Reasons and outcome of patients transferred from hemodialysis to peritoneal dialysis in a Sub-Saharan environment: example of the Aristide Le Dantec University Hospital in Dakar

Abstract

Introduction:

Few data are available in the literature regarding patients with end-stage renal disease initially treated with chronic hemodialysis and then transferred to peritoneal dialysis. The aims of this study were to evaluate the reasons for transferring patients from chronic hemodialysis to peritoneal dialysis and monitor their outcome in peritoneal dialysis.

Patients and Methods:

A retrospective, descriptive and analytical study over 17 years, conducted at the peritoneal dialysis unit of the Aristide Le Dantec University Hospital. Included were patients over 18 years of age in chronic hemodialysis for at least 3 months, then transferred to peritoneal dialysis. Data were collected from medical records.  

Results: Twenty-six patients were collected. The average age at initiation of peritoneal dialysis was 52.19±15.37 years. The sex ratio was 0.62. The main causal nephropathy was hypertensive nephropathy (46.2%). The reasons for transfer were personal choice (50%), vascular access problems (42.3%), hemodynamic intolerance (3.8%) and cardiovascular instability (3.8%). Concerning the outcome: 52.2% of patients died, 43.5% returned to hemodialysis and 4.3% had a kidney transplant. The average survival was 503,000±108,343 days. Female gender and transient vascular access were risk factors for mortality of transferred patients (OR=0.043 95% CI [1.085; 148.243] p=0.045) and (OR=0.047 95% CI [1.035; 112.840] p=0.048) respectively.

Conclusion: The transfer from hemodialysis to peritoneal dialysis must be anticipated in our context to reduce the morbidity and mortality of our patients on chronic dialysis.   

Peritoneal dialysis (PD) and hemodialysis (HD) are two complementary extrarenal dialysis techniques[1]. Patients treated with PD appear to have a better quality of life and satisfaction, with equivalent or better survival than those treated with HD, at least during the first two years[2][3][4]. The main limitations of HD are vascular access problems, cardiovascular instability, and hemodynamic intolerance during the HD session as well as the patient’s personal choice to switch to PD [1,5]. PD is most often chosen as a “backup” method of extrarenal dialysis (EAD) when patients are at the end of a long period on HD[1].

The transition from PD to HD is relatively common and has been the subject of several publications. In contrast, data are limited regarding patients with end-stage renal disease (ESRD) who are initially treated with chronic HD and then transferred to PD[6]. In the Netherlands, for example, transfers from HD to PD are three times less frequent than transfers from PD to HD[7].

Chronic PD is not widely used in sub-Saharan Africa for patients with ESRD although it has been available in Senegal since 2004[8][9]. Moreover, data on the transition of patients from HD to PD are scarce in this part of the continent. Thus, the aim of this study was to evaluate the reasons for patients being transferred from HD to PD in Senegal and to monitor the fate of these PD patients.

This is a retrospective, descriptive and analytical study covering a 17-year period (March 31, 2004 to December 31, 2021) based on patient medical records from the only PD unit in Senegal, located in the nephrology department of the Centre Hospitalier Universitaire Aristide Le Dantec de Dakar (CHU-ALD). The cut-off date was June 30, 2022.

The PD unit was inaugurated on March 31, 2004, and is divided into a patient waiting room, medical consultation room, nurses’ room, archive room, and PD training room. The study population underwent conventional hemodialysis comprising three four-hour sessions per week. The dialysis membrane used was polysulfone.

We included patients over 18 years of age who had been in chronic HD for at least 3 months and were then transferred to the PD unit. Patients whose records could not be used due to lack of data as well as patients who were lost to follow-up were excluded.

Data were collected on a data processing form based on medical records.

The following data were collected:

- Epidemiological data: age at transfer to PD, gender, initial nephropathy. Existence of comorbidity at the time of transfer to PD was investigated. The Charlson comorbidity score was calculated at PD initiation.

- HD data: length of stay (in months), vascular approach used, duration in HD, existence of an RIF calculated from the mean of the sum of urea and creatinine clearances, assessed on a 24-hour urine collection.

- PD data: reason for transfer, circumstances of PD initiation (scheduled, emergency), start of exchanges after PD catheter placement (in days), PD modality and patient autonomy.

- Data at point date: length of stay in PD (in months) at point date (June 30, 2022); fate of patients after transfer to PD: deceased, renal transplant, returned to HD or still in PD.

The survival of PD patients was evaluated. We collected the completed forms and filed them in a dedicated binder.

Data were collected on a pre-established form, entered in Excel, and analyzed using SPSS (Statistical Package for Social Sciences) Statistics version 25. Data were expressed using measures of central tendency and dispersion (means ± standard deviation or median) for quantitative variables, and frequencies for qualitative variables. Data comparison was carried out using the chi-square test and Student’s t-test (or a Mann-Whitney test), depending on the type of variable. Logistic regression was used to determine mortality risk factors.

The probability of survival for the entire duration of post-transfer follow-up in PD was estimated using the Kaplan-Meier method. The Cox regression model was used to investigate the factors that may have affected survival, and the assumption of proportionality in the Cox model was assessed using graphical methods. A p-value of less than 0.05 was considered significant.

Results

Two hundred and forty-one (241) patients were placed on PD at CHU-ALD, of whom 29 (12.03%) were transferred after completing 3 months of chronic HD (Figure 1.).

Figure 1.Flow chart of patients transferred from HD to PD

The mean age of patients was 52.19±15.37 years, with extremes of 25.00 and 79.00 years. The majority of patients were in the 40–49 age bracket (23.1%) (Figure 2.).

Figure 2.Distribution of the 26 patients transferred according to age at PD initiation

Females predominated, with a sex ratio of 0.62. Nephroangiosclerosis (NAS) was the most common nephropathy (46.2%), followed by undetermined nephropathies (23.1%) (Figure 3.).

Figure 3.Distribution of the 26 patients transferred according to initial nephropathy

Hypertension was the most frequent comorbidity and was present in 24 patients (92.3%), followed by diabetes in 4 patients (15.4%), and dyslipidemia in one patient (3.8%). The patients’ mean Charlson index at transfer to PD was 4.81±1.81.

Only 7.7% of patients had started hemodialysis on a native arteriovenous fistula (AVF). The other patients had had either a transient (34.6%) or a transient and then permanent approach (57.7%). The mean Kt/V was 1.44±0.22. The mean duration of hemodialysis was 28.85±32.74

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