| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Part 5: PD in Pediatric, Elderly, and Diabetic Patients |
Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, PR China
Correspondence to: P.K.T. Li, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, PR China. philipli{at}cuhk.edu.hk
 |
ABSTRACT |
|---|
 TOP ABSTRACT PATIENTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
The aging population has significant implications for the community. The
increasing number of elderly end-stage renal disease (ESRD) patients presses
the renal team to find an appropriate management plan. We used a retrospective
analysis to study the effectiveness of continuous ambulatory peritoneal
dialysis (CAPD) in elderly ESRD patients. Of the 328 CAPD patients recruited
for the study, 121 were in the elderly group (
One hundred elderly patients (82.6% of the group) performed their CAPD
exchanges by themselves. We observed no significant difference in clinical
outcome—including patient survival, technique survival, and
peritonitis-free period—between the elderly self-care CAPD and the
elderly assisted CAPD groups.
In elderly ESRD patients, CAPD is an effective dialysis modality. A
slightly longer training time is to be expected for elderly patients.
Self-care CAPD for elderly patients who are capable of performing their own
exchanges provides them with an independent home life.
65 years of age), and 207
were in the control group (under 65 years of age). Median age in the elderly
group was 71 years, and in the control group, 51 years. The elderly group had
a higher prevalence (54.5%) of diabetes mellitus. The 2-year and 5-year rates
of patient survival were 89.3% and 54.8% respectively in the elderly group and
92.2% and 62.9% in the control group (p = 0.19). The 2-year and
5-year rates of technique survival were 84.0% and 45.7% respectively in the
elderly group and 80.9% and 49.1% in the control group (p = 0.75).
The probability of a 12-month peritonitis-free period was 76.6% in the elderly
group and 76.5% in the control group (p = 0.75).
KEY WORDS: Elderly; end-stage renal disease; continuous ambulatory peritoneal dialysis; self-care CAPD; assisted CAPD; patient survival; technique survival; peritonitis-free period.
With advances in medicine and an improved living environment, more people survive into old age. The increasing proportion of elderly people in the general population is accompanied by an age-related increase in the incidence of chronic renal failure (1). In recent years, the elderly dialysis population has increased rapidly in most developed countries around the world (2–5). Records from the Hong Kong Renal Registry showed 3321 peritoneal dialysis (PD) patients in Hong Kong at 1 August 2006. Among them, 1465 (44.1%) were 65 years of age or older.
More liberal acceptance criteria for dialysis is a major factor contributing to the rapid growth of the elderly dialysis population (6,7). The comparable outcomes in elderly and younger dialysis patients have made nephrologists aware that older age is, in itself, no longer a reason for not accepting elderly patients for renal replacement therapy (8–10). A previous survey also showed that 84% of elderly patients would choose dialysis treatment and that 74% of them would prefer home dialysis if they had been well informed about the nature of end-stage renal disease (ESRD) and treatment options (11).
The aging population has significant implications for the community; the increase in elderly dialysis patients poses special challenges for the renal team. Medical and social issues both have to be considered in providing appropriate care to elderly dialysis patients.
Most continuous ambulatory PD (CAPD) patients perform their exchanges at home by themselves. The success of CAPD relies mainly on the exchange technique. Elderly people have physiologic changes related to normal aging, and certain common health problems—anxiety, depression, dementia, and eye problems, for example—occur frequently. A previous study showed a high prevalence of cognitive impairment in elderly CAPD patients (12).
Some nephrologists may be reluctant to start CAPD for elderly ESRD patients because of worries about their ability to perform self-care CAPD. Elderly patients who cannot adequately perform self-care CAPD need either good family and social support for assisted CAPD or long-term institutional care.
