation. Delayed graft function for kidney transplant: -It is defined as the need for dialysis within the 1st seven days of kidney transplantation.
-DGF is lower in PD than HD as PD patients are not likely to be volume depleted so ensure adequate perfusion of allograft, and there are differences in immune function and cytokine production. Thrombosis of allograft : -Thrombosis of graft is higher in the PD patient compared with HD patient , may be due to the relative -PD patients have increased Pro-coagulant factors and hemo-concentration as compared to HD patients. Risk of infection and diabetes mellitus after transplantation: -Infectious complications related to PD catheter may occur after transplantation. – DM is dependable on multivariable factors but not evidenced to be related to a specific dialysis modality. Long-term outcome: -Preemptive kidney transplant was associated with better patient’s survival and graft’s survival as well. -PD is associated with better allograft and patient survival than HD patients.
Abdullah Raoof
3 years ago
patient survival and quality of life after kidney transplantation is far better when compared to being on dialysis.
some studies have favored PD as a better choice of pre-transplant dialysis
modality than HD.
Preemptive kidney transplantation is ideal for many, as it is associated with lower rates of acute rejection, increased allograft and patient survival .
for the patients who plan on receiving a transplant after starting dialysis, PD can be a better bridge therapy to kidney transplantation, especially, when a lot of patients initiating hemodialysis (HD) via catheters are associated with adverse outcomes.
Among all prevalent ESRD patients,
63.2% of patients were on HD,
29.6% had a functioning kidney transplant and
only 7% of patients were utilizing PD.
PD is an acceptable and could be a preferred form of RRT owing to
flexibility,
autonomy,
care satisfaction,
better preservation of residual renal function,
better hypertension control ,
lower intradialytic hypotension episodes,
lower risk of dementia,
slower cognitive decline
adjusted mortality rate for patients on HD was slightly higher than patients on PD
another study showed two important findings, mortality rates for PD patients were much lower as compared to HD and secondly elderly patients tend to do better on PD versus HD.
overall adjusted survival probability of incident patients on PD is much
better at the end of 3 years than patients on HD
Delayed graft function for kidney transplant
DGF defined as need of dialysis within seven days of kidney transplantation,
Numerous studies have investigated DGF rates and have
found mostly similar to lower rates of DGF in PD versus HD patients. .
A large study investigated this question also found a lower incidence of DGF
among PD patients .
Thrombosis of the allograft: Comparing prior HD to PD
In contrast to DGF, thrombosis of the graft may be surprisingly higher in the PD
patients as compared to their HD counterparts
Risk of infection and diabetes mellitus after transplantation
incidence of post-operative infections after
transplantation was found to be increased in PD patients as compared to HD patients
. another study found higher risks of peritonitis and urinary tract infection in PD patients
after transplantation .
Long-term outcome: Comparing those on prior HD vs PD
Preemptive kidney transplant without dialysis was associated with excellent patient
survival compared to HD prior to transplant . another group reported better graft outcomes in patients previously treated predominantly with PD as compared to HD patients
Balaji Kirushnan
3 years ago
Introduction:
Ideally Pre emptive kidney transplantation is the best fo CKD V patients and is associated with best patient and graft survial. It has been reported to have better survival rates as compared to dialysis and transplantation after dialysis too. However worldwide the rates of pre emptive transplants are very low (around 17%) due to poor patient acceptance, lack of patient education and counselling.
All patients of CKD will need renal replacement therapy at some point of time. Adequate, multiple episodes of counselling are needed regarding the pros and cons of PD vs HD. Infact patients can even be introduced to another patient on HD and PD to interact and understand the process better.
Peritoneal dialysis has many advantages and it can be done from home. It reserves residual renal functions, avoidance of recurrent hospital visits, least interference with cardiac status, less microinflammation and serves as the best bridge therapy before transplantation.
ESRD outcomes of HD and PD:
Age adjusted mortality data from USRDS in 2015 suggest that HD patients have a higher mortality as compared to PD. It was clear from studies that PD patients did better as compared to HD patients in the initial few days (first 90 days). Elderly patients do better on PD as compared to HD.
Overall survival probability is better in PD after 3 years of PD initiation as compared to HD. With reagrds to the hospitalization rates for PD and HD, HD patients have a higher initial hospitlization rates as compared to PD patients, who get admitted later due to catheter related UFF and Peritonitis. in the Pre transplant period, PD is always better as it is associated with lower costs as compared to HD barring the initial admission cost for PD.
Delayed Graft function and Kidney transplant:
The available evidences are contradictory. Few studies have shown no difference in the overall outcome of PD and HD towards delayed graft function. Few studies have shown PD patients to have less incidence of DGF due to better preservation of residual renal function, less immune activation due to “natural” membrane as compared to synthetic membrane exposure in HD, lead time bias in PD patients being more motivated and allowing access to transplant, better volume status prior transplant as they usually are allowed normal fluid. HD patients on the other hand will be dialyzed before Transplant and some form of volume depletion may contribute to decrease perfusion pressure of transplant kidney.
Graft thrombosis and PD vs HD:
thrombosis of the graft maybe higher in PD patients as compared to HD patients. HD patients are often heparinized so making them less susceptible to thrombosis. In PD patients their hypercoaguable state is unmasked and it is revealed only at the time of transplant. PD patients are transferred after graft/AVF thrombosis in HD so studies would have shown PD patients to be ironically more thrombogenic. PD patients are proven to have higher levels of apolipoprotein A, factors II,IV,X,IX due to constant stimulation of the peritoneal membrane by glucose based fluids.
Risk of infection after Transplantation:
Patients with DGF who need transient PD after transplant have a higher chance of wound infection and skin leak. Studies have also shown exit site infection even if the catheter was not used.
no major difference in the incidence of PTDM was noted.
Overall PD patients have lower risk of hospitalizations, lower risk of infection as compared to HD. PD patients and incenter HD have the same mortality as per studies from the USRDS data. However in terms of post transplant outcomes, PD patients have better graft and overall survival with less incidences of DGF. The conflicting rates in various studies are due to number of patients in the US being more on HD as compared to Europe, Australia and Canada where PD is very popular.
Practices followed in our country:
The choice is driven by patient and care giver education level, their accessibility to hospital and dialysis centers and the insurance coverage if any.
We follow a practice to initiate elderly patients with cardiac dysfunction on PD as they tolerate it better. If the family accepts, a caregiver is usually trained in the hospital by our trained PD staff over 2 weeks before discharge. They are then followed up daily by them over phone and complications are reported to us. It is sad that PD has become a dialysis only by the rich as most of the insurance companies do not give coverage for out patient PD. It is very vital that they recognize this form of dialysis to get covered by the insurance. Hemodialysis is accepted by many others as it is easily available and accessible and most importantly covered by insurances.
Ahmed Omran
3 years ago
Renal Tx offers better patient survival and quality of life compared with dialytic therapy. Due to of lack ,its timely feasibility dialytic therapy is used s bridge to Tx and PD is underutilized in spite of being favored to HD .Causes explaining this are different including for example, physician experience ,patient culture ,PD related issues with easier availability of HD and its profitability.
ESRD OUTOMES
Survival probability at 3 years is better with PD than HD .PD is superior to HD financial wise but both PD and HD are inferior to Tx .Hospitalization rate is the same in both and PD and HD and double that in case of Tx .PD has lower mortality than HD.PD patients are more likely candidates for Tx due to underutilization.
Delayed graft function for kidney transplant
Better outcome regarding DGF is in favor of PD .Some explanations include better residual kidney function ,immunogenic aspects ,with different response to ischemic kidneys in PD vs HD. Regular HD before Tx is a major contributor to DGF .Absence of hyperkalemia in PD abates need for additional HD session before Tx .Adequate volume status in PD leads to good perfusion to the allograft ;the reverse applies for HD .Pre Tx HD counter the beneficial effect of intra-op aggressive hydration on DGF.
Thrombosis of the allograft
Some studies support increased thrombosis in allograft in cases of PD due to various causes while others do not.
Risk of infection and DM after Tx
Post op infections increased in PD comparted with HD .In contrast ,risk of new onset TB and chronic hepatitis C are increased in HD.
Risk factors of for PTDM are not related to dialytic modality .However, PD was found to be associated with PTDM in univariate analysis but not in a multivariate analysis in another study.
Long term outcome
Pre-emptive Tx has the best outcome among different RRT options .Survival is better in case of PD compared with HD .HD dialyzer membrane could have deleterious immunogenic impact so increasing risk of graft loss. Cardiovascular mortality is lower in PD .Lack of deserved interest in OD among medical care givers affects patient culture and consequently his preferences and actual use to be directed to patient education for better care and outcome. of RRT option .Efforts are needed .
In Saudi Arabia, PD mainly available in governmental centers; aforementioned explanations stand behind that pattern of practice especially patient culture as relate companies supplies materials , training for doctors and patients together with necessary technical support
AMAL Anan
3 years ago
Kidney transplantation is ideal form of renal replacement therapy as it is provide best quality of life and for patient survival than being on dialysis .
However dialysis consider as a bridge therapy to those who plan to receive transplant or on waiting lists.
In contrast to USA , PD is under-utilised due to lack of experience,inadequate training, comfort with HD and other factors may related to patient.
PD is an acceptable and could be a preferred form of RRT due to flexibility, autonomy, care satisfaction .better preservation of residual renal function ,better hypertension control
, lower intradialytic hypotension episodes
, lower risk of dementia, slower cognitive decline.
better anemia management with lower doses of erythropoietin stimulating agents, and lower proportions of patients needing ESAs.
ESRD OUTCOMES :
*Studies done to patients started renal replacement therapy with HD shown that mortality rates in patients
< 65 years of age decreased in comparison to patients aged ≥ 65 years . But to those who started renal replacement therapy with PD , mortality rate increased in both patients aged less or more than sixty five years.
* survival probability on PD much better at end of 3 years than patients on HD .
* Expenditure of PD is better than HD and HD is highly cost than TX.
* hospitalisation rates is similar in both HD and PD but double in kidney transplantation.
~ Delayed graft function for TX :
DGF is need for dialysis for 7 days of TX .
* low incidence of DGF with PD than HD.
* PD is protected against some DGF with haemoglobin (12-13 g/d).
* Increased risk of wound infection and leakage in PD than HD .
* Shortened length of hospitalisation and lesser time requiring for dialysis post operatives in PD than HD.
* GFR is the same within 1 month , 6 month or 1 years in both HD and PD.
* HD is more related to DGF than PD as pd provide daily dialysis , so patient is less likely to be hyperkalaemic or overloaded with less requirement to additional treatment prior to TX.
* Thrombosis of allograft may be higher in PD than HD due to moderate non specific inflammatory cells harvesting when the peritoneal membrane exposed to dialysis solution , this leads to macrophage activation and increase presence of thromboplastin and plasminogen activator in peritoneal cavity.
* Risk of infection is higher with PD than HD , as PD catheter increase risk of extra-site infection and peritonitis with risk of leakage of dialysate fluid from surgical incision , so better to remove PD catheter if there is no longer needed.
* On other side , high risk of new onset TB and chronic hepatitis c in patients after 90 days of TX in those treated with prior HD.
~ Long -term outcomes in PD vs HD:
* Better graft outcomes in patients previously treated with PD in comparison to HD.
* High risk of death censored graft failure in multivariate analysis in HD in comparison to PD after 10 y of follow up.
* Better recipient survival who on predominant PD prior to TX .
* Lower post post transplant mortality on those with preceding PD than HD , this may due to immunogenicity of HD membrane.
* PD patients are better prepared with increased access transplantation care both pre and post .
.
Ramy Elshahat
3 years ago
Choice of dialysis modality prior to kidney transplantation: Does it matter?
ESRD has 3modalities for RRT which are HD,PD and kidney tranplantation.
Kidney tranplantation is ideal therapy regarding multiple aspects like mortality,morbidity, quality of life and financial burden in comparison to other modalities.
There are agap between time of renal transplantation and patient need for RRT in which patient will start another modality such as HD or PD and patients are admitted to waiting list with median 4y waiting for newly listed patients according to SRTR registry. a preemptive transplantation not exceeding 17% of all CKD patients which is ideal in many aspects loke rate of rejection, patient and graft survival.
Peritoneal dialysis is more physiological process associated with better patient quality of life,less hypovolemic and hypotension episodes ,lower risk of dementia and cognitive disorders, better anemia and hypertension control but this modality is underutilized because
1) physician specific:lack of experience, inadequate training, comfort e HD and difficult acute line insertion.
2) patient specific: lack of education, burden of therapy,age and comorbidities.
Modality specific: concern about mortality,solute clearance, peritonitis and treatment failure
ESRD outcomes
1)Mortality rate: slightly higher in HD specially in elderly patients
2)Expenditure:PD(75140$)HD(88750$)RTX(34084$)per patient per year
3)Hospitalizations: similar but double kidney tranplantation
Kidney tranplantation outcome
1)DGF:after adjustment of multiple clinical covariates,PD lower than HD in risk of DGF this because PD patients have better anemia control,lower risk of hypovolemia or hyperkalemia,less cytokines and good residual kidney function
2) infection:higher in PD than HD but one year survival and graft loss related to infection are the same.
Thrombosis: PD more risk of thrombotic event than HD and maybe due to no AV fistula to discover thrombotic tendency ,PD patients shifted from HD after failed access after its thrombosis and increase procoagulation factors in PD as compared to HD
Infection PD associated with increase risk of peritonitis,exit site infection and leakage of dialysate from surgical incision it’s better to remove PD catheter once there is no reason to keep it on the other hand HD associated with increase risk of TB and chronic HCV
PTDM univariate analysis but not multi variety analysis showed PD associated with increase risk of PTDM
Long term outcomes:premptive is the best regarding CVS mortality and graft survival but long term graft survival after PD and HD is mixed and after controlling for multiple varieties HD higher in graft failure and patient mortality.
So current evidence favor PD over HD regard lower risk of hospitalization, Expenditure and mortality and associated with lower DGF and CVS mortality but increase in risk of thrombosis and infection
Dialysis modality has impact on renal transplantation and preemptive transplantation should be encouraged
My own experience about PD pre-transplant is very limited as this modality nearly not available.
Ahmed mehlis
3 years ago
●Preemptive is the best modality for ESRD
●preemptive kidney transplant (17%
overall) is not always possible for many reasons:
disparities in health insurance, race/ethnicity, patient education level,
socioeconomic status, access to healthcare, diabetes status and regional variations.
●PD
PD is an acceptable and could be a
preferred form of RRT owing to flexibility, autonomy, care satisfaction, better
preservation of residual renal function, better hypertension control, lower intra-
dialytic hypotension episodes, lower risk of dementia, slower cognitive decline
,better anemia management with lower doses of erythropoietin stimulating agents
(ESA) and lower proportions of patients needing ESAs
. It is largely underutilized inthe USA due to variety of reasons which have been explored by many researchers andfound causes to be multifactorial which were physician specific (lack of experience,inadequate training, comfort with HD); patient specific (lack of adequate PD
education, health literacy, burden of therapy, age, comorbidities); modality specific
(concerns for mortality, solute clearance, peritonitis, treatment failure, regulatory
issues on PD fluid, easy availability of HD); and financial incentives for HD units.
●mortality rates for PD patients were much lower as compared to
HD and secondly elderly patients tend to do better on PD versus HD. However, one
concern from this mortality data arises that whether it is PD or HD, elderly patients
age ≥ 65 years suffer from far more increased risk of mortality as compared to patients
HD
post-transplant peritonitis especially among those who had DGF
requiring dialysis. In addition, PD catheter was associated with an increased risk of
exit-site infection and peritonitis even if it’s not used[52]
. There is also a report of
increased conversion from PD to HD after transplant due to leakage of dialysate fluid
from surgical incision.
2:diabetes mellitus:no difference ,but PD was associated
with an increased risk for PTDM in univariate analysis, but not in multivariate analysis. The factors associated with new onset of diabetes after transplantation aremultiple and variable, but not limited to presence of pre diabetes,immunosuppressive medication regimen, improved appetite and weight gain post-transplant among other.
●Long-term outcome: Comparing those on prior HD vs PD:
Tang et al ,did not found 5 years graft survival rate to bedifferent with pre-transplant PD as compared to HD technique in their meta-analysis
(HR 0.92, 95%CI: 0.84-1.01, P = 0.08).
Mahmoud Hamada
3 years ago
– DGF is a common post transplantation complication, it was found to be more in hemodialysis patients than PD ones. Reasons may be Pd patients are more welling for kidney transplantation. Also, PD patients has less inflammatory cytokines and IHD than HD patients.
– Regarding thrombosis in grafts, it occurs more in PD pateints who may have more coagulation factors.
– PTDM and infection are more common among PD patients.
– There are controversy regarding long term outcomes among both modalities, however, more studies are noting a better bias for PD than HD patients.
Kidney transplant is considered the typical line in the management of ESRD patients but sometimes the patients need to wait until transplant due to alot of factors so dialysis must be initiated and several causes and it’s effect on transplant outcome(long and short term) should be taken in consideration and this article shows the variables of both modalities and their effect on graft survivalusing PD has less effect on daily activity and it’s preferred especially after decreasing the risk of peritonitis.
MORTALITY RATES:is much higher in HD in different age group also old age patients have better condition than HD that effect on the transplantation ,PD has less cost effect ,but in hospital admission rate both are the same .
DELAY GRAFT FUNCTION (DGF): can be avoided by keeping the patient in good hydration state especially at time of operation this will minimize the need of dialysis in the first few days after transplantation, DGF is low in PD patients also there is difference in hospitalization post transplant due to PD patients have higher eDFR than HD patients and more electrolytes disturbance in HD patients.
THROMBOSIS OF THE ALLOGRAFT:most studies show risk of graft thrombosis is higher in PD patients this may due to activation of pro coagulatory factors ,when peritoneal membrane come in contact with dialysis fluid this lead to inflammatory cells activation thus macrophages activation and also presence of plasminogen and thromboplastin in the peritoneal activity also the patient may have history of HD with thrombosis vascular access ane then switched to PD.
DIABETES AND INFECTION :PD catheter is the main risk factor for infection and sometimes in case of DGF need to do HD in PD patients due to leakage of dialysis fluid from graft site ,this make infection rate is higher in PD ,also diabetes is more common in PD .
LONG TERM OUTCOMES: patients survival is better in PD patients and long term kidney survival is better this due to less cardiovascular disease and low mortality rate due CVD in PD patients.
Regarding the question
Since both patients have similar comorbidities so the choice will depend on the effect of the donor kidney on outcomes and since DGF is lower in PD and long term survival also better in PD so I will prefer PD patient especially in case if deseaced donor.
While preparing the ESRD patient for transplantation , most of them require dialysis , numerous studies tried to to determind which dialysis modality is better for transplant patients HD or PD . Current evidence Prefers PD over HD as pretransplant dialysis modality of choice as it is associated with Better short term graft outcome as it is associated with lower incidence of DGF and postransplantation hospitalization . This may be related to presence of residual kidney function , PD patients are less likely to suffer hyperkalemia or volume overload thus don’t require more pretransplantation dialysis sessions which is a major cause for DGF. For graft thrombosis, it was higher in PD patients compared with HD patients, this may be due to undiagnosed hypercoagulable statue in the patient that was not discovered as there was no previuos dialysis access thrombosis.
Regarding posttransplantation infections ,there was higher incidence of infections in PD than HD patients specially PD Cather exit infections, UTI and peritonitis.
Regarding posttransplantation DM, GFR, hospital readmition within 6 months, acute rejection episodes and graft loss at one year, there were the same in PD and HD patients .
In zagagig nephrology depatrment , we only shift the patients to CAPD when no further vascular access is available. PD is not our first choice modality of dialysis as our patients commonly suffer from peritonitis and Cather obstruction. Also, PD requires highly educated patients and their relatives which is not always present.
saja Mohammed
3 years ago
Summary of the reveiw article:
The prevalence of chronic kidney disease (CKD) is increasing worldwide with increasing numbers of patient reaching ESKD requiring renal replacement therapy, more old patients with ESRD with comorbid, kidney transplantation remained the best treatment associated with improved Quality of live and better patient survival as compared being on dialysis, the preemptive kidney transplant is the ideal choice once affordable , most patients with ESKD , choose HD over PD dialysis in USA and this may be explained by many factors related to the physician choice , lack PD facility or training , cost , in addition to other factors related to the patients education , social and fanatical support
The objective of this study :
1-Discuss the ESRD demographics and outcome
2-Type of dialysis and associated kidney transplant events
3- to review the current evidence in regards to choice of
RRT and impact on kidney transplantation outcomes,
Short term outcome measures the prevalence of DGF, graft thrombosis
And mortality rate as long-term outcome.
ESRD Demographics:
According to the recent data from USRDS registry 2017 there is steady increase in patient with ESRD waiting for kidney transplantation since, with increasing age around 43% they are above 50s years with a range (50-65) with increased number of old patients on hemodialysis 23% above the age of 65years on dialysis and waiting for kidney transplant Recently the incidence of ESRD increasing with in time, the unadjusted incidence rate of 380/ million with more than 36% they did not have predialysis care ,in addition 83% they started on HD with more than 80% with catheter as access for HD ,hemodialysis was the preferred mode over PD, while in center HD mode was preferred in 98% OF HD patients with fewer using home HD mode.
PD as RRT is underutilized in USA as compared with other countries like hoingkoing , more than 70% using PD program , Mexico 50%
PD is preferred as first choice of dialysis as its associated with better BP control, anemia control and preservation of renal function, lower interdialytic hypotension, care stratification and flexibility with treatment
In USA the use of PD was limited to less than 7% due to physician decision center preference , lack of training or expertise in PD , also due to factors related to the patients like lack of education about the procedure , health literacy age , comorbid , social support.
ESRD outcome:
Mortality rates for PD patients were much lower as compared to HD.
HD patients have higher rate of death compared to PD and its even higher in old Hemodialysis patients with longer waiting list for transplant.
PD is cost effective mode compared to HD
Hospital admission rate similar for both modalities at earlier years but within time the Hospital admission rate will be higher in PD population (infection).
Delayed graft function for kidney transplant:
The DGF rate was higher in HD patients versus PD patients, this is confirmed by many studies after adjustment of multiple clinical covariates.
Thrombosis of the allograft was higher in PD patients
Risk of infection and diabetes mellitus after transplantation:
Infection rate increased in PD patient in post transplantation especially in the Prescence of DGF with increase risk of exit site infection , peritonitis and peritoneal fluid leak from the wound, In addition many studies confirm higher rate of PTDM among PD patients .
Long-term outcome: Comparing those on prior HD vs PD:
pre- emptive kidney transplantation associated with better survival
over all better survival rate in prior PD mode of RRT this can be explained by better preparation, preserved renal function and easier access to transplantation with lower cardiovascular death post kidney transplantation but the 5 years and 10 years survival rate was similar between two modalities.
In conclusion:
The ESRD prevalence is globally increaing with high numbers of patients on renal replacement therapyincluding more old populations in waiting list for transplantion kidney transplantation is the Preferred renal replacement therapy for ESKD patients and preemptive kidney transplant associated with the best survival outcome,
in USA the hemodialysis with catheter as access is the preferred mode of RRT, PD is associated with lower rate of DGF, lower cardiovascular death, but higher rate of garft thrombosis ,infection and PTDM as compared to HD mode ,access to PD need better attention by health autherity with improving the educational gaps about this mode of RRT at the level of the physicians and patients whom involved in this treatment its affordable with less cost compared to HD.
in reflection to my current practice , the PD serviece not available currently in our centre as we have only in-centre hemodialysis service but we do do all the educations regarding the all facilities including PD and according to the patient choice will proceed as the PD Service in Oman under the MOH care.
also the evidence from this review based on review of cohorts of retrospective obervational studies so we need more research for fruther calrifications .
Abdulrahman Ishag
3 years ago
Preemptive kidney transplant without dialysis is associated with excellent graft outcome as compared to dialysis.
There is reported better graft outcome and patient survival in patients treated with PD compared to HD patient.
The risk of death censored graft failure is higher in HD patients as compared to PD patients .
Cardiovascular mortality is increased in HD patients compared to PD patients.
Maintenance dialysis prior transplantation is one of the contributor for delayed graft function .
There is better out come in term of delayed graft function in PD compared to HD, may be due to differences in immune function , cytokines production and response to ischemia (as the volume status is affected by mode of dialysis) .
Incidence of allograft thrombosis is higher in PD compared to HD, this can be explained by increased in pro-coagulant factors in PD patient (due to peritoneal inflammatory response to dialysis solution exposure).
Infection post transplantation found to be increased in PD patients compared to HD patients specially in those who had DGF. In addition PD catheter increases the risk of exit-site infection and peritonitis In patient with increase risk of DGF ,PD catheter showed be removed once no longer needed . risk of UTI and peritonitis is increased in PD patients . There is reported increase risk of tuberculosis and chronic hepatitis C virus in HD patients.
