Papers from Japan: Catheter Implantation, and the Link Between Frailty and Mortality

Like many other treatments in healthcare, dialysis is designed to modify a disease, with the objective of achieving specific goals, such as living longer or functioning better. So the central question is how best to deliver the therapy. Two papers from Tokyo, Japan, in this issue of Peritoneal Dialysis International investigate disparate questions pertinent to delivery of the therapy. Does case volume impact complications associated with peritoneal dialysis catheter (PDC) insertion? What is the role of frailty and sarcopenia on outcome? The first paper examined the relationship between annual case load of catheter implantation (number of procedures conducted) and in-hospital perioperative complications for PDC insertion in Japanese hospitals based on a Nationwide Diagnosis Procedure Combination database of 2,500 cases from 2007 to 2012 (1). The standard being assessed was complication-free catheter insertion, although the broader goal could be framed as whether PD access formation was successful and provided a positive patient experience. Having divided centers according to tertile of volume—low (1 – 6 cases/year), mid (7 – 13 cases per year), and high (≥ 14 cases per year)—, the authors showed less frequent adverse events and shorter hospital stays in the higher-volume centers. Case volume, even in the largest center in this study, was smaller than in many centers worldwide. This association between activity and outcome confirms information on center size and technique failure (TF) more broadly from PD. For example, a recent paper from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) registry demonstrated a reduced risk of TF where centers had more than 48 patients, and higher risk in centers treating fewer than 16 (2). A response to this issue might be to limit catheter insertion to larger centers; however, such a recommendation may have the unwanted effect of restricting access to PD. This study provides information on the frequency of perioperative adverse events following PDC insertion in Japanese hospitals. The requirement for blood transfusion was around 1%, peritonitis at 0.6% – 0.8%, mechanical complications at 0.5% – 0.9%, catheter-related infection at 1.3% – 2.1%. These complication rates are lower than those generally reported as they pertain only to the immediate postoperative period. Rather surprisingly, the postoperative length of stay was in the range of 8 – 12 days, which is much longer than that routinely reported for catheter insertion (3,4). This may relate to patient training for PD being performed prior to discharge from hospital. Wide international differences exist in the clinical practice of PD and the Peritoneal Dialysis Outcomes and Practice Study will examine these. The second paper explored the interrelation of sarcopenia and frailty at a single center (5). These themes are relevant to the rehabilitative goals of dialysis that go beyond poorly validated biochemical measures. One such goal is to support patients in meeting their physical function objectives, requiring that consideration be given to a range of issues such as nutrition, muscle strength, and fatigue. In the study, sarcopenia was evaluated from the assessment of muscle mass (using bioelectrical impedance), strength (hand-grip), and function (walking speed), whereas frailty was assessed using a Clinical Frailty Score (CFS) described as an “easily applicable clinical tool. ” Both of these parameters were unsurprisingly associated with increased mortality and less preferable biochemical parameters. An important question is how assessment of these measures in the clinical setting would inform other competing patientcentered goals and lead to interventions that may change the outcome in these patients. The assessment of sarcopenia required quite complex evaluation, but the frailty tool may possibly be more generally applicable. Although this paper did not discuss interventions to address frailty, it highlights the extent of the problem at this particular center, which affects 8% of their population, being strongly related to age and sarcopenia. The authors provide a broad definition of frailty, describing it as a multifunctional age-related disorder that is associated with a higher risk of adverse outcomes, such as a decline in functional ability, increased falls, delirium, institutionalization, hospitalization, and death. Frail individuals are frequent users of services across health and social care and are at high risk of adverse outcomes. Benefits accrue when such events can be avoided through timely assessment and appropriate planning of community services. The diagnosis of frailty should trigger realistic discussions of prognosis and patient preferences around their priorities of care if their condition were to deteriorate. Thus frailty assessment is clearly important and has the potential to be more generally applied. Peritoneal Dialysis International is pleased to report an increase in its impact factor for 2016 to 2.009. We are grateful to the whole PD community, including our readers, contributors, reviewers, editorial team, and publisher for contributing to this success—which ultimately is directed toward improving the opportunities for people with kidney disease to lead as healthy lives as possible. To that end, we are particularly keen to solicit papers that report research exploring individualization of PD care and would like to encourage submissions that can be included in a themed issue in 2019.