Predictors of Early Technique Failure in Peritoneal Dialysis

Technique failure in peritoneal dialysis is a major complication of the modality and is associated with risk to patients. The first year on peritoneal dialysis is a particularly vulnerable period; just less than half of patients on peritoneal dialysis who experience technique failure do so within the first year of treatment. Published rates of early technique failure vary, but the rates range from 4.9% to 20.9%, and there have been consistent reports of the risk association with an early transfer to hemodialysis. Of the patients who switch to hemodialysis in the first year of treatment, >80% do so with a temporary vascular catheter, increasing the risk for infection, prolonged hospitalization, mortality, and increased health care costs.

The variability between studies of rates of peritoneal dialysis technique failure is attributed, in part, to the lack of a standardized definition of technique failure. The composite recommended definition of peritoneal dialysis technique is transfer to hemodialysis therapy for >30 days or death on peritoneal therapy or within 30 days of transfer to hemodialysis therapy. There have been only two studies examining risk factors for early technique failure in peritoneal dialysis and neither study used the recommended definition. Further, only a limited number of patient characteristics were included in the adjusted analyses.

At present, there is no consensus on the key risk factors and risk periods for early technique failure in peritoneal dialysis. Emily J. See, MBBS, and colleagues recently conducted a cohort study designed to analyze factors associated with the development of technique failure in the first year of peritoneal dialysis. The researchers also sought to describe the time-dependent variation in the cause of technique failure. Study results were reported in the American Journal of Kidney Diseases [2018;72(2):188-197].

The multicenter cohort study utilized data from patient records in the Australia and New Zealand Dialysis and Transplant Registry. The registry collects data from all units in Australia and New Zealand on all patients receiving renal replacement therapy (RRT). All adults ≥18 years of age who initiated peritoneal dialysis from January 1, 2000, through December 31, 2014, were included in the study (n=16,748). The cohort included patients who had previously received RRT in the form of hemodialysis or kidney transplantation. Patients were censored at the time of kidney transplantation, recovery of kidney function, loss to follow-up, or 365.25 days after peritoneal dialysis therapy initiation.

Of the 16,748 patients, 726 received a kidney transplant within the first year of peritoneal dialysis therapy, 188 recovered kidney function sufficient to cease dialysis therapy, and 13 were lost to follow-up. Median age of the cohort was 61 years, 58% were male, and 68% were white.

There were 4389 (26.2%) patients who experienced technique failure within the first year: 17.8% switched to hemodialysis therapy and 8.4% died. Those with early technique failure were more likely to be >70 years of age; be white; have body mass index (BMI) <185 kg/m2; have a history of ischemic heart disease, cerebrovascular disease, or peripheral vascular disease; or be referred late to a nephrology service.

Patients with technique failure were also less likely to be incident to RRT, to receive continuous ambulatory peritoneal dialysis, to have initiated peritoneal dialysis in 2010 through 2014, or be managed in a larger center or in New Zealand. Estimated glomerular filtration rates were comparable for patients with and without early technique failure (7.1 mL/min/1.73 m2 and 7.5 mL/min/1.73 m2, respectively).

In the multivariable competing-risk regression model, there was an association between technique failure within the first 12 months and age >70 years (subhazard ratio [SHR], 1.44; 95% confidence interval [CI], 1.31-1.58) compared with <50 years, BMI <18.5 kg/m2 (SHR, 1.46; 95% CI, 1.26-1.70) compared with BMI 18.5 to 30 kg/m2, diabetes (SHR, 1.13- 95% CI, 1.02-1.26), ischemic heart disease (SHR, 1.17; 95% CI, 1.09-1.26), cerebrovascular disease (SHR, 1.15; 95% CI, 1.05-1.25), or peripheral vascular disease (SHR, 1.14; 95% CI, 1.06-1.23).

Technique failure was more likely in patients who had previously received either ≤90 days (SHR, 1.44, 95% CI, 1.34-1.56) or >90 days (SHR, 1.68; 95% CI, 1.55-1.82) of RRT compared with incident patients, been referred late to nephrology care (SHR, 1.14; 95% CI, 1.06-1.23), or managed in a medium-size center compared with a large unit (SHR, 1.16; 95% CI, 1.09-1.24). Compared with white race, there was an association between Asian or other race and a lower risk for early technique failure; there was no association with Aboriginal or Torres Strait Islander or Maori or Pacific Islander race.

There was no association between BMI >30 kg/m2 and early technique failure. Compared with initiating peritoneal therapy between 2000 to 2004, there was an association between initiating therapy between 2010 through 2014 and reduced risk. There was also an association between continuous ambulatory peritoneal therapy and reduced risk of technique failure.

During the first year of peritoneal dialysis therapy, the risk of technique failure due to death or infection was consistent; however, mechanical and other causes accounted for a greater number of cases of technique failure within the first 9 months of treatment.

Citing limitations to the study, the authors noted that technique failure is a complex clinical issue and the use of registry data led to a lack of some demographic, clinical, and laboratory variables. There were also no data available on management protocols and training practices in place in individual units, use of disconnect systems, catheter type, and timing between catheter insertion and start of therapy, creating the possibility of residual confounding.

“Several modifiable and nonmodifiable factors are associated with early technique failure in peritoneal dialysis. Targeted interventions should be considered in high-risk patients to avoid the consequences of an unplanned transfer to hemodialysis therapy or death,” the researchers said.

Takeaway Points

  1. Technique failure in the first year of peritoneal dialysis therapy is associated with increased risk for infection, prolonged hospitalization, mortality, and rising health care costs.
  2. Researchers conducted a multicenter cohort study to examine factors associated with the development of early technique failure and describe time-dependent variation in the cause of technique failure within the first year of peritoneal dialysis.
  3. Factors associated with increased risk for early technique failure included age >70 years, diabetes or vascular disease, prior renal replacement therapy, late referral to nephrology service, or being managed in a smaller center.