Results of the cooperative study of Spanish peritoneal dialysis registries: analysis of 12 years of follow-up
Resultados del trabajo cooperativo de los registros españoles de diálisis peritoneal: análisis de 12 años de seguimiento
Grupo Cooperativo Registros Españoles de Diálisis Peritoneala, César Remón-Rodríguezb, Pedro Quirós-Gangac, José Portolés-Pérezd, Carmina Gómez-Roldáne, Alfonso Miguel-Carrascof, Merce Borràs-Sansg, Mercè Borràs-Sansh, Ana Rodríguez-Carmonai, Miguel Pérez-Fontánj, J. Emilio Sánchez-Álvarezk, Carmen Rodríguez Suárezk
a Servicio de Nefrología Hospital Universitario Puerto Real-Puerta del Mar, Cádiz
b UGC de Nefrología, Hospital Universitario Puerto Real-Puerta del Mar, Cádiz
c UGC de Nefrología, Hospital Universitario Puerto Real, Cádiz
d Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Madrid,
e Servicio de Nefrología, Complejo Hospitalario y Universitario de Albacete,
f Servicio de Nefrología, Hospital Clínico Universitario de Valencia,
g Servicio de Nefrología Hospital Arnau de Vilanova, Lérida, Spain,
h Servicio de Nefrología, Hospital Arnau de Vilanova, Lleida,
i Servicio de Nefrología, Hospital Universitario Juan Canalejo, La Coruña,
j Servicio de Nefrología, Hospital Universitario Juan Canalejo La Coruña,
k Servicio de Nefrología, Hospital Universitario Central de Asturias, Oviedo,
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PD, despite being a technique performed by the patient in their own home and requiring fewer resources, is poorly developed in our country, although there are very significant differences among autonomous communities.</p><p class="elsevierStylePara">Some of these communities have separately reported the results of their PD registries, such as the Eastern region, Madrid and Centre and Andalusia,<span class="elsevierStyleSup">1</span> but there is currently, unlike the case for kidney patients as a whole,<span class="elsevierStyleSup">2</span> no registry that gives a complete and overall view of the PD situation in Spain.</p><p class="elsevierStylePara">After some years spent developing a report on PD in Spain from separate data from each regional registry and society, which were presented at different Spanish PD meetings, we made an effort to compile and analyse all these data in aggregate and comparatively, in order to better understand the situation of this renal replacement therapy (RRT) technique in Spain, and we achieved a sample which may be considered representative and which may be extrapolated to the whole of Spain. This was the main objective of this study, which may be broken down into three parts as follows:</p><li>Collect epidemiological, clinical and progression data of the incident and prevalent PD population over the last decade (1999-2010) and over the largest possible geographic area in Spain.</li><li>Determine descriptive and intermediary result data for this population: incidence and prevalence (overall and by community), as well as other demographic data and data on the technique and its main complications.</li><li>Carry out studies on morbidity and mortality and patient and technique survival as final results variables.</li><p class="elsevierStylePara">As we will discuss in the corresponding section, we encountered significant methodological difficulties in this report, mainly due to the different developmental processes of the autonomous community registries that contributed data.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">PATIENTS AND METHOD</span><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic"><span class="elsevierStyleBold"> </span></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Study design and population</span><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">This was a descriptive, observational cohort study whose aim was to understand the PD situation in Spain, covering the largest possible percentage of the Spanish adult population (over 14 years of age) that we could recruit, at least over the last decade (1999-2010), and over the largest possible geographic area, in terms of demographic data, technique penetration, geographic differences, incidence and prevalence, technical aspects, intermediate indicators, comorbidity and final outcomes, such as patient and technique survival.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Information collection strategies</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold"><span class="elsevierStyleItalic">A. Identification of the main autonomous and/or local/regional PD registries in Spain:</span></span></p><p class="elsevierStylePara">Not all autonomous communities have these registries. From previous publications and reports at conferences, we identified the following communities and/or areas that could participate in the study:</p><ul><li>Autonomous Community of Andalusia: through the Autonomous Transplant Coordination Information System.</li><li>Autonomous Communities of Galicia and Asturias.</li><li>Autonomous Community of the Basque Country.</li><li>Eastern registry: Valencian Community, Community of Murcia and Cuenca and Albacete provinces.</li><li>Central registry: Autonomous Community of Madrid and Cáceres, Ciudad Real, Guadalajara, Ávila, Valladolid, Segovia, Burgos, Soria, Palencia and Zaragoza provinces.</li><li>Autonomous Community of Catalonia: through the Registre de Malalts Renals de Catalunya, Organització Catalana de Trasplantaments.</li></ul><p class="elsevierStylePara"><span class="elsevierStyleBold"><span class="elsevierStyleItalic">B. Communication with heads of the different autonomous PD registries and requests to share their data in the single registry that is the subject of this project-report.</span></span></p><p class="elsevierStylePara">To guarantee the maximum number of positive responses and minimise losses, we developed an information strategy for the registry heads via electronic and telephone communication and at meetings before we sent and they completed the questionnaires in the different PD forums already existing in Spain (the National Peritoneal Dialysis Conference, the National Conference of the Spanish Society of Nephrology and the Support Group for Peritoneal Dialysis Development in Spain, etc.).</p><p class="elsevierStylePara"><span class="elsevierStyleBold"><span class="elsevierStyleItalic">C. Authorisation for data transfer by the competent registry heads.</span></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"><span class="elsevierStyleItalic">D. The sending, completion and return of the questionnaire for data collection.</span></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Data processing strategies</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Once the information had been received and processed, it was included as aggregate data, to be studied and compared as described in the following analysis section, which could also be used for future needs (various future projects).