NDT Advance Access originally published online on February 26, 2008
Nephrology Dialysis Transplantation 2008 23(5):1475-1478; doi:10.1093/ndt/gfn068
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Success of the peritoneal dialysis programme in Hong Kong
Departments of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
Correspondence and offprint requests to: Philip K. T. Li, Departments of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, N.T., Hong Kong, China. Tel: +852-2632-3616; Fax: +852-2637-5396; Email: philipli{at}cuhk.edu.hk
Keywords: connectology; peritoneal dialysis; peritonitis; survival
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Is CAPD successful in Hong Kong? |
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The success of a dialysis programme can be exemplified by a high utilization rate, excellent patient and technique survival, reduced complication rates and good quality of life.
Utilization rate
The incidence of dialysis-dependent end-stage renal disease (ESRD) in Hong Kong in 2005 was 173 per million population in Hong Kong while the prevalence of ESRD was 965 per million population. This figure is comparable to most western countries, with the exception of Taiwan and the USA [1]. As of 31 March 2007, there were 3410 patients treated with peritoneal dialysis (PD) in Hong Kong, with a median age of 62.3 years. Nearly 40% of all new dialysis patients had diabetic nephropathy as the underlying disease while around 21% had glomerulonephritis. Only 
5% of our chronic PD patients used automated PD. The discussion will therefore focus on continuous ambulatory peritoneal dialysis (CAPD).
Patient and technique survival
In general, Chinese CAPD patients enjoyed an excellent survival. Our previous cohort study showed that the 2-year actuarial survival was 83.0% [2], which compared favourably to that of the Canadian (79.7%) and USA subgroup (63.2%) of the CANUSA study [3]. Our recent cohort of 328 incident CAPD patients recruited in the Prince of Wales Hospital between 1 January 2000 and 31 December 2004 also showed a very acceptable patient and technique survival. There were 170 male patients and 158 female patients with a mean age of 57.6 ± 13.9 years (mean ± SD). 38% (127/328) had the renal failure caused by diabetes mellitus (DM). Another 25 patients (8%) had DM as a comorbid condition and not the cause of the renal failure. The 2-year patient survival was 91% and technique survival 82% (Figure 1). Even for elderly patients (>65 years old), our recent analysis showed excellent 2- and 5-year technique survival of 84.0% and 45.7%, respectively [4].
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Peritonitis rate
With the extensive use of disconnect and double-bag systems, our patients enjoyed very low peritonitis rates. In the mid-1990s, our peritonitis rate was around one episode every 17 patient-months of treatment with a simple disconnect system [5]. It gradually improved to one episode every 29 to 34 patient-months in the late 1990s [6] and then to every 36 to 45 patient-months with the application of double-bag systems [7]. Our recent analysis also showed that the probability of a 12-month peritonitis-free period for our CAPD patients was 76% [4]. With the improvement in connectology, however, the proportion of peritonitis episodes caused by Gram-negative bacteria, especially Pseudomonas species, has been increasing [7], which may have a potential impact on the choice of first-line antibiotics for the treatment of CAPD-related peritonitis.
Quality of life
Although many of our patients are elderly and have multiple comorbidities, their functional status compares favourably to patients on long-term haemodialysis. In our previous survey, nearly 90% of our CAPD patients were able to carry on normal activity with no need of any special care, and over 70% were able to join social functions with minimal restriction most of the time [8].
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Why is CAPD successful in Hong Kong? |
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Table 1 summarizes the various inherent patient factors that would affect survival in PD. Among dialysis patients, Asian Americans had a markedly lower adjusted relative mortality risk than whites [9]. The difference in death rates does not appear to be primarily treatment related, but is likely related to background death rates [9], which may be explained by the differences in genetics, dietary habits, life style and cultural practices [10,11]. In dialysis patients, the difference in mortality between Chinese and white subjects may also be attributed to the differences in body size, dialysis prescription, compliance to treatment, prevalence of comorbid conditions and possibly peritoneal transport characteristics [10,11]. For example, our previous study showed that the socioeconomic status is closely associated with the rate of peritonitis among CAPD patients [12].
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Not only is the absolute mortality different but there is also a major difference in the cause of death between Chinese and white CAPD patients. In the CANUSA study [3], 76% of the deaths were due to cardiovascular or cerebrovascular disease. In contrast, vascular disease was the cause of death in only 53% of our patients [2]. The discrepancy in the prevalence of vascular disease is, at least in part, caused by the difference in genetic make-up. For example, in one of our previous studies we found that the deletion–deletion (DD) genotype of the angiotensin-converting enzyme (ACE) gene was present in 32–42% of a normal white population, but only in 14% of Hong Kong Chinese [13]. A subsequent study showed that the ACE D allele was associated with macroangiopathy in Chinese patients with type 2 diabetes with nephropathy, and the association is dependent on its effect on the serum ACE activity [14]. In addition, a high peritoneal transport status—which is associated with increased cardiovascular morbidity in CAPD patients [15]—appears to be less common in our patient population [16].
