Advancing Dialysis Recent Findings: PD first ... what's next?

1. AdvancingDialysis.org
Peritoneal Dialysis
Transitions to Hemodialysis
Summarized findings of outcomes after patients transition to
hemodialysis and interventional considerations
Kansal SK, Morfin JA, Weinhandl ED. Survival And Kidney Transplant Incidence On Home Versus In-
center Hemodialysis, Following Peritoneal Dialysis Technique Failure. Perit Dial Int. 2019 39:25-34.

2. AdvancingDialysis.org
Background
• Peritoneal dialysis utilization
has increased since Medicare
reimbursement changes in
2009
• Percentage of patients
initiating peritoneal dialysis
from 2009 – 2016 has grown
from 6.4% to 10%1
1USRDS 2018 Annual Data Report. Reference table D1: Percentages & counts of reported ESRD patients: by treatment
modality
85%
90%
95%
100%
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Incident Dialysis Patients by Modality
PD
HD

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Number of Patients
Initiating Peritoneal Dialysis
6,939 6,771 6,525 6,602
7,141
7,755
8,345
9,601
10,733
11,264
11,864 12,095
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
OVER 12,000 PERITONEAL
DIALYSIS STARTS IN 2016
1USRDS 2018 Annual Data Report. Reference table D1: Percentages & counts of reported ESRD patients: by treatment
modality

4. AdvancingDialysis.org
High Peritoneal Dialysis Therapy
Attrition Rates Commonly Reported
1Guo A, Mujais S. Patient and technique survival on peritoneal dialysis in the United States: evaluation in large incident
cohorts. Kidney Int Suppl 2003; (88):S3–12.
2Afolalu B, Troidle L, Osayimwen O, Bhargava J, Kitsen J, Finkelstein FO. Technique failure and center size in a large cohort
of peritoneal dialysis patients in a defined geographic area. Perit Dial Int 2009; 29(3):292–6.
3Weinhandl ED, Collins AJ. Trend in peritoneal dialysis technique failure in incident dialysis patients. American Society of
Nephrology, San Diego, CA, 2018.
Therapy Attrition Studies Year Sample Size Findings
Guo and Mujais1 2003 >30,000 patients
First-year technique failure rates between 18.7% and 20.5%
from 1999 to 2001
Afolalu et al.2 2009 5,003 patients
15.6% and 11.9% among large and small centers,
respectively, in a regional cohort from 2001 to 2005
Weinhandl ED, Collins AJ3 2016 22,197 patients
19.5 and 20.8 events per 100 patient-years from 2005 to
2009
18.1 and 18.9 events per 100 patient-years from 2010 to
2012

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7,016 7,320 7,250 7,274 7,589 7,894
8,493
9,307
10,109
10,675
11,949
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
1Analysis of United States Renal Data System Standard Analysis Files. PD technique failure defined by at least 30 days of HD
immediately following PD.
MORE ATTENTION NEEDED TO KEEP PATIENTS HOME
IN 2015 – NEARLY 12,000 PERITONEAL DIALYSIS PATIENTS TRANSITIONED TO HEMODIALYSIS1

6. AdvancingDialysis.org
• Peritonitis
• Catheter failure
• Ultrafiltration failure
• Inadequate solute clearance
• Psychosocial factors
• Abdominal complications
• Malnutrition
Common Complications Resulting in
Peritoneal Dialysis Technique Failure1,2
1Kolesnyk I, Dekker FW, Boeschoten EW, Krediet RT. Time-dependent reasons for peritoneal dialysis technique failure and mortality.
Perit Dial Int 2010; 30(2):170–7. 2Kansal SK, Morfin JA, Weinhandl ED. Survival And Kidney Transplant Incidence On Home Versus In-
center Hemodialysis, Following Peritoneal Dialysis Technique Failure. Perit Dial Int. 2019 39:25-34.
Home Dialysis Continuation
needing to transition to hemodialysis,
transitioned to home hemodialysis2
>4% of patients

7. AdvancingDialysis.org
Planned Transitions to
Hemodialysis may Improve Outcomes
• Fewer “crashes” into hemodialysis1
• Improvements in fistula placement2
• Less occurrence of fluid overload3
• Reduced hospitalizations and fewer hospitalization days1
• Improved survival and lower risk of death1
1Kansal SK, Morfin JM, Weinhandl ED. Survival and Kidney Transplant Incidence on Home versus In-Center Hemodialysis, Following
Peritoneal Dialysis Technique Failure. Perit Dial Int. January-February 2019 vol. 39 no. 1 25-34. 2Boissinot L, et al. Is transition
between peritoneal dialysis and hemodialysis really a gradual process? Perit Dial Int 2013; 33(4):391–7. 3Bakris GL, et al. Intensive
hemodialysis, blood pressure, and antihypertensive medication use. Am J Kidney Dis2016; 68(5s1):S15–23.