</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Data analysis</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">In this section, we include all PD data from the last decade in Spain (1999 to 2010). Some registries may not have provided data for the whole period, in which case, data corresponding to the years they provided were included in the analysis.</p><ul><li>The start of follow-up for each patient was defined as the date in which they were included in the PD programme. Patients diagnosed with acute renal failure were excluded.</li><li>The end of follow-up for each patient was defined as the time when they discontinued the PD technique, either due to transplantation, death or transfer to HD. Those who were still on the technique at the end of the study period (31 December 2010), were described as “living and on PD”.</li><li>INCIDENCE was defined as the number of new PD patients per year.</li><li>PREVALENCE was defined as the number of patients on PD on 31 December of each year.</li><li>Causes of chronic kidney disease and death were defined in accordance with the European Dialysis and Transplant Association codification system.</li><li>In the survival analysis, the starting point was defined as the first day of PD.</li><li>The final events for survival analysis were:</li></ul><p class="elsevierStylePara">-      Patient death (patient survival studies): patients who were withdrawn due to transplantation, transfer to HD or loss to follow-up were excluded from this analysis.</p><p class="elsevierStylePara">-      Transfer to HD (technique survival studies): patients who were withdrawn due to transplantation, death or loss to follow-up were excluded from this analysis.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Variables</span></span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic"> </span></p><p class="elsevierStylePara">The variables analysed were demographic variables, such as sex, age at the start of the technique, kidney disease aetiology, technique aspects, such as whether the patient was on automatic PD (APD) or continuous ambulatory PD (CAPD), type of solutions (lactate or bicarbonate with low glucose degradation products, icodextrin), implantation technique and type of catheter, initial comorbidity (diabetes, high blood pressure, cardiovascular disease, old age, etc.), Charlson index, mean technique duration time, condition at the end of follow-up (deceased, received a transplant, transferred to HD, or living and on PD) and cause of death, if applicable.</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Statistical methodology</span></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">The data were analysed using the SPSS statistical software. We used central tendency and dispersion measurements (means, standard deviation) for quantitative variables and frequencies for qualitative variables; for inferential statistics, data comparison using the χ<span class="elsevierStyleSup">2</span> test and the Student’s <span class="elsevierStyleItalic">t</span>-test according to the types of variables, risk identification and 95% confidence intervals, Kaplan-Meier survival curves and the log-rank test for curve comparison. For multivariate analysis, we used the Cox proportional hazards model.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Descriptive and population characteristics</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The data collected by the different autonomous registries, over a maximum period from 1 January 1999 to 31 December 2010, were taken from <span class="elsevierStyleBold">6445 patients.</span></p><p class="elsevierStylePara">Table 1 lists the incident patients in each registry in the period studied, the mean annual incidence per million inhabitants, prevalent patients at 31 December 2010 (2095 patients in total), as well as the rate of prevalent patients per million inhabitants and by geographical area on this date.</p><p class="elsevierStylePara">It should be noted that not all communities provided patient data for the whole period, which was due to the difficulties involved in homogenising the databases, as well as the registry structure of each community, the time at which they started collecting data and their degree of availability.</p><p class="elsevierStylePara">However, we were able to collect data from a <span class="elsevierStyleBold">total geographic area covering</span><span class="elsevierStyleBold">32,853,251 inhabitants older than 14 years of age, that is, 84% of the total Spanish population of this age</span>, which provided us with results that are highly representative of the situation in our country with regard to PD technique, and these results can be extrapolated to the whole of Spain (Figure 1).</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Incidence: </span>Figure 2 displays a slight increase in overall incidence in PD in Spain (broken red arrow), particularly in recent years, and in almost all autonomous communities, with Madrid-Centre, Catalonia and Andalusia showing a moderate and continuous increase from the start of the period studied.</p><p class="elsevierStylePara">As we can see in Table 1, the mean annual rate of incident patients per million inhabitants (ppm) varied between the different communities, with values between 17.81ppm in Andalusia and 29.90ppm in the Basque Country being observed.</p><p class="elsevierStylePara">In a mean 78.5% of these incident patients, PD was the first RRT, with the mean treatment background percentages for HD and transplantation being 16.4% and 5.1%, respectively. These frequencies were fairly homogeneous for all communities (Figure 3).</p><p class="elsevierStylePara">On average, in 80% of cases, PD was freely chosen by patients (range between values of 83% in Andalusia and 92% in Madrid-Centre and values of around 70%-73% in the Eastern region and the Basque Country); in the remaining 20%, there was a medical cause, mainly vascular access problems (impossibility or exhaustion) and heart diseases, that prevented PD from being selected</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Prevalence (Table 1 and Figure 4):</span> the mean annual prevalence per million inhabitants was very heterogeneous and varied between different geographic regions. PD had a higher penetration in communities such as Galicia-Asturias (99ppm) and the Basque Country (86ppm), medium penetration in the Eastern region (58.3ppm) and a relatively low penetration in communities such as Andalusia (42ppm), Madrid-Centre (45ppm) and Catalonia (42.5ppm). These differences have been reduced in recent years and, as such, in the last year (at 31 December 2010) we observed an increase in prevalence in the latter communities (51-55ppm) with respect to the mean for the whole study period.</p><p class="elsevierStylePara">Figure 5 shows <span class="elsevierStyleBold">distribution by age and sex</span>, which was very homogeneous for all communities, with a higher concentration of patients between 40-60 and 60-80 years of age being observed. There was a higher number of males with respect to females, with a male index ranging from 1.27 in the Eastern region to 1.81 in Catalonia.