IS PD A FIRST CHOICE IN THE ADULTS? RÜMEYZA KAZANCIOGLU, MD BEZMIALEM VAKIF UNIVERSITY FACULTY OF MEDICINE / DIVISION OF NEPHROLOGY

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1 IS PD A FIRST CHOICE IN THE ADULTS? RÜMEYZA KAZANCIOGLU, MD BEZMIALEM VAKIF UNIVERSITY FACULTY OF MEDICINE / DIVISION OF NEPHROLOGY

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

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

4 PD WORLDWIDE

5 PD PREVALENCE

6 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%

7 % HONG KONG

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

10 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?

11 WHAT IS THE BEST LONG-TERM TREATMENT? Opinion Reality Ledebo I., Ronco C. NDT Plus 2008; 6:

12 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

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

14 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

15 INITIAL SURVIVAL ADVANTAGE Canada patients Fenton AJKD 30:334-42, 1997

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

17 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.

18 INITIAL SURVIVAL ADVANTAGE Preservation of RRF

19 USRDS 5 year survival

20 SURVIVAL ADVANTAGE OF PD TSN RENAL REGISTRY YEARS TOTAL HEMODIALYSIS PERITONEAL DIALYSIS ,2 95,6 92, , , , , ,2 79, , ,4 74,4 62, , ,4 70,5 57, , , , , ,7 61, , , , ,9 61,1 53

21 Patient survival on PD (Crude survival probability) PD SURVIVAL HAS IMPROVED HD PD HD PD Between and , the risk of death decreased for PD patients by 19% (95% CI 15 22%) year 2 years 5 years ERA-EDTA registry: Retrospective, Observational study of incident PD patients Kramer A, et al. Nephrol Dial Transplant 2009;24:

22 Cumulative hazard ratio (PD:HD) Cumulative hazard ratio (PD:HD) Favours PD Favours HD Months of follow-up 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

23 SURVIVAL ADVANTAGE OF PD 2035 PD, 4538 HD

24 SURVIVAL ADVANTAGE OF PD HD: PD: Mehrotra et al. Arch Intern Med 171: , 2011

25 SURVIVAL ADVANTAGE OF PD

26 SURVIVAL ADVANTAGE OF PD Haapio et al. Nephrol Dial Transplant 2013

27 SURVIVAL ADVANTAGE OF PD Haapio et al. Nephrol Rümeyza Dial Kazancıoglu, Transplant 2013 MD

28 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

29 RESIDUAL RENAL FUNCTION Increase in GFR by 0.5 ml/min Decreases mortality risk by 9%

30 RESIDUAL RENAL FUNCTION Davies, S., 2000 Provides endocrine functions Erythropoietin production Ca++, phosphorus and vitamin D homeostasis Contributes to total solute clearance (1 ml/min CrCl = 10 liter CrCl/week) Reduces Mortality Improves 2-microglobulin and middle molecule clearance Improves QoL Increases total Na removal Improves nutritional status Allows for more liberal diet and fluid intake Facilitates volume control Bargman et al. J Am Soc Nephrol 12: , 2001 Mehrotra Kopple Adv Renal Repl Rümeyza Ther 10: , Kazancıoglu, 2003 MD

31 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

32 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

33 RESIDUAL RENAL FUNCTION HD pts randomized to Group I Group II : Biocompatible membrane : Bioincompatible membrane HD 3/week, 4-5 hours Blood flow: ml/min Dialysate flow: 500 ml/min Lang SM et al. Perit Dial Int 2001

34 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

35 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

36 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: Wu A et al. JASN Rümeyza 2004; Kazancıoglu, 15: MD

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

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

39 SATISFACTION WITH PD Molsted Nephron 2007 Jager AJKD 2004

40 SATISFACTION WITH PD

41 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

42 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

43 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 anti- HCV(+) 8 of the 18 anti-hcv(+) CAPD patients (44%) had undergone HD treatment prior to CAPD treatment

