Search

To examine new evidence linking expanded hemodialysis (HDx) using a Medium Cut-Off (MCO) membrane with hospitalizations, hospital days, medication use, costs, and patient utilities. This retrospective study utilized data from Renal Care Services medical records database in Colombia from 2017 to 2019. Clinics included had switched all patients from high flux hemodialysis (HD HF) to HDx and had at least a year of data on HD HF and HDx. Data included demographic characteristics, comorbidities, years on dialysis, hospitalizations, medication use, and quality of life measured by the 36 item and Short Form versions of the Kidney Disease Quality of Life survey at the start of HDx, and 1 year after HDx, which were mapped to EQ-5D utilities. Generalized linear models were run on the outcomes of interest with an indicator for being on HDx. Annual cost estimates were also constructed. The study included 81 patients. HDx was significantly associated with lower dosing of erythropoietin stimulating agents, iron, hypertension medications and insulin. HDx was also significantly associated with lower hospital days per year (5.94 on HD versus 4.41 on HDx) though not with number of hospitalizations. Estimates of annual hospitalization costs were 23.9% lower using HDx and patient utilities did not appear to decline. HDx was statistically significantly associated with reduced hospitalization days and lower medication dosages. Further, this preliminary analysis suggested potential for HDx being a dominant strategy in terms of costs and utility and should motivate future work with larger samples and better controls. This article is protected by copyright. All rights reserved.

Background: The benefits of automated peritoneal dialysis (APD) have been established, but patient adherence to treatment remains a concern. Remote patient monitoring (RPM) programs are a potential solution; however, the cost implications are not well established. This study modeled, from the payer perspective, expected net costs and clinical consequences of a novel RPM program in Colombia. Methods: Amarkov model was used to project costs and clinical outcomes for APD patients with and without RPM. Clinical inputs were directly estimated from Renal Care Services data or taken from the literature. Dialysis costs were estimated from national fees. Inpatient costs were obtained from a recent Colombian study. The model projected overall direct costs and several clinical outcomes. Deterministic and probabilistic sensitivity analyses (DSA and PSA) were also conducted to characterize uncertainty in the results. Results: The model projected that the implementation of an RPM program costing US$35 per month in a cohort of 100 APD patients over 1 year would save US$121,233. The model also projected 31 additional months free of complications, 27 fewer hospitalizations, 518 fewer hospitalization days, and 6 fewer peritonitis episodes. In the DSA, results were most sensitive to hospitalization rates and days of hospitalization, but cost savings were robust. The PSA found there was a 91% chance for the RPM program to be cost saving. Conclusion: The results of the model suggest that RPM is cost-effective in APD patients which should be verified by a rigorous prospective cost analysis.

Background: Estimating morbidity outcomes and the rate of progression of chronic kidney disease (CKD) patients is of great importance for the health systems. Objective: The objective of this study is to estimate the incidence of dialysis initiation and the rate of CKD progression in 2 years follow-up and identify factors associated with dialysis starts. Methods: A retrospective cohort study of adult with diagnosed CKD stages-G3, G4 (estimated glomerular filtration rate between 60 and 15 ml/min/1.73 m2) enrolled into a CKD prevention program in Bogota-Colombia, since January 1, 2016, to June 30, 2017, with follow-up until June 30, 2019. Cohort’s outcomes were arrival to dialysis and stage G5, dropout of the program, hospitalization, and mortality. Repeated measurements of the estimation of glomerular filtration rate (eGFR) allowed us to estimate the change over time in 4-month periods using a mixed-effects model. An Extended Cox model was adjusted for the time to start dialysis. Results: One thousand four hundred forty-eight patients were included in the analysis; the incidence rate of dialysis initiation was 2.1 events per 100 patients-year (95% CI: 1.5 2.7). The mean of eGFR variation was +1.1 ml/min/1.73 m2/year; and for diabetics was −1.0 ml/min/m2/year. Being diabetic and having poorly controlled hypertension were significant risk factors for time to dialysis initiation. Conclusion: The incidence rates of dialysis initiation, dropout, and hospitalization are outcomes of significant interest in a CKD prevention program. Being diabetic and poor blood pressure control are risk factors for a more rapid progression to dialysis.