</p><p class="elsevierStylePara">We observed a quite high degree of homogeneity in the <span class="elsevierStyleBold">aetiology of kidney disease</span> (Figure 6); glomerular diseases, diabetic nephropathy, vascular nephropathy (hypertensive-arteriosclerotic) and polycystic kidney disease were the most common aetiologies.</p><p class="elsevierStylePara">The percentage of our patients <span class="elsevierStyleBold">included in the kidney transplant waiting list </span>was quite high, with a mean value of 43%. Old age and associated comorbidities were the main reasons for exclusion.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Data on the technique</span> </p><p class="elsevierStylePara">In recent years, we observed a progressive mean increase in <span class="elsevierStyleBold">APD use</span> with respect to CAPD use, reaching almost 50% (range between 25%-65%). The broken red arrow in Figure 7 illustrates this fact. This increase in the use of an automatic technique was practically constant for all autonomous communities, although there were notable differences in its use amongst those with more extreme values (25% Eastern region and 65% Madrid-Centre).</p><p class="elsevierStylePara">The most commonly used <span class="elsevierStyleBold">catheters</span> were Swan-Neck and double-cuff straight Tenckhoff catheters. The <span class="elsevierStyleBold">implantation technique</span> was surgical in almost 80% of patients, although in the last few years, percutaneous implantation by the nephrologist has increased. The location was predominantly paramedian (80%).</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Peritonitis</span><span class="elsevierStyleItalic"><span class="elsevierStyleBold">:</span></span> peritonitis rate per patient and year (Figure 8) varied between the different communities, although in general, it decreased slightly during the period studied (broken red line).<span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">With respect to the causative germ, overall (mean of all data reported), the culture was positive for gram-positive germs in 57.3% and for gram-negative germs in 22%. Peritonitis was polymicrobial in 2.4% of patients, fungal in 2.7% and no growth was detected (sterile peritonitis) in 14.2%. These data were displayed by community in Figure 9.</p><p class="elsevierStylePara">Peritonitis (Figure 10) was mostly cured (80%), 8% had recurrences and it was necessary to withdraw the catheter in approximately 11% of cases. In just over 1% of cases, patients died due to peritoneal infection.  </p><p class="elsevierStylePara"><span class="elsevierStyleBold">The reasons for withdrawing from the PD programme</span> were distributed quite homogeneously between the different communities (Figure 11). In almost a third of cases, withdrawal was due to patient death (mean 28%), in a third, it was due to renal transplantation (mean 39%) and a third were transferred to HD (technique failure: mean 32%). The main reasons known/reported for transfer to HD continue to be peritonitis (in almost one third of cases: 31.1%), followed by ultrafiltration problems, insufficient dialysis or problems related to the peritoneal catheter (26%) (Figure 12).</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Comorbidity and patient and technique survival</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The <span class="elsevierStyleBold">main comorbidities at the start of the technique</span> were cardiovascular disease (30.2%) and diabetes mellitus (24.2%). The mean Charlson Index was 4.6. We observed a slight increase in diabetic nephropathy in the latter years. All these data are presented as means and separately by autonomous community in Figure 13, which also displays diabetic nephropathy prevalence progression during the period studied and by geographic area.</p><p class="elsevierStylePara">The<span class="elsevierStyleBold"> gross annual mortality rate</span> for patients on PD has decreased continuously in recent years (Figure 14, broken red line) in almost all geographic areas that provided these data.</p><p class="elsevierStylePara">There was consistency between communities with regard to <span class="elsevierStyleBold">causes of death,</span> cardiovascular disease (mean 39%) and infection (mean 22.5%) being the main causes.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Patient survival</span></span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Table 2 displays annual accumulated survival (in percentages) of patients by autonomous community. Bearing in mind that the data contributed by the Madrid-Centre and Basque Country regions only referred to patients with PD as the first RRT and that these data were taken into account for the calculation, mean survival was 92.2%, 82.8%, 74.2%, 64.8% and 57% after one, two, three, four and five years, respectively.</p><p class="elsevierStylePara">To analyse the influence of risk factors for patient survival present at the time the technique was introduced, we compared survival curves using the log-rank test in some communities and geographic regions such as Andalusia, Catalonia and the Eastern region (Figure 15). We observed that the presence of diabetes mellitus or cardiovascular disease at that time (<span class="elsevierStyleItalic">p</span><.001 for Andalusia and Catalonia; <span class="elsevierStyleItalic">p</span><.05 for the Eastern region) significantly influenced survival. Likewise, the period in which PD was started (before or after 2004) also had a statistically significant influence.</p><p class="elsevierStylePara">To assess the independence of the different factors on their influence on survival, the Cox multivariate proportional hazards model (Figure 15) was used both in Andalusia and in the Eastern region. The following factors significantly and independently had the worst survival rates: a) age (Andalusia and the Eastern region), b) cardiovascular disease (Andalusia and the Eastern region), c) diabetes mellitus (Andalusia and the Eastern region), d) CAPD compared to APD (Andalusia), e) starting PD in the first period studied, before 2004 (Andalusia) and f) residual renal function at the start of PD (the Eastern region).</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Technique survival</span></span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Lastly, Table 3 displays annual accumulated survival rates (in percentages) of the technique (patients were excluded for withdrawal due to death [apart from in Catalonia] or transplantation) and survival rates by autonomous community.</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">For the first time, this study collected a sufficient amount of data on RRT with PD, highly representative of the progression of this technique in Spain over the last decade and obtained a snapshot of the present day situation, showing epidemiological, demographic, technical, comorbidity and survival results, both for patients and technique. Methodological difficulties were mainly due to the different developmental processes of the autonomous registries that contributed data and this was the report’s main limitation.