Perit Dial Int
29(Supplement_2):
102-107
2009
© 2009 International Society for Peritoneal Dialysis
Part 3: Clinical Experiences |
PATIENT SELECTION FOR AUTOMATED PERITONEAL DIALYSIS: FOR WHOM, WHEN?
Vassilios Liakopoulos1 and
Nicholas Dombros2
Department of Nephrology,1 Medical School,
University of Thessaly, Larissa, and Peritoneal Dialysis
Unit,2 1st Department of Internal Medicine, AHEPA
Hospital, Faculty of Medicine, Aristotle University of Thessaloniki,
Thessaloniki, Greece
Correspondence to: N. Dombros, 32 Ethnikis Aminis Street, Thessaloniki 54621
Greece.
dombros{at}auth.gr
 |
ABSTRACT
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The use of the various forms of automated peritoneal dialysis (APD) has
increased considerably in the past few years. This increase has in part been
driven by technology, through improved cycler design. Other contributing
factors include better adjustment of APD to patient lifestyle, the flexibility
that APD offers to patients, and the increased ability of APD to achieve
adequacy and ultrafiltration targets. For high transporters and for patients
unable to perform peritoneal dialysis (PD) on their own (for example,
pediatric and elderly patients), APD is considered the most suitable PD
modality. Furthermore, APD has been associated with improved compliance, lower
intraperitoneal pressure, and lower incidences of peritonitis. On the other
hand, concerns have been raised regarding increased complexity and cost, a
more rapid decline in residual renal function, inadequate sodium removal, and
disturbed sleep. Automated PD is an alternative to continuous ambulatory PD
when a higher dialysis dose is needed, and it could be a reliable alternative
for unplanned or urgent dialysis start. Other than beneficial results in high
transporters, the medical advantages of APD remain controversial. Individual
patient choice therefore remains the main indication for the application of
APD, which should be made available to all patients starting PD.
KEY WORDS: APD; high transporters; indications; patient preference; patient selection.
The use of the various forms of automated peritoneal dialysis (APD) has
considerably increased in recent years, mainly because of technological
improvements and better adjustment to various patient lifestyles. Since the
late 1990s, a clear trend toward increased numbers of peritoneal dialysis (PD)
patients undergoing APD has been observed in the United States. The
simultaneous decline in overall PD utilization suggests that the growth of APD
has occurred at the expense of CAPD; in 2007, almost 59% of U.S. patients
undergoing PD were on some form of APD
(1). The situation is not very
different in Europe: according to the 2006 annual registry report of the
European Renal Association/European Dialysis and Transplant Association, the
use of APD has substantially increased. In many European countries such as
Belgium, Denmark, and Finland, APD is the predominant PD modality, involving
almost 60% of PD patients. In the rest of Europe (Greece, Italy, Spain, the
Netherlands, and the United Kingdom) 30%–40% of PD patients are on APD
(2). The trend towards
increased utilization of APD has been confirmed by French registry data: a
rise in the use of APD to 36% in 2005 from 23% in 1995 has been reported
(3). In Australia and New
Zealand, APD accounts for 42% of PD patients
(4). In Asian countries,
continuous ambulatory PD (CAPD) is the predominant form of dialysis, and APD
is not widely used, probably for financial reasons
(5). The increased use of APD
observed in the developed world is driven mainly by patient choice
(6). This preference is not
supported by strong medical evidence, but by apparent lifestyle benefits and
improved cycler design (7).
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APD AND HIGH PERITONEAL PERMEABILITY
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The European best practice guidelines acknowledge three indications for
using APD: patient preference, the necessity to avoid increased
intraperitoneal pressure, and an inability to obtain adequate ultrafiltration
and solute clearance, especially in high transporters
(8). Similarly, the
International Society for Peritoneal Dialysis Ad Hoc Committee on
Ultrafiltration Management in Peritoneal Dialysis recommends APD for
ultrafiltration failure in patients with high transport status
(9).
"High" or, better, "fast" transport status
(10) is probably the ideal
setting for the application of APD. High peritoneal permeability is already
known to be associated with worse patient and technique survival in PD
(11–13).
However, a number of studies have shown that the use of APD can prove
beneficial in fast transporters. The European APD Outcome Study (EAPOS), which
included 177 anuric APD patients and liberally used icodextrin for the long
day dwell, showed that baseline membrane transport status was not related to
the ultrafiltration achieved in the first year and had no effect on patient
survival (14). A registry
report from Australia and New Zealand (ANZDATA) linked high peritoneal
permeability with worse outcome only in CAPD patients and not in patients
undergoing APD (13).
Furthermore, in a very recent retrospective study from Toronto, fast transport
status did not predict worse patient survival or technique failure in patients
on APD with or without icodextrin
(15). Therefore, with the help
of APD, especially in combination with icodextrin, the concern about clinical
outcome in fast transporters undergoing PD could be an artifact of the past
(10).
