IS PD A FIRST CHOICE IN THE ADULTS? RÜMEYZA KAZANCIOGLU, MD BEZMIALEM VAKIF UNIVERSITY

FACULTY OF MEDICINE / DIVISION OF NEPHROLOGY

✓ Health care policies ✓ Choice of the patient ✓ According to the available evidence

Rümeyza Kazancıoglu, MD

✓ Health care policies ✓ Choice of the patient ✓ According to the available evidence

Rümeyza Kazancıoglu, MD

PD WORLDWIDE

Rümeyza Kazancıoglu, MD

PD PREVALENCE

Rümeyza Kazancıoglu, MD

AND ACROSS COUNTRIES 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

84%

43% 39% 27% 23% 21% 18%

9%

9%

9%

8,5% 8%

5%

Rümeyza Kazancıoglu, MD

06 20

04 20

02 20

00 20

98 19

96 19

94 19

92 19

90 19

88 19

86 19

84

90 79 79 81 80 80 81 81 81 81 81 82 82 81 81 80 78 75 80 70 72 70 63 59 60 49 50 43 40 33 30 20 10 0 19

%

HONG KONG

Rümeyza Kazancıoglu, MD

Rümeyza Kazancıoglu, MD

✓ Health care policies ✓ Choice of the patient ✓ According to the available evidence

Rümeyza Kazancıoglu, MD

WHAT IS THE BEST LONG-TERM TREATMENT? 1. PD 2. HD in-center 3. HD home/selfcare

Ask the nephrology providers which dialysis modality they would select if they had ESRD? Rümeyza Kazancıoglu, MD

WHAT IS THE BEST LONG-TERM TREATMENT?

Opinion

Reality

Ledebo I., Ronco C.Rümeyza NDT Plus Kazancıoglu, 2008; 6:403-408 MD

ABSOLUTE CONTRAINDICATIONS FOR PD Documented loss of peritoneal function or extensive abdominal adhesions (previous abd. surgeries)  limit dialysate flow

Uncorrectable mechanical defects (e.g., diaphragmatic hernia)

In the absence of a suitable assistant, a patient who is physically or mentally incapable of performing PD Rümeyza Kazancıoglu, MD

✓ Health care policies ✓ Choice of the patient ✓ According to the available evidence

Rümeyza Kazancıoglu, MD

PD AS THE INITIAL FORM OF RENAL REPLACEMENT THERAPY • Better initial, equal long-term survival • Preserves residual renal function • Quality of life • Reduced risk of being infected by a blood borne

virus • PD  Transplant: reduced risk of early acute renal failure • Cost of therapy

Rümeyza Kazancıoglu, MD

INITIAL SURVIVAL ADVANTAGE Canada 11.970 patients

Fenton AJKDKazancıoglu, 30:334-42, 1997 Rümeyza MD

INITIAL SURVIVAL ADVANTAGE PD patients have 27% less mortality rate compared to HD Mortality risk factors are the same in both PD and HD

Rümeyza Kazancıoglu, MD

INITIAL SURVIVAL ADVANTAGE USRDS data – 99,048 HD and 18,110 PD patients

Mortality risk is PD < HD in non-diabetic patients PD better survival in the first 2 years

Collins et al.

Rümeyza Kazancıoglu, MD

INITIAL SURVIVAL ADVANTAGE ❖ Preservation of RRF

Rümeyza Kazancıoglu, MD

USRDS

5 year survival Rümeyza Kazancıoglu, MD

SURVIVAL ADVANTAGE OF PD TSN RENAL REGISTRY YEARS

TOTAL

HEMODIALYSIS

PERITONEAL DIALYSIS

1.

90.9

86

90.5

85,2

95,6

92,1

2.

84.5

77

84.1

76

90

84,4

3.

78.6

69

78.0

67,8

86

78,3

4.

73.5

62,4

73.0

61,2

79,6

68

5.

68.7

56,5

68.2

55,4

74,4

62,2

6.

64.1

50,7

63.7

49,4

70,5

57,5

7.

60.9

46,9

60.4

45,5

67

55,6

8.

58.5

44,2

58.0

42,7

61,1

53

9.

55.9

41,5

55.3

40

61,1

53

10.