PD found to associated with increase of post transplant diabetes , but not in multivariate analysis.
The choice of dialysis modality prior to transplantation is a matters.
Regarding effect dialysis modality in transplantation in my practice;
No study in our area ,discussing this issue
We have small number of PD patients
They remain for a long period of time in PD
Infection is noticed in PD and is usually occur during the first week post transplant ( mainly peritonitis).
Cardiovascular complications is seen more HD patients.
Dalia Ali
3 years ago
Preemptive kidney transplantation is the ideal form of renal replacement therapy (RRT) in patients with end stage renal disease (ESRD). Because it is associated with lower rates of acute rejection, increased allograft and patient survival
Peritoneal dialysis (PD)is associatied with minimal disruption of the patient’s life, So the patient can be continue to work or go to school.it is considered as a bridge therapy for kidney transplantation.
DGF
DGF defined as need of dialysis within seven days of kidney transplantation
Because PD is performed daily so the patients are less likely to develop hyperkalemia or fluid over load and these patients have better preservation of residual renal function hence are less likely to need additional treatments just before kidney transplantation.
PD patients are not likely to develop volume depletion so this will also maintain adequate perfusion of the allograft. HD prior to transplant associated with volume depletion which result in decreased perfusion of the transplanted organ which may be lead to tubular necrosis and increased risk for graft failure
Thrombosis of the allograft
thrombosis of the graft occurs more in PD patients than HD. Because underlying thrombotic abnormalities may be masked during PD Since PD patients do not have an arteriovenous access.
PD patients may have increased pro-coagulant factors such as apolipoprotein A, factors II, VII, VIII, IX, X, XI and factor XII, and hemo-concentration as compared to HD patients which can predispose them at higher risk of allograft thrombosis.
The reasons behind increase in these factors are mainly due to moderate non-specific inflammatory cell when the peritoneal membrane gets exposed to dialysis solutions. This leads to macrophage activation and increased presence of thromboplastin and plasminogen activator in the peritoneal cavity.
Risk of infection
post-operative infections after transplantation more common in PD patients as compared to HD patients
PD catheter is associated with increased risk of exit-site infection and peritonitis even if it’s not used so PD catheter should be removed at time of transplantation in patients with low risk of DGF. In patients with an increased risk of DGF, PD catheter can be left in place but to be removed at the earliest once no longer needed
diabetes mellitus
PD was associated with an increased risk of PTDM. PTDM also can occur due to other factors like
presence of pre diabetes, immunosuppressive medication regimen, improved appetite and weight gain post transportation
Long-term outcome
Preemptive kidney transplant is associated with excellent patient survival compared to HD prior to transplant.PD patients have better graft outcomes,patients survival and decrease Cardiovascular mortality if compared with HD patients
In our center we are dealing with pediatric age group so we prefer to do PD more than HD because of difficult vascular access in pediatric and risk of frequent hypotension when we put the child on hemodialysis machine
Assafi Mohammed
3 years ago
SUMMARY OF THE ARTICLE Choice of dialysis modality prior to kidney transplantation: Does it matter?
A large number oF ESRD patients who desire a kidney transplant ultimately end up needing some form of dialysis therapy.
Preemptive kidney transplantation is ideal for many, as it is associated with lower rates of acute rejection, increased allograft and patient survival. However, a preemptive kidney transplant (17% overall) is not always possible for many reasons which were explored by Jay et al, which included disparities in health insurance, race/ethnicity, patient education level, socioeconomic status, access to healthcare, diabetes status and regional variations. It is also well established that patient survival and quality of life after kidney transplantation is far better when compared to being on dialysis.
PD is an acceptable and could be a preferred form of RRT owing to:
flexibility, autonomy & care satisfaction.
better preservation of residual renal function.
better hypertension control.
lower intra- dialytic hypotension episodes.
lower risk of dementia & slower cognitive decline.
better anemia management with lower doses of erythropoietin stimulating agents (ESA) and lower proportions of patients needing ESAs.
ESRD OUTCOMES
mortality rates for PD patients were much lower as compared to HD.
elderly patients tend to do better on PD versus HD.
overall survival probability of incident patients on PD is much better at the end of 3 years than patients on HD.
Expenditure of PD is also better than HD but much higher than cost for transplant patients.
HD and PD patients have similar hospitalizations rate (1.7 per patient year) but almost double of patients with kidney transplantation.
Patients on HD gradually has lower hospitalization rates as time goes on but patients on PD tends to have slightly higher hospitalization rates with time but still remained lower than HD cohort (1.7 PPY).
PD is a more cost effective modality with somewhat lower risk of mortality as compared to HD in pre-transplant period.
on the waitlist for a kidney transplant, mortality for PD and in-center HD patients was found to be similar
RELATION OF RRT MODALITY TO POST-TRANSPLANT EVENTS 1.Delayed graft function for kidney transplant
Numerous studies have investigated DGF rates and have found mostly similar to lower rates of DGF in PD versus HD patients. A large study by Snyder et al found a lower incidence of DGF among PD patients after adjustment of multiple clinical covariates. They also noted that PD patients were 1.39 times more likely to get transplanted as compared to HD patients.
In a recent study by Molnar et al, The case-mix-adjusted risk of DGF was 34% lower for patients on PD vs HD .However, once adjusted for malnutrition inflammation complex syndrome and donor characteristics, PD was no longer an independent predictor for decreased DGF. But, PD was found to be protective against DGF in a subgroup of patients with hemoglobin between 12 and 13 gram/dL. A meta- analysis by Tang et al found significantly lower risk of DGF in PD patients as compared to HD patients, also postulated higher risk of DGF in HD patients based upon the observation that there more dialysis events were noted in HD group.
In a retrospective observation study of patients with DGF requiring HD or PD, Thomson et al found an increased risk of wound infection/leakage (PD 5/14 vs HD 6/63, P = 0.024), shorter length of hospitalization (PD 13.7 d vs HD 18.7 d, P = 0.009) and lesser time requiring dialysis post-operatively (PD 6.5 d vs HD 11.0 d, P = 0.043) with use of PD however no differences in readmission to hospital within 6 mo, graft loss or acute rejection episodes at one year. GFR also did not differ between the PD and HD groups at one month, six months or at one year.
Reasons for better outcome in terms of DGF in PD patients are not entirely clear. PD patients have better preservation of residual renal function.Few other reasons like difference in immune function, cytokine production, and different response to ischemic kidneys among PD vs HD patients have been proposed as well.
PD is performed daily and patients are less likely to be hyperkalemic and are not likely to be volume depleted either, so less likely to require additional treatments just prior to kidney transplantation.
Intra-op aggressive hydration has been proved to be effective in reducing DGF, which may have been countered against by pre-transplant HD.
2.Thrombosis of the allograft: Comparing prior HD to PD
In contrast to DGF, thrombosis of the graft may be surprisingly higher in the PD patients as compared to their HD counterparts.
Change in pre-transplant dialysis modality was also predictive of RVT among patients who switched from HD to PD (OR = 3.59, P < 0.001) as compared to HD patients who never switched and among patients who switched from PD to HD as compared to HD patients who never switched (OR = 1.62, P = 0.047).
In a study of 119 HD and 39 PD patients who underwent simultaneous kidney-pancreas transplantation, renal allograft loss due to thrombosis was much more common in PD patients as compared to HD patients (5.1% vs 0%, P = 0.058)[50].
Studies by (Pérez Fontánet al) beside studies by (Lin et al and Escuinet al) found no difference in incidence of graft thrombosis among PD versus HD patients.
Reasoning and Justifications for thrombosis of the allograft in PD with higher rate than HD:
Since most patients on PD do not have an arteriovenous access, underlying thrombotic tendencies may be masked, and only uncovered at the time of transplantation.
Some PD patients may have been driven to switch after repeated thrombosis of the HD access.
PD patients are noted to have increased pro-coagulant factors such as apolipoprotein A, factors II, VII, VIII, IX, X, XI and factor XII, and hemo-concentration as compared to HD patients which can predispose them at higher risk of allograft thrombosis. The reasons behind increase in such factors are likely due to moderate non-specific inflammatory cell harvesting when the peritoneal membrane gets exposed to dialysis solutions. This leads to macrophage activation and increased presence of thromboplastin and plasminogen activator in the peritoneal cavity.
3.Risk of infection and diabetes mellitus after transplantation
Infectious complications related with PD catheter after transplantation remain a concern.
In a study by Rizzi et al on 313 PD patients who underwent transplantation between 2000 to 2015, authors found that 8.9% patients had post-transplant peritonitis especially among those who had DGF requiring dialysis.
PD catheter was associated with an increased risk of exit-site infection and peritonitis even if it’s not used.
There is a report of increased conversion from PD to HD after transplant due to leakage of dialysate fluid from surgical incision. Hence, authors had suggested low threshold for PD catheter removal at time of transplantation in patients with low risk of DGF. In patients with an increased risk of DGF, PD catheter could be left in place but to be removed at the earliest once no longer needed.
incidence of post-operative infections after transplantation was found to be increased in PD patients as compared to HD patients with an increased median length of hospital stay.
Lin et al also found higher risks of peritonitis and urinary tract infection in PD patients after transplantation. But, authors reported higher risk of new onset tuberculosis and chronic hepatitis C in patients after 90 d of kidney transplantation treated with prior HD.
Risk factors for post-transplant diabetes mellitus (PTDM):
PTDM was evaluated by Courivaud et al among 137 patients and did not find any impact of dialysis modality on development of PTDM.
On the contrary, in a cohort of 72 patients, Madziarska et al found that PD was associated with an increased risk of PTDM (P = 0.007) in the multivariate analysis. In another study of 121 non-diabetic patients by Seifi et al , authors found when used as pre-transplant modality, PD was associated with an increased risk for PTDM in univariate analysis, but not in multivariate analysis. The factors associated with new onset of diabetes after transplantation are multiple and variable, but not limited to presence of pre diabetes, immunosuppressive medication regimen, improved appetite and weight gain post- transplant among other.
4.Long-term outcome: Comparing those on prior HD vs PD:
1.Preemptive kidney transplant without dialysis was associated with excellent patient survival compared to HD prior to transplant (HR 0.81 with 95%CI of 0.73-0.89, P < 0.001)[9].
2.Data on long-term graft survival after PD and HD is mixed from most studies.
(i) Goldfarb et al analyzed 92844 patients who underwent kidney or kidney- pancreas transplants in 1990-1999. They reported better graft outcomes in patients previously treated predominantly with PD as compared to HD patients (HR 0.97 with 95%CI of 0.94-1.0, P < 0.05), after controlling for multiple variables.
(ii) Lin et al[41] also reported higher risk of death censored graft failure in a multivariate analysis in HD patients as compared to PD patients after 10 years of follow up (HR 1.31, 95%CI 1.03- 1.84, P = 0.031).
(iii) Tang et al did not found 5 years graft survival rate to be different with pre-transplant PD as compared to HD technique in their meta-analysis (HR 0.92, 95%CI: 0.84-1.01, P = 0.08).
3.Ten year graft survival was reported to be similar between a cohort of 80 HD and 80 PD patients.
In another study of 11664 PD and 45561 HD patient, a similar death-censored graft survival was reported (P = 0.39).
Discrepancies in these results were evaluated by Kramer et al in a cohort of 29088 patients who received kidney transplantation between 1999 and 2008 and found that statistically significant association of PD with better allograft and patient survival in a multivariable cox regression analysis disappeared when used instrumental variable method that used the case-mix adjusted center percentage of PD as predictor variable.
4.Patient survival may also be better after kidney transplantation in those on preceding PD as compared to HD.
The Goldfarb et al study revealed that predominate PD prior to transplant was independently associated with better recipient survival compared to patients on preceding HD (HR 0.96 with 95%CI of 0.92-0.99, P < 0.05). Authors also looked at various RRT combinations and outcomes. They found that patient survival was significantly better in those on prior PD only when compared to those whose prior treatment consisted of solely HD (HR 0.90 with CI of 0.86 to 0.94, P < 0.001)[9].
In another study by López-Oliva et al , authors looked at a cohort of 236 patients and reported that long term patient survival was higher for the PD group than the HD group (P = 0.04).
Interestingly the combination of prior PD and HD had a worse survival than those on HD alone (HR 1.10, with 95%CI of 1.06 to 1.15, P < 0.001).
European center in 2006 reported that prior-PD patients fare better and have lower post-transplant mortality than those on preceding HD. The same authors had postulated that exposure to the HD dialyzer membrane could be immunogenic and lead to an increased risk of graft loss. They found that despite using the biocompatible membranes, patient survival on pre-transplant PD was still superior to the HD counterparts.
Mortality benefits in PD patients were again seen in the results reported by Molnar et al from 2012. They reported that patients who had been on PD before receiving a kidney transplant have an adjusted 43% lower death risk compared to those on prior HD (HR 0.57 with CI of 0.38-0.87).
Cardiovascular mortality in recipients who were on prior PD was lower compared to those on prior HD, controlling for many variables (HR 0.94).
In one study, superior survival of PD patients after transplantation was reported to be due to lower risk of cardiovascular death in a cohort of 60008 patients.
Overall,the choice of dialysis modality prior to kidney transplantation matters:
Current evidence favors PD over HD as modality of choice as it is associated with lower risk of hospitalizations, healthcare expenditures and mortality.
conflicting data exists on mortality benefit of PD versus HD; as mortality for PD and in-center HD patients was found to be similar while on the waitlist.
PD was associated with lower risk of DGF and cardiovascular mortality as compared to HD but with higher risk of infectious complications.
Reports on allograft thrombosis, 5 years and 10 years graft survival and patient survival showed mixed results.
Wessam Moustafa
3 years ago
The no. Of ESRD patients is increasing and the well known best form of RRT is kidney transplantation .
Pre emptive kidney transplantation has better outcomes regarding less incidence of acute rejection and better patient and graft survival,
However this option is not always available for all patients .
This review emphasis on the better RRT option while awaiting kidney transplantation, regarding short and long term outcomes .
Studies comparing HD and PD outcomes related to transplantation , showed mixed results , however increasing evidence that PD is associated with less complications and better patient and graft survival .
Regarding short term outcomes , patients with pre transplant PD ,are less likely to develop DGF , but more likely to have vascular thrombosis than HD patients.
PD patients were at higher risk for peritonitis and UTIs after transplantation.
HD patients were at higher risk of TB and chronic HCV infections after transplantation.
And about long term graft and patients survival after transplantation, PD patients were associated with better long term patient and graft survival
Nasrin Esfandiar
3 years ago
Treatment options for patients with ESKD are kidney transplantation peritoneal dialysis (PD) and hemodialysis (HD). Among them preemptive kidney transplantation is the modality of choice if available .There are different reasons that this option is not available is many patients like long time waiting list. Sixty-six percent of patients in waiting list (as UNOS report in 2017) were aged above 50 years. This rate is increasing sustain since 2012 in USA and their care was not optimum before ESKD. Majority of them initiated HD (87.8 %) VS PD (9.6).Among all modalities 65.2% and 63.2% were on PD or HD respectively. Only 2% of HD patients were utilizing home HD. But in other countries there were more patients on PD. With advancing PD techniques ,in recent years outcome of these patients has improved and mortality of them was lower comparing HD. Mortality of HD patients was increased in older patients and much time spent on HD. But in patients receiving PD Mortality was not increased in older people. Other studies showed PD as more cost effective option comparing HD .The mortality rate was increased among patients receiving TX, PD and HD respectively .In addition delayed graft function (DGF) rates after TX were lower in PD vs HD as pre-transplant modality. But rate of graft thrombosis was higher in PD group. In contrary infection of dialysis access were more frequent in PD vs HD patient. Some studied showed increasing rate of PTDM among PD patients. Patient and graft survival were better in PD vs HD patients. The reason behind this is better RRF preserving and less immunogenicity of PD.
Weam Elnazer
3 years ago
I will choose the PD patient. as this is a marginal kidney. better to avoid the DGF that occurred more between HD patients than PD patients.
Mujtaba Zuhair
3 years ago
Preemptive kidney transplantation is associated with better patient and graft survival. But due to organ shortage many patients need HD or peritoneal dialysis before transplantation.
PD has several advantages over HD which includes self dependency, better preservation of residual kidney function, better volume status management less requirement of ESA.
The mortality rate was slightly lower in PD patients and older patients do better with PD.
Outcome after transplantation :
(1) Delayed graft function: PD patients has lower incidence of DGF when compared to HD patients. This could be due to the PD patients are less likely to be volume depleted than HD patients or due to better residual kidney function of PD patients.
(2) Thrombosis of the graft:
The incidence of graft thrombosis and early graft loss (<3 months) was higher in PD patients . This could be due inflammation in the peritoneal cavity or increase in the coagulation factors in their blood.
(3) Risk of infection post transplantation :
There is increased risk of infection in PD patients ( peritonitis , UTI ) , So the PD catheter should be removed as early as possible . On the other hand HD patients had higher incidence of TB and HCV infection post transplantation.
(4) Risk of DM after transplantation:
Some studies found that PD is associated with higher incidence of DM after transplantation , other studies did not found difference .
(5) Long term outcome :
PD is associated with slightly better 10 years graft survival.
PD is associated with better patient survival after transplantation and lower cardiovascular mortality post transplantation when compared to HD.
In our center , PD is less far common than HD , due to multiple factors , HD is easier to the patient , lack of education , lack of experience , the fear of peritonitis.
Shereen Yousef
3 years ago
Introduction
Number of ESRD patients is increasing annually this unfortunately make the waiting list for transplantation longer with lower chances especially for older patients.
Kidney transplantation is the best choice for patients with ESRD ;preemptive transplantation is ideal as it is associated with less acute rejection episodes ,better patient and graft survival but it is not always possible to do transplantation befor dialysis for different reasons and most of the patients will need to start dialysis.
The choice of dialysis type may affect transplantation outcoms a meta-analysis done by Tang et al in 2016 concluded that PD was a better choice of pre-transplant dialysis modality than HD.
Although a study by Resende et al and Dipalma et al did not find any difference on graft function or patient’s survival after transplantation with different dialysis modality.
ESRD DEMOGRAPHICS
According to United Network for Organ Sharing, in 2017, there were 94897 patients on the waiting list for kidney transplantation most of them were above the age of 50 years Only, 19849 patients received kidney transplantation.
Number of ESRD patients is increasing annually and unfortunately one third of them had to start dialysis via a catheter and didn’t receive enough care to be prepared by arteriovenous access
with majorty of patients preferred HD to PD.
the USA, HD is the most common modality of renal therapy than PD while in other countries like New Zealand, Thailand, Colombia, Australia, and Canada PD is more used than HD.
PD is the preferred form of RRT because of its flexibility, care satisfaction, better preservation of renal function, better control of blood pressure with lower intradialytic hypotension episodes, low risk of dementia and slower cognitive decline, decrease in erythropoietin demand.
PD underutilized in the USA due to many reasons including for example; physician specific (lack of experience, inadequate training,); patient specific (lack of adequate PD education, health literacy, burden of therapy, age, comorbidities); modality specific (concerns for mortality, solute clearance, peritonitis, treatment failure.
ESRD outcome
Mortality in HD patients are higher than PD patients and much more higher than transplanted patients with higher mortality rates among patients >65 years.
Improvement in PD technique has improved and risk of peritonitis and studies showed that elderly patients tend to do better on PD versus HD.
ESRD patient population is aging and dying waiting for a transplant, and it will be better to increase their chances in kidney transplantation early .
Expenditure of PD is also better than HD but much higher than cost for transplant patients . HD and PD patients have similar hospitalizations rate but almost double of patients with kidney transplantation .
Delayed graft function for kidney transplant
DGF defined as need of dialysis within seven days of kidney transplantation
patients received PD before transplantation showed lower rates of DGF than HD patients but GFR did not differ between the PD and HD groups at one month, six months or at one year.
No clear cause of the better results of PD patients over HD patients but they might have preservation of residual renal function ,difference in immune function, cytokine production, and different response to ischemic kidneys and they are less likely to be volume depleted which ensure adequate perfusion of the allograft in contrastto HD patients .
Thrombosis of the allograft:
There are higher rates for allograft thrombosis in PD than HD patients which might be due to ;
•Previous hypercoagulable state of the patient that caused thrombosis in AV fistula and shifted the patient to PD .
• increased pro-coagulant factors such as apolipoprotein A, factors II, VII, VIII, IX, X, XI and factor XII due to irritation of peritoneal membrane leading to macrophages activation.
•hemo-concentration as compared to HD patients also can be a cause.
Risk of infection and diabetes mellitus after transplantation
Immunosuppression after transplantation
is associated with increased incidence of infections in general , in PD patients there is a higher risk of catheter site infection and peritonitis even if it’s not used .
Some studies also showed Increased incidence of urinary tract infection in PD patients .
No clear results on the effect of dialysis modality on the occurrence of post-transplantation DM
some studies showed no difference between HD and PD while other showed higher incidence in PD .
Long-term outcome: Comparing those on prior HD vs PD
Preemptive kidney transplant without dialysis was associated with the best results on patient survival compared to HD before transplantation.
Some studies reported better outcome on graft and patient survival for PD patients over HD patients ; this may be due to better planning before starting PD, PD patients are better prepared; In addition, this could be explained by the better preservation of residual kidney function on PD,also increased risk of cardiovascular diseases with HD patients.
Another study showed that combination of prior PD and HD had a worse survival than those on HD alone.
Although, Tang et al did not found 5 years graft survival rate to be different with pre-transplant PD as compared to HD technique in their meta-analysis.
In conclusion
Despite conflicting data Current evidence favors PD over HD a as it is associated with lower risk of hospitalizations, healthcare expenditures and mortality.
In regards to kidney transplantation outcomes, PD was associated with lower risk of DGF and cardiovascular mortality as compared to HD but with higher risk of infectious complications.
Ahmed Fouad Omar
3 years ago
CKD is increasing all over the world accounting for around 10% of the population. However, only 10% of the population receives some form of RRT to remain alive.
Kidney transplantation is the ideal form of RRT despite improvement in the dialysis techniques and mortality .
Unfortunately, due to lack of organ supply, pre-emptive transplantation account for only 17% of the total transplanted patients despite its benefits on patient and graft survival. Accordingly, patients may need some form of RRT before getting transplanted so they become more older with increased comorbidities increasing the burden on health care systems.
Peritoneal dialysis provides a good bridge therapy to renal transplantation being more flexible, better self-satisfaction and autonomy. However, in some health care systems like USA it is largely underutilized compared to other countries like Hong Kong and Mexico due to multifactorial causes that could be patient, physician, financial or modality specific causes.
This paper reviewed the impact of RRT choice whether hemodialysis or peritoneal dialysis on mortality, short and term and long term transplantation outcomes.
Peritoneal dialysis was found to be more cost effective, have lower hospitalization, and mortality compared to hemodialysis especially in elderly who tend to do better on PD compared to HD. Although there is some conflicting data on mortality benefit as PD and in Centre HD mortality were similar while on the wait list for transplantation.
short term transplantation outcomes:
PD was associated with lower incidence of delayed graft functions than HD (defined as need for dialysis within 7 days of transplantation)attributed to better preservation of renal functions, less volume depletion and better perfusion of renal graft .
On the contrary, PD was associated with more higher risks of infectious complications including postoperative infections, PD catheter exit site infection and peritonitis even if PD catheter is not used
The risk of post transplantation allograft thrombosis showed mixed results with higher PD risk for graft thrombosis in some studies due to masking of thrombotic tendency in the absence in the absence of AV access and the presence of presence of pro-coagulant factors due to peritoneal membrane inflammation when exposed to dialysis solutions. However, other studies showed similar PD and HD results
long term transplantation outcomes :
The outcome of long term graft survival and death censored graft failure showed mixed results where some studies showed some superiority of PD over HD while others did not show a 5 or 10 years graft survival benefit between the 2 modalities
With regard to patient survival some studies showed a better survival benefit with PD which may be attributed to better planning and preparation when starting PD as well as better preservation or residual kidney functions. However other studies showed no favor of any modality over the other with regard to mortalities but still PD showed a lower post transplantation cardiovascular mortality when compared to HD.
To conclude: PD is an underutilized modality of renal replacement which could be the therapy of choice to bridge for renal transplantation and effort should be made to remove different obstacles regarding that including better education and training of medical staff, improving the patient education about this modality in low clearance clinics using a patient centered universal approach.
