First-year outcomes of incident peritoneal dialysis patients in the United States

Background: Patterns of early outcomes in peritoneal dialysis (PD) are not well studied and dialysis providers need to establish a baseline of key outcomes for continuous quality improvement initiatives.

Study design: Retrospective cohort study.

Setting & participants: Incident PD patients from Fresenius Medical Care, North America from January 1 through December 31, 2009.

Factors: Case-mix, comorbid illness, and baseline laboratory values.

Outcomes: Death, hospitalization, peritonitis, and switch to hemodialysis (HD) within the first year on PD therapy.

Measurements: Event rates and outcome predictors.

Results: Of 1,677 incident PD patients, 1,313 started on PD therapy and 367 switched from HD therapy within the first 90 days. Normalized first-year event rates for mortality, switch to HD therapy, peritonitis, and hospitalization were 10, 27, 42, and 128 per 100 patient-years, respectively. 336 of 463 (72.6%) first peritonitis episodes and 637 of 939 (67.8%) first hospitalizations occurred within the first 6 months of PD treatment. Black race, higher body mass index, non-Hispanic ethnicity, peripheral vascular disease, and low weekly Kt/V associated with peritonitis risk. Dialysis vintage, female sex, diabetes, congestive heart failure, peripheral vascular disease, and history of limb amputation along with lower laboratory values for albumin, hemoglobin, and phosphorus and weekly Kt/V associated with hospitalization. Switchers to HD therapy (n=350) used central venous catheters 81.4% of the time as initial access (still 78.3% at 90 days later) because of lack of permanent access.

Limitations: Residual confounding from unmeasured variables and exclusion of patients with a training day but who never started home PD therapy.

Conclusions: Despite low first-year mortality, incident PD patients had high morbidity, particularly within the first 3-6 months. Increased focus to identify patients at greatest risk for peritonitis and hospitalization, as well as evaluation of care processes and implementation of preventive strategies, is required. Access planning for transition to HD therapy needs more attention, even during the first PD year.