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          "en" => "Achievement of CV risk objectives&#44; at the start&#44; a year later and throughout the year in patients with a minimum of one year follow-up"
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION </span></p><p class="elsevierStylePara">Over the past years&#44; the prevalence of advanced chronic kidney disease &#40;ACKD&#41; and kidney replacement therapy in any of its forms has increased&#46; On a social&#47;public health level&#44; this involves an elevated cardiovascular &#40;CV&#41; morbid-mortality and uses a great amount of resources&#46;<span class="elsevierStyleSup">1 </span></p><p class="elsevierStylePara">This scenario compels the clinical staff and manager to insure the efficiency of resources to a maximum&#46; One of the tools developed to this effect are the global standard guidelines&#44; which facilitate decision-making and drafting of improvement plans&#44; both for processes and results&#46;<span class="elsevierStyleSup">2 </span></p><p class="elsevierStylePara">The improvement cycle passes through four basic stages&#58; indicator elaboration and attainment&#44; comparison of these with references or standards&#44; solution planning for the identified area to be improved and implementation of these actions&#46; In summary&#44; achievement of the best possible results is sought after as well as the reduction in inter-individual variability in the service provided&#46;<span class="elsevierStyleSup">2 </span></p><p class="elsevierStylePara">This is why a research group was created in 2002 for the Management of Quality in Nephrology&#44; supported by Spanish Society of Nephrology &#40;SEN&#41;&#44; which has drafted several guidelines with quality indicators&#44; mainly in the field of haemodialysis &#40;HD&#41;&#46;<span class="elsevierStyleSup">3-5</span></p><p class="elsevierStylePara">In 2007&#44; thanks to the collaboration with a group of peritoneal dialysis &#40;PD&#41;<span class="elsevierStyleSup">6 </span>experts&#44; the Scientific-technical Quality and Improvement Programme in Peritoneal Dialysis was published&#44; aimed at establishing &#40;faced with the absence of sufficient scientific evidence to date&#41; quality indicators and their standards in this field&#46; Lastly&#44; indicators and objectives are published in 2010&#46;<span class="elsevierStyleSup">7 </span></p><p class="elsevierStylePara">To date&#44; only a few research groups&#44; both national<span class="elsevierStyleSup">8-10 </span>and internacional&#44;<span class="elsevierStyleSup">6&#44;11 </span>have tried to transfer the proposed indicators to real situations in their units&#44; basically as far as efficacy and safety of the technique&#44; as well as control of anaemia or mineral metabolism&#46;</p><p class="elsevierStylePara">The aim of our study was to analyze the characteristics of the PD incident patients&#44; the compliance with these clinical guidelines and the subsequent evolution of these patients&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">PATIENTS AND METHODS </span></p><p class="elsevierStylePara">This is a multicentre observational cohort study&#44; with systematic consecutive sampling of the patients belonging to different departments of the hospitals in the PD regional health care system &#40;GCDP by spanish initials&#41; with a maximum follow-up of three years&#46; This group is composed of 19 public hospitals in the central region of the country&#44; serving a global health care community of 8&#46;8 million people&#46;</p><p class="elsevierStylePara">Over three years &#40;from January 2003 to January 2006&#41;&#44; all the patients starting PD are recorded and monitored until the end of treatment or death&#46; On admission&#44; demographic parameters&#44; cause of the nephropathy&#44; comorbidity&#44; origin and reason for choosing this technique &#40;free choice or by medical indication due to HD contraindication&#41; are collected&#46; The Charlson index was used to estimate comorbidity&#44; previously validated for PD&#46;<span class="elsevierStyleSup">12 </span>Data regarding objectives&#44; efficacy&#44; residual function&#44; peritoneal transport&#44; anaemia treatment and blood pressure &#40;BP&#41; were collected at the beginning and at six months&#46; The peritonitis&#44; programme admissions or exits were recorded as they occurred&#46;</p><p class="elsevierStylePara">Each centre uses identical databases&#44; specifically designed for this multipurpose data collection&#46; The databases are collected in a central office and unified every six months&#46; A Data Manager audits and debugs the data by ranks and logical routines&#46; Patients sign the informed consent on commencement of the therapy&#46;</p><p class="elsevierStylePara">Although there are no unified treatment protocols&#44; complying with the current guidelines objectives of efficacy&#44; anaemia and BP control is recommended&#46;<span class="elsevierStyleSup">7 </span>According to the degree of control of BP figures&#44; patients are classified into three subgroups&#58; optimum control if the BP is less than 140&#47;90mmHg&#44; the limits are lowered to 130&#47;80mmHg for DM patients or with prior CV event&#59; isolated SBP when the diastolic blood pressure &#40;DBP&#41; is controlled and the systolic blood pressure &#40;SBP&#41; is greater than the limit&#59; and poorly controlled if the DBP is greater than the limit&#44; independent of the SBP value&#46; Statistical management and analysis of all this data is performed with the SPSS v11&#46;0 statistical manager&#46; Data of numerical variables are shown as mean and standard deviation &#40;SD&#41;&#46; Variables without normal distribution &#40;for example&#58; age&#44; Charlson index&#41; are presented as median and range or interquartile interval&#46; All the rates obtained &#40;mortality&#44; admissions and peritonitis&#41; are referred to the technique real time for each patient&#46; Comparisons are made using Student&#8217;s t-tests&#44; the Student&#8217;s t-tests for paired samples&#44; the chi-square or McNemar&#44; according to the nature of the variables&#46; Survival analysis test is made with Kaplan-Meier&#46; Survival data is displayed as mean survival probability and confidence interval at 95&#37; &#40;CI 95&#37;&#41;&#46; All the incident patients are included in the analysis and the loss in follow-up reduced to 0&#46;8&#37;&#46; For each survival analysis&#44; different events are considered&#44; considering the remaining people leaving the programme as follow-up losses&#46; Therefore&#44; the four analyses performed consider&#58; death as an event for patient survival analysis&#59; switching to HD as an event for the technique maintenance analysis&#59; the aggregate of death and switch to HD is the event for successful analysis of the technique and&#44; lastly&#44; the death aggregate including change to HD&#44; transplantation&#44; recovery of renal function and transferral &#40;any programme exit or loss of follow-up&#41; allow us to estimate the technique real time&#46; This last data can be of great interest for the design of management models or prospective follow-up studies&#44; since it is the real time we have to care for and supervise the patient&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Cohort description </span></p><p class="elsevierStylePara">This analysis included 490 incident patients from 2003 to 2006 with a follow-up of 532&#46;26 years-patient and a mean follow-up of 13&#46;36 months &#40;range&#58; 0&#46;1 to 36 months&#41;&#46; The most relevant admission characteristics were&#58; 53&#46;6 years &#40;range&#58; 16-92&#41;&#44; 61&#46;6&#37; male&#44; Charlson comorbidity index &#40;Ch index&#41; 5&#44; interquartile range &#40;3-7&#41;&#44; 19&#46;1&#37; with diabetes mellitus &#40;DM&#41; diagnosis and 23&#46;7&#37; with prior CV events&#46; The most prevalent advanced ACKD aetiologies were&#58; glomerulonephritis 25&#46;5&#37;&#44; diabetic nephropathy 16&#37;&#44; ischemic vascular 12&#46;4&#37;&#44; interstitial 13&#46;3&#37;&#44; adult polycystic kidney disease &#40;APKD&#41; 10&#46;6&#37;&#46; 89&#46;9&#37; are in PD because they decided so and