Reflection on personal experience:
I worked in different health care systems in the Gulf and UK , so there are many obstacles with regard to implementation of PD programs:
Patient related factors:
· Lack of availability of suitable home situations and support by other family members
· PD put a burden on patients during their training and carrying the procedure and need of complete aseptic precautions to minimize the risk of peritonitis which could be higher in the more hot countries in the gulf. Accordingly, some patients becomes more comfortable when they go to the hospital where medical and nursing staff could help
· Lack of available information and PD education about this modality compared to HD and health literacy for some of the patients
Physician specific:
· Inadequate training and lack of education of the medical staff because some health care systems do not focus on such modality compared to HD
However, some countries specially in UK and centers took active steps so that PD can take a fair share in the RRRT modalities specially in patients who have a good residual renal functions, elderly patients and as a good bridge to renal transplantation
Ben Lomatayo
3 years ago
Unfortunately in my practice at the moment, PD is very challenging because the insurance coverage to dialysis treatment is not recognizing PD. This means PD candidate have to pay out of pocket to get the services. This is very difficult as most the patients cannot afford it although is available. We forced to do PD only. in cases of patients with end-stage vascular access failure. Currently we don’t have any PD patients in our transplant programme and therefore I would our experience with PD patients after transplantation is not existing practically, all is HD.
Abstract ; The numbers of patients with ESRD requiring dialysis treatment is increasing, this increase prolong the waiting list time for transplantation. Although PD is preferred dialysis modality before transplantation, many incident ESRD select HD over PD for different reasons. PD is associated with less DGF but higher allograft thrombosis than HD. More infections are seen in PD cohorts than HD. Overall there is some signal that PD may be associated with better long-term survival. Introduction ; Kidney transplantation is the best form of RRT for patients with ESRD. Many studies look at the outcomes of transplantation after PD versus HD. A meta-analysis by Tang et al(7) showed that PD was better option of pre-transplant dialysis than HD. Interestingly Resende et al(10) and Dipalma et al (11) couldn’t not find effect of dialysis modality on graft or patient survival after transplantation. ESRD Demographics ; Majority of patients with ESRD in USA are above 50 years of age (12). There is noticeable increase in both incidence and prevalence of ESRD (13)(15). Many of the incident ESRD patients in USA choose HD over PD as RRT modality. This may be due to physician factors (experience and training), patients specific( PD education, burden of therapy, age), and modality specific(peritonitis, logistics, cost, availability of HD) (22- 24). This is in contrast to other countries in the world(e.g. Hong Kong, Mexico) where PD is favourable than HD(14). ESRD Outcomes ; Generally mortality is high in patients above 65 years of age but less mortality is seen in PD than HD patients(25). The cost of PD is less compared to HD but higher than that of kidney transplantation. The rate of hospitalization is initially higher with HD, with time hospitalization rates for PD increases but still lower than HD(27) Delayed Graft Function for Kidney Transplant ; DGF is the requirement for dialysis in the first seven days after transplantation(29). Compared to HD, PD have lower rates of DGF(29-39). Why PD have better outcomes than HD is not clear. However, it may be due to preservation of the residual kidney function(37,38), differences in immune function, and motivations of PD patients. Thrombosis of the allograft : Comparing Prior HD to PD; Allograft thrombosis is more common in PD than HD( 38,44,46). This may be due to increased pro-coagulant factors (e.g. Apolipoprotein , other clotting factors) and haem-concentration in PD populations. Other studies reported similar incidence of primary allograft thrombosis between PD and HD patients(47)(41)(49) Risk of Infection and Diabetes Mellitus after Transplantation ; Infections related complications are higher in PD than HD patients(42,45). These includes ; post tx peritonitis and exit site infections. Some centres recommended removal of the PD catheter in low risk patients due to concerns of peritonitis and possibility of PD fluid leakage from the surgical incision(52). Postoperative infections and UTIs are also reported to be higher in PD cohorts. HD have been associated with new onset TB and chronic HCV in the first 3 months. Regarding post transplant diabetes, results are conflicting, some studies demonstrated no impact of dialysis modality on the risk of PTDM(54), while others reported statistical significance(56) Long-term Outcomes : Comparing those on Prior HD versus PD ; This is a matter of debate, many studies showed better long-term survival with PD than HD. (9)(11)(58). The reason may be due to lower rate of cardiovascular mortality in PD group than HD(39), preservation of residual kidney function, better planning for PD, and motivations in PD populations(65-66). Other studies revealed no survival benefit of PD over HD(10,11,58). This mixed results can attributed to other factors which may determine the long-term survival benefit after transplantation. Conclusion ; Most patients with incident ESRD in USA choose HD over PD. PD is associated with less DGF but higher allograft thrombosis compared to HD. Long-term survival is favouring PD, although other studies didn’t find any differences. Patients education is of para-amount importance regarding dialysis modality selections. Further researches are needed to close the gap in this matter.
This is the way to summarise an article. Well done
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Mahmud Islam
3 years ago
Renal transplant is the best choice ever for ESRD. preemptive transplantation is better than after being on dialysis. although data are conflicting many studies showed that PD is more favored with fewer complications and less hospitalization compared to hemodialysis. In the US patients favor hemodialysis. transplantation is better in terms of expenditure followed by PD than HD. (transplant is much cheaper especially after the fourth year because of high expenditure in the first year; not shown in this article).In regard to delayed graft function, the preemptive transplant was better than from deceased ones. surprisingly, thrombotic events were more than those who were on PD before transplantation. In regard to peritonitis after transplantation, peritonitis was more pronounced in PD patients.
In our practice, early education and preparing patients either by direct or paired transplant is planned. ın some centers 8 pairs are matched and favored. outcomes are better than transplants after dialysis. I some patients who are in late-stage 5D dialysis is performed by central catheter to avoid üremic and metabolic complications. some times this is done only in case of delayed graft function. as PD is not favored due to some other reasons, for patients in the pretransplant period no center in Turkey uses PD in planned transplant patients as far as I know.
Asmaa Khudhur
3 years ago
This article discussed the choice of RRT modality and the impact on kidney transplantation outcome
Current evidence favors PD over HD as modality of Choice as it is associated with lower risk of hospitalization,healthcare expenditures and mortality.
Preemptive kidney transplantation is ideal as it is associated with lower rate of acute rejection ,increased allograft and patients survival .
The review divided into two parts:
short-term outcome (DGF and allograft thrombosis)
Long-term outcomes including mortality.
in regards to kidney transplantation outcome PD was associated with lower risk of DGF and cardiovascular mortality as compared to HD but with higher risk of infectious complications.
Regarding allograft thrombosis, graft survival and patients survival showed mixed result between PD and HD.
No impact of dialysis modality on development of PTDM
My experience showed similar outcome regarding the choice of modality of RRT before renal transplantation.
Reem Younis
3 years ago
-Kidney transplantation is the ideal form of renal replacement therapy (RRT) in patients with end-stage renal disease (ESRD).
-Preemptive kidney transplantation is associated with lower rates of acute rejection and increased allograft and patient survival.
-Patient survival and quality of life after kidney transplantation is better when compared to being on dialysis.
-A lot of patients are removed from a waiting list for renal transplant due to death or decline in medical condition.
-there is improvement in the overall dialysis-related mortality.
-The average time on the waitlist for a deceased donor is quite variable depending on age, blood group, panel reacting antibodies, history of prior transplantation, race/ethnicity, and regional factors.
-Peritoneal dialysis (PD) lead to minimal disruption of the patient, s life, and the patient can participate in his management.
– According to several studies PD is better to bridge therapy to renal transplantation than hemodialysis (HD). ESRD demographics
-According to United Network for Organ Sharing, in 2017, there were 94897 patients on the waiting list for kidney transplantation.
-Majority of patients are above 50 years old.
-Only 19849 received kidney transplantation in the year 2017.
-In the USA, In –center HD is the most common modality of renal therapy than PD while in other countries like Qatar, Mexico, New Zealand, Thailand, Colombia, Australia, and Canada PD is more used than HD.
-PD is the preferred form of RRT because of its flexibility, autonomy, care satisfaction, better preservation of renal function, better hypertension control, lower intradialytic hypotension episodes, low risk of dementia, slower cognitive decline, better anemia management, and lower proportion of patient needing erythropoietin.
ESRD outcome
-Success of the PD technique has improved so the risk of peritonitis is reduced.
– In 2015, according to USRD, the mortality rate for patients on HD was high than patients on PD and much higher than patients who received kidney transplantation.
-Elderly patients are doing better in PD than HD but patients older than 65 years have an increased risk of mortality as compared to patients less than 65 years of age.
– Expenditure of PD is better than HD but much higher than the cost for transplant patients and the overall adjusted survival probability of incident patients on PD better than patients on HD.
-HD and PD patients have similar hospitalization rates but almost double those of patients with kidney transplantation.
-One study showed that mortality for PD and in-center HD patients was found to be similar. Delayed graft function for kidney transplant(DGF):
-It is defined as the need for dialysis within seven days of kidney transplantation.
-DGF is lower in PD than HD that maybe PD patients are not likely to be volume depleted so ensure adequate perfusion of allograft, and there are differences in immune function, cytokine production, and different response to ischemic kidney among PD versus HD patients. Thrombosis Of allograft :
-Thrombosis of graft (RVT) is higher in the PD patient compared with HD patients.
-PD patients have increased Pro-coagulant factors such as apolipoprotein, factors II, VIII, VII, IX, X, XI, and hemoconcentration as compared to HD patients. Risk of infection and diabetes mellitus after transplantation:
-Infectious complications (Exit –site infection and peritonitis)related to PD catheter may occur after transplantation.
– One study shows there is no impact of dialysis modality on the development of posttransplant diabetes mellitus(PTDM) while other studies result, PD associated with PTDM. Long–term outcome:
-Preemptive kidney transplant was associated with excellent patient survival.
-PD is associated with better allograft and patient survival than HD patients.
–In Sudan, there are PD centers, the number of patients is small, and sometimes there are problems with PD catheters and PD solutions. The complications are few due to the small number of patients.
Renal transplantation is the best treatment for patients with ESRD About 10% of world population has CKD. I USA only 9% of ESRD patients are on PD program, but in other countries the percentage reach 70% as in Hong Kong.
Patients on PD program show better blood pressure control, need less doses of erythropoietin to treat anaemia, & preservation of residual renal function. The large difference between USA & other countries in patients number on PD program may contribute to different factors as patient, physicians , & modality specific.
Several studies comparing the graft survival after transplantation with the modality of dialysis. These studies show better graft survival , patient survival, cardiovascular mortality & mortality from any cause in patients on PD than patients on HD. DGF was less in recipients on PD & this may be due to preservation of renal residual function & the patients are not volume depleted which can improve graft perfusion.
But it was noted that graft thrombosis rate is higher in patients on PD prior transplantation leading to early graft loss. This observation also occur in patient who switch the modality of dialysis as from HD to PD & vise versa. This may be explained by increase in procoagulant factors inPD patients.
After transplantation & because use of immunosuppressive drugs the risk of infection is increased especially in PD patients( peritonitis, post operative infection), so increase the inhospitable admission.
The incidence of post transplantation DM is different among studies, some show no relation between modality of dialysis & incidence of DM but other show that PD increase the risk.
Regarding the reflection of our practice unfortunately there is no PD program in my country, hoping it will be soon.
Heba Wagdy
3 years ago
Kidney transplant in patients with end stage renal disease is associated with better quality of life and better patient survival as compared to patients on dialysis.
Pre-emptive kidney transplant results in better graft and patient survival but it is not always available and patients may need to initiate dialysis before transplantation.
Many studies compared the outcome of transplantation after peritoneal dialysis (PD) versus hemodialysis (HD), some of them showed that PD was a better choice pre transplant and HD was associated with higher risk of graft failure and patient death, while other studies reported that modality of dialysis has no impact on patient survival or graft failure.
PD may be favored as it is associated with flexibility, care satisfaction, more preservation of kidney function, better blood pressure control, better anemia management and lower risk of dementia.
Other factors lead to underutilization of PD are lack of experience and training of physicians, more comfort with HD, comorbidities and burden of therapy on the patient, lack of knowledge about PD and fear of complications as treatment failure and peritonitis. Also, PD fluids are not always available.
A study showed that mortality rate is much lower in patients on PD than in patients on HD and elderly patients have better outcome on PD.
Studies reported that the cost of PD is less than that of HD, the rate of hospitalization is the same but as time goes, Patients on PD have higher hospitalization rate.
PD is more cost-effective with lower risk of mortality than HD in pre transplant period.
Delayed graft function (DGF)
It is the need for dialysis within 7 days after transplantation
Studies showed that the rate of DGF in PD is lower than that in HD.
A retrospective study reported that patients with DGF who receive PD have increased risk of wound infection but shorter hospital stay and shorter time requiring dialysis post operatively.
Better outcome of PD regarding DGF may be due to better preservation of kidney function, it is daily, not associated with volume depletion (may cause decreased perfusion of transplanted organ, tubular necrosis) also patient on PD can have intra operative aggressive hydration that decrease risk of DGF.
other suggested reasons include difference in immune function, cytokine production and different response to ischemic kidneys in PD and HD patients.
Thrombosis of allograft
It is more common in patients on prior PD than on prior HD.
This may be due to underlying masked thrombotic tendencies in PD patients (as they have no A-V access), patients may have switched to PD after repeated thrombosis of HD access.
PD patients have increased pro coagulant factors due to exposure of peritoneal membranes to dialysis solutions leading to macrophages activation, increased thromboplastin and plasminogen activator in peritoneal cavity.
Other studies showed no difference in incidence of graft thrombosis in PD & HD patients
Risk of infection post transplant
Infectious complications related to PD catheter and post transplant peritonitis is a concern
PD catheters are associated with exit site infection (even if not used).
patients on PD have risk of leakage of dialysate fluid from surgical incision, increased risk of UTI and peritonitis.
It is preferred to remove PD catheter at time of transplantation.
Long term outcome:
Some studies showed that long term graft outcome and patients survival are better in PD patients as compared to HD patients. Also, showed that HD patients are at are higher risk of death censored graft failure.
Suggested reason for better long term outcome with PD is that exposure to HD dialyzer membrane may be immunogenic and increase risk of graft loss despite using biocompatible membrane and better preservation of kidney function in patients on PD which enhance graft survival.
Studies showed that cardiovascular mortality is lower in PD
Other studies showed no survival benefits of PD over HD, no significant difference in the risk of death in PD and HD and that graft survival is the same with both modalities.
The choice of dialysis modality before transplant should include impact on lifestyle and kidney transplantation.
PD is underutilized and can be the therapy of choice especially with better outcome with transplantation.
Well done Heba
This is the way to summarise article.
I have sent you a present
Theepa Mariamutu
3 years ago
In Malaysia, we are still lacking behind in imposing or advocate PD first policies like Hong Kong or even Thailand. Most of our patients are preferring HD compared to PD due to lack of self confidence, and least awareness about PD. We have been advertising PD as a first choice RRT compared to HD but hesitancy from the patients’ still make it difficult to increase the number of PD. We are trying our best to do preemptive transplantations but availabilities of cadaveric donors and cultural beliefs towards kidney transplantations making our efforts tougher.
Regarding choices of RRT and its impact in graft survival post renal transplantation, we seems to see similar graft survival, allograft rejections and graft loss in Malaysia, at least at my centre.
Admiring this excellent response and reflections on practice and outcomes. Excellent Theepa
Theepa Mariamutu
3 years ago
Choice of Dialysis modality prior to KT
ESRD outcome
• Mortality rate for HD was slightly higher than PD and much higher than KT
• Mortality rate for those underwent HD and aged less than 65 better than more than 65, but in PD, mortality rate is much lower than HD and tend to do better for those aged more than 65
• Overall adjusted survival probability of incident on PD is better than end of 3 years than HD
• Expenditure also lesser in PD than HD while higher than KT
• HD patients have lower hospitalisation over the years and PD patients have slightly higher rates of hospitalisation over the time but still lower than HD cohort
• Inrig et al- showed that only no differences in 2 year mortality among PD and HD patients
Delayed graft function for KT
• most of the studies showed lower rates of DGF in PD versus HD patients even after adjustment for multiple clinical covariates
• some suggested that once adjustment for malnutrition inflammation complex syndrome and donor characteristics, PD no longer superior to HD but PD found to be protective against DGF in subgroup analysis among patient who had Hb12-13g/dL
• reason for better outcome –
o not clear, PD has better preservations of residual renal function.
o PD patients are more motivated
o Cytokine production and differences in response to Ischaemic kidneys
o He prior to KT results in volume depleted while PD patients are well hydrated
Thrombosis of the allograft
• Higher in PD patients
• Higher adjusted risk for both allograft failure and death censored allograft failure for PD patients
• Higher odds at renal vein thrombosis in PD
• Possible explanations
o Increased pro-coagulant factors such as apolipoprotein A, factors 2,7,8,9,10,11 and 12
o Haemoconcentrated compared to HD
o Exposed to dialysate solutions lead to macrophages activation and increased presence of thromboplastin and plasminogen
Risk of infection and diabetes after transplantation
• PD associated higher risk if infection with catheter infections and peritonitis
• HD associated with new onset tuberculosis and Chronic hepatitis C
• PD associated with increased risk of diabetes
Long term outcome
• PD has a better long term graft survival and death censored graft failure and patient survival
• PD and HD combination or switching had worse patient survival comopared to HD alone
• Possible explanations
o HD dialysis membranes could be immunogenic and lead to increased risk of graft loss
• Cardiovascular risk is lower in PD patients and this superiority carried on after kidney transplantation
Mohamad Habli
3 years ago
Kidney transplantation is the best renal replacement therapy for patients with end stage renal disease.The early the transplantation, the better the outcomes. However, not all patients are offered kidney allografts. This is because there is a great gap between the increasing number in ESRD patients and number of offered kidneys. While waiting on the transplantation waitlist, most of the patients are undergoing different modalities of dialysis, but does this matter? Is one modality better than other in the pre-transplant period? Should we offer a specific type of dialysis?
Choice of dialysis modality prior to kidney transplantation: Does it matter?
This review article has focused on short and long term outcomes of transplant patients based on the dialysis modality in the pre-transplant period.
The distribution of dialysis modalities among ESRD patients varies between countries, regions , hospitals and also nephrologist experience. For example most of ESRD are treated with hemodialysis with only 7% of patients were utilizing PD. In contrast, in Australia, Canada, Qatar and other countries, PD accounts for priority of dialysis modality. In general PD s acceptable and could be the preferred modality of RRT, owing to better preservation of residual renal function, less hemodynamic instabilities, better control of phosphorus, flexibility, autonomy, better hypertension control , lower risk of dementia, slower cognitive decline, better anemia management and lower inflammatory markers.
Delayed graft function is defined as the need of dialysis within seven days of kidney transplantation. Several studies demonstrated benefit rate in terms of graft survival in patients receiving PD in the pretransplant period, comparing with hemodialysis with prominent DGF.
In a retrospective observation study of patients with delayed graft function requiring dialysis, found an increased risk of wound infection/leakage, shorter length of hospitalization and lesser time requiring dialysis post-operatively with use of PD. However, no differences in readmission to hospital within 6 months, graft loss or acute rejection episodes at one year.
Thrombosis of the allograft was higher in the PD comparing to their HD.
In the post-transplant period, recipients receive multiple immunosuppressive therapies, which increases the risk of infections .PD catheter was associated with an increased risk of infection and peritonitis even if it’s not used.
Data on long-term graft survival after PD and HD is in favor of better graft outcomes in patients previously treated predominantly with PD as compared to HD patient. European center in 2006 reported that prior-PD patients have better graft and overall survival.
Based on meta-analysis of studies done in 2014, pre-transplant PD is associated with better post-transplant survival than HD. Pre-transplant PD was also associated with decreased risk for DGF compared with HD, although these results were unadjusted. There was no significant difference in graft survival between pre-transplant HD and PD. These results suggest that PD may be the preferred dialysis modality for patients expected to receive a transplant (1).
Another review article published in 2017 was looking for the best renal replacement modality for patients with ESRD in the pretransplant period and whether Nephrologists should Promote Peritoneal Dialysis as a Bridge to Transplantation? The answer was that PD might be less likely to be associated with delayed graft function probably because PD is associated with better pro-inflammatory state and better control of volume status, but article was not firmly conclusive (2).
Choice of dialysis modality prior to kidney transplantation in my practice
In my practice, hemodialysis is the unique modality offered to patients with ESRD. Most patients prefer in-center dialysis rather than at home because of the fear of complications, where in-center HD, nurses and doctors are always available.
From financial point of view, some insurance companies do not cover the cost of cycler for automated PD and some PD solutions, while HD is financially covered totally.
At personal level, we were not adequately trained to prescribe peritoneal dialysis, with the lack of PD centers, educators and awareness. So with time some nephrologists will lack the experience to prescribe PD and follow-up PD patients and will be easier for them to prescribe HD.
Thank you Dr Alaa for your question.
What I meant is that we offered our patients hemodialysis because we lack PD centers, educators for PD, no financial coverage for PD cycler, and preferances of most patients to be managed in centers rather than at home.
Excellent Mahmoud
Titles and subtitles is the way to structure your summary. I have sent you a present.
Riham Marzouk
3 years ago
Aim to compare HD and PD as a pre-transplant modality and their impact on transplant outcome graft and patient.
Different modality of RRT should be discussed with the patient before initiating the modality.
Of course, preemptive renal transplantation has positive impact on graft and patient survival post-transplant, but this may be not available in the most of time because of many factors like patient education, socioeconomic status, problems related to health insurance, race/ethnicity, health care center access…etc.
The choice of the method depends on the patient need and his/her life style, work, and social life. PD modality offer lesser complications than HD.
PD modality started to increase and rate of complication as peritonitis was declined. Complications of HD is much more than PD , mortality of the patients on PD is much better than those on HD, however elderly patients mortality either on PD or HD is worse than young patients on PD or HD.
DGF delayed graft function ( need for dialysis in the 1st week post transplant )
DGF incidence increase in the patients of HD more than PD patients;
In the PD patients: 1- more residual renal function.
2- Less affection of the volume status, so free use of intra operative hydration to guard against DGF.
3- Less hyperkalemia because of daily dialysis.
Allograft thrombosis increased incidence in PD patients than HD patients
1- May be some patients of PD were shifted from HD due to poor vascular access.
2- Increase pro-coagulant factors in PD patients more than HD
3- Increased thromboplastin and plasminogen activator in the peritoneal cavity because of inflammatory process done because of peritoneal dialysis solutions.
Risk of infection and DM post transplant
There is higher risk of infection and peritonitis of PD patients post transplant, because of presence of PD cath even if not used, so should be removed as early as possible post transplant.
Also there is increased risk of UTI in PD patients post transplant compared to HD patients. But there is increase risk of new onset TB and chronic hepatitis C post transplant among the patients of HD.
There is no effect of dialysis modality on development of PTDM (post transplant DM).
Graft and patients survival is better in PD patients compared to HD patients (immunogenic dialyzer membrane in HD patients may be risk factor for graft loss, also more cardiovascular complications and mortality in HD patients compared to PD patients) , and worse survival was noticed in the patients with combined PD and HD than the patients with HD alone. Pre emptive renal transplant has an excellent outcome.
There are multiple factors deciding the choice of modality pre transplant and also many factors may be present and hinder the true comparison between HD and PD graft and survival outcome post transplant, hence there are different opinions of many studies.
This is despite the fact that kidney transplantation is optimal and linked with substantially improved clinical outcomes for individuals with ESRD than dialysis.
The current data supports PD over HD since it is related to decreased hospitalization, healthcare costs, and death.
While evidence on the mortality benefit of PD over HD is mixed, waiting list mortality for both PD and HD patients is similar.
In terms of kidney transplant outcomes, PD had lower DGF and cardiovascular mortality than HD, but greater infectious complications. In the literature, allograft thrombosis was reported seldom.
Overall, we feel that dialysis modality is important prior to kidney transplantation. While it is impossible to conduct a large randomized controlled experiment to address this issue, education on pre-transplant dialysis modality choices has to be multi-faceted.
long-term consequences and lifestyle impacts. The teaching and training must be patient-centric, employing a universal approach, regardless of the patient’s health literacy level.
PD is an underused technique in the USA that may increase transplant success.
In our centre, we did not notice a significant difference between both modalities of dialysis.
Sherif Yusuf
3 years ago
There are 3 modalities for treatment of RRT : HD, PD and renal transplantation
HD is the most common modality used then renal transplantation and PD at the end. PD is underutilized due to lack of experience of staff, lack of education of the patient, complications such as peritonitis and availability.
Patient survival is higher in pre-emptive renal transplantation followed by PD then HD,
Hospitalization is more frequent in HD than PD with the least are transplant recipients.
QOL of renal transplant patients is the best followed by PD then HD .
