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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE  
Year : 2015  |  Volume : 26  |  Issue : 5  |  Page : 906-911
Is CAPD a viable option among ADPKD with end stage renal disease population in India? Its outcomes and economics


Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

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Date of Web Publication7-Sep-2015
 

   Abstract 

Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited renal disease, with 50-75% of these patients requiring renal replacement therapy (RRT). The outcome of peritoneal dialysis (PD) in ADPKD with end-disease renal disease (ESRD) is not clearly defined, more so in developing countries. We conducted a retrospective analysis of the outcomes and economics of PD in these ESRD patients and compared them with other causes of ESRD on PD. Data were reviewed of all the PD patients who were followed-up at our institute from January 2007 to December 2011. The inclusion criteria were ADPKD patients who chose PD as the dialysis modality (Group 1), while age and gender-matched ESRD (other than ADPKD) patients who were started on PD during the same period were considered as the other group (Group 2). A total of 26 ADPKD patients underwent PD with an average size of kidneys among ADPKD ESRD patients of 15.2 + 2.1 cm. The overall peritonitis rates were similar among the compared groups. The median survival for the first peritonitis episodes were 1.2 and 1.8 years (95% confidence interval 0.82-1.91) for the control and ADPKD groups, respectively. The overall patient survival was 22 among PKD while five patients died among the control group. Among PKD, one patient died due to intra-cerebral bleed while one patient had severe cyst hemorrhage and infection, while three others had peritonitis and sepsis. Hernia was observed in four ADPKD patients, once on PD that was surgically corrected and PD was resumed in all. Two patients lost the catheter due to peritonitis while one patient had membrane failure while one underwent surgical exploration due to diverticulosis. PD treatment was not prevented by voluminous kidneys in any of these patients and no patient ceased PD treatment due to insufficient peritoneal space. Besides this, the cost on PD was much less as compared with that on hemodialysis (HD). PD is a reasonable mode of RRT among ADPKD, where HD is not possible or contraindicated with lesser risks to bleeding and infections, and the cost benefit favoring PD in general.

How to cite this article:
Kaul A, Bhadhuaria D, Prasad N, Gupta A, Sharma R K. Is CAPD a viable option among ADPKD with end stage renal disease population in India? Its outcomes and economics. Saudi J Kidney Dis Transpl 2015;26:906-11

How to cite this URL:
Kaul A, Bhadhuaria D, Prasad N, Gupta A, Sharma R K. Is CAPD a viable option among ADPKD with end stage renal disease population in India? Its outcomes and economics. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2022 Dec 4];26:906-11. Available from: https://www.sjkdt.org/text.asp?2015/26/5/906/164570

   Introduction Top


Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited renal disease, accounting for about 3% of cases of end-stage renal disease (ESRD) in the United States [1] and 8.2% of all patients above 40 years with ESRD in India.2 The most commonly opted mode of dialysis in these patients is hemodialysis (HD), followed by peritoneal dialysis (PD).

Life expectancy among the patients with ADPKD undergoing HD appears to be superior to that of patients with other causes of ESRD, possibly due to a lower incidence of coronary artery disease in these generally more healthy patients. [3] However, these patients are at risk to gross hematuria, pain and cyst infections even on HD. [3]

PD is a less often chosen option in ADPKD patients in comparison with that in patients with other forms of ESRD. [4] Such assumptions are based on literature evidences of increased risk for abdominal wall hernia and peritoneal leaks [5] and increased risk of gram-negative peritonitis, owing to an increased incidence of diverticulitis in ADPKD patients with ESRD and reduced the available effective peritoneal surface area.

The outcome of PD in ADPKD with ESRD is not clearly defined. Despite the possible increased risk of complications of PD in this subset of ESRD population, the adjusted survival benefit is favorable as compared with patients with other causes of ESRD. [4] The recent encouraging reports of success of PD in the ADPKD population showed no difference in long-term outcome as compared with the non-diabetic matched control group, [6],[7],[8] adding to the hope of its utility in this subset of patients.

There is paucity of data on the outcome and economics of PD, especially from developing and resource-poor countries like India, where PD could be a viable option because of good family support and less number of HD centers, localized mainly to major cities.

Because economic evaluation stands a useful tool in the planning and operation of a healthcare program, especially in developing countries like India where resources are self-generated, unlike developed countries where insurance companies bear the budget. Hence, we conducted an observational study to analyze the outcomes of PD in these ESRD patients in comparison with patients with other causes of ESRD on PD. We also analyzed the economics of these patients on PD in comparison with those on HD.


   Methods Top


The study was designed as a retrospective observational study. To study the outcome, we reviewed the records of all the PD patients who were followed-up at our institute between January 2007 and December 2011. The inclusion criteria were ADPKD patients who chose PD as the dialysis modality (Group 1), while ageand gender-matched ESRD (other than ADPKD) on PD during the same period served as the control group (Group 2).