8. AdvancingDialysis.org
Reported Outcomes in Patients that
Transitioned from Peritoneal Dialysis to Hemodialysis1
1Kansal SK, Morfin JM, Weinhandl ED. Survival and Kidney Transplant Incidence on Home versus In-Center Hemodialysis,
Following Peritoneal Dialysis Technique Failure. Perit Dial Int. January-February 2019 vol. 39 no. 1 25-34
Transplantation Incidence
(4-year follow-up)
Survival
(4-year follow-up)
Hospitalization Days
Hemodialysis Setting
Study Population 33,452 peritoneal dialysis patients
transitioned to hemodialysis
521 patients
to Home HD (3.8%)
9.1 hospitalization days
during transition
70.1% survived
28.8% transplanted
32,931 patients
to In-center HD (96.2%)
18.5 hospitalization days
during transition
62.4% survived
22.4% transplanted

9. AdvancingDialysis.org
• 24% lower risk of death in transitions to
home hemodialysis vs. in-center
hemodialysis
• Risk of death varied significantly based on
Medicare coverage:
‒ 43% lower risk of death in non-
Medicare patients
‒ 8% lower risk of death in Medicare
patients
• ESRD duration at the time of PD therapy
attrition was 1.4 years greater in home
hemodialysis patients with vs. without Medicare
Lower Risk of Death in Transitions
to Home Hemodialysis1
Hazard ratios of death for home hemodialysis versus
matched in-center hemodialysis patients. HHD = home
hemodialysis; IHD = in-center hemodialysis.
Hazard ratio
0.76 (0.65–0.90)
1Kansal SK, Morfin JM, Weinhandl ED. Survival and Kidney Transplant Incidence on Home versus In-Center Hemodialysis,
Following Peritoneal Dialysis Technique Failure. Perit Dial Int. January-February 2019 vol. 39 no. 1 25-34

10. AdvancingDialysis.org
62.4%
70.1%
• 4-year survival differences between home
hemodialysis and in-center were 7.7%
overall
• Survival differences varied by Medicare
coverage:
‒ 12.5 point improvement 4-year
survival in non-Medicare patients
‒ 4.0 point improvement 4-year survival
in Medicare patients
• ESRD duration at the time of PD therapy
attrition was 1.4 years greater in home
hemodialysis patients with vs. without Medicare
Improved Survival in Transitions
to Home Hemodialysis1
Survival in non-Medicare peritoneal dialysis patients
transitioned to home hemodialysis and In-center
hemodialysis.
1Kansal SK, Morfin JM, Weinhandl ED. Survival and Kidney Transplant Incidence on Home versus In-Center Hemodialysis,
Following Peritoneal Dialysis Technique Failure. Perit Dial Int. January-February 2019 vol. 39 no. 1 25-34

11. AdvancingDialysis.org
• Transplantation incidence differences
between home hemodialysis and in-
center were 6.4% overall
• The likelihood of transplant was 36%
higher with home hemodialysis versus
in-center, and varied greatly by
Medicare coverage
‒ 86% higher likelihood of
transplantation in non-Medicare
patients
‒ No statistical difference in likelihood
in Medicare patients
Improved Transplantation Incidence in
Transitions to Home Hemodialysis1
Cumulative incidence of kidney transplant among home
hemodialysis and matched in-center hemodialysis
patients following peritoneal dialysis technique failure
1Kansal SK, Morfin JM, Weinhandl ED. Survival and Kidney Transplant Incidence on Home versus In-Center Hemodialysis,
Following Peritoneal Dialysis Technique Failure. Perit Dial Int. January-February 2019 vol. 39 no. 1 25-34
22.4%
28.8%

12. AdvancingDialysis.org
Planning for Transitions to Hemodialysis:
Proposed Clinical Indicators
When the Peritoneal Dialysis to Home Hemodialysis Therapy Transition Makes Sense. Multidisciplinary, Quality Improvement Team
Final Report on file. 2014.
Accelerate education and intervention
Waning Adequacy Hospitalizations
Physical
Appearance
Qualitative
Concerns
Medical
Complications
Vintage Malnutrition

13. AdvancingDialysis.org
Transition Planning Overview
When the Peritoneal Dialysis to Home Hemodialysis Therapy Transition Makes Sense. Multidisciplinary, Quality Improvement Team
Final Report. 2014.
Stage
1
Healthy PD
Adjustment
Prepare for the future even
as they begin home dialysis
Educate on modality options,
create Life Plan
Stage
2
PD @ Risk
Re-evaluation
Closely monitor
for signs of decline as the
journey continues
Re-assess if therapy is
meeting needs, re-educate
on modality options
Stage
3
PD Decline
Imminent Transition
Proactively plan to keep them
at home, if that’s what they
want
Establish access, train on
chosen modality

14. AdvancingDialysis.org
Recommended Indicators to Manage
Planned Patient Transitions to Hemodialysis
Stage 1: Healthy PD
Stage 2: PD @ Risk
Stage 3: PD Decline
Adjustment
• Peritonitis episode
• Albumin level < 3.5
• Life-changing events (family, change
in social support, depression)
• PD vintage > 5 years
• Transplant waiting list > 2 years
When the Peritoneal Dialysis to Home Hemodialysis Therapy Transition Makes Sense. Multidisciplinary, Quality Improvement Team
Final Report. 2014.