</p><p class="elsevierStylePara">PD growth in our country is discrete but clear. It is not homogeneous but it is universal for the different communities, with a 3.7% increase in the mean annual incidence rate between 2004 and 2010. This trend has been maintained over the last six years and is steady, without intermittent decreases. The Registry of the Spanish Society of Nephrology also observed this increase in PD incidence in recent years, although a slight decrease in HD incidence has also been observed, since transplantation has increased thanks to living donor and early transplantation.<span class="elsevierStyleSup">2</span> Likewise, an increased prevalence has been observed.</p><p class="elsevierStylePara">The mean overall age of the PD population, 54.7 years, is lower than that reported for HD patients. In terms of age distribution, there is prevalence in the 40-60 and 60-80 year old groups, as is the case for the other national and international registries.<span class="elsevierStyleSup">2-7</span></p><p class="elsevierStylePara">The most common known aetiologies of kidney disease in PD patients were glomerulonephritis (20.1 %), followed by diabetic nephropathy (17.2%), unlike in the National Registry for all RRT, which displays diabetes as an aetiology in 25% of patients. This difference may be explained by communities in the north of Spain, which are those that most use PD, having a lower incidence of diabetes.<span class="elsevierStyleSup">8</span> We can also argue that PD is being indicated less in older diabetic patients, given the lower survival rate communicated for this group in some studies, such as those of the American Registry<span class="elsevierStyleSup">9</span> or the Australia-New Zealand Registry.<span class="elsevierStyleSup">10</span></p><p class="elsevierStylePara">In the aetiology of our cooperative study, there was some discrepancy between communities in terms of labelling an aetiology as “unknown” or “other”, which may have corresponded to differences with regard to the definition of these concepts, and even to their inclusion within these groups or the vascular nephropathy group.</p><p class="elsevierStylePara">The inclusion of PD patients on transplant waiting lists is high and higher than for HD,<span class="elsevierStyleSup">1</span> which may be explained by the population being younger and having less comorbidity.</p><p class="elsevierStylePara">During the period observed, there was initially an increase in APD, and in the last few years, its use has stabilised at around 50%. These data are very similar to those of most developed countries.</p><p class="elsevierStylePara">The mean peritonitis rate in 2010 was 0.49 episodes/patient/year (approximately one episode every 25 months/patient), an incidence that had been decreasing slightly since previous years. These rates were lower than those indicated as the maximum amount acceptable by the Guidelines of the International Society for Peritoneal Dialysis, which is one episode every 18 months (0.67 per year at risk).<span class="elsevierStyleSup">11</span> Although the peritonitis rate depends on the characteristics of the population being treated, they are still above levels considered optimal of one episode every 40 to 50 months published by some authors.<span class="elsevierStyleSup">12,13</span></p><p class="elsevierStylePara">The most common reasons for discontinuing PD were distributed almost in three thirds, corresponding to patient death, renal transplantation and technique failure. This distribution in patient withdrawal was consistent with that reported previously by other authors.<span class="elsevierStyleSup">14</span> The fact that two registries (the Basque Country and Madrid-Centre) only collected data for patients who started RRT with PD logically resulted in noticeably higher withdrawal due to transplantation and lower mortality, and probably less technique failure, since there was greater residual renal function. We were not able to carry out a differential analysis of incident patients whose first treatment was PD because we did not have this data for many registries.</p><p class="elsevierStylePara">PD patient survival in Spain, measured both by the gross mortality rate and annual survival probability, has seen an overall improvement in the last decade. Overall survival is similar to that published by most European registries<span class="elsevierStyleSup">15-17</span> and higher than that of the American<span class="elsevierStyleSup">9,18 </span>and Australia-New Zealand<span class="elsevierStyleSup">10</span> registries (Table 4).</p><p class="elsevierStylePara">Several factors have a more significant influence on this better prognosis. We know, due to multivariate studies carried out in some of the participating communities (Andalusia and the Eastern region), that comorbidities at the start of the technique, such as the patient’s age, diabetes, cardiovascular disease or loss of residual renal function have an unfavourable influence. By contrast, patient inclusion in PD programmes in more recent years has had a positive influence on survival. This is probably due to a better protection of the peritoneal membrane and its ultrafiltration capacity, the use of more biocompatible solutions that have a lower glucose concentration as an osmotic agent, such as icodextrin,<span class="elsevierStyleSup">19 </span>particularly indicated in patients with a temporary or permanent hyperpermeable peritoneum or in patients with PD of long duration (both in CAPD and APD), or as a strategy in overhydrated patients, and lastly, due to better quality in the general practice of the technique: appropriate dialysis dose, patient monitoring, prevention and management of complications (peritonitis, etc.), prevention and treatment of metabolic and cardiovascular risks (dyslipidaemia, high blood pressure, fluid overload control, etc.).<span class="elsevierStyleSup">20-22</span></p><p class="elsevierStylePara">Likewise, technique survival has also increased, with mean figures above 50% after 5 years being observed, which is comparable to results of other registries and studies (Table 5).<span class="elsevierStyleSup">23,24</span> We understand that, as well as the better protection of the peritoneal membrane referred to above and the use of these solutions, accumulated experience on the technique, better patient selection for PD in hospitals, the decrease in peritonitis rates and its better treatment have also had an influence, amongst others.