Background and Aims Comparing and interpreting regional differences in peritoneal dialysis (PD) time on therapy needs to consider differences in the rates of permanent transfer to hemodialysis (HDT), death or kidney transplantation. Here we describe these outcomes among countries in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS), as well as reasons for PD discontinuation. Method PDOPPS is a prospective cohort study of randomly selected patients across national samples of PD facilities from Australia/New Zealand (A/NZ), Canada, Japan, Thailand, the UK, and the US. Fine and Gray models were used on a population of 7115 patients, of varying PD vintages at study entry [median (IQR) vintage = 0.82 yrs (0.21, 2.03)], to analyse the cumulative incidence from PD start of transplantation, HDT, or death (on PD or within 7 days of transfer to HD). This allows for the determination of the % of patients remaining on PD at each PD vintage referred to as Time on Therapy (ToT). Models were left truncated to account for PD vintage at time of study enrollment. HDT was defined as no return from HD therapy within 12 weeks of transferring to HD. Cox models were used to calculate hazard ratios (HR) for death accounting for facility clustering and adjusted for patient age, sex, US black race, heart disease, diabetes, psychiatric disorder, prior HD experience, urine volume, and transplant waitlist referral. Results Mean patient age ranged from 56 yrs in Thailand to 64 yrs in Japan (Figure). Overall, 1261 patients transferred to HD, 76 patients transferred to HD/PD hybrid therapy, 900 patients died and 506 were transplanted during follow-up. By 3 years, the % of patients remaining on PD ranged from 25% in UK, 34-40% in A/NZ, Canada and US, to 47% in Thailand, and 54% in Japan (Figure). The much lower % of patients on PD at 3 yrs in the UK vs Japan was largely due to the high % of patients transplanted in the UK vs Japan: % transplanted ranged from 2% in Japan and Thailand to 32% in the UK at 3 yrs. When defining a ‘poor outcome’ as either death or HDT: (1) the % of patients still on PD or having been transplanted were quite similar across all 6 countries, and (2) death was a much larger proportion of this ‘poor outcome’ in Thailand vs other countries. Similar risks of HDT were seen across all countries except Thailand which displayed much lower risks of HDT. This finding changed little with covariate adjustment (not shown). Infection, reported as primary HDT cause, varied from 30% (Canada) to 66% (Thailand) of cases, and insufficient solute or water clearance as primary HDT cause ranged from 6% (Thailand) to 44% (Japan) of cases (not shown). In Cox models, the adjusted HR of death, compared to the US, was higher in Thailand [1.55 (1.17-2.06)], lower in Canada [0.75 (0.61-0.92)], A/NZ [0.60 (0.47-0.78)], and Japan [0.36 (0.27-0.48)], and close to 1 in UK [0.98 (0.75-1.28)]. Conclusion Time on PD therapy differed considerably across countries. This was mainly due to large country differences in proportion transplanted, so that transplantation has a greater impact on country variability in ToT than HDT and death. Risk of death varied greatly across countries, particularly when accounting for case-mix. With the exception of Thailand, differences between countries in risk of HDT were modest. Marked differences in recorded reasons for HDT merit additional study.

Background and Aims Fatigue is a symptom with a high prevalence in patients on hemodialysis therapy due to uremic toxins, anemia, associated comorbidity, and hemodialysis treatment per se. Our objective is to evaluate the prevalence of fatigue reported by patients and their association with the nutritional status. Method This was a prospective observational, multicenter cohort study. Prevalent patients on HD therapy for at least 90 days, older than 18, at the Baxter Renal Care Services were included between September 1, 2017, to November 30, 2017 with one-year follow-up. Socio-demographic and clinical characteristics of all patients were summarized descriptively, the nutritional status was evaluated by protein Energy waste (PEW). Patient reported fatigue was measured with high flux membrane and medium cut-off membrane (Theranova). A generalized linear binomial multivariable model was conducted to assess the effect of PEW on fatigue symptom controlling for some confounding variables. Results We found that the fatigue reported by the patients has a prevalence of 55% [95% CI: 52.2 to 57.7] in our population, there are no statistical differences due to the use of different types of membranes p= 0.911, and neither did we find that the nutritional status is an independent factor that explains this symptom. If we find that women and diabetics have a higher risk of fatigue; RR=1.17 [95% CI: 1.06 to 1.29] and RR= 1.19 [95% CI: 1.00 to 1.42] respectively. Conclusion The fatigue is a prevalent symptom in the chronic hemodialysis population; being a woman and the diagnosis of diabetes are risk factors associated with this outcome. PEW and the type of dialysis membrane used were not associated with this symptom. Studies evaluating the recovery time from post-dialysis symptoms and its relationship with the type of membrane are necessary.

Background and Aims The EuroQol-5D (EQ-5D-3L) is a generic questionnaire to evaluate the quality of life related to health, and simultaneously facilitates the obtaining of preference values (utilities) In the economic evaluation of health interventions. Quality-adjusted life year (QALY) is a commonly used metric. Our objective is to evaluate the quality of life (QoL) and obtaining of utilities according the dialytic treatment. Method This was an observational, multicentre cross-sectional study. Prevalent patients on dialysis for at least 90 days, older than 18, at the Baxter Renal Care Services Colombia were included between August 2, 2019, to December 11, 2020. Socio-demographic and clinical characteristics of all patients were summarized descriptively, additionally, all categorical variables were compared with Pearson’s χ2 test or Fisher’s exact test and continuous variables were analysed with Student’s t-test or Mann Whitney U test. The difference in the QoL by domains will be evaluated using Pearson's χ2 test or Fisher’s exact test. The EQ VAS provides a quantitative measure of the patient’s perception of their overall health. Results A total 254 patients were evaluated, the median age was 55 years, 55% were men. At enrolment the median dialysis vintage 3.2 years, and 63% were in peritoneal dialysis treatment (Table 1). We did not find differences in the proportions by dialysis treatment when exploring each of the 5 dimensions of the QoL (Table 2). We observed that the patient´s perception of their overall health was similar median EQ VAS score 80 in HD and EQ VAS score 80 in PD (Figure 1). We did not find statistically significant differences in health status 11111, which represents not having problems in any dimension 46.8% versus 45.6%, HD and PD respectively, p-value= 0.855. Conclusion The quality of life reported by the patients and health status in haemodialysis was similar to peritoneal dialysis.

