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Peritoneal DialysisJames Heaf
Herlev HospitalUniversity of Copenhagen
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Choice of dialysis modality Herlev 2012
HD Choice
HD Abdomen
HD Psych
HD Poor condition
HD Other
HD Switch to PD
PD Choice
HD Choice
HD Abdomen
HD Psych
HD Poor condition
HD Other
HD Switch to PD
PD Choice
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Peritonitis-free Survival Denmark 2000-2014
00-04 05-120 1 2 3 4 5
Years
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1,0
Pe
rito
niti
s-fr
ee
Su
rviv
al
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PD as a viable long term dialysis option
James HeafUniversity of Copenhagen
Herlev Hospital
The Fate of PD patients
0 1 2 3 4 5 6 7 8
Survival Time
0,0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1,0
Cum
ulat
ive
Pro
port
ion
Sur
vivi
ng
Denmark 2000-2010
Death
Transplant
HD
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The Poor and the SmartHome Dialysis World Leaders 2011
ScotlandRep. of Korea
NorwayUK^
NetherlandsCanada
ThailandFinlandSweden
DenmarkAustralia
ColombiaJalisco (Mexico)
New ZealandHong Kong
0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0
PDHD
USRDS 2013
36,66738,22210,2477,85567,72356,20255,15846,0985,67852,23246,14238,58999,6223,113
38,589
GDP/capita USD
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Countries with High Home HD Prevalence
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Corruption Index
Transparency International 2011
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Dialysis CostsDanish National Health ServiceMedical Technology Assessment Report 2006
Centre HD Self Care HD Home HD PD0
5
10
15
20
25
30
35
40
45
50€
x100
0/ye
ar
1 € = 85pwww.nephrology.dk
Aim: 45% on Home Dialysiswithin 10 years
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Two basic types• Automatic PD, APD• CAPD
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PD VariationsPD Variations
APD
CAPD
Night Cycler
Night (9 hours) Day (15 hours)
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CAPD VariationsCAPD Variations
Night (9 hours) Day (15 hours)
Possibly Night cycler
Gentle start PD
CAPD x 5
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APD: Wet and Dry DaysAPD: Wet and Dry Days
APD with wet day
APD withDry day
Night (9 hours) Day (15 hours)
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Osmotic Pressure and Ultrafiltration
1,5%
IcodextrinExtraneal®
4,25%
2,5%
KI 62;S81,21 2002
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Peritoneal Equilibration Test (PET)Twardowski Perit Dial Bull 7:138 1987
82
68
52
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2 year Survival in CAPDCANUSA Studiet. Churchill et al. J Am Soc Nephrol. 1998; 9:1285-92
40
50
60
70
80
90
100
Teknik Overlevelse PatientOverlevelse
Kombineret
Surv
ival
(%
)
Langsom Mellem Langsom Mellem Hurtig Hurtig
Technique Patient CombinedSurvival Survival Survival
Slow Slow average Fast average Fast
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PET og Ultrafiltration
2000 ml medium strength (2.2-2.5%) for 4 hours
Transport Type UF
Slow >650 ml
Slow average 370-650 ml
Fast Average 85-370 ml
Fast <85 ml
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Ultrafiltration og transportstatus
-800
-600
-400
-200
0
200
400
0 2 4 6 8 10 12 14 16Time (hr)
Lav Lav-middel Høj-middel Høj
CAPDNight
APDDay
Neg UF
Mujais S, Vonesh E. Kidney Int. 2002;62(suppl 81):S17-S22. 1.5% Glucose
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Outcome in high transporters is improved during recent years
Commencing 1990-1997 Commencing 1998-2005
Davies SJ, Kidney Int 70: S76-S83, 2006
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ADP vs CAPD: Transport Status
0
0,5
1
1,5
2
2,5
High High average Low average Low.
