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PD IN THE DEVELOPING WORLD |
ala
Nephrology and Dialysis Department, "Sestre Milosrdnice" Clinical Hospital, Zagreb, Croatia
Correspondence to: S. ala, Nephrology and Dialysis Department,
"Sestre Milosrdnice" Clinical Hospital, Vinogradska c. 29, Zagreb,
Croatia.
svjetlana.cala{at}bol-svduh.t-com.hr
Objective: To present the state of renal replacement
therapy (RRT) in Croatia, assess the quality of dialytic treatment, verify the
value of peritoneal dialysis (PD), and promote expansion of PD in Croatia
based on results attained locally. According to the integrative care concept,
PD is the best way to start life-long RRT. Croatian nephrologists have adopted
the policy of increasing the use of PD. However, evidence for recommendations
were obtained in specific circumstances and might not be relevant elsewhere.
The aim of this observational study is to compare the outcome of PD with that
of hemodialysis (HD), as practiced in Croatia. Methods: Since 2000, the Croatian Registry for Renal
Replacement Therapy has been collecting individual patient data for all
patients on RRT, with complete coverage. Results: As of 31 December 2004, there were 251 prevalent
patients on PD (continuous ambulatory PD and automated PD) in Croatia,
accounting for 7% of all patients on RRT and giving a prevalence of 57
patients per million population. From 1 January 2000 to 31 December 2004, 377
patients started PD and were followed from the first day of RRT. For 80% of
them, PD was the first mode of RRT. The probability of staying on PD for 5
years was 31% [95% confidence interval (CI) 29-32]. Five-year technique
survival (excluding transplanted, recovered, and deceased patients) was 68%
(95%CI 65-70). For survival analysis and comparison between PD and HD, only
patients on the same method from the start of their RRT were included.
Patients changing treatment were censored after 60 days (intention-to-treat
analysis). Unadjusted 5-year survival in the PD-first group (301 patients) was
60% (95%CI 54-65), which is significantly better than in the 2789 HD-first
patients (42%, 95%CI 40-44; log-rank p < 0.0001). When data were
stratified for age and diabetes, 5-year mortality rates on HD were higher in
all strata. Only in patients 
70 years old was the advantage of PD less
impressive. Standardized mortality ratio was 1.85 (p < 0.01) in
favor of PD. Hazard ratio of HD versus PD was 2.1 (95%CI 1.6-2.8). After
adjustments for age, gender, diabetes, and nephroangiosclerosis, the hazard
ratio settled at 1.5 (95%CI 1.1-1.9). Conclusion: In Croatia, PD is used mostly as the first
RRT. Almost one third of patients continue PD for 5 years due to good patient
and technique survival. Starting RRT with PD offers 50% superior 5-year
survival in comparison to HD. Dialysis patients in Croatia would benefit from
an expanded PD program.
KEY WORDS: KEY WORDS:; Survival; technique survival; age; diabetes; RRT registry.
Received 16 September 2006; accepted 20 March 2007.
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