the rest by medical indication&#46; 8&#37; come from failed transplantation and 19&#46;7&#37; from HD&#46; 26&#46;48&#37; of the patients were included on the transplant list in the first 6 months&#46; Table 1 gathers other cohort parameters&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Evolution </span></p><p class="elsevierStylePara">At the end of the follow-up 21&#46;4&#37; of the patients underwent a transplantation&#44; 5&#46;5&#37; deceased&#44; 7&#46;4&#37; switched to HD and 2&#46;1&#37; recovered renal function&#44; the rest remained with the technique&#46; Only 4 patients left the follow-up &#40;0&#46;8&#37;&#41;&#46;</p><p class="elsevierStylePara">Thirty patients deceased during the follow-up&#44; calculating a mortality of 5&#46;6&#37; per year in risk and an annual mortality rate for the population of 0&#46;056 with a CI at 95&#37; &#40;0&#46;04-0&#46;08&#41;&#46; The most outstanding causes of death are&#58; 46&#46;6&#37; CV&#44; 20&#37; infectious&#44; 10&#37; tumoral&#44; 6&#46;7&#37; PD suspension&#44; 3&#46;3&#37; respiratory and 3&#46;3&#37; hepatic-digestive&#46;</p><p class="elsevierStylePara">Mean patient survival is estimated at 33&#46;4 months with a CI at 95&#37; &#40;32&#46;4-34&#46;5&#41;&#59; technique maintenance is estimated at 32&#46;3 &#40;31&#46;1-33&#46;5&#41;&#59; technique success &#40;event&#58; death or switch to HD&#41; is estimated at 30&#46;02 &#40;28&#46;65-31&#46;38&#41; and PD permanence &#40;event&#58; any person leaving the programme or loss of follow-up&#41; is estimated at 22&#46;47 &#40;21&#46;09-23&#46;85&#41; &#40;Figure 1&#41;&#46;</p><p class="elsevierStylePara">Admission per patient and year in risk was 0&#46;65 &#40;without considering admissions for peritonitis&#41; and an estimated annual rate within the interval at 95&#37; &#40;0&#46;58-0&#46;72&#41;&#46; Including stays for peritonitis over 2 days&#44; the annual admission rate is 0&#46;79 &#40;0&#46;72-0&#46;87&#41; admissions per patient and year&#44; i&#46;e&#46; one admission every 1&#46;26 years&#46; The mean hospital stay does not follow a normal distribution and presents an average median stay of 5&#46;5 days and an interquartile range of &#40;2-11&#41;&#46;</p><p class="elsevierStylePara">There were 264 cases of peritonitis in 151 patients &#40;31 patients had two episodes&#44; 18 three and 13 over three&#41;&#44; with a global rate in the sample of 0&#46;5 episodes of peritonitis per year in risk and a CI at 95&#37; of 0&#46;44-0&#46;56 episodes per year&#59; i&#46;e&#46; one peritonitis event every two years&#46; 41&#46;1&#37; of the patients with peritonitis required admission&#46;</p><p class="elsevierStylePara">The mean rate of loss of residual kidney function in cases remaining at least one year on the technique was 2ml&#47;min per year&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Cardiovascular risk </span></p><p class="elsevierStylePara">Before commencing PD&#44; 9&#46;15&#37; had suffered an acute myocardial infarction&#44; 12&#46;68&#37; had peripheral arteriopathy &#40;1&#37; with major amputation&#41;&#44; 4&#46;78&#37; had acute cerebrovascular disease and 6&#46;44&#37; some episode of congestive heart failure &#40;CHF&#41;&#46; As a whole&#44; 23&#46;7&#37; of the patients had suffered some prior CV event and 2&#46;2&#37; &#40;n &#61; 11&#41; three or more&#46;</p><p class="elsevierStylePara">82&#46;02&#37; of the hypertensive patients received hypotension treatment&#46; The baseline BP values were 132&#46;47 &#40;SD &#61; 20&#46;36&#41; and</p><p class="elsevierStylePara">79&#46;86 &#40;SD &#61; 12&#46;49&#41; mmHg&#46; Stratified according to the degree of control&#44; 47&#46;2&#37; presented optimum control&#44; 23&#46;1&#37; isolatedsystolic blood pressure &#40;SBP&#41; and 29&#46;7&#37; poor control&#46; Diabetic patients controlled their blood pressure worse than non-diabetics &#40;each according to the optimum recommended degree of control&#41;&#44; 28&#46;4&#37; versus 47&#46;2&#37; respectively &#40;chi-square 10&#46;23&#59; value P 0&#46;001&#41;&#46; Data displayed in Table 1&#46;</p><p class="elsevierStylePara">Patients diagnosed with DM had greater prevalence of prior CV events at the start of PD &#40;48&#46;9&#37; versus 17&#46;7&#37;&#59; P &#60; 0&#46;001&#41;&#46; The prevalence of uncontrolled CV risk factors was greater among the DM&#46; Therefore&#44; greater percentages of uncontrolled SBP stand out &#40;40&#46;9&#37; versus 17&#46;9&#37; for isolated SBP and 30&#46;7&#37; versus 34&#46;9&#37; for SBP&#41;&#59; as well as obesity &#40;body mass index &#91;BMI&#93; &#62; 30&#58; 22&#46;1 versus 16&#46;6&#37;&#44; P &#61; 0&#46;02&#59; BMI 26&#46;85 &#91;SD &#61; 4&#46;15&#93; versus 25&#46;65 &#91;SD &#61; 4&#46;6&#93;&#59; P &#61; 0&#46;026&#41; and dyslipidaemia &#40;33&#46;69 versus 21&#46;85&#37;&#59; P &#61; 0&#46;02&#41;&#46; Neither age nor gender is associated to different degrees of achievement of BP control objectives&#46;</p><p class="elsevierStylePara">The evolution over the first year of the control of classic CV risk factors is collected in Table 2&#46; The annual comorbidity updates gather three new DM diagnoses and 21 new diagnoses of CV pathology in patients that did not previously have these diagnoses&#46; The causes of admission were&#58; 21 episodes of coronary ischemia or acute myocardial infarction &#40;AMI&#41;&#44; 7 cases of heart failure &#40;CHF&#41;&#44; 4 strokes &#40;CVA&#41;&#44; 8 amputations and one arrhythmia&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Efficacy and peritoneal dialysis techniques </span></p><p class="elsevierStylePara">The initial technique was CAPD with manual interchange in 65&#46;5&#37; of the patients&#44; the rest used a cycling technique chosen by the nephrologist in charge&#46; Table 1 displays the cohort descriptive data&#46; Patient distribution by peritoneal permeability according to the baseline Twardoski PET was&#58; 14&#46;3&#37;&#44; high transport&#59; 35&#46;1&#37;&#44; mid-high&#59; 37&#46;3&#37;&#44; mid-low&#44; and 13&#46;3&#37;&#44; low transport&#46;</p><p class="elsevierStylePara">In the first efficacy measurement available a month after commencing the technique&#44; 67&#46;6&#37; of the patients met all the efficacy objectives in the SEN Guidelines&#46; Of the patients with more than one year follow-up &#40;n &#61; 176&#41;&#44; only 38&#46;6&#37; had all their values within range during the year&#46; Table 2 describes the distribution in techniques and efficacy data&#44; achievement of objectives and peritoneal permeability by techniques and their evolution over the first year&#46; For this evolutional analysis&#44; only patients in the same type of technique during follow-up are considered&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Anaemia treatment </span></p><p class="elsevierStylePara">79&#46;3&#37; of the patients received treatment with erythropoietic factors &#40;47&#46;9&#37; with EPO &#945;o &#946;and 52&#46;1&#37; with darbepoetin &#945;&#41; to reach a mean haemoglobin &#40;Hb&#41; of 12&#46;1g&#47;dl&#46; 67&#37; maintain Hb &#62; 11g&#47;dl during the entire first year of follow-up and only 25&#46;6&#37; between 11 and 13g&#47;dl&#46; The evolution of patients in the first year is displayed in Table 2&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION </span></p><p class="elsevierStylePara">Our study provides current and reliable estimators on meeting therapeutic objectives&#44; admission and mortality rates in our representative incident population&#46; This data can be useful as an initial comparison reference with the recently published Quality Objectives Guidelines&#46; The importance of a systemised approximation with a global viewpoint to our patients&#8217; problems is clear&#58; knowing the results of our surroundings and comparing them with external references can help to improve these results&#46;<span class="elsevierStyleSup">2 </span>From an individual viewpoint&#44; there are publications proving that patients who meet the greater number of therapeutic objectives have a better vital prognosis&#46; For the time being these are only available to patients on HD&#44; but not PD&#46;<span class="elsevierStyleSup">13 </span></p><p