Renal M

ed

icin

e

David JohnsonPrincess Alexandra Hospital

Brisbane, Australia

A Comparison of APD A Comparison of APD vs CAPD on Patient vs CAPD on Patient

OutcomesOutcomes

Badve S, Hawley CM, Mudge DW,Rosman JB, Brown FG, Johnson DW

?CAPD APD

APD vs CAPD Use in Australia

0200400600800

100012001400160018002000

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

CAPDAPD

5% 7% 11%14%

Num

ber

22%27%

33%39% 41% 43%

APD Use: USA vs Aust vs UK

0

10

20

30

40

50

60

70

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

Per

cent

of

PD

Pat

ient

s

USAAustraliaUK

Traditional APD Indications

Enhance small solute clearances Enhance ultrafiltration (esp high transport) Social reasons

– Employment

– School

– Care of elderly/debilitated patients

Mechanical problems– Hernias, leaks, back pain, body image

Reduce peritonitis rates

Rabindranath NDT (In press)

N=139

Ultrafiltration: APD vs CAPD

0

200

400

600

800

1000

1200

1400

1600

1800U

F (

ml/

da

y)

P=NS

N=25

Bro et al Perit Dial Int 19:526-33,1999

CAPD APD

QOL: APD vs CAPD

Scale Scores Parameter

APD (n=12)

CAPD (n=13)

P Value

Social Time 3.21.2 1.20.5 0.0005

Physical discomfort 1.91.0 2.21.3 NS

Emotional discomfort 1.81.0 2.21.4 NS

Anorexia 2.81.3 2.90.6 NS

Sleep Problems 2.30.9 1.81.3 NS

Bro et al Perit Dial Int 19:526-33,1999

RRF Loss: APD vs CAPD

0

1

2

3

4

5

6

7

0 6 12

Follow-up (months)

Res

idua

l Cl C

r (m

l/min

)

CAPD APD

Hufnagel et al Nephrol Dial Transplant 14:1224-8, 1999

* ** p<0.05n=36

US Study

Survival Technique Survival

HR P HR P

Age 1.04 <0.0001 1.007 <0.0001

PD 1st 0.725 <0.0001 0.789 <0.0001

Diabetes 0.701 <0.0001 0.852 <0.0001

Centre 0.94 <0.0001

APD 0.845 <0.0001

Mujais and Story Kidney Int 70:S21-6, 2006

USA

Aim

To compare patient survival and death-censored technique survival in patients treated with APD vs CAPD using ANZDATA

Methods

All ANZ patients starting PD between April 1, 1999 and March 31, 2004

Complete follow-up 1° outcomes death and death-censored technique

failure Survival time calculated from date of

commencement of each PD episode to the date of death, transfer to hemodialysis, transplantation, loss of follow up, or March 31, 2004.

Statistics Kaplan-Meier and multivariate Cox proportional

hazards model analyses PD modality included as a time-dependent

covariate Analyses stratified according to initial or

subsequent episodes of PD Used a conditional risk set model for multiple

failure data Standard errors calculated using robust variance

estimation for the correlated data, clustered according to the centre of initial treatment

Baseline Characteristics

Characteristic All patients CAPD (APD never) APD ever Number of observations 10391 5067 (48.8%) 5324 (51.2%) Male gender a 5549 (53.4%) 2567 (50.7%) 2982 (56%) Age (years) a 58 ± 16 60 ± 14.5 56.1 ± 17.1

Racial origin a

Caucasians 7388 (71.1%) 3435 (67.8%) 3953 (74.3%) Aboriginal, Torres Strait Islander 557 (5.4%) 281 (5.6%) 276 (5.2%) MPI, Cook Islander, Samoan, Tongan 1364 (13.1%) 812 (16%) 552 (10.4%) Asian 922 (8.9%) 459 (9.1%) 463 (8.7%) Others 160 (1.6%) 80 (1.6%) 80 (1.5%)

Chronic lung disease 1360 (13.1%) 695 (13.7%) 665 (12.5%) Coronary artery disease a 3880 (37.3%) 2042 (40.3%) 1838 (34.5%) Peripheral vascular disease 2621 (25.2%) 1304 (25.7%) 1317 (24.7%) Cerebrovascular disease a 1449 (13.9%) 768 (15.2%) 681 (12.8%) Diabetes mellitus a 3832 (36.9%) 2073 (40.9%) 1759 (33%) Smoking status b Never 5065 (48.7%) 2410 (47.6%) 2655 (49.9%) Former 4027 (38.8%) 1993 (39.3%) 2034 (38.2%) Current 1299 (12.5%) 664 (13.1%) 635 (11.9%) Body mass index (kg/m2) a 26 ± 5.2 26.3 ± 5.2 25.7 ± 5.2

≤ 19.9 1038 (10%) 427 (8.4%) 611 (11.5%) 20-24.9 3830 (36.9%) 1818 (35.9%) 2012 (37.8%) 25-29.9 3420 (32.9%) 1718 (33.9%) 1702 (32%) ≥ 30 2094 (20.2%) 1102 (21.8%) 992 (18.7%) D-P Cr 4h a 0.69 ± 0.12 0.69 ± 0.12 0.70 ± 0.12 Peritoneal membrane transport status a Low 510 (4.9%) 263 (5.2%) 247 (4.6%) Low average 2946 (28.4%) 1550 (30.6%) 1396 (26.2%) High average 5200 (50%) 2485 (49%) 2715 (51%)

Patient Survival0.

000.

250.

500.

751.

00

0 1 2 3 4 5Years

CAPD APD

Patient survival by PD modality

Badve et al Kidney Int (In press)

N=4128

AHR 1.03 (95% CI 0.86-1.24) p=0.72

Death-Censored Technique Survival

0.00

0.25

0.50

0.75

1.00

0 1 2 3 4 5Years

CAPD APD

Death-censored technique survival by PD modality

N=4128

AHR 1.08 (95% CI 0.91-1.27) p=0.38

Badve et al Kidney Int (In press)

Death-Censored Technique Survival after 1st Failure Occurrence

0.00

0.25

0.50

0.75

1.00

0 1 2 3 4 5Years

CAPD bef ore the 1st f ailure APD before the 1st f ailure

CAPD af ter the 1st f ailure APD af ter the 1st f ailure

Kaplan-Meier Graph for Death Censored Technique survival

Badve et al Kidney Int (In press)

Propensity Score: Survival

Model HR 95%CI P

Unadjusted 0.92 0.77 – 1.09 0.336

Adjusted 1.03 0.86 – 1.24 0.723

Adjusted+PS 0.84 0.68 – 1.03 0.09

Badve et al Kidney Int (In press)

PS: Death-Censored Technique Survival

Model HR 95%CI P

Unadjusted 1.09 0.92 – 1.30 0.319

Adjusted 1.08 0.91 – 1.27 0.381

Adjusted+PS 1.07 0.91 – 1.27 0.381

Badve et al Kidney Int (In press)

Conclusions

APD results in similar patient survival and technique success rates compared to CAPD in 4,128 ANZ PD patients followed over 6,982 person-years

There is currently no strong clinical evidence, except for lifestyle considerations, for favouring APD over CAPD