Castellano, Giuseppe

Abstract Background and Aims Although the choice of dialysis technique is based on several factors, patient survival is undoubtedly one of the most relevant. In a context where randomization to either peritoneal dialysis (PD) or hemodialysis (HD) proved to be extremely challenging, previous meta-analyses were greatly limited due to the inclusion of historical studies. Method We performed a systematic review by searching multiple databases up to April 22nd, 2022. We included studies meeting the following criteria: adult patients (>18 years) with end-stage kidney disease on dialysis; comparison of PD versus HD; reporting mortality data via intention-to-treat analysis; initiation of dialysis after 2000; patient classification by dialysis modality at 90 days post-initiation; and ≥50 patients per group (Figs 1 and 2). The primary outcome was the association between dialysis modality (PD vs HD) and mortality assessed via hazard ratios (HR) [Fig. 3]. Subgroup analyses were conducted to explore potential sources of heterogeneity, including sex, age, diabetes, dialysis vintage, geographical location, HD access, and study cohort inclusion period [Figs 4 and 5]. Results Database search yielded 5317 citations, from which, 27 observational studies met the eligibility criteria, including 1 033 362 incident dialysis patients [Figs 1 and 2]. The pooled mortality HR for PD versus HD was 1.01 (95% CI 0.93–1.10 [Fig. 3]). Heterogeneity was substantial (I2 = 94%) and was largely explained by different baseline features of the included populations. A statistically significant subgroup effect was demonstrated for age (>65 vs.<65 years; P = 0.01), geographical location of the studies (Oceania vs. Europe vs. Asia vs. North America; P < 0.01), and HD vascular access (central venous catheter vs. arteriovenous fistula; P < 0.01, only one study included) [Figs 4 and 5]. Conclusion This meta-analysis suggests that overall PD and incentre HD likely carry equivalent survival benefits. However, differences were detected among subgroups based on age, geographic location, HD access type, but not on sex, diabetes status, dialysis vintage and study cohort inclusion period.

Abstract Background Although the choice of dialysis technique is based on several factors, patient survival is undoubtedly one of the most relevant. In a context where randomization to either peritoneal dialysis (PD) or hemodialysis (HD) proved to be extremely challenging, previous meta-analyses were greatly limited due to the inclusion of historical studies. Methods We performed a systematic review by searching multiple databases up to April 22nd, 2022. The primary outcome was the association between dialysis modality (PD vs HD) and mortality assessed via hazard ratios (HR). Subgroup analyses were conducted to explore potential sources of heterogeneity, including sex, age, diabetes, dialysis vintage, geographical location, HD access, and study cohort inclusion period. Results Database search yielded 5317 citations, from which, 27 observational studies met the eligibility criteria, including 1 033 362 incident dialysis patients. The pooled mortality HR for PD versus HD was 1.01 (95% CI 0.93–1.10). Heterogeneity was substantial ( I 2 = 94%) and was largely explained by different baseline features of the included populations. A statistically significant subgroup effect was demonstrated for age (> 65 vs.<65 years; p = 0.01), geographical location of the studies (Oceania vs. Europe vs. Asia vs. North America; p < 0.01), and HD vascular access (central venous catheter vs. arteriovenous fistula; p < 0.01, only one study included). Conclusions This meta-analysis suggests that overall PD and incentre HD likely carry equivalent survival benefits. However, differences were detected among subgroups based on age, geographic location, HD access type, but not on sex, diabetes status, dialysis vintage and study cohort inclusion period.

Abstract Peritoneal dialysis—(PD) related infections continue to be a major cause of morbidity and mortality in patients on PD. Although great advances have been made in the prevention and treatment of infectious complications over the past two decades, catheter-related infections represent a significant cause of technical failure in PD. Recent studies support the role of exit-site/tunnel infections in causing peritonitis. Peritonitis secondary to tunnel infection led to catheter loss in most cases. Thus, removing the catheter when exit-site/tunnel infection is refractory to medical therapy has been recommended. This approach requires interrupting PD and, after the placement of a central venous catheter, and transferring the patient to haemodialysis. In order to continue PD, simultaneous catheter removal and replacement of the PD catheter has been suggested. Although simultaneous catheter removal and replacement avoids temporary haemodialysis, it implies the removal/reinsertion of the catheter and the immediate initiation of PD with the risk of mechanical complications, such as leakage and malfunction. Hence, several mini-invasive surgical techniques, such as curettage, cuff-shaving, removal of the superficial cuff, and partial reimplantation of the catheter, have been proposed as rescue treatments. These procedures may allow the rescue of the catheter with a success rate of 70–100%. Therefore, in case of refractory exit-site/tunnel infection, a mini-invasive surgical revision should be considered before removing the catheter.

Abstract Background Incremental peritoneal dialysis (incPD) as the initial PD strategy represents a convenient and resource-sparing approach, but its impact on patient, healthcare and environment has not been thoroughly evaluated. Methods This study includes 147 patients who started incPD at our institution between 1st January, 2009 and 31st December, 2021. Adequacy measures, peritoneal permeability parameters, peritonitis episodes, hospitalizations and increase in CAPD dose prescriptions were recorded. The savings related to cost, patient glucose exposure, time needed to perform dialysis, plastic waste, and water usage were compared to full-dose PD treatment. Results During the study follow-up 11.9% of the patients transitioned from incremental to full dose PD. Patient cumulative probability of remaining on PD at 12, 24, 36, 48 and 60 months was 87.6, 65.4, 46.1, 30.1 and 17.5%, respectively. The median transition time from 1 to 2 exchanges, from 2 to 3 and 3 to 4 exchanges were 5, 9 and 11.8 months, respectively. Compared to full dose PD, 1, 2, and 3 exchanges per day led to reduction in glucose exposure of 20.4, 14.8 or 8.3 kg/patient-year, free lifetime gain of 18.1, 13.1 or 7.4 day/patient-year, a decrease in cost of 8700, 6300 or 3540 €/patient-year, a reduction in plastic waste of 139.2, 100.8 or 56.6 kg/patient-year, and a decline in water use of 25,056, 18,144 or 10,196 L/patient-year. Conclusions In comparison with full-dose PD, incPD allows to reduce the time spent for managing dialysis, glucose exposure, economic cost, plastic waste, and water consumption. Graphical abstract