Another important characteristic of Chinese CAPD patients is that a lower dialysis volume is usually required. In contrast to the usual 8 l/day treatment in white patients, nearly 80% of our previous cohort study received only 6 l/day dialysis [2]. A lower number of daily CAPD exchange does not only save time and cost, it may also reduce the risk of peritonitis, hyperglycaemia as well as overweight due to lesser glucose absorption [17]. In addition, compliance to treatment may be enhanced. Blake et al. [18] reported significant differences in compliance to CAPD regimens, with regimens above four exchanges per day being an independent predictor for non-compliance.
Reimbursement policy
In addition to patient-related factors, local reimbursement policy of dialysis therapy has a major impact on the utilization of CAPD. In many developing countries, the annual cost of CAPD is greater than the per-capita gross national income (GNI) while the absolute cost of PD fluid varies very little [19]. Thus, in some developing countries, renal failure patients can be expected to have access problems to CAPD. In countries with unequal reimbursement policies between CAPD and haemodialysis, a lack of incentive to prescribe CAPD also exists [19]. In contrast, the ‘PD first’ concept has been practiced in Hong Kong for over one decade: under the current policy of the Hospital Authority of Hong Kong, CAPD is provided as the first-line dialysis modality unless a medical contraindication dictates otherwise [11,19]. All the patients in the predialysis education in Hong Kong will be introduced to both PD and HD. However, the Hospital Authority of Hong Kong will only reimburse patients for PD if there is no medical contraindication for PD. The patients can choose, paying out of their own pockets, to go to non-profit making charitable HD centre or private HD centre if they choose HD as their treatment despite being medically fit for doing PD. Thus, the success of a ‘PD first’ strategy requires fundamental changes in health care reimbursement systems in many countries by increasing the incentives for clinicians and hospitals to initiate patients on CAPD. In a recent ‘Asian Roundtable on Dialysis Economics’, academic nephrologists and government officials in Asia agreed to look into ways to increase the utilization of PD in order to improve the clinical and financial management of patients with ESRD [20].
Centre effects and technique-related factors
Huisman et al. [21] found that having <20 CAPD patients in a centre or having a small fraction of patients on CAPD carries an increased risk of technique failure. In Hong Kong, most of the dialysis centres take care of around 300 CAPD patients. This high patient volume certainly depends on the availability of special medical expertise in the practice of CAPD, dedicated staff, well-designed patient training programmes and integrated back-up facilities [11]. In our centre, Tenckhoff catheter insertion and removal are mostly performed by committed nephrologists, which helps in reducing unnecessary surgical consultations and facilitates timely treatment. As a result of a well-designed patient training programme and advances in CAPD connectology, our median duration of CAPD training is 4–5 days [7,22]. A recent study further showed that the presence of dedicated training nurses could reduce the risk of peritonitis [22].
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Perspectives |
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In summary, a successful CAPD programme requires dedicated staff, prudent application of current technology and appropriate health-economic settings. Patient-related factors, however, do contribute to the excellent survival of Chinese CAPD patients. There are several problems in the clinical practice of CAPD that require further research and improvement, including prevention of peritonitis [23], preservation of residual renal function [24], avoidance of malnutrition and cardiovascular disease [25], peritoneal fibrosis and technique failure [11]. Further research in these areas is needed to further improve the longevity of CAPD patients.
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Acknowledgments |
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This study was supported in part by the Chinese University of Hong Kong (CUHK) Research Grant Account 6900570 and the Richard Yu CUHK PD Research Fund.
Conflict of interest statement. None declared.
(See related article by Wim van Biesen et al. Why less success of the peritoneal dialysis programmes in Europe?. Nephrol Dial Transplant 2008; 23: 1478–1481.)
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References |
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- Constantini E. United States Renal Data System 2006 Annual Data Report. Am J Kidney Dis (2007) 49(Suppl_1):A1–A296.
- Szeto CC, Wong TY, Leung CB, et al. Importance of dialysis adequacy in mortality and morbidity of Chinese CAPD patients. Kidney Int (2000) 58:400–407.[CrossRef][ISI][Medline]
- CANADA-USA (CANUSA) Peritoneal Dialysis Study Group. Adequacy of dialysis and nutrition in continuous peritoneal dialysis: association with clinical outcomes. J Am Soc Nephrol (1996) 7:198–207.[Abstract]
- Li PK, Law MC, Chow KM, et al. Good patient and technique survival in elderly patients on continuous ambulatory peritoneal dialysis. Perit Dial Int (2007) 27(Suppl 2):S196–S201.
[Abstract/Free Full Text] - Li PK, Chan TH, So WY, et al. Comparisons of Y-set disconnect system (Ultraset) versus conventional spike system in uremic patients on CAPD: outcome and cost analysis. Perit Dial Int (1996) 16(Suppl 1):S368–S370.[Abstract]
- Li PK, Szeto CC, Law MC, et al. Comparison of double-bag and Y-set disconnect systems in continuous ambulatory peritoneal dialysis—a randomised prospective multi-center study. Am J Kidney Dis (1999) 33:535–540.[Medline]
- Li PK, Law MC, Chow KM, et al. Comparison of clinical outcome and ease of handling in two double-bag systems in continuous ambulatory peritoneal dialysis—a prospective randomized controlled multi-center study. Am J Kidney Dis (2002) 40:373–380.[CrossRef][ISI][Medline]
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[Abstract/Free Full Text]
Accepted in revised form: 28. 1.08
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