Deat
h R
isk
APD
/CAPD
P<0.01
P<0.05
Johnson NDT 25,1973 2010Multivariate analysis
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PD Prevalance Denmark 1990-2010
Mortality
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HD vs. PD: Status 2014
3 6 9 12 15 18 21 24 27 30 360.30.40.50.60.70.80.9
11.11.21.31.41.5
Heaf NDT 02Termorhuizen JASN 03Liem KI 07McDonald JASN 09Weinhandl JASN 10Marshall AJKD 11Luijtgaarden NDT 11Mehrotra AIM 11Quinn JASN 11Yeates NDT 12Heaf PlosOne 14
Months
PD
/HD
Mo
rtal
ity
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PD vs. HD: Effect of CohortDenmark 1990-2010
.5
.6
.7
.8
.9
1
1.1
1.2
1.3
1.4
1.5
Est
. tim
e-d
epen
dent
haz
ard
rat
io P
D v
s. H
D
0 .5 1 1.5 2 3 4 5 6
Time after ESRD (years)
1990-99 2000-10
Heaf PlosOne 2014
Adjusted forage, sex,renal diagnosisComorbidity,& referral pattern
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Effect of Cohort & Diabetes
.5
.6
.7
.8
.9
1
1.1
1.2
1.3
1.4
1.5
Est
. tim
e-d
epen
dent
haz
ard
rat
io P
D v
s. H
D
0 .5 1 1.5 2 3 4 5 6
Time after ESRD (years)
DM: 1990-99 DM: 2000-10Non DM: 1990-99 Non DM: 2000-10
Heaf PlosOne 2014
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Effect of Cohort & Age
.5
.6
.7
.8
.9
1
1.1
1.2
1.3
1.4
1.5
Est
. tim
e-d
epen
dent
haz
ard
rat
io P
D v
s. H
D
0 .5 1 1.5 2 3 4 5 6
Time after ESRD (years)
>= 65: 1990-99 >=65: 2000-10< 65: 1990-99 < 65: 2000-10
Heaf PlosOne2014
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Effect of Cohort & Referral
.5
.6
.7
.8
.9
1
1.1
1.2
1.3
1.4
1.5
Est
. tim
e-d
epen
dent
haz
ard
rat
io P
D v
s. H
D
0 .5 1 1.5 2 3 4 5 6
Time after ESRD (years)
E&R: 1990-99 E&R: 2000-10Not E&R: 1990-99 Not E&R: 2000-10
Heaf PlosOne2014
E&R:Early ReferralPlanned, out-patientDialysis initiation
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Risk Factors for Residual Renal Function LossMoist JASN 11:556-565, 2000
0 0,5 1 1,5 2 2,5 3 3,5
Fllow-up time
Female
Coloured
Diabetes
Heart Failure
Serum Calcium (mg/dl)
HD
ACE-I
Calciumantagonist
Odds Ratio Multivariate Analyse
1843 patients50% PD50% HD
*:p<0.05**:p<0.01***:p<0.001
*****
***
**
**
***
***
*
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Peritoneal and Renal Clearance: Different Effects on Mortality
Cr Clear Kt/V Cr Clear Kt/V-50
-40
-30
-20
-10
0
10
CANUSA 96ADEMEX 02Rocco 02
%
Peritoneal Renal Creatinine Clearance:Change per 1 ml/min
Kt/V: Change per 0.1/week
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Wu: QOL after 1 Year Wu JASN 15,743 2004
SymptomsCognitive
SleepSex
Body ImageQOL
FreedomTravel
RecreationFinance
WorkDiet
TimeAccess
50 60 70 80 90
PD
HD
HRQOL-ESRD Score
**
* p<0.05**p<0.01
***
**
*
*
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CAPD på en tømmerflåde
With thanks toJohan Povlsen
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Conclusions
• Economical compared to Center HD• Popular in Scandinavia• Better patient survival the first two years, possibly due to better
preservation of renal function• Not a longterm therapy• CAPD and APD choice based on transport characteristics and patient
wishes• A sensible choice for patients who want freedom from hospital and
freedom to travel