Peritoneal Dialysis in Italy: the 8th GPDP-SIN Census 2022 – 2nd Part: the Centers

Abstract

Objectives. The results are presented of the 8th National Census (Cs-22) of the Peritoneal Dialysis Project Group of the Italian Society of Nephrology relating to the characteristics of the Centers in Italy which used PD in 2022.
Materials and methods. The 227 non-pediatric centers which used Peritoneal Dialysis (PD) in 2022 took part. The data requested were sent in aggregate form. For the first time, the resources available and training were investigated as well as home visits. The Centers have been divided into Quartiles according to the number of prevalent PD patients at 31/12/2022.
Results. Centers with a smaller PD program (<9 pts) are characterized by 1. smaller overall size – 2. fewer personnel (doctors/nurses) dedicated to PD – 3. greater recourse to external personnel for training – 4. Less incremental prescription and evaluation of peritoneal permeability – 5. higher drop-out to HD in particular for choice/impossibility to continue and for adequacy/catheter-related issues. A lower peritonitis rate was recorded in Centers with a more extensive PD program (≥25 pts). Home visits are carried out regularly by a small minority of Centers. Conclusions. The analysis shows an association between size of Center PD program and available resources, PD modality and outcome.

 

 

Graphical abstract

 

Keywords: Peritoneal Dialysis, Center effect, technique failure

Background

Besides results pertaining to peritoneal dialysis (PD), the Peritoneal Dialysis Project Group Census also investigates a number of organizational aspects, which were broadened in the last edition relating to 2022 to the resources available for PD (premises and dedicated personnel) and training. The PD results were published recently in this Journal [1]. In this second part, the characteristics are reported of the 227 Centers which used PD in 2022 and which have remained virtually the same over almost 20 years, in other words a minority of the Dialysis Centers in Italy.

The first Italian Society of Nephrology Census relating to 2004 had shown that PD was used in 64.3% of the non-pediatric public Centers (209 out of 325 Centers) and practically unused in all the 286 private Centers surveyed at the time. The use of PD was conditioned by whether the Center was public or private (absent in the latter), size of Center and HD bed occupancy (the greater the size and pressure on HD places, the greater the use of PD). In turn, the presence of private Centers ‒ significant in some areas ‒ reduces the size of the public Centers, reinforcing the negative effect on the use of PD.

However, there were large public Centers with a high HD bed occupancy rate which were not using PD, while it was used – even extensively – by others with opposite characteristics. Clearly, alongside the structural factors given there was also a fourth element conditioning the use of PD: the Center’s “policy”. This aspect was investigated by means of a 2007 questionnaire, also carried out by the PD Study Group, the results of which have never been published though. The methodology and breadth of the survey make it quite unique, still today. In an attempt to understand the state of affairs in Italy, it seemed to us only right to retrieve its results, attaching them to this paper.

 

Materials and methods

The methodology of the Census was described at great length in the recent paper published in this Journal, which can be referred to [1].

The characteristics of the Centers surveyed were the existence of premises for PD, the presence of medical and nursing personnel dedicated to PD (whose sole or exclusively attributed activity is PD), training methods in terms of both who performs it and where it is carried out, the performance of PET and lastly home visits.

As with other similar analyses, to facilitate the interpretation of the results the Centers have been divided into quartiles (Table 1) based on the number of prevalent patients on PD at 31/12/2022.

QUARTILE PREVALENT ON DP CENTERS %
MIN (from) MAX (to)
Q1 1 8 55 24,2
Q2 9 14 58 25,6
Q3 15 24 58 25,6
Q4 25 112 56 24,7
227  
Table 1. Division into quartiles of the 227 PD Centers surveyed based on number of prevalent patients on PD at December 31st 2022.

The groups were then compared for “structural” characteristics (size and percentage use of PD, geographical distribution, presence of dedicated personnel and spaces, training methods, home visits and performance of PET), for “use” of PD (manual or automated modality, incremental PD, assisted PD) and for “results” obtained (drop-out and turnover, peritonitis).

The Census represents a snapshot of the situation relating to PD in Italy. The statistical analysis (chi-square) was therefore limited to any differences between the groups.

 

Results

STRUCTURAL CHARACTERISTICS OF THE CENTERS

Size of Center and percentage use of PD

Table 2 shows the structural characteristics of the Centers divided into the 4 quartiles of PD prevalence.

The size of Centers was assessed by considering the total number of dialysis patients (HD + PD) at 31/12/2022, and as a result limited to the 183 Centers which provided HD prevalence data. As can be seen (Table 2), as the overall size of the Center increases, not only the number but also the percent proportion of PD patients with respect to total dialysis patients rise from 6.5% in Centers with a minimal PD program (Q1, 1-8 PD patients per Center) to 20.9% in “large” Centers (Q4, ≥25 patients).

Although it is not certain, the estimate can be considered valid as the number of PD patients per Center (“PD PTS per CENTER”) is practically superimposable on those recorded in all 227 Centers (Table 2).

ALL PD CENTERS CENTERS WITH HD PREVALENCE AVAILABLE
CENTERS PD

PREVAL.

PD PTS per CENTER CENTERS PD

PREVAL.

HD

PREVAL.

PD PTS per CENTER HD PTS per CENTER TOT PTS per CENTER %PD
Q1 55 265 4.8 45 213 3063 4.7 68.1 72.8 6.5
Q2 58 662 11.4 46 535 4466 11.6 97.1 108.7 10.7
Q3 58 1124 19.4 47 903 5134 19.2 109.2 128.4 15.0
Q4 56 2101 37.5 45 1661 6279 36.9 139.5 176.4 20.9
ITALY 227 4152 18.3 183 3312 18942 18.1 103.5 121.6 14.9
Table 2. Percentage use of PD and size of Center. The analysis was only possible for the 183 Centers which provided HD prevalence data. The missing Centers were equally distributed among the 4 groups, and the size of PD program was found to be practically superimposable (“PD PTS per CENTER”). The overall size of the Center is given in the “TOT PTS per CENTER” column: the sum of HD and PD prevalent patients.

The distribution of the Centers in Figure 1 shows how there are some significantly-sized Centers where the use of PD is limited, and other smaller Centers using it in a high percentage of patients, confirming the finding of the first SIN Census.

