Workshop DIN 2017 Peritoneaal dialyse

Landelijke trend Stellingen PROMS Casus

(potentiële) Belangenverstrengeling Geen

Voor bijeenkomst mogelijk relevante relaties met bedrijven -

•   Sponsoring of onderzoeksgeld •   Honorarium of andere (financiële)

vergoeding •   Aandeelhouder •   Andere relatie, namelijk

•  Geen •  Sprekersvergoeding

•  Nvt •  Nvt

Dialysis Initiatives Nefrologen 2017

Disclosure belangen C.W.H. de Fijter

Landelijke PD-ontwikkeling

Stelling 1

•  De afname van PD in Nederland kent verschillende redenen, die vooral toe te schrijven zijn aan:

•  Patiënt •  Nefroloog •  Infrastructuur •  Uitkomst/complicaties

Stelling 2

•  Minimaal 3-6 maanden is nodig om een patiënt goed voor te lichten over nierfunctievervangende therapie.

Stelling 3

•  De startende nefroloog is beperkt geschoold in PD

NIO enquête parttime PD stage OLVG 6 maanden 1 dag per week

•   1. Eén dag per week PD stage elders vond ik zinvol, vanwege extra patiëntencontacten, en stimulerend door nieuwe gezichtspunten therapie/werkwijze/organisatie.

•   2. Expositie aan PD patiënten en problemen was ruim voldoende aanwezig en aanvulling op ervaring in eigen opleidingscentrum.

•   3. Follow-up van (poli)klinische patiënten en problemen: goed mogelijk ondanks parttime aanwezigheid op locatie.

•   4. Voor- en nadelen van PD alsmede complicaties zijn voldoende aan bod gekomen. Zeker. Bijdrage thuisbehandeling aan flexibiliteit / mogelijkheid te werken.

•   5. Ik voel mij in staat zelf PD kandidaten te werven, met PD te starten en de behandeling te monitoren. Meer capabel en zelfstandig.

•   6. Evaluatie stage in 1 woord of zin. Zeer nuttig, leerzaam en leuk. “geleerd hoe elegant PD behandeling is”; “gevoel gekregen voor waar grenzen liggen”; “stimulans om eigen standpunt te bepalen”

Samenvatting NIO-dag PD april 2017

N = 37

Hoe lang bent u bezig met het aandachtsgebied?

0

5

10

15

20

25

30

35

40

13 11

8

4

1

35

30

22

11

3

aantal

percentage

Hoeveel PD patiënten behandelt u zelfstandig?

0

10

20

30

40

50

60

70

80

0-5 6-10 11-15 16-20 21-25 >25

27

6

1 1 0 1

75

17

3 3 0

3

aantal

percentage

Hoeveel PD patiënten worden er in uw centrum behandeld?

Is er voldoende PD expertise in uw centrum?

0

10

20

30

40

50

60

70

80

90

ja nee anders

32

2 3

86

5 8

aantal

percentage

0

5

10

15

20

25

30

0-5 6-10 11-15 16-20 21-25 >25 ?

5

3 2

9

5

10

3

14

8

5

24

14

27

8

aantal

percentage

Is er een aparte PD stage?

0

5

10

15

20

25

30

35

40

13 11

8

4

1

35

30

22

11

3

aantal

percentage

Wordt er voldoende aandacht besteed aan PD tijdens uw opleiding?

0

5

10

15

20

25

30

35

40

45

50

ja nee anders

18

13

6

49

35

16

aantal

percentage

Hoe lang bent u bezig met het aandachtsgebied?

0

5

10

15

20

25

30

35

40

13 11

8

4

1

35

30

22

11

3

aantal

percentage

Hoeveel uur per week bent u bezig met PD?

0

5

10

15

20

25

30

35

40

14

6 6

0 1

7

2

39

17 17

0

3

19

6

aantal

percentage

Stellingen over PD vs HD

0 10 20 30 40 50 60 70 80 90

100

eens oneens geen mening

0

37

0 0

100

0 0

10 20 30 40 50 60 70 80

eens oneens ligt aan type patient

28

8 1

76

22

3

0

10

20

30

40

50

60

eens oneens anders

12 20

5

32

54

14

PD is een inferieure behandeling tov centrum HD

PD is een gelijkwaardige behandeling t.o.v. centrum HD

PD is een betere behandeling t.o.v. centrum HD

Wat mist u tijdens uw opleiding m.b.t. PD?

Transitie predialyse -> PD PD overbrugging naar Tx Stage Praktijkervaring Betrokkenheid plaatsing katheter Structureel onderwijs Theoretische achtergrond

Hands-on ervaring Betrokkenheid meerdere nefrologen Patiënten Onderwijs PD poli mag vaker Structurele begeleiding

Er is geen plaats voor PD in de acute setting

0

10

20

30

40

50

60

70

80

eens oneens anders

7

28

2

19

76

5

aantal

percentage

Welcoming patients to the floor: PROMs HD vs PD in OLVG Oost

•  About 40% of patients is durably treated with peritoneal dialysis in our teaching hospital.

