Peritoneal Dialysis vs. Kidney Disease Mortality Rate

Introduction

The dialysis method is the latest in an arsenal of therapeutic agents to be performed in cases where there is no other option to prolong a patient’s life. Today, peritoneal dialysis practice has one of the leading places in the therapy of patients with the terminal stage of chronic kidney disease (CKD) accompanied by chronic renal failure (CRF). This is because a huge proportion of patients with end-stage renal failure consists of persons with concomitant cardiovascular or systemic diseases, and for them, hemodialysis is contraindicated. Thus, peritoneal dialysis received a large distribution in the urological practice. The quality of therapy with peritoneal dialysis is mainly determined by the reliability of the type of catheter used for penetration – it is either the Central Venous Catheter (CVC) or the Arteriovenous Fistula (AVF). According to several studies, a choice of catheter can contribute to the factors that influence patients’ mortality rate. The goal of this literature review is to critically assess these studies.

The Impact of Peritoneal Dialysis on Patients’ Mortality Rate and Quality of Life

One of the most important aspects when conducting the treatment of patients with kidney substitution therapy is the quality of their life. This problem remains the most acute because this group of patients feels constant dependence of their health and life on the factors they have little control of. Vonesh et al. (2004) have found that “PD was associated with an increased risk of death in the 40% of the population comprised of Diabetes Mellitus patients aged 45 and older” (p. 2394). However, a thorough analysis performed in this study showed that mortality rates associated with peritoneal dialysis vary widely concerning many factors. Additionally, Vonesh et al. (2004) concluded that persistent improvements in PD techniques might decrease mortality risks.

Another study concluded by Kao et al. (2020) assessed psychological problems associated with unplanned dialysis and their impact on patients’ quality of life. According to Kao et al. (2020), “the causes for sleep disturbance in CKD patients include depression, anxiety, uremic toxins, and adverse effects of drugs, as well as, potentially, the use of dialysis therapy” (p. 255). The conducted research evaluated specifically the influence of dialysis therapy on psychological disturbances through questionnaires and scientific analysis. However, the researchers did not find a significant correlation between unplanned dialysis and patients’ psychological condition. Still, it was advised that a multidisciplinary care program might help relieve the symptoms of anxiety and depression.

The prevention of dialysis therapy also plays an important role in treatment prescription. Research shows that early appointment with a nephrologist reduces mortality and hospital stay (Ng, & Li, 2018). In addition, current research related to the common viral disease COVID-19 indicates an increased risk of mortality from coronavirus (Gansevoort & Hilbrands, 2020). These indicators force the development of new predictive methods and an integrated approach to dialysis patients. For example, a group of scientists has developed a method for predicting mortality based on retrospective administrative and clinical indicators of patients, considering the main causes: heart failure, metastatic cancer and lymphoma (Wick et al., 2017). Although the proposed tool has not been validated, research in this direction may help guide clinical decisions for older people with renal failure.

Difficulties in Choosing the Catheter Type

Modern advanced laparoscopic techniques allow patients in need of kidney substitution therapy to successfully apply peritoneal dialysis, even in the case of concomitant abdominal pathologies. However, there are several aspects to the choice of a correct dialysis tool for each case. A significant study by Hagen et al. (2014) shows that “a PD catheter failure rate up to 35% is described, which certainly calls for improvement” (p. 922). The authors conducted a meta-analysis to determine the factors that might influence the PD failure associated with the catheter choice and identified the benefits of using different types of catheters. A study performed by Dell’Aquila et al. (2007) supports the issue, claiming that “overcoming catheter-related problems means giving a real chance to development of the peritoneal technique” (p. 119). However, this research did not imply in detail the process of catheter choice, rather stating that most of the catheter types could be used freely if special attention is paid to their care.