44 Yüzde 100 HEPATITIS IN PD 90 89, ,4 5,7 0,6 HbsAg (+) Anti-HCV (+) HbsAg (+) ve Anti-HCV (+) HbsAg (-) ve Anti-HCV (-) Turkish Society of Nephrology Registry 2010

45 Yüzde / Percent HEPATITIS IN PD Prevalan (mevcut) PD hastalarında hepatit serolojisi Hepatitis serology in prevalent PD patients Yıl / Year HBsAg (+) Anti-HCV(+) Turkish Society of Nephrology Registry 2010

46 WHY LOWER RISK OF HEPATITIS IN PD? Pereira KI 1997; 51: 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

47 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

48 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, 1996, 16: 48-54

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

50 TRANSPLANTATION AND PD Examined outcomes in 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,

51 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

52 COST OF THERAPY IN USA USRDS 2009

53 16 NHS Units 2006/2007 Hospital HD 28,860 Center HD 22,152 CAPD 18,980 APD 21,900

54 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

55 Just, et al. Health Policy 86:

56 Just, et al. Health Policy 86:

57 PERİTON DİYALİZİ HEMODİYALİZ YTL Kur $ TL Kur $ (TL/$) (TL/$) PD Solüsyon Fiyatı PSF - Tüm Kurumlar (KDV hariç) 18,25 1,35 13,50 Hemodiyaliz Seans Başı Maliyet (KDV hariç) 138,00 1, Kurum İskontosu 11% Ortalama Aylık HD Seans 13,0 İskontolu PD Solüsyon Fiyatı 16,24 Ortalama Yıllık HD Seans 156 Yıllık Tedavi Sayısı Ağırlıklı Hasta Başı Yıllık Tedavi Maliyeti Ağırlıklı Hasta Başı Yıllık Tedavi Maliyeti PD Hasta Sayısı 2005 Sonu HD Hasta Sayısı 2005 sonu EPO (İthal) EPO (İthal) EPO Kullanım Oranı (2005 Registry) 52,70% EPO Kullanım Oranı (2005 Registry) 60,40% EPO Kullanan Hasta Sayısı EPO Kullanan Hasta Sayısı Ortalama Haftalık Hasta Başı EPO Kullanımı (kutu) 0,25 Ortalama Haftalık Hasta Başı EPO Kullanımı (kutu) 0,50 Ortalama Aylık Hasta Başı EPO Kullanımı (kutu) 1,08 Ortalama Aylık Hasta Başı EPO Kullanımı (kutu) 2,17 cheaper Ağırlıklı Aylık Hasta Başı EPO Kullanımı (kutu) 0,57 Ağırlıklı Aylık Hasta Başı EPO Kullanımı (kutu) 1,31 Ağırlıklı Hasta Başı Yıllık EPO Maliyeti Ağırlıklı Hasta Başı Yıllık EPO Maliyeti DEMİR (Yerli) DEMİR (Yerli) Demir Kullanım Oranı (EPO Kullanım oranı ile aynı) 52,70% Demir Kullanım Oranı (EPO Kullanım oranı ile aynı) 57,20% Demir Kullanan Hasta Sayısı Demir Kullanan Hasta Sayısı Ortalama Haftalık Hasta Başı Demir Kullanımı (PO kutu) 0,25 Ortalama Haftalık Hasta Başı Demir Kullanımı (IV kutu) 0,50 Ortalama Aylık Hasta Başı Demir Kullanımı (PO kutu) 1,08 Ortalama Aylık Hasta Başı Demir Kullanımı (IV kutu) 2,17 Ağırlıklı Aylık Hasta Başı Demir Kullanımı (PO kutu) 