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APD VS CAPD
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The possible superiority of APD as compared with CAPD in terms of patient
and technique survival has been controversial. Conducting relative randomized
trials is obviously very difficult, and conducting blind randomized trials is
impossible. A number of cohort studies have produced conflicting results: A
U.S. study by Guo and Mujais, based on the Baxter Healthcare Corporation
OnCall electronic data interchange system and involving almost 30 000
patients, reported better 1-year patient and technique survival for APD
patients (16). In a more
recent publication involving almost 40 000 patients in a similar pool, Mujais
and Story reported that APD was a determinant of technique survival with a
hazard ratio of 0.845 as compared with CAPD
(17). In a registry report
from ANZDATA, application of APD or CAPD led to similar technique and patient
survival in the 4128 patients studied
(4). A meta-analysis of three
randomized studies comparing APD and CAPD, which included 139 patients, could
not identify any benefit for any modality regarding mortality or technique
survival (18).
In a 24-hour period, APD involves only 1 connection and 1 disconnection;
CAPD involves 4 connections and 4 disconnections. The smaller number of
manipulations required from the patient could result in a substantial
reduction in the incidence of peritonitis. Moreover, leukocyte function has
been shown to improve during a long PD dwell
(19), such as the day dwell in
continuous cycling PD (CCPD), and human peritoneal mesothelial cells have
shown improved activity after several hours of peritoneal rest
(20), as is the case during
the day in nightly intermittent PD (NIPD). On the other hand, concerns have
been raised about delayed diagnosis of peritonitis in APD. In this context,
studies addressing the issue of peritonitis incidence in the two modalities
have yielded conflicting results. Retrospective studies have concluded in
favor both of APD (21) and of
CAPD
(22,23),
and similar results between the two modalities have also been reported
(24). A large prospective
nonrandomized study of 328 patients found similar peritonitis and exit-site
infection rates (25), but a
much smaller study (n = 20) found a lower peritonitis rate in APD
patients (26). A recent
publication from Mexico with a total of 237 patients reported a significantly
lower peritonitis rate in favor of APD. In the same study, the relative risk
for the first peritonitis episode was 0.68 for patients on APD as compared
with those on CAPD (27). The
previously mentioned meta-analysis published in 2007 showed a similar relative
risk for peritonitis, but a significantly lower peritonitis rate for APD
(18). However, that
meta-analysis was based on just three randomized studies, only two of which
addressed the issue of peritonitis, with one of those three reporting just 3
episodes of peritonitis. The results of this meta-analysis are therefore
actually based on one study
(28) and should be interpreted
with caution (29).
Increased intraperitoneal pressure can be a problem during the application
of PD and may result in the occurrence of hernias and fluid leaks or
discomfort for some patients. Performing the dwells in supine position, as is
the case with APD, leads to a more than 50% decrease in intraperitoneal
pressure as compared with pressures in patients walking upright with a full
abdomen. The incidence of hernias has been reported to be lower in patients on
APD (8), a finding not
supported by others (18).
However, increased nighttime volumes and decreased daytime volumes (or even a
"dry day" abdomen) could prove beneficial in patients having
problems tolerating increased intraperitoneal pressure
(30). Furthermore, APD could
be an alternative to surgical treatment for hernia
(6).
Compliance with the dialysis regimen is an important issue, and a
significant percentage of PD patients are noncompliant, with detrimental
effects on patient and technique survival
(31). A greater risk for
noncompliance has been reported for patients on CAPD than for those on APD,
probably because of the higher number of connections and disconnections needed
for CAPD (32). Abdominal
discomfort linked to increased intraperitoneal pressure during CAPD may also
contribute to this noncompliance
(33).
Ultrafiltration targets are not always easy to achieve, especially when
residual renal function declines. The role of APD in achieving adequate
ultrafiltration remains controversial. In a prospective 10-month study of 53
CAPD and 51 APD patients, ultrafiltration and sodium removal were consistently
lower in the APD patients. Furthermore, the CAPD patients had better blood
pressure control (34). In the
EAPOS study, on the other hand, more than 75% of the enrolled 177 anuric APD
patients achieved an ultrafiltration target of more than 750 mL daily
(35). In a Canadian study of
56 APD patients, with liberal use of icodextrin for the day dwell, blood
pressure control was achieved in 93% of the patients and volume control was
independent of sodium removal
(36). These results show that,
provided the dose is adjusted to the decline of residual renal function, APD
can be used successfully, with excellent results regarding ultrafiltration
(37).
Another issue of concern is the possibility of a faster decline in residual
renal function in patients undergoing APD, especially those undergoing NIPD.
Many studies have yielded conflicting results, but as was stated in a recent
review of all the relevant studies, the decline in residual renal function in
APD patients was not significantly different from that in CAPD patients
(38).