class="elsevierStylePara">The use of clinical guidelines&#44; objectives&#44; quality plans and indicators began in the field of HD spurred on by the eagerness to guarantee appropriate quality and uniformity in patient care&#46; The public health system that finances dialysis treatment and the SEN have encouraged the arranged HD supply companies to develop these systems&#46;<span class="elsevierStyleSup">3-5 </span>However&#44; the scenario for PD is another matter&#46; With a minority presence with respect to HD &#40;one PD patient for every eight on HD&#41; and fairly disperse programs &#40;less than 25 patients per centre mean prevalence in our register&#41;&#44; we have required more time to develop these actions&#46;<span class="elsevierStyleSup">7 </span>On the other hand&#44; we do not have sufficient contrasted evidence to establish the objectives that allow us to reduce the risk&#44; nor the prior experience to indicate the standards for our indicators&#46; This explains that in the guidelines published this year&#44; more than half the indicators still have no defined standard&#46;<span class="elsevierStyleSup">7 </span></p><p class="elsevierStylePara">The demographic characteristics of our population &#40;basically regarding age and DM presence is concerned&#41; are more similar to European and Canadian studies than those from the USA&#46;<span class="elsevierStyleSup">14&#44;15 </span>As previously discussed in other analyses of our group&#44; the elevated prevalence of DM and the obesity in the registers from the USA make it difficult to extrapolate their results to our situation&#46;</p><p class="elsevierStylePara">The hospitalisation rate was lower than registered in other series&#44; such as the USRDS register&#44; a likely fact in relation to lower age and comorbidity in our patients&#46;<span class="elsevierStyleSup">16&#44;17 </span>The rate of admissions due to peritonitis is inferior to that published in other series<span class="elsevierStyleSup">17&#44;18 </span>and meets the recommendation of the quality standards&#46;<span class="elsevierStyleSup">7 </span></p><p class="elsevierStylePara">In comparison with other studies&#44; such as the NECOSAD &#40;with an 80&#37; survival rate after 2 years&#41;&#44; our mortality rate is lower&#46;<span class="elsevierStyleSup">15 </span>It is even lower than the national mean recorded in the register of renal patients&#46; To explain this&#44; we considered as possible factors the fact of including only incident patients&#44; the not too elevated age and a lower DM prevalence&#46; Most of the studies found less or similar mortality in PD patients than in HD patients during the first 2 years&#44;<span class="elsevierStyleSup">14 </span>a tendency that progressively evens out&#44; especially in patients aged over 65&#46;<span class="elsevierStyleSup">15 </span>Furthermore&#44; the chosen dialysis technique does not seem to have prognostic value&#44; particularly when it is corrected by selection and comorbidity criteria&#46;<span class="elsevierStyleSup">19 </span>These considerations&#44; added to the lack of quality indicators that are sufficiently validated in PD &#40;can be compared to the HD&#41;&#44; have not allowed the establishment of clear recommendations for one or the other technique&#46;</p><p class="elsevierStylePara">Although we do not have clear and defined indicators in PD as regards validation and prediction of the cardiovascular risk&#44; we have observed that the degree of control of conventional factors such as BP is sufficient&#46; This is in harmony with that reported in other series in our surroundings&#46;<span class="elsevierStyleSup">10 </span></p><p class="elsevierStylePara">As previously published&#44; the comorbidity at the start of the PD is the main factor of vital prognosis&#46; We cannot discern whether the final results depend on the combined action of CV events prior to commencing the technique&#44; age&#44; the DM itself or the patient&#8217;s treatment during the technique process&#46;<span class="elsevierStyleSup">20 </span>In our opinion&#44; systematic detection of CV disease in the early stages of the CKD could result more advantageous for control of CV morbid-mortality&#46; <span class="elsevierStyleSup">21 </span></p><p class="elsevierStylePara">The initial attainment of dialysis efficacy objectives is not difficult in the first stages on PD&#44; in a similar way to that referred to by other groups in our surroundings&#46;<span class="elsevierStyleSup">8 </span>However&#44; maintenance of these after a year of follow-up decreases dramatically&#44; together with the loss of RFR and even less patients maintain them in all the available values throughout the first year&#46; Anyway&#44; several randomised studies have proven that a larger dose of dialysis does not improve survival&#46;<span class="elsevierStyleSup">22 </span></p><p class="elsevierStylePara">Data obtained with respect to anaemia treatment are acceptable if duly evaluated &#40;baseline and after a year&#41;&#44; even though it is true that in only 25&#37; Hb is maintained within the recommended target during the first year&#46; However&#44; this fact is better than the previous HD references&#46; In a recently published Spanish study&#44; less than 5&#37; of the patients on HD were able to maintain their Hb values in the range throughout the year&#44; although in this case monthly determinations were carried out&#46;<span class="elsevierStyleSup">23 </span>The analysis of the factors that associated a better approach to these objectives is not within the scope of this study and does not allow for adequate comparison with other records&#46;<span class="elsevierStyleSup">16 </span></p><p class="elsevierStylePara">The main limitations of this study are the absence of shared action protocols and the follow-up time of the patients&#44; which is under 2 years&#46; An early and integral approach to the advanced ACKD and the various kidney replacement techniques allow for patient mobility between PD&#47;HD&#47;transplantation&#46; Therefore&#44; one third of those commencing the follow-up do not finalise the study&#46; In any case&#44; it should be pointed out that the mean stay does not increase much in other studies or registers with longer track records&#46;<span class="elsevierStyleSup">10&#44;19 </span>It is more relevant that the first cause of leaving the PD programme is transplantation and approximately one in 4 incident patients have already received a transplant in an average time of little over a year&#46; It seems that the new model of integrated kidney replacement treatment has a preferential route in PD as the anteroom to transplant&#46;<span class="elsevierStyleSup">24 </span>The other limitation is the absence of shared protocols&#44; however&#44; the GCDP holds 6-monthly meetings in which the application of clinical guidelines is recommended&#44; results are analysed and specific aspects of patient treatment are discussed&#46; It is to be expected&#44; that over time&#44; this operating system will lead us to standardise our methods&#46;</p><p class="elsevierStylePara">It is a relevant study both for its design as well as its sample size&#46; It allows for identification of areas susceptible of improvement and start up corrective actions&#46; Furthermore&#44; faced with the absence of published nationwide data&#44; it can aid other PD units as a reference&#44; with the final objective for all of reducing their existing variability&#46;<span class="elsevierStyleSup">8 </span></p><p class="elsevierStylePara">In summary&#44; patients that begin PD in our surroundings are younger than in HD&#44; although they present a similar pondered Charlson index adjusted to their age&#46; The hospitalisation&#44; mortality and peritonitis rate was lower than that of other registers&#46; We still have no adequate instruments for measuring CV risk in PD&#44; and the current situation suggests that our patients are not sufficiently controlled&#46; The degree of control in hypertension&#44; anaemia and efficacy improves after a year&#44; however they are far from the recommendations&#44; especially if they are evaluated throughout the whole study&#46;</p><p