0,57 Ağırlıklı Aylık Hasta Başı Demir Kullanımı (IV kutu) 1,24 Ağırlıklı Hasta Başı Yıllık Demir Maliyeti Ağırlıklı Hasta Başı Yıllık Demir Maliyeti Including medication: P BAĞLAYICI (2005 Registry) 86,20% P BAĞLAYICI (2005 Registry) 85,40% 0 P Bağlayıcı Kullanan Hasta Sayısı P Bağlayıcı Kullanan Hasta Sayısı Ortalama Haftalık Hasta Başı P-bağlayıcı Kullanımı (PO kutu) 0,25 Ortalama Haftalık Hasta Başı P-bağlayıcı Kullanımı (PO kutu) 0,50 Ortalama Aylık Hasta Başı P-bağlayıcı Kullanımı (PO kutu) PD: 1,08 18,418 Ortalama USD Aylık Hasta Başı P-bağlayıcı Kullanımı (PO kutu) 2,17 Ağırlıklı Aylık Hasta Başı P-bağlayıcı Kullanımı (PO kutu) 0,93 Ağırlıklı Aylık Hasta Başı P-bağlayıcı Kullanımı (PO kutu) 1,85 Ağırlıklı Hasta Başı Yıllık P-bağlayıcı Maliyeti 264 Ağırlıklı Hasta Başı Yıllık P-bağlayıcı Maliyeti HD: 24,242 USD PD vs HD 5,800 USD/year VİTAMİN D (İthal) VİTAMİN D (İthal-oral) Vit D Kullanım Oranı (PO) (2005 Registry) 39,8% Vit D Kullanım Oranı (PO) (2005 Registry) 14,8% Vit D Kullanan Hasta Sayısı Vit D Kullanan Hasta Sayısı Ortalama Haftalık Hasta Başı Vit D Kullanımı (PO kutu) 0,23 Ortalama Haftalık Hasta Başı Vit D Kullanımı (PO kutu) 0,23 Ortalama Aylık Hasta BaşıVit D Kullanımı (PO kutu) 1,00 Ortalama Aylık Hasta BaşıVit D Kullanımı (PO kutu) 1,00 Ağırlıklı Aylık Hasta BaşıVit D Kullanımı (PO kutu) 0,40 Ağırlıklı Aylık Hasta BaşıVit D Kullanımı (PO kutu) 0,15 Ağırlıklı Hasta Başı Yıllık Vit D (PO) Maliyeti Ağırlıklı Hasta Başı Yıllık Vit D (PO) Maliyeti Vit D Kullanım Oranı (IV) (2005 Registry) 1,7% Vit D Kullanım Oranı (IV) (2005 Registry) 29,1% Vit D Kullanan Hasta Sayısı 57 Vit D Kullanan Hasta Sayısı Ortalama Haftalık Hasta Başı Vit D Kullanımı (IV kutu) 0,17 Ortalama Haftalık Hasta Başı Vit D Kullanımı (IV kutu) 0,17 Ortalama Aylık Hasta Başı Vit D Kullanımı (IV kutu) 0,74 Ortalama Aylık Hasta Başı Vit D Kullanımı (IV kutu) 0,74 Ağırlıklı Aylık Hasta Başı Vit D Kullanımı (IV kutu) Yearly: 0,01 Ağırlıklı Aylık Hasta Başı Vit D Kullanımı (IV kutu) 0,22 Ağırlıklı Hasta Başı Yıllık Vit D (IV) Maliyeti Ağırlıklı Hasta Başı Yıllık Vit D (IV) Maliyeti AĞIRLIKLI YILLIK HASTA BAŞI TOPLAM MALİYET AĞIRLIKLI YILLIK HASTA BAŞI TOPLAM MALİYET PD: 15,143 USD HD: 15,917 USD HASTA BAŞI HD - PD FARKI TL USD TL USD İthal Edilen (Harcanan Döviz) Miktar 4.641, % İthal Edilen (Harcanan Döviz) Miktar , HASTA BAŞI HD - PD DÖVİZ ÇIKIŞ FARKI 5824 Utas C, 2008

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

61 CONCLUSION Dratwa 1999 Following an integrated strategy of dialysis that 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.

62 THANK YOU FOR YOU ATTENTION