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We evaluated a total of 667 patients and those under 18 years of age were excluded&#46; The cohort was divided into three periods&#44; corresponding to each successive decade &#40;1980-1990&#44; 1991-2000 and 2001-10&#41;&#44; and comparative studies were carried out between the three groups with regard to initial comorbidity&#44; patient survival and technique survival&#46;</p><p class="elsevierStylePara">Data were collected from medical records&#58; age at start of PD&#44; sex&#44; cause of CKD&#44; DM&#44; comorbidity according to the Charlson index&#44;<span class="elsevierStyleSup">11&#44;12</span> origin before the start of the technique &#40;transplant&#44; HD&#44; CKD consultation or acute renal failure &#91;ARF&#93;&#41;&#44; mean duration of the technique&#44; PD stage &#40;if patients had more than one period on PD after a failed renal transplantation or recovery of renal function&#41;&#44; status at the end of follow-up &#40;death&#44; transplantation&#44; transfer to HD or continuation of the technique&#41; and cause of death&#44; if relevant&#46;</p><p class="elsevierStylePara">Failure of the technique was defined as transfer to HD and the determining factors were categorised as ultrafiltration failure&#44; mechanical problems&#44; patient decision&#44; peritonitis&#44; catheter-related problems and insufficient dialysis&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Statistical analysis</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Statistical analysis was performed using the SPSS software version 13&#46;0 &#40;SPSS Inc&#46;&#44; Chicago&#44; Illinois&#44; USA&#41;&#46; All data are expressed using measures of central tendency and dispersion &#40;means &#177; standard deviation&#41; for quantitative variables and frequencies for qualitative variables&#59; for statistical inference&#44; data comparison was carried out using the &#967;<span class="elsevierStyleSup">2</span> test and Student&#8217;s t test in accordance with the types of variables&#46; We used the Kaplan-Meier method for technique and patient survival and the log-rank test to compare the curves&#46; For multivariate analyses&#44; we used the Cox proportional hazards model&#46; A <span class="elsevierStyleItalic">P </span>value<span class="elsevierStyleItalic"> </span>below &#46;05 was considered significant&#46; In patient survival analysis&#44; patients who were lost to follow-up&#44; who received a kidney transplant&#44; recovered renal function or were transferred to HD were censored&#46; In the technique survival analysis&#44; patients who were lost to follow-up&#44; those who recovered renal function&#44; died or received a kidney transplant were censored&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Patient characteristics</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The general profile of the patients is illustrated in Table 1&#46; 54&#46;4&#37; were male&#44; the mean age at the start of PD was 51&#46;47&#177;15&#46;89 years and the follow-up mean was 30&#46;6&#177;28 months &#40;median 23&#46;1 months&#41;&#46;</p><p class="elsevierStylePara">The causes of CKD were in 131 &#40;19&#46;6&#37;&#41; cases&#44; tubulointerstitial nephritis&#44; in 131 &#40;19&#46;6&#37;&#41; cases&#44; diabetic nephropathy&#44; in 114 &#40;17&#46;1&#37;&#41; cases&#44; chronic glomerulonephritis&#44; in 73 &#40;10&#46;9&#37;&#41; cases&#44; unknown&#44; in 66 &#40;9&#46;9&#37;&#41; cases&#44; autosomal dominant polycystic kidney and liver disease&#44; in 61 &#40;9&#46;1&#37;&#41; cases&#44; hypertensive nephropathy&#44; in 59 &#40;8&#46;8&#37;&#41; cases&#44; systemic diseases&#44; in 15 &#40;2&#46;2&#37;&#41; cases&#44; vascular and in 7 &#40;1&#37;&#41; cases&#44; hereditary kidney diseases&#46;</p><p class="elsevierStylePara">The reasons for starting PD were in 498 &#40;74&#46;7&#37;&#41; patients&#44; due to CKD progression&#44; in 57 &#40;8&#46;5&#37;&#41;&#44; due to loss of renal graft&#44; in 67 &#40;10&#37;&#41;&#44; due to transfer from HD and in 45 &#40;6&#46;7&#37;&#41; patients&#44; non-recovery from an episode of ARF&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Solutions used in peritoneal dialysis</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">A total of 146 patients &#40;21&#46;59&#37;&#41; used icodextrin and from 2004&#44; we used the biocompatible PD solutions in 138 &#40;21&#37;&#41; patients&#46; We did not find any differences in the survival between patients who were treated with or without icodextrin &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;5&#41; and those treated or not with biocompatible PD solutions&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Comparative data according to decades</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The data are displayed in Table 1&#46; We observed a progressive increase in the number of incident patients in the three periods&#46; No differences were observed in age&#44; sex&#44; Charlson index&#44; follow-up time or cause of CKD on comparing the three periods&#44; with the most common causes of CKD being tubulointerstitial nephritis &#40;19&#46;6&#37;&#41; and DM &#40;19&#46;6&#37;&#41;&#46; In the last period&#44; we observed a higher incidence of diabetic patients &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;03&#41;&#44; patients on automated PD &#40;APD&#41; &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;000&#41; and patients whose origin was a kidney transplant &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;000&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Reasons for discontinuing peritoneal dialysis</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">At the end of the study&#44; 199 &#40;29&#46;8&#37;&#41; patients died&#44; 232 &#40;34&#46;8&#37;&#41; received a kidney transplant&#44; 149 &#40;22&#46;3&#37;&#41; were transferred to HD&#44; 38 &#40;5&#46;7&#37;&#41; were transferred to another centre&#44; 14 &#40;2&#46;1&#37;&#41; recovered renal function and 35 &#40;5&#46;2&#37;&#41; continued on PD&#46;</p><p class="elsevierStylePara">We observed a significant increase in PD discontinuation due to renal transplantation &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;000&#41; over the three decades&#44; with a decrease in the mortality rate &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;0001&#41;&#44; without observing differences in the transfer to HD&#46; The patients who received a transplant were significantly younger&#44; had a lower Charlson index score and lower prevalence of DM &#40;Table 2&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Analysis of patient survival</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The main cause of death was cardiovascular&#44; followed by infection&#44; without significant differences being observed over the three periods&#46; The median survival was 64&#46;66 months&#46; The overall survival of the patients was 92&#44; 73&#44; 54&#44; 36 and 19&#46;6&#37; at 1&#44; 3&#44; 5&#44; 7 and 10 years&#46; A significant decrease in mortality was observed between the second and third decades &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;04&#41; &#40;Figure 1&#41;&#46; The main risk factors that influenced patient survival were age greater than 65 years &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;000&#41;&#44; male sex &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;037&#41;&#44; a Charlson index score &#62;5 &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;000&#41;&#44; DM &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;000&#41;&#44; type 2 DM in particular &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;000&#41;&#44; and chronic ambulatory PD &#40;CAPD&#41; &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;03&#41;&#46;</p><p class="elsevierStylePara">In the Cox multivariate model&#44; the Charlson index&#44; age and HD origin were related to patient survival&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Analysis of technique survival</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The survival of the technique was 93&#46;4&#44; 78&#46;5&#44; 64&#46;2&#44; 47&#46;1 and 39&#46;6&#37; at 1&#44; 3&#44; 5&#44; 7 and 10 years&#46; Median survival was 82 months&#46; The reasons for transfer to HD were&#58; membrane failure in 38 &#40;25&#46;5&#37;&#41; patients&#44; peritonitis in 33 &#40;22&#46;14&#37;&#41;&#44; wall problems in 16 &#40;10&#46;73&#37;&#41;&#44; patient decision in 44 &#40;29&#46;5&#37;&#41;&#44; insufficient dialysis in 2 &#40;1&#46;34&#37;&#41;&#44; catheter malfunction in 2 &#40;1&#46;34&#37;&#41; and various causes in 14 &#40;9&#46;39&#37;&#41;&#46; The main risk factors for technique survival were age &#62;65 years &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;000&#41;&#44; Charlson