class="elsevierStylePara">The lack of standardisation in many of the tools proposed lately continues to limit the doctors&#8217; efforts to reduce the variability of their clinical practice&#46; Therefore&#44; we are still in need of studies on the prognosis of our patients in the different kidney replaced treatment techniques&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflict of interest </span></p><p class="elsevierStylePara">The authors affirm that they have no conflicts of interest&#46; This project is jointly funded by&#58; Baxter &#40;2003-2009&#41;&#44; Amgen &#40;2005&#173;2009&#41;&#44; Fresenius &#40;2007-2009&#41; and Gambro &#40;2008-2009&#41; through an agreement with the Nephrology Foundation of Madrid &#40;<span class="elsevierStyleItalic">Fundaci&#243;n Madrile&#241;a de Nefrolog&#237;a-</span>SOMANE&#41;&#46;</p><p class="elsevierStylePara">The authors affirm the sources of prior or subsequent sponsorship as the journal requires&#44; but the characteristics of the article consider that there is no conflict of interest&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10458&#95;108&#95;9192&#95;en&#95;10458&#95;t1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10458_108_9192_en_10458_t1.jpg" alt="Achievement of CV risk objectives&#44; at the start&#44; a year later and throughout the year in patients with a minimum of one year follow-up "></img></a></p><p class="elsevierStylePara">Table 1&#46; Achievement of CV risk objectives&#44; at the start&#44; a year later and throughout the year in patients with a minimum of one year follow-up </p><p class="elsevierStylePara"><a href="grande&#47;10458&#95;108&#95;9193&#95;en&#95;10458&#95;t2&#46;jpg" class="elsevierStyleCrossRefs"><img src="10458_108_9193_en_10458_t2.jpg" alt="Achievement of anaemia and adaptation objectives at the start&#44; after a year and throughout the year in patients with a minimum of one year follow-up "></img></a></p><p class="elsevierStylePara">Table 2&#46; Achievement of anaemia and adaptation objectives at the start&#44; after a year and throughout the year in patients with a minimum of one year follow-up </p><p class="elsevierStylePara"><a href="grande&#47;10458&#95;108&#95;9194&#95;en&#95;10458&#95;f1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10458_108_9194_en_10458_f1.jpg" alt="Kaplan-Meier estimator for patient survival &#40;A&#41;&#44; transferral to HD &#40;B&#41;&#44; leaving the technique due to combined event &#40;death or HD&#41; &#40;C&#41;&#44; and exit for any cause &#40;death&#44; switch to HD&#44; transferral&#44; recovery of kidney function or transplantation&#41;&#46; Mean survival"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Kaplan-Meier estimator for patient survival &#40;A&#41;&#44; transferral to HD &#40;B&#41;&#44; leaving the technique due to combined event &#40;death or HD&#41; &#40;C&#41;&#44; and exit for any cause &#40;death&#44; switch to HD&#44; transferral&#44; recovery of kidney function or transplantation&#41;&#46; Mean survival</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introducci&#243;n&#58;</span>&#160;El Plan de Calidad y Mejora en Di&#225;lisis Peritoneal &#40;DP&#41; de la Sociedad Espa&#241;ola de Nefrolog&#237;a &#40;S&#46;E&#46;N&#46;&#41;&#160;recomienda el uso de indicadores y est&#225;ndares&#46; Hasta el momento pocos grupos los han evaluado&#46; <span class="elsevierStyleBold">Objetivo</span>&#58; Estudiar la evoluci&#243;n y cumplimiento de dichos indicadores&#46; <span class="elsevierStyleBold">M&#233;todos&#58;</span> Recogida prospectiva de los pacientes incidentes en DP &#40;2003-2006&#41; del Grupo Centro de Di&#225;lisis Peritoneal&#46; Se recogen datos basales y semestrales de prescripci&#243;n y evoluci&#243;n cl&#237;nica&#44; eficacia&#44; factores de riesgo&#44; morbimortalidad cardiovascular&#44; anemia y abandono de t&#233;cnica&#46; <span class="elsevierStyleBold">Resultados&#58;</span>&#160;490 pacientes &#40;edad&#58; 53&#44;6 a&#241;os&#59; 61&#44;6&#37; hombres&#41; con seguimiento m&#225;ximo de 3 a&#241;os&#46; Causas de ERC&#58; glomerular 25&#44;5&#37;&#44; diab&#233;tica 16&#44;0&#37;&#44; vascular 12&#44;4&#37;&#44; intersticial 13&#44;3&#37;&#46; El 26&#44;48&#37; estaban en lista de trasplante<span class="elsevierStyleBold">&#46; </span><span class="elsevierStyleItalic">Efi</span><span class="elsevierStyleItalic">cacia de di&#225;lisis&#58; </span>en la primera disponible&#44; la funci&#243;n renal residual era 6&#44;37ml&#47;min&#44; el 67&#44;6&#37; de los pacientes cumpl&#237;a todos los objetivos de eficacia&#46; S&#243;lo un 38&#44;6&#37; se mantiene dentro de rango todo el primer a&#241;o&#46; <span class="elsevierStyleItalic">Anemia&#58;</span> el<span class="elsevierStyleItalic"> </span>79&#44;3&#37; reciben agentes eritropoy&#233;ticos y consiguen una hemoglobina &#40;Hb&#41; media de 12&#44;1 g&#47;dl&#46; El porcentaje de pacientes en rango &#40;Hb&#58; 11-13 g&#47;dl&#41; mejora al a&#241;o &#40;58&#44;4 frente a&#160;56&#44;3&#37;&#41;&#44; manteni&#233;ndose durante el primer a&#241;o s&#243;lo un 25&#44;6&#37;&#46; <span class="elsevierStyleItalic">Riesgo cardiovascular &#40;CV&#41;&#58; </span>el control &#243;ptimo tensional mejora del 36&#44;9 al 47&#44;4&#37;&#44; s&#243;lo el 15&#44;3&#37; permanece en rango durante todo el a&#241;o&#46; Los diab&#233;ticos presentan mayor comorbilidad cardiovascular &#40;48&#44;9 frente a&#160;17&#44;7&#37; con eventos CV previos&#59; p &#60;0&#44;001&#41; y peor control sobre estos factores&#58; hipertensi&#243;n &#40;40&#44;9 frente a 17&#44;9&#37;&#59; p &#60;0&#44;01&#41;&#59; obesidad &#40;22&#44;1 frente a&#160;16&#44;6&#37;&#59; p &#60;0&#44;02&#41; y dislipemia &#40;33&#44;7 frente a&#160;21&#44;8&#37;&#59; p &#60;0&#44;02&#41;&#46;&#160;<span class="elsevierStyleItalic">Evoluci&#243;n&#58;</span>&#160;se estiman tasas de&#58; <span class="elsevierStyleItalic">1&#41; </span>mortalidad&#58; 0&#44;06 &#40;IC 95&#37; 0&#44;04-0&#44;08&#41; muertes&#47;paciente-a&#241;o&#59; <span class="elsevierStyleItalic">2&#41; </span>hospitalizaci&#243;n 0&#44;65 &#40;0&#44;58-0&#44;72&#41; ingresos&#47;paciente-a&#241;o&#59; <span class="elsevierStyleItalic">3&#41;</span> infecci&#243;n peritoneal 0&#44;50 &#40;0&#44;44-0&#44;56&#41; episodios&#47;paciente-a&#241;o&#46; <span class="elsevierStyleBold">Conclusi&#243;n&#58; </span>Disponemos de una referencia multic&#233;ntrica para los nuevos indicadores&#46; El grado de control en HTA&#44; anemia y eficacia mejoran al a&#241;o&#44; pero se alejan de las recomendaciones&#44; especialmente si se valoran durante todo el seguimiento&#46; Los diab&#233;ticos presentan mayor comorbilidad y peor control de los factores CV&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Introduction&#58;</span> In 2007 the Scientific Quality-technical and Improvement of Quality in Peritoneal Dialysis was edited&#46; It includes several quality indicators&#46; As far as we know&#44; only some groups of work had evaluated these indicators&#44; with inconclusive results&#46;<span class="elsevierStyleBold"> Aim&#58;</span> To study the evolution and impact of guidelines in Peritoneal Dialysis&#46; <span class="elsevierStyleBold">Methods&#58;</span> Prospective cohort study of each incident of patients in Peritoneal Dialysis&#44; in a regional public health care system &#40;2003-2006&#41;&#46; We prospectively collected baseline clinical and analytical data&#44; technical efficacy&#44; cardiovascular risk&#44; events and deaths&#44; hospital admissions and also prescription data was collected every 6 months&#46; <span class="elsevierStyleBold">Results&#58;</span></span><span class="elsevierStyleItalic"> Over a period of 3 years&#44; 490 patients &#40;53&#46;58 years of age&#59; 61&#46;6&#37; males&#46;&#41; Causes of ERC&#58; glomerular 25&#46;5&#37;&#44; diabetes 16&#37;&#44; vascular 12&#46;4&#37;&#44; and interstitial 13&#46;3&#37;&#46; 26&#46;48&#37; were on the list for transplant&#46; Dialysis efficacy&#58; Of the first available results&#44; the residual renal function was 6&#46;37 ml&#47;min&#44; achieving 67&#46;6&#37; of all the objectives K&#47;DOQI&#46; 38&#46;6&#37; remained within the range during the entire first year&#46; Anaemia&#58; 79&#46;3&#37; received erythropoietic sttimulating agents and maintained an average Hb of 12&#46;1 g&#47;dl&#46; The percentage of patients in the range &#40;Hb&#58; 11-13 g&#47;dl&#41; improved after a year &#40;58&#46;4&#37; vs 56&#46;3&#37; keeping in the range during this time of 25&#46;6&#37;&#41;&#46; Evolution&#58; it has been estimated that per patient-year the risk of&#58; </span>1&#41;<span class="elsevierStyleItalic"> mortality is 0&#46;06 IC 95&#37; &#91;0&#46;04-0&#46;08&#93;&#59;</span> 2&#41;<span class="elsevierStyleItalic"> admissions 0&#46;65 &#91;0&#46;58-0&#46;72&#93;&#59;</span> 3&#41; <span class="elsevierStyleItalic">peritoneal infections 0&#46;5 &#91;0&#46;44-0&#46;56&#93;&#46; <span class="elsevierStyleBold">Conclusion&#58;</span> Diabetes Mellitus patients had a higher cardiovascular risk and prevalence of events&#46; The degrees of control during the follow-up in many topics of peritoneal dialysis improve each year&#59; however they are far from the recommended guidelines&#44; especially if they are evaluated throughout the whole study&#46;</span></p>"
