Evolution of peritoneal dialysis in France since 2018 and during the «COVID years. RDPLF data report

Abstract

Almost all (99%) of the patients treated by peritoneal dialysis in France are registered in the RDPLF database. Apart from any statistical analysis aimed at interpreting the figures, this work is a report of the raw data observed in the population of Stage V renal failure patients treated by peritoneal dialysis since the beginning of the Covid epidemic and in the two years preceding it. Since the beginning of the epidemic, these data seem to show a decrease in the incidence of peritoneal dialysis treatment and an increase in transfers to center-based hemodialysis. In addition, there has been a decrease in the number of registrations on the transplant waiting list and a decrease in the number of transplants. While the temporary decrease in transplantation activity may be explained by the disorganization caused by the epidemic in the hospitals, a decrease in the number of indications for home dialysis probably merits further reflection on its causes, especially since this result is in contrast with trends in other countries. This report is intended to encourage more precise studies on the value of home dialysis during the epidemic.

INTRODUCTION

The occurrence of the SARS-Cov2 epidemic has had dramatic consequences on the morbidity and mortality of patients with stage-V chronic kidney disease or transplanted patients. In France, the evolution of the rate of contamination and lethality is communicated weekly by the Agence de Biomédecine and the REIN registry [1]. While many teams around the world have recommended prioritizing home dialysis and particularly peritoneal dialysis (PD) [2];[3];[4], we thought it was important to investigate the situation in France.

We report the evolution of PD in France since 2018. This is raw data extracted from the RDPLF database, specifically from its main module that represents 99% of patients treated with PD in France. We present this information in the form of tables and graphs, without interpretation, with our aim being to provide the reader with immediately accessible general information that can be used as a support for oral presentations and as a basis for reflection for future work. All tables and figures may be freely used provided that their origin is cited (reference of this article or at least its DOI).

I - PROFILE OF PATIENTS TREATED WITH PERITONEAL DIALYSIS IN MAINLAND FRANCE IN 2021

Prevalent patients in the year (Table I and Figure 1)

Sexe ratio : women : 36,4 % Men : 63,6 %

Table I.Total number of patients treated at least one day during the year

	All patients	CAPD	APD
Numbers	4110	2568	1542
Age	66,2±16,2	70,6±14,2	58,9±16,8

Figure 1.Age distribution of PD patients treated in 2021

Diabetes status

44.8% of patients treated with peritoneal dialysis in metropolitan France in 2021 had diabetes. The distribution of patients according to diabetic status and treatment of their diabetes is summarized in Table II.

Among diabetic patients on insulin, 98.7% were on subcutaneous insulin and 1.34% on intraperitoneal insulin.

Table II.Distribution of diabetic status among patients treated with PD in 2021

Diabetic status	Percentages
Non-diabetics	65,28%
Diabetics treated with diet	4,21%
Orally treated diabetics	6,89%
Diabetics on subcutaneous insulin	23,31%
Diabetics on intraperitoneal insulin	0,32%

Autonomy and PD type (CAPD vs APD)

In 2021, 43.7% of patients required assistance to perform their peritoneal dialysis; this assistance is mostly provided by private nurses at home, paid by national health insurance (Table III).

Table III.Breakdown of patients by level of autonomy

Autonomy	Numbers	Percentages
Autonomous	2314	0.56302
Nurse assisted	1560	0.37956
Family assisted	213	0.05182
Assisted (unspecified)	21	0.00511
Missing data	2	0.00049

Table IV.Profile of PD patient;s according to type of treatment

	CAPD	APD
Number/%	1748 (61%)	1095 (49%)
Age	70.7±13,5	60.5±15,1
Sex ratio (F/M)	38.4%/61.6%	33.6%/66.7%
Diabetics	40.6%	24.7%
Autonomous	45.1%	81.9%
Nurse assisted	50.3%	13.35%
Family assisted	4.6%	4.75%

CAPD patients are older than those on APD, more often diabetic and 50% require nurse assistance, contrary to APD where the majority (nearly 82%) are autonomous (Table IV).

Partition of PD techniques at 31 December 2021

On December 31, 2021, 2724 patients were treated by PD in metropolitan France, 1714 (63%) in CAPD and 1010 (37%) in APD.