Distribution of the 183 Centers which also provided HD data. PD prevalence by size of Center
Figure 1. Distribution of the 183 Centers which also provided HD data. PD prevalence by size of Center (HD and PD). The lines define the quartiles of the 2 variables.

Geographical distribution

The geographical breakdown of the Centers by size, which was already partly analyzed in the previous paper, shows how PD programs are more widespread in Centers in the North.

While the number of the Centers using PD per million inhabitants (pmp) is practically superimposable (Table 3), varying only a little from the national average of 3.9 PD Centers pmp, those located in the NORTH follow a greater number of patients (21.9 ±16.5 patients per Center) than the others. It follows that PD prevalence pmp in the NORTH (81.7 PD patients pmp) is also higher than in the Centers in Central Italy (72.9 PD patients pmp) and in the SOUTH and ISLANDS where it is practically identical (55.22 and 55-20 PD patients pmp respectively) (Table 3). However, an examination of the Centers which also sent data for HD confirm (Table 4) the finding of some 20 years ago. The Centers in the SOUTH and ISLANDS which use PD are on average smaller, in terms of both overall size and PD program, but with a higher percentage of PD patients (Table 4).

PD PREVAL. per CENTER
CENTERS
(no.)
POPULATION
(inhabit.)
PD PREVAL.
(no of pts)
PD PREVAL.
(pmp)
CENTERS
(pmp)
MEAN (±DS)
(no. of pts)
MEDIAN
(no. of pts)
NORTH 102 27,349,747 2235 81.7 3.7 21.9±16.5 19
CENTER 54 11,693,240 853 72.9 4.6 15.8±12.0 12
SOUTH 47 12,894,027 712 55.2 3.6 15.1±13.1 13
ISLANDS 24 6,377,044 352 55.2 3.8 14.7±13.9 10
ITALY 227 58,314,058 4152 71.2 3.9 3.3    ±14.8 15
Table 3. Geographical distribution of the Centers in the 4 macro regions of Italy and their size of PD program. The regional breakdown and population are 2022 ISTAT (Italian National Institute of Statistics) data, the prevalence is at 31/12/2022.  pmp = per million population; THE REGIONS OF ITALY AS DEFINED BY ISTAT – NORTH = Valle d’Aosta, Piemonte, Lombardia, Trentino Alto Adige, Friuli Venezia Giulia, Veneto, Emilia Romagna, Liguria – CENTER = Toscana, Marche, Umbria, Lazio – SOUTH = Abruzzo, Molise, Puglia, Campania, Basilicata, Calabria – ISLANDS = Sicily, Sardinia.
CENTERS PREVALENCE (no.)
no. % HD PD SIZE PD/CENTER %PD
NORTH 83 81.4 11588 1751 160.7 21.1 13.1
CENTER 51 94.4 4210 821 98.6 16.1 16.3
SOUTH 29 61.7 2057 443 86.2 15.3 17.7
ISLANDS 20 83.3 1087 297 69.2 14.9 21.5
ITALY 183 80.6 18942 3312 121.6 18.1 14.9
Table 4. Characteristics of the Centers in the 4 macro areas of Italy which also sent data relating to HD. “SIZE” = total number of patients (HD+PD) on dialysis at 31/12/2022 – “PD/CENTER” = prevalent PD patients per Center – “%PD” = mean percentage PD prevalence in the Centers.

Resources dedicated to PD

Most of the Centers (95.1%) have facilities dedicated to PD whatever the size of their PD program, while there are significant differences with regard to the personnel – both medical and nursing – dedicated to PD (Table 5).

In particular, nearly half the small Centers (48.1%) have no one member of staff – either medical or nursing – as a point of reference (“everyone can handle PD as well”). This percentage drops to 12.5% in the Centers with an extensive PD program (Table 5).

CENTERS FACILITIES DOCTORS NURSES BOTH NONE DOCTOR OR NURSE (%)
Q1 54* 49 20 23 15 26 51.9
Q2 58 54 19 30 17 26 55.2
Q3 57* 56 32 44 31 12 78.9
Q4 56 55 36 45 41 7 87.5
ITALY 225 214 107 142 104 71 68.4
NS p<0.005 p<0.00005     p<0.00005
Table 5. Resources for PD in the 227 Centers which use it. For the personnel, dedicated professionals are considered to be doctors and nurses who are engaged exclusively with PD, but also those who, in particular in the “small” Centers, are assigned the exclusive task of handling it. “Both” refers to the Centers where there are both medical and nursing personnel dedicated to PD (the difference between “Doctors” plus “Nurses” and “Both” provides the number of Centers which have only the Doctor or Nurse as dedicated PD professional). “None” refers to the Centers which have no dedicated PD professionals. * Two Centers (Q1 and Q3) did not provide information on Training.

Activities

The activities considered by the Census are training, home visits and the performance of PET.

Training. Training is carried out by in-Center personnel in 57.3% of the Centers, by external personnel in 11.6% and by both in 31.1%. The contribution of external personnel is lower in the large and medium-small Centers (Q4 and Q2, 26.8% and 41.4% of Centers respectively) and greater in the Centers with a small or medium-large PD program (Q1 and Q3, 51.9% and 50.9% of Centers respectively) (Table 6). The place where the training takes place more frequently is the Center (52.4% of cases), partly at home and partly in the Center in 37.8% of cases and only at home in 9.8% of the Centers (Table 6). The location of the training depends on the provider. In fact, when the training is performed by in-house personnel (57.3% of the Centers) it takes place mostly in the Hospital (80.6% of cases), while in the Centers in which only or partly external personnel are involved (42.7% of the Centers) the training is performed exclusively or partly at home (85.4% of the Centers, p<0.000001) (Figure 2).

PROVIDER PLACE OF TRAINING
CENTERS CENTER EXTERNAL BOTH % CENTER CENTER HOME BOTH % HOME
Q1 54* 26 7 21 48.1 27 5 22 50.0
Q2 58 34 11 13 58.6 36 5 17 37.9
Q3 57* 28 5 24 49.1 20 6 31 64.9
Q4 56 41 3 12 73.2 35 6 15 37.5
ITALY 225 129 26 70 57.3 118 22 85 47.6
p<0.03 p<0.001
Table 6. The Provider and Place where the Training takes place. The Provider can be “Center” personnel only, “External” personnel only, or “Both” if it is performed in the Center by both in-house and external personnel. The absolute values and percentages refer to the Centers and NOT to the number of Trainings.* Two Centers did not provide information on Training. “% CENTER” is the percentage of Centers in which the Training is performed by in-house personnel. “% HOME” is the percentage of Centers which perform the Training exclusively or partly at home.
Figure 2. Training divided by provider.
Figure 2. Training divided by provider. The place (home, hospital or both) where it is carried out is given for each provider.