Background and Aims According to emerging evidence, medium cut-off membrane improves clearance of molecules larger than 25 kDa, including larger uremic toxins. There is growing evidence on clinical effectiveness outcomes associated with the use of these membranes. Our aim was to evaluate clinical effectiveness of medium cut-off (HDx) versus high flux (HF-HD) dialyzers in terms of hospitalization rate and duration, cardiovascular event rate and survival in a HD prevalent cohort in Colombia through an observational, multicenter retrospective cohort analysis. Method Adult Prevalent HD patients (> 90 days in HD) at Baxter Renal Care Services Colombia were included between September 1st, 2017 to November 30th, 2017 (follow-up until 2 years). Socio-demographic and clinical characteristics of all patients were summarized descriptively. Inverse probability of treatment weighting on the propensity score was used to balance comparison groups on indicators of baseline socio-demographic and clinical characteristics. Weighted incidence rate ratios (IRRs) and rates and duration of hospitalization and cardiovascular events according to dialyzer type were obtained using binomial negative regression with the weighting sample. Results We evaluated 1098 patients (37.7% women): 534 in HF-HD vs 564 in HDx (Table 1), median age was 60.6 years. Mean time on HD was 5.6 years (SD 5.51) for HF-HD and 5.88 for HDX (SD 5.48) We observed lower hospitalization rates in HDx group, (IRR HDx/HF-HD: 0.82 95% CI 0.69 to 0.98; p=0.03); and cardiovascular events rate, (IRR HDx/HF-HD: 0.65 95% CI 0.47 to 0.91; p=0.01) see Table 2. Main cause of hospitalization was cardio-cerebrovascular (Table 3). We observed no differences in hospitalization duration or survival. Conclusion We evaluated 1098 patients (37.7% women): 534 in HF-HD vs 564 in HDx (Table 1), median age was 60.6 years. Mean time on HD was 5.6 years (SD 5.51) for HF-HD and 5.88 for HDX (SD 5.48) We observed lower hospitalization rates in HDx group, (IRR HDx/HF-HD: 0.82 95% CI 0.69 to 0.98; p=0.03); and cardiovascular events rate, (IRR HDx/HF-HD: 0.65 95% CI 0.47 to 0.91; p=0.01) see Table 2. Main cause of hospitalization was cardio-cerebrovascular (Table 3). We observed no differences in hospitalization duration or survival.

Background and Aims Patients with remote monitoring are followed-up daily by clinical teams, allowing early detection and correction of problems, which could result in improvements in therapy outcomes. Aims: To evaluate the association between Remoted Patient Monitoring (RPM) program and clinical outcomes (technique failure and peritonitis rates). Method A historical, multicenter, observational cohort study in Automatized Peritoneal Dialysis (APD) prevalent patients, included between October 1, 2016, and June 30, 2017 with follow-up until June 30, 2018, at Renal Therapy Services (RTS) network. Patients were older than 18 years, divided into two cohorts based on the RPM use: 1) APD-RPM cohort: patients using the HomeChoice Claria® device with Sharesource® technology (Baxter Healthcare, Deerfield, USA) and 2) APD-Without RPM cohort: patients using APD systems HomeChoice Legacy® without RPM. Socio-demographic and clinical characteristics of all patient were summarized descriptively. Propensity score matching 1:1 was used. Results 558 patients met the inclusion criteria for data analysis. The mean age was 54 years, 40% were female, 26% had APD RPM, see Table 1. After propensity score matching, APD therapy with RPM (n=148) as compared to APD-Without RPM (n=148) was associated with significant reduction in technique failure, IRR= 0.46 95% CI: [0.24 - 0 .89], and a trend in peritonitis rate reduction, IRR= 0.87 [0.41 - 1.00], P= 0.051, see table 2. Main reasons of technique failure are presented in table 3. Conclusion The use of RPM program in APD patients is associated with lower technique failure rate, supporting the role of this technology as performance enhancer.

Background and Aims Peritoneal dialysis (PD) is a renal replacement therapy widely used in the world; about 197,000 patients use it. The main limitation of the use is related to technique failure. Extending time free of technique failure remains a long-term challenge in PD. To estimate the incidence of technique failure in PD and, describe the main reasons for failure. Method A historical, multicenter, observational cohort study of all adult patients starting PD between January 1, 2010, and December 31, 2015, with follow-up until December 31, 2018, at Renal Therapy Services (RTS) network. The definition of technique failure applied when a patient was switched to Hemodialysis (HD) for at least 30 days. Socio-demographic and clinical characteristics of all patients were summarized descriptively by PD modality. We estimate the failure rate with an analysis of Kaplan Meier and analysis that incorporate competing risks as death and transplant. Results 6452 patients met the inclusion criteria for data analysis, 67% were in CAPD modality. The mean age was 59 years, 54% were male, and 53.7% had a history of diabetes, see Table 1. There were 1462 technique failures events with a rate of 10.67 events per 100 patients-year [95% CI, 10.14 – 11.24]. The median technique survival time was 5.8 years [ 95% CI: 5.11 to 5.45]. Technique failure rates did not differ by PD modality (Wilcoxon test = 0.4986), Figure 1. In the presence of competing events, the cumulative incidence of technique failure for the first year was 6.9 events per 100 persons-risk [95% CI: 6.27 to 7.56], Table 2. The most common causes of technique failure were catheter complications, followed by psychological and medical indications, Table 3. Conclusion The incidence of PD technique failure is around ten events per 100 patient-year, and this is lower than the previous cohort reports in the literature. Catheter problems remain the leading cause of technique failure