54.8

40,3

54.2

39,9

61,1

53

Rümeyza Kazancıoglu, MD

PD SURVIVAL HAS IMPROVED HD 1997–2001

PD 1997–2001

HD 2002–2006

PD 2002–2006

Patient survival on PD (Crude survival probability)

100 Between 1997–2001 and 2002–2006, the risk of death decreased for PD patients by 19% (95% CI 15–22%)

80 60 40 20 0

1 year

2 years

5 years

ERA-EDTA registry: Retrospective, Observational study of incident PD patients Kramer A, et al. Nephrol Dial Transplant 2009;24:3557–66

Rümeyza Kazancıoglu, MD

2.00

1.50 1.25

1.00 0.80 0.67 0.50

2001–2004 Favours PD Favours HD

1991–1995

Cumulative hazard ratio (PD:HD)

Cumulative hazard ratio (PD:HD)

2.00

1.50 1.25

1.00 0.80 0.67 0.50

6

12

18

24

30

36

42

Months of follow-up

48

54

60

6

12

18

24

30

36

42

48

54

60

Months of follow-up

CORR: Retrospective, observational study in incident patients in Canada, with follow-up through to 2007 (N=>46,000)

Yeates K, et al. Nephrol Dial Transplant 2012

Rümeyza Kazancıoglu, MD

SURVIVAL ADVANTAGE OF PD 2035 PD, 4538 HD

Rümeyza Kazancıoglu, MD

SURVIVAL ADVANTAGE OF PD HD: 620 020 PD: 64 406

1996-1998 1999-2001 2002-2004

Mehrotra et al . Arch Intern Med 171: 110-118, 2011

Rümeyza Kazancıoglu, MD

SURVIVAL ADVANTAGE OF PD

Rümeyza Kazancıoglu, MD

SURVIVAL ADVANTAGE OF PD

2000-2009

Haapio et al. Nephrol Dial Transplant 2013

Rümeyza Kazancıoglu, MD

SURVIVAL ADVANTAGE OF PD

Haapio et al. Nephrol Dial Kazancıoglu, Transplant 2013 Rümeyza MD

PD AS THE INITIAL FORM OF RENAL REPLACEMENT THERAPY • Better initial, equal long-term survival • Preserves residual renal function • Quality of life • Reduced risk of being infected by a blood borne

virus • PD  Transplant: reduced risk of early acute renal failure • Cost of therapy

Rümeyza Kazancıoglu, MD

RESIDUAL RENAL FUNCTION Increase in GFR by 0.5 mL/min

Decreases mortality risk by 9%

Rümeyza Kazancıoglu, MD

RESIDUAL RENAL FUNCTION Davies, S., 2000 Contributes to total solute clearance (1 ml/min CrCl = 10 liter CrCl/week)

Provides endocrine functions • Erythropoietin production • Ca++, phosphorus and vitamin D homeostasis

Improves 2-microglobulin and middle molecule clearance

Reduces Mortality

Improves QoL Facilitates volume control Increases total Na removal Improves nutritional status

Allows for more liberal diet and fluid intake

Bargman et al. J Am Soc Nephrol 12:2158-2162, 2001 Mehrotra  Kopple Adv Renal Repl Ther 10:1994-212, 2003 Rümeyza Kazancıoglu, MD

RESIDUAL RENAL FUNCTION NECOSAD 2 study

522 (279 HD, 243 PD) patients Predialysis renal function 3., 6., 12. months control PD > HD

Jansen et al Kidney Int 2002

Rümeyza Kazancıoglu, MD

RESIDUAL RENAL FUNCTION Germany Single center prospective study 15 PD / 30 HD patients At the initiation, 6.,12. and 24. months RRF

Lang SM et al. Perit Dial Int 2001

Rümeyza Kazancıoglu, MD

RESIDUAL RENAL FUNCTION ❖HD pts randomized to ❖Group I

: Biocompatible membrane

❖Group II

: Bioincompatible membrane

❖HD ❖3/week, 4-5 hours ❖Blood flow: 200 – 280 mL/min ❖Dialysate flow: 500 mL/min

Lang SM et al. Perit Dial Int 2001

Rümeyza Kazancıoglu, MD

RESIDUAL RENAL FUNCTION RRF decreased twice faster in HD patients !