Home visits. The home visits (HV) program once the PD has started is in keeping with training practice. They are not envisaged by the majority of the Centers (55.2%), with no significant differences between the 4 groups (Table 7), while only a minority of the remainder carry them out regularly following a pre-defined program (8.5%). In the other Centers they are basically performed when necessary. With respect to previous years, the percentage of the Centers with no HV program once PD has started has increased (48.5% in 2016), while the percentage of the number of the Centers with a regular HV program remains unchanged, as an absolute value as well (Figure 3).

FREQUENCY OF HOME VISITS
CENTERS NOT ENVISAGED VARIABLE REGULAR % NO
Q1 53 25 25 3 47.2
Q2 57 32 21 4 56.1
Q3 57 30 22 5 52.6
Q4 56 36 13 7 64.3
ITALY 223 123 81 19 55.2
Table 7. Frequency of home visits after PD has started. The question was answered by 223 of the 227 Centers considered. The difference between the groups was NOT significant. Variable frequency is to be understood as meaning “only during the initial period”, which was not further specified, “at the start when needed” and lastly “only if necessary”. “Not envisaged” means they are not considered by the Center for PD follow-up.
Figure 3. Home visits over time.
Figure 3. Home visits over time. The data relating to 2019 are incomplete. The home visits considered are those carried out once PD has started, i.e. excluding those during training.

PET. Evaluation of the peritoneal membrane by PET is not performed by 11.9% of the Centers, mostly the smaller ones (NO PET – Q1 = 18.2%; Q2 = 13.8%; Q3 = 12.1%; Q4 = 3.6% – p = N.S.), although the difference is not statistically significant.

PD MODALITY

CAPD/APD and incremental PD in incident patients

Overall, the most used PD modality in incident patients is CAPD (52.1%), but with a significant difference between the groups according to size of PD program: the smaller Centers mostly use APD, while CAPD is the most widely-used modality in the larger Centers (p<0.005). This is partly associated with incremental prescription, for which CAPD is preferred, with its use rising as size of Center increases (Table 8). Lastly, admissions from HD and Tx increase (percentage-wise with respect to total admissions) as PD program size grows, although not significantly.

INCIDENT PATIENTS OTHER ADMISSIONS
CENTERS CAPD APD TOT % CAPD INCR % INCR from HD/Tx TOT IN % from HD/Tx
Q1 55 38 54 92 41,3 25 27,2 12 104 11,5
Q2 58 104 120 224 46,4 65 29,0 33 257 12,8
Q3 58 240 164 404 59,4 170 42,1 55 459 12,0
Q4 56 321 309 630 51,0 217 34,4 126 756 16,7
ITALIA 227 703 647 1350 52,1 477 35,3 226 1576 14,3
P<0,005 P<0,005 N.S.
Table 8. PD modality (CAPD and APD) and incremental prescription (“INCR”) at the start of treatment by size of PD program. On the right, admissions from HD and transplant (Tx), and their percentage weight on the total of admissions to PD recorded in 2022.

The percentage of late referrals to PD was shown NOT to differ significantly among the groups (Q1 = 5.4% – Q2 = 8.0% – Q3 = 11.4% – Q4 = 7.9% – p = N.S.)

CAPD/APD and assisted PD in prevalent patients

APD is confirmed as the most used PD modality for prevalent patients, but ‒ as with incident patients ‒ significantly more so in the smaller Centers (Table 9). Recourse to assisted PD, on the other hand, is greater in the smaller Centers, in particular in the second quartile compared to the fourth. Overall it is used in 26% of prevalent patients in the Centers with fewer than 15 prevalent PD patients, and in 19.8% of patients in the Centers with a higher prevalence.

No significant difference emerged between the Quartiles with regard to type of caregiver, with a family member being confirmed as the most commonly-involved caregiver in Italy (86.3%) (Table 9).

PREVALENT PTS – TYPE OF PD PREVALENT PTS – ASSISTED PD
CENTERS CAPD APD TOT % CAPD RSA FAM. CARER IP TOT ASS. PD % ASS. PD
Q1 55 98 167 265 37.0 3 47 2 5 57 21.5
Q2 58 261 401 662 39.4 2 165 14 3 184 27.8
Q3 58 513 611 1124 45.6 20 212 18 2 252 22.4
Q4 56 931 1170 2101 44.3 15 334 31 5 385 18.3
ITALY 227 1803 2349 4152 43.4 40 758 65 15 878 21.1
p<0.01 N.S. p<0.0001
Table 9. PD modality (CAPD and APD) and assisted PD in prevalent PD patients at 31/12/2022. “RSA” = nursing home, facility for the elderly – “FAM.” = family-member caregiver– “CARER” = live-in carer, paid assistant – “IP” = nurse (or other healthcare worker) who performs the dialysis at the patient’s home – “% ASS. PD” represents the percentage of prevalent patients on assisted PD.

OUTCOME

Peritonitis

Although the incidence of peritonitis was lower in the larger Centers, it was substantially superimposable. The percentage of negative cultures was not significantly different either (Table 10).

CENTERS PERITONITIS INCIDENCE NEGATIVE % NEGATIVE
Q1 54 50 0.186 7 14.0
Q2 58 115 0.185 23 20.0
Q3 58 221 0.209 35 15.8
Q4 56 310 0.156 69 22.3
ITALY 226 696 0.176 134 19.3
Table 10. Episodes of peritonitis (total and culture-negative peritonitis) and size of Centers. The peritonitis rate is expressed as episodes per patient year. “% NEGATIVE” is the percentage of culture-negative peritonitis out of total episodes (N.S.). Only one Center did not provide data on peritonitis.