Background and Aims Dialysate flow rate (Qd) has minimal effect in removal of molecules in hemodialysis, allowing to use lower amounts of dialysate with no effect in clearance of molecules. According to recent literature, Expanded hemodialysis (HDx) improves the clearance of middle size molecules, diminishing the effect of Qd in adequacy. We found no data about clearance at different dialysate flow rates in HDx. Our aim is to evaluate the clearance of middle molecules (beta 2 microglobuline [Mβ2], interleukin-6 [IL-6], interleukin-10 [IL-10 light chains (CLL-κ -λ) with HDx at different Qd using membranes TheranovaMR in patients with body weight less than 70 Kg. Method We performed an observational retrospective analysis of clearance of Mβ2, IL-6, IL-10, CLL-κ; CLL-λ in HDx using TheranovaMR filters with Qd 400 mL/min and 500 mL/min. We performed variance analysis, T student test and Wilcoxon test. Data were extracted from an HDx multicentric trial performed in Bogotá, Colombia in 2018. Results 11 (47%) patients received Qd 400 mL/min and 12 (52.1%) patients with Qd 500ml/min. Demographic data are included in table 1. We found no differences in reduction rate of mid-molecules. (Table 2) We found that lower water consume in the Qd 400 mL/min group, with water savings of 24 Liters/patient (13824 L in 12 weeks of follow up). (Table 3) Conclusion Expanded hemodialysis seems to allow diminishing Qd rate without changes in mid-size molecules clearance.

Clinical interventional studies in diabetes mellitus usually exclude patients undergoing peritoneal dialysis (PD). This study evaluates the impact of an educational program and a basal-bolus insulin regimen on the blood glucose level control and risk of hypoglycemia in this population.A before-and-after study was conducted in type 1 and type 2 DM patients undergoing PD at the Renal Therapy Services (RTS) clinic network, Bogota, Colombia. An intervention was instituted consisting of a three-month educational program and a basal-bolus detemir (Levemir, NovoNordisk) and aspart (Novorapid, NovoNordisk) insulin regimen. Prior to the intervention and at the end of treatment were conducted measures of HbA1c levels and continuous glucose monitoring (CGM).Forty-seven patients were recruited. Mean HbA1c level decreased from 8.41% ± 0.83 to 7.68% ± 1.32 (mean difference -0.739, 95% CI -0.419, -1.059; P.0001). Of subjects, 52% achieved HbA1c levels7.5% at the end of study. Mean blood glucose level reduced from 194.0 ± 42.5 to 172.9 ± 31.8 mg/dl ( P = .0015) measured by CGM. Significant differences were not observed in incidence of overall ( P = .7739), diurnal ( P = .3701), or nocturnal ( P = .5724) hypoglycemia episodes nor in area under the curve (AUC)54 mg/dl ( P = .9528), but a reduction in AUC180 ( P.01) and AUC250 ( P = .01) was evidenced for total, diurnal, and nocturnal episodes.An intervention consisting of an educational program and a basal-bolus insulin regimen in type 1 and type 2 diabetes mellitus patients undergoing PD caused a decrease in HbA1c levels, and mean blood glucose levels as measured from CGM with no significant increases in hypoglycemia episodes.