6 Months

12 Months

PD

0.6 ml/min

1.4 ml/min

HD

2.8 ml/min

3.7 ml/min

Lang SM et al. Perit Dial Int 2001

Rümeyza Kazancıoglu, MD

PD AS THE INITIAL FORM OF RENAL REPLACEMENT THERAPY • Better initial, equal long-term survival • Preserves residual renal function • Quality of life • Reduced risk of being infected by a blood borne

virus • PD  Transplant: reduced risk of early acute renal failure • Cost of therapy

Rümeyza Kazancıoglu, MD

CHOICE - QUALITY OF LIFE: PD VS HD PD patients reported better QOL then HD patients in the following domains: • • • • • •

Bodily pain Travel Diet restrictions Dialysis access Financial well-being Physical functioning (only at baseline, not at 1 year)

Wu A et al. JASN 2004; 15: 743-753 Wu A et al. JASN 2004;Kazancıoglu, 15: 743-753 Rümeyza MD

QUALITY OF LIFE ❖ Response rate: ❖ 656 out of 736 (89%)

Rümeyza Kazancıoglu, MD

QUALITY OF LIFE

PD patients were significantly more likely to give excellent ratings of dialysis care overall compared to HD patients (85% vs 56%)

Rümeyza Kazancıoglu, MD

SATISFACTION WITH PD

Molsted Nephron 2007

Jager AJKD 2004

Rümeyza Kazancıoglu, MD

SATISFACTION WITH PD

Rümeyza Kazancıoglu, MD

SATISFACTION WITH PD ➢ PD patients are more satisfied with therapy ➢ PD patients believe treatment has less impact on life style ➢ HD patients report more dissatisfaction than PD

Rümeyza Kazancıoglu, MD

PD AS THE INITIAL FORM OF RENAL REPLACEMENT THERAPY • Better initial, equal long-term survival • Preserves residual renal function • Quality of life • Reduced risk of being infected by a blood borne

virus • PD  Transplant: reduced risk of early acute renal failure • Cost of therapy

Rümeyza Kazancıoglu, MD

TRANSMISSION OF BLOOD BORNE VIRUSES WITH PD • 360 HD patients, 456 CAPD patients from 13 dialysis units • 35 of 201 HD patients (17%) and 18 of 286 PD patients (6%) became antiHCV(+) • 8 of the 18 anti-HCV(+) CAPD patients (44%) had undergone HD treatment prior to CAPD treatment

Rümeyza Kazancıoglu, MD

HEPATITIS IN PD 100 89,2

90

80

70

Yüzde

60

50

40

30

20

10 4,4

5,7 0,6

0 HbsAg (+)

Anti-HCV (+)

HbsAg (+) ve Anti-HCV (+)

HbsAg (-) ve Anti-HCV (-)

Turkish Society of Nephrology 2010 MD RümeyzaRegistry Kazancıoglu,

HEPATITIS IN PD

3.9

9.2 4.9

5.5

9.6

11.3 5.6

5.6

13.8

15.1 7.2

5

6.9 4.9 5.9 4.4 5.7 5.0 4.7 4.8 4.5

21.3 8.6

10.5

9.2

10

5.8 7.3

15

20.8

21.3 14.2 16.7 11.0

20

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

1999

1998

1997

1996

0 1995

Yüzde / Percent

25

21.3

Prevalan (mevcut) PD hastalarında hepatit serolojisi Hepatitis serology in prevalent PD patients

Yıl / Year HBsAg (+)

Anti-HCV(+) Turkish Society of Nephrology 2010 MD RümeyzaRegistry Kazancıoglu,

WHY LOWER RISK OF HEPATITIS IN PD? Pereira KI 1997; 51:981-999

• Lower requirement for blood transfusion than HD patients • The absence of a vascular access site and

extracorporeal blood circuit reduces the risk for parenteral exposure to the virus • PD is a home therapy and it offers a more isolated environment

Rümeyza Kazancıoglu, MD

PD AS THE INITIAL FORM OF RENAL REPLACEMENT THERAPY • Better initial, equal long-term survival • Preserves residual renal function • Quality of life • Reduced risk of being infected by a blood borne

virus • PD  Transplant: reduced risk of early acute renal failure • Cost of therapy

Rümeyza Kazancıoglu, MD

TRANSPLANTATION AND PD • Graft function immediately after transplantation is important • 24% of PD patients have delayed graft function (DGF) vs. 50% of HD patients* • Patients with delayed graft function have a 10% decreased graft survival • Reduced need of post-transplantation dialysis • PD patients have lower usage of immunosuppressive medication* • PD patients suffer a lower incidence of late infections* * Perez Fontan M, Perit Dial Int,Kazancıoglu, 1996, 16: 48-54 Rümeyza MD

TRANSPLANTATION AND PD 10 years after tx : Graft and patient survivals were similar in PD and HD groups

Rümeyza Kazancıoglu, MD

TRANSPLANTATION AND PD Examined outcomes in 12416 HD and 2092 PD patients having first kidney transplantation Mortality, graft failure and delayed graft function PD before tx was associated with increased survival vs HD Pretransplant PD was associated with • 17% reduced death censored graft failure • 36% lower delayed graft function • But these disappeared after adjustment for covariates Noted similar benefits in a propensity score matched cohort