Drop-out from PD

The average duration of PD, taken from the Replacement Index (ratio between Prevalent patients at 31/12/2022 and all admissions recorded in 2022, expressed in years) was higher in the larger Centers (RI – Q1 = 2.5 equivalent to 30.6 months; Q2 = 2.6 equivalent to 30.9 months; Q3 = 2.4 equivalent to 29.4 months; Q4 = 2.8 equivalent to 33.3 months).

Causes of drop-out from PD. In 2022 a total of 464 patients were transferred to HD, 400 died and 296 received a transplant for a total of 29.3 drop-outs from PD per 100 patient-years. Mortality was significantly different, while a higher number of transplants and in particular Drop-Outs to HD were recorded in small Centers (Table 11).

EVENTS EVENTS / 100 PT-YEARS
CENTERS PREV. TRANSF DEATH TX D-O DEATH TX
Q1 55 265 64 30 35 22.9 10.8 12.5
Q2 58 662 80 49 49 12.9 7.9 7.9
Q3 58 1124 140 120 61 13.2 11.3 5.8
Q4 56 2101 180 201 151 9.0 10.1 7.6
ITALY 227 4152 464 400 296 11.7 10.1 7.5
p<0.00001 N.S. p<0.001
Table 11. Drop-out from PD due to transfer to HD (TRANSF), death and transplant (Tx) during 2022 divided by size of Centers.

As regards the specific causes of transfer to HD, in the small Centers (subject to a higher drop-out to HD) the main cause is choice or impossibility to continue, followed by catheter and dialysis adequacy issues. Confirming the validity of this is peritonitis as cause of drop-out which, like incidence of peritonitis, is also essentially superimposable in the different quartiles (Table 12).

EVENTS ep/100 pt-years
CENTERS TOT. TRANSF PERITON. CAT./ADEQ, CH./IMP. PERITON. CAT./ADEQ. CH./IMP.
Q1 55 64 9 27 28 3.2 9.7 10.0
Q2 58 80 22 37 21 3.5 6.0 3.4
Q3 58 140 25 60 55 2.4 5.7 5.2
Q4 56 180 53 76 51 2.7 3.8 2.6
ITALY 227 464 109 200 155 2.8 5.1 3.9
p<0.05
Table 12. Drop-out from PD for transfer to HD (TRANSF), death and transplant (Tx) during 2022 divided by size of Centers. “PERITON:” = peritonitis; “CAT./ADEQ.” = malfunctioning or infected catheter/adequacy both clearance and UF;“CH./IMP.” = choice or impossibility to continue.

 

Discussion

The limitations of the Census were already extensively discussed in part one [1].

The results of the 2022 Census confirm the findings of the first SIN Census in 2004. The use of PD is proportional in percentage terms to the size of Center and, as emerges from the geographical distribution of the Centers, lower wherever there are more private Centers, although the few Centers which do use it in these regions do so to a greater than average extent (see Annex – Questionnaire).

From an organizational point of view, smaller Centers are characterized first and foremost by fewer personnel dedicated to PD, either exclusively or – in the smaller Centers – as PD point of reference even though they certainly (Annex – Questionnaire) perform other activities. In the Centers in which there are no dedicated personnel, the “everyone does everything” principle most probably applies and in the end recourse to external personnel is necessary for training, the most important part of a PD program. Indeed, the Centers with a limited PD program rely more for training on external personnel, whose role – if any – in PD patient follow up was not however investigated. Though a positive aspect of training performed by external personnel or in combination is that it is carried out at home, this ends up “separating” PD patients even more from their Center. Lastly, another characteristic of the Centers with a limited PD program is less incremental prescription, and therefore greater use of APD.

Finally it is confirmed how home visits after starting on PD are carried out regularly only by a tiny minority of Centers.

Mortality is substantially superimposable in the different groups, while drop-out to HD is significantly higher in the Centers with a modest PD program, in which the main cause of drop-out to HD is patient choice and/or impossibility to continue. The latter term however, as discussed in the first part, is ambiguous as it can refer not only to loss of self-sufficiency but also clinical causes, to which inaccurate patient selection or insufficient follow up can contribute. Drop-out for adequacy due to catheter-related causes is also higher in smaller Centers. Peritonitis rates seem to be lower in the Centers with an extensive PD program, but drop-out for this cause is substantially similar.

 

Conclusions

In the public Centers in Italy which use PD the resources deployed, the modality of use and drop-out are associated (negatively) with size of PD program. In turn, the size of PD program is influenced by well-known factors which, as illustrated in “The Questionnaire” annex also condition – though only partly – the opinions Nephrologists in Centers not using PD have of this modality. There are therefore many reasons for the limited use of PD which are not justified by the results obtained and its potential, or by the prospect of having to treat increasingly fragile patients with ever more limited resources.

 

Acknowledgements

We thank the contacts in the Centers which took part in the Census and whose commitment made the collection of the data and this paper possible:

