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FACULTY OF HEALTH
Matthew JoseMBBS, FRACP, PhD, FASN, AFRACMA
Royal Hobart Hospital
Update in Peritoneal dialysis
I pay my respects to the traditional owners of
this land, the Larrakia people, and to their elders
past, present and emerging.
2FACULTY OF HEALTH
Conflicts of Interest
– Member International Society of Peritoneal Dialysis (ISPD)
– Chairperson, PD working group of AKTN
(Australasian Kidney Trials Network)
– Chairperson, ANZDATA Steering Committee
(Australia and New Zealand Dialysis and Transplant Registry)
– No commercial conflicts of interest
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ANZDATA Working Groups:
Advanced trainee membership 2017
HD – Emily See
PD – Jenny Chen
Transplant – Eric Au
Paediatrics – Jean Koh
PROMs – Nicole Lioufas
Indigenous – no nomination
Learning Objectives
– Know the recent publications on PD
– Recognise clinical practice variation
– Recognise variation in clinical outcomes
– Know the current resources available to assist
optimising PD outcomes for both patients and
staff
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Peritoneal Dialysis in Australia
and New Zealand:
Current practice and outcomes
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0
20
40
60
80
100
Pe
rce
nt
QLD NSW/ACT VIC TAS SA NT WA NZ
2016 ANZDATA Annual Report, Figure 2.6
at end of 2015
Dialysis Modality by State
PD Home HD Other HD
ANZDATA 2016 Annual report
Number of Patients=2514
0
5
10
15
20
25
Pe
rce
nt
0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+
2016 ANZDATA Annual Report, Figure 5.4
Australia 2015
Age (%) of current peritoneal dialysis patients
0.00
0.25
0.50
0.75
1.00
Pa
tie
nt S
urv
iva
l
0 1 2 3 4 5Years
Age
<40 (1255)
40-59 (2655)
60-74 (3090)
=75 (1441)
2016 ANZDATA Annual Report, Figure 5.11
2004 - 2015Censored for transplant - Australia
Patient survival - peritoneal dialysis at 90 days
0.00
0.25
0.50
0.75
1.00
Te
chn
iqu
e S
urv
iva
l
0 1 2 3 4 5Years
Age
<40 (1255)
40-59 (2655)
60-74 (3090)
=75 (1441)
2016 ANZDATA Annual Report, Figure 5.14
2004 - 2015Censored for transplant - Australia
Technique survival - peritoneal dialysis at 90 days
0
50
100
150
200
250
Nu
mb
er
of P
atien
ts
0 1 2 3 4 5 6 7 8 9 =10Years on PD
2016 ANZDATA Annual Report, Figure 5.1
Prevalent PD patients Australia 31 Dec 2015
Time on peritoneal dialysis
Proportion of PD patients in unit
Darwin 2006
13
“Eminence-based” Medicine
V
Evidence-based Medicine
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PD pathway
14
Pt selection Catheter
insertion
PD training Novice PD Veteran PD
Clinical Governance
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http://academy.theisn.org
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PDI 2016;
PDI 2017; 37 (2): 141-154
Li et al Perit Dial Int 2016; 36 (5): 481-508
PDI 2017; 37(4): 362-374
PD pathway
22
Pt selection
Patient selection
23
Mr T.D
male
50yo
Rural location
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24
PD: Making it happen
25
Pt-targeted pre-dialysis education:
• Increases likelihood of choosing PD OR 2.2 (1.07-4.32)
• Increases likelihood of receiving PD OR3.50 (2.82-4.35)
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Devoe et al, AJKD 2016; 68(3): 422
PD pathway
26
Pt selection Catheter
insertion
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Preventing infections in PD: Screening for S.aureus
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Preventing infections in PD: what do we actually do?Screening for S.aureus
64% screen for S.aureus, but treatment length is variable
Campbell et al, PDI 2017; 37(2): 191FACULTY OF HEALTH
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Preventing infections in PD: what do we actually do?
Antibiotics at the time of catheter insertion
Mostly cephalosporin at time of surgeryCampbell et al, PDI 2017; 37(2): 191FACULTY OF HEALTH
Insertion of PD Catheters: Who & How?