Regarding the cost the best is renal transplantation followed by PD and HD comes at last
Regarding likehood of renal transplantation, PD patients were forund to be more likley to be transplanted than HD patients
Post transplant graft and patient survival was found to be higher in patients with prior PD when compared to prior HD while the incidence of DGF was found to be lower in PD than HD patients. this may be due to :
⦁ Improved patient satisfaction and motivation
⦁ Better preservation of residual renal function
⦁ Better cognitive function
⦁ lower incidence of hyperkalemia and volume depletion
Post transplant graft thrombosis was found by some (not all) studies to be higher in PD when compared to HD patients this may be due to :
⦁ Hidden thrombophilia which is not discovered due to absence of AVF
⦁ Increase procoagulant factors when compared to HD due to chronic low grade inflammation of peritoneum
⦁ Hemoconcentration
Regarding infections it was found that :
⦁ TB and viral hepatitis in first 3 m after transplantation are more common in HD when compared to PD patients
⦁ Post transplant peritonitis and exit site infection, fluid leakage and UTI are common in PD patients especially if DGF occur thus it is recommended to remove PD catheter before transplantation if there is low probability of DGF, if not it should be removed as soon as possible once graft function is stable
Excellent Sherief
Titles and subtitles is the way to structure your summary.
I have sent you a present.
Huda Al-Taee
3 years ago
Kidney transplantation is the preferred modality of RRT for ESRD patients.
Preemptive kidney transplantation is ideal for those patients as it is associated with better patient & graft survival, but unfortunately there are many limiting factors for preemptive transplantation such as disparities in health insurance, race, education level, socioeconomic status, access to healthcare, diabetes status and regional variation.
Around 10% of the population are diagnosed with CKD all over the world & about only 10% of those patients receives treatment in the form of dialysis or transplantation.
Many patients are on the waiting list for transplantation and these patients have to wait many years to get a donor due to the shortage of the organs, as a result the age of the patients on waiting list is increasing and some of them will be declined due to disease burden or death. So there is a need for other form of RRT for these patients till they get their donor.
Regarding PD as a form of RRT :
It is associated with minimal disruption of patient’s life
Better bridge therapy to kidney transplantation.
The success of the technique is improved & the risk of peritonitis has been diminished.
Decreased mortality for both patients of > 65 years old & < 65 years old as compared to HD.
Better preservation of residual renal function.
Lower risk of delayed graft function.
Higher rate of graft thrombosis.
The incidence of post transplant infections is increased as compared to HD patients.
In univariate but not multivariate analysis, PD was associated with increased risk of PTDM.
Better patient survival after transplantation as compared to HD.
Still the choice of dialysis modality before transplantation is based on patient’s preference, education & socioeconomic status and the availability of these modalities.
Mohamed Fouad
3 years ago
Renal failure patients progressively increasing in numbers worldwide and choosing the suitable RRT modality for each patient is sometimes challenging regarding availability, financial cost and long-term outcome.
Kidney transplantation is documented as the best form of renal replacement therapy (RRT) in patients with end stage renal disease (ESRD).
This article discusses the impact of each dialysis modality on kidney transplant related events.
Preemptive kidney transplantation is ideal for many patients, as it is associated with lower rates of acute rejection, increased allograft and patient survival but it is not usually available. So, majority of ESRD patients established in waiting list for transplantation spending variable time on one or more form of dialysis modalities.
Peritoneal dialysis (PD) seems of less impaction on the patient’s life, thereby allowing the patient to continue to work, travel along with encouraging patient to be independent in management of their dialysis. Hence, for the patients who plan on receiving a transplant after starting dialysis, it can be a better bridge therapy to kidney transplantation.
Several studies have addressed the outcome of kidney transplantation after PD versus HD. Some studies concluded that PD is better than HD as a choice of pre-transplant dialysis modality. In another Cohort of 92884 patients, HD as a choice of RRT was associated with an increased risk for graft failure and recipient death. On the other hand, study by Resende et al and Dipalma et al did not find any impact of dialysis modality on graft function or patient’s survival after transplantation.
Short term outcome including DGF, and allograft thrombosis: Numerous studies have investigated DGF rates and have found lower rates of DGF in PD versus HD patients. In fact, maintenance dialysis prior to transplantation is noted to be a major contributor to DGF.
Thrombosis of the graft may be higher in the PD patients as compared to their HD. PD patients are noted to have increased pro-coagulant factors such as apolipoprotein A, factors II, VII, VIII, IX, X, XI and factor XII, and hemoconcentration as compared to HD patients which can predispose them at higher risk of allograft thrombosis.
long-term outcomes, including mortality: There is conflicting data exists on mortality benefit of PD versus HD as mortality for PD and in-center HD patients was found to be similar while the ESRD patients in the waiting list. Regarding kidney transplantation outcomes, PD was associated with lower risk of cardiovascular mortality as compared to HD Referrences
Kasiske BL, Snyder JJ, Matas AJ, Ellison MD, Gill JS, Kausz AT. Preemptive kidney transplantation: the advantage and the advantaged. J Am Soc Nephrol 2002; 13: 1358-1364
Siedlecki A, Irish W, Brennan DC. Delayed graft function in the kidney transplant. Am J Transplant 2011; 11: 2279-2296 [PMID
Goldfarb-Rumyantzev AS, Hurdle JF, Scandling JD, Baird BC, Cheung AK. The role of pretransplantation renal replacement therapy modality in kidney allograft and recipient survival. Am J Kidney Dis 2005; 46: 537-549
Resende L, Guerra J, Santana A, Mil-Homens C, Abreu F, da Costa AG. Influence of dialysis duration and modality on kidney transplant outcomes. Transplant Proc 2009; 41: 837-839 [PMID
Dipalma T, Fernández-Ruiz M, Praga M, Polanco N, González E, Gutiérrez-Solis E, Gutiérrez E, Andrés A. Pre-transplant dialysis modality does not influence short- or long-term outcome in kidney transplant recipients: analysis of paired kidneys from the same deceased donor. Clin Transplant 2016; 30: 1097-1107 [PMID
From my experience in our patients, PD patients are more keen for renal transplantation and they are taking the option of PD as a bridge for renal transplantation.
Thank you so much for your kind efforts and support, Appreciating
Amit Sharma
3 years ago
1. In your own words, summarise this article.
As the prevalence of end stage renal disease (ESRD) is on the rise, so is the wait for getting a kidney transplant. While waiting for a transplant, patients are either on hemodialysis (HD) or on peritoneal dialysis (PD).
It is important to assess the effect of pre-transplant modality of renal replacement therapy (RRT) on the transplant outcomes as it will help in making an informed choice for RRT mode selection.
Data available suggests that mortality rate in patients on HD decreases with time on dialysis, while that of PD patients increases with time on PD, although the death rates are low in PD patients, regardless of age.
Post-transplant, PD patients have been shown to have reduced rates of delayed graft function (DGF), presumably due to better residual renal function and lead time bias, as compared to patients who were on HD prior to transplant. PD patients have been shown to have increased incidence of graft thrombosis as compared to HD patients. PD patients are also prone to have increased episodes of peritonitis and exit site infections, as well as post-operative infections. Increased incidence of new-onset Tuberculosis and Hepatitis C infection post transplant has been shown to be associated with HD patients. Incidence of post transplant diabetes mellitus is also more in PD patients as compared to HD patients.
Data for long-term effects including patient survival and graft survival is not clear-cut but a number of studies point towards better patient and graft survival in PD patients with 43% lower risk of death that HD patients. HD patients were shown to have increased death censored graft failure at 10 years.
2. Please reflect on your practice if possible.
In our set-up, majority of patients are initiated on HD as primary modality of RRT. Patients opting for PD are usually those who do not have a living prospective donor available. According to the published literature, PD patients have an edge over HD patients as far as graft outcomes are concerned and while discussing modalities of RRT with ESRD patients, this aspect should be highlighted.
We do highlight the positives of PD. But due to hesitancy among the patients, especially related to low self-confidence in taking their treatment literally in their own hands,PD is not very popular.
MICHAEL Farag
3 years ago
Kidney transplantation is the ideal form of renal replacement therapy (RRT) in patients with end-stage renal disease (ESRD).
Preemptive kidney transplantation is ideal for many, as it is associated with lower rates of acute rejection, increased allograft, and patient survival. However, a preemptive kidney transplant is not always possible for many reasons; disparities in health insurance, race/ethnicity, patient education level, socioeconomic status, access to healthcare, diabetes status, and regional variations.
Peritoneal dialysis (PD) leads to minimal disruption of the patient’s life, thereby allowing the patient to continue to work or school or other usual activities, along with encouraging patient empowerment in self-management. Hence, for the patients who plan on receiving a transplant after starting dialysis, it can be a better bridge therapy to kidney transplantation, especially, when a lot of patients initiating hemodialysis (HD) via catheters are associated with adverse outcomes.
overall adjusted survival probability of incident patients on PD is much better at the end of 3 years than patients on HD
Many studies had been performed to answer this question; PD or HD is a better modality as RRT before kidney transplant and the studies considered the short- and long-term outcomes.
Peritoneal dialysis shows better outcomes in the following aspects:
Flexibility, autonomy, care satisfaction, better preservation of residual renal function, better hypertension control, lower intradialytic hypotension episodes, lower risk of dementia, slower cognitive decline, better anemia management with lower doses of erythropoietin stimulating agents.
lower rates of DGF in PD versus HD patients may be due to better preservation of residual kidney function
Better long term outcome including graft and patient survival
Hemodialysis has better outcomes in the following:
Less incidence of wound infection or leakage post-operative
Less incidence of graft thrombosis
Less incidence of post-transplant diabetes mellitus (PTDM)
For me still, the choice is challenging and should be taken on an individual basis according to the patient situation (level of education, socioeconomic state, quality of life) comorbid, the availability of PD versus HD
Well done for the summary. It is well structured
I have sent you a present
Mahmoud Rabie
3 years ago
Pre-emptive renal transplantation is the best choice of renal replacement therapy. It is also associated with lower rates of rejections and increased patient and graft survival.
Patients mat stay for years on the waiting list due to many factors as PRA level, blood group, age of the patient,….etc., so most patient will need RRT while they are waiting for transplantation.
Many points may give PD an advantage over HD as an option for RRT pre transplantation.
In general, mortality rate in HD is higher than in PD and markedly more than mortality rate in transplantation.
The rate of hospitalization in PD and HD is equal.
DGF risk is more in patients received HD pre transplantation if compared to PD patients.
This can be explained by some points as the lower incidence of volume depletion in PD, and also HD patients need HD session and volume removal pre transplantation that may lead to decreased graft perfusion.
Risk of graft thrombosis is higher in patients were on PD pre-transplantation if compared to HD patients. This is because in PD there is higher levels of procoagulant factors and also the PD patients has no AV access so a hidden thrombosis tendency may be present and only discovered after transplantation.
Infection is a risk factor post TX due to the use of immunosuppressive drugs. Risk of post transplantation infections is more in PD patients if compared to HD patients especially peritonitis and UTI, however new onset TB and chronic HCV were reported after 3 months of transplantation in a pre-transplant HD patients.
PTDM is multifactorial and is not related to pre-transplant modality of RRT.
Finally, the studies showed mixed results regarding graft survival in pre-transplant PD and HD patients. While 10 years survival was better in PD than HD patients and also the cardiovascular risk as a cause of mortality post transplantation is lower in PD patients than in HD patients
Professor Ahmed Halawa
Admin
3 years ago
Dear All If you have a marginal CADAVERIC kidney offer for 2 patients. Both are in their 70s with no no difference in comorbidities. The only difference is one on HD and the second one on PD. Which patient you would prefer and why?
I think according to this paper, I will choose the PD patient to decrease the risk of DGF which is already high in this case due to the use of marginal donor kidney and also the 10 year survival rate is better in PD patients.
On other hand, the more mortality rate in HD patients if compared to to PD may give the priority to HD patient but I think it is better to give him more optimal graft.
In a prospective 70 year old transplant recipient, I am more worried about short-term outcomes and hence a PD patient would be better choice due to decreased rate of DGF (as the donor is marginal one, the chances of DGF are high and it could further rise in HD patient). Still, we have to be cautious due to higher rates of graft thrombosis and wound infections.
I will choose that on PD because of higher patient, graft survival, lower incidence of DGF, but we should focus on graft thrombosis, PTDM and peritonitis which occur higher in prior PD patients
In Cadaveric or deceased donor transplantation, the graft thrombosis and failure where similar to those patient on HD or PD prior to transplantations. In this situation, the multiple comorbids and variables has been adjusted, so my answer will be no differences in HD or PD
I think the primary recipient’s related factor that will affect the short outcome is the age itself. Kidney transplantation in the elderly is associated with an increased risk of mortality in the first 3 months and then the survival benefit of transplantation will be gained for the survivors (1). But, both recipient candidates from the proposed scenario of Dr Ahmed are of the same age and co-morbid conditions.
References:
1) Legeai C, Andrianasolo RM, Moranne O, et al. Benefits of kidney transplantation for a national cohort of patients aged 70 years and older starting renal replacement therapy. Am J Transplant. 2018;18(11):2695.
Durations of dialysis dependence beyond 10 yearsassociated with increased rates of short-term complications including delayed graft function and graft loss in short duration post transplant.
Reference: Kishikawa H, Ichikawa Y, Arichi N, Tokugawa S, Yoshioka I, Nishimura K, et al. Kidney transplantation in patients receiving dialysis treatment for more than 10 years. Transplant Proc. 2006;38(10):3445.
In the context of high risk of delayed graft function,given the donation of marginal cadaveric kidney, I will consider patient with less additional risks for DGF. But in this old age we have to take into account the risk of catheter infection/peritonitis and their outcomes especially in the postoperative period.
In the settings of same age and comorbidities, I would discuss the risks and benefits of marginal kidneys with the patients, and If both are accepting the risk I would offer it to the PD patient.
As we discussed last week, the marginal kidney is a kidney with a KDPI of more than 85% (1). The one- and 2-years allograft survival are markedly lower for this allograft category, as illustrated in the attached figure (1). Therefore, I will try to avoid the additional higher risk of DGF noted with recipients on haemodialysis. I would recommend offering this allograft to the PD patients if he accepts to receive a marginal kidney.
study by Resende et al and Dipalma et al did not find any impact of dialysis modality on graft function or patient’s survival after transplantation. Dipalma T, Fernández-Ruiz M, Praga M, Polanco N, González E, Gutiérrez-Solis E, Gutiérrez E, Andrés A. Pre-transplant dialysis modality does not influence short- or long-term outcome in kidney transplant recipients: analysis of paired kidneys from the same deceased donor. Clin Transplant 2016; 30: 1097-1107
In practical point of view I did not experience a conversation between the transplant nephrologists regarding pre transplant dialysis modality that affecting their decision regarding organ allocation.
It is not just the dialysis modality and also Durations of dialysis dependence beyond 10 years were associated with further deterioration in short-term transplant outcomes. That is why they prioritize patients based on date of dialysis initiation or wait-listing.
although this paper’s conclusion favors PD, It is not that strong with prominent differences. one could fear of PD as there is a catheter that may have complications. of course, I am in the committee (as three patients are called for each diseased patient, I will favor the one with the least immunologic risk without paying attention to the previous dialysis modality. theoretically suppose they are very similar, I don’t know to whom I may vote
The recipient risk factors that may affect the outcome of this graft:
age of the pt (better if < 65 years), but here both pts are in the 70s.However elderly patients tend to do better on PD compared to HD
The duration on renal replacement therapy(the longer the duration, the poorer the outcome like cardiovascular complications)
The presence of residual renal function(so PD help to preserve renal functions better than HD).
patients on PD shows a less incidence to delayed graft function and need for dialysis after transplantation
In view that this is a marginal kidney with lower allograft survival and that elderly patients do better on PD , so it could be a better bridge to renal transplantation than HD
Tricky question, as some debates exists on the matter
I would go for PD
Possible reasons are ;
Preserve residual kidney functions
Low cardiovascular mortality
Better immune function
optimal volume status peri-transplant /can high volume tolerate intraoperative fluid administration
Less hyperkalaemia peri-transplant
PD patient is more likely to be motivated and therefore better outcome
Ibrahim Omar
3 years ago
1- Summary :
Unfortunately, both the incidence and prevalence of CKD and ESRD are increasing worldwide. it is estimated that about 10% of the population have some degree of CKD and 10% of these CKD pts are receiving a form of renal replacement therapy. these increases are parallel with consequent increases in total costs and also the demands for functioning organs for transplantations.
No doubt that the best option for this group of pts is renal transplantation as it has the best outcome regarding well-being, lifestyle, morbidity, mortality, …. etc. it also gives the maximum beneficial effect if transplantation was done without a preceding dialysis. also, if transplantation was done after a period of peritoneal dailysis, the prognosis is better if compared to a preceding hemodialysis.
Due to the severe lake of donors, only 17% of ESRD pts get pre-emptive transplantation. the majority of remaining pts start RRT by hemodialysis rather than peritoneal dialysis and also via catheter rather than AVF. for those remaining dialysis ( HD&PD) pts, mortality is the same for them.
Renal transplantation with a preceding peritoneal dialysis has a low rates of delayed graft function and also cardiovascular mortality, if compared with a preceding hemodialysis.
Long-term effects of renal transplantation with a preceding PD are varaible as compared with a preceding hemodialysis. the results of studies comparing the 5 and 10 years graft survival and also patient survival in these 2 groups of pts, give mixed results.
2- Really, as my practice in transplantation is not high, I will adhere to the previous conclusion points.
Preemptive kidney transplantation is an ideal choice for renal replacement therapy in ESKD patients and it is associated with better patient and allograft survival, but it is not always possible due to different reasons, therefore many ESKD patients end up needing some form of RRT while they are waiting for transplantation, and they have to choose among modalities of dialysis which are fit to their lifestyle. Although the patient’s survival and quality of life is better after kidney transplantation compared to being on dialysis. PD can be preferred RRT as a bridge to kidney transplantation because of flexibility, autonomy, better preservation of residual renal function, better hypertension control, better cognitive function, better anemia management, and adverse outcomes of insertion of catheter for HD.
Regarding the outcome of kidney transplantation after HD versus PD, studies have reported mixed results.
In the USA, the majority of ESKD patients have chosen HD over PD and approximately 80% of them have catheter as opposed to AVF for HD.
In recent years, PD techniques have improved and the risk of peritonitis has declined. In addition, adjusted mortality rates are significantly lower in patients on PD compared to patients on HD, and PD is a more cost-effective modality as well.
Most studies found similar to lower rates of DGF in patients on PD versus on HD. It may be because of better preservation of residual kidney function. Other reasons such as difference in immune function, cytokine production, lower degree of volume depletion, and different responses to ischemia have been proposed as well.
Thrombosis of graft is surprisingly higher in patients on PD compared to their HD counterparts. Different reasons are proposed: underlying thrombotic tendency may be masked, switch from HD to PD because of repeat thrombosis of HD access, increased procoagulant factors, hemoconcentration, and increased presence of thromboplastin and plasminogen activator in the context of peritoneal membrane subtle inflammation.
The risk of infectious complications after kidney transplant comprising UTI, exit site infection and peritonitis is a serious concern in patients on PD and PD catheter should be removed at the earliest once no longer needed. There are mixed results regarding the increased risk of PTDM in Patients on PD.
Data regarding long-term graft survival after PD and HD is mixed. Patient survival may be better after kidney transplantation in those on PD as compared to HD. Patients on PD may be associated with a lower risk of cardiovascular mortality.
Doaa Elwasly
3 years ago
Kidney transplantation is the ideal modality of RRT in ESRD patients .
The average time on the waitlist is variable depending on age, blood group, panel reacting antibodies, history of prior transplantation. So patients will need RRT till transplantation time.
Studies concluded that PD is a better option for patients pre- renal transplantation and before liver-kidney transplantation if compared to HD.
Majority of ESRD patients chose HD over PD in the USA which is opposite in other parts of the world
PD is preferred over HD due to flexibility, care satisfaction, better preservation of residual renal function, better hypertension control, lower intradialytic hypotension, less risk of dementia, and cognitive decline as well as , better anemia management with lower ESA .
Data by the USRDS , in 2015,mentioned that mortality rate for HD patients was slightly higher than those on PD and exceeding patients who received kidney transplantation.
Elderly patients tend to do better on PD versus HD as concluded by one study, it was noticed also that elderly patients age ≥ 65 years suffer from increased risk of mortality as compared to patients < 65 years whether they were on HD or PD .
Therefore PD is cost effective with lower risk of mortality as compared to HD in pre-transplant period. DGF defined as need of dialysis within seven days of kidney transplantation. DGF rates was lower in PD compared to HD
A study stated that PD was protective against DGF in patients with hemoglobin between 12 and 13 gram/dL.
PD patients have better preservation of residual renal function, on the other hand PD patients could be more motivated and may have increased transplant access. Thrombosis of the allograft in patients previously on HD versus PD
Graft thrombosis and graft loss may be higher in the PD patients as compared to those on HD can be explained by increased pro-coagulant factors, and hemo-concentration as compared to HD
Other studies found no difference in incidence of graft thrombosis among PD versus HD patients. Risk of infection and diabetes mellitus after transplantation was noticed to be higher in PD patients as PD catheter was associated with an increased risk of exit-site infection and peritonitis .
Also studies found higher risks of peritonitis and urinary tract infection in PD patients after transplantation. But, authors reported higher risk of new onset tuberculosis and chronic hepatitis C in patients priorly on HD after 90 days of kidney transplantation
Some authors found no effect of dialysis modality on occurrence of DM post transplantation while others found increased association with PD prior transplantation Long-term outcome for prior HD vs PD patients
Kidney transplant without dialysis was associated with best survival compared to HD prior to transplant.
Other studies showed no differences between HD and PD long term outcomes , others mentioned better patient survival in prior PD treated patients
The combination of prior PD and HD had a worse survival than those on HD alone due to lower risk of cardiovascular death.
Preemptive kidney transplantation is ideal due to
lower rates of acute rejection
increased allograft and patient survival.
When compared to dialysis, patient survival and quality of life are significantly improved after kidney transplantation.
The average time on the waitlist for a deceased donor is variable.
mortality of pts who received tx< those who were on PD< those who were on HD.
elderly patients tend to do better on PD versus HD.
Individuals beyond the age of 65 have a significantly higher risk of death than patients under the age of 65.
Delayed graft function for kidney transplant
DGF defined as need of dialysis within seven days of kidney tx, occurs in 21.3%.
lower rates of DGF in PD versus HD patients.
reasons could be better preservation of residual kidney function in pts on PD,also pts on PD are less likely to be volume depleted.
Thrombosis of the allograft: Comparing prior HD to PD
thrombosis of the graft is higher in the PD patients as compared to the HD pts.
reasons could be pts on PD have increased procoagulant factors,underlying thrombotic tendencies may be masked in them.
Risk of infection and diabetes mellitus after transplantation
PD is associated with higher risk of infections post tx like peritonitis,exit site infections,UTI.higher risk of new onset tuberculosis and chronic hepatitis C with prior HD.
Long-term outcome: Comparing those on prior HD vs PD
Mixed results
conclusion
kidney tx better than PD or HD
PD associated with lower risk of hospitalisation,expenditure,mortality.
PD associated with lower risk of DGF and CVS mortality.
PD associated with higher risk of infections post tx.
allograft thrombosis and 5 and 10 yr graft and patient survival showed mixed results for PD vs HD post tx.
It’s better to do Preemptive kidney transplantation as it is associated with lower rates of acute rejection, increased allograft and patient survival.
ESRD patients are increasing steadily and majority of them choose HD (87.8%) over PD (9.6%) and 80% of patients initiated HD with a catheter as opposed to preferred arteriovenous access.
Causes of preferring HD on PD due to multifactorial :
*physician specific (lack of experience, inadequate training, comfort with HD)
*patient specific (lack of adequate PD education, health literacy, burden of therapy, age, comorbidities)
*modality specific (concerns for mortality, solute clearance, peritonitis, treatment failure, regulatory issues on PD fluid, easy availability of HD)
Peritoneal dialysis (PD) is a better choice of pre-transplant dialysis modality than HD and is considered as a bridge therapy for kidney transplantation due to preservation of residual renal function , better hypertension control , lower intra- dialytic hypotension episodes , lower risk of dementia, slower cognitive decline , better anemia management with lower doses of erythropoietin stimulating agents (ESA) and lower proportions of patients needing ESAs.
RRT modalities and their impact on short-term outcomes, including delayed graft function (DGF), and allograft thrombosis , and long-term outcomes, including mortality.
Delayed graft function for kidney transplant (DGF)
It is defined as need of dialysis within seven days of kidney transplantation.
DGF rates are lower in PD versus HD patients and the causes are unclear and may be due to :
*preservation of residual renal function.
*Difference in immune function, cytokine production, and different response to ischemic kidneys among PD vs HD
*PD patients are not likely to be volume depleted leads to adequate perfusion of the allograft.
Thrombosis of the allograft
thrombosis of the graft occurs more in PD patients than HD.
PD patients may have increased pro-coagulant factors such as apolipoprotein A, factors II, VII, VIII, IX, X, XI and factor XII, and hemo-concentration as compared to HD patients which can predispose them at higher risk of allograft thrombosis.