Abdulsattar Giamila (Oristano); Alberghini Elena (Cinisello Balsamo); Albrizio Paolo (Voghera); Alessandrello Maria Grazia Ivana (Modica); Alfano Gaetano (Modena); Amar Karen (Cernusco sul Naviglio); Ambrogio Antonina (Rovigo); Ancarani Paolo (Sestri Levante); Angelini Maria Laura (forlì); Ansali Ferruccio (Civitavecchia); Apponi Francesca (Frosinone); Argentino Gennaro (Napoli); Avella Alessandro (Varese); Barattini Marina (Massa); Barbera Vincenzo (Colleferro); Basso Anna (Padova); Bellotti Giovanni (Sapri); Benozzi Luisa (Borgomanero); Bermond Francesca (Torino); Bianco Beatrice (Verona); Bigatti Giada (Sesto San Giovanni); Bilucaglia Donatella (Torino); Boccadoro Roberto (Rimini); Boito Rosalia (Crotone); Bonesso Cristina (San Donà di Piave); Bonincontro Maria Luisa (Bolzano); Bonvegna Francesca (Verbania); Borettaz Ilaria (Melegnano – Vizzolo Predabissi); Borrelli Silvio (Napoli); Bosco Manuela (Gorizia); Braccagni Beatrice (Poggibonsi); Budetta Fernando (Eboli); Cabibbe Mara (Milano); Cabiddu Gianfranca (Cagliari); Cadoni Maria Chiara (San Gavino Monreale); Campolo Maria Angela (Lamezia Terme); Cannarile Daniela Cecilia (Bologna); Cannavo’ Rossella (Firenze); Canonici Marta (Fabriano); Cantarelli Chiara (Parma); Caponetto Carmelo (Siracusa); Cappadona Francesca (Genova); Cappelletti Francesca (Siena); Caprioli Raffaele (Pisa); Capurro De Mauri Federica Andreana (Novara); Caria Simonetta (Quartu Sant’ Elena); Carta Annalisa (Nuoro); Caselli Gian Marco (Firenze); Casuscelli di Tocco Teresa (Messina); Cataldo Emanuela (Altamura); Cernaro Valeria (Messina); Cerroni Franca (Rieti); Ciabattoni Marzia (Savona); Cianfrone Paola (catanzaro); Cimolino Michele (Pordenone); Comegna Carmela (Tivoli); Consaga Marina (Livorno); Contaldo Gina (Monza); Conti Paolo (Arezzo); Cornacchia Flavia (Cremona); Cosa Francesco (Legnano); Cosentini Vincenzo (San Bonifacio); Costantini Luigia (Vercelli); Costantino Ester Grazia Maria (Manerbio); Costanza Giuseppa (Gela); D’Alonzo Silvia (Roma); D’Altri Christian (Martina Franca); D’Amico Maria (Erice); De Blasio Antonietta (Caserta); Del Corso Claudia (Pescia); Della Gatta Carmine (Nola); D’Ercole Martina (La Spezia); Di Franco Antonella (Barletta); Di Liberato Lorenzo (Chieti); Di Loreto Ermanno (Atri); Di Renzo Brigida (Brindisi); Di Somma Agnese (San Marco Argentano); Di Stante Silvio (Pesaro – Fano); Dinnella Angela Maria (Anzio); Distratis Cosimo (Manduria); Dodoi Diana Teodora (Chieri); Domenici Alessandro (Roma); Esposito Samantha (Grosseto); Esposito Vittoria (Pavia); Farina Marco (Lodi); Ferrando Carlo (Cuneo); Ferrannini Michele (Roma); Ferrara Gaetano (San Giovanni Rotondo); Figliano Ivania Maria (Vibo Valentia); Figliola Carmela (Gallarate); Filippini Armando (Roma); Finato Viviana (San Miniato); Fiorenza Saverio (Imola); Frattarelli Daniele (Roma Ostia); Gabrielli Danila (Aosta); Gai Massimo (Torino); Garofalo Donato (Fermo); Gazo Antonietta (Vigevano); Gennarini Alessia (Bergamo); Gherzi Maurizio (Ceva); Giancaspro Vincenzo (Molfetta); Gianni Glauco (Prato); Giovannetti Elisabetta (Camaiore); Giovannetti Elisabetta (Lido di Camaiore); Giozzet Morena (Feltre); Giuliani Anna (Vicenza); Giunta Federica (Macerata); Graziani Romina (Ravenna); Guizzo Marta (Castelfranco Veneto); Heidempergher Marco (Milano); Iacono Rossella (Civita Castellana); Iadarola Gian Maria (Torino); Iannuzzella Francesco (Reggio Emilia); Incalcaterra Francesca (Palermo); La Milia Vincenzo (Lecco); Laudadio Giorgio (Bassano del Grappa); Laudon Alessandro (Trento); Lenci Federica (Ancona); Leonardi Sabina (Trieste); Lepori Gianmario (Olbia); Leveque Alessandro (Citta’ di Castello); Licciardello Daniela (Acireale); Lidestri Vincenzo (Chioggia); Lisi Lucia (Vimercate); Lo Cicero Antonina (San Daniele del Friuli ); Luciani Remo (Roma); Maffei Stefano (Asti); Magnoni Giacomo (Bologna); Malandra Rossella (Teramo); Manca Rizza Giovanni (Pontedera); Mancuso Verdiana (Agrigento); Manfrini Vania (Seriate); Manini Alessandra (Crema); Marcantoni Carmelita (Catania); Marchetti Valentina (Lucca); Marini Alvaro (Popoli); Martella Vilma (Lecce); Masa Maria Alessandra (Sondrio); Mastrippolito Silvia (Lanciano); Mastrosimone Stefania (Treviso); Matalone Massimo (Catania); Mauro Teresa (Corigliano Rossano); Mazzola Giuseppe (Mantova); Melfa Gianvincenzo (Como); Messina Antonina (Catania); Miglio Roberta (Busto Arsizio); Miniello Vincenzo (Pistoia); Mollica Agata (Cosenza); Montalto Gaetano (Taormina); Montanari Marco (Ariccia); Montemurro Vincenzo (Firenze); Musone Dario (Formia); Nardelli Luca (Milano); Neri Loris (Alba); Orani Maria Antonietta (Milano); Palmiero Giuseppe (Napoli); Palumbo Roberto (Roma); Panuccio Vincenzo Antonio (Reggio Calabria); Panzino Antonio Rosario (Catanzaro); Parodi Denise (Arenzano); Pastorino Nadia Rosa (Novi Ligure); Pellegrino Cinzia (Cetraro); Perilli Luciana (Vasto); Perna Concetta (Cerignola); Perosa Paolo (Pinerolo); Pieracci Laura (Imperia); Pietanza Stefania (Putignano); Pignone Eugenia (Torino); Pinerolo Maria Cristina (Milano); Piraina Valentina (ivrea); Pirrottina Maria Anna (San Benedetto del Tronto); Pisani Antonio (Napoli); Pogliani Daniela Rosa Maria (Garbagnate Milanese); Porreca Silvia (Bari); Pozzi Marco (Desio); Prerez Giuseppina (Dolo); Previti Antonino (Santorso); Puliti Maria Laura (Palestrina); Randone Salvatore (Avola); Ricciardi Daniela (Castiglione del Lago); Ricciatti Annamaria (Ancona); Rocca Anna Rachele (Roma); Rubini Camilla (Venezia Mestre); Russo Francesco Giovanni (Scorrano); Russo Roberto (Bari); Sabatino Stefania  (Udine); Sacco Colombano (Biella); Sammartino Fulvio Antonio (Pescara); Santarelli Stefano (Jesi); Santese Domenico (Taranto); Santinello Irene (Piove di Sacco); Santirosi Paola Vittori (Foligno-Spoleto); Santoferrara Angelo (Civitanova Marche); Saraniti Antonello (Milazzo); Savi Umberto (Belluno); Scalso Berta Ida (Cirie’); Scarfia Rosalia Viviana (Caltagirone); Serriello Ilaria (Roma); Signorotti Sara (Cesena); Silvana Baranello (Campobasso); Somma Giovanni (Castellamare di Stabia); Sorice Mario (Senigallia); Spissu Valentina (Sassari); Stacchiotti Lorella (Giulianova); Stucchi Andrea (Milano); Taietti Carlo (Treviglio); Tata Salvatore (Venezia); Teri Antonino (Foggia); Tettamanzi Fabio (Tradate); Timio Francesca (Perugia); Todaro Ignazio (Piazza Armerina); Toriello Gianpiero (Polla); Torraca Serena (Salerno); Trepiccione Francesco (Napoli); Trubian Alessandra (Legnago); Turchetta Luigi (Cassino); Vaccaro Valentino (Alessandria); Valsania Teresa (Piacenza); Vecchi Luigi (Terni); Veronesi Marco (Ferrara); Visciano Bianca (Magenta); Viscione Michelangelo (Avellino); Vizzardi Valerio (Brescia); Zanchettin Gianantonio (Conegliano); Zeiler Matthias (Ascoli Piceno).

