Htay Htay, Cho Yeoungjee, Pascoe Elaine M, Darssan Darsy, Nadeau-Fredette Annie-Claire, Hawley Carmel, Clayton Philip A, Borlace Monique, Badve Sunil V, Sud Kamal, Boudville Neil, McDonald Stephen P, Johnson David W
Due to the number of contributing authors, the affiliations are provided in the Supplemental Material .
Clin J Am Soc Nephrol. 2017 Jul 7;12(7):1090-1099. doi: 10.2215/CJN.12321216. Epub 2017 Jun 21.
Technique failure is a major limitation of peritoneal dialysis. Our study aimed to identify center- and patient-level predictors of peritoneal dialysis technique failure.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: All patients on incident peritoneal dialysis in Australia from 2004 to 2014 were included in the study using data from the Australia and New Zealand Dialysis and Transplant Registry. Center- and patient-level characteristics associated with technique failure were evaluated using Cox shared frailty models. Death-censored technique failure and cause-specific technique failure were analyzed as secondary outcomes.
The study included 9362 patients from 51 centers in Australia. The technique failure rate was 0.35 (95% confidence interval, 0.34 to 0.36) episodes per patient-year, with a sevenfold variation across centers that was mainly associated with center-level characteristics. Technique failure was significantly less likely in centers with larger proportions of patients treated with peritoneal dialysis (>29%; adjusted hazard ratio, 0.83; 95% confidence interval, 0.73 to 0.94) and more likely in smaller centers (<16 new patients per year; adjusted hazard ratio, 1.10; 95% confidence interval, 1.00 to 1.21) and centers with lower proportions of patients achieving target baseline serum phosphate levels (<40%; adjusted hazard ratio, 1.15; 95% confidence interval, 1.03 to 1.29). Similar results were observed for death-censored technique failure, except that center target phosphate achievement was not significantly associated. Technique failure due to infection, social reasons, mechanical causes, or death was variably associated with center size, proportion of patients on peritoneal dialysis, and/or target phosphate achievement, automated peritoneal dialysis exposure, icodextrin use, and antifungal use. The variation of hazards of technique failure across centers was reduced by 28% after adjusting for patient-specific factors and an additional 53% after adding center-specific factors.
Technique failure varies widely across centers in Australia. A significant proportion of this variation is related to potentially modifiable center characteristics, including peritoneal dialysis center size, proportion of patients on peritoneal dialysis, and proportion of patients on peritoneal dialysis achieving target phosphate level.
技术失败是腹膜透析的一个主要限制因素。我们的研究旨在确定腹膜透析技术失败的中心层面和患者层面的预测因素。
设计、地点、参与者及测量方法：利用澳大利亚和新西兰透析与移植登记处的数据，纳入了2004年至2014年在澳大利亚开始进行腹膜透析的所有患者。使用Cox共享脆弱模型评估与技术失败相关的中心层面和患者层面特征。将死亡删失的技术失败和特定原因的技术失败作为次要结局进行分析。
该研究纳入了来自澳大利亚51个中心的9362名患者。技术失败率为每名患者每年0.35次（95%置信区间，0.34至0.36），各中心之间存在7倍的差异，这主要与中心层面特征相关。在接受腹膜透析治疗的患者比例较高的中心（>29%；调整后的风险比，0.83；95%置信区间，0.73至0.94），技术失败的可能性显著降低；而在较小的中心（每年<16名新患者；调整后的风险比，1.10；95%置信区间，1.00至1.21）以及达到目标基线血清磷酸盐水平的患者比例较低的中心（<40%；调整后的风险比，1.15；95%置信区间，1.03至1.29），技术失败的可能性更高。对于死亡删失的技术失败，观察到了类似的结果，只是中心磷酸盐达标情况与技术失败无显著关联。因感染、社会原因、机械原因或死亡导致的技术失败与中心规模、腹膜透析患者比例和/或磷酸盐达标情况、自动腹膜透析暴露、艾考糊精使用及抗真菌药物使用存在不同程度的关联。在调整患者特异性因素后，各中心技术失败风险的差异降低了28%，在加入中心特异性因素后又降低了53%。
在澳大利亚，各中心之间技术失败的差异很大。这种差异的很大一部分与潜在可改变的中心特征有关，包括腹膜透析中心规模、腹膜透析患者比例以及腹膜透析患者达到目标磷酸盐水平的比例。