Surgeon? Nephrologist?
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Shanmugalingam et al, PDI 2017; 37(4): 434
Insertion of PD Catheters: Who & How: Liverpool group
140 of 171 (82%) successful
171 of 217 (79%)
percutaneous
Shanmugalingam et al, PDI 2017; 37(4): 434
Insertion of PD Catheters: Who & How: Liverpool group
How often should you flush the catheter: actual practice
34Y.Cho et al, Periton. Dial Int 2017 in pressFACULTY OF HEALTH
When can you start PD?Royal Brisbane & Rockhampton
– RCT, n=122 Catheter leak
– Week 1 28.2%
– Week 2 9.5%
– Week 4 2.4% P=0.001 (ITT)
Ranganathan et al, PDI 2017; 37 (4): 420
Urgent start PD (within 2 weeks): Higher leakage & catheter migration
See et al, PDI 2017; 37(4): 414
Single centre, matched case control study (not RCT)
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Urgent start PD (within 2 weeks):but overall outcomes no different
See et al, PDI 2017; 37(4): 414FACULTY OF HEALTH
PD pathway
38
Pt selection Catheter
insertion
PD training
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Factors the impact on PD success
39FACULTY OF HEALTH
Jose et al, Nephrology 2011
23.7%
26.3%
13.2%
15.8%
21.1%
On average, how many hours does your unit spend on training a new PD nurse to become
competent in training PD patients?
<15 hours
15-39 hours
40-69 hours
70-99 hours
100+ hours
Boudville et al, Nephrology 2017 (in press)
14.3%
54.3%
17.1%
14.3%
What is the average duration of patient training prior to PD initiation at home?
2-3 days per patient
4-5 days per patient
6-7 days per patient
>7 days per patient
Boudville et al, Nephrology 2017 (in press)
PD training practices by PDOPPS country164 facilities Australia Canada Japan UK US
Number of facilities 14 20 26 32 68
When training occurs
Prior to PD catheter insertion 7% 5% 62% 3% 3%
1 week after PD catheter insertion 0% 30% 27% 9% 19%
2-3 weeks after PD catheter insertion 64% 65% 0% 72% 63%
Other 29% 0% 12% 16% 15%
Training location
Facility only 43% 84% 100% 31% 53%
Combination of home and facility 57% 16% 0% 50% 47%
Home only 0% 0% 0% 19% 0%
Duration of training, days
2-3 15% 22% 39% 39% 14%
4-5 69% 56% 17% 52% 29%
6-7 8% 17% 13% 10% 30%
>7 8% 6% 30% 0% 27%
Figueiredo et al. ASN oral abstract (2016)
PD training practices by PDOPPS country
Australia Canada Japan UK US
Number of facilities 14 20 26 32 68
Final training assessment
Procedure demonstration 93% 100% 100% 100% 100%
Written test 29% 30% 8% 9% 87%
Oral test 50% 40% 24% 34% 69%
Other 7% 5% 0% 3% 10%
Number of nurses training one patient
One nurse 64% 95% 28% 81% 97%
Several nurses 36% 5% 72% 19% 3%
Figueiredo et al. ASN oral abstract (2016)
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INSERT FACULTY NAME IN FOOTER 45
Education
level
Hours of
Training
Centre size Timing of
Training
Figueiredo et al, PDI 2016
Figueiredo et al, PDI 2016
A Targeted Education ApproaCH toimprove Peritoneal Dialysis outcomes
The HOME Network &
AKTN PD Working Group
PD pathway
49
Pt selection Catheter
insertion
PD training Novice PD
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Patient perspectiveson prevention and treatment of peritonitis
Campbell et al, PDI 2016; 36(6): 631
Exit site care
2017
Worth reading…......
Preventing infections in PD: what do we actually do?