 

Bibliography

  1. Neri L, Viglino G, Vizzardi V, Porreca S, Mastropaolo C, Marinangeli G, Cabiddu G. Peritoneal Dialysis in Italy: the 8th GPDP-SIN census 2022. G Ital Nefrol. 2023 Jun 29;40(3):2023-vol3. PMID: 37427898.
  2. Viglino G, Neri L, Alloatti S, Cabiddu G, Cocchi R, Limido A, Marinangeli G, Russo R, Teatini U, Schena FP. Analysis of the factors conditioning the diffusion of peritoneal dialysis in Italy. Nephrol Dial Transplant. 2007 Dec;22(12):3601-5. https://doi.org/10.1093/ndt/gfm416.

Peritoneal Dialysis in Italy: the 8th GPDP-SIN census 2022

Abstract

Objectives. The results are reported here of the 8th National Census (Cs-22) of Peritoneal Dialysis in Italy, carried out in 2022-23 by the Italian Society of Nephrology’s Peritoneal Dialysis Project Group and relating to 2022.
Methods. The Census was conducted in the 227 non pediatric centers which performed Peritoneal Dialysis (PD) in 2022. The results have been compared with the previous Censuses carried out since 2005.
Results. Incidence: in 2022, 1350 patients (CAPD=52.1%) started on PD (1st treatment for ESRD). PD was started incrementally by 35.3% in 136 Centers. The catheter was placed exclusively by a Nephrologist in 17.0% of known cases. Prevalence: there were 4152 (CAPD=43.4%) patients on PD on 31/12/2022, with 21.1% of prevalent patients on assisted PD (family member caregiver: 86.3%). Out: in 2022 the PD drop-out rate (ep/100 pt-yrs) was: 11.7 to HD; 10.1 death, down; 7.5 Tx. The main cause of transfer to HD remains peritonitis (23.5%), although its reduction over the years is confirmed (Cs-05: 37.9%). Peritonitis/EPS: the incidence of peritonitis in 2022 was 0.176 ep/pt-yr (696 episodes). The incidence of new cases of EPS fell in 2021-22 (7 cases). Other results: the number of Centers using 3.86% for the peritoneal equilibration test (PET) (57.7%) increased. PD for heart failure continues to be used in 44 Centers (66 pts).
Conclusions. Cs-22 confirms PD’s good results in Italy.

Keywords: Peritoneal Dialysis, technique failure, incremental Peritoneal Dialysis, peritonitis, peritoneal equilibration test (PET)

Background

The Peritoneal Dialysis Project Group (GPDP) of the Italian Society of Nephrology (SIN) investigates the state of Peritoneal Dialysis (PD) in Italy periodically by means of a Census carried out in the Centers which use it [16]. In the last edition, relating to 2019 [6], the situation was shown to be substantially stable, although the survey was conducted at the height of the CoViD pandemic and for the first time was incomplete.

All the Centers using PD took part again in the current edition, which was the Eighth and relates to 2022. It should be remembered, however, that these Centers represent around two-thirds of public Centers (PD is not available as a service in the remainder). When it is considered also that PD is not used in private Centers, the method is actually provided in a minority of Italian Dialysis Centers, and used by less than 10% of patients on Dialysis. The reasons for such a disheartening picture were investigated in the very first Census carried out by SIN in 2004 [7] and are likely to still be the same, all the more so if the constant improvement in the results achieved by PD over the years is considered.

The current edition features various grounds for interest and new aspects. First of all, it is the first “post-CoViD” edition. The number of Centers taking part using the new data collection system [6] increased significantly, allowing for greater precision in the data collected. For the first time the Census thoroughly investigated not only the incidence, but also the etiology of peritonitis, and certain structural aspects of PD Centers, such as the dedicated personnel and the training which will be examined in future.

This report presents the results of the 8th edition, conducted in 2022-2023 and relating to 2022, compared with those of the previous years.

Completing the report is the examination by leading experts on the subjects of certain aspects of PD, including the incremental prescription, peritoneal sclerosis and an assessment of peritoneal permeability.

 

Materials and methods

The GPDP Census collects aggregate data relating to PD, and is targeted at all the non-pediatric Centers which have used PD in the year in question.

Data collection. As for 2019 [6], in the current edition the aggregate data were collected in two different ways. The first was analytical, using specially designed software: a sort of medical record in which individual patients are entered systematically and the data are exported for the Census in aggregate form. For the protection of privacy, the program was developed without a cloud component, so all the data collected are stored locally and the possibility of backup to server is delegated to the operator. The number of Centers using this system increased from 110 in 2019 to 175 in 2022. The method used by the remaining 52 Centers was the traditional collection of data by filling in the online questionnaire used for previous editions.

In total, the Census reports data from 227 Centers, which is 100% of Italian PD Centers. Of the 8 editions so far, only the Census relating to 2019 was incomplete (198 Centers).