One of the most important goals of dialysis is to provide patients with a
good quality of life. In this area, APD has been shown to have some advantages
over CAPD, but the overall results are once again inconclusive. In a
multicenter study from the Netherlands, APD patients had better mental health
and were less anxious and less depressed than CAPD patients with the same
dialysis duration. On the other hand, physical aspects of quality of life and
role functioning were similar in both groups
(39). Another study from
Denmark concluded that APD patients had more time off dialysis for work,
family, and social activities. A trend toward less physical and emotional
discomfort in APD patients as compared with CAPD patients was also observed,
but the difference did not reach statistically significant levels
(40). A very interesting,
although small (18 patients), crossover study was published quite recently.
Patients underwent CAPD for 6 months and then were transferred to APD for
another semester. While on APD, these patients showed a trend towards better
vitality, social functioning, and mental health, but again without
statistically significant differences
(41).
Worries that APD could result in disturbed sleep were supported by a
randomized prospective study by Bro et al., who showed that patients
on APD tended to have more sleep problems than did patients on CAPD
(40). However, in a recent
paper, the use of APD was associated with improved sleep quality and a lower
incidence of sleep apnea, probably because of better fluid control during the
night (42).
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APD AND ASSISTED PD
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A considerable number of PD patients have to be assisted in the performance
of their PD exchanges by either a partner or a nurse or other caregiver. In
this case, APD could be the treatment of choice. The requirement for only 2
connections daily is a significant time-sparing advantage; it reduces the
everyday burden on the caregiver and could prove advantageous even in patients
staying in skilled nursing facilities
(19,43).
A Danish study in which 65 physically dependent patients underwent assisted
APD with very satisfactory results (54% 2-year survival and 1 peritonitis
episode per 26 patient–months), has confirmed these opinions
(44).
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APD IN PEDIATRIC AND ELDERLY PATIENTS
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Pediatric and elderly patients are two distinct subgroups of the PD
population. In the United States, 91% of children younger than 19 years with
end-stage chronic kidney disease are undergoing APD
(1). The picture is similar in
Europe. In Italy for example, 96% of children undergoing PD are on APD
(45). At the other end of the
age spectrum, APD is also the predominant PD modality. More than 60% of U.S.
patients over 65 years of age are on APD
(1). In elderly patients
undergoing PD, the need for the exchanges to be performed by another person is
increased (46), a fact that
could explain the increased use of APD.
In addition, in patients over 65 years of age, APD has proved a reliable
renal replacement modality. In a U.S. study, elderly patients (>65 years)
on APD did not differ from younger patients in regard to technique failure and
peritonitis rate. Most importantly, quality of life indices were similar in
all age groups (47).
Automated PD has a pivotal role in the management of pediatric patients
with end-stage renal disease, especially infants. For parents and children,
APD offers more free time during the day, and adolescents can attend school
without the need to perform bag exchanges
(48). Children on APD had a
lower incidence of peritonitis as compared with children on CAPD
(48). In another study, the
switch of more than 300 pediatric patients from CAPD to APD resulted in better
ultrafiltration, less edema, lower mean arterial blood pressure, lower
peritonitis rates, and fewer hospital admissions
(49). Furthermore, a study
from Hong Kong gave impressive results regarding quality of life. Pediatric
patients undergoing APD (and their parents) had a quality of life similar to
that for transplanted children and their parents
(50).
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WHEN TO APPLY APD
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For patients failing to achieve adequacy and ultrafiltration targets with
CAPD, APD may be an alternative. In these cases, an increase in the number of
CAPD exchanges compromises quality of life and often leads to transfer to
hemodialysis. The use of APD with larger dwell volumes and longer nocturnal
sessions, especially in combination with the use of icodextrin for the long
dwell or the addition of a day exchange ("enhanced CCPD" or
"CCPD plus") could prolong technique survival with good results.
In patients with slow transport rates, a more CAPD–like regimen
(less-frequent exchanges during the night and probably the addition of a
manual exchange during the day) could be used.
Furthermore, APD has been tried as an initial dialysis modality in patients
requiring urgent dialysis. The association of APD with lower intraperitoneal
pressures probably makes this modality the best option for urgent PD start. In
a retrospective study from Denmark, patients who started APD in less than 24
hours after peritoneal catheter insertion had a technique survival that was
similar to that of patients who started APD in a planned manner
(51). In a prospective study
from France, acute initiation of APD was an effective dialysis modality
(52). Moreover, APD has been
performed as a frontline acute dialysis therapy option with good results
(53).
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SUMMARY
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Automated PD is the fastest-growing PD modality, with apparent lifestyle
benefits. Possible medical advantages remain controversial, and only high
peritoneal permeability seems to be a solid indication for the use of APD. The
modality offers flexibility; it can be more easily performed by employed
patients, and it offers more time for personal and family activities. The APD
modality is suitable for children, elderly patients, and patients needing
assisted PD. Because individual choice cannot be overlooked, APD should be
offered according to patient preference. Accepting a patient's choice of
dialysis modality has been shown to improve quality of life
(54), probably the most
important aspect in the life of a dialysis-dependent patient.
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ABSTRACT
APD AND HIGH PERITONEAL...