In the area of nephrology, the practical application of relative survival methodologies can provide information regarding the impact of outcomes for patients with kidney failure on dialysis compared with what would be expected in the absence of this condition.Compare the net survival of hemodialysis (HD) and peritoneal dialysis (PD) patients in a cohort of incident patients on chronic dialysis in Colombia, according to the dialysis therapy modality.Observational, analytic, historical cohort.Renal Therapy Services (RTS) clinic network across Colombia.Patients over 18 years old with chronic kidney disease, incidents in dialytic therapy, which reached day 90 of therapy. Recruitment took place from January 1, 2008, to December 31, 2013, with a follow-up until December 31, 2018. The final cohort for analysis corresponds to a total of 12 508 patients, of which 5330 patients (42.6%) began HD and 7178 patients (57.4%) began PD.Demographic, socioeconomic, and clinical variables were measured.Analyses were conducted according to the treatment assigned (PD or HD) at the time of the inception of the cohort and another approach of analysis was done with a subsample of those patients who never changed the initial modality. To calculate expected survival, life tables were constructed for Colombia for the years 2006 to 2018. Net survival estimates were made using the Pohar Perme estimator. The comparison of the net survival curves was done using the method developed by Pavlič and Perme, the log-rank type.Net survival at 5 years compared with the general population was estimated at 0.53 (95% confidence interval 0.52-0.54) in the dialysis cohort. In intention-to-treat analyses of 7178 patients on PD and 5330 patients on HD, by global and Pohar-Perme methods, survival (expressed as a ratio of survival in patients on dialysis to survival in an age-, sex- and geographic-matched general Colombian population) was higher in patients on HD than in those on PD. In year 1, net survival by Pavlov-Perme on PD was 0.79 (95% confidence intervals [CI] 0.78 - 0.80) and on HD 0.85 (95% CI 0.84 - 0.86); in year 5, 0.36 (95% CI 0.34 - 0.38) and 0.57 (95% CI 0.55 - 0.59) for PD and HD respectively.There may be imbalances among the populations analyzed (HD vs PD), in which one or more variables other than the type of therapy may influence the survival of the patients. In Colombia there are marginal levels of underreporting of demographic data in some subpopulations that may affect life-tables construction.An important difference was observed in terms of survival between the dialysis population and the population of reference without dialysis. Statistically significant differences were found in net survival between HD and PD, net survival was higher in patients on HD than in those on PD.En néphrologie, l’application pratique des méthodologies de survie relative peut fournir des renseignements sur l’impact des résultats des patients atteints d’insuffisance rénale suivant des traitements de dialyse comparativement à ce qui serait attendu en l’absence de cette affection.Comparer la survie nette, selon la modalité de dialyse, dans une cohorte de patients colombiens traités par hémodialyse (HD) ou par dialyse péritonéale (DP) de façon chronique.Étude de cohorte observationnelle, analytique et historique.Le réseau Renal Therapy Services (RTS) de la Colombie.Des patients adultes souffrant d’insuffisance chronique ayant nouvellement débuté la dialyse depuis plus de 90 jours. Le recrutement a eu lieu du 1er janvier 2008 au 31 décembre 2013, et le suivi s’est poursuivi jusqu’au 31 décembre 2018. L’analyse porte sur un total de 12 508 patients, dont 5 330 (42,6 %) avaient entrepris des traitements d’hémodialyse et 7 178 (57,4 %) de dialyse péritonéale.Les données démographiques, socio-économiques et cliniques des patients.Les analyses ont été menées en fonction du traitement attribué (DP ou HD) au moment de la création de la cohorte. Une autre analyse a été réalisée sur un sous-échantillon de patients n’ayant jamais changé la modalité depuis le début du traitement. Des tables de survie spécifiques à la Colombie entre les années 2006 et 2018 ont été élaborées pour calculer la survie attendue. Les estimations de survie nette ont été faites en utilisant l’estimateur de Pohar Perme. Et la méthode développée par Pavlič et Perme, soit le test du log-rank a servi à la comparaison des courbes de survie nette.La survie nette après cinq ans, comparée à celle de la population générale, a été estimée à 0,53 (IC 95 %: 0,52 à 0,54) dans la cohorte de patients dialysés. Dans les analyses en intention de traiter portant sur 7 178 patients sous HD et 5 330 patients sous DP — réalisées par méthode globale et avec l’estimateur Pohar Perme — la survie (exprimée sous forme de rapport entre la survie de patients dialysés et la survie de Colombiens de la population générale du même âge, sexe et région géographique) s’est avérée plus élevée chez les patients sous HD que chez les patients sous DP. Au cours de la première année, la survie nette (Pavlov Perme) des patients sous DP s’établissait à 0,79 (IC 95 % : 0,78-0,80) et celle des patients sous HD à 0,85 (IC 95 % : 0,84-0,86); après cinq ans, elle était passée à 0,36 (IC 95 % : 0,34-0,38) pour les patients sous DP et à 0,57 (IC 95 % : 0,55-0,59) pour les patients sous HD.Il pourrait exister des disparités parmi les populations analysées (HD vs DP), où des variables autres que la modalité pourraient influencer la survie des patients. Il existe, dans certaines sous-populations de Colombie, des niveaux marginaux de sous-déclaration des données démographiques qui pourraient affecter l’élaboration des tables de survie.Une différence importante a été observée entre la survie des patients dialysés et celle d’une population de référence (personnes non dialysées). On a également constaté des différences statistiquement significatives entre le groupe sous HD et le groupe sous DP en ce qui concerne la survie nette, laquelle s’est avérée plus élevée chez les patients sous HD.

Background Automated peritoneal dialysis (APD) is a growing PD modality but as with other home dialysis methods, the lack of monitoring of patients’ adherence to prescriptions is a limitation with potential negative impact on clinical outcome parameters. Remote patient monitoring (RPM) allowing the clinical team to have access to dialysis data and adjust the treatment may overcome this limitation. The present study sought to determine clinical outcomes associated with RPM use in incident patients on APD therapy. Methods A retrospective cohort study included 360 patients with a mean age of 57 years (diabetes 42.5%) initiating APD between 1 October 2016 and 30 June 2017 in 28 Baxter Renal Care Services (BRCS) units in Colombia. An RPM program was used in 65 (18%) of the patients (APD-RPM cohort), and 295 (82%) were treated with APD without RPM. Hospitalizations and hospital days were recorded over 1 year. Propensity score matching 1:1, yielding 63 individuals in each group, was used to evaluate the association of RPM exposure with numbers of hospitalizations and hospital days. Results After propensity score matching, APD therapy with RPM ( n = 63) compared with APD-without RPM ( n = 63) was associated with significant reductions in hospitalization rate (0.36 fewer hospitalizations per patient-year; incidence rate ratio [IRR] of 0.61 [95% confidence interval (CI) 0.39 – 0.95]; p = 0.029) and hospitalization days (6.57 fewer days per patient-year; IRR 0.46 [95% CI 0.23 – 0.92]; p = 0.028). Conclusions The use of RPM in APD patients is associated with lower hospitalization rates and fewer hospitalization days; RPM could constitute a tool for improvement of APD therapy.

Remote Patient Management (RPM) offers renal health care providers and patients with end stage kidney disease (ESKD) opportunities to embrace home dialysis therapies with greater confidence and the potential to obtain better clinical outcomes. Barriers and evidence required to increase adoption of RPM by the nephrology community need to be clearly defined. Ten healthcare providers from specialties including nephrology, cardiology, pediatrics, epidemiology, nursing, and health informatics with experience in home dialysis and the use of RPM systems gathered in Vienna, Austria to discuss opportunities, barriers, and system requirements of RPM as it applies to the home dialysis patient. While improved outcomes and cost effectiveness of RPM have been demonstrated in patients with diabetes mellitus and heart disease, only observational data on RPM has been gathered in patients on dialysis. The current review focused on RPM systems currently in use, on how RPM should be integrated into future care, and the evidence needed for optimized implementation in order to improve clinical and economic outcomes. Randomized controlled trials and/or large observational studies could inform the most effective and economical use of RPM in home dialysis. These studies are needed to establish the value of existing and/or future RPM models among patients, policy makers, and healthcare providers.