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Approach to quality objectives in incidents of patients in peritoneal dialysis
Cumplimiento de objetivos de calidad y evolución de los pacientes incidentes en diálisis peritoneal
Grupo Centro de Dialisis Peritoneal, Grupo Centro de Diálisis Peritoneal, J. Portolésb, J.. Portolésc, J. Ocañab, J.. Ocañac, P. López-Sánchezb, P.. López-Sánchezc, M. Gómezb, M.. Gómezc, MT. Riverad, M.T.. Riverae, G. del Pesof, G.. del Pesog, E. Corchetec, MA. Bajoh, M.A.. Bajog, JR. Rodriguez-Palomaresi, J.R.. Rodríguez-Palomarese, A. Fernández-Perpenj..., A.. Fernández-Perpenk, JM. López-Gómezl, J.M.. López-GómezmVer más
b Nephrology Department, University Hospital Fundación Alcorcón, (REDinREN Carlos III. Red 06/0016), Alcorcón, Madrid, Spain,
c Servicio de Nefrología, Hospital Universitario Fundación Alcorcón (REDinREN Carlos III. Red 06/0016), Alcorcón, Madrid,
d Nephrology Department, Ramón y Cajal University Hospital, Madrid, Spain,
e Servicio de Nefrología, Hospital Universitario Ramón y Cajal, Madrid,
f Nephrology Department, La Paz University Hospital, REDinREN (Carlos III. Red 06/0016), Madrid, Spain,
g Servicio de Nefrología, Hospital Universitario La Paz. REDinREN (Carlos III. Red 06/0016), Madrid,
h Nefrologia, La Paz University Hospital, REDinREN (Carlos III. Red 06/0016), Madrid, Spain,
i Nefrologia, Ramón y Cajal University Hospital, Madrid, Madrid, Spain,
j Nefrologia, La Princesa University Hospital, (REDinREN Carlos III. Red 06/0016) Madrid, Madrid, Spain,
k Servicio de Nefrología, Hospital Universitario de la Princesa (REDinREN Carlos III. Red 06/0016), Madrid,
l Nefrologia, Gregorio Marañón University Hospital, Alcorcón, Madrid, Spain,
m Servicio de Nefrología, Hospital General Universitario Gregorio Marañón, Madrid,
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peritoneal transport&#44; anaemia treatment and blood pressure &#40;BP&#41; were collected at the beginning and at six months&#46; The peritonitis&#44; programme admissions or exits were recorded as they occurred&#46;</p><p class="elsevierStylePara">Each centre uses identical databases&#44; specifically designed for this multipurpose data collection&#46; The databases are collected in a central office and unified every six months&#46; A Data Manager audits and debugs the data by ranks and logical routines&#46; Patients sign the informed consent on commencement of the therapy&#46;</p><p class="elsevierStylePara">Although there are no unified treatment protocols&#44; complying with the current guidelines objectives of efficacy&#44; anaemia and BP control is recommended&#46;<span class="elsevierStyleSup">7 </span>According to the degree of control of BP figures&#44; patients are classified into three subgroups&#58; optimum control if the BP is less than 140&#47;90mmHg&#44; the limits are lowered to 130&#47;80mmHg for DM patients or with prior CV event&#59; isolated SBP when the diastolic blood pressure &#40;DBP&#41; is controlled and the systolic blood pressure &#40;SBP&#41; is greater than the limit&#59; and poorly controlled if the DBP is greater than the limit&#44; independent of the SBP value&#46; Statistical management and analysis of all this data is performed with the SPSS v11&#46;0 statistical manager&#46; Data of numerical variables are shown as mean and standard deviation &#40;SD&#41;&#46; Variables without normal distribution &#40;for example&#58; age&#44; Charlson index&#41; are presented as median and range or interquartile interval&#46; All the rates obtained &#40;mortality&#44; admissions and peritonitis&#41; are referred to the technique real time for each patient&#46; Comparisons are made using Student&#8217;s t-tests&#44; the Student&#8217;s t-tests for paired samples&#44; the chi-square or McNemar&#44; according to the nature of the variables&#46; Survival analysis test is made with Kaplan-Meier&#46; Survival data is displayed as mean survival probability and confidence interval at 95&#37; &#40;CI 95&#37;&#41;&#46; All the incident patients are included in the analysis and the loss in follow-up reduced to 0&#46;8&#37;&#46; For each survival analysis&#44; different events are considered&#44; considering the remaining people leaving the programme as follow-up losses&#46; Therefore&#44; the four analyses performed consider&#58; death as an event for patient survival analysis&#59; switching to HD as an event for the technique maintenance analysis&#59; the aggregate of death and switch to HD is the event for successful analysis of the technique and&#44; lastly&#44; the death aggregate including change to HD&#44; transplantation&#44; recovery of renal function and transferral &#40;any programme exit or loss of follow-up&#41; allow us to estimate the technique real time&#46; This last data can be of great interest for the design of management models or prospective follow-up studies&#44; since it is the real time we have to care for and supervise the patient&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Cohort description </span></p><p class="elsevierStylePara">This analysis included 490 incident patients from 2003 to 2006 with a follow-up of 532&#46;26 years-patient and a mean follow-up of 13&#46;36 months &#40;range&#58; 0&#46;1 to 36 months&#41;&#46; The most relevant admission characteristics were&#58; 53&#46;6 years &#40;range&#58; 16-92&#41;&#44; 61&#46;6&#37; male&#44; Charlson comorbidity index &#40;Ch index&#41; 5&#44; interquartile range &#40;3-7&#41;&#44; 19&#46;1&#37; with diabetes mellitus &#40;DM&#41; diagnosis and 23&#46;7&#37; with prior CV events&#46; The most prevalent advanced ACKD aetiologies were&#58; glomerulonephritis 25&#46;5&#37;&#44; diabetic nephropathy 16&#37;&#44; ischemic vascular 12&#46;4&#37;&#44; interstitial 13&#46;3&#37;&#44; adult polycystic kidney disease &#40;APKD&#41; 10&#46;6&#37;&#46; 89&#46;9&#37; are in PD because they decided so and the rest by medical indication&#46; 8&#37; come from failed transplantation and 19&#46;7&#37; from HD&#46; 26&#46;48&#37; of the patients were included on the transplant list in the first 6 months&#46; Table 1 gathers other cohort parameters&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Evolution </span></p><p class="elsevierStylePara">At the end of the follow-up 21&#46;4&#37; of the patients underwent a transplantation&#44; 5&#46;5&#37; deceased&#44; 7&#46;4&#37; switched to HD and 2&#46;1&#37; recovered renal function&#44; the rest remained with the technique&#46; Only 4 patients left the follow-up &#40;0&#46;8&#37;&#41;&#46;</p><p class="elsevierStylePara">Thirty patients deceased during the follow-up&#44; calculating a mortality of 5&#46;6&#37; per year in risk and an annual mortality rate for the population of 0&#46;056 with a CI at 95&#37; &#40;0&#46;04-0&#46;08&#41;&#46; The most outstanding causes of death are&#58; 46&#46;6&#37; CV&#44; 20&#37; infectious&#44; 10&#37; tumoral&#44; 6&#46;7&#37; PD suspension&#44; 3&#46;3&#37; respiratory and 3&#46;3&#37; hepatic-digestive&#46;</p><p class="elsevierStylePara">Mean patient survival is estimated at 33&#46;4 months with a CI at 95&#37; &#40;32&#46;4-34&#46;5&#41;&#59; technique