The patients' data were collected from the electronic medical records, hospital information system of the institute and patients' booklets. The following variables were looked for: i. e., demographic profile, basic diseases, date of starting of dialysis, peritonitis data, data regarding renal complications like cyst infections, hematuria and renal angle tenderness and pain, other co-morbid conditions like cerebrovascular and cardiovascular disease, data related to extrarenal complications like bilateral nephrectomy, hernia surgeries, valvular heart disease, leaks, bowel perforation secondary to diverticular disease and intracranial hemorrhage secondary to ruptured vascular aneurysm; all these data were noted. Details regarding transplantation, number of antihypertensive requirements, dose of erythropoietin and number of blood transfusions were also noted. Biochemical data included were baseline hemoglobin, albumin, lipid profile, calcium and phosphates.

Dialysis dose (Kt/V) was calculated from 24h dialysate collection using computer software (Adequacy, Baxter Pvt. Ltd, Gurgoan, India). Peritoneal membrane transport and dialysateto-plasma ratios of creatinine at 4 h (D:Pcr) was calculated from PET13 and residual renal function was measured from standardized 24-h urine collection (calculated as mean of urea and creatinine clearance and expressed normalized to 1.73 m 2 body surface area). All patients were dialyzed using conventional lactate-buffered glucose-based PD solutions. Estimated glomerular filtration rates were calculated according to the Modification of Diet in Renal Disease formula 14 using the following equation: 186.3 × serum creatinine - 1.154 × age - 0.203 × 0.742 (if female patient) × 1.212 (if black).

The economics of PD and HD among ADPKD patients at public and private sectors were also studied. To study the economics between PD patients of ADPKD and patients on HD, we reviewed the records of all the ADPKD patients on PD and HD who were followed-up at our institute from January 2007 to December 2011.

The study was conducted at the Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow and approved by the review board of the institute.

Few definitions used during the study

  1. Patient survival is a measure of renal replacement program effectiveness (KDOQI Guidelines no. 21).
  2. Technique survival: Failure of the therapy or the dialysis facility resulted in transfer, which could include: Complications of the therapy, inability to perform the therapy [lack of suitable access, no partner to do self-care, medical contra-indication(s)] and patient request/lifestyle issues (KDOQI Guideline no 22). PD technique survival is dependent on many factors including infections, patient motivation, ultrafiltration (transport characteristics) and total solute clearance.
  3. Peritoneal membrane failure: When ultrafiltration during continuous ambulatory peritoneal dialysis (CAPD) is <400 mL after 4-h dwell with 2 L 4.25% glucose (Perit Dial Int. 2000;20(suppl 4):S5-S21).



   Statistical Analysis Top


The data are expressed as mean ± standard deviation (SD). All probabilities were two tailed and the level of significance was set at 0.05. Student's "t" test was used to compare the significance of mean and the Chi square and Fisher exact tests were used to compare the proportion between the two groups. All data were analyzed by using SPSS 10 version software.


   Results Top


A total of 26 patients of ADPKD (Group 1) were compared with 38 control patients (Group 2). Each ADPKD ESRD patient started on PD was matched for age, sex and year of ESRD. The biochemical parameters, mean duration on PD, estimated glomerular filtration rate at the beginning of PD therapy in the PKD group [Table 1]. Other PD parameters including dialysate inflow and outflow times measured during the peritoneal equilibrium test (PET), residual dialysate volume, baseline dialysis clearances, residual renal function and membrane function between the two groups including Kt/V was similar in the two groups [Table 2]. The average size of kidneys among ADPKD ESRD patients was 15.2 + 2.1 cm.
Table 1: Demographics and biochemical characteristics of ADPKD and control patients at the beginning of PD therapy.

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Table 2: Baseline dialysis adequacy and membrane function of ADPKD and control patients.

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Peritonitis rates

Overall, the peritonitis rates were similar among the compared groups; Group 1, one episode per 21 months and Group 2, one episode per 27 months. The mean duration of the first peritonitis episode after catheter insertion was 1.2 and 1.8 years (95% confidence interval 0.82-1.91), for the control and ADPKD groups, respectively. Overall, the technique survival was similar in both groups (catheter loss was 2 in Group 1 and 3 in Group 2). Types of organisms grown in the two groups were almost similar.

Patient survival

Overall, the patient survival was similar between the two groups. Among ADPKD, one patient died due to intracerebral bleed while the other died due to severe cyst hemorrhage and infection. Two patients died due to peritonitis and sepsis.

Complications

Hernia was observed in four ADPKD patients; one on PD at a median follow-up period of 4.5 + 1.52 months, which was surgically corrected and PD was resumed in all four with no difficulty. Two patients were performing four exchanges till date and two controls also had hernia at a median follow-up period of 6.9 + 1.6 months. Four ADPKD and one control patient were transferred to HD temporarily following surgical repair.