Objetivo Los programas de prevención de la Enfermedad Renal Crónica (ERC) permiten controlar la morbimortalidad y/o retrasar el ingreso a terapia de reemplazo renal. Se documenta el diseño de un programa de prevención de la ERC y se describe cómo se integran los niveles primario y secundario de atención mediante la caracterización de una población admitida para prevención secundaria.Métodos La descripción del programa se realizó con base en una revisión documental. Para la caracterización de los pacientes participantes en el programa se utilizaron herramientas de estadística descriptiva.Resultados El diseño e implementación del programa de prevención se basó en la integración de redes de servicios y niveles de atención. Se detallan las actividades fundamentales del programa según el nivel de atención en el que se realizan. Un total de 3 487 pacientes fueron admitidos para control en el segundo nivel de atención por presentar tasa de filtración glomerular estimada

Background: Growth of the elderly population is linked to the increase of comorbid conditions such as chronic kidney disease (CKD), depression, and cognitive impairment (CI). Cognitive impairment can vary from minimal deficits in the normal aging, to mild cognitive impairment with a prevalence ranging from 1 to 29 % in people ≥ 65 years of age, up to severe impairment with a prevalence of 6 to 42 %. The CI induced by depression usually affects the functional performance of the elderly. Objective: The objective of the study is to describe the prevalence of CI and depression in patients ≥ 55 years with CKD stages 3 and 4, attending a secondary prevention program during 2012–2013. Design: The design of the study is a cross-sectional study of simple random sampling, and 308 patients were invited to participate. Setting: Patients were being treated in a CKD secondary prevention program in Bogotá, Colombia, during 2012–2013. Patients: Participants were over 54 years diagnosed with CKD in stages 3 to 4 according to the K/DOQI classification. Measurements: CI was assessed using NEUROPSI and modified Lawton Scale; depression was measured with Yesavage Geriatric Depression Scale and the MINI International Neuropsychiatric Interview. Methods: Through an interview with the subjects, information regarding age, occupation, civil status, educational level, and clinical baseline variables was collected. Clinical assessment with specific instruments was performed by a multidisciplinary team composed of nephrologists, a psychiatrist, a neurologist, and a neuropsychologist. Results: Two hundred and fifty-one patients agreed to participate. The average age was 76.3 (SD = 7.9) years, 67 % were males, and 86.5 % had CKD stage 3. Overall prevalence of CI was 51 % (95 % CI 44.7 to 57.2), and the prevalence of major depression reached 8 % (95 % CI 4.5 to 11.3); 4.8 % of the patients (n = 12) had both CI and depression. Limitations: A limitation of the study is its design, which does not allow establishing the direction of the association between predictors and outcomes. Suggested associations must be interpreted cautiously as they are generated as hypothesis, which should be investigated in properly designed trials. Conclusions: CI and depression are prevalent conditions among patients with CKD stages 3–4, with the greatest occurrence of CI, affecting half of the investigated Colombian patients with age ≥ 55 years. Mise en contexte: On a constaté un lien entre la croissance de la population âgée et l’augmentation de pathologies comorbides telles que les maladies rénales chroniques et la dépression ou un trouble cognitif. Ce dernier peut varier de la déficience légère observée lors du vieillissement normal à un trouble cognitif léger, dont la prévalence s’étend de 1 à 29 % chez les gens âgés de plus de 65 ans, jusqu’à une déficience grave dont la prévalence se situe entre 6 et 42 %. Le trouble cognitif provoqué par la dépression a des répercussions sur les performances fonctionnelles des personnes âgées. Objectifs de l’étude: Cette étude avait pour but de qualifier la prévalence d’un trouble cognitif et de la dépression chez les patients âgés de plus de 55 ans atteints d’insuffisance rénale chronique (IRC) de stade 3 ou de stade 4, et engagés dans un programme de prévention secondaire en 2012 et 2013. Type d’étude: Il s’agit d’une étude transversale où on a utilisé un échantillonnage aléatoire simple et à laquelle 308 patients ont été invités à participer. Participants et cadre de l’étude: L’étude a porté sur des cas de patients provenant d’un programme de prévention secondaire à Bogota, en Colombie. Les participants étaient tous âgés de plus de 54 ans et avaient reçu un diagnostic d’IRC de stade 3 ou de stade 4 conformément au classement de la KDOQI (Kidney Disease Outcome Quality Initiative). Mesures: Le trouble cognitif a été mesuré à l’aide de l’évaluation neuropsychologique NEUROPSI et d’une échelle de Lawton modifiée. La dépression a été diagnostiquée en utilisant l’échelle de dépression gériatrique de Yesavage et le questionnaire MINI (Mini International Neuropsychiatric Interview). Méthodologie: Les renseignements personnels des participants tels que l’âge, la profession, l’état civil, le niveau de scolarité et les paramètres cliniques initiaux des participants ont été recueillis par le biais d’entrevues. L’évaluation clinique, effectuée à l’aide d’instruments spécifiques, est le fruit de la collaboration d’une équipe multidisciplinaire composée de néphrologues, d’un psychiatre, d’un neurologue et d’un neuropsychologue. Résultats: En tout, 251 patients ont accepté de participer à l’étude. Les hommes constituaient 67 % de la cohorte, l’âge médian se situait à 76,3 ans avec un écart-type de 7,9 ans et 85 % des participants souffraient d’IRC de stade 3. La prévalence globale d’un trouble cognitif était de 51 % (IC à 95 % entre 44,7 et 57,2) et la prévalence de dépression majeure se situait à 8 % (IC à 95 % entre 4,5 et 11,3). De plus, 4,8 % des participants (n = 12) présentaient à la fois un trouble cognitif et une forme de dépression. Limites de l’étude: La méthodologie de cette étude en limite la portée puisqu’elle ne permet pas d’établir la nature de l’association entre les indicateurs prévisionnels et les résultats. Ainsi, les liens potentiels devraient être interprétés avec prudence. Ils sont générés à titre d’hypothèses et devraient faire l’objet d’études ultérieures menées dans le cadre d’essais bien conçus. Conclusions: La dépression et les troubles cognitifs sont des affections prévalentes chez les patients souffrant d’IRC de stade 3 et de stade 4. Les troubles cognitifs se sont avérés très fréquents, affectant la moitié des patients Colombiens de plus de 55 ans ayant fait l’objet de cette étude.