maintenance is estimated at 32&#46;3 &#40;31&#46;1-33&#46;5&#41;&#59; technique success &#40;event&#58; death or switch to HD&#41; is estimated at 30&#46;02 &#40;28&#46;65-31&#46;38&#41; and PD permanence &#40;event&#58; any person leaving the programme or loss of follow-up&#41; is estimated at 22&#46;47 &#40;21&#46;09-23&#46;85&#41; &#40;Figure 1&#41;&#46;</p><p class="elsevierStylePara">Admission per patient and year in risk was 0&#46;65 &#40;without considering admissions for peritonitis&#41; and an estimated annual rate within the interval at 95&#37; &#40;0&#46;58-0&#46;72&#41;&#46; Including stays for peritonitis over 2 days&#44; the annual admission rate is 0&#46;79 &#40;0&#46;72-0&#46;87&#41; admissions per patient and year&#44; i&#46;e&#46; one admission every 1&#46;26 years&#46; The mean hospital stay does not follow a normal distribution and presents an average median stay of 5&#46;5 days and an interquartile range of &#40;2-11&#41;&#46;</p><p class="elsevierStylePara">There were 264 cases of peritonitis in 151 patients &#40;31 patients had two episodes&#44; 18 three and 13 over three&#41;&#44; with a global rate in the sample of 0&#46;5 episodes of peritonitis per year in risk and a CI at 95&#37; of 0&#46;44-0&#46;56 episodes per year&#59; i&#46;e&#46; one peritonitis event every two years&#46; 41&#46;1&#37; of the patients with peritonitis required admission&#46;</p><p class="elsevierStylePara">The mean rate of loss of residual kidney function in cases remaining at least one year on the technique was 2ml&#47;min per year&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Cardiovascular risk </span></p><p class="elsevierStylePara">Before commencing PD&#44; 9&#46;15&#37; had suffered an acute myocardial infarction&#44; 12&#46;68&#37; had peripheral arteriopathy &#40;1&#37; with major amputation&#41;&#44; 4&#46;78&#37; had acute cerebrovascular disease and 6&#46;44&#37; some episode of congestive heart failure &#40;CHF&#41;&#46; As a whole&#44; 23&#46;7&#37; of the patients had suffered some prior CV event and 2&#46;2&#37; &#40;n &#61; 11&#41; three or more&#46;</p><p class="elsevierStylePara">82&#46;02&#37; of the hypertensive patients received hypotension treatment&#46; The baseline BP values were 132&#46;47 &#40;SD &#61; 20&#46;36&#41; and</p><p class="elsevierStylePara">79&#46;86 &#40;SD &#61; 12&#46;49&#41; mmHg&#46; Stratified according to the degree of control&#44; 47&#46;2&#37; presented optimum control&#44; 23&#46;1&#37; isolatedsystolic blood pressure &#40;SBP&#41; and 29&#46;7&#37; poor control&#46; Diabetic patients controlled their blood pressure worse than non-diabetics &#40;each according to the optimum recommended degree of control&#41;&#44; 28&#46;4&#37; versus 47&#46;2&#37; respectively &#40;chi-square 10&#46;23&#59; value P 0&#46;001&#41;&#46; Data displayed in Table 1&#46;</p><p class="elsevierStylePara">Patients diagnosed with DM had greater prevalence of prior CV events at the start of PD &#40;48&#46;9&#37; versus 17&#46;7&#37;&#59; P &#60; 0&#46;001&#41;&#46; The prevalence of uncontrolled CV risk factors was greater among the DM&#46; Therefore&#44; greater percentages of uncontrolled SBP stand out &#40;40&#46;9&#37; versus 17&#46;9&#37; for isolated SBP and 30&#46;7&#37; versus 34&#46;9&#37; for SBP&#41;&#59; as well as obesity &#40;body mass index &#91;BMI&#93; &#62; 30&#58; 22&#46;1 versus 16&#46;6&#37;&#44; P &#61; 0&#46;02&#59; BMI 26&#46;85 &#91;SD &#61; 4&#46;15&#93; versus 25&#46;65 &#91;SD &#61; 4&#46;6&#93;&#59; P &#61; 0&#46;026&#41; and dyslipidaemia &#40;33&#46;69 versus 21&#46;85&#37;&#59; P &#61; 0&#46;02&#41;&#46; Neither age nor gender is associated to different degrees of achievement of BP control objectives&#46;</p><p class="elsevierStylePara">The evolution over the first year of the control of classic CV risk factors is collected in Table 2&#46; The annual comorbidity updates gather three new DM diagnoses and 21 new diagnoses of CV pathology in patients that did not previously have these diagnoses&#46; The causes of admission were&#58; 21 episodes of coronary ischemia or acute myocardial infarction &#40;AMI&#41;&#44; 7 cases of heart failure &#40;CHF&#41;&#44; 4 strokes &#40;CVA&#41;&#44; 8 amputations and one arrhythmia&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Efficacy and peritoneal dialysis techniques </span></p><p class="elsevierStylePara">The initial technique was CAPD with manual interchange in 65&#46;5&#37; of the patients&#44; the rest used a cycling technique chosen by the nephrologist in charge&#46; Table 1 displays the cohort descriptive data&#46; Patient distribution by peritoneal permeability according to the baseline Twardoski PET was&#58; 14&#46;3&#37;&#44; high transport&#59; 35&#46;1&#37;&#44; mid-high&#59; 37&#46;3&#37;&#44; mid-low&#44; and 13&#46;3&#37;&#44; low transport&#46;</p><p class="elsevierStylePara">In the first efficacy measurement available a month after commencing the technique&#44; 67&#46;6&#37; of the patients met all the efficacy objectives in the SEN Guidelines&#46; Of the patients with more than one year follow-up &#40;n &#61; 176&#41;&#44; only 38&#46;6&#37; had all their values within range during the year&#46; Table 2 describes the distribution in techniques and efficacy data&#44; achievement of objectives and peritoneal permeability by techniques and their evolution over the first year&#46; For this evolutional analysis&#44; only patients in the same type of technique during follow-up are considered&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Anaemia treatment </span></p><p class="elsevierStylePara">79&#46;3&#37; of the patients received treatment with erythropoietic factors &#40;47&#46;9&#37; with EPO &#945;o &#946;and 52&#46;1&#37; with darbepoetin &#945;&#41; to reach a mean haemoglobin &#40;Hb&#41; of 12&#46;1g&#47;dl&#46; 67&#37; maintain Hb &#62; 11g&#47;dl during the entire first year of follow-up and only 25&#46;6&#37; between 11 and 13g&#47;dl&#46; The evolution of patients in the first year is displayed in Table 2&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION </span></p><p class="elsevierStylePara">Our study provides current and reliable estimators on meeting therapeutic objectives&#44; admission and mortality rates in our representative incident population&#46; This data can be useful as an initial comparison reference with the recently published Quality Objectives Guidelines&#46; The importance of a systemised approximation with a global viewpoint to our patients&#8217; problems is clear&#58; knowing the results of our surroundings and comparing them with external references can help to improve these results&#46;<span class="elsevierStyleSup">2 </span>From an individual viewpoint&#44; there are publications proving that patients who meet the greater number of therapeutic objectives have a better vital prognosis&#46; For the time being these are only available to patients on HD&#44; but not PD&#46;<span class="elsevierStyleSup">13 </span></p><p class="elsevierStylePara">The use of clinical guidelines&#44; objectives&#44; quality plans and indicators began in the field of HD spurred on by the eagerness to guarantee appropriate quality and uniformity in patient care&#46; The public health system that finances dialysis treatment and the SEN have encouraged the arranged HD supply companies to develop these systems&#46;<span class="elsevierStyleSup">3-5 </span>However&#44; the scenario for PD is another matter&#46; With a minority presence with respect to HD &#40;one PD patient for every eight on HD&#41; and fairly disperse programs &#40;less than 25 patients per centre mean prevalence in our register&#41;&#44; we have required more time to develop these actions&#46;<span class="elsevierStyleSup">7 </span>On the other hand&#44; we do not have sufficient contrasted evidence to establish the objectives that allow us to reduce the risk&#44; nor the prior experience to indicate the standards for our indicators&#46; This explains that in the guidelines published this year&#44; more than half the indicators still have no defined standard&#46;<span class="elsevierStyleSup">7 </span></p><p class="elsevierStylePara">The demographic characteristics of our population &#40;basically regarding age and