Molnar CJASN 2012, 7, 332-341MD Rümeyza Kazancıoglu,

PD AS THE INITIAL FORM OF RENAL REPLACEMENT THERAPY • Better initial, equal long-term survival • Preserves residual renal function • Quality of life • Reduced risk of being infected by a blood borne

virus • PD  Transplant: reduced risk of early acute renal failure • Cost of therapy

Rümeyza Kazancıoglu, MD

COST OF THERAPY IN USA

USRDS 2009

Rümeyza Kazancıoglu, MD

16 NHS Units 2006/2007 Hospital HD

28,860 £

Center HD

22,152 £

CAPD

18,980 £

APD

21,900 £ Rümeyza Kazancıoglu, MD

COST OF THERAPY IN UK 7 Hospitals Multi-center study Nephrologists, head nurses and business managers Hospital HD

35,023 £

Center HD

32,669 £

APD

21,655 £

CAPD

15,570 £

Baboolal K, et al. Nephrol Dial Transplant 23:1982–9, 2008

Rümeyza Kazancıoglu, MD

Just, et al. Health Policy 86:163–80 2008

Rümeyza Kazancıoglu, MD

Just, et al. Health Policy 86:163–80 2008

Rümeyza Kazancıoglu, MD

PERİTON DİYALİZİ

HEMODİYALİZ YTL

PD Solüsyon Fiyatı PSF - Tüm Kurumlar (KDV hariç) Kurum İskontosu İskontolu PD Solüsyon Fiyatı Yıllık Tedavi Sayısı

18,25 11% 16,24 1.260

Ağırlıklı Hasta Başı Yıllık Tedavi Maliyeti

20466

PD Hasta Sayısı 2005 Sonu

3.381

EPO (İthal) EPO Kullanım Oranı (2005 Registry) EPO Kullanan Hasta Sayısı Ortalama Haftalık Hasta Başı EPO Kullanımı (kutu) Ortalama Aylık Hasta Başı EPO Kullanımı (kutu) Ağırlıklı Aylık Hasta Başı EPO Kullanımı (kutu)

Kur (TL/$) 1,35

$ 13,50

15.143

Ağırlıklı Hasta Başı Yıllık EPO Maliyeti

138,00 13,0 156

PD vs HD

Ağırlıklı Hasta Başı Yıllık Tedavi Maliyeti

21511

HD Hasta Sayısı 2005 sonu

28.507

EPO (İthal) EPO Kullanım Oranı (2005 Registry) EPO Kullanan Hasta Sayısı Ortalama Haftalık Hasta Başı EPO Kullanımı (kutu) Ortalama Aylık Hasta Başı EPO Kullanımı (kutu) Ağırlıklı Aylık Hasta Başı EPO Kullanımı (kutu)

60,40% 17.218 0,50 2,17 1,31

cheaper

3987

Ağırlıklı Hasta Başı Yıllık Demir Maliyeti

Hemodiyaliz Seans Başı Maliyet (KDV hariç) Ortalama Aylık HD Seans Ortalama Yıllık HD Seans

5,800 USD/year

52,70% 1.782 0,25 1,08 0,57

DEMİR (Yerli) Demir Kullanım Oranı (EPO Kullanım oranı ile aynı) Demir Kullanan Hasta Sayısı Ortalama Haftalık Hasta Başı Demir Kullanımı (PO kutu) Ortalama Aylık Hasta Başı Demir Kullanımı (PO kutu) Ağırlıklı Aylık Hasta Başı Demir Kullanımı (PO kutu)

TL

2.950

Ağırlıklı Hasta Başı Yıllık EPO Maliyeti

49

36

Ağırlıklı Hasta Başı Yıllık Demir Maliyeti

Including medication:

P BAĞLAYICI (2005 Registry) P Bağlayıcı Kullanan Hasta Sayısı Ortalama Haftalık Hasta Başı P-bağlayıcı Kullanımı (PO kutu) Ortalama Aylık Hasta Başı P-bağlayıcı Kullanımı (PO kutu) Ağırlıklı Aylık Hasta Başı P-bağlayıcı Kullanımı (PO kutu)

Ağırlıklı Hasta Başı Yıllık P-bağlayıcı Maliyeti VİTAMİN D (İthal) Vit D Kullanım Oranı (PO) (2005 Registry) Vit D Kullanan Hasta Sayısı Ortalama Haftalık Hasta Başı Vit D Kullanımı (PO kutu) Ortalama Aylık Hasta BaşıVit D Kullanımı (PO kutu) Ağırlıklı Aylık Hasta BaşıVit D Kullanımı (PO kutu)