index scores &#62;5 &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;000&#41;&#44; DM &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;000&#41;&#44; type 2 DM &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;000&#41; and CAPD modality &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;034&#41;&#46; No differences were observed over the three decades &#40;Figure 2&#41;&#46; In the Cox multivariate model&#44; the Charlson index&#44; age&#44; DM&#44; type 2 DM and ADP are independently related to the survival of the technique&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">In the present study&#44; we assessed patient and technique survival in our PD unit after 30 years of experience&#44; comparing the results in the different decades&#46;</p><p class="elsevierStylePara">According to the 2011 Spanish Renal Disease Registry&#44; the prevalence of CKD in Spain is 1078 pmp and over the years&#44; we have observed an increase in the use of PD as an initial treatment option&#44; although it continues to be the least employed treatment modality &#40;5&#46;27&#37;&#41;&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">The demographic characteristics of the patients in this study are similar to the characteristics of those starting dialysis in Spain&#46; The proportion of diabetic patients in our cohort was 23&#46;3&#37; and the main causes of kidney disease were DM and tubulointerstitial nephritis&#44; which is similar to data reported in other cohorts in Spain&#44; such as that of the registry of Andalusia&#46;<span class="elsevierStyleSup">13&#44;14</span></p><p class="elsevierStylePara">Overall patient survival at five years in our cohort was 54&#37;&#44; which is similar to rates reported in other studies&#44;<span class="elsevierStyleSup">7-10</span> with a significant decrease in mortality between the second and third decades&#46; The improvement in the prognosis of PD patients has been evident in recent decades&#44; as is demonstrated by data in the Renal Registry of Renal Diseases and also in the 2009 ERA-EDTA European population registries&#46;<span class="elsevierStyleSup">15</span> In Spain&#44; Quiros-Ganga reported the experience of PD in Andalusia after 12 years&#44; comparing the results before and after the introduction of biocompatible PD solutions&#44; and improvements in survival could be observed in the last period&#46;<span class="elsevierStyleSup">13</span></p><p class="elsevierStylePara">In line with other studies&#44; age and DM were independent predictors of patient survival&#46;<span class="elsevierStyleSup">10&#44;16&#44;17</span> Improved survival was observed in APD&#44; similar to the results shown by Mujais et al&#46; in the United States&#59;<span class="elsevierStyleSup">10</span> this may be due to variables not taken into account in the study that define the profile of patients starting on APD&#44; such as increased compliance with treatment and possibly higher ultrafiltration&#44; which has an influence on survival&#46;</p><p class="elsevierStylePara">The comorbidity of patients in our study was measured by the Charlson index&#44; and in PD it has proven to be a good predictor and more useful than age&#44; DM or cardiovascular disease separately&#46;<span class="elsevierStyleSup">12</span> In this study&#44; comorbidity was associated with reduced survival of the technique and the patient&#46;</p><p class="elsevierStylePara">Other factors not analysed in this study were shown to influence survival in PD patients&#44; such as serum albumin&#44; serum creatinine&#44; high blood pressure&#44; residual renal function&#44; the peritonitis rate&#44; the creatinine dialysate&#47;plasma ratio and Kt&#47;v urea&#44;<span class="elsevierStyleSup">7&#44;9</span> but most studies agree that PD patient survival is influenced to a much greater extent by the conditions at the beginning of the technique &#40;age&#44; comorbidity and DM&#41; and that these other factors play a marginal role after statistical adjustments are made&#44; including multiple variables&#46;<span class="elsevierStyleSup">6</span></p><p class="elsevierStylePara">In our unit&#44; the survival rate for the technique at five years was 64&#46;2&#37;&#46; In general&#44; the rates reported in other series are variable&#44; with rates at five years from 20&#37; to 68&#46;2&#37;&#44; the latter being described by