DM presence is concerned&#41; are more similar to European and Canadian studies than those from the USA&#46;<span class="elsevierStyleSup">14&#44;15 </span>As previously discussed in other analyses of our group&#44; the elevated prevalence of DM and the obesity in the registers from the USA make it difficult to extrapolate their results to our situation&#46;</p><p class="elsevierStylePara">The hospitalisation rate was lower than registered in other series&#44; such as the USRDS register&#44; a likely fact in relation to lower age and comorbidity in our patients&#46;<span class="elsevierStyleSup">16&#44;17 </span>The rate of admissions due to peritonitis is inferior to that published in other series<span class="elsevierStyleSup">17&#44;18 </span>and meets the recommendation of the quality standards&#46;<span class="elsevierStyleSup">7 </span></p><p class="elsevierStylePara">In comparison with other studies&#44; such as the NECOSAD &#40;with an 80&#37; survival rate after 2 years&#41;&#44; our mortality rate is lower&#46;<span class="elsevierStyleSup">15 </span>It is even lower than the national mean recorded in the register of renal patients&#46; To explain this&#44; we considered as possible factors the fact of including only incident patients&#44; the not too elevated age and a lower DM prevalence&#46; Most of the studies found less or similar mortality in PD patients than in HD patients during the first 2 years&#44;<span class="elsevierStyleSup">14 </span>a tendency that progressively evens out&#44; especially in patients aged over 65&#46;<span class="elsevierStyleSup">15 </span>Furthermore&#44; the chosen dialysis technique does not seem to have prognostic value&#44; particularly when it is corrected by selection and comorbidity criteria&#46;<span class="elsevierStyleSup">19 </span>These considerations&#44; added to the lack of quality indicators that are sufficiently validated in PD &#40;can be compared to the HD&#41;&#44; have not allowed the establishment of clear recommendations for one or the other technique&#46;</p><p class="elsevierStylePara">Although we do not have clear and defined indicators in PD as regards validation and prediction of the cardiovascular risk&#44; we have observed that the degree of control of conventional factors such as BP is sufficient&#46; This is in harmony with that reported in other series in our surroundings&#46;<span class="elsevierStyleSup">10 </span></p><p class="elsevierStylePara">As previously published&#44; the comorbidity at the start of the PD is the main factor of vital prognosis&#46; We cannot discern whether the final results depend on the combined action of CV events prior to commencing the technique&#44; age&#44; the DM itself or the patient&#8217;s treatment during the technique process&#46;<span class="elsevierStyleSup">20 </span>In our opinion&#44; systematic detection of CV disease in the early stages of the CKD could result more advantageous for control of CV morbid-mortality&#46; <span class="elsevierStyleSup">21 </span></p><p class="elsevierStylePara">The initial attainment of dialysis efficacy objectives is not difficult in the first stages on PD&#44; in a similar way to that referred to by other groups in our surroundings&#46;<span class="elsevierStyleSup">8 </span>However&#44; maintenance of these after a year of follow-up decreases dramatically&#44; together with the loss of RFR and even less patients maintain them in all the available values throughout the first year&#46; Anyway&#44; several randomised studies have proven that a larger dose of dialysis does not improve survival&#46;<span class="elsevierStyleSup">22 </span></p><p class="elsevierStylePara">Data obtained with respect to anaemia treatment are acceptable if duly evaluated &#40;baseline and after a year&#41;&#44; even though it is true that in only 25&#37; Hb is maintained within the recommended target during the first year&#46; However&#44; this fact is better than the previous HD references&#46; In a recently published Spanish study&#44; less than 5&#37; of the patients on HD were able to maintain their Hb values in the range throughout the year&#44; although in this case monthly determinations were carried out&#46;<span class="elsevierStyleSup">23 </span>The analysis of the factors that associated a better approach to these objectives is not within the scope of this study and does not allow for adequate comparison with other records&#46;<span class="elsevierStyleSup">16 </span></p><p class="elsevierStylePara">The main limitations of this study are the absence of shared action protocols and the follow-up time of the patients&#44; which is under 2 years&#46; An early and integral approach to the advanced ACKD and the various kidney replacement techniques allow for patient mobility between PD&#47;HD&#47;transplantation&#46; Therefore&#44; one third of those commencing the follow-up do not finalise the study&#46; In any case&#44; it should be pointed out that the mean stay does not increase much in other studies or registers with longer track records&#46;<span class="elsevierStyleSup">10&#44;19 </span>It is more relevant that the first cause of leaving the PD programme is transplantation and approximately one in 4 incident patients have already received a transplant in an average time of little over a year&#46; It seems that the new model of integrated kidney replacement treatment has a preferential route in PD as the anteroom to transplant&#46;<span class="elsevierStyleSup">24 </span>The other limitation is the absence of shared protocols&#44; however&#44; the GCDP holds 6-monthly meetings in which the application of clinical guidelines is recommended&#44; results are analysed and specific aspects of patient treatment are discussed&#46; It is to be expected&#44; that over time&#44; this operating system will lead us to standardise our methods&#46;</p><p class="elsevierStylePara">It is a relevant study both for its design as well as its sample size&#46; It allows for identification of areas susceptible of improvement and start up corrective actions&#46; Furthermore&#44; faced with the absence of published nationwide data&#44; it can aid other PD units as a reference&#44; with the final objective for all of reducing their existing variability&#46;<span class="elsevierStyleSup">8 </span></p><p class="elsevierStylePara">In summary&#44; patients that begin PD in our surroundings are younger than in HD&#44; although they present a similar pondered Charlson index adjusted to their age&#46; The hospitalisation&#44; mortality and peritonitis rate was lower than that of other registers&#46; We still have no adequate instruments for measuring CV risk in PD&#44; and the current situation suggests that our patients are not sufficiently controlled&#46; The degree of control in hypertension&#44; anaemia and efficacy improves after a year&#44; however they are far from the recommendations&#44; especially if they are evaluated throughout the whole study&#46;</p><p class="elsevierStylePara">The lack of standardisation in many of the tools proposed lately continues to limit the doctors&#8217; efforts to reduce the variability of their clinical practice&#46; Therefore&#44; we are still in need of studies on the prognosis of our patients in the different kidney replaced treatment techniques&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflict of interest </span></p><p class="elsevierStylePara">The authors affirm that they have no conflicts of interest&#46; This project is jointly funded by&#58; Baxter &#40;2003-2009&#41;&#44; Amgen &#40;2005&#173;2009&#41;&#44; Fresenius &#40;2007-2009&#41; and Gambro &#40;2008-2009&#41; through an agreement with the Nephrology Foundation of Madrid &#40;<span class="elsevierStyleItalic">Fundaci&#243;n Madrile&#241;a de Nefrolog&#237;a-</span>SOMANE&#41;&#46;</p><p class="elsevierStylePara">The authors affirm the sources of prior or subsequent sponsorship as the journal requires&#44; but the characteristics of the article consider that there is no conflict of interest&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10458&#95;108&#95;9192&#95;en&#95;10458&#95;t1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10458_108_9192_en_10458_t1.jpg" alt="Achievement of CV risk