•   Patient’s perspectives were studied by patient reported outcome measurements (PROMs) to find out why the generally reported decline in the use of PD hardly occurred in our facility.

PROMs - Methods

•  All 75 prevalent adult dialysis patients (HD duration 27, PD 16 months) were included. All had received predialysis care and education for > 6 months.

•  Cross-sectional sociodemographic and clinical data*,

SF-36, KDQOL-SF, frailty and predialysis anxiety/depression scores were collected in February 2016.

•  Differences in PROMs between PD and HD patients were analyzed.

•   *including age, sex, ethnicity, primary kidney disease, comorbidity, residual renal function [rGFR, urine production], body mass index (BMI), dialysis modality, time on dialysis, erythropoietin use, and subjective global assessment (SGA).

Herkomst patiënten

Nederland 46%

Suriname 20%

Antillen 3%

Marokko 3%

Turkije 6%

China 3%

Filippijnen 3%

Pakistan 3%

Egypte 3%

Chili 3%

Italie 3%

Luxemburg 3%

Oekraine 3%

Nederland 21%

Suriname 36%

Antillen 4%

Marokko 11%

Turkije 15%

Filippijnen 2%

Egypte 2%

Eritrea 2%

Armenie 2%

Senegal 2%

Sierra Leone 2%

PD

HD

PD (n=33)

HD (n=42)

p-value

Age 66 ± 14 66 ± 11 0.89 Aged > 80 years (n(%)) 7(21) 4(10) 0.16 Male (n(%)) 9(27) 27(64) 0.44 Ethnicity (n(%)) Caucasian Afro-American Asian

21(64) 9(27) 3(9)

17(40) 23(55)

2(5)

0.06

Born in the Netherlands (n(%))

16(48) 11(24) 0.08

Primary kidney disease (n(%)) Diabetic nephropathy Glomerulonephritis Renal vascular disease ADPKD Others

13(40) 4(12) 11(33) 2(6) 3(9)

16(38) 1(2)

15(36) 2(5)

8(19)

0.41

Diabetes Mellitus (n(%)) 14(42) 19(45) 0.81 Davies comorbidity score None Intermediate High

3(9)

13(39) 17(52)

13(31) 17(40) 12(29)

0.04

BMI (kg/m2) 29.9 ± 7.2

27.6 ± 6.2

0.15

Patient characteristics. Mean values +/- SD or median values (interquartile range), depending on the distribution.

PD (n=33)

HD (n=42)

p-value

nPNA (g/kg/day) 1.1 ± 0.1 1.1 ± 0.2 0.26 Erythropoietin use (n(%)) 18(55) 42(100) 0.00 Anuric patients (n(%)) 6(18) 22(52) <0.001 Urine production in non anuric patients ml/24u

919 ± 573

1121 ± 556

0.23

rGFR in non-anuric patients (ml/min)

5.0 ± 2.2 4.1 ± 2.6 0.21

Hemoglobin (g/dl) 11.4 ± 0.7

10.9 ± 0.8 0.09

Parathyroid hormone (pmol/l)

27.5 ± 16.7

30.1 ± 17.3

0.53

Serum albumin (g/l) 37.5 ± 4.5

39.6 ± 4.2 0.05

Dialysis Kt/Vurea* 2.0 ± 0.4 1.4 ± 0.3 Months on dialysis

16 (10-34)

27 (12-57)

0.06

HADS score (n of returned forms) Anxiety Depression HADS score > 12 (n(%))

28 5.5 ± 3.9 6.6 ± 4.4 12.0 ±

7.7 12(43)

29 8.4 ± 3.8 7.7 ± 4.9

16.1 ± 8.1 20(69)

0.01 0.36 0.06 0.03

CSHA frailty score Living alone (n(%))

3.9 + 1.1 9(27)

3.7 + 1.0 16(38)

0.13 0.37

SF-36 en KDQoL: gemiddelde + SD score op fysiek, mentaal en sociaal gebied van de HD- en PD-patiënten uit het OLVG

Bodily pain 58 ± 25 45 ± 29 0.05

PD HD p-value Short Form 36

KDQOL

Symptoms/problems 71 ± 16 64 ± 15 0.05

Table 3: Multiple linear regression models for PROM components comparing PD and HD. A positive β value of a score means superiority of PD, its value represents the difference in scores. Crude β: Adjusted β

model 1*: Adjusted β model 2**:

Short form 36 Physical component score

10.2 (0.3-20.0) §

9.1 (-0.9-19.1) 12.1 (0.7-25.0) §

Mental component score

12.8 (1.9-23.6) §

11.4 (0.4-22.5) §

17.0 (3.3-30.6) §

Social function 12.9

(-0.2-26.1) 10.8

(-2.5-24.1) 17.8 (1.9-33.7) §

Mental health 9.5 (0.9-18.0) § 9.2 (0.6-17.9) § 9.3 (-1.4-20.0)

Bodily pain 14.8 (2.3-27.3)

§ 14.1 (1.5-26.6)

§ 19.8 (3.9-35.7) §

KDQOL Effects of kidney disease

12.3 (2.2-22.4) §

12.1 (1.6-22.5) §

13.1 (0.1-26.2) §

Symptoms/problems

8.0 (-0.3-16.3) 8.5 (0.1-17.1) § 15.5 (5.5-25.4) §

Abbreviations: PROM=patient reported outcome measures; *adjusted for age, sex, time on dialysis; **+ born in the Netherlands, Davies comorbidity score, anuria, diabetes mellitus;§p<0.05.