P BAĞLAYICI (2005 Registry) P Bağlayıcı Kullanan Hasta Sayısı Ortalama Haftalık Hasta Başı P-bağlayıcı Kullanımı (PO kutu) Ortalama Aylık Hasta Başı P-bağlayıcı Kullanımı (PO kutu) Ağırlıklı Aylık Hasta Başı P-bağlayıcı Kullanımı (PO kutu)

86,20% 3.816 0,25 1,08 0,93

PD: 18,418 USD HD: 24,242 USD

Ağırlıklı Hasta Başı Yıllık P-bağlayıcı Maliyeti

264

VİTAMİN D (İthal-oral) Vit D Kullanım Oranı (PO) (2005 Registry) Vit D Kullanan Hasta Sayısı Ortalama Haftalık Hasta Başı Vit D Kullanımı (PO kutu) Ortalama Aylık Hasta BaşıVit D Kullanımı (PO kutu) Ağırlıklı Aylık Hasta BaşıVit D Kullanımı (PO kutu)

39,8% 1.346 0,23 1,00 0,40

Ağırlıklı Hasta Başı Yıllık Vit D (PO) Maliyeti

103

Vit D Kullanım Oranı (IV) (2005 Registry) Vit D Kullanan Hasta Sayısı Ortalama Haftalık Hasta Başı Vit D Kullanımı (IV kutu) Ortalama Aylık Hasta Başı Vit D Kullanımı (IV kutu) Ağırlıklı Aylık Hasta Başı Vit D Kullanımı (IV kutu)

1,7% 57 0,17 0,74 0,01

76

Yearly:

Ağırlıklı Hasta Başı Yıllık Vit D (IV) Maliyeti AĞIRLIKLI YILLIK HASTA BAŞI TOPLAM MALİYET

24 24.893

İthal Edilen (Harcanan Döviz) Miktar

TL 4.641,80

18 18.418

PD: 15,143 USD HD: 15,917 USD USD 3.435

19%

Ağırlıklı Hasta Başı Yıllık Vit D (PO) Maliyeti

57,20% 16.306 0,50 2,17 1,24

1169

865

85,40% 24.345 0,50 2,17 1,85

0

489

362

14,8% 4.219 0,23 1,00 0,15

38

28

29,1% 8.296 0,17 0,74 0,22

Ağırlıklı Hasta Başı Yıllık Vit D (IV) Maliyeti AĞIRLIKLI YILLIK HASTA BAŞI TOPLAM MALİYET

417 32.764

HASTA BAŞI HD - PD FARKI

7.871

HASTA BAŞI HD - PD DÖVİZ ÇIKIŞ FARKI

102

6761

Vit D Kullanım Oranı (IV) (2005 Registry) Vit D Kullanan Hasta Sayısı Ortalama Haftalık Hasta Başı Vit D Kullanımı (IV kutu) Ortalama Aylık Hasta Başı Vit D Kullanımı (IV kutu) Ağırlıklı Aylık Hasta Başı Vit D Kullanımı (IV kutu)

İthal Edilen (Harcanan Döviz) Miktar

$

15917

9138

DEMİR (Yerli) Demir Kullanım Oranı (EPO Kullanım oranı ile aynı) Demir Kullanan Hasta Sayısı Ortalama Haftalık Hasta Başı Demir Kullanımı (IV kutu) Ortalama Aylık Hasta Başı Demir Kullanımı (IV kutu) Ağırlıklı Aylık Hasta Başı Demir Kullanımı (IV kutu)

52,70% 1.782 0,25 1,08 0,57

Kur (TL/$) 1,35

309 24242 5824

TL 22.559,31

USD 16.692

1

5824

Utas C, 2008

Rümeyza Kazancıoglu, MD

Rümeyza Kazancıoglu, MD

Rümeyza Kazancıoglu, MD

IN SUMMARY ✓ Health care policies ✓ Choice of the patient ✓ Available evidence PD IS STILL THE FIRST CHOICE IN ADULTS

Rümeyza Kazancıoglu, MD

CONCLUSION Following an integrated strategy of dialysis that Dratwa 1999

uses PD as an initial therapy then HD may improve total patient survival and preserve

societal resources which could be reallocated to treat more of the continuously increasing population of ESRD patients. Rümeyza Kazancıoglu, MD

THANK YOU FOR YOU ATTENTION Rümeyza Kazancıoglu, MD