BackgroundPeritonitis is the most important complication of peritoneal dialysis (PD), and early peritonitis rate is predictive of the subsequent course on PD. Our aim was to calculate the early peritonitis rate and to identify characteristics and predisposing factors in a large nationwide PD provider network in Colombia.MethodsThis was a historical observational cohort study of all adult patients starting PD between January 1, 2012, and December 31, 2013, in 49 renal facilities in the Renal Therapy Services in Colombia. We studied the peritonitis rate in the first 90 days of treatment, its causative micro-organisms, its predictors and its variation with time on PD and between individual facilities.ResultsA total of 3,525 patients initiated PD, with 176 episodes of peritonitis during 752 patient-years of follow-up for a rate of 0.23 episodes per patient year equivalent to 1 every 52 months. In 41 of 49 units, the rate was better than 1 per 33 months, and in 45, it was better than 1 per 24 months. Peritonitis rates did not differ with age, ethnicity, socioeconomic status, or PD modality. We identified high incidence risk periods at 2 to 5 weeks after initiation of PD and again at 10 to 12 weeks.ConclusionAn excellent peritonitis rate was achieved across a large nationwide network. This occurred in the context of high nationwide PD utilization and despite high rates of socioeconomic deprivation. We propose that a key factor in achieving this was a standardized approach to management of patients.

Latin America is a heterogeneous region comprised of 20 countries, former colonies of European countries, in which Latin-derived languages are spoken. According to the Latin American Society of Nephrology and Hypertension/ Sociedad Latino Americana de Nefrologia e Hipertensión (SLANH), the acceptance rate for renal replacement therapy is 103 new patients per million population. In Latin America, hemodialysis is the predominant form of replacement therapy for end-stage renal disease; however, some countries employ peritoneal dialysis (PD) in 30% or more patients. In particular, Mexico is the country with the largest PD utilization in the world, and furthermore, it is estimated that approximately 25% of the world's PD population may be found Latin America. Data concerning clinical practice and long-term outcome of PD in Latin America are scarce, although regional registries are increasing in number and quality. In this review article, we present an overview of the situation of PD in several countries of Latin America, based on the registry of the SLAHN, national registries, and personal communication with PD experts from different countries.

Background and Objective Colombia is a country of diverse geographic regions, some with mountainous terrain that can make access to urban areas difficult for individuals who live in remote areas. In 2005, a program was initiated to establish remote peritoneal dialysis (PD) centers in Colombia to improve access to PD for patients with end-stage renal disease who face geographic or financial access barriers. Patients and Methods The present study was a multi-center cohort observational study of prevalent home PD patients who were at least 18 years of age and were being managed by one of nine established remote PD centers in Colombia over a 2-year period. Data were collected from clinical records, databases, and patient interviews. Patient survival, incidence of peritonitis, and rate of withdrawal from PD therapy were assessed. Results A total of 345 patients were eligible for the study. The majority (87.8%) of patients lived on one to two times a minimum monthly salary (equivalent to US$243 – US$486). On average, patients traveled 1.2 hours and 4.3 hours from their home to their remote PD center or an urban reference renal clinic, respectively. The incidence rate of peritonitis was 2.54 episodes per 100 patient-months of therapy. A bivariate analysis showed a significantly higher risk of peritonitis in patients who were living on less than one times a monthly minimum salary ( p < 0.05) or who had a dirt, cement, or unfinished wood floor ( p < 0.05). The 1-year and 2-year patient survival rates were 92.44% and 81.55%, respectively. The 1-year and 2-year technique survival rates were 97.27% and 89.78%, respectively. Conclusions With the support of remote PD centers that mitigate geographic and financial barriers to healthcare, home PD therapy is a safe and appropriate treatment option for patients who live in remote areas in Colombia.