More detailed information on the use of certain types of catheters, such as arteriovenous fistula (AVF), arteriovenous graft (AVG), and central venous catheter (CVC), was provided by Kim et al. (2020)’s research. Their findings identify that the “AVG group showed the worst patients’ survival among the three types of vascular accesses, while AVF presented the best results out of the three” (p. 33). Overall, the authors concluded that the use of AVF had the most impact on the patients’ mortality rate and depression score, specifically in the kidney disease field. The results of this study might be recommended to consider while choosing a catheter type due to their high reliability – the authors used a multidimensional approach when conducting analysis.

However, relevant research performed by Lee et al. (2018) has provided a counterargument to the preferred use of AVF for peritoneal dialysis. The authors claim that “AVF outcomes are uniformly worse among female patients due to a lower rate of success, a higher likelihood of assisted AVF use, and a higher potential of abandonment” (p. 18). According to their statistical analysis, AVG grafts might be a better choice for peritoneal dialysis in female patients.

CVC use is often associated with increased hospital admissions and mortality. However, a deeper analysis shows that it is not the very fact of using this type of catheter that leads to death, but rather the poor systemic state of patients and emergency therapy intervention with its use, and given the high economic costs of dialysis patients, this problem requires careful consideration (Shimizu et al.., 2020). In the case of emergency and planned initiation of dialysis, AVF is considered the preferred type, since statistics indicate much lower mortality in patients who started treatment using this type of catheter (Ozeki et al., 2017). Oftentimes, lack of data or misdiagnoses can disrupt statistical research and lead to inaccurate conclusions (Asakura & Kimura, 2017). Due to this, the identification of such clinical environmental factors associated with high mortality in the early stages of dialysis has the potential to create positive momentum and understanding in the management of advanced CKD and collaborative decision-making.

Conclusion

Recent studies in the field of the pathogenesis of chronic renal failure show a wide multitude of factors influencing the outcomes of the treatment. Among them, peritoneal dialysis remains one of the most discussed techniques due to the higher dependence of success on external factors, such as catheter type choice. Still, the improvements of approaches to kidney disease complications and concomitant pathologies treatment and intensive development of dialysis technologies open up wide prospects for optimizing long-term treatment results of patients with CKD. Studies from this literature review show that problems associated with dialysis therapy can be partially prevented with the right approach to the choice of tools at the beginning of treatment. Additionally, they point out the necessity of a timely change of approach if the capabilities of the technique in a particular patient are exhausted or the risks of damage are too high. However, further research is required to determine the extent of the issue and plan the interventions to reduce the associated risks.

References

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Gansevoort, R. T., & Hilbrands, L. B. (2020). CKD is a key risk factor for COVID-19 mortality. Nature Reviews Nephrology, 16(12), 705-706.

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Kao, Y.-Y., Lee, W.-C., Wang, R.-H., & Chen, J.-B. (2020). Correlation of sociodemographic profiles with psychological problems among hospitalized patients receiving unplanned hemodialysis. Renal Failure, 42(1), 255–262.

Kim, D. H., Park, J. I., Lee, J. P., Kim, Y.-L., Kang, S.-W., Yang, C. W., Kim, N.-H., Kim, Y. S., & Lim, C. S. (2019). The effects of vascular access types on the survival and quality of life and depression in the incident hemodialysis patients. Renal Failure, 42(1), 30–39.

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Ng, J. K. C., & Li, P. K. T. (2018). Chronic kidney disease epidemic: how do we deal with it?. Nephrology, 23, 116-120.

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Shimizu, Y., Nakata, J., Yanagisawa, N., Shirotani, Y., Fukuzaki, H., Nohara, N., & Suzuki, Y. (2020). Emergent initiation of dialysis is related to an increase in both mortality and medical costs. Scientific Reports, 10(1), 1-8.

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Wick, J. P., Turin, T. C., Faris, P. D., MacRae, J. M., Weaver, R. G., Tonelli, M. & Hemmelgarn, B. R. (2017). A clinical risk prediction tool for 6-month mortality after dialysis initiation among older adults. American Journal of Kidney Diseases, 69(5), 568-575.