PROMs – Results - summary

•  Despite more comorbidity in the PD population, generally used dialysis parameters were adequate and similar between HD (n=42) and PD (n=33) patients as was annual mortality (13 vs 11%).

•  Many factors associated with a predialysis modality choice for PD were absent.

•  A higher anxiety/depression score was found in pre-HD compared to pre-PD patients.

•  PROMs were returned by 97%. •  PD patients performed better on a number of PROMS

than their HD mates.

PROMs - Conclusion

•   Single center cross-section with a low number of patients but an almost 100% patient response shows that having a high% of patients on PD is possible with excellent results in terms of patient reported outcomes.

•   A structured patient education with attention for personal needs of patients, an adequate infrastructure for PD and a dedicated team with ongoing patient support are key factors.

•   Sharing best practices may help to slow down or even reverse the decline of PD which is a pity both for patients and society.

Casus gecompliceerde SLE

•  Mw M 52 jaar •  2003 NS t.g.v. SLE nefritis V, complicatie: v. porta

trombose -  P/aza: goede respons; leverbx: verstoorde microcirkulatie

•  2013 Recidiverend hematemesis en ascites -   TIPS/chirurgie onmogelijk: frequent RBL varices, diuretica,

ascitesdrainage, albumine iv -  Opname 16x, a 2 wk, nierfunctie stapsgewijs naar 12%,

Karnofsky score drastisch omlaag naar 20-30

Casus SLE

•   Physical examination: -   RR 130/80 mmHg, tense ascites with collateral circulation reflected in abdominal

wall veins.

•   Lab: -   normal liver function and enzymes, creatinine 5.7 mg/dl, urea 70 mg/dl. ECC 12 ml/

min, proteinuria of 0.5 g/24 h. -   Serum albumin was 37 g/l, ascites albumin 9 g/l, SAAG 28 g/l. Ascites white blood

count 0.1 x 10e9/l.

•   Abdominal echography: -   portal vein thrombosis with collateral vasculature, a hepatopetal flow and ascites.

•   Endoscopy: -   bleeding varices, treated by multiple banding sessions.

•   Echocardiography: -   no cardiac failure or cardiac inflow obstruction.

…refractory ascites, the need for frequent large volume paracenteses, deteriorating renal function with uremia, trombocytosis & activated clotting cascade, low quality of life and frequent hospitalisation due to relapsing overt hematemesis with hypotension….

•  Nephrological management challenge -   CVVH w regional citrate: not (cost-effective) for the long run. -   HDF w/wo anticoagulant? Frequent hypotension -   PD?

. No evidence based solution!

PD as last resort?

•  After drainage of ascites a Swan-neck Tenckhoff catheter was laparoscopically placed without complications.

•   Initially, drainage of the ascites was started and gradually PD fluid was introduced to achieve a negative fluid balance.

•  No episodes of hypotension or peritoneal fluid leakage were observed.

•  CAPD: 4 x 1,5L 1,36% glucose

The following years…

•  no peritonitis or other PD-related complications. •  no episodes of oedema, and she presented less frequently

with bleeding episodes.

•  Endoscopic studies showed diminishing gastric and oesophageal varices.

•  Liver function tests remained normal. Salbumin 37 g/l. •  At present, a residual diuresis of 1100 ml, a renal creatinine

clearance of 7 ml/min, Kt/V of 2.2.

The following years…

•  Hospitalisation rate decreased tremendously (from 55 days/ year in the year prior to PD to 14 and 0 days/year in the two consecutive years with CAPD, respectively).

•  Her clinical condition as well as her quality of life increased favourably (Karnofsky score improved from 20-30 to 70). At present she feels well.

•  PD appears cost-effective with respect to hospitalisation rate, morbidity and quality of life.

Casus PD as last resort?

•  Hr D 61yr, ESRD due to DM2 •  2002 IHD 3x/week •  2006 collaps, hypoxemia: CT no pulmonary embolism but

pericardial & pleural effusion; ascites, hypalbuminemia, hypotension.

•  Kt/V 1,3; daily haemodialysis and isolated ultrafiltration were necessary because of overhydration.

•  Echocardiography revealed a good left and right ventricular function, no valve abnormalities, and pericardial effusion of 1 cm all around without inflow obstruction.

•  The ascites was a straw-coloured exudate, had a white blood cell count of 0.1 x 109/l and a SAAG of 1 g/l.

•  Ascites culture and cytology were negative, including a polymerase chain reaction for typical and atypical mycobacteria.

•  Liver function tests, iron studies, thyroid-stimulating hormone, and parathyroid hormone were normal.

•  No evidence was found of portal hypertension, cardiac or pericardial disease, peritoneal infection or malignancy.