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">KEY POINTS</span></p><li>PD incidence and prevalence in Spain are increasing moderately and in a generalised manner, although they continue to maintain an irregular distribution by autonomous community. </li><li>APD use has shown a global increase, particularly in autonomous communities in which it was initially less implemented. </li><li>Peritonitis rate is approximately one episode every 25-30 months/patient, with a slight decrease being observed in recent years.</li><li>Patient survival has increased in recent years, with the analysis being adjusted for age and comorbidity.</li><li>Technique survival is greater than 50% after 5 years.</li><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article.</p><p class="elsevierStylePara"><a href="grande/12106_16025_54610_en_t112106.jpg" class="elsevierStyleCrossRefs"><img src="12106_16025_54610_en_t112106.jpg" alt="Mean number of incident and prevalent patients and rate per million inhabitants by registry for the whole study period. "></img></a></p><p class="elsevierStylePara">Table 1. Mean number of incident and prevalent patients and rate per million inhabitants by registry for the whole study period. </p><p class="elsevierStylePara"><a href="grande/12106_16025_54611_en_f2121063.jpg" class="elsevierStyleCrossRefs"><img src="12106_16025_54611_en_f2121063.jpg" alt="Annual accumulated patient survival (%) by year and community. "></img></a></p><p class="elsevierStylePara">Table 2. Annual accumulated patient survival (%) by year and community. </p><p class="elsevierStylePara"><a href="grande/12106_19904_54612_en_12106_t3.jpg" class="elsevierStyleCrossRefs"><img src="12106_19904_54612_en_12106_t3.jpg" alt="Accumulated annual technique survival (%) by year and community. "></img></a></p><p class="elsevierStylePara">Table 3. Accumulated annual technique survival (%) by year and community. </p><p class="elsevierStylePara"><a href="grande/12106_16025_54613_en_t41210617.jpg" class="elsevierStyleCrossRefs"><img src="12106_16025_54613_en_t41210617.jpg" alt="Table comparing patient survival."></img></a></p><p class="elsevierStylePara">Table 4. Table comparing patient survival.</p><p class="elsevierStylePara"><a href="grande/12106_19904_54614_en_12106_t5_copy2.jpg" class="elsevierStyleCrossRefs"><img src="12106_19904_54614_en_12106_t5_copy2.jpg" alt="International comparison. Accumulated annual technique survival (%) by year."></img></a></p><p class="elsevierStylePara">Table 5. International comparison. Accumulated annual technique survival (%) by year.</p><p class="elsevierStylePara"><a href="grande/12106_16025_54615_en_f112106.jpg" class="elsevierStyleCrossRefs"><img src="12106_16025_54615_en_f112106.jpg" alt="Population"></img></a></p><p class="elsevierStylePara">Figure 1. Population</p><p class="elsevierStylePara"><a href="grande/12106_16025_54616_en_f10121063.jpg" class="elsevierStyleCrossRefs"><img src="12106_16025_54616_en_f10121063.jpg" alt="Peritonitis progression by year and registry."></img></a></p><p class="elsevierStylePara">Figure 10. Peritonitis progression by year and registry.</p><p class="elsevierStylePara"><a href="grande/12106_16025_54617_en_f11121063.jpg" class="elsevierStyleCrossRefs"><img src="12106_16025_54617_en_f11121063.jpg" alt="Percentages of the three main causes of withdrawal from peritoneal dialysis treatment by registry."></img></a></p><p class="elsevierStylePara">Figure 11. Percentages of the three main causes of withdrawal from peritoneal dialysis treatment by registry.</p><p class="elsevierStylePara"><a href="grande/12106_16025_54618_en_f12121063.jpg" class="elsevierStyleCrossRefs"><img src="12106_16025_54618_en_f12121063.jpg" alt="Reasons for transfer to haemodialysis."></img></a></p><p class="elsevierStylePara">Figure 12. Reasons for transfer to haemodialysis.</p><p class="elsevierStylePara"><a href="grande/12106_16025_54619_en_f13121063.jpg" class="elsevierStyleCrossRefs"><img src="12106_16025_54619_en_f13121063.jpg" alt="Percentage of cardiovascular disease and diabetes at the start of the technique, and the Charlson index and percentage progression of diabetic nephropathy by year and community."></img></a></p><p class="elsevierStylePara">Figure 13. Percentage of cardiovascular disease and diabetes at the start of the technique, and the Charlson index and percentage progression of diabetic nephropathy by year and community.</p><p class="elsevierStylePara"><a href="grande/12106_16025_54620_en_f14121063.jpg" class="elsevierStyleCrossRefs"><img src="12106_16025_54620_en_f14121063.jpg" alt="Progression of the gross annual mortality rate by year and registry. "></img></a></p><p class="elsevierStylePara">Figure 14. Progression of the gross annual mortality rate by year and registry. </p><p class="elsevierStylePara"><a href="grande/12106_16025_54621_en_t51210617.jpg" class="elsevierStyleCrossRefs"><img src="12106_16025_54621_en_t51210617.jpg" alt="Survival study (Andalusia, Catalonia and Eastern registries); survival curves by the log-rank test, in accordance with presence of diabetes, cardiovascular disease and the start period. Multivariate Cox proportional hazards model."></img></a></p><p class="elsevierStylePara">Figure 15. Survival study (Andalusia, Catalonia and Eastern registries); survival curves by the log-rank test, in accordance with presence of diabetes, cardiovascular disease and the start period. Multivariate Cox proportional hazards model.</p><p class="elsevierStylePara"><a href="grande/12106_16025_54622_en_f2121063.jpg" class="elsevierStyleCrossRefs"><img src="12106_16025_54622_en_f2121063.jpg" alt="Number of new patients by year and registry (incidence)."></img></a></p><p class="elsevierStylePara">Figure 2. Number of new patients by year and registry (incidence).</p><p class="elsevierStylePara"><a href="grande/12106_16025_54623_en_f3121063_copy1.jpg" class="elsevierStyleCrossRefs"><img src="12106_16025_54623_en_f3121063_copy1.jpg" alt="Treatment background of peritoneal dialysis patients by different registries and the mean."></img></a></p><p class="elsevierStylePara">Figure 3. Treatment background of peritoneal dialysis patients by different registries and the mean.</p><p class="elsevierStylePara"><a href="grande/12106_16025_54624_en_f4121063.jpg" class="elsevierStyleCrossRefs"><img src="12106_16025_54624_en_f4121063.jpg" alt="Prevalence by year and per million inhabitants. Comparison of the mean for the whole period with the year 2010."></img></a></p><p class="elsevierStylePara">Figure 4. Prevalence by year and per million inhabitants. Comparison of the mean for the whole period with the year 2010.</p><p class="elsevierStylePara"><a href="grande/12106_16025_54625_en_f5121063_copy1.jpg" class="elsevierStyleCrossRefs"><img src="12106_16025_54625_en_f5121063_copy1.jpg" alt="Mean age and standard deviation, patient distribution by age and sex in accordance with the different registries."></img></a></p><p class="elsevierStylePara">Figure 5. Mean age and standard deviation, patient distribution by age and sex in accordance with the different registries.