objectives&#44; at the start&#44; a year later and throughout the year in patients with a minimum of one year follow-up "></img></a></p><p class="elsevierStylePara">Table 1&#46; Achievement of CV risk objectives&#44; at the start&#44; a year later and throughout the year in patients with a minimum of one year follow-up </p><p class="elsevierStylePara"><a href="grande&#47;10458&#95;108&#95;9193&#95;en&#95;10458&#95;t2&#46;jpg" class="elsevierStyleCrossRefs"><img src="10458_108_9193_en_10458_t2.jpg" alt="Achievement of anaemia and adaptation objectives at the start&#44; after a year and throughout the year in patients with a minimum of one year follow-up "></img></a></p><p class="elsevierStylePara">Table 2&#46; Achievement of anaemia and adaptation objectives at the start&#44; after a year and throughout the year in patients with a minimum of one year follow-up </p><p class="elsevierStylePara"><a href="grande&#47;10458&#95;108&#95;9194&#95;en&#95;10458&#95;f1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10458_108_9194_en_10458_f1.jpg" alt="Kaplan-Meier estimator for patient survival &#40;A&#41;&#44; transferral to HD &#40;B&#41;&#44; leaving the technique due to combined event &#40;death or HD&#41; &#40;C&#41;&#44; and exit for any cause &#40;death&#44; switch to HD&#44; transferral&#44; recovery of kidney function or transplantation&#41;&#46; Mean survival"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Kaplan-Meier estimator for patient survival &#40;A&#41;&#44; transferral to HD &#40;B&#41;&#44; leaving the technique due to combined event &#40;death or HD&#41; &#40;C&#41;&#44; and exit for any cause &#40;death&#44; switch to HD&#44; transferral&#44; recovery of kidney function or transplantation&#41;&#46; Mean survival</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introducci&#243;n&#58;</span>&#160;El Plan de Calidad y Mejora en Di&#225;lisis Peritoneal &#40;DP&#41; de la Sociedad Espa&#241;ola de Nefrolog&#237;a &#40;S&#46;E&#46;N&#46;&#41;&#160;recomienda el uso de indicadores y est&#225;ndares&#46; Hasta el momento pocos grupos los han evaluado&#46; <span class="elsevierStyleBold">Objetivo</span>&#58; Estudiar la evoluci&#243;n y cumplimiento de dichos indicadores&#46; <span class="elsevierStyleBold">M&#233;todos&#58;</span> Recogida prospectiva de los pacientes incidentes en DP &#40;2003-2006&#41; del Grupo Centro de Di&#225;lisis Peritoneal&#46; Se recogen datos basales y semestrales de prescripci&#243;n y evoluci&#243;n cl&#237;nica&#44; eficacia&#44; factores de riesgo&#44; morbimortalidad cardiovascular&#44; anemia y abandono de t&#233;cnica&#46; <span class="elsevierStyleBold">Resultados&#58;</span>&#160;490 pacientes &#40;edad&#58; 53&#44;6 a&#241;os&#59; 61&#44;6&#37; hombres&#41; con seguimiento m&#225;ximo de 3 a&#241;os&#46; Causas de ERC&#58; glomerular 25&#44;5&#37;&#44; diab&#233;tica 16&#44;0&#37;&#44; vascular 12&#44;4&#37;&#44; intersticial 13&#44;3&#37;&#46; El 26&#44;48&#37; estaban en lista de trasplante<span class="elsevierStyleBold">&#46; </span><span class="elsevierStyleItalic">Efi</span><span class="elsevierStyleItalic">cacia de di&#225;lisis&#58; </span>en la primera disponible&#44; la funci&#243;n renal residual era 6&#44;37ml&#47;min&#44; el 67&#44;6&#37; de los pacientes cumpl&#237;a todos los objetivos de eficacia&#46; S&#243;lo un 38&#44;6&#37; se mantiene dentro de rango todo el primer a&#241;o&#46; <span class="elsevierStyleItalic">Anemia&#58;</span> el<span class="elsevierStyleItalic"> </span>79&#44;3&#37; reciben agentes eritropoy&#233;ticos y consiguen una hemoglobina &#40;Hb&#41; media de 12&#44;1 g&#47;dl&#46; El porcentaje de pacientes en rango &#40;Hb&#58; 11-13 g&#47;dl&#41; mejora al a&#241;o &#40;58&#44;4 frente a&#160;56&#44;3&#37;&#41;&#44; manteni&#233;ndose durante el primer a&#241;o s&#243;lo un 25&#44;6&#37;&#46; <span class="elsevierStyleItalic">Riesgo cardiovascular &#40;CV&#41;&#58; </span>el control &#243;ptimo tensional mejora del 36&#44;9 al 47&#44;4&#37;&#44; s&#243;lo el 15&#44;3&#37; permanece en rango durante todo el a&#241;o&#46; Los diab&#233;ticos presentan mayor comorbilidad cardiovascular &#40;48&#44;9 frente a&#160;17&#44;7&#37; con eventos CV previos&#59; p &#60;0&#44;001&#41; y peor control sobre estos factores&#58; hipertensi&#243;n &#40;40&#44;9 frente a 17&#44;9&#37;&#59; p &#60;0&#44;01&#41;&#59; obesidad &#40;22&#44;1 frente a&#160;16&#44;6&#37;&#59; p &#60;0&#44;02&#41; y dislipemia &#40;33&#44;7 frente a&#160;21&#44;8&#37;&#59; p &#60;0&#44;02&#41;&#46;&#160;<span class="elsevierStyleItalic">Evoluci&#243;n&#58;</span>&#160;se estiman tasas de&#58; <span class="elsevierStyleItalic">1&#41; </span>mortalidad&#58; 0&#44;06 &#40;IC 95&#37; 0&#44;04-0&#44;08&#41; muertes&#47;paciente-a&#241;o&#59; <span class="elsevierStyleItalic">2&#41; </span>hospitalizaci&#243;n 0&#44;65 &#40;0&#44;58-0&#44;72&#41; ingresos&#47;paciente-a&#241;o&#59; <span class="elsevierStyleItalic">3&#41;</span> infecci&#243;n peritoneal 0&#44;50 &#40;0&#44;44-0&#44;56&#41; episodios&#47;paciente-a&#241;o&#46; <span class="elsevierStyleBold">Conclusi&#243;n&#58; </span>Disponemos de una referencia multic&#233;ntrica para los nuevos indicadores&#46; El grado de control en HTA&#44; anemia y eficacia mejoran al a&#241;o&#44; pero se alejan de las recomendaciones&#44; especialmente si se valoran durante todo el seguimiento&#46; Los diab&#233;ticos presentan mayor comorbilidad y peor control de los factores CV&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Introduction&#58;</span> In 2007 the Scientific Quality-technical and Improvement of Quality in Peritoneal Dialysis was edited&#46; It includes several quality indicators&#46; As far as we know&#44; only some groups of work had evaluated these indicators&#44; with inconclusive results&#46;<span class="elsevierStyleBold"> Aim&#58;</span> To study the evolution and impact of guidelines in Peritoneal Dialysis&#46; <span class="elsevierStyleBold">Methods&#58;</span> Prospective cohort study of each incident of patients in Peritoneal Dialysis&#44; in a regional public health care system &#40;2003-2006&#41;&#46; We prospectively collected baseline clinical and analytical data&#44; technical efficacy&#44; cardiovascular risk&#44; events and deaths&#44; hospital admissions and also prescription data was collected every 6 months&#46; <span class="elsevierStyleBold">Results&#58;</span></span><span class="elsevierStyleItalic"> Over a period of 3 years&#44; 490 patients &#40;53&#46;58 years of age&#59; 61&#46;6&#37; males&#46;&#41; Causes of ERC&#58; glomerular 25&#46;5&#37;&#44; diabetes 16&#37;&#44; vascular 12&#46;4&#37;&#44; and interstitial 13&#46;3&#37;&#46; 26&#46;48&#37; were on the list for transplant&#46; Dialysis efficacy&#58; Of the first available results&#44; the residual renal function was 6&#46;37 ml&#47;min&#44; achieving 67&#46;6&#37; of all the objectives K&#47;DOQI&#46; 38&#46;6&#37; remained within the range during the entire first year&#46; Anaemia&#58; 79&#46;3&#37; received erythropoietic sttimulating agents and maintained an average Hb of 12&#46;1 g&#47;dl&#46; The percentage of patients in the range &#40;Hb&#58; 11-13 g&#47;dl&#41; improved after a year &#40;58&#46;4&#37; vs 56&#46;3&#37; keeping in the range during this time of 25&#46;6&#37;&#41;&#46; Evolution&#58; it has been estimated that per patient-year the risk of&#58; </span>1&#41;<span class="elsevierStyleItalic"> mortality is 0&#46;06 IC 95&#37; &#91;0&#46;04-0&#46;08&#93;&#59;</span> 2&#41;<span class="elsevierStyleItalic"> admissions 0&#46;65 &#91;0&#46;58-0&#46;72&#93;&#59;</span> 3&#41; <span class="elsevierStyleItalic">peritoneal infections 0&#46;5 &#91;0&#46;44-0&#46;56&#93;&#46; <span class="elsevierStyleBold">Conclusion&#58;</span> Diabetes Mellitus patients had a higher cardiovascular risk and prevalence of events&#46; The degrees of control during the follow-up in many topics of peritoneal dialysis improve each year&#59; however they are far from the recommended guidelines&#44; especially if they are evaluated throughout the whole study&#46;</span></p>"
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Article information
ISSN: 20132514
Original language: English
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