The reasons behind increase in these factors are mainly due to moderate non-specific inflammatory cell when the peritoneal membrane gets exposed to dialysis solutions. This leads to macrophage activation and increased presence of thromboplastin and plasminogen activator in the peritoneal cavity.
Risk of infection
post-operative infections after transplantation more common in PD patients as compared to HD patients
PD catheter is associated with increased risk of exit-site infection and peritonitis even if it’s not used so PD catheter should be removed at time of transplantation in patients with low risk of DGF. In patients with an increased risk of DGF, PD catheter can be left in place but to be removed at the earliest once no longer needed
diabetes mellitus
PD was associated with an increased risk of PTDM.
PTDM also can occur due to other factors like presence of pre diabetes, immunosuppressive medication regimen, improved appetite and weight gain post transportation
Long-term outcome
PD patients have better graft outcomes, survival and decrease Cardiovascular mortality if compared with HD patients
Dear All
Suppose you have the choice to give a cadaveric kidney (donor is 67 years old, hypertensive, eGFR before retrieval is 63 mls/min) to one of 2 potential recipients. Both are similar to in comorbidities and the same age, but one oh HD and the other on PD.
Which one would you select? The one on HD or the one in PD and why?
HD patient , because higher incidence of graft thrombosis in PD patient who may be shifted from HD because of vascular access problem
I will give it to HD patient as he is at higher risk for cardiovascular disease, dialysis access failure and many other HD complications that increase the more time he spend on HD but PD PD patients had less complications and the longevity of PD time might not affect the out come of TX
Dear Dr Ahmed,
This cadaveric kidney is considered an ECD kidney (equivalent to high KDPI). The one- and 2-years allograft survival is markedly lower for this allograft category, as illustrated in the attached figure (1). Therefore, I will try to avoid the additional higher risk of DGF noted with recipients on haemodialysis. DGF has a negative impact on the kidney allograft outcome.
I would recommend offering this allograft to the PD patient if he accepts to receive a marginal kidney.
References:
1) John Vella. Kidney transplantation in adults: Risk factors for graft failure. © 2021 UpToDate. (Accessed on 24 November 2021).
I would choose the PD patient. The PD patient had lower incidence of DGF and had better residual kidney function. Also I would consider dual kidney transplantation.
A PD patient would be better choice due to decreased rate of DGF (as the donor is marginal one, the chances of DGF are high and it could further rise in HD patient). A dual kidney transplant would be a better option.
I will select the patient on PD as the provided graft is from a marginal donor and in PD patient there is a lower rate of DGF( which is a common problem with marginal kidneys) as compared to HD patients, better volume status on PD patients, better patient and graft survival on PD patients, still dual kidney transplantation is an option if the patient accept the idea and if his anatomical and surgical condition allow.
This donor is considered a marginal donor ( ECD ) so inorder to improve outcomes and decrease incidence of DGF , I would prefer to give him to the PD patient
I will offer the kidney to patient on PD.
the justification for my choice:
I will choose the PD patient
because the donor already have marginal kidney and choosing HD patient will lead to increase the risk of graft failure
PD patient will have better graft outcomes and patient survival
It is difficult for me to make a decision and select between them only based on being on HD or on PD. I will consider other factors in both of them, such as duration of stay on HD or PD, presence of access failure or any problem with catheters, and the adequacy of dialysis.
If the situation is exactly similar between them and there isn’t any urgency or emergency for kidney transplantation, I will select patient on PD, because of lower risk of DGF and better patient survival.
Based on the comorbidities of the donor, kidneys are considered from the expanded criteria donor. The decision is not easy. In the context of high risk of delayed graft function, given the donation of marginal cadaveric kidney, I will consider patient with less additional risks for DGF. But in this old age we have to take into account the risk of catheter infection/peritonitis, allograft thrombosis and their outcomes especially in the postoperative period.
In the settings of same age and comorbidities, I would discuss the risks and benefits of marginal kidneys with the patients, and If both are accepting the risk I would offer it to the PD patient, but both are still candidates.
This is DD transplant with marginal donor by age and comorbid with the current GFR , in this case there is high risk of DGF anyway for both with increased chance infection in case of use of PD catheter post transplantaion as access for dialysis , in that case may be logical such marginal donor will go to HD recipient as his survival rate on waiting list will be lower compaired to PD Patient with preserved kidney function
To the HD patient as he is at higher risk for CVD and dialysis related complications with poorer outcome in comparison with PD patient , while the other patient being on PD modality may indicate better residual kidney function than the HD patien , also as the transplanted graft is a marginal graft ( ECD) and the risk of graft thrombosis is higher in PD patients , thus itis better to give it to the HD patient.
Dear All
Thank you very much for your reflection. This question represents a grey area in transplantation. It depends on your justifications. I do not feel (no enough evidence) regarding the thombogenicity of PD.
I will chose the PD patient for the following reasons (all mentioned)
PD patients has better outcomes with DGF .. and residual kidney function.
This considered marginal kidney doner so we dual tx must be in consideration .
I would select PD one .
Due to :
1- Better preservation of residual kidney functions on PD.
2- Better patient survival who is predominately on PD prior to transplantation.
3- Expenditure is less in PD than HD.
4- Risk of TB and chronic hepatitis C in 90 days after TX those who are on HD prior to TX.
5- Better graft outcomes in patient predominant on PD prior to TX.
6-DGF is less likely with PD due to daily PD provide patients with less likely to be hyperkalaemic , overloaded or need additional treatment prior to TX.
It’s better for both to receive kidney transplantation even ECD as renal transplantation has better survival and quality of life than those who still in waiting list .
i will prefer to give this kidney for PD pt , as he has lower rate of DGF, CV complications also there is residual kidney function which will help the transplanted kidney….
Sir…
This donor becomes ECD (expanded criteria donor). I would prefer to give this ECD to patient on PD as they would better tolerate the DGF which is anticipated after transplant as they would have better native urine output and less immunogenic as compared to HD patients lowering the further risk of immune activation
i will choose the reciepient who was on PD . because this graft has high risk of delayed graft function and the patients on HD also has higher risk foe delayed graft function compared to HD .
PD patients having residual kidney function ;making PD a reasonable option
Pre-emptive kidney transplantation is the best option and is associated with the best patient and graft survival. All patients with CKD will need renal replacement therapy at some point in time. Adequate, counseling is needed regarding the type of dialysis PD vs HD and also in the mean time referral to transplant center for the best option for him.
Peritoneal dialysis has many advantages and it can be done at home. It reserves residual renal functions, avoidance of recurrent hospital visits, least interference with cardiac status, less microinflammation, and serves as the best bridge therapy before transplantation.
Data from USRDS in 2015 suggest that HD patients have higher mortality as compared to PD. Overall survival probability is better in PD after 3 years of PD initiation as compared to HD. With regards to the hospitalization rates for PD and HD, HD patients have higher initial hospitalization rates as compared to PD patients, who get admitted later due to catheter-related Peritonitis. In the Pre transplant period, PD is always better as it is associated with lower costs as compared to HD .
In terms of DGF:
HD patients will be dialyzed before Transplant and some form of volume depletion may contribute to decreasing perfusion pressure of transplant kidney.
Graft thrombosis may be higher in PD patients as compared to HD patients. In PD patients their hypercoagulable state is unmasked and it is revealed only at the time of transplant.
Overall PD patients have a lower risk of hospitalizations, a lower risk of infection as compared to HD. PD patients and incenter HD have the same mortality as per studies from the USRDS data. However, in terms of post-transplant outcomes, PD patients have better graft and overall survival with less incidences of DGF.
Abstract
The population of patients with end stage renal disease (ESRD) is increasing,
lengthening waiting lists for kidney transplantation. Majority of the patients are not able
to receive a kidney transplant in timely manner even though it is well established that
patient survival and quality of life after kidney transplantation is far better when
compared to being on dialysis. A large number of patients who desire a kidney transplant
ultimately end up needing some form of dialysis therapy. Most of incident ESRD patients
choose hemodialysis (HD) over peritoneal dialysis.
Introduction:
transplantation is the ideal form of RRT in patients ESRD.
Preemptive kidney transplantation is ideal for many, as it is associated with lower rates
of acute rejection, increased allograft and patient survival.
. However, a preemptive kidney transplant (17% overall) is not always possible for many
patient.
ESRD DEMOGRAPHICS:
As per the United Network for Organ Sharing, in 2017, there
were 94897 patients on the waiting list.
ESRD OUTCOMES :
In recent times, success of PD technique has improved and risk of peritonitis had
dwindled. Review of the data also suggests that as per the USRDS.
Delayed graft function for kidney transplant:
DGF defined as need of dialysis within seven days of kidney transplantation, occurred in 21.3% of patients .
Numerous studies have investigated DGF rates and have found mostly similar to lower
rates of DGF in PD versus HD patients.
Thrombosis of the allograft:
Comparing prior HD to PD In contrast to DGF, thrombosis of the graft may be
surprisingly higher in the PD .
Risk of infection and diabetes mellitus after transplantation
Patients receive multiple immunosuppressive medications in post-transplant period
which increases the risk of infections. Infectious complications related with PD catheter
after transplantation remain a concern also PTDM common with PD.
Introduction:–Kidney transplantation is the ideal form of renal replacement therapy in patients with end-stage renal disease .
-Preemptive kidney transplantation is associated with lower rates of acute rejection and increased allograft and patient survival.
-A lot of patients are removed from a waiting list for renal transplant due to death or decline in medical condition.
-The average time on the waitlist for a deceased donor is quite variable depending on age, blood group, panel reacting antibodies, history of prior transplantation.
– According to several studies PD is better as a transient therapy to renal transplantation than HD .
ESRD demographics
-In the USA, In –center HD is the most common modality of renal therapy than PD while in other countries like Qatar, Mexico, New Zealand, Thailand PD is more used than HD.
-PD is the a better form of RRT than HD because of its flexibility, autonomy, care satisfaction, better preservation of renal function, better hypertension control, lower intradialytic hypotension episodes, low risk of dementia, slower cognitive decline, better anemia management, and lower proportion of patient needing erythropoietin.
-Expenditure of PD is better than HD but much higher than the cost for transplant patients and the overall adjusted survival probability of incident patients on PD better than patients on HD.
-HD and PD patients have similar hospitalization rates but almost double those of patients with kidney transplantation.
Delayed graft function for kidney transplant:
-It is defined as the need for dialysis within the 1st seven days of kidney transplantation.
-DGF is lower in PD than HD as PD patients are not likely to be volume depleted so ensure adequate perfusion of allograft, and there are differences in immune function and cytokine production.
Thrombosis of allograft :
-Thrombosis of graft is higher in the PD patient compared with HD patient , may be due to the relative
-PD patients have increased Pro-coagulant factors and hemo-concentration as compared to HD patients.
Risk of infection and diabetes mellitus after transplantation:
-Infectious complications related to PD catheter may occur after transplantation.
– DM is dependable on multivariable factors but not evidenced to be related to a specific dialysis modality.
Long-term outcome:
-Preemptive kidney transplant was associated with better patient’s survival and graft’s survival as well.
-PD is associated with better allograft and patient survival than HD patients.
patient survival and quality of life after kidney transplantation is far better when compared to being on dialysis.
some studies have favored PD as a better choice of pre-transplant dialysis
modality than HD.
Preemptive kidney transplantation is ideal for many, as it is associated with lower rates of acute rejection, increased allograft and patient survival .
for the patients who plan on receiving a transplant after starting dialysis, PD can be a better bridge therapy to kidney transplantation, especially, when a lot of patients initiating hemodialysis (HD) via catheters are associated with adverse outcomes.
Among all prevalent ESRD patients,
63.2% of patients were on HD,
29.6% had a functioning kidney transplant and
only 7% of patients were utilizing PD.
PD is an acceptable and could be a preferred form of RRT owing to
adjusted mortality rate for patients on HD was slightly higher than patients on PD
another study showed two important findings, mortality rates for PD patients were much lower as compared to HD and secondly elderly patients tend to do better on PD versus HD.
overall adjusted survival probability of incident patients on PD is much
better at the end of 3 years than patients on HD
Delayed graft function for kidney transplant
DGF defined as need of dialysis within seven days of kidney transplantation,
Numerous studies have investigated DGF rates and have
found mostly similar to lower rates of DGF in PD versus HD patients. .
A large study investigated this question also found a lower incidence of DGF
among PD patients .
Thrombosis of the allograft: Comparing prior HD to PD
In contrast to DGF, thrombosis of the graft may be surprisingly higher in the PD
patients as compared to their HD counterparts
Risk of infection and diabetes mellitus after transplantation
incidence of post-operative infections after
transplantation was found to be increased in PD patients as compared to HD patients
. another study found higher risks of peritonitis and urinary tract infection in PD patients
after transplantation .
Long-term outcome: Comparing those on prior HD vs PD
Preemptive kidney transplant without dialysis was associated with excellent patient
survival compared to HD prior to transplant . another group reported better graft outcomes in patients previously treated predominantly with PD as compared to HD patients
Introduction:
Ideally Pre emptive kidney transplantation is the best fo CKD V patients and is associated with best patient and graft survial. It has been reported to have better survival rates as compared to dialysis and transplantation after dialysis too. However worldwide the rates of pre emptive transplants are very low (around 17%) due to poor patient acceptance, lack of patient education and counselling.
All patients of CKD will need renal replacement therapy at some point of time. Adequate, multiple episodes of counselling are needed regarding the pros and cons of PD vs HD. Infact patients can even be introduced to another patient on HD and PD to interact and understand the process better.
Peritoneal dialysis has many advantages and it can be done from home. It reserves residual renal functions, avoidance of recurrent hospital visits, least interference with cardiac status, less microinflammation and serves as the best bridge therapy before transplantation.
ESRD outcomes of HD and PD:
Age adjusted mortality data from USRDS in 2015 suggest that HD patients have a higher mortality as compared to PD. It was clear from studies that PD patients did better as compared to HD patients in the initial few days (first 90 days). Elderly patients do better on PD as compared to HD.
Overall survival probability is better in PD after 3 years of PD initiation as compared to HD. With reagrds to the hospitalization rates for PD and HD, HD patients have a higher initial hospitlization rates as compared to PD patients, who get admitted later due to catheter related UFF and Peritonitis. in the Pre transplant period, PD is always better as it is associated with lower costs as compared to HD barring the initial admission cost for PD.
Delayed Graft function and Kidney transplant:
The available evidences are contradictory. Few studies have shown no difference in the overall outcome of PD and HD towards delayed graft function. Few studies have shown PD patients to have less incidence of DGF due to better preservation of residual renal function, less immune activation due to “natural” membrane as compared to synthetic membrane exposure in HD, lead time bias in PD patients being more motivated and allowing access to transplant, better volume status prior transplant as they usually are allowed normal fluid. HD patients on the other hand will be dialyzed before Transplant and some form of volume depletion may contribute to decrease perfusion pressure of transplant kidney.
Graft thrombosis and PD vs HD:
thrombosis of the graft maybe higher in PD patients as compared to HD patients. HD patients are often heparinized so making them less susceptible to thrombosis. In PD patients their hypercoaguable state is unmasked and it is revealed only at the time of transplant. PD patients are transferred after graft/AVF thrombosis in HD so studies would have shown PD patients to be ironically more thrombogenic. PD patients are proven to have higher levels of apolipoprotein A, factors II,IV,X,IX due to constant stimulation of the peritoneal membrane by glucose based fluids.
Risk of infection after Transplantation:
Patients with DGF who need transient PD after transplant have a higher chance of wound infection and skin leak. Studies have also shown exit site infection even if the catheter was not used.
no major difference in the incidence of PTDM was noted.
Overall PD patients have lower risk of hospitalizations, lower risk of infection as compared to HD. PD patients and incenter HD have the same mortality as per studies from the USRDS data. However in terms of post transplant outcomes, PD patients have better graft and overall survival with less incidences of DGF. The conflicting rates in various studies are due to number of patients in the US being more on HD as compared to Europe, Australia and Canada where PD is very popular.
Practices followed in our country:
The choice is driven by patient and care giver education level, their accessibility to hospital and dialysis centers and the insurance coverage if any.
We follow a practice to initiate elderly patients with cardiac dysfunction on PD as they tolerate it better. If the family accepts, a caregiver is usually trained in the hospital by our trained PD staff over 2 weeks before discharge. They are then followed up daily by them over phone and complications are reported to us. It is sad that PD has become a dialysis only by the rich as most of the insurance companies do not give coverage for out patient PD. It is very vital that they recognize this form of dialysis to get covered by the insurance. Hemodialysis is accepted by many others as it is easily available and accessible and most importantly covered by insurances.
Renal Tx offers better patient survival and quality of life compared with dialytic therapy. Due to of lack ,its timely feasibility dialytic therapy is used s bridge to Tx and PD is underutilized in spite of being favored to HD .Causes explaining this are different including for example, physician experience ,patient culture ,PD related issues with easier availability of HD and its profitability.
ESRD OUTOMES
Survival probability at 3 years is better with PD than HD .PD is superior to HD financial wise but both PD and HD are inferior to Tx .Hospitalization rate is the same in both and PD and HD and double that in case of Tx .PD has lower mortality than HD.PD patients are more likely candidates for Tx due to underutilization.
Delayed graft function for kidney transplant
Better outcome regarding DGF is in favor of PD .Some explanations include better residual kidney function ,immunogenic aspects ,with different response to ischemic kidneys in PD vs HD. Regular HD before Tx is a major contributor to DGF .Absence of hyperkalemia in PD abates need for additional HD session before Tx .Adequate volume status in PD leads to good perfusion to the allograft ;the reverse applies for HD .Pre Tx HD counter the beneficial effect of intra-op aggressive hydration on DGF.
Thrombosis of the allograft
Some studies support increased thrombosis in allograft in cases of PD due to various causes while others do not.
Risk of infection and DM after Tx
Post op infections increased in PD comparted with HD .In contrast ,risk of new onset TB and chronic hepatitis C are increased in HD.
Risk factors of for PTDM are not related to dialytic modality .However, PD was found to be associated with PTDM in univariate analysis but not in a multivariate analysis in another study.
Long term outcome
Pre-emptive Tx has the best outcome among different RRT options .Survival is better in case of PD compared with HD .HD dialyzer membrane could have deleterious immunogenic impact so increasing risk of graft loss. Cardiovascular mortality is lower in PD .Lack of deserved interest in OD among medical care givers affects patient culture and consequently his preferences and actual use to be directed to patient education for better care and outcome. of RRT option .Efforts are needed .
In Saudi Arabia, PD mainly available in governmental centers; aforementioned explanations stand behind that pattern of practice especially patient culture as relate companies supplies materials , training for doctors and patients together with necessary technical support
Kidney transplantation is ideal form of renal replacement therapy as it is provide best quality of life and for patient survival than being on dialysis .
However dialysis consider as a bridge therapy to those who plan to receive transplant or on waiting lists.
In contrast to USA , PD is under-utilised due to lack of experience,inadequate training, comfort with HD and other factors may related to patient.
PD is an acceptable and could be a preferred form of RRT due to flexibility, autonomy, care satisfaction .better preservation of residual renal function ,better hypertension control
, lower intradialytic hypotension episodes
, lower risk of dementia, slower cognitive decline.
better anemia management with lower doses of erythropoietin stimulating agents, and lower proportions of patients needing ESAs.
ESRD OUTCOMES :
*Studies done to patients started renal replacement therapy with HD shown that mortality rates in patients
< 65 years of age decreased in comparison to patients aged ≥ 65 years . But to those who started renal replacement therapy with PD , mortality rate increased in both patients aged less or more than sixty five years.
* survival probability on PD much better at end of 3 years than patients on HD .
* Expenditure of PD is better than HD and HD is highly cost than TX.
* hospitalisation rates is similar in both HD and PD but double in kidney transplantation.
~ Delayed graft function for TX :
DGF is need for dialysis for 7 days of TX .
* low incidence of DGF with PD than HD.
* PD is protected against some DGF with haemoglobin (12-13 g/d).
* Increased risk of wound infection and leakage in PD than HD .
* Shortened length of hospitalisation and lesser time requiring for dialysis post operatives in PD than HD.
* GFR is the same within 1 month , 6 month or 1 years in both HD and PD.
* HD is more related to DGF than PD as pd provide daily dialysis , so patient is less likely to be hyperkalaemic or overloaded with less requirement to additional treatment prior to TX.
* Thrombosis of allograft may be higher in PD than HD due to moderate non specific inflammatory cells harvesting when the peritoneal membrane exposed to dialysis solution , this leads to macrophage activation and increase presence of thromboplastin and plasminogen activator in peritoneal cavity.
* Risk of infection is higher with PD than HD , as PD catheter increase risk of extra-site infection and peritonitis with risk of leakage of dialysate fluid from surgical incision , so better to remove PD catheter if there is no longer needed.
* On other side , high risk of new onset TB and chronic hepatitis c in patients after 90 days of TX in those treated with prior HD.
~ Long -term outcomes in PD vs HD:
* Better graft outcomes in patients previously treated with PD in comparison to HD.
* High risk of death censored graft failure in multivariate analysis in HD in comparison to PD after 10 y of follow up.
* Better recipient survival who on predominant PD prior to TX .
* Lower post post transplant mortality on those with preceding PD than HD , this may due to immunogenicity of HD membrane.
* PD patients are better prepared with increased access transplantation care both pre and post .
.
Choice of dialysis modality prior to kidney transplantation: Does it matter?
ESRD has 3modalities for RRT which are HD,PD and kidney tranplantation.
Kidney tranplantation is ideal therapy regarding multiple aspects like mortality,morbidity, quality of life and financial burden in comparison to other modalities.
There are agap between time of renal transplantation and patient need for RRT in which patient will start another modality such as HD or PD and patients are admitted to waiting list with median 4y waiting for newly listed patients according to SRTR registry. a preemptive transplantation not exceeding 17% of all CKD patients which is ideal in many aspects loke rate of rejection, patient and graft survival.
Peritoneal dialysis is more physiological process associated with better patient quality of life,less hypovolemic and hypotension episodes ,lower risk of dementia and cognitive disorders, better anemia and hypertension control but this modality is underutilized because
1) physician specific:lack of experience, inadequate training, comfort e HD and difficult acute line insertion.
2) patient specific: lack of education, burden of therapy,age and comorbidities.
Modality specific: concern about mortality,solute clearance, peritonitis and treatment failure
ESRD outcomes
1)Mortality rate: slightly higher in HD specially in elderly patients
2)Expenditure:PD(75140$)HD(88750$)RTX(34084$)per patient per year
3)Hospitalizations: similar but double kidney tranplantation
Kidney tranplantation outcome
1)DGF:after adjustment of multiple clinical covariates,PD lower than HD in risk of DGF this because PD patients have better anemia control,lower risk of hypovolemia or hyperkalemia,less cytokines and good residual kidney function
2) infection:higher in PD than HD but one year survival and graft loss related to infection are the same.
Thrombosis: PD more risk of thrombotic event than HD and maybe due to no AV fistula to discover thrombotic tendency ,PD patients shifted from HD after failed access after its thrombosis and increase procoagulation factors in PD as compared to HD
Infection PD associated with increase risk of peritonitis,exit site infection and leakage of dialysate from surgical incision it’s better to remove PD catheter once there is no reason to keep it on the other hand HD associated with increase risk of TB and chronic HCV
PTDM univariate analysis but not multi variety analysis showed PD associated with increase risk of PTDM
Long term outcomes:premptive is the best regarding CVS mortality and graft survival but long term graft survival after PD and HD is mixed and after controlling for multiple varieties HD higher in graft failure and patient mortality.
So current evidence favor PD over HD regard lower risk of hospitalization, Expenditure and mortality and associated with lower DGF and CVS mortality but increase in risk of thrombosis and infection
Dialysis modality has impact on renal transplantation and preemptive transplantation should be encouraged
My own experience about PD pre-transplant is very limited as this modality nearly not available.
●Preemptive is the best modality for ESRD
●preemptive kidney transplant (17%
overall) is not always possible for many reasons:
disparities in health insurance, race/ethnicity, patient education level,
socioeconomic status, access to healthcare, diabetes status and regional variations.
●PD
PD is an acceptable and could be a
preferred form of RRT owing to flexibility, autonomy, care satisfaction, better
preservation of residual renal function, better hypertension control, lower intra-
dialytic hypotension episodes, lower risk of dementia, slower cognitive decline
,better anemia management with lower doses of erythropoietin stimulating agents
(ESA) and lower proportions of patients needing ESAs
. It is largely underutilized inthe USA due to variety of reasons which have been explored by many researchers andfound causes to be multifactorial which were physician specific (lack of experience,inadequate training, comfort with HD); patient specific (lack of adequate PD
education, health literacy, burden of therapy, age, comorbidities); modality specific
(concerns for mortality, solute clearance, peritonitis, treatment failure, regulatory
issues on PD fluid, easy availability of HD); and financial incentives for HD units.
