Patients transferring from peritoneal dialysis (PD) as their initial dialysis modality to hemodialysis (HD) have the highest risk for death in the first month after transfer, with the rates declining to nadir at 4 to 6 months, according to a recent study.
The finding is from a study that included patients in 4 registries who transferred from PD to HD from 2000 to 2014: the Australia and New Zealand Dialysis and Transplantation registry (ANZDATA; 6683 patients), Canadian Organ Replacement Register (CORR; 5847 patients), European Renal Association (ERA) Registry (21,574 patients); and the US Renal Data System (80,459 patients).
Crude mortality rates at their peak reached 48, 68, 32, and 34 deaths per 100 patient-years, respectively, a team led by Annie-Claire Nadeau-Fredette, MD, MSc, of the Centre de Recherche et Hôpital Maisonneuve-Rosemont in Montreal, Quebec, Canada, reported in Kidney International Reports.
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Mortality stabilized at 4 to 6 months in all registries.
Crude mortality rates were lower for patients transferring in the most recent years compared with earlier years, according to the investigators.
The median duration on PD before transfer to HD was 1.1 years in Europe and the US and 1.3 years in Australia/New Zealand and Canada.
Older age and longer PD vintage predicted an increased mortality risk, a finding consistent across registries.
“This study highlights the vulnerability of patients at the time of modality transfer and the need to improve transitions,” Dr Nadeau-Fredette and colleagues concluded.
Nephrologist Rita L. McGill, MD, who was not part of the new study but has published research characterizing the transition from PD as the initial dialysis modality to HD in the United States, noted that the study underscores that the first months following transition from PD to HD “are a perilous period for patients.”
“Mortality is less than that of incident hemodialysis patients, possibly reflecting the lower age and lesser burden of comorbid disease among PD patients, possibly reflecting that patients who transition are by definition already receiving specialty care,” said Dr McGill, associate professor of medicine at University of Chicago Medical Center and medical director of Davita Park Manor Dialysis, one of the university’s HD centers.
Immediate mortality differed among the 4 registries, but by 60 days, a consistent mortality risk was observed, she noted.
“Other findings are consonant with what is known about survival with kidney failure,” she said. “Older patients have greater mortality in every treatment situation, and longer use of PD reflects a longer duration of kidney failure and more accumulated burden of associated metabolic disorders.”
Dr McGill explained that the event precipitating transfer from PD to HD would have an obvious effect on mortality.
For example, a patient transferring due to PD peritonitis or an intra-abdominal illness would certainly have a high short-term mortality, as would patients who transferred after a critical illness because of inability to continue self-care.
She added, “While some patients enjoy lengthy success with PD, many patients ultimately transfer to HD. Despite specialty care, the rate of initiating HD with a central venous catheter is even greater for patients who transfer from PD than the rate in incident HD patients, suggesting that providers have difficulty identifying which patients will transfer, and therefore miss opportunities to plan and prepare for modality change. Providers taking care of PD patients need to accept that modality attrition occurs in order to optimize the care of PD patients who need to transfer to HD.”