Peritoneal membrane failure

Two patients lost the catheter due to peritonitis while one had membrane failure, while one patients underwent surgical exploration due to diverticulosis. Ten ADPKD and 14 control patients underwent renal transplant during this period, with PD as a bridge before surgery, which was similar between the two groups.

PD treatment was not prevented by voluminous kidneys in any of these patients and no patient ceased PD treatment due to insufficient peritoneal space.


   Discussion Top


The study was designed on the backdrop of literature evidences to show a poorer technique survival in ADPKD ESRD patients due to increased risks of abdominal hernias, infections and diverticulosis in these ESRD patients; however, recent reports are encouraging. [7],[8],[9] In India, with a population of 1129 million but only 700 nephrologists and approximately 400 HD units, [10] the most important concern always remains about the infrastructure of dialysis facilities. A maximum of 2% of patients can be subjected to maintenance HD. With 100 renal transplant centers, mostly in private setups, not more than 3000-4000 transplants are performed annually. [11],[12] Thus, it is estimated that less than 10% of all Indians ESRD patients receive any meaningful renal replacement therapy. [13]

As of now, there are over 300 centers practicing PD in India and there are approximately 6500 patients on chronic ambulatory PD.

In the presence of poor availability of dialysis facilities in developing countries and a wide disputed data of PD in the ADPKD ESRD population, this study was performed to evaluate the efficacy of PD in them and to identify specific risks besides the economics of PD compared with HD in this selected population. Our study showed that patient and technique outcomes were similar among the two groups. Hadimeri et al [6] and Kumar et al, [8] had results that are consistent with our findings; however, the former study consisted of only a few patients with a short follow-up duration and with an ill-defined control group. Contrary to the high incidence of hernias in ADPKD ESRD patients, our study group showed lower incidences; four among the ADPKD patients on PD at a median follow-up 4.5 months while two among the control patients at a median follow-up of 8.7 months. Although Del Peso et al [5] showed a higher relative risk of the development of abdominal wall hernia (mainly umbilical) among the ADPKD patients than in those with other causes of ESRD, promising results were observed by Henrik Hadimeri et al, [6] where morbidity due to herniations did not increase nor did it prevent continuation of treatment. Kumarandh and his collegues [8] have also observed that complications related to ADPKD were not significantly large enough to prevent patients in choosing this modality in ADPKD patients. Fletcher et al [9] reported five cases of acute right-sided hydrothoraces complicating PD, four of whom had PKD. It is important to understand, and also pay serious thought to, whether these complications associated with PD in these patients are a concern for poor long-term outcome, which was however not observed in our study. This would require a large study group to substantiate our results.

The next risk is that of increased incidence of gram-negative peritonitis among ADPKD patients on PD due to diverticulosis, which is a common manifestation among these patients. Studies by Fetcher et al [9] and DeVecchi et al [14] have shown similar rates of peritonitis among cases and controls. These results are promising as it is consistent with our study population. We observed a high incidence of culturenegative peritonitis among both the groups, the possible reason being early start of therapy before the sample collection. Gram-negative (originating from the bowel) organisms were not significantly higher among PKD patients. Response to empiric therapy among both groups was similar in our study population.

The next serious concern while choosing PD as the mode of RRT among ADPKD is its efficacy in situations where effective peritoneal surface area is reduced due to large kidneys. In our study group, however, despite its large size, we did not require nephrectomy before initiation of PD. The peritoneal membrane functions including dialysis dose adequacy (Kt/V), weekly creatinine clearance, daily ultrafiltration volume and dialysate: plasma creatinine ratio determined at the fourth hour of the peritoneal equilibration test were similar in both groups, despite the fact that PD was attempted in patients who had larger kidney size with an average of 15.23 + 2.3 cm (which are fairly large kidneys) with compromised peritoneal cavity. Similar results are observed by other authors (Hadimeri et al [6] and Pirson et al [15] . Moreover, no difference in dialysate inflow and outflow times, nor in residual dialysate volume, was found between the groups. Thus, such studies give a positive impact on technique survival, suggesting that the mere presence of polycystic kidneys does not affect peritoneal function. Because we all know the significance of residual renal functions in PD, nephrectomy should definitely be avoided in such individuals. There has been no difference in nutritional status evidenced by the serum albumin levels at the start and on follow up in both the groups suggesting that a better albumin at start of CAPD has better outcome results. [16],[17],[18]

Our observation is that the cost on PD even in the private sector is much less than the cost on HD, even at the government setup and because majority of the population in developing countries like India lives in rural areas. Dialysis facilities are available only in major cities and patients and their families have to travel long distances; in many instances, they have to be relocated with a resultant loss of livelihood and jobs. Besides this, the prescription of HD dose is largely empirical and water quality standards for HD are not appropriate. PD, with its ambulatory nature and freedom from complicated and expensive technology could be a more cost-effective modality in the wake of data favoring favorable outcome in ADPKD ESRD.