●mortality rates for PD patients were much lower as compared to
HD and secondly elderly patients tend to do better on PD versus HD. However, one
concern from this mortality data arises that whether it is PD or HD, elderly patients
age ≥ 65 years suffer from far more increased risk of mortality as compared to patients
HD
post-transplant peritonitis especially among those who had DGF
requiring dialysis. In addition, PD catheter was associated with an increased risk of
exit-site infection and peritonitis even if it’s not used[52]
. There is also a report of
increased conversion from PD to HD after transplant due to leakage of dialysate fluid
from surgical incision.
2:diabetes mellitus:no difference ,but PD was associated
with an increased risk for PTDM in univariate analysis, but not in multivariate analysis. The factors associated with new onset of diabetes after transplantation aremultiple and variable, but not limited to presence of pre diabetes,immunosuppressive medication regimen, improved appetite and weight gain post-transplant among other.
●Long-term outcome: Comparing those on prior HD vs PD:
Tang et al ,did not found 5 years graft survival rate to bedifferent with pre-transplant PD as compared to HD technique in their meta-analysis
(HR 0.92, 95%CI: 0.84-1.01, P = 0.08).
– DGF is a common post transplantation complication, it was found to be more in hemodialysis patients than PD ones. Reasons may be Pd patients are more welling for kidney transplantation. Also, PD patients has less inflammatory cytokines and IHD than HD patients.
– Regarding thrombosis in grafts, it occurs more in PD pateints who may have more coagulation factors.
– PTDM and infection are more common among PD patients.
– There are controversy regarding long term outcomes among both modalities, however, more studies are noting a better bias for PD than HD patients.
Thanks Dr Mahmoud
Please expand on your answer.
Kidney transplant is considered the typical line in the management of ESRD patients but sometimes the patients need to wait until transplant due to alot of factors so dialysis must be initiated and several causes and it’s effect on transplant outcome(long and short term) should be taken in consideration and this article shows the variables of both modalities and their effect on graft survivalusing PD has less effect on daily activity and it’s preferred especially after decreasing the risk of peritonitis.
MORTALITY RATES:is much higher in HD in different age group also old age patients have better condition than HD that effect on the transplantation ,PD has less cost effect ,but in hospital admission rate both are the same .
DELAY GRAFT FUNCTION (DGF): can be avoided by keeping the patient in good hydration state especially at time of operation this will minimize the need of dialysis in the first few days after transplantation, DGF is low in PD patients also there is difference in hospitalization post transplant due to PD patients have higher eDFR than HD patients and more electrolytes disturbance in HD patients.
THROMBOSIS OF THE ALLOGRAFT:most studies show risk of graft thrombosis is higher in PD patients this may due to activation of pro coagulatory factors ,when peritoneal membrane come in contact with dialysis fluid this lead to inflammatory cells activation thus macrophages activation and also presence of plasminogen and thromboplastin in the peritoneal activity also the patient may have history of HD with thrombosis vascular access ane then switched to PD.
DIABETES AND INFECTION :PD catheter is the main risk factor for infection and sometimes in case of DGF need to do HD in PD patients due to leakage of dialysis fluid from graft site ,this make infection rate is higher in PD ,also diabetes is more common in PD .
LONG TERM OUTCOMES: patients survival is better in PD patients and long term kidney survival is better this due to less cardiovascular disease and low mortality rate due CVD in PD patients.
Regarding the question
Since both patients have similar comorbidities so the choice will depend on the effect of the donor kidney on outcomes and since DGF is lower in PD and long term survival also better in PD so I will prefer PD patient especially in case if deseaced donor.
Well done
While preparing the ESRD patient for transplantation , most of them require dialysis , numerous studies tried to to determind which dialysis modality is better for transplant patients HD or PD . Current evidence Prefers PD over HD as pretransplant dialysis modality of choice as it is associated with Better short term graft outcome as it is associated with lower incidence of DGF and postransplantation hospitalization . This may be related to presence of residual kidney function , PD patients are less likely to suffer hyperkalemia or volume overload thus don’t require more pretransplantation dialysis sessions which is a major cause for DGF. For graft thrombosis, it was higher in PD patients compared with HD patients, this may be due to undiagnosed hypercoagulable statue in the patient that was not discovered as there was no previuos dialysis access thrombosis.
Regarding posttransplantation infections ,there was higher incidence of infections in PD than HD patients specially PD Cather exit infections, UTI and peritonitis.
Regarding posttransplantation DM, GFR, hospital readmition within 6 months, acute rejection episodes and graft loss at one year, there were the same in PD and HD patients .
In zagagig nephrology depatrment , we only shift the patients to CAPD when no further vascular access is available. PD is not our first choice modality of dialysis as our patients commonly suffer from peritonitis and Cather obstruction. Also, PD requires highly educated patients and their relatives which is not always present.
Summary of the reveiw article:
The prevalence of chronic kidney disease (CKD) is increasing worldwide with increasing numbers of patient reaching ESKD requiring renal replacement therapy, more old patients with ESRD with comorbid, kidney transplantation remained the best treatment associated with improved Quality of live and better patient survival as compared being on dialysis, the preemptive kidney transplant is the ideal choice once affordable , most patients with ESKD , choose HD over PD dialysis in USA and this may be explained by many factors related to the physician choice , lack PD facility or training , cost , in addition to other factors related to the patients education , social and fanatical support
The objective of this study :
1-Discuss the ESRD demographics and outcome
2-Type of dialysis and associated kidney transplant events
3- to review the current evidence in regards to choice of
RRT and impact on kidney transplantation outcomes,
Short term outcome measures the prevalence of DGF, graft thrombosis
And mortality rate as long-term outcome.
ESRD Demographics:
According to the recent data from USRDS registry 2017 there is steady increase in patient with ESRD waiting for kidney transplantation since, with increasing age around 43% they are above 50s years with a range (50-65) with increased number of old patients on hemodialysis 23% above the age of 65years on dialysis and waiting for kidney transplant Recently the incidence of ESRD increasing with in time, the unadjusted incidence rate of 380/ million with more than 36% they did not have predialysis care ,in addition 83% they started on HD with more than 80% with catheter as access for HD ,hemodialysis was the preferred mode over PD, while in center HD mode was preferred in 98% OF HD patients with fewer using home HD mode.
PD as RRT is underutilized in USA as compared with other countries like hoingkoing , more than 70% using PD program , Mexico 50%
PD is preferred as first choice of dialysis as its associated with better BP control, anemia control and preservation of renal function, lower interdialytic hypotension, care stratification and flexibility with treatment
In USA the use of PD was limited to less than 7% due to physician decision center preference , lack of training or expertise in PD , also due to factors related to the patients like lack of education about the procedure , health literacy age , comorbid , social support.
ESRD outcome:
Mortality rates for PD patients were much lower as compared to HD.
HD patients have higher rate of death compared to PD and its even higher in old Hemodialysis patients with longer waiting list for transplant.
PD is cost effective mode compared to HD
Hospital admission rate similar for both modalities at earlier years but within time the Hospital admission rate will be higher in PD population (infection).
Delayed graft function for kidney transplant:
The DGF rate was higher in HD patients versus PD patients, this is confirmed by many studies after adjustment of multiple clinical covariates.
Thrombosis of the allograft was higher in PD patients
Risk of infection and diabetes mellitus after transplantation:
Infection rate increased in PD patient in post transplantation especially in the Prescence of DGF with increase risk of exit site infection , peritonitis and peritoneal fluid leak from the wound, In addition many studies confirm higher rate of PTDM among PD patients .
Long-term outcome: Comparing those on prior HD vs PD:
pre- emptive kidney transplantation associated with better survival
over all better survival rate in prior PD mode of RRT this can be explained by better preparation, preserved renal function and easier access to transplantation with lower cardiovascular death post kidney transplantation but the 5 years and 10 years survival rate was similar between two modalities.
In conclusion:
The ESRD prevalence is globally increaing with high numbers of patients on renal replacement therapyincluding more old populations in waiting list for transplantion kidney transplantation is the Preferred renal replacement therapy for ESKD patients and preemptive kidney transplant associated with the best survival outcome,
in USA the hemodialysis with catheter as access is the preferred mode of RRT, PD is associated with lower rate of DGF, lower cardiovascular death, but higher rate of garft thrombosis ,infection and PTDM as compared to HD mode ,access to PD need better attention by health autherity with improving the educational gaps about this mode of RRT at the level of the physicians and patients whom involved in this treatment its affordable with less cost compared to HD.
in reflection to my current practice , the PD serviece not available currently in our centre as we have only in-centre hemodialysis service but we do do all the educations regarding the all facilities including PD and according to the patient choice will proceed as the PD Service in Oman under the MOH care.
also the evidence from this review based on review of cohorts of retrospective obervational studies so we need more research for fruther calrifications .
Preemptive kidney transplant without dialysis is associated with excellent graft outcome as compared to dialysis.
There is reported better graft outcome and patient survival in patients treated with PD compared to HD patient.
The risk of death censored graft failure is higher in HD patients as compared to PD patients .
Cardiovascular mortality is increased in HD patients compared to PD patients.
Maintenance dialysis prior transplantation is one of the contributor for delayed graft function .
There is better out come in term of delayed graft function in PD compared to HD, may be due to differences in immune function , cytokines production and response to ischemia (as the volume status is affected by mode of dialysis) .
Incidence of allograft thrombosis is higher in PD compared to HD, this can be explained by increased in pro-coagulant factors in PD patient (due to peritoneal inflammatory response to dialysis solution exposure).
Infection post transplantation found to be increased in PD patients compared to HD patients specially in those who had DGF. In addition PD catheter increases the risk of exit-site infection and peritonitis In patient with increase risk of DGF ,PD catheter showed be removed once no longer needed . risk of UTI and peritonitis is increased in PD patients . There is reported increase risk of tuberculosis and chronic hepatitis C virus in HD patients.
PD found to associated with increase of post transplant diabetes , but not in multivariate analysis.
The choice of dialysis modality prior to transplantation is a matters.
Regarding effect dialysis modality in transplantation in my practice;
No study in our area ,discussing this issue
We have small number of PD patients
They remain for a long period of time in PD
Infection is noticed in PD and is usually occur during the first week post transplant ( mainly peritonitis).
Cardiovascular complications is seen more HD patients.
Preemptive kidney transplantation is the ideal form of renal replacement therapy (RRT) in patients with end stage renal disease (ESRD). Because it is associated with lower rates of acute rejection, increased allograft and patient survival
Peritoneal dialysis (PD)is associatied with minimal disruption of the patient’s life, So the patient can be continue to work or go to school.it is considered as a bridge therapy for kidney transplantation.
DGF
DGF defined as need of dialysis within seven days of kidney transplantation
Because PD is performed daily so the patients are less likely to develop hyperkalemia or fluid over load and these patients have better preservation of residual renal function hence are less likely to need additional treatments just before kidney transplantation.
PD patients are not likely to develop volume depletion so this will also maintain adequate perfusion of the allograft. HD prior to transplant associated with volume depletion which result in decreased perfusion of the transplanted organ which may be lead to tubular necrosis and increased risk for graft failure
Thrombosis of the allograft
thrombosis of the graft occurs more in PD patients than HD. Because underlying thrombotic abnormalities may be masked during PD Since PD patients do not have an arteriovenous access.
PD patients may have increased pro-coagulant factors such as apolipoprotein A, factors II, VII, VIII, IX, X, XI and factor XII, and hemo-concentration as compared to HD patients which can predispose them at higher risk of allograft thrombosis.
The reasons behind increase in these factors are mainly due to moderate non-specific inflammatory cell when the peritoneal membrane gets exposed to dialysis solutions. This leads to macrophage activation and increased presence of thromboplastin and plasminogen activator in the peritoneal cavity.
Risk of infection
post-operative infections after transplantation more common in PD patients as compared to HD patients
PD catheter is associated with increased risk of exit-site infection and peritonitis even if it’s not used so PD catheter should be removed at time of transplantation in patients with low risk of DGF. In patients with an increased risk of DGF, PD catheter can be left in place but to be removed at the earliest once no longer needed
diabetes mellitus
PD was associated with an increased risk of PTDM. PTDM also can occur due to other factors like
presence of pre diabetes, immunosuppressive medication regimen, improved appetite and weight gain post transportation
Long-term outcome
Preemptive kidney transplant is associated with excellent patient survival compared to HD prior to transplant.PD patients have better graft outcomes,patients survival and decrease Cardiovascular mortality if compared with HD patients
In our center we are dealing with pediatric age group so we prefer to do PD more than HD because of difficult vascular access in pediatric and risk of frequent hypotension when we put the child on hemodialysis machine
SUMMARY OF THE ARTICLE
Choice of dialysis modality prior to kidney transplantation: Does it matter?
A large number oF ESRD patients who desire a kidney transplant ultimately end up needing some form of dialysis therapy.
Preemptive kidney transplantation is ideal for many, as it is associated with lower rates of acute rejection, increased allograft and patient survival. However, a preemptive kidney transplant (17% overall) is not always possible for many reasons which were explored by Jay et al, which included disparities in health insurance, race/ethnicity, patient education level, socioeconomic status, access to healthcare, diabetes status and regional variations. It is also well established that patient survival and quality of life after kidney transplantation is far better when compared to being on dialysis.
PD is an acceptable and could be a preferred form of RRT owing to:
ESRD OUTCOMES
RELATION OF RRT MODALITY TO POST-TRANSPLANT EVENTS
1.Delayed graft function for kidney transplant
2.Thrombosis of the allograft: Comparing prior HD to PD
Reasoning and Justifications for thrombosis of the allograft in PD with higher rate than HD:
3.Risk of infection and diabetes mellitus after transplantation
Risk factors for post-transplant diabetes mellitus (PTDM):
4.Long-term outcome: Comparing those on prior HD vs PD:
1.Preemptive kidney transplant without dialysis was associated with excellent patient survival compared to HD prior to transplant (HR 0.81 with 95%CI of 0.73-0.89, P < 0.001)[9].
2.Data on long-term graft survival after PD and HD is mixed from most studies.
3.Ten year graft survival was reported to be similar between a cohort of 80 HD and 80 PD patients.
4.Patient survival may also be better after kidney transplantation in those on preceding PD as compared to HD.
Overall,the choice of dialysis modality prior to kidney transplantation matters:
The no. Of ESRD patients is increasing and the well known best form of RRT is kidney transplantation .
Pre emptive kidney transplantation has better outcomes regarding less incidence of acute rejection and better patient and graft survival,
However this option is not always available for all patients .
This review emphasis on the better RRT option while awaiting kidney transplantation, regarding short and long term outcomes .
Studies comparing HD and PD outcomes related to transplantation , showed mixed results , however increasing evidence that PD is associated with less complications and better patient and graft survival .
Regarding short term outcomes , patients with pre transplant PD ,are less likely to develop DGF , but more likely to have vascular thrombosis than HD patients.
PD patients were at higher risk for peritonitis and UTIs after transplantation.
HD patients were at higher risk of TB and chronic HCV infections after transplantation.
And about long term graft and patients survival after transplantation, PD patients were associated with better long term patient and graft survival
Treatment options for patients with ESKD are kidney transplantation peritoneal dialysis (PD) and hemodialysis (HD). Among them preemptive kidney transplantation is the modality of choice if available .There are different reasons that this option is not available is many patients like long time waiting list. Sixty-six percent of patients in waiting list (as UNOS report in 2017) were aged above 50 years. This rate is increasing sustain since 2012 in USA and their care was not optimum before ESKD. Majority of them initiated HD (87.8 %) VS PD (9.6).Among all modalities 65.2% and 63.2% were on PD or HD respectively. Only 2% of HD patients were utilizing home HD. But in other countries there were more patients on PD. With advancing PD techniques ,in recent years outcome of these patients has improved and mortality of them was lower comparing HD. Mortality of HD patients was increased in older patients and much time spent on HD. But in patients receiving PD Mortality was not increased in older people. Other studies showed PD as more cost effective option comparing HD .The mortality rate was increased among patients receiving TX, PD and HD respectively .In addition delayed graft function (DGF) rates after TX were lower in PD vs HD as pre-transplant modality. But rate of graft thrombosis was higher in PD group. In contrary infection of dialysis access were more frequent in PD vs HD patient. Some studied showed increasing rate of PTDM among PD patients. Patient and graft survival were better in PD vs HD patients. The reason behind this is better RRF preserving and less immunogenicity of PD.
I will choose the PD patient. as this is a marginal kidney. better to avoid the DGF that occurred more between HD patients than PD patients.
Preemptive kidney transplantation is associated with better patient and graft survival. But due to organ shortage many patients need HD or peritoneal dialysis before transplantation.
PD has several advantages over HD which includes self dependency, better preservation of residual kidney function, better volume status management less requirement of ESA.
The mortality rate was slightly lower in PD patients and older patients do better with PD.
Outcome after transplantation :
(1) Delayed graft function: PD patients has lower incidence of DGF when compared to HD patients. This could be due to the PD patients are less likely to be volume depleted than HD patients or due to better residual kidney function of PD patients.
(2) Thrombosis of the graft:
The incidence of graft thrombosis and early graft loss (<3 months) was higher in PD patients . This could be due inflammation in the peritoneal cavity or increase in the coagulation factors in their blood.
(3) Risk of infection post transplantation :
There is increased risk of infection in PD patients ( peritonitis , UTI ) , So the PD catheter should be removed as early as possible . On the other hand HD patients had higher incidence of TB and HCV infection post transplantation.
(4) Risk of DM after transplantation:
Some studies found that PD is associated with higher incidence of DM after transplantation , other studies did not found difference .
(5) Long term outcome :
PD is associated with slightly better 10 years graft survival.
PD is associated with better patient survival after transplantation and lower cardiovascular mortality post transplantation when compared to HD.
In our center , PD is less far common than HD , due to multiple factors , HD is easier to the patient , lack of education , lack of experience , the fear of peritonitis.
Introduction
Number of ESRD patients is increasing annually this unfortunately make the waiting list for transplantation longer with lower chances especially for older patients.
Kidney transplantation is the best choice for patients with ESRD ;preemptive transplantation is ideal as it is associated with less acute rejection episodes ,better patient and graft survival but it is not always possible to do transplantation befor dialysis for different reasons and most of the patients will need to start dialysis.
The choice of dialysis type may affect transplantation outcoms a meta-analysis done by Tang et al in 2016 concluded that PD was a better choice of pre-transplant dialysis modality than HD.
Although a study by Resende et al and Dipalma et al did not find any difference on graft function or patient’s survival after transplantation with different dialysis modality.
ESRD DEMOGRAPHICS
According to United Network for Organ Sharing, in 2017, there were 94897 patients on the waiting list for kidney transplantation most of them were above the age of 50 years Only, 19849 patients received kidney transplantation.
Number of ESRD patients is increasing annually and unfortunately one third of them had to start dialysis via a catheter and didn’t receive enough care to be prepared by arteriovenous access
with majorty of patients preferred HD to PD.
the USA, HD is the most common modality of renal therapy than PD while in other countries like New Zealand, Thailand, Colombia, Australia, and Canada PD is more used than HD.
PD is the preferred form of RRT because of its flexibility, care satisfaction, better preservation of renal function, better control of blood pressure with lower intradialytic hypotension episodes, low risk of dementia and slower cognitive decline, decrease in erythropoietin demand.
PD underutilized in the USA due to many reasons including for example; physician specific (lack of experience, inadequate training,); patient specific (lack of adequate PD education, health literacy, burden of therapy, age, comorbidities); modality specific (concerns for mortality, solute clearance, peritonitis, treatment failure.
ESRD outcome
Mortality in HD patients are higher than PD patients and much more higher than transplanted patients with higher mortality rates among patients >65 years.
Improvement in PD technique has improved and risk of peritonitis and studies showed that elderly patients tend to do better on PD versus HD.
ESRD patient population is aging and dying waiting for a transplant, and it will be better to increase their chances in kidney transplantation early .
Expenditure of PD is also better than HD but much higher than cost for transplant patients . HD and PD patients have similar hospitalizations rate but almost double of patients with kidney transplantation .
Delayed graft function for kidney transplant
DGF defined as need of dialysis within seven days of kidney transplantation
patients received PD before transplantation showed lower rates of DGF than HD patients but GFR did not differ between the PD and HD groups at one month, six months or at one year.
No clear cause of the better results of PD patients over HD patients but they might have preservation of residual renal function ,difference in immune function, cytokine production, and different response to ischemic kidneys and they are less likely to be volume depleted which ensure adequate perfusion of the allograft in contrastto HD patients .
Thrombosis of the allograft:
There are higher rates for allograft thrombosis in PD than HD patients which might be due to ;
•Previous hypercoagulable state of the patient that caused thrombosis in AV fistula and shifted the patient to PD .
• increased pro-coagulant factors such as apolipoprotein A, factors II, VII, VIII, IX, X, XI and factor XII due to irritation of peritoneal membrane leading to macrophages activation.
•hemo-concentration as compared to HD patients also can be a cause.
Risk of infection and diabetes mellitus after transplantation
Immunosuppression after transplantation
is associated with increased incidence of infections in general , in PD patients there is a higher risk of catheter site infection and peritonitis even if it’s not used .
Some studies also showed Increased incidence of urinary tract infection in PD patients .
No clear results on the effect of dialysis modality on the occurrence of post-transplantation DM
some studies showed no difference between HD and PD while other showed higher incidence in PD .
Long-term outcome: Comparing those on prior HD vs PD
Preemptive kidney transplant without dialysis was associated with the best results on patient survival compared to HD before transplantation.
Some studies reported better outcome on graft and patient survival for PD patients over HD patients ; this may be due to better planning before starting PD, PD patients are better prepared; In addition, this could be explained by the better preservation of residual kidney function on PD,also increased risk of cardiovascular diseases with HD patients.
Another study showed that combination of prior PD and HD had a worse survival than those on HD alone.
Although, Tang et al did not found 5 years graft survival rate to be different with pre-transplant PD as compared to HD technique in their meta-analysis.
In conclusion
Despite conflicting data Current evidence favors PD over HD a as it is associated with lower risk of hospitalizations, healthcare expenditures and mortality.
In regards to kidney transplantation outcomes, PD was associated with lower risk of DGF and cardiovascular mortality as compared to HD but with higher risk of infectious complications.
CKD is increasing all over the world accounting for around 10% of the population. However, only 10% of the population receives some form of RRT to remain alive.
Kidney transplantation is the ideal form of RRT despite improvement in the dialysis techniques and mortality .
Unfortunately, due to lack of organ supply, pre-emptive transplantation account for only 17% of the total transplanted patients despite its benefits on patient and graft survival. Accordingly, patients may need some form of RRT before getting transplanted so they become more older with increased comorbidities increasing the burden on health care systems.
Peritoneal dialysis provides a good bridge therapy to renal transplantation being more flexible, better self-satisfaction and autonomy. However, in some health care systems like USA it is largely underutilized compared to other countries like Hong Kong and Mexico due to multifactorial causes that could be patient, physician, financial or modality specific causes.
This paper reviewed the impact of RRT choice whether hemodialysis or peritoneal dialysis on mortality, short and term and long term transplantation outcomes.
Peritoneal dialysis was found to be more cost effective, have lower hospitalization, and mortality compared to hemodialysis especially in elderly who tend to do better on PD compared to HD. Although there is some conflicting data on mortality benefit as PD and in Centre HD mortality were similar while on the wait list for transplantation.
short term transplantation outcomes:
PD was associated with lower incidence of delayed graft functions than HD (defined as need for dialysis within 7 days of transplantation)attributed to better preservation of renal functions, less volume depletion and better perfusion of renal graft .
On the contrary, PD was associated with more higher risks of infectious complications including postoperative infections, PD catheter exit site infection and peritonitis even if PD catheter is not used
The risk of post transplantation allograft thrombosis showed mixed results with higher PD risk for graft thrombosis in some studies due to masking of thrombotic tendency in the absence in the absence of AV access and the presence of presence of pro-coagulant factors due to peritoneal membrane inflammation when exposed to dialysis solutions. However, other studies showed similar PD and HD results
long term transplantation outcomes :
The outcome of long term graft survival and death censored graft failure showed mixed results where some studies showed some superiority of PD over HD while others did not show a 5 or 10 years graft survival benefit between the 2 modalities
With regard to patient survival some studies showed a better survival benefit with PD which may be attributed to better planning and preparation when starting PD as well as better preservation or residual kidney functions. However other studies showed no favor of any modality over the other with regard to mortalities but still PD showed a lower post transplantation cardiovascular mortality when compared to HD.
To conclude: PD is an underutilized modality of renal replacement which could be the therapy of choice to bridge for renal transplantation and effort should be made to remove different obstacles regarding that including better education and training of medical staff, improving the patient education about this modality in low clearance clinics using a patient centered universal approach.