In CAPD, the age was 70.6 years±13.6, the sex ratio was 38% female and 61.7% male. In APD the age was 60 years±16.2 and the sex ratio was 33.6% women and 66.4% men.

Figure 2 shows the distribution of the PD technique used according to age.

Figure 2.Age distribution of patients treated with CAPD or APD, on December 2021. Percentages in a technique, CAPD or APD, are calculated in relation to the total number in the technique.

Peritoneal infections in 2021

The latest ISPD guidelines recommend that peritonitis recidives should not be counted in the calculation of the peritonitis rate; nevertheless, clinical recurrences are indeed additional stresses for patients and their peritoneal membrane, so we report the results with and without counting recurrences. All calculations were computed using the method recommended by ISPD [5].

- Rate of peritoneal infection (including recidives): 1 episode every 37.8 months or 0.32 episodes per year

- Rate of peritoneal infection (excluding recidives): 1 episode every 40 months or 0.30 episodes per year

TheTable V summarizes the distribution of organisms cultured in 2021. Multiple germ peritonitis is not detailed but is the subject of an accepted work in the journal Nephrology Dialysis and Transplantation (in press) [6].

The percentage of aseptic peritonitis was 15.1%, in line with international recommendations. However, it should be remembered that the rate of culture-negative peritonitis may vary considerably between centers, as we have previously shown [7].

Table V.Distribution of organisms identified in peritonitis occurring in 2021.

Germs	Numbers	Percentages
Gram Plus cocci	387	44,7%
Gram negative Bacilli	231	26,7%
Gram plus bacilli	39	4,5%
Negative cultures	131	15,1%
Multiple germs	62	7,2%
Yeasts	10	1,2%
Gram less cocci	5	0,6%
Various	1	0,1%

Waiting times for 2021 transplanted patients (Table VI)

Table VI.205 patients treated by peritoneal dialysis were transplanted during the year. Their duration of treatment before transplantation varied from less than 1 year to more than 5 years. Slightly less than 50% were transplanted before 2 years of treatment. The percentages are calculated in relation to the total number of transplant recipients.

Duration of treatment before transplant	Numbers	Percentages
0-1 years	27	13,2%
1-2 years	73	35,6%
2-3 years	47	22,9%
3-4 years	24	11,7%
4-5 years	14	6,8%
5 years and more	20	9,8%

II- Profiles and evolution of patients treated with PD in metropolitan France from January 2018 to June 2022

We observe a relative stability in the number of new peritoneal dialysis patients until the first half of 2020 and, after a transitory increase at the beginning of 2021, the number of new patients starting PD decreases steadily, especially men until the first half of 2022. (Figure 3).

Figure 3.Incident patients per semester (S)

This is reflected by an identical evolution of the number of prevalent patients at the end of each semester ( Figure 4.)

Figure 4.Patients in treatment on the last day of each semester.

Evolution of PD dropouts and their reasons

Since the beginning of 2020, the trend observed is an increase in the number of transfers from peritoneal dalysis to hemodialysis in centers, associated with a decrease in transplantation ( Figure 5. and Table VII ; Table VIII)

Figure 5.Six-monthly trends in causes of peritoneal dialysis discontinuation. Percentages are calculated in relation to the total number of patients discharged from PD in each period

Table VII.Six-monthly evolution of causes of peritoneal dialysis discontinuation. Percentages are calculated in relation to the total number of patients discharged from PD in each period.

Semesters	2018/1	2018/2	2019/1	2019/2	2020/1	2020/2	2021/1	2021/2	2022/1
Deaths	256 (41,8%)	233 (37,7%)	256 (39,0%)	236 (37,9%)	257 (39,4%)	262 (42,0%)	254 (39,7%)	226 (36,4%)	269 (40,9%)
Transfers to HD	225 (36,8%)	249 (40,3%)	248 (37,8%)	259 (41,6%)	292 (44,8%)	245 (39,3%)	289 (45,2%)	274 (44,1%)	259 (39,4%)
Kidney transplantation	127 (20,8%)	133 (21,5%)	144 (22,0%)	123 (19,8%)	101 (15,5%)	106 (17,0%)	87 (13,6%)	114 (18,4%)	121 (18,4%)
Renal function recovery	4 (0,7%)	3 (0,5%)	8 (1,2%)	4 (0,6%)	2 (0,3)	11 (1,8%)	10 (1,6%)	7 (1,1%)	8 (1,2%)

Table VIII. Six-monthly evolution of the causes of transfers from PD to in-center HD. Percentages are calculated in relation to the total number of patients transferred to HD center in each period.