Participating Centers. The initial list of public Centers using PD established in the first SIN Census conducted for 2004 [7] has been updated over the years through attendances at Congresses, Conferences and subsequent SIN Censuses.

The number of Centers taking part for 2022 was 229, 2 of which were excluded as they did not treat any patients during 2022 (having ceased PD activity). While all the Centers responded to the questions on the incidence and prevalence of PD, 50 Centers provided no data on the incidence and prevalence of HD (Figure 1).

Information. The structure of the Census provides for a series of repeated pieces of information – unchanged since the first edition in 2005 [1] – relating to incidence, prevalence, method change or interruption, assisted PD, peritonitis, and non-renal PD. Encapsulating peritoneal sclerosis (EPS) has been added since 2008, and home visits and the peritoneal equilibration test (PET) since 2010 [2]. The questions on catheters resumed in the 2016 edition [5]. Furthermore, with the analytical data collection method information has become available for the first time on the causes of Renal Insufficiency, causes of death, certain organizational aspects such as training methods and available resources, and the etiology of peritonitis.

Data verification and comparison. The data collected initially were subjected to an initial congruence analysis. Any inconsistent data were corrected wherever possible by follow-up phone call, or were considered missing or incomplete, as appropriate. Any corrections and the number of Centers involved are reported in detail in the presentation of the single results.

Definitions and calculations. All the patients who started as first treatment on PD and HD from 01/01/2022 to 31/12/2022 were considered incident. Of these, the patients on ≤2 exchanges/day or ≤4 sessions/week with CAPD (Incr-CAPD) and APD (Incr-APD) respectively were considered as on incremental PD (Incr-PD). Prevalence referred to patients on dialysis at December 31st. For these, a need for assistance referred to the involvement of a caregiver in the performance of the dialysis procedures. Patients on PD due to non-renal causes (GFR ≥15 ml/min/1.73m2) were considered separately: the Census data always refer to patients who started PD due to ESRD.

The calculation of the follow-up to which events are related represents the critical aspect of the Census. With it being impossible to calculate the actual data (the sum of the periods all patients spent on PD in 2022) the follow-up has always been estimated by taking the mean of prevalent patients at the beginning and the end of the year, a method which has also recently been validated [8]. The prevalent patients at the beginning of the year were calculated by taking the prevalent patients at the end of the year, adding drop-outs for all causes, and subtracting new patients to PD (information available). This year it was possible to calculate the follow-up precisely for the 175 Centers which used the “2.2” program. In these Centers the comparison between the two methods showed that “traditional” follow-up underestimates the “actual” follow-up by 5.4%, so it overestimates by an equivalent amount the incidence of the events considered. As the data collection system was still mixed for 2022, the traditional method was used to calculate follow-up for all 227 Centers in order to be able to compare current results with previous years.

The drop-outs from PD recorded in the year were related to 100 patient-years of follow-up, while for peritonitis the incidence was calculated as episodes/patient-years (ep/pt-year). Episodes of EPS refer to the entire 2021-22 two-year period in the case of traditional collection, and the 2020-22 three-year period for the analytical method.

Statistical analysis was limited to looking for any differences with the Chi-square test.

Figure 1: Centers which used PD in 2022 for at least 1 patient.
Figure 1: centers which used PD in 2022 for at least 1 patient. They all sent the data relating to PD; 50 of these did not send the incidence and prevalence data relating to HD. The system used for sending the data is shown in the graphic: 52 by means of the traditional system, which provides for the entry of aggregate data; 175 using the dedicated program in which each patient is entered separately, and the program calculates and sends the aggregate data.

 

Results

Incidence and initial method

In 2022 PD was started on as first treatment by 1350 patients, 703 of whom using CAPD and 647 APD. The Centers with no incidence in PD in 2022 numbered 11.

As regards HD, 177 Centers provided incidence and prevalence data. In these 177 Centers, 1066 patients started on PD as first treatment, and 4329 on HD, giving a percentage incidence of PD of 19.8% (Table I) (Figure 2). So in relation to the 177 Centers which also sent data on HD, a fall in both the number of patients treated overall with PD in Italy (-15.4% compared to 2016) and the percentage incidence of PD was recorded for 2022. The most widely-used initial PD method remains CAPD (52.1%).

Table I: incident patients and initial PD method in the non-pediatric Centers which used PD in 2022 compared with previous years. The number of Centers not sending HD incidence data has constantly increased since 2016.
Table I: incident patients and initial PD method in the non-pediatric Centers which used PD in 2022 compared with previous years. The number of Centers not sending HD incidence data has constantly increased since 2016.
Figure 2: Number of new patients on 1st treatment (incident) in the years surveyed.
Figure 2: number of new patients on 1st treatment (incident) in the years surveyed. The percentage incidence is calculated on the total number of incident patients (PD + HD). Since 2016 a number of Centers have not sent HD incidence data, so the PD percentage is only calculated for the Centers which have sent the data (light yellow, value in italics). The total number of incident patients is given at the top of each column. It is to be remembered that the 2019 data are incomplete.

For the first time, basic nephropathy data are available, though only for the Centers which sent data using the 2.2 system. The conditions in which PD is most used are Nephroangiosclerosis (24.4%) and chronic Glomerulonephritis (22.3%). Diabetic nephropathy is the cause of ESRD in 15.4% of cases, while in 15.3% it is not known (Figure 3).

Figure 3: Type of nephropathy in incident patients on PD.
Figure 3: type of nephropathy in incident patients on PD. This was not requested by the traditional system for sending the data, so the breakdown shown in the Figure refers to 1004 patients in 174 Centers (1 Center was excluded for data incongruence).

Placement of the peritoneal catheter

All insertions were considered for the placement of the catheter. Excluding 96 patients due to incongruent data (which will be verified in a subsequent analysis), in the 1480 patients who started on PD in 2022, there was a further increase in placements by a surgeon alone, the number of placements by a surgeon and a nephrologist together was stable, and placements by a nephrologist alone diminished (Figure 4).

Figure 4: Operators involved in the placement of the peritoneal catheter.
Figure 4: operators involved in the placement of the peritoneal catheter. The percentage has also been calculated excluding the catheters for which the response was “other” or not specified. The 2016 data are given in the box (excluding “other” and not specified).