Reflection on personal experience:
I worked in different health care systems in the Gulf and UK , so there are many obstacles with regard to implementation of PD programs:
Patient related factors:
· Lack of availability of suitable home situations and support by other family members
· PD put a burden on patients during their training and carrying the procedure and need of complete aseptic precautions to minimize the risk of peritonitis which could be higher in the more hot countries in the gulf. Accordingly, some patients becomes more comfortable when they go to the hospital where medical and nursing staff could help
· Lack of available information and PD education about this modality compared to HD and health literacy for some of the patients
Physician specific:
· Inadequate training and lack of education of the medical staff because some health care systems do not focus on such modality compared to HD
However, some countries specially in UK and centers took active steps so that PD can take a fair share in the RRRT modalities specially in patients who have a good residual renal functions, elderly patients and as a good bridge to renal transplantation
Unfortunately in my practice at the moment, PD is very challenging because the insurance coverage to dialysis treatment is not recognizing PD. This means PD candidate have to pay out of pocket to get the services. This is very difficult as most the patients cannot afford it although is available. We forced to do PD only. in cases of patients with end-stage vascular access failure. Currently we don’t have any PD patients in our transplant programme and therefore I would our experience with PD patients after transplantation is not existing practically, all is HD.
Thanks Ben
welcome Prof
Abstract ; The numbers of patients with ESRD requiring dialysis treatment is increasing, this increase prolong the waiting list time for transplantation. Although PD is preferred dialysis modality before transplantation, many incident ESRD select HD over PD for different reasons. PD is associated with less DGF but higher allograft thrombosis than HD. More infections are seen in PD cohorts than HD. Overall there is some signal that PD may be associated with better long-term survival.
Introduction ; Kidney transplantation is the best form of RRT for patients with ESRD. Many studies look at the outcomes of transplantation after PD versus HD. A meta-analysis by Tang et al(7) showed that PD was better option of pre-transplant dialysis than HD. Interestingly Resende et al(10) and Dipalma et al (11) couldn’t not find effect of dialysis modality on graft or patient survival after transplantation.
ESRD Demographics ; Majority of patients with ESRD in USA are above 50 years of age (12). There is noticeable increase in both incidence and prevalence of ESRD (13)(15). Many of the incident ESRD patients in USA choose HD over PD as RRT modality. This may be due to physician factors (experience and training), patients specific( PD education, burden of therapy, age), and modality specific(peritonitis, logistics, cost, availability of HD) (22- 24). This is in contrast to other countries in the world(e.g. Hong Kong, Mexico) where PD is favourable than HD(14).
ESRD Outcomes ; Generally mortality is high in patients above 65 years of age but less mortality is seen in PD than HD patients(25). The cost of PD is less compared to HD but higher than that of kidney transplantation. The rate of hospitalization is initially higher with HD, with time hospitalization rates for PD increases but still lower than HD(27)
Delayed Graft Function for Kidney Transplant ; DGF is the requirement for dialysis in the first seven days after transplantation(29). Compared to HD, PD have lower rates of DGF(29-39). Why PD have better outcomes than HD is not clear. However, it may be due to preservation of the residual kidney function(37,38), differences in immune function, and motivations of PD patients.
Thrombosis of the allograft : Comparing Prior HD to PD; Allograft thrombosis is more common in PD than HD( 38,44,46). This may be due to increased pro-coagulant factors (e.g. Apolipoprotein , other clotting factors) and haem-concentration in PD populations. Other studies reported similar incidence of primary allograft thrombosis between PD and HD patients(47)(41)(49)
Risk of Infection and Diabetes Mellitus after Transplantation ; Infections related complications are higher in PD than HD patients(42,45). These includes ; post tx peritonitis and exit site infections. Some centres recommended removal of the PD catheter in low risk patients due to concerns of peritonitis and possibility of PD fluid leakage from the surgical incision(52). Postoperative infections and UTIs are also reported to be higher in PD cohorts. HD have been associated with new onset TB and chronic HCV in the first 3 months. Regarding post transplant diabetes, results are conflicting, some studies demonstrated no impact of dialysis modality on the risk of PTDM(54), while others reported statistical significance(56)
Long-term Outcomes : Comparing those on Prior HD versus PD ; This is a matter of debate, many studies showed better long-term survival with PD than HD. (9)(11)(58). The reason may be due to lower rate of cardiovascular mortality in PD group than HD(39), preservation of residual kidney function, better planning for PD, and motivations in PD populations(65-66). Other studies revealed no survival benefit of PD over HD(10,11,58). This mixed results can attributed to other factors which may determine the long-term survival benefit after transplantation.
Conclusion ; Most patients with incident ESRD in USA choose HD over PD. PD is associated with less DGF but higher allograft thrombosis compared to HD. Long-term survival is favouring PD, although other studies didn’t find any differences. Patients education is of para-amount importance regarding dialysis modality selections. Further researches are needed to close the gap in this matter.
This is the way to summarise an article. Well done
I have sent you a reward (please check your email).
Renal transplant is the best choice ever for ESRD. preemptive transplantation is better than after being on dialysis. although data are conflicting many studies showed that PD is more favored with fewer complications and less hospitalization compared to hemodialysis. In the US patients favor hemodialysis. transplantation is better in terms of expenditure followed by PD than HD. (transplant is much cheaper especially after the fourth year because of high expenditure in the first year; not shown in this article).In regard to delayed graft function, the preemptive transplant was better than from deceased ones. surprisingly, thrombotic events were more than those who were on PD before transplantation. In regard to peritonitis after transplantation, peritonitis was more pronounced in PD patients.
In our practice, early education and preparing patients either by direct or paired transplant is planned. ın some centers 8 pairs are matched and favored. outcomes are better than transplants after dialysis. I some patients who are in late-stage 5D dialysis is performed by central catheter to avoid üremic and metabolic complications. some times this is done only in case of delayed graft function. as PD is not favored due to some other reasons, for patients in the pretransplant period no center in Turkey uses PD in planned transplant patients as far as I know.
This article discussed the choice of RRT modality and the impact on kidney transplantation outcome
Current evidence favors PD over HD as modality of Choice as it is associated with lower risk of hospitalization,healthcare expenditures and mortality.
Preemptive kidney transplantation is ideal as it is associated with lower rate of acute rejection ,increased allograft and patients survival .
The review divided into two parts:
short-term outcome (DGF and allograft thrombosis)
Long-term outcomes including mortality.
in regards to kidney transplantation outcome PD was associated with lower risk of DGF and cardiovascular mortality as compared to HD but with higher risk of infectious complications.
Regarding allograft thrombosis, graft survival and patients survival showed mixed result between PD and HD.
No impact of dialysis modality on development of PTDM
My experience showed similar outcome regarding the choice of modality of RRT before renal transplantation.
-Kidney transplantation is the ideal form of renal replacement therapy (RRT) in patients with end-stage renal disease (ESRD).
-Preemptive kidney transplantation is associated with lower rates of acute rejection and increased allograft and patient survival.
-Patient survival and quality of life after kidney transplantation is better when compared to being on dialysis.
-A lot of patients are removed from a waiting list for renal transplant due to death or decline in medical condition.
-there is improvement in the overall dialysis-related mortality.
-The average time on the waitlist for a deceased donor is quite variable depending on age, blood group, panel reacting antibodies, history of prior transplantation, race/ethnicity, and regional factors.
-Peritoneal dialysis (PD) lead to minimal disruption of the patient, s life, and the patient can participate in his management.
– According to several studies PD is better to bridge therapy to renal transplantation than hemodialysis (HD).
ESRD demographics
-According to United Network for Organ Sharing, in 2017, there were 94897 patients on the waiting list for kidney transplantation.
-Majority of patients are above 50 years old.
-Only 19849 received kidney transplantation in the year 2017.
-In the USA, In –center HD is the most common modality of renal therapy than PD while in other countries like Qatar, Mexico, New Zealand, Thailand, Colombia, Australia, and Canada PD is more used than HD.
-PD is the preferred form of RRT because of its flexibility, autonomy, care satisfaction, better preservation of renal function, better hypertension control, lower intradialytic hypotension episodes, low risk of dementia, slower cognitive decline, better anemia management, and lower proportion of patient needing erythropoietin.
ESRD outcome
-Success of the PD technique has improved so the risk of peritonitis is reduced.
– In 2015, according to USRD, the mortality rate for patients on HD was high than patients on PD and much higher than patients who received kidney transplantation.
-Elderly patients are doing better in PD than HD but patients older than 65 years have an increased risk of mortality as compared to patients less than 65 years of age.
– Expenditure of PD is better than HD but much higher than the cost for transplant patients and the overall adjusted survival probability of incident patients on PD better than patients on HD.
-HD and PD patients have similar hospitalization rates but almost double those of patients with kidney transplantation.
-One study showed that mortality for PD and in-center HD patients was found to be similar.
Delayed graft function for kidney transplant(DGF):
-It is defined as the need for dialysis within seven days of kidney transplantation.
-DGF is lower in PD than HD that maybe PD patients are not likely to be volume depleted so ensure adequate perfusion of allograft, and there are differences in immune function, cytokine production, and different response to ischemic kidney among PD versus HD patients.
Thrombosis Of allograft :
-Thrombosis of graft (RVT) is higher in the PD patient compared with HD patients.
-PD patients have increased Pro-coagulant factors such as apolipoprotein, factors II, VIII, VII, IX, X, XI, and hemoconcentration as compared to HD patients.
Risk of infection and diabetes mellitus after transplantation:
-Infectious complications (Exit –site infection and peritonitis)related to PD catheter may occur after transplantation.
– One study shows there is no impact of dialysis modality on the development of posttransplant diabetes mellitus(PTDM) while other studies result, PD associated with PTDM.
Long–term outcome:
-Preemptive kidney transplant was associated with excellent patient survival.
-PD is associated with better allograft and patient survival than HD patients.
–In Sudan, there are PD centers, the number of patients is small, and sometimes there are problems with PD catheters and PD solutions. The complications are few due to the small number of patients.
Thanks Reem
Well done
I have sent you a present
Renal transplantation is the best treatment for patients with ESRD About 10% of world population has CKD. I USA only 9% of ESRD patients are on PD program, but in other countries the percentage reach 70% as in Hong Kong.
Patients on PD program show better blood pressure control, need less doses of erythropoietin to treat anaemia, & preservation of residual renal function. The large difference between USA & other countries in patients number on PD program may contribute to different factors as patient, physicians , & modality specific.
Several studies comparing the graft survival after transplantation with the modality of dialysis. These studies show better graft survival , patient survival, cardiovascular mortality & mortality from any cause in patients on PD than patients on HD. DGF was less in recipients on PD & this may be due to preservation of renal residual function & the patients are not volume depleted which can improve graft perfusion.
But it was noted that graft thrombosis rate is higher in patients on PD prior transplantation leading to early graft loss. This observation also occur in patient who switch the modality of dialysis as from HD to PD & vise versa. This may be explained by increase in procoagulant factors inPD patients.
After transplantation & because use of immunosuppressive drugs the risk of infection is increased especially in PD patients( peritonitis, post operative infection), so increase the inhospitable admission.
The incidence of post transplantation DM is different among studies, some show no relation between modality of dialysis & incidence of DM but other show that PD increase the risk.
Regarding the reflection of our practice unfortunately there is no PD program in my country, hoping it will be soon.
Kidney transplant in patients with end stage renal disease is associated with better quality of life and better patient survival as compared to patients on dialysis.
Pre-emptive kidney transplant results in better graft and patient survival but it is not always available and patients may need to initiate dialysis before transplantation.
Many studies compared the outcome of transplantation after peritoneal dialysis (PD) versus hemodialysis (HD), some of them showed that PD was a better choice pre transplant and HD was associated with higher risk of graft failure and patient death, while other studies reported that modality of dialysis has no impact on patient survival or graft failure.
PD may be favored as it is associated with flexibility, care satisfaction, more preservation of kidney function, better blood pressure control, better anemia management and lower risk of dementia.
Other factors lead to underutilization of PD are lack of experience and training of physicians, more comfort with HD, comorbidities and burden of therapy on the patient, lack of knowledge about PD and fear of complications as treatment failure and peritonitis. Also, PD fluids are not always available.
A study showed that mortality rate is much lower in patients on PD than in patients on HD and elderly patients have better outcome on PD.
Studies reported that the cost of PD is less than that of HD, the rate of hospitalization is the same but as time goes, Patients on PD have higher hospitalization rate.
PD is more cost-effective with lower risk of mortality than HD in pre transplant period.
Delayed graft function (DGF)
It is the need for dialysis within 7 days after transplantation
Studies showed that the rate of DGF in PD is lower than that in HD.
A retrospective study reported that patients with DGF who receive PD have increased risk of wound infection but shorter hospital stay and shorter time requiring dialysis post operatively.
Better outcome of PD regarding DGF may be due to better preservation of kidney function, it is daily, not associated with volume depletion (may cause decreased perfusion of transplanted organ, tubular necrosis) also patient on PD can have intra operative aggressive hydration that decrease risk of DGF.
other suggested reasons include difference in immune function, cytokine production and different response to ischemic kidneys in PD and HD patients.
Thrombosis of allograft
It is more common in patients on prior PD than on prior HD.
This may be due to underlying masked thrombotic tendencies in PD patients (as they have no A-V access), patients may have switched to PD after repeated thrombosis of HD access.
PD patients have increased pro coagulant factors due to exposure of peritoneal membranes to dialysis solutions leading to macrophages activation, increased thromboplastin and plasminogen activator in peritoneal cavity.
Other studies showed no difference in incidence of graft thrombosis in PD & HD patients
Risk of infection post transplant
Infectious complications related to PD catheter and post transplant peritonitis is a concern
PD catheters are associated with exit site infection (even if not used).
patients on PD have risk of leakage of dialysate fluid from surgical incision, increased risk of UTI and peritonitis.
It is preferred to remove PD catheter at time of transplantation.
Long term outcome:
Some studies showed that long term graft outcome and patients survival are better in PD patients as compared to HD patients. Also, showed that HD patients are at are higher risk of death censored graft failure.
Suggested reason for better long term outcome with PD is that exposure to HD dialyzer membrane may be immunogenic and increase risk of graft loss despite using biocompatible membrane and better preservation of kidney function in patients on PD which enhance graft survival.
Studies showed that cardiovascular mortality is lower in PD
Other studies showed no survival benefits of PD over HD, no significant difference in the risk of death in PD and HD and that graft survival is the same with both modalities.
The choice of dialysis modality before transplant should include impact on lifestyle and kidney transplantation.
PD is underutilized and can be the therapy of choice especially with better outcome with transplantation.
Well done Heba
This is the way to summarise article.
I have sent you a present
In Malaysia, we are still lacking behind in imposing or advocate PD first policies like Hong Kong or even Thailand. Most of our patients are preferring HD compared to PD due to lack of self confidence, and least awareness about PD. We have been advertising PD as a first choice RRT compared to HD but hesitancy from the patients’ still make it difficult to increase the number of PD. We are trying our best to do preemptive transplantations but availabilities of cadaveric donors and cultural beliefs towards kidney transplantations making our efforts tougher.
Regarding choices of RRT and its impact in graft survival post renal transplantation, we seems to see similar graft survival, allograft rejections and graft loss in Malaysia, at least at my centre.
Admiring this excellent response and reflections on practice and outcomes. Excellent Theepa
Choice of Dialysis modality prior to KT
ESRD outcome
• Mortality rate for HD was slightly higher than PD and much higher than KT
• Mortality rate for those underwent HD and aged less than 65 better than more than 65, but in PD, mortality rate is much lower than HD and tend to do better for those aged more than 65
• Overall adjusted survival probability of incident on PD is better than end of 3 years than HD
• Expenditure also lesser in PD than HD while higher than KT
• HD patients have lower hospitalisation over the years and PD patients have slightly higher rates of hospitalisation over the time but still lower than HD cohort
• Inrig et al- showed that only no differences in 2 year mortality among PD and HD patients
Delayed graft function for KT
• most of the studies showed lower rates of DGF in PD versus HD patients even after adjustment for multiple clinical covariates
• some suggested that once adjustment for malnutrition inflammation complex syndrome and donor characteristics, PD no longer superior to HD but PD found to be protective against DGF in subgroup analysis among patient who had Hb12-13g/dL
• reason for better outcome –
o not clear, PD has better preservations of residual renal function.
o PD patients are more motivated
o Cytokine production and differences in response to Ischaemic kidneys
o He prior to KT results in volume depleted while PD patients are well hydrated
Thrombosis of the allograft
• Higher in PD patients
• Higher adjusted risk for both allograft failure and death censored allograft failure for PD patients
• Higher odds at renal vein thrombosis in PD
• Possible explanations
o Increased pro-coagulant factors such as apolipoprotein A, factors 2,7,8,9,10,11 and 12
o Haemoconcentrated compared to HD
o Exposed to dialysate solutions lead to macrophages activation and increased presence of thromboplastin and plasminogen
Risk of infection and diabetes after transplantation
• PD associated higher risk if infection with catheter infections and peritonitis
• HD associated with new onset tuberculosis and Chronic hepatitis C
• PD associated with increased risk of diabetes
Long term outcome
• PD has a better long term graft survival and death censored graft failure and patient survival
• PD and HD combination or switching had worse patient survival comopared to HD alone
• Possible explanations
o HD dialysis membranes could be immunogenic and lead to increased risk of graft loss
• Cardiovascular risk is lower in PD patients and this superiority carried on after kidney transplantation
Kidney transplantation is the best renal replacement therapy for patients with end stage renal disease.The early the transplantation, the better the outcomes. However, not all patients are offered kidney allografts. This is because there is a great gap between the increasing number in ESRD patients and number of offered kidneys. While waiting on the transplantation waitlist, most of the patients are undergoing different modalities of dialysis, but does this matter? Is one modality better than other in the pre-transplant period? Should we offer a specific type of dialysis?
Choice of dialysis modality prior to kidney transplantation: Does it matter?
This review article has focused on short and long term outcomes of transplant patients based on the dialysis modality in the pre-transplant period.
The distribution of dialysis modalities among ESRD patients varies between countries, regions , hospitals and also nephrologist experience. For example most of ESRD are treated with hemodialysis with only 7% of patients were utilizing PD. In contrast, in Australia, Canada, Qatar and other countries, PD accounts for priority of dialysis modality. In general PD s acceptable and could be the preferred modality of RRT, owing to better preservation of residual renal function, less hemodynamic instabilities, better control of phosphorus, flexibility, autonomy, better hypertension control , lower risk of dementia, slower cognitive decline, better anemia management and lower inflammatory markers.
Delayed graft function is defined as the need of dialysis within seven days of kidney transplantation. Several studies demonstrated benefit rate in terms of graft survival in patients receiving PD in the pretransplant period, comparing with hemodialysis with prominent DGF.
In a retrospective observation study of patients with delayed graft function requiring dialysis, found an increased risk of wound infection/leakage, shorter length of hospitalization and lesser time requiring dialysis post-operatively with use of PD. However, no differences in readmission to hospital within 6 months, graft loss or acute rejection episodes at one year.
Thrombosis of the allograft was higher in the PD comparing to their HD.
In the post-transplant period, recipients receive multiple immunosuppressive therapies, which increases the risk of infections .PD catheter was associated with an increased risk of infection and peritonitis even if it’s not used.
Data on long-term graft survival after PD and HD is in favor of better graft outcomes in patients previously treated predominantly with PD as compared to HD patient. European center in 2006 reported that prior-PD patients have better graft and overall survival.
Based on meta-analysis of studies done in 2014, pre-transplant PD is associated with better post-transplant survival than HD. Pre-transplant PD was also associated with decreased risk for DGF compared with HD, although these results were unadjusted. There was no significant difference in graft survival between pre-transplant HD and PD. These results suggest that PD may be the preferred dialysis modality for patients expected to receive a transplant (1).
Another review article published in 2017 was looking for the best renal replacement modality for patients with ESRD in the pretransplant period and whether Nephrologists should Promote Peritoneal Dialysis as a Bridge to Transplantation? The answer was that PD might be less likely to be associated with delayed graft function probably because PD is associated with better pro-inflammatory state and better control of volume status, but article was not firmly conclusive (2).
Choice of dialysis modality prior to kidney transplantation in my practice
In my practice, hemodialysis is the unique modality offered to patients with ESRD. Most patients prefer in-center dialysis rather than at home because of the fear of complications, where in-center HD, nurses and doctors are always available.
From financial point of view, some insurance companies do not cover the cost of cycler for automated PD and some PD solutions, while HD is financially covered totally.
At personal level, we were not adequately trained to prescribe peritoneal dialysis, with the lack of PD centers, educators and awareness. So with time some nephrologists will lack the experience to prescribe PD and follow-up PD patients and will be easier for them to prescribe HD.
References
1- 10.3747/pdi.2016.00011
2- doi.org/10.3747/pdi.2016.00269
“Hemodialysis is the unique modality offered to patients with ESRD.”
You mean; the only available RRT.
Thank you Dr Alaa for your question.
What I meant is that we offered our patients hemodialysis because we lack PD centers, educators for PD, no financial coverage for PD cycler, and preferances of most patients to be managed in centers rather than at home.
Excellent Mahmoud
Titles and subtitles is the way to structure your summary. I have sent you a present.
Aim to compare HD and PD as a pre-transplant modality and their impact on transplant outcome graft and patient.
Different modality of RRT should be discussed with the patient before initiating the modality.
Of course, preemptive renal transplantation has positive impact on graft and patient survival post-transplant, but this may be not available in the most of time because of many factors like patient education, socioeconomic status, problems related to health insurance, race/ethnicity, health care center access…etc.
The choice of the method depends on the patient need and his/her life style, work, and social life. PD modality offer lesser complications than HD.
PD modality started to increase and rate of complication as peritonitis was declined. Complications of HD is much more than PD , mortality of the patients on PD is much better than those on HD, however elderly patients mortality either on PD or HD is worse than young patients on PD or HD.
DGF delayed graft function ( need for dialysis in the 1st week post transplant )
DGF incidence increase in the patients of HD more than PD patients;
In the PD patients: 1- more residual renal function.
2- Less affection of the volume status, so free use of intra operative hydration to guard against DGF.
3- Less hyperkalemia because of daily dialysis.
Allograft thrombosis increased incidence in PD patients than HD patients
1- May be some patients of PD were shifted from HD due to poor vascular access.
2- Increase pro-coagulant factors in PD patients more than HD
3- Increased thromboplastin and plasminogen activator in the peritoneal cavity because of inflammatory process done because of peritoneal dialysis solutions.
Risk of infection and DM post transplant
There is higher risk of infection and peritonitis of PD patients post transplant, because of presence of PD cath even if not used, so should be removed as early as possible post transplant.
Also there is increased risk of UTI in PD patients post transplant compared to HD patients. But there is increase risk of new onset TB and chronic hepatitis C post transplant among the patients of HD.
There is no effect of dialysis modality on development of PTDM (post transplant DM).
Graft and patients survival is better in PD patients compared to HD patients (immunogenic dialyzer membrane in HD patients may be risk factor for graft loss, also more cardiovascular complications and mortality in HD patients compared to PD patients) , and worse survival was noticed in the patients with combined PD and HD than the patients with HD alone. Pre emptive renal transplant has an excellent outcome.
There are multiple factors deciding the choice of modality pre transplant and also many factors may be present and hinder the true comparison between HD and PD graft and survival outcome post transplant, hence there are different opinions of many studies.
Well done Riham
This is the way to summarise an article
Thanks a lot our professor
This is despite the fact that kidney transplantation is optimal and linked with substantially improved clinical outcomes for individuals with ESRD than dialysis.
The current data supports PD over HD since it is related to decreased hospitalization, healthcare costs, and death.
While evidence on the mortality benefit of PD over HD is mixed, waiting list mortality for both PD and HD patients is similar.
In terms of kidney transplant outcomes, PD had lower DGF and cardiovascular mortality than HD, but greater infectious complications. In the literature, allograft thrombosis was reported seldom.
Overall, we feel that dialysis modality is important prior to kidney transplantation. While it is impossible to conduct a large randomized controlled experiment to address this issue, education on pre-transplant dialysis modality choices has to be multi-faceted.
long-term consequences and lifestyle impacts. The teaching and training must be patient-centric, employing a universal approach, regardless of the patient’s health literacy level.
PD is an underused technique in the USA that may increase transplant success.
In our centre, we did not notice a significant difference between both modalities of dialysis.
There are 3 modalities for treatment of RRT : HD, PD and renal transplantation
HD is the most common modality used then renal transplantation and PD at the end. PD is underutilized due to lack of experience of staff, lack of education of the patient, complications such as peritonitis and availability.
Patient survival is higher in pre-emptive renal transplantation followed by PD then HD,
Hospitalization is more frequent in HD than PD with the least are transplant recipients.