Our present study gives some hope for PD as a reasonable mode of renal replacement therapy among ADPKD where HD is not possible or contraindicated, with lesser risks to bleeding and infections, the cost benefit favoring PD in general. However, our study population is not large and a prospective larger study is required to substantiate these results. Till then, it seems to be encouraging to choose PD among such patients with bigger kidneys.

 
   References Top

1.
US Renal Data Services. Table A.1, Incident Counts of Reported ESRD: All Patients. USRDS 2008 Annual Data Report. Vol. 3. 2008. p. 7.  Back to cited text no. 1
    
2.
Geda SB, Parthasarathy S, Sakhuja V, Jha V. Referral pattern of patients with end stage renal disease and its impact on outcome at a tertiary care centre in North India. Nephrology 2005;10 Suppl:A152-3.  Back to cited text no. 2
    
3.
Abbott KC, Agodoa LY. Polycystic kidney disease at end-stage renal disease in the United States: Patient characteristics and survival. Clin Nephrol 2002;57:208-14.  Back to cited text no. 3
    
4.
Prischl FC, Dieplinger G, Wallner M, Seiringer E, Hofinger I, Kramar R. Peritoneal dialysis in patients with polycystic kidney disease. Wien Klin Wochenschr 2005;117 Suppl 6:24-8.  Back to cited text no. 4
    
5.
Del Peso G, Bajo MA, Costero O, et al. Risk factors for abdominal wall complications in peritoneal dialysis patients. Perit Dial Int 2003;23:249-54.  Back to cited text no. 5
    
6.
Hadimeri H, Johansson AC, Haraldsson B, Nyberg G. CAPD in patients with autosomal dominant polycystic kidney disease. Perit Dial Int 1998;18:429-32.  Back to cited text no. 6
    
7.
Pandya BK, Friede T, Williams JD. A comparison of peritonitis in polycystic and non-polycystic patients on peritoneal dialysis. Perit Dial Int 2004;24:79-81.  Back to cited text no. 7
    
8.
Kumar S, Fan SL, Raftery MJ, Yaqoob MM. Long term outcome of patients with autosomal dominant polycystic kidney diseases receiving peritoneal dialysis. Kidney Int 2008;74:946-51.  Back to cited text no. 8
    
9.
Fletcher S, Turney JH, Brownjohn AM. Increased incidence of hydrothorax complicating peritoneal dialysis in patients with adult polycystic kidney disease. Nephrol Dial Transplant 1994;9:832-3.  Back to cited text no. 9
    
10.
Keshaviah P. Resource limitations and strategies for the treatment of uremia. A dialysis unit in the Himalayan foothills. Blood Purif 2001;19:44-52.  Back to cited text no. 10
    
11.
Modi GK, Jha V. The incidence of end-stage renal disease in India: A population-based study. Kidney Int 2006;70:2131-3.  Back to cited text no. 11
    
12.
John AG, Rao M, Jacob CK. Preemptive liverelated renal transplantation. Transplantation 1998;66:204-9.  Back to cited text no. 12
    
13.
Sakuja V, Sud K. End stage renal disease in India and Pakistan: burden of disease and management issues. Kidney Int suppl 2003:83: S115-S118.  Back to cited text no. 13
    
14.
De Vecchi AF, Scalamogna A, Scanziani R, et al. Polycystic kidney disease and late peritoneal leakage in PD: Are they related? Perit Dial Int 2003;22:82-3.  Back to cited text no. 14
    
15.
Pirson Y, Christophe JL, Goffin E. Outcome of renal replacement therapy in autosomal dominant polycystic kidney disease. Nephrol Dial Transplant 1996;11 Suppl 6:24-8.  Back to cited text no. 15
    
16.
Blake PG, Flowerdew G, Blake RM, Oreopoulos DG. Serum albumin in patients on continuous ambulatory peritoneal dialysis - Predictors and correlations with outcomes. J Am Soc Nephrol 1993;3:1501-7.  Back to cited text no. 16
    
17.
Kaysen GA. The micro inflammatory state in uremia: Causes and potential consequences. J Am Soc Nephrol 2001;12:1549-57.  Back to cited text no. 17
    
18.
Wang Q, Bernardini J, Piraino B, Fried L. Albumin at the start of peritoneal dialysis predicts the development of peritonitis. Am J Kidney Dis 2003;41:664-9.  Back to cited text no. 18
    

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Correspondence Address:
Anupma Kaul
Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-2442.164570

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