No quotation from it or information derived from it may be published without full acknowledgment of the source. Published by the University of Cape Town (UC) in terms of the non-exclusive license granted to UC by the author. I authorize the university to reproduce for research purposes either the whole or any part of the content in any matter whatsoever.
This work was made possible by the support of the ISN Salmasi Family Fellowship and the APFP for sponsoring my fellowship training. Dropout of PD- Termination of PD due to PD technique failure for any reason. Chronic peritoneal dialysis (PD) is the preferred first choice of dialysis modality in many centers because of its advantages over hemodialysis (HD).
We sought to investigate the rate at which children at the Red Cross War Memorial Children's Hospital (RCWMCH) drop out of school with chronic PD and describe some of the reasons for this dropout. Objectives: To describe the dropout rate of children with ESKD from chronic PD, timing and factors associated with this dropout at RCWMCH. Outcome measures: Proportion dropout during the study period (permanent switch to HD or death from PD-related complications), factors associated with dropout, and time from onset of chronic PD to dropout.
Study utility: Findings from this study will help design strategies to improve outcomes of patients with chronic PD, prolong PD technique survival, and reduce chronic dialysis costs at RCWMCH.
Purpose of the study
Introduction/background
PD technique survival is lower than HD survival from some chronic PD registries, but patient survival does not differ between those who switch to HD and those who remain on PD (8, 9). Failure rates of the PD technique in children requiring conversion to HD range from 6 to 17% in developed countries (1, 10) and up to 28% in developing countries (11-16).
Literature review
Drop-out from chronic PD and associated factors
Kapembwa et al. found in a study of PD technique survival at Tygerberg hospital among 170 adults from 2008 to 2014 peritonitis as the most frequent cause of technique failure and older age of the patients(11). Another study by Ramon et al in Limpopo showed that 46.7% of the 152 patients died or developed technique failure requiring transfer to HS. It was the most frequent cause of technique failure requiring transfer to HD(12), especially more than one episode.
Other factors found to be associated with poor outcome of PD were anaemia, low albumin and BMI. Low serum albumin has also been shown to be associated with an increased risk of chronic PD failure in children, from a study by Gulati et al in Canada(21). Repeated (>2) episodes of peritonitis remained the most frequent cause of technique failure requiring transfer to HD.
However, a report on 628 infants initiating chronic PD from the North American Pediatric Renal Cooperative Study and Trials (NAPRTCS), which has maintained a pediatric renal registry since 1992, also showed that infants and neonates were surviving longer long with DP in the second decade. of their follow-up compared with more PD interruptions for kidney transplant, and fewer interruptions due to death or transfer to hemodialysis (23, 24). There is a need to investigate the extent of dropout of children from chronic PD and.
Timing of drop-out from chronic PD
Problem statement
Justification
Research questions
Study setting
Study design
Target population
Study population
Inclusion criteria
Exclusion criteria
Study procedure
Study variables collected
Data management
Factors associated with PD discontinuation were assessed using the chi-square test or Fischer's exact test where numbers were small.
Ethical considerations
Confidentiality
Dissemination of results
RESULTS
Study profile
Baseline characteristics of study participants
About 28% of patients had PD interruptions in terms of temporary switching to HD due to some complications. Catheter manipulations that occurred in 25% of the patients were due to temporary blockages from fibrin, omentum, or adhesions.
Causes of End stage kidney disease (ESKD) among study participants
Peritoneal fluid culture results based on the first episode of peritonitis
Peritoneal dialysis outcomes among the study participants
Description of the participants that dropped-out from PD
Factors for drop-out from chronic PD among the study participants
The risk of failure was not different among those who had one episode versus two or more episodes of peritonitis. Age at PD initiation and gender were not significant factors for dropout from PD in this study.
Blood indices as risk factors for drop-out from PD
20 4.9 Factor related to failure of PD Table 6: Factor related to failure of PD.