Nakamoto et al&#46;<span class="elsevierStyleSup">18</span> in the Japanese population in 2006&#44; which is similar to that described in our series&#46; It is important to highlight that the psychosocial factors that primarily include the voluntary decision to withdraw the technique&#44; usually due to the inability to care for oneself&#44; are the main cause of failure &#40;29&#46;5&#37;&#41; in our series and constitute a factor on which technological advances and improved dialysis practices have less influence&#46;</p><p class="elsevierStylePara">Failure rates for the technique show much variability between the different centres&#44; as has been demonstrated in multiple studies&#46;<span class="elsevierStyleSup">10&#44;19-21</span> Huismans et al&#46; analysed several Dutch registration centres and found that this variation is related to the absolute number and proportion of PD patients&#44; with low survival being displayed for the technique in centres with less than 20 patients&#46;</p><p class="elsevierStylePara">Data from our centre represent the longest accumulated experience &#40;30 years&#41; reported to date in the literature&#46; We have seen an increased incidence of PD patients over the three decades&#44; with a significant decrease in mortality between the second and third decade&#46; It is possible that over time certain factors&#44; such as better patient selection&#44; the centre&#8217;s own experience in the technique &#40;collective learning curve&#41;&#44; knowledge of the most appropriate dialysis doses&#44; the use of biocompatible PD solutions&#44; the increased use of APD and continuity of medical and nursing care have contributed to better outcomes in our centre&#46;</p><p class="elsevierStylePara">In terms of its limitations&#44; the design is a single-centre&#44; retrospective study&#44; and as such&#44; we cannot rule out the effect of the centre on survival&#46; Moreover&#44; other factors related to the quality of dialysis&#44; the characteristics of the peritoneal membrane and the peritonitis rate&#44; among others&#44; that may influence patient or technique survival&#44; were not taken into account in this study&#44; although they were analysed in other specific studies&#46;</p><p class="elsevierStylePara">We conclude that in our PD unit&#44; after 30 years of experience&#44; we have seen an increase in the incidence of patients&#44; greater use of APD and an improvement in survival&#46; The maturity of the technique is demonstrated with these indicators&#44; but each patient continues to require high quality care&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Acknowledgements</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors wish to express their gratitude to the Instituto Reina Sof&#237;a de Investigaci&#243;n Nefrol&#243;gica &#40;IRSIN&#41; and REDinREN &#40;RETICS 06&#47;0016 of ISC III&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11956&#95;16025&#95;48096&#95;en&#95;t111956&#95;02&#95;cambiado&#95;abstract&#95;maquetacin&#95;1&#46;jpg" class="elsevierStyleCrossRefs"><img src="11956_16025_48096_en_t111956_02_cambiado_abstract_maquetacin_1.jpg" alt="Baseline characteristics of peritoneal dialysis patients according to decade"></img></a></p><p class="elsevierStylePara">Table 1&#46; Baseline characteristics of peritoneal dialysis patients according to decade</p><p class="elsevierStylePara"><a href="grande&#47;11956&#95;16025&#95;48097&#95;en&#95;t211956&#95;02&#95;cambiado&#95;abstract&#95;maquetacin&#95;12&#46;jpg" class="elsevierStyleCrossRefs"><img src="11956_16025_48097_en_t211956_02_cambiado_abstract_maquetacin_12.jpg" alt="Reasons for discontinuing the technique"></img></a></p><p class="elsevierStylePara">Table 2&#46; Reasons for discontinuing the technique</p><p class="elsevierStylePara"><a href="grande&#47;11956&#95;16025&#95;48098&#95;en&#95;f111956&#95;02&#95;cambiado&#95;abstract&#95;maquetacin&#95;13&#46;jpg" class="elsevierStyleCrossRefs"><img src="11956_16025_48098_en_f111956_02_cambiado_abstract_maquetacin_13.jpg" alt="Survival curves by decade &#40;1980-2010&#41;"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Survival curves by decade &#40;1980-2010&#41;</p><p class="elsevierStylePara"><a href="grande&#47;11956&#95;16025&#95;48099&#95;en&#95;f211956&#46;jpg" class="elsevierStyleCrossRefs"><img src="11956_16025_48099_en_f211956.jpg" alt="Risk factors that influence patient