Glucose-containing peritoneal dialysis solutions may exacerbate metabolic abnormalities and increase cardiovascular risk in diabetic patients. Here, we examined whether a low-glucose regimen improves metabolic control in diabetic patients undergoing peritoneal dialysis. Eligible patients were randomly assigned in a 1:1 manner to the control group (dextrose solutions only) or to the low-glucose intervention group (IMPENDIA trial: combination of dextrose-based solution, icodextrin and amino acids; EDEN trial: a different dextrose-based solution, icodextrin and amino acids) and followed for 6 months. Combining both studies, 251 patients were allocated to control (n=127) or intervention (n=124) across 11 countries. The primary endpoint was change in glycated hemoglobin from baseline. Mean glycated hemoglobin at baseline was similar in both groups. In the intention-to-treat population, the mean glycated hemoglobin profile improved in the intervention group but remained unchanged in the control group (0.5% difference between groups; 95% confidence interval, 0.1% to 0.8%; P=0.006). Serum triglyceride, very-low-density lipoprotein, and apolipoprotein B levels also improved in the intervention group. Deaths and serious adverse events, including several related to extracellular fluid volume expansion, increased in the intervention group, however. These data suggest that a low-glucose dialysis regimen improves metabolic indices in diabetic patients receiving peritoneal dialysis but may be associated with an increased risk of extracellular fluid volume expansion. Thus, use of glucose-sparing regimens in peritoneal dialysis patients should be accompanied by close monitoring of fluid volume status.

During the 2008 Congress of the International Society for Peritoneal Dialysis, academic nephrologists, nephrology societies, and government officials from Colombia, Brazil, Argentina, Chile, Central America, Ecuador, and Mexico participated in a roundtable discussion on the Economics of Dialysis and Chronic Kidney Disease in Latin America. The main focus was policy and health care financing. The roundtable promoted open discussion between policymakers and clinicians on how to find viable solutions to contain spending on treatment for end-stage renal disease into the future. A number of options were proposed, including early medical intervention (disease management programs) to slow the progression of chronic kidney disease in high-risk patients, promotion of pre-emptive renal transplantation, and use of the most cost-effective dialysis therapy that can be offered to a patient without compromising outcome. It was concluded that the burden of treating more patients in the future could be alleviated by wider utilization of peritoneal dialysis (PD). However, important changes in health care reimbursement systems and realignment of incentives in the region are required to support wider PD penetration.

The goal of the Dialysis Outcomes in Colombia (DOC) study was to compare the survival of patients on hemodialysis (HD) vs peritoneal dialysis (PD) in a network of renal units in Colombia. The DOC study examined a historical cohort of incident patients starting dialysis therapy between 1 January 2001 and 1 December 2003 and followed until 1 December 2005, measuring demographic, socioeconomic, and clinical variables. Only patients older than 18 years were included. As-treated and intention-to-treat statistical analyses were performed using the Kaplan-Meier method and Cox proportional hazard model. There were 1094 eligible patients in total and 923 were actually enrolled: 47.3% started HD therapy and 52.7% started PD therapy. Of the patients studied, 751 (81.3%) remained in their initial therapy until the end of the follow-up period, death, or censorship. Age, sex, weight, height, body mass index, creatinine, calcium, and Subjective Global Assessment (SGA) variables did not show statistically significant differences between the two treatment groups. Diabetes, socioeconomic level, educational level, phosphorus, Charlson Co-morbidity Index, and cardiovascular history did show a difference, and were less favorable for patients on PD. Residual renal function was greater for PD patients. Also, there were differences in the median survival time between groups: 27.2 months for PD vs 23.1 months for HD (P less than 0.001) by the intention-to-treat approach; and 24.5 months for PD vs 16.7 months for HD (P less than 0.001) by the as-treated approach. When performing univariate Cox analyses using the intention-to-treat approach, associations were with age ?65 years (hazard ratio (HR)=2.21; confidence interval (CI) 95% (1.77-2.755); P less than 0.001); history of cardiovascular disease (HR=1.96; CI 95% (1.58-2.90); P less than 0.001); diabetes (HR=2.34; CI 95% (1.88-2.90); P less than 0.001); and SGA (mild or moderate-severe malnutrition) (HR=1.47; CI 95% (1.17-1.79); P=0.001); but no association was found with gender (HR=1.03, CI 95% 0.83-1.27; P=0.786). Similar results were found with the as-treated approach, with additional associations found with Charlson Index (0-2) (HR=0.29; Cl 95% (0.22-0.38); P less than 0.001); Charlson Index (3-4) (HR=0.61; Cl 95% (0.48-0.79); P less than 0.001); and SGA (mild-severe malnutrition) (HR=1.43; Cl 95% (1.15-1.77); P less than 0.001). Similarly, the multivariate Cox model was run with the variables that had shown association in previous analyses, and it was found that the variables explaining the survival of patients with end-stage renal disease in our study were age, SGA, Charlson Comorbidity Index 5 and above, diabetes, healthcare regimes I and II, and socioeconomic level 2. The results of Cox proportional risk model in both the as-treated and intention-to-treat analyses showed that there were no statistically significant differences in survival of PD and HD patients: intention-to-treat HD/PD (HR 1.127; CI 95%: 0.855-1.484) and as-treated HD/PD (HR 1.231; CI 95%: 0.976-1.553). In this historical cohort of incident patients, there was a trend, although not statistically significant, for a higher (12.7%) adjusted mortality risk associated with HD when compared to PD, even though the PD patients were poorer, were more likely to be diabetic, and had higher co-morbidity scores than the HD patients. The variables that most influenced survival were age, diabetes, comorbidity, healthcare regime, socioeconomic level, nutrition, and education. © 2008 International Society of Nephrology.