Rationale & Objective

Identifying patients who are likely to transfer from peritoneal dialysis (PD) to hemodialysis (HD) before transition could improve their subsequent care. This study developed a prediction tool for transition from PD to HD.

Study Design

Retrospective cohort study.

Setting & Participants

Adults initiating PD between January 2008 and December 2011, followed up through June 2015, for whom data were available in the US Renal Data System (USRDS).

Predictors

Clinical characteristics at PD initiation and peritonitis claims.

Outcomes

Transfer to HD, with the competing outcomes of death and kidney transplantation.

Analytical Approach

Outcomes were ascertained from USRDS treatment history files. Subdistribution hazards (competing-risk) models were fit using clinical characteristics at PD initiation. A nomogram was developed to classify patient risk at 1, 2, 3, and 4 years. These data were used to generate quartiles of HD transfer risk; this quartile score was incorporated into a cause-specific hazards model that additionally included a time-dependent variable for peritonitis.

Results

29,573 incident PD patients were followed up for a median of 21.6 (interquartile range, 9.0-42.3) months, during which 41.2% transferred to HD, 25.9% died, 17.1% underwent kidney transplantation, and the rest were followed up to the study end in June 2015. Claims for peritonitis were present in 11,733 (40.2%) patients. The proportion of patients still receiving PD decreased to <50% at 22.6 months and 14.2% at 5 years. Peritonitis was associated with a higher rate of HD transfer (HR, 1.82; 95% CI, 1.76-1.89; P < 0.001), as were higher quartile scores of HD transfer risk (HRs of 1.31 [95% CI, 1.25-1.37), 1.51 [95% CI, 1.45-1.58], and 1.78 [95% CI, 1.71-1.86] for quartiles 2, 3, and 4 compared to quartile 1 [P < 0.001 for all]).

Limitations

Observational data, reliant on the Medical Evidence Report and Medicare claims.

Conclusions

A large majority of the patients who initiated renal replacement therapy with PD discontinued this modality within 5 years. Transfer to HD was the most common outcome. Patient characteristics and comorbid diseases influenced the probability of HD transfer, death, and transplantation, as did episodes of peritonitis.

中文翻译：

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开始腹膜透析肾脏替代治疗的美国患者转为血液透析

 理由和目标

在转变之前识别可能从腹膜透析（PD）转变为血液透析（HD）的患者可以改善他们的后续护理。这项研究开发了一种从 PD 到 HD 过渡的预测工具。

 研究设计

回顾性队列研究。

 背景及参与者

2008 年 1 月至 2011 年 12 月期间开始 PD 的成年人，随访至 2015 年 6 月，美国肾脏数据系统 (USRDS) 中提供了这些人的数据。

 预测因素

PD 启动时的临床特征和腹膜炎索赔。

 结果

转移到 HD，伴随着死亡和肾移植的竞争结果。

 分析法

结果是根据 USRDS 治疗历史文件确定的。使用 PD 启动时的临床特征拟合次分布风险（竞争风险）模型。开发了列线图来对 1 年、2 年、3 年和 4 年的患者风险进行分类。这些数据用于生成 HD 转移风险的四分位数；该四分位数分数被纳入特定原因的危害模型中，该模型还包括腹膜炎的时间依赖性变量。

 结果

29,573 例 PD 患者的中位随访时间为 21.6（四分位距，9.0-42.3）个月，其中 41.2% 转为 HD，25.9% 死亡，17.1% 接受肾移植，其余随访至研究结束2015 年 6 月。有 11,733 名 (40.2%) 患者提出腹膜炎索赔。仍接受 PD 治疗的患者比例在 22.6 个月时下降至 <50%，在 5 年时下降至 14.2%。腹膜炎与较高的 HD 转移率相关（HR，1.82；95% CI，1.76-1.89； P < 0.001），HD 转移风险的四分位评分较高（HR 为 1.31 [95% CI，1.25-1.37]） ）、四分位数 2、3 和 4 与四分位数 1 相比，分别为 1.51 [95% CI, 1.45-1.58] 和 1.78 [95% CI, 1.71-1.86] [ 所有P < 0.001]）。

 局限性

观察数据，依赖于医疗证据报告和医疗保险索赔。

 结论

大多数因 PD 开始肾脏替代治疗的患者在 5 年内停止了这种治疗方式。转移到 HD 是最常见的结果。患者特征和合并症影响 HD 转移、死亡和移植的可能性，腹膜炎的发作也是如此。