Exit site care
Campbell et al, PDI 2017; 37(2): 191
Preventing infections in PD: what do we actually do?Antifungal prophylaxis
Campbell et al, PDI 2017; 37(2): 191
Preventing Peritonitis: Fluid choice
0
20
40
60
80
100
Pe
rce
nt
CAPD APD
NT
NS
W/A
CT
VIC
QL
D
SA
WA
TA
S
NZ
NT
NS
W/A
CT
VIC
QL
D
SA
WA
TA
S
NZ
Proportions not presented if <10 patients
2016 ANZDATA Annual Report, Figure 5.7
Prevalent patients December 2015
Icodextrin use by state and country
Yes
No
Icodextrin
2014
Li et al Perit Dial Int 2016; 36 (5): 481-508
PD pathway
60
Pt selection Catheter
insertion
PD training Novice PD Veteran PD
Clinical Governance
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Clinical Governance
Performance Indicators – HD & PD
Identified hospital report - Dialysis
Data 2009-2014
Dialysis hospital report, Jan 2016
KPIs and uptake of PD: Victoria
Toussaint et al, PDI 2017; 37(2): 198
KPI-3: Proportion of dialysis patients who are 35% dialyzing at
home, both incident and (incident and prevalent rates prevalent)
Clinical Practice Variation:Proportion of PD patients in unit
Clinical practice variation: Evidenced-basedEminence-basedExperience-based
– Local practice patterns differ in individual renal units
– Lack of high quality evidence for clinical nephrology practice
– Lack of clinical trials
66
“Albatross” model
Each renal unit doing
its’ own thing
Clinical practice variation: observational data
6
12
18
36
Pa
tie
nt-
mo
nth
s p
er
ep
iso
de
0
.5
1
1.5
2
Ep
iso
de
s p
er
ye
ar
(95
% C
I)
0 20 40 60Treating unit
Excludes units with <10 person-years PD over 2006-2015
2016 ANZDATA Annual Report, Figure 5.25
By treating unit, Australia 2006-2015
PD peritonitis rate
QLD
NSW
ACT
VIC
TAS
SA
NT
WA
12
15
18
20
24
30
Pa
tie
nt-
mo
nth
s p
er
ep
iso
de
.4
.5
.6
.7
.8
.9
Ep
iso
de
s p
er
ye
ar
(95
% C
I)
2016 ANZDATA Annual Report, Figure 5.23
By state, Australia 2006-2015
PD peritonitis rate
Facility peritonitis rates*
Perl et al. ASN oral abstract (2016)
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6A/NZ Canada Japan United Kingdom United States
Peritonitis rate (95% CI), events per patient year
Rank
*Restricted to facilities with at least 5 patient years of follow-up (n=79)
71
It’s your fault
Variation: We often blame the patient
72FACULTY OF HEALTH
A greater use of PD = less peritonitis
73Nadeau-Fredette et al, PDI 2016; 36: 509-518FACULTY OF HEALTH
Centre Variation in Peritonitis Rates
Htay H et al, Clin J Am Soc Nephrol 2017; 12(7): 1090
16% patient
34% centre
Unadjusted
Patient-adjusted
Facility-adjusted
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Centre Variation in Peritonitis Cure
.8.9
11
.11
.2
Odd
ra
tio
0 10 20 30 40 50Center rank
Unadjusted
Patient-adjusted
Facility-adjusted
9% patient
66% centre
Htay H et al, unpublishedFACULTY OF HEALTH
Centre Variation in Technique Failure
.6.8
11
.21
.41
.6
Haza
rd R
atio
0 10 20 30 40 50Center rank
28% patient
53% centre
Htay H et al, Clin J Am Soc Nephrol 2017; 12(7): 1090FACULTY OF HEALTH
Collaboration:
to create new knowledge
Individual unit practice Collaboration between units
“Albatross Model” “Duck model” (flying-V)
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18
20
24
30P
atie
nt-
mo
nth
s p
er
ep
iso
de
.3
.4
.5
.6
.7
Ep
iso
de
s p
er
ye
ar
(95
% C
I)
2005 2007 2009 2011 2013 2015
2016 ANZDATA Annual Report, Figure 5.22
Australia 2006-2015
PD peritonitis rate
PD pathway
81
Pt selection Catheter
insertion
PD training Novice PD Veteran PD
Clinical Governance
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82
A good outcome?
83
www.songinitiative.org
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Acknowledgements
• Professor David Johnson
• Professor Josephine Chow
• Professor Neil Boudville
• Dr Yeoungjee Cho
• PD Nursing staff
• many New Zealanders
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