survival&#46; Univariate analysis by&#58; Charlson Index &#40;A&#41;&#44; diabetes mellitus &#40;B&#41;&#44; age &#40;C&#41; and peritoneal dialysis modality &#40;D&#41;&#46;"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Risk factors that influence patient survival&#46; Univariate analysis by&#58; Charlson Index &#40;A&#41;&#44; diabetes mellitus &#40;B&#41;&#44; age &#40;C&#41; and peritoneal dialysis modality &#40;D&#41;&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introducci&#243;n&#58;</span> La di&#225;lisis peritoneal &#40;DP&#41; es una t&#233;cnica establecida de tratamiento renal sustitutivo que gracias a los avances tecnol&#243;gicos y cl&#237;nicos ha mejorado sus tasas de supervivencia en los &#250;ltimos a&#241;os&#46; <span class="elsevierStyleBold">Objetivos&#58;</span> Evaluar la supervivencia del paciente y la t&#233;cnica en DP a lo largo de 30 a&#241;os y seg&#250;n las d&#233;cadas para consolidar su utilidad sanitaria&#46; <span class="elsevierStyleBold">M&#233;todos&#58;</span> Estudio retrospectivo de cohorte de todos los pacientes del programa de DP del Hospital Universitario La Paz &#40;Madrid&#41; desde 1980 a 2010&#46; Variables demogr&#225;ficas y cl&#237;nicas fueron recolectadas de los registros cl&#237;nicos&#46; <span class="elsevierStyleBold">Resultados&#58;</span> Se incluyeron 667 pacientes&#44; 54&#44;4&#160;&#37; varones&#44; con edad media de 51&#44;47 a&#241;os y una mediana de seguimiento de 23&#44;1 meses&#46; Se observ&#243; un aumento progresivo de pacientes incidentes&#44; especialmente en DP automatizada &#40;DPA&#41;&#46; La supervivencia del paciente a 5 a&#241;os fue de 54&#160;&#37;&#44; con una mediana de 64&#44;66 meses&#44; con un aumento significativo en la &#250;ltima d&#233;cada &#40;p &#61; 0&#44;000&#41;&#46; La edad&#44; la comorbilidad&#44; el sexo masculino&#44; la DP cr&#243;nica ambulatoria &#40;DPCA&#41; y la diabetes fueron predictores de la supervivencia del paciente&#46; La supervivencia de la t&#233;cnica a los 5 a&#241;os fue del 64&#44;2&#160;&#37; y la mediana de 82 meses&#46; El &#233;xito de la t&#233;cnica fue mayor en j&#243;venes&#44; en DPA y con menor comorbilidad&#46; <span class="elsevierStyleBold">Conclusiones&#58; </span>Durante 30 a&#241;os se observ&#243; un aumento de los pacientes incidentes&#46; La edad&#44; la comorbilidad y la diabetes siguen siendo los principales determinantes de la supervivencia&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold"><span class="elsevierStyleItalic">Introduction&#58;</span></span><span class="elsevierStyleItalic"> Peritoneal dialysis &#40;PD&#41; is an established renal replacement therapy technique which thanks to the technological and clinical advances has improved its survival rates in recent years&#46; <span class="elsevierStyleBold">Objectives&#58;</span> The aim of this study was to evaluate patient and technique survival in PD over 30 years&#44; according to the different decades in order to consolidate its usefulness in healthcare&#46; <span class="elsevierStyleBold">Method&#58;</span> Retrospective cohort study including all patients in the PD programme of the Hospital Universitario La Paz &#40;Madrid&#41;&#44; from 1980 to 2010&#46; Demographic and clinical variables were collected from medical records&#46; <span class="elsevierStyleBold">Results&#58;</span> A total of 667 patients were included&#44; 54&#46;4&#37; male&#44; with a mean age of 51&#46;47 years and a median follow-up period of 23&#46;1 months&#46; There was a progressive increase in PD incident patients&#44; especially in automated PD &#40;APD&#41;&#46; Patient survival at 5 years was 54&#37;&#44; with a median of 64&#46;66 months&#44; increasing significantly in the last decade &#40;P</span>&#61;&#46;000<span class="elsevierStyleItalic">&#41;&#46; Age&#44; comorbidity&#44; male sex&#44; chronic ambulatory PD &#40;CAPD&#41; and diabetes were predictors of patient survival&#46; Technique survival at 5 years was 64&#46;2&#37; with a median of 82 months&#46; The success of the technique was greater in younger patients on APD and with lower comorbidity&#46;&#160;<span class="elsevierStyleBold">Conclusions&#58;</span> Over 30 years&#44; we found an increase in incident patients&#46; Age&#44; comorbidity and diabetes still continue to be the main determining factors for survival&#46;</span></p>"
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