</p><p class="elsevierStylePara"><a href="grande/12106_16025_54626_en_f6121063_copy1.jpg" class="elsevierStyleCrossRefs"><img src="12106_16025_54626_en_f6121063_copy1.jpg" alt="Kidney disease aetiologies. Means for the whole period studied and by registry. "></img></a></p><p class="elsevierStylePara">Figure 6. Kidney disease aetiologies. Means for the whole period studied and by registry. </p><p class="elsevierStylePara"><a href="grande/12106_16025_54627_en_f7121063.jpg" class="elsevierStyleCrossRefs"><img src="12106_16025_54627_en_f7121063.jpg" alt="Progression in the use of automatic peritoneal dialysis for the whole period in the different registries."></img></a></p><p class="elsevierStylePara">Figure 7. Progression in the use of automatic peritoneal dialysis for the whole period in the different registries.</p><p class="elsevierStylePara"><a href="grande/12106_16025_54628_en_f8121063.jpg" class="elsevierStyleCrossRefs"><img src="12106_16025_54628_en_f8121063.jpg" alt="Progression in peritonitis rate; patient/year means by registry. Mean rate in the last year."></img></a></p><p class="elsevierStylePara">Figure 8. Progression in peritonitis rate; patient/year means by registry. Mean rate in the last year.</p><p class="elsevierStylePara"><a href="grande/12106_16025_54629_en_f9121063_copy1.jpg" class="elsevierStyleCrossRefs"><img src="12106_16025_54629_en_f9121063_copy1.jpg" alt="Mean percentages of the different germs that cause peritonitis by community."></img></a></p><p class="elsevierStylePara">Figure 9. Mean percentages of the different germs that cause peritonitis by community.</p>" "pdfFichero" => "P1-E565-S4493-A12106-EN.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:6 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec438983" "palabras" => array:1 [ 0 => "Supervivencia técnica" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec438985" "palabras" => array:1 [ 0 => "Supervivencia de los pacientes" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec438987" "palabras" => array:1 [ 0 => "Prevalencia" ] ] 3 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec438989" "palabras" => array:1 [ 0 => "Incidencia" ] ] 4 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec438991" "palabras" => array:1 [ 0 => "Peritonitis" ] ] 5 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec438993" "palabras" => array:1 [ 0 => "Registro de diálisis peritoneal" ] ] ] "en" => array:6 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec438984" "palabras" => array:1 [ 0 => "Technique survival" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec438986" "palabras" => array:1 [ 0 => "Patient survival" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec438988" "palabras" => array:1 [ 0 => "Prevalence" ] ] 3 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec438990" "palabras" => array:1 [ 0 => "Incidence rate" ] ] 4 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec438992" "palabras" => array:1 [ 0 => "Peritonitis" ] ] 5 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec438994" "palabras" => array:1 [ 0 => "Peritoneal dialysis registry" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "es" => array:1 [ "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introducción y objetivos: </span>Actualmente no existe un registro que muestre en su conjunto y globalidad la realidad de la diálisis peritoneal (DP) en España. Sin embargo, para distintos congresos y reuniones se ha elaborado durante varios años un informe sobre la DP en España a partir de datos comunicados por cada uno de los registros de las comunidades autónomas y regiones. El objetivo fundamental del presente trabajo es analizar todos estos datos en forma agrupada y comparativa, con objeto de conseguir una muestra representativa de la población española en DP en los últimos años, para su análisis y resultados en cuanto a datos demográficos, penetración de la técnica, diferencias geográficas, incidencia y prevalencia, aspectos técnicos, indicadores intermedios, comorbilidad y resultados finales como supervivencia del paciente y de la técnica puedan ser extrapolables a todo el territorio nacional. <span class="elsevierStyleBold">Diseño, material y métodos:</span> Estudio observacional de cohortes de registros autonómicos de DP, abarcando el mayor porcentaje posible de la población española adulta (mayores de 14 años) en DP, al menos en la última década (1999-2010), y en la mayor área geográfica que nos ha sido posible reclutar. Se ha seguido una estrategia precisa de recogida de información de cada registro autonómico. Una vez recibida la información y depurada, se integran como datos agregados, para su estudio estadístico. <span class="elsevierStyleBold">Resultados: </span>Los registros autonómicos que han participado representan un área geográfica total que engloba a 32 853 251 habitantes mayores de 14 años, el 84 % de la población española total a partir de esa edad. La tasa anual media de incidentes por millón de habitantes (ppm) es variable (entre los 17,81 ppm de Andalucía y los 29,90 ppm del País Vasco), observándose en los últimos años un discreto y permanente aumento de la incidencia global en la DP en España. La prevalencia media anual por millón de población (ppm) es muy heterogénea (desde 42 a 99 ppm). Se observa un aumento progresivo medio en el uso de la diálisis peritoneal automática (DPA). La tasa de peritonitis es de aproximadamente un episodio cada 25-30 meses/paciente, observándose una ligera disminución en los años más recientes. Las causas de salida del programa de DP se distribuyen, de forma bastante homogénea entre las distintas comunidades, prácticamente en un tercio por muerte del paciente (media 28 %), un tercio por trasplante renal (media 39 %) y un tercio pasan a hemodiálisis (fracaso de la técnica: media 32 %). Las principales comorbilidades fueron la enfermedad cardiovascular (30,2 %) y la diabetes mellitus (24,2 %). La supervivencia global media acumulada ha sido del 92,2 %, 82,8 %, 74,2 %, 64,8 % y 57 %, al año, dos, tres, cuatro y cinco años, respectivamente. Proporcionaron de forma significativa e independiente una peor supervivencia para el paciente una mayor edad, la enfermedad cardiovascular, la diabetes mellitus, la técnica de diálisis peritoneal continua ambulatoria (frente a DPA), el inicio de la DP antes de 2004 (analizado en Andalucía y Cataluña) y la menor función renal residual al inicio de la DP (analizado en el registro de Levante). De igual forma, actualmente ha mejorado la supervivencia de la técnica, presentando unas cifras promedio superiores al 50 % a los 5 años. <span class="elsevierStyleBold">Conclusiones: </span>La incidencia y la prevalencia de la DP en España están creciendo moderadamente de forma generalizada, si bien siguen manteniendo una distribución por comunidades autónomas irregular. Tanto la supervivencia del paciente como de la técnica es superior al 50 % a los 5 años, habiendo mejorado en los últimos años, y siendo comparable a los países de mejores resultados en este tratamiento.