QOL of renal transplant patients is the best followed by PD then HD .
Regarding the cost the best is renal transplantation followed by PD and HD comes at last
Regarding likehood of renal transplantation, PD patients were forund to be more likley to be transplanted than HD patients
Post transplant graft and patient survival was found to be higher in patients with prior PD when compared to prior HD while the incidence of DGF was found to be lower in PD than HD patients. this may be due to :
⦁ Improved patient satisfaction and motivation
⦁ Better preservation of residual renal function
⦁ Better cognitive function
⦁ lower incidence of hyperkalemia and volume depletion
Post transplant graft thrombosis was found by some (not all) studies to be higher in PD when compared to HD patients this may be due to :
⦁ Hidden thrombophilia which is not discovered due to absence of AVF
⦁ Increase procoagulant factors when compared to HD due to chronic low grade inflammation of peritoneum
⦁ Hemoconcentration
Regarding infections it was found that :
⦁ TB and viral hepatitis in first 3 m after transplantation are more common in HD when compared to PD patients
⦁ Post transplant peritonitis and exit site infection, fluid leakage and UTI are common in PD patients especially if DGF occur thus it is recommended to remove PD catheter before transplantation if there is low probability of DGF, if not it should be removed as soon as possible once graft function is stable
PTDM is more common in PD than HD patients
Excellent Sherief
Titles and subtitles is the way to structure your summary.
I have sent you a present.
Kidney transplantation is the preferred modality of RRT for ESRD patients.
Preemptive kidney transplantation is ideal for those patients as it is associated with better patient & graft survival, but unfortunately there are many limiting factors for preemptive transplantation such as disparities in health insurance, race, education level, socioeconomic status, access to healthcare, diabetes status and regional variation.
Around 10% of the population are diagnosed with CKD all over the world & about only 10% of those patients receives treatment in the form of dialysis or transplantation.
Many patients are on the waiting list for transplantation and these patients have to wait many years to get a donor due to the shortage of the organs, as a result the age of the patients on waiting list is increasing and some of them will be declined due to disease burden or death. So there is a need for other form of RRT for these patients till they get their donor.
Regarding PD as a form of RRT :
Still the choice of dialysis modality before transplantation is based on patient’s preference, education & socioeconomic status and the availability of these modalities.
Renal failure patients progressively increasing in numbers worldwide and choosing the suitable RRT modality for each patient is sometimes challenging regarding availability, financial cost and long-term outcome.
Kidney transplantation is documented as the best form of renal replacement therapy (RRT) in patients with end stage renal disease (ESRD).
This article discusses the impact of each dialysis modality on kidney transplant related events.
Preemptive kidney transplantation is ideal for many patients, as it is associated with lower rates of acute rejection, increased allograft and patient survival but it is not usually available. So, majority of ESRD patients established in waiting list for transplantation spending variable time on one or more form of dialysis modalities.
Peritoneal dialysis (PD) seems of less impaction on the patient’s life, thereby allowing the patient to continue to work, travel along with encouraging patient to be independent in management of their dialysis. Hence, for the patients who plan on receiving a transplant after starting dialysis, it can be a better bridge therapy to kidney transplantation.
Several studies have addressed the outcome of kidney transplantation after PD versus HD.
Some studies concluded that PD is better than HD as a choice of pre-transplant dialysis modality. In another Cohort of 92884 patients, HD as a choice of RRT was associated with an increased risk for graft failure and recipient death. On the other hand, study by Resende et al and Dipalma et al did not find any impact of dialysis modality on graft function or patient’s survival after transplantation.
Short term outcome including DGF, and allograft thrombosis: Numerous studies have investigated DGF rates and have found lower rates of DGF in PD versus HD patients. In fact, maintenance dialysis prior to transplantation is noted to be a major contributor to DGF.
Thrombosis of the graft may be higher in the PD patients as compared to their HD. PD patients are noted to have increased pro-coagulant factors such as apolipoprotein A, factors II, VII, VIII, IX, X, XI and factor XII, and hemoconcentration as compared to HD patients which can predispose them at higher risk of allograft thrombosis.
long-term outcomes, including mortality: There is conflicting data exists on mortality benefit of PD versus HD as mortality for PD and in-center HD patients was found to be similar while the ESRD patients in the waiting list. Regarding kidney transplantation outcomes, PD was associated with lower risk of cardiovascular mortality as compared to HD
Referrences
Kasiske BL, Snyder JJ, Matas AJ, Ellison MD, Gill JS, Kausz AT. Preemptive kidney transplantation: the advantage and the advantaged. J Am Soc Nephrol 2002; 13: 1358-1364
Siedlecki A, Irish W, Brennan DC. Delayed graft function in the kidney transplant. Am J Transplant 2011; 11: 2279-2296 [PMID
Goldfarb-Rumyantzev AS, Hurdle JF, Scandling JD, Baird BC, Cheung AK. The role of pretransplantation renal replacement therapy modality in kidney allograft and recipient survival. Am J Kidney Dis 2005; 46: 537-549
Resende L, Guerra J, Santana A, Mil-Homens C, Abreu F, da Costa AG. Influence of dialysis duration and modality on kidney transplant outcomes. Transplant Proc 2009; 41: 837-839 [PMID
Dipalma T, Fernández-Ruiz M, Praga M, Polanco N, González E, Gutiérrez-Solis E, Gutiérrez E, Andrés A. Pre-transplant dialysis modality does not influence short- or long-term outcome in kidney transplant recipients: analysis of paired kidneys from the same deceased donor. Clin Transplant 2016; 30: 1097-1107 [PMID
From my experience in our patients, PD patients are more keen for renal transplantation and they are taking the option of PD as a bridge for renal transplantation.
Well done for the summary. It is well structured
I have sent you a present
Thank you so much for your kind efforts and support, Appreciating
1. In your own words, summarise this article.
As the prevalence of end stage renal disease (ESRD) is on the rise, so is the wait for getting a kidney transplant. While waiting for a transplant, patients are either on hemodialysis (HD) or on peritoneal dialysis (PD).
It is important to assess the effect of pre-transplant modality of renal replacement therapy (RRT) on the transplant outcomes as it will help in making an informed choice for RRT mode selection.
Data available suggests that mortality rate in patients on HD decreases with time on dialysis, while that of PD patients increases with time on PD, although the death rates are low in PD patients, regardless of age.
Post-transplant, PD patients have been shown to have reduced rates of delayed graft function (DGF), presumably due to better residual renal function and lead time bias, as compared to patients who were on HD prior to transplant. PD patients have been shown to have increased incidence of graft thrombosis as compared to HD patients. PD patients are also prone to have increased episodes of peritonitis and exit site infections, as well as post-operative infections. Increased incidence of new-onset Tuberculosis and Hepatitis C infection post transplant has been shown to be associated with HD patients. Incidence of post transplant diabetes mellitus is also more in PD patients as compared to HD patients.
Data for long-term effects including patient survival and graft survival is not clear-cut but a number of studies point towards better patient and graft survival in PD patients with 43% lower risk of death that HD patients. HD patients were shown to have increased death censored graft failure at 10 years.
2. Please reflect on your practice if possible.
In our set-up, majority of patients are initiated on HD as primary modality of RRT. Patients opting for PD are usually those who do not have a living prospective donor available. According to the published literature, PD patients have an edge over HD patients as far as graft outcomes are concerned and while discussing modalities of RRT with ESRD patients, this aspect should be highlighted.
Please highlight on this aspect, Amit.
We do highlight the positives of PD. But due to hesitancy among the patients, especially related to low self-confidence in taking their treatment literally in their own hands,PD is not very popular.
Kidney transplantation is the ideal form of renal replacement therapy (RRT) in patients with end-stage renal disease (ESRD).
Preemptive kidney transplantation is ideal for many, as it is associated with lower rates of acute rejection, increased allograft, and patient survival. However, a preemptive kidney transplant is not always possible for many reasons; disparities in health insurance, race/ethnicity, patient education level, socioeconomic status, access to healthcare, diabetes status, and regional variations.
Peritoneal dialysis (PD) leads to minimal disruption of the patient’s life, thereby allowing the patient to continue to work or school or other usual activities, along with encouraging patient empowerment in self-management. Hence, for the patients who plan on receiving a transplant after starting dialysis, it can be a better bridge therapy to kidney transplantation, especially, when a lot of patients initiating hemodialysis (HD) via catheters are associated with adverse outcomes.
overall adjusted survival probability of incident patients on PD is much better at the end of 3 years than patients on HD
Many studies had been performed to answer this question; PD or HD is a better modality as RRT before kidney transplant and the studies considered the short- and long-term outcomes.
Peritoneal dialysis shows better outcomes in the following aspects:
Flexibility, autonomy, care satisfaction, better preservation of residual renal function, better hypertension control, lower intradialytic hypotension episodes, lower risk of dementia, slower cognitive decline, better anemia management with lower doses of erythropoietin stimulating agents.
lower rates of DGF in PD versus HD patients may be due to better preservation of residual kidney function
Better long term outcome including graft and patient survival
Hemodialysis has better outcomes in the following:
Less incidence of wound infection or leakage post-operative
Less incidence of graft thrombosis
Less incidence of post-transplant diabetes mellitus (PTDM)
For me still, the choice is challenging and should be taken on an individual basis according to the patient situation (level of education, socioeconomic state, quality of life) comorbid, the availability of PD versus HD
What is the main challenge to making your own decision? reflect on daily practice
Well done for the summary. It is well structured
I have sent you a present
Pre-emptive renal transplantation is the best choice of renal replacement therapy. It is also associated with lower rates of rejections and increased patient and graft survival.
Patients mat stay for years on the waiting list due to many factors as PRA level, blood group, age of the patient,….etc., so most patient will need RRT while they are waiting for transplantation.
Many points may give PD an advantage over HD as an option for RRT pre transplantation.
In general, mortality rate in HD is higher than in PD and markedly more than mortality rate in transplantation.
The rate of hospitalization in PD and HD is equal.
DGF risk is more in patients received HD pre transplantation if compared to PD patients.
This can be explained by some points as the lower incidence of volume depletion in PD, and also HD patients need HD session and volume removal pre transplantation that may lead to decreased graft perfusion.
Risk of graft thrombosis is higher in patients were on PD pre-transplantation if compared to HD patients. This is because in PD there is higher levels of procoagulant factors and also the PD patients has no AV access so a hidden thrombosis tendency may be present and only discovered after transplantation.
Infection is a risk factor post TX due to the use of immunosuppressive drugs. Risk of post transplantation infections is more in PD patients if compared to HD patients especially peritonitis and UTI, however new onset TB and chronic HCV were reported after 3 months of transplantation in a pre-transplant HD patients.
PTDM is multifactorial and is not related to pre-transplant modality of RRT.
Finally, the studies showed mixed results regarding graft survival in pre-transplant PD and HD patients. While 10 years survival was better in PD than HD patients and also the cardiovascular risk as a cause of mortality post transplantation is lower in PD patients than in HD patients
Dear All
If you have a marginal CADAVERIC kidney offer for 2 patients. Both are in their 70s with no no difference in comorbidities. The only difference is one on HD and the second one on PD. Which patient you would prefer and why?
I think according to this paper, I will choose the PD patient to decrease the risk of DGF which is already high in this case due to the use of marginal donor kidney and also the 10 year survival rate is better in PD patients.
On other hand, the more mortality rate in HD patients if compared to to PD may give the priority to HD patient but I think it is better to give him more optimal graft.
Outcomes of kidney transplantation for PD patients are more favorable than HD patients
Better graft outcome and patient survival in patients treated previously with PD than HD.
In a prospective 70 year old transplant recipient, I am more worried about short-term outcomes and hence a PD patient would be better choice due to decreased rate of DGF (as the donor is marginal one, the chances of DGF are high and it could further rise in HD patient). Still, we have to be cautious due to higher rates of graft thrombosis and wound infections.
I will choose that on PD because of higher patient, graft survival, lower incidence of DGF, but we should focus on graft thrombosis, PTDM and peritonitis which occur higher in prior PD patients
according to the study, PD patients for more favorable outcome
In Cadaveric or deceased donor transplantation, the graft thrombosis and failure where similar to those patient on HD or PD prior to transplantations. In this situation, the multiple comorbids and variables has been adjusted, so my answer will be no differences in HD or PD
What is the primary recipient’s related factor that will affect the short outcome?
Dear Dr Alaa,
I think the primary recipient’s related factor that will affect the short outcome is the age itself. Kidney transplantation in the elderly is associated with an increased risk of mortality in the first 3 months and then the survival benefit of transplantation will be gained for the survivors (1). But, both recipient candidates from the proposed scenario of Dr Ahmed are of the same age and co-morbid conditions.
References:
1) Legeai C, Andrianasolo RM, Moranne O, et al. Benefits of kidney transplantation for a national cohort of patients aged 70 years and older starting renal replacement therapy. Am J Transplant. 2018;18(11):2695.
age
Durations of dialysis dependence beyond 10 years associated with increased rates of short-term complications including delayed graft function and graft loss in short duration post transplant.
Reference:
Kishikawa H, Ichikawa Y, Arichi N, Tokugawa S, Yoshioka I, Nishimura K, et al. Kidney transplantation in patients receiving dialysis treatment for more than 10 years. Transplant Proc. 2006;38(10):3445.
I think the immunologic risk
Yes, you should never cardiovascular disease
age
In the context of high risk of delayed graft function,given the donation of marginal cadaveric kidney, I will consider patient with less additional risks for DGF. But in this old age we have to take into account the risk of catheter infection/peritonitis and their outcomes especially in the postoperative period.
In the settings of same age and comorbidities, I would discuss the risks and benefits of marginal kidneys with the patients, and If both are accepting the risk I would offer it to the PD patient.
As we discussed last week, the marginal kidney is a kidney with a KDPI of more than 85% (1). The one- and 2-years allograft survival are markedly lower for this allograft category, as illustrated in the attached figure (1). Therefore, I will try to avoid the additional higher risk of DGF noted with recipients on haemodialysis. I would recommend offering this allograft to the PD patients if he accepts to receive a marginal kidney.
References:
1) John Vella. Kidney transplantation in adults: Risk factors for graft failure. © 2021 UpToDate. (Accessed on 24 November 2021).
study by Resende et al and Dipalma et al did not find any impact of dialysis modality on graft function or patient’s survival after transplantation.
Dipalma T, Fernández-Ruiz M, Praga M, Polanco N, González E, Gutiérrez-Solis E, Gutiérrez E, Andrés A. Pre-transplant dialysis modality does not influence short- or long-term outcome in kidney transplant recipients: analysis of paired kidneys from the same deceased donor. Clin Transplant 2016; 30: 1097-1107
In practical point of view I did not experience a conversation between the transplant nephrologists regarding pre transplant dialysis modality that affecting their decision regarding organ allocation.
It is not just the dialysis modality and also Durations of dialysis dependence beyond 10 years were associated with further deterioration in short-term transplant outcomes. That is why they prioritize patients based on date of dialysis initiation or wait-listing.
I will prefer the ones with PD treatment because he has less cytokines released ,better immunity ,good volume not dehydrated
although this paper’s conclusion favors PD, It is not that strong with prominent differences. one could fear of PD as there is a catheter that may have complications. of course, I am in the committee (as three patients are called for each diseased patient, I will favor the one with the least immunologic risk without paying attention to the previous dialysis modality. theoretically suppose they are very similar, I don’t know to whom I may vote
The recipient risk factors that may affect the outcome of this graft:
age of the pt (better if < 65 years), but here both pts are in the 70s.However elderly patients tend to do better on PD compared to HD
The duration on renal replacement therapy(the longer the duration, the poorer the outcome like cardiovascular complications)
The presence of residual renal function(so PD help to preserve renal functions better than HD).
patients on PD shows a less incidence to delayed graft function and need for dialysis after transplantation
In view that this is a marginal kidney with lower allograft survival and that elderly patients do better on PD , so it could be a better bridge to renal transplantation than HD
Tricky question, as some debates exists on the matter
I would go for PD
Possible reasons are ;
1- Summary :
2- Really, as my practice in transplantation is not high, I will adhere to the previous conclusion points.
Thanks Dr Ibrahim
Well done
Preemptive kidney transplantation is an ideal choice for renal replacement therapy in ESKD patients and it is associated with better patient and allograft survival, but it is not always possible due to different reasons, therefore many ESKD patients end up needing some form of RRT while they are waiting for transplantation, and they have to choose among modalities of dialysis which are fit to their lifestyle. Although the patient’s survival and quality of life is better after kidney transplantation compared to being on dialysis. PD can be preferred RRT as a bridge to kidney transplantation because of flexibility, autonomy, better preservation of residual renal function, better hypertension control, better cognitive function, better anemia management, and adverse outcomes of insertion of catheter for HD.
Regarding the outcome of kidney transplantation after HD versus PD, studies have reported mixed results.
In the USA, the majority of ESKD patients have chosen HD over PD and approximately 80% of them have catheter as opposed to AVF for HD.
In recent years, PD techniques have improved and the risk of peritonitis has declined. In addition, adjusted mortality rates are significantly lower in patients on PD compared to patients on HD, and PD is a more cost-effective modality as well.
Most studies found similar to lower rates of DGF in patients on PD versus on HD. It may be because of better preservation of residual kidney function. Other reasons such as difference in immune function, cytokine production, lower degree of volume depletion, and different responses to ischemia have been proposed as well.
Thrombosis of graft is surprisingly higher in patients on PD compared to their HD counterparts. Different reasons are proposed: underlying thrombotic tendency may be masked, switch from HD to PD because of repeat thrombosis of HD access, increased procoagulant factors, hemoconcentration, and increased presence of thromboplastin and plasminogen activator in the context of peritoneal membrane subtle inflammation.
The risk of infectious complications after kidney transplant comprising UTI, exit site infection and peritonitis is a serious concern in patients on PD and PD catheter should be removed at the earliest once no longer needed. There are mixed results regarding the increased risk of PTDM in Patients on PD.
Data regarding long-term graft survival after PD and HD is mixed. Patient survival may be better after kidney transplantation in those on PD as compared to HD. Patients on PD may be associated with a lower risk of cardiovascular mortality.
Kidney transplantation is the ideal modality of RRT in ESRD patients .
The average time on the waitlist is variable depending on age, blood group, panel reacting antibodies, history of prior transplantation. So patients will need RRT till transplantation time.
Studies concluded that PD is a better option for patients pre- renal transplantation and before liver-kidney transplantation if compared to HD.
Majority of ESRD patients chose HD over PD in the USA which is opposite in other parts of the world
PD is preferred over HD due to flexibility, care satisfaction, better preservation of residual renal function, better hypertension control, lower intradialytic hypotension, less risk of dementia, and cognitive decline as well as , better anemia management with lower ESA .
Data by the USRDS , in 2015,mentioned that mortality rate for HD patients was slightly higher than those on PD and exceeding patients who received kidney transplantation.
Elderly patients tend to do better on PD versus HD as concluded by one study, it was noticed also that elderly patients age ≥ 65 years suffer from increased risk of mortality as compared to patients < 65 years whether they were on HD or PD .
Therefore PD is cost effective with lower risk of mortality as compared to HD in pre-transplant period.
DGF defined as need of dialysis within seven days of kidney transplantation. DGF rates was lower in PD compared to HD
A study stated that PD was protective against DGF in patients with hemoglobin between 12 and 13 gram/dL.
PD patients have better preservation of residual renal function, on the other hand PD patients could be more motivated and may have increased transplant access.
Thrombosis of the allograft in patients previously on HD versus PD
Graft thrombosis and graft loss may be higher in the PD patients as compared to those on HD can be explained by increased pro-coagulant factors, and hemo-concentration as compared to HD
Other studies found no difference in incidence of graft thrombosis among PD versus HD patients.
Risk of infection and diabetes mellitus after transplantation was noticed to be higher in PD patients as PD catheter was associated with an increased risk of exit-site infection and peritonitis .
Also studies found higher risks of peritonitis and urinary tract infection in PD patients after transplantation. But, authors reported higher risk of new onset tuberculosis and chronic hepatitis C in patients priorly on HD after 90 days of kidney transplantation
Some authors found no effect of dialysis modality on occurrence of DM post transplantation while others found increased association with PD prior transplantation
Long-term outcome for prior HD vs PD patients
Kidney transplant without dialysis was associated with best survival compared to HD prior to transplant.
Other studies showed no differences between HD and PD long term outcomes , others mentioned better patient survival in prior PD treated patients
The combination of prior PD and HD had a worse survival than those on HD alone due to lower risk of cardiovascular death.
I agree, there is conclusive evidence that PD is associated with higher incidence of graft thrombosis.
Any reply
Preemptive kidney transplantation is ideal due to
lower rates of acute rejection
increased allograft and patient survival.
When compared to dialysis, patient survival and quality of life are significantly improved after kidney transplantation.
The average time on the waitlist for a deceased donor is variable.
mortality of pts who received tx< those who were on PD< those who were on HD.
elderly patients tend to do better on PD versus HD.
Individuals beyond the age of 65 have a significantly higher risk of death than patients under the age of 65.
Delayed graft function for kidney transplant
DGF defined as need of dialysis within seven days of kidney tx, occurs in 21.3%.
lower rates of DGF in PD versus HD patients.
reasons could be better preservation of residual kidney function in pts on PD,also pts on PD are less likely to be volume depleted.
Thrombosis of the allograft: Comparing prior HD to PD
thrombosis of the graft is higher in the PD patients as compared to the HD pts.
reasons could be pts on PD have increased procoagulant factors,underlying thrombotic tendencies may be masked in them.
Risk of infection and diabetes mellitus after transplantation
PD is associated with higher risk of infections post tx like peritonitis,exit site infections,UTI.higher risk of new onset tuberculosis and chronic hepatitis C with prior HD.
Long-term outcome: Comparing those on prior HD vs PD
Mixed results
conclusion
kidney tx better than PD or HD
PD associated with lower risk of hospitalisation,expenditure,mortality.
PD associated with lower risk of DGF and CVS mortality.
PD associated with higher risk of infections post tx.
allograft thrombosis and 5 and 10 yr graft and patient survival showed mixed results for PD vs HD post tx.
It’s better to do Preemptive kidney transplantation as it is associated with lower rates of acute rejection, increased allograft and patient survival.
ESRD patients are increasing steadily and majority of them choose HD (87.8%) over PD (9.6%) and 80% of patients initiated HD with a catheter as opposed to preferred arteriovenous access.
Causes of preferring HD on PD due to multifactorial :
*physician specific (lack of experience, inadequate training, comfort with HD)
*patient specific (lack of adequate PD education, health literacy, burden of therapy, age, comorbidities)
*modality specific (concerns for mortality, solute clearance, peritonitis, treatment failure, regulatory issues on PD fluid, easy availability of HD)
Peritoneal dialysis (PD) is a better choice of pre-transplant dialysis modality than HD and is considered as a bridge therapy for kidney transplantation due to preservation of residual renal function , better hypertension control , lower intra- dialytic hypotension episodes , lower risk of dementia, slower cognitive decline , better anemia management with lower doses of erythropoietin stimulating agents (ESA) and lower proportions of patients needing ESAs.
RRT modalities and their impact on short-term outcomes, including delayed graft function (DGF), and allograft thrombosis , and long-term outcomes, including mortality.
Delayed graft function for kidney transplant (DGF)
It is defined as need of dialysis within seven days of kidney transplantation.
DGF rates are lower in PD versus HD patients and the causes are unclear and may be due to :
*preservation of residual renal function.
*Difference in immune function, cytokine production, and different response to ischemic kidneys among PD vs HD
*PD patients are not likely to be volume depleted leads to adequate perfusion of the allograft.
Thrombosis of the allograft
thrombosis of the graft occurs more in PD patients than HD.
PD patients may have increased pro-coagulant factors such as apolipoprotein A, factors II, VII, VIII, IX, X, XI and factor XII, and hemo-concentration as compared to HD patients which can predispose them at higher risk of allograft thrombosis.
The reasons behind increase in these factors are mainly due to moderate non-specific inflammatory cell when the peritoneal membrane gets exposed to dialysis solutions. This leads to macrophage activation and increased presence of thromboplastin and plasminogen activator in the peritoneal cavity.
Risk of infection
post-operative infections after transplantation more common in PD patients as compared to HD patients
PD catheter is associated with increased risk of exit-site infection and peritonitis even if it’s not used so PD catheter should be removed at time of transplantation in patients with low risk of DGF. In patients with an increased risk of DGF, PD catheter can be left in place but to be removed at the earliest once no longer needed
diabetes mellitus
PD was associated with an increased risk of PTDM.
PTDM also can occur due to other factors like presence of pre diabetes, immunosuppressive medication regimen, improved appetite and weight gain post transportation
Long-term outcome
PD patients have better graft outcomes, survival and decrease Cardiovascular mortality if compared with HD patients