Peritoneal dialysis adequacy and risk of death.

Peritoneal dialysis adequacy and risk of death. United States in the 1990s. Investigations by Owen et al Background. The purpose of this study was to evaluate the (1), Parker et al (2), Collins et al (3), Hakim et al (4), relationship between dialysis dose, patient characteristics, and and others have all demonstrated that mortality rates medical comorbidities on mortality in chronic peritoneal dial- among hemodialysis patients decreased as dose of dial- ysis patients. ysis increased in hemodialysis patients. These observa- Methods. This work comprised a study cohort of 1446 pa- tients obtained from a random sample of chronic peritoneal tions were used in the development of guidelines by the dialysis patients from each dialysis center in three southeastern National Kidney Foundation Dialysis Outcomes Quality states. Data collected on a standardized form were used to Initiative (DOQI) (5) for a minimal dose of dialysis in calculate weekly Kt/V urea and creatinine clearance. Data were hemodialysis patients. Efforts by individual end-stage linked to Network files containing data on patient demographic renal disease (ESRD) networks as well as by national and medical comorbidities. Results. Both weekly Kt/V urea and creatinine clearance organizations such as the National Kidney Foundation were measured at least once in only 60.5% of continuous ambu- (NKF) and the Health Care Financing Administration's latory peritoneal dialysis (CAPD) patients and 63.7% of cycler ESRD Core Indicators project have led to widespread patients. Among the 873 patients who had at least one calcula- dissemination of these clinical performance measures ble adequacy measure, the mean (6SD) weekly Kt/V urea and improvement in the dose of dialysis delivered to was 2.13 6 0.55, and the normalized mean weekly creatinine clearance was 62.9 6 20.4 L/week/m 2 . During the seven month hemodialysis patients (6, 7). period of follow-up, there were 140 deaths. In separate logistic Similar interest is now focused on the association be- regression models that included all of the studied risk factors, tween dialysis adequacy and mortality among peritoneal using separate variables for the urinary and peritoneal compo- dialysis (PD) patients. Several studies have shown that nents of dialysis adequacy, each 10 L/week/1.73 m 2 increase the dialysis dose is also associated with survival among in the urinary component of weekly creatinine clearance was associated with a 40% decreased risk of death, and each 0.1 PD patients (8-10). These observations have been incor- unit increase in the urinary component of weekly Kt/V urea porated into the NKF-DOQI guideline recommendations was associated with a 12% decreased risk of death. In contrast, (5). In addition, data from the HCFA Core Indicators the dialysate components of neither weekly creatinine clearance project indicate that in late 1994 and early 1995 that one nor weekly Kt/V urea were predictive of death. Other factors third of patients did not have an adequacy measure over that were associated with an increased risk of death included increasing age, diabetes mellitus as the cause of end-stage renal a six-month period and from in late 1995 and early 1996 disease (ESRD), and a history of myocardial infarction. that less than one third of patients received adequate Conclusions. Residual renal function, as expressed by weekly dialysis as defined by the DOQI recommendations creatinine clearance or Kt/V urea, is an important predictor of (11, 12). The purpose of this report is to describe the death in chronic peritoneal dialysis patients. The nonsignificant adequacy of dialysis and the association between dose findings regarding peritoneal clearances and mortality may pos- sibly be secondary to the narrow range of peritoneal clearances of dialysis and mortality in a population-based sample in this study cohort. of PD patients studied just prior to the publication of the DOQI Guidelines.