To obtain a clearer picture about clinical outcome in elderly CAPD patients, we carried out a retrospective study of all patients who started CAPD over a 5-year period in a single PD unit in Hong Kong. We also investigated the effectiveness of self-care CAPD in elderly ESRD patients.
|
PATIENTS AND METHODS |
|---|
|
TOPABSTRACTPATIENTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
Patients who started CAPD during the study period were divided into two groups based on age: patients who had reached at least the age of 65 years at the start of CAPD were included in the elderly group, and patients under 65 years of age at the start of CAPD were included in the control group. Patients were not included in the study analysis if
To investigate the effectiveness of self-care CAPD in elderly patients, the patients in the elderly group were further divided into two comparison groups based on their ability to perform their own CAPD exchanges: a self-care CAPD group, and an assisted CAPD group. The patients were followed until death, permanent switch to hemodialysis, renal transplantation, withdrawal from CAPD, or study end (1 January 2006), for a minimum follow-up of 12 months.
DATA COLLECTION
We retrieved pertinent information from the hospital records of all
patients who started CAPD between 1 January 2000 and 31 December 2004,
including case notes and data from the hospital database. The first day of
CAPD training was accepted as the study entry date. Baseline demographic and
clinical data retrieved included age, sex, underlying renal disease, weekly
total Kt/V, normalized protein catabolic rate (nPCR), residual renal function,
serum albumin level, CAPD connection system, duration on CAPD, use of a helper
for exchanges, and length of CAPD training in days. Outcome measures included
patient mortality, technique failure, peritonitis episodes, and training
duration in days.
STATISTICAL ANALYSIS
We used the SPSS software package (SPSS, Chicago, IL, U.S.A.), version
12.0, for statistical analysis and deemed p < 0.05 to be
statistically significant. Results are expressed as mean ± standard
deviation unless otherwise stated. Baseline demographic data, baseline
clinical data, and training data were compared between groups by the
chi-square test, Fisher exact test, t-test, or Mann–Whitney
U-test, as appropriate. Patient survival, technique survival, and
peritonitis-free period were analyzed by the Kaplan–Meier life-table
method, and we assessed the differences between groups by the log rank
test.
|
RESULTS |
|---|
|
TOPABSTRACTPATIENTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
|
We observed no significant difference in weekly total Kt/V (p = 0.389) and residual renal function (p = 0.309) between the elderly group and the control group. However, the patients in the elderly group had a significantly lower level of serum albumin (p = 0.008) and of nPCR (p = 0.033) than did the patients in the control group. Elderly patients in this study more often had diabetes as the underlying primary cause of renal failure. Patients in the control group more often had glomerulonephritis and systemic lupus erythematosus as the underlying renal disease. The elderly group had a significantly higher prevalence of diabetes (p = 0.029).
COMPARISONS OF CLINICAL OUTCOME
Figure 1 shows the
Kaplan–Meier curves for cumulative patient survival, technique survival,
and peritonitis-free period in the elderly and control groups. We observed no
statistically significant difference between the elderly group and the control
group in any of the three outcomes. The 2-year and 5-year rates of patient
survival were 89.3% and 54.8% respectively in the elderly group and 92.2% and
62.9% in the control group [p = 0.19,
Figure 1(a)]. The 2-year and
5-year rates of technique survival were 84.0% and 45.7% respectively in the
elderly group and 80.9% and 49.1% in the control group [p = 0.75,
Figure 1(b)]. The probability
of a 12-month peritonitis-free period was 76.6% in the elderly group and 76.5%
in the control group [p = 0.75,
Figure 1(c)].
|
|
|
DISCUSSION |
|---|
|
TOPABSTRACTPATIENTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
A frequent concern in the care of elderly ESRD patients is their ability to have an independent life on dialysis. A previous study in a renal unit with a "PD first" policy for elderly patients found that 84.6% of their PD patients used home PD, but that 94.9% of the patients required a helper for exchanges (13).
Our study showed a high percentage of elderly self-care CAPD patients
(82.6%). This phenomenon can be explained by local factors, including a
"PD first" policy and other cultural factors. Chinese have strong
family cohesiveness and prefer to stay at home with family until they become
dependent on others for their activities of daily living. Chinese do not like
to feel that they are burden to others, and so that trait would make our
patients keener to perform self-care CAPD. Another possible reason for the
high proportion of self-care CAPD patients in our study may be our definition
of elderly as 65 years of age [the earlier study defined elderly as 75
years (13)].