Factors associated with drop-out from PD
Timing of drop-out from chronic PD
Discussion
Drop-out rates from PD
Looking at other developing countries, our mortality and conversion rates to HD were lower than those reported by Frehat et al (15) among children in Jordan, who reported mortality at 27.5%, conversion to HD at 15% and a low transplant rate of 10 %. The authors attributed these outcomes to longer stays on PD as they depend on only living related donors. Better outcomes in our study may reflect the use of both living relatives and cadaveric donors that reduced the time to transplantation.
Young age < 24 months was the most significant factor for poor outcome (death or transition to HD) of PD, which were more frequent compared to our findings. In contrast, age at onset of PD was not significantly associated with outcome in our study. This rate was low compared to our study despite the fact that their study included only patients with peritonitis.
Factors associated with drop-out from chronic PD
Furthermore, overexposure of the peritoneal membrane to high concentration glucose solutions of 2.5% and 4.25% causes thickening and fibrosis of the peritoneum with eventual loss of ultrafiltration over time. A previous retrospective study among children with PD between 2000 and 2008 at our institution reported a peritonitis rate of 2.8 episodes per patient years (29). From our study (Table 5), of the 4 deaths, one of the 4 deaths was due to recurrent pancytopenia bleeding requiring multiple platelet transfusions, and one was due to poor adherence to PD leading to recurrent fluid overload and hypertension, thus set on palliation, so there was a contribution. to fall from other non-infectious or non-mechanical factors.
One transfer to HD was due to a gastrocolic fistula from the PEG, 3 transfers to HD had peritonitis along with catheter-related problems; 2 blocked and 1 leaked. There was therefore a contribution from mechanical complications, but was not significant as a stand-alone factor for failure. In our study, we did not specifically assess for factors related to peritonitis, as the focus was on PD dropout.
The incidence of peritonitis in this study was 1.2 episodes per patient years, which shows an improvement over time from 2.8. However, this rate is still higher than the cut-off of 0.5 episodes per patient years, i.e. Among 57 children in Korea, Lee et al (31) found significantly lower peritonitis episodes among children on APD, 0.06 episodes compared to 0.48 episodes per patient years on CAPD, but overall the frequency was low with 0.43 episodes per patient-year and low drop-out rate of 1.8 per cent.
Children with anemia, low albumin and TB peritonitis tended to drop out in our study. Gulati et al (21) reported that ≥ two episodes of peritonitis were associated with a switch to HD, but were also predictive of low serum albumin, probably due to increased protein loss in the effluent, and systemic inflammation. Children who start PD at a young age, especially infants, have been shown to have worse outcomes, with a higher risk of mortality and low survival (23), as they tend to have more infectious and mechanical complications.
This was not a significant factor for dropout in our study when stratified by age below or above five years at PD onset. When stratified by two years, those younger than two years at baseline tended to drop out, although the number was very small (only two initial PDs younger than two years). In general, outcomes of PD in infants have improved over the years due to better technology, experience, and increased number of transplants (23).
Timing of drop-out from chronic PD
Strengths and Limitations
Similarly, the retrospective nature of the study did not allow identification of factors associated with peritonitis, making it difficult to predict which. However, the strength of the study is that it is the first pediatric study to examine dropout from PD in sub-Saharan Africa. In addition, RCWMCH is a tertiary centre, the PD program is led by nephrologists and PD nurses, and the center uses nocturnal APD and therefore represents the best possible care in a resource-constrained setting.
Guidelines are followed when inserting PD catheters, training of carers and home visits are done at the start of PD, there is long-term follow-up and records are kept. This study provides important clinical information to help promote longer stays on PD at the Red Cross Hospital.
Conclusions
Recommendations
Continuous ambulatory peritoneal dialysis in Limpopo Province, South Africa: predictors of patient and technique survival. Outcome of Iranian children on continuous ambulatory peritoneal dialysis: The first report from the Iranian national registry. Frehat MQF, Al-salaita GM, Al-bderat JT, Alhadidi AM, Mohammad SA, Shaaban AM, et al.
Changes in patient and technique survival over time among incident peritoneal dialysis patients in Canada. …….Kidney Transplant/Fallout Transfer to HD, Dropout Death/Still on PD at time of study.