</p>" ] "en" => array:1 [ "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction and objectives:</span> There is currently no registry that gives a complete and overall view of the peritoneal dialysis (PD) situation in Spain. However, a report on PD in Spain was developed for various conferences and meetings over several years from data provided by each registry in the autonomous communities and regions. The main objective of this study is to analyse this data in aggregate and comparatively to obtain a representative sample of the Spanish population on PD in recent years, in order that analysis and results in terms of demographic data, penetration of the technique, geographical differences, incidence and prevalence, technical aspects, intermediate indicators, comorbidity, and outcomes such as patient and technique survival may be extrapolated to the whole country. <span class="elsevierStyleBold">Design, material and method:</span> Observational cohort study of autonomous PD registries, covering the largest possible percentage of the adult Spanish population (over 14 years of age) on PD, at least in the last decade (1999-2010), and in the largest possible geographical area in which we were able to recruit. A precise data collection strategy was followed for each regional registry. Once the information was received and clarified, they were added as aggregate data for statistical study. <span class="elsevierStyleBold">Results:</span> The regional registries that participated represent a total geographical area that encompasses 32,853,251 inhabitants over 14 years of age, 84% of the total Spanish population older than that age. The mean annual rate of incidents per million inhabitants (ppm) was variable (between 17.81ppm in Andalusia and 29.90ppm in the Basque Country), with a discrete and permanent increase in the overall PD incidence in Spain being observed in recent years. The mean annual prevalence per million population (ppm) was very heterogeneous (from 42 to 99ppm). A mean progressive increase in the use of automated peritoneal dialysis (APD) was observed. The peritonitis rate was approximately one episode every 25-30 months/patient, with a slight decrease being observed in recent years. The causes of discontinuing PD were distributed fairly evenly between communities; almost a third was due to patient death (mean 28%), a third was due to renal transplantation (mean 39%) and a third was due to transfer to haemodialysis (technique failure: mean 32%). The main comorbidities were cardiovascular disease (30.2%) and diabetes mellitus (24.2%). The overall accumulated mean survival was 92.2%, 82.8%, 74.2%, 64.8% and 57% after one, two, three, four and five years respectively. There was significantly and independently worse survival for older patients and those with cardiovascular disease, patients with diabetes mellitus, those on continuous ambulatory peritoneal dialysis (vs. APD), those who started PD before 2004 (analysed in Andalusia and Catalonia), and patients with lower residual renal function at the start of PD (analysed in the Levante registry). Similarly, the technique survival has improved, showing a mean figure above 50% after 5 years. <span class="elsevierStyleBold">Conclusions:</span> The incidence and prevalence of PD in Spain are growing moderately and in a generalised manner and continue to maintain an irregular distribution by autonomous community. Both patient and technique survival were greater than 50% after 5 years, with an improvement being observed in recent years, and are comparable to countries with better results in this treatment.</p>" ] ] "multimedia" => array:20 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12106_16025_54610_en_t112106.jpg" "Alto" => 801 "Ancho" => 2159 "Tamanyo" => 259294 ] ] "descripcion" => array:1 [ "en" => "Mean number of incident and prevalent patients and rate per million inhabitants by registry for the whole study period." ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12106_16025_54611_en_f2121063.jpg" "Alto" => 1193 "Ancho" => 2119 "Tamanyo" => 582689 ] ] "descripcion" => array:1 [ "en" => "Annual accumulated patient survival (%) by year and community." ] ] 2 => array:8 [ "identificador" => "fig3" "etiqueta" => "Tab. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12106_19904_54612_en_12106_t3.jpg" "Alto" => 122 "Ancho" => 600 "Tamanyo" => 70402 ] ] "descripcion" => array:1 [ "en" => "Accumulated annual technique survival (%) by year and community." ] ] 3 => array:7 [ "identificador" => "tbl1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "12106_16025_54613_en_t41210617.jpg" "imagenAlto" => 861 "imagenAncho" => 2163 "imagenTamanyo" => 301581 ] ] ] ] ] "descripcion" => array:1 [ "en" => "comparing patient survival." ] ] 4 => array:8 [ "identificador" => "fig4" "etiqueta" => "Tab. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12106_19904_54614_en_12106_t5_copy2.jpg" "Alto" => 409 "Ancho" => 1076 "Tamanyo" => 287556 ] ] "descripcion" => array:1 [ "en" => "International comparison. Accumulated annual technique survival (%) by year." ] ] 5 => array:8 [ "identificador" => "fig5" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12106_16025_54615_en_f112106.jpg" "Alto" => 804 "Ancho" => 1013 "Tamanyo" => 233759 ] ] "descripcion" => array:1 [ "en" => "Population" ] ] 6 => array:8 [ "identificador" => "fig6" "etiqueta" => "Fig. 10" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12106_16025_54616_en_f10121063.jpg" "Alto" => 881 "Ancho" => 1010 "Tamanyo" => 131500 ] ] "descripcion" => array:1 [ "en" => "Peritonitis progression by year and registry." ] ] 7 => array:8 [ "identificador" => "fig7" "etiqueta" => "Fig. 11" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12106_16025_54617_en_f11121063.jpg" "Alto" => 889 "Ancho" => 1011 "Tamanyo" => 151671 ] ] "descripcion" => array:1 [ "en" => "Percentages of the three main causes of withdrawal from peritoneal dialysis treatment by registry." ] ] 8 => array:8 [ "identificador" => "fig8" "etiqueta" => "Fig. 12" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12106_16025_54618_en_f12121063.jpg" "Alto" => 795 "Ancho" => 1018 "Tamanyo" => 155617 ] ] "descripcion" => array:1 [ "en" => "Reasons for transfer to haemodialysis." ] ] 9 => array:8 [ "identificador" => "fig9" "etiqueta" => "Fig. 13" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12106_16025_54619_en_f13121063.jpg" "Alto" => 1516 "Ancho" => 2110 "Tamanyo" => 440194 ] ] "descripcion" => array:1 [ "en" => "Percentage of cardiovascular disease and diabetes at the start of the technique, and the Charlson index and percentage progression of diabetic nephropathy by year and community." ] ] 10 => array:8 [ "identificador" => "fig10" "etiqueta" => "Fig. 14" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12106_16025_54620_en_f14121063.jpg" "Alto" => 1213 "Ancho" => 2106 "Tamanyo" => 547435 ] ] "descripcion" => array:1 [ "en" => "Progression of the gross annual mortality rate by year and registry." ] ] 11 => array:8 [ "identificador" => "fig11" "etiqueta" => "Tab. 15" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12106_16025_54621_en_t51210617.jpg" "Alto" => 