Semesters	2018/1	2018/2	2019/1	2019/2	2020/1	2020/2	2021/1	2021/2	2022/1
Inadequat dialysis	30,4%	35,3%	27,8%	29,7%	29,3%	29,5%	34,4%	29,5%	37,5%
Peritonitis	13,8%	10,4%	12,1%	13,5%	13,9%	13,1%	8,5%	14,4%	17,4%
Catheter problem	12,1%	7,2%	11,3%	11,2%	9,9%	9,2%	6,9%	10,5%	4,5%
Loss of ultrafiltration	9,4%	11,6%	11,7%	11,2%	9,5%	7,6%	8,5%	8,8%	7,6%
Malnutrition	0,9%	1,2%	0,0%	1,9%	1,0%	2,0%	0,3%	0,7%	0,4%
Other	33,5%	34,1%	37,1%	32,4%	35,7%	34,3%	34,8%	31,6%	30,3%
COVID	0,0%	0,0%	0,0%	0,0%	0,7%	4,4%	6,6%	4,6%	2,3%

Evolution of the number of registrations on the transplant waiting list

2018: 372

2019: 381

2020: 325

2021: 310

Supposed causes of COVID-19 contamination

Only clinically symptomatic and proven COVID-19 infections were counted. Cases of COVID-19 infections diagnosed with a positive PCR test without clinical signs were not counted.

645 episodes of symptomatic COVID-19 were reported. 95 times, the cause was not recorded; in the remaining 553, COVID-19 patients were asked to indicate what they considered most likely to have caused the contamination. The suspected causes are summarized in the table below. In 34% of the cases, the patient did not know the probable source, but contamination by a family member and during a hospital stay for consultation or hospitalization came in first and second place (Table IX).

Table IX.Distribution of suspected causes of COVID-19 contamination when the item was recorded in the database (this item was not filled in exhaustively and should be interpreted with caution)

Source of contamination	Numbers	Percentages
Unknown	188	34,0%
Family	203	36,7%
External Visitor	25	4,5%
Nursing home	38	6,9%
Hospitalization	83	15,0%
Consultation	7	1,3%
Work	9	1,6%

Synthesis

These raw results show that, in metropolitan France, there has been no increase in the prescription of PD since the beginning of the SARS-Cov2 epidemic, contrary to what has been reported or observed in other countries. In addition, there appears to be an increase in the number of transfers from PD to in-center hemodialysis with a high and increasing proportion of transfers for inadequat dialysis. There was also a slight decrease in the number of new registrations on the transplant waiting list.

Suggestions for future work

Upon request, anonymized exports of the RDPLF database can be made available to teams wishing to study the above figures in more detail or to use them as inspiration for future research. The Home Dialysis Bulletin would, should they wish it, allow them a quick publication if their work is accepted after critical peer review.

- A national survey would be useful to identify the causes of this decrease in the incidence of PD during the period of theoretical risk of nosocomial contamination, whereas other countries have a different evolution..

- An identical study by region would also be necessary.

- The risk of contamination should also be differentiated according to autonomy and type of assistance.

- the high frequency of transfers due to inadequat dialysis should be analyzed by taking into account the association with the practice of empty peritoneal cavity periods, or the decrease in the number of dialysis exchanges or interruptions during the week.

- we preferred, for this report, in order to be nationally representative, to study only PD patients, as 99% of whom are included in the database. A similar study should be done for patients treated by home hemodialysis. Nevertheless, a preliminary Belgian study at the beginning of the COVID period seemed to also show a decrease in the number of patients starting a home hemodialysis treatment at the same period [8]. Non-medical organizational factors may explain these results. An opposite trend has been recently observed in United States [9].

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