15. AdvancingDialysis.org
Recommended Indicators to Manage
Planned Patient Transitions to Hemodialysis
Stage 1: Healthy PD
Stage 2: PD @ Risk
Stage 3: PD Decline
Re-evaluation
• Declining or loss of Residual Renal Function
• Albumin level <3.0
‒ or decrease of .2 every 2 months
• 3 or more infections within a year
‒ Ex. peritonitis, ES, tunnel
‒ 1 very severe episode (fungal, sclerosing)
• <1 L/day of UF combined with residual and
therapy
• Increasing number of exchanges
• Use of Icodextrin
• Declining adequacy
‒ Kt/V<1.7 after Rx adjustments
• Decline in physical appearance and or abilities
When the Peritoneal Dialysis to Home Hemodialysis Therapy Transition Makes Sense. Multidisciplinary, Quality Improvement Team
Final Report. 2014.

16. AdvancingDialysis.org
Recommended Indicators to Manage
Planned Patient Transitions to Hemodialysis
Stage 1: Healthy PD
Stage 2: PD @ Risk
Stage 3: PD Decline
Imminent Transition
• 3 or more indicators, plus the following:
• Medical complications
• Ex. cardiovascular decline, fractures, hernias,
leaks
• >3 hospitalizations in 1 year (ICU)
When the Peritoneal Dialysis to Home Hemodialysis Therapy Transition Makes Sense. Multidisciplinary, Quality Improvement Team
Final Report. 2014.

17. AdvancingDialysis.org
Key Takeaways
FINDING1
• Keeping patients on a home
home modality offers better
outcomes
• PD patients transitioning to
hemodialysis already are
accustomed to managing
treatment at home
RECOMMENDATION1
• Planning modality transitions, with the
aim of keeping patients home, should
be a core strategy as the dialysis
patient population grows
• Leverage patient knowledge of chronic
disease, self-management at home
‒ Previously trained to manage
supplies, interface with a dialysis
cycler and aseptic techniques and
supplies
When the Peritoneal Dialysis to Home Hemodialysis Therapy Transition Makes Sense. Multidisciplinary, Quality Improvement Team
Final Report. 2014.

18. AdvancingDialysis.org
Broader context as summarized by Dr. José Morfín:
UC Davis School of Medicine
• Increased hemodialysis treatment frequency may be particularly important for peritoneal
patients, particularly after transitioning to hemodialysis
• Transiting to more frequent home hemodialysis may be especially helpful for patients with:
‒ Deteriorating cardiac status (due to volume expansion)
‒ Rising blood pressure
‒ Worsening left ventricular hypertrophy
• The most practical setting that conforms to increased treatment frequency is home
• Encouraging the transition from peritoneal dialysis to home hemodialysis is an evidence-based
approach and we have 12,000 (or more) chances each year to make this transition happen
Dr. José Morfín is an Associate Professor at UC Davis School of Medicine and is the Medical Director of Home Dialysis Services at
Satellite Wellbound in Sacramento, California. Dr. Morfín launched his first home program in 2009 and in 2017, launched Optimal
Transitions™—A first-of-its-kind program that provides dialysis patients and their families the time, support and resources needed to select
the right dialysis therapy for them.
Dr. Morfín is a member of NxStage Medical’s Scientific Advisory Board.

19. AdvancingDialysis.org
About this presentation
This presentation is one in an ongoing series focused on recent articles, clinical findings or
guidelines related to issues affecting dialysis patients.
AdvancingDialysis.org is dedicated to providing clinicians and patients with better access to and
more awareness of the reported clinical benefits and improved quality of life made possible with
home dialysis, including more frequent, solo, more intensive, and nocturnal therapy schedules.
For more information, visit AdvancingDialysis.org
AdvancingDialysis.org is a project of NxStage Medical, Inc.

20. AdvancingDialysis.org
Risk and Responsibility
All forms of hemodialysis, including treatments performed in-center and at home, involve
some risks. When vascular access is exposed to more frequent use, infection of the site,
and other access related complications may also be potential risks. In addition, there are
certain risks unique to treatment in the home environment. Patients differ and not everyone
will experience the reported benefits of more frequent hemodialysis.
Certain risks associated with hemodialysis treatment are increased when performing solo
home hemodialysis because no one is present to help the patient respond to health
emergencies.
Certain risks associated with hemodialysis treatment are increased when performing
nocturnal therapy due to the length of treatment time and because therapy is performed
while the patient and care partner are sleeping.

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