825 "Ancho" => 2172 "Tamanyo" => 345055 ] ] "descripcion" => array:1 [ "en" => "Survival study (Andalusia, Catalonia and Eastern registries); survival curves by the log-rank test, in accordance with presence of diabetes, cardiovascular disease and the start period. Multivariate Cox proportional hazards model." ] ] 12 => array:8 [ "identificador" => "fig12" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12106_16025_54622_en_f2121063.jpg" "Alto" => 1193 "Ancho" => 2119 "Tamanyo" => 582689 ] ] "descripcion" => array:1 [ "en" => "Number of new patients by year and registry (incidence)." ] ] 13 => array:8 [ "identificador" => "fig13" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12106_16025_54623_en_f3121063_copy1.jpg" "Alto" => 845 "Ancho" => 1015 "Tamanyo" => 169016 ] ] "descripcion" => array:1 [ "en" => "Treatment background of peritoneal dialysis patients by different registries and the mean." ] ] 14 => array:8 [ "identificador" => "fig14" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12106_16025_54624_en_f4121063.jpg" "Alto" => 926 "Ancho" => 2098 "Tamanyo" => 210469 ] ] "descripcion" => array:1 [ "en" => "Prevalence by year and per million inhabitants. Comparison of the mean for the whole period with the year 2010." ] ] 15 => array:8 [ "identificador" => "fig15" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12106_16025_54625_en_f5121063_copy1.jpg" "Alto" => 1213 "Ancho" => 1023 "Tamanyo" => 217325 ] ] "descripcion" => array:1 [ "en" => "Mean age and standard deviation, patient distribution by age and sex in accordance with the different registries." ] ] 16 => array:8 [ "identificador" => "fig16" "etiqueta" => "Fig. 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12106_16025_54626_en_f6121063_copy1.jpg" "Alto" => 1383 "Ancho" => 1007 "Tamanyo" => 240807 ] ] "descripcion" => array:1 [ "en" => "Kidney disease aetiologies. Means for the whole period studied and by registry." ] ] 17 => array:8 [ "identificador" => "fig17" "etiqueta" => "Fig. 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12106_16025_54627_en_f7121063.jpg" "Alto" => 1338 "Ancho" => 2102 "Tamanyo" => 547856 ] ] "descripcion" => array:1 [ "en" => "Progression in the use of automatic peritoneal dialysis for the whole period in the different registries." ] ] 18 => array:8 [ "identificador" => "fig18" "etiqueta" => "Fig. 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12106_16025_54628_en_f8121063.jpg" "Alto" => 1209 "Ancho" => 2110 "Tamanyo" => 609090 ] ] "descripcion" => array:1 [ "en" => "Progression in peritonitis rate; patient/year means by registry. Mean rate in the last year." ] ] 19 => array:8 [ "identificador" => "fig19" "etiqueta" => "Fig. 9" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12106_16025_54629_en_f9121063_copy1.jpg" "Alto" => 1302 "Ancho" => 1011 "Tamanyo" => 167421 ] ] "descripcion" => array:1 [ "en" => "Mean percentages of the different germs that cause peritonitis by community." ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Remo-Rodríguez C, Ganga-Ganga PL, Cunquero JM, Ruiz SR, Fosalba NA, Fernández AR, et al. Diez años de diálisis peritoneal en Andalucía (1999-2008): datos epidemiológicos, tipos de tratamiento, peritonitis, comorbilidad y supervivencia de pacientes y técnica. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 5 | 13 |
| 2024 October | 63 | 33 | 96 |
| 2024 September | 65 | 31 | 96 |
| 2024 August | 64 | 46 | 110 |
| 2024 July | 53 | 26 | 79 |
| 2024 June | 82 | 49 | 131 |
| 2024 May | 67 | 43 | 110 |
| 2024 April | 54 | 35 | 89 |
| 2024 March | 51 | 21 | 72 |
| 2024 February | 35 | 35 | 70 |
| 2024 January | 34 | 27 | 61 |
| 2023 December | 22 | 34 | 56 |
| 2023 November | 48 | 28 | 76 |
| 2023 October | 41 | 39 | 80 |
| 2023 September | 38 | 33 | 71 |
| 2023 August | 35 | 17 | 52 |
| 2023 July | 36 | 32 | 68 |
| 2023 June | 41 | 20 | 61 |
| 2023 May | 53 | 34 | 87 |
| 2023 April | 25 | 9 | 34 |
| 2023 March | 72 | 18 | 90 |
| 2023 February | 53 | 19 | 72 |
| 2023 January | 54 | 43 | 97 |
| 2022 December | 75 | 36 | 111 |
| 2022 November | 74 | 28 | 102 |
| 2022 October | 70 | 48 | 118 |
| 2022 September | 61 | 30 | 91 |
| 2022 August | 41 | 39 | 80 |
| 2022 July | 39 | 47 | 86 |
| 2022 June | 31 | 42 | 73 |
| 2022 May | 35 | 33 | 68 |
| 2022 April | 30 | 53 | 83 |
| 2022 March | 47 | 47 | 94 |
| 2022 February | 38 | 44 | 82 |
| 2022 January | 35 | 29 | 64 |
| 2021 December | 35 | 35 | 70 |
| 2021 November | 48 | 30 | 78 |
| 2021 October | 48 | 44 | 92 |
| 2021 September | 36 | 38 | 74 |
| 2021 August | 33 | 33 | 66 |
| 2021 July | 36 | 30 | 66 |
| 2021 June | 33 | 30 | 63 |
| 2021 May | 59 | 38 | 97 |
| 2021 April | 120 | 36 | 156 |
| 2021 March | 67 | 40 | 107 |
| 2021 February | 62 | 20 | 82 |
| 2021 January | 39 | 22 | 61 |
| 2020 December | 47 | 16 | 63 |
| 2020 November | 46 | 20 | 66 |
| 2020 October | 36 | 26 | 62 |
| 2020 September | 37 | 23 | 60 |
| 2020 August | 64 | 14 | 78 |
| 2020 July | 43 | 13 | 56 |
| 2020 June | 26 | 20 | 46 |
| 2020 May | 60 | 16 | 76 |
| 2020 April | 52 | 23 | 75 |
| 2020 March | 47 | 19 | 66 |
| 2020 February | 66 | 28 | 94 |
| 2020 January | 57 | 26 | 83 |
| 2019 December | 48 | 25 | 73 |
| 2019 November | 55 | 24 | 79 |
| 2019 October | 29 | 13 | 42 |
| 2019 September | 26 | 21 | 47 |
| 2019 August | 25 | 21 | 46 |
| 2019 July | 31 | 26 | 57 |
| 2019 June | 47 | 28 | 75 |
| 2019 May | 59 | 18 | 77 |
| 2019 April | 63 | 43 | 106 |
| 2019 March | 58 | 30 | 88 |
| 2019 February | 38 | 16 | 54 |
| 2019 January | 36 | 25 | 61 |
| 2018 December | 165 | 44 | 209 |
| 2018 November | 195 | 32 | 227 |
| 2018 October | 165 | 25 | 190 |
| 2018 September | 111 | 33 | 144 |
| 2018 August | 78 | 18 | 96 |
| 2018 July | 73 | 13 | 86 |
| 2018 June | 78 | 14 | 92 |
| 2018 May | 87 | 14 | 101 |
| 2018 April | 75 | 7 | 82 |
| 2018 March | 58 | 17 | 75 |
| 2018 February | 70 | 15 | 85 |
| 2018 January | 57 | 9 | 66 |
| 2017 December | 53 | 9 | 62 |
| 2017 November | 87 | 23 | 110 |
| 2017 October | 53 | 5 | 58 |
| 2017 September | 57 | 27 | 84 |
| 2017 August | 55 | 41 | 96 |
| 2017 July | 56 | 30 | 86 |
| 2017 June | 72 | 41 | 113 |
| 2017 May | 113 | 23 | 136 |
| 2017 April | 66 | 27 | 93 |
| 2017 March | 69 | 31 | 100 |
| 2017 February | 189 | 29 | 218 |
| 2017 January | 35 | 21 | 56 |
| 2016 December | 100 | 13 | 113 |
| 2016 November | 179 | 16 | 195 |
| 2016 October | 248 | 16 | 264 |
| 2016 September | 384 | 6 | 390 |
| 2016 August | 288 | 2 | 290 |
| 2016 July | 309 | 13 | 322 |
| 2016 June | 176 | 0 | 176 |
| 2016 May | 186 | 0 | 186 |
| 2016 April | 156 | 0 | 156 |
| 2016 March | 166 | 0 | 166 |
| 2016 February | 151 | 0 | 151 |
| 2016 January | 131 | 0 | 131 |
| 2015 December | 118 | 0 | 118 |
| 2015 November | 109 | 0 | 109 |
| 2015 October | 114 | 0 | 114 |
| 2015 September | 120 | 0 | 120 |
| 2015 August | 104 | 0 | 104 |
| 2015 July | 150 | 0 | 150 |
| 2015 June | 60 | 0 | 60 |
| 2015 May | 71 | 0 | 71 |
| 2015 April | 11 | 0 | 11 |
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