Because training was one of the outcome measures in the present study, we excluded from the analysis patients who had been transferred into our unit after their CAPD training. We also excluded patients that had been transferred out to other units and those in whom dialysis had been withdrawn by a nephrologist within 90 days of CAPD start for reasons unrelated to CAPD complications. We chose the latter exclusion criteria to meet the standard definition of 90 days of continuous dialysis for chronic patients; this choice was important because we included survival as an outcome measure. Early deaths (within the first 90 days) are typically attributable to pre-dialysis factors rather than to dialysis modality (14).
Of the patients newly accepted into the CAPD program during the 5-year study period, 36.9% belonged to the elderly group. The major primary renal diagnoses in this cohort of patients were diabetes mellitus and glomerulonephritis. The pattern of age distribution and the underlying renal diagnoses for patients in this study were similar to those found in the Hong Kong Registry Report (15). The similarities suggested that little patient selection bias occurred in this study.
We found no difference in dialysis adequacy and residual glomerular filtration rate between the elderly and control groups. Elderly patients had a lower serum albumin level and nPCR than did patients in the control group. The higher prevalence of diabetes in the elderly group may explain the difference in nutrition status.
In the evaluation of clinical outcomes, the data are consistent with other published reports showing that elderly PD patients can have a reasonable survival rate (9,10,16). We found no significant differences between the elderly group and the control group in regard to the clinical outcomes of patient survival, technique survival, and peritonitis-free period.
The second focus of our study was to determine the effectiveness of self-care CAPD in elderly ESRD patients. We found no significant differences in clinical outcome between the self-care CAPD patients and the elderly assisted CAPD patients.
In preparation for dialysis, our team—which includes doctors, nurses, and medical social workers—assesses the clinical and socioeconomic background of every individual about to enter the program. Dietitians, occupational therapists, and physiotherapists also work to support these patients. Patients who have the ability to do CAPD exchanges by themselves are trained for self-care CAPD. Otherwise, arrangements are made for the patient to have assistance with CAPD at home or to be considered for institutional care when they become dependent on others for activities of daily living.
Although significantly more patients in the elderly group than in the control group required a helper for exchanges (p = 0.002), the elderly group still contained a very high percentage of self-care CAPD patients (82.64%). We observed no significant difference in clinical outcome between the elderly self-care CAPD patients and the elderly assisted CAPD patients. The median training period was 5 days for the elderly self-care CAPD group, a duration that is quite reasonable and similar to the training time required in our previously reported study of double-bag systems in the overall ESRD population (17).
|
CONCLUSIONS |
|---|
|
TOPABSTRACTPATIENTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
Nephrologists should no longer use age alone to determine whether to offer or withhold dialysis for elderly ESRD patients. The CAPD modality is a good option that can be offered to elderly patients. Respecting the needs and rights of elderly patients and maintaining their ability for self-care are other important aspects to consider when planning for long-term dialysis (18). Renal team members should be prepared for a slightly longer training time when providing CAPD to elderly ESRD patients.
The present study confirmed that CAPD is an effective dialysis modality for elderly ESRD patients. Self-care CAPD is possible in most cases, and assisted CAPD provides comparably good clinical outcome in terms of patient and technique survival and peritonitis-free period.
|
ACKNOWLEDGMENTS |
|---|
|
REFERENCES |
|---|
|
TOPABSTRACTPATIENTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
This article has been cited by other articles:
|
|
 |
|
  C. Castrale, D. Evans, C. Verger, E. Fabre, D. Aguilera, J.-P. Ryckelynck, and T. Lobbedez Peritoneal dialysis in elderly patients: report from the French Peritoneal Dialysis Registry (RDPLF) Nephrol. Dial. Transplant., January 1, 2010; 25(1): 255 - 262. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. J. Nessim, J. M. Bargman, P. C. Austin, K. Story, and S. V. Jassal Impact of Age on Peritonitis Risk in Peritoneal Dialysis Patients: An Era Effect Clin. J. Am. Soc. Nephrol., January 1, 2009; 4(1): 135 - 141. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. K.-T. Li and C.-C. Szeto Success of the peritoneal dialysis programme in Hong Kong Nephrol. Dial. Transplant., May 1, 2008; 23(5): 1475 - 1478. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