Initial dialysis dose – incremental peritoneal dialysis

PD was started with the incremental method (Incr-PD) by 477 patients in 2022, equaling 35.3% of total incident patients (Figure 5); it was used for at least 1 patient by 136 Centers, equaling 59.9% of the 227 Centers (63.0% when excluding the 11 Centers with no incidence).

For the patients who started PD with an incremental dose, the most widely-used method, as in previous years, was CAPD (82.8%), as opposed to the patients who started with a full-dose prescription, for whom APD is significantly more widely-used (64.7% – p<0.0001) (Figure 5). CAPD is a PD method that is increasingly associated with the incremental prescription and the Centers that perform it.

Over the years the number and percentage of incident patients on Incr-PD have been constantly rising, from the 11.9% of 2005 to the current 35.3% (Figure 6). The number of Centers prescribing it, which increased until 2016, remained the same in 2022 in terms of percentage (62.9% in 2016; 63.0% in 2022 of the Centers which started new patients on PD) (Figure 7). The increase recorded in 2022 can therefore be attributed to an increased use in the Centers which already used it, where it was prescribed for 47.8% of patients.

The Centers using Incr-PD are “larger” than the Centers which do not prescribe it, in terms of both incident (7.3 pt/year vs 4.4 pt/year) and prevalent patients (21.3 patients vs 15.0 patients) (Figure 8).

Excluding the Centers with zero incidence and those which did not send HD data, the use of incremental PD is associated, as in previous years, with greater use of PD in general (22.4% in 114 Centers vs 14.4% in 56 Centers – p<0.005) (Figure 9).

Figure 5: Incremental dialysis in 2022. The method of PD used (CAPD and APD) is given in the lateral columns for “incremental” (on the left) and “full dose” patients (right).
Figure 5: incremental dialysis in 2022. The method of PD used (CAPD and APD) is given in the lateral columns for “incremental” (on the left) and “full dose” patients (right).
Figure 6: Percentage of total incident patients who started PD with an incremental prescription (2 or fewer exchanges on CAPD and 4 or fewer sessions on APD).
Figure 6: percentage of total incident patients who started PD with an incremental prescription (2 or fewer exchanges on CAPD and 4 or fewer sessions on APD).
Figure 7: Percentage of Centers which used the incremental prescription for at least one patient.
Figure 7: percentage of Centers which used the incremental prescription for at least one patient. The percentage was calculated excluding the Centers which did not start any incident patients. If it is related to the total number of Centers the value is slightly lower, but the trend over time does not change.
Figure 8: A) Percentage of Centers over time divided into those which recorded no new patients (INCID = 0)
Figure 8: A) percentage of Centers over time divided into those which recorded no new patients (INCID = 0), those which recorded new patients but did not prescribe the incremental mode (INCR = 0), and those which used it for at least 1 patient (INCR>0). B) Size of the 3 types of Centers, in terms of both incident (above) and prevalent patients (below) in relation to 2022.
Figure 9: A) The percentage use of PD for incident patients in the Centers which do or do not use the incremental prescription.
Figure 9: A) the percentage use of PD for incident patients in the Centers which do or do not use the incremental prescription. The data relates to the 177 Centers which also provided HD data. Of these, 7 were excluded for Incidence = 0. Of the remaining 170, Incr-PD was prescribed in 114 Centers (INCREM.SI). B) The PD admission Odds Ratio in INCREM.SI with respect to INCREM.NO Centers over the years.

Patients from other treatments

In 2022, 178 patients transferred from HD to PD (Figure 10) (Table II).

1st TREAT. FROM HD FROM TX NEW TO PD FROM HD (%) FROM Tx (%)
2005 1443 89 25 1557 5,7 1,6
2008 1379 82 32 1493 5,5 2,1
2010 1429 126 36 1591 7,9 2,3
2012 1433 113 50 1596 7,1 3,1
2014 1652 161 46 1859 8,7 2,5
2016 1595 119 50 1764 6,7 2,8
2019 1363 125 44 1532 8,2 2,9
2022 1350 178 48 1576 11,3 3,0
Table II: patients (absolute value and percentage of all new patients to PD) from HD and return post-Transplant.
Figure 10: New patients to PD, sum of incident patients, transfers from HD and returns post-Tx.
Figure 10: new patients to PD, sum of incident patients, transfers from HD and returns post-Tx.

As expected, this data is decidedly lower than the number of patients switching from PD to HD (464 drop-outs in 2022), but higher in both absolute and percentage terms: indeed, in 2022 it represents 11.3% of all new patients to PD compared to 5.7% in 2005 (Figure 11). If for every 100 patients who transferred from PD to HD in 2005 17 took the reverse path, in 2022 the latter figure was 37. As regards a return to PD post-Transplant, the numbers and percentages have remained substantially unchanged over time (Figure 12).

Figure 11: Trend over time in the percentage of patients who started on PD from HD and Tx out of the total number of new patients on PD.
Figure 11: trend over time in the percentage of patients who started on PD from HD and Tx out of the total number of new patients on PD.
Figure 12: Percentages of patients returning post-Transplant on HD (red) and on PD. Only Centers with complete data for HD as well are considered.
Figure 12: percentages of patients returning post-Transplant on HD (red) and on PD. Only Centers with complete data for HD as well are considered.

Change of PD method

Information on the change of method were available for 224 Centers. In these Centers, 165 patients transferred from CAPD to APD in 2022, while 43 transferred from APD to CAPD (Figure 13). As in previous years, the reason for the change in around half of cases was patient and/or caregiver choice. Other grounds were insufficient clearance / UF for the switch from CAPD to APD, and catheter malfunction for the switch from APD to CAPD.

Figure 13: Change of PD method in 2022. Three Centers did not provide the data.
Figure 13: change of PD method in 2022. Three Centers did not provide the data.

Prevalence and PD method

At December 31st 2022 there were 4152 patients on PD, with 1803 on CAPD and 2349 on APD. Therefore, compared with 2016, a reduction of 9.9% was recorded in the prevalent population (Figure 14) (Table III). In the 177 Centers with complete incidence and prevalence data for HD as well, there were 3191 patients on PD and 18,259 on HD, with a 14.9% PD prevalence.

The most widely-used PD method among prevalent patients is APD (56.6%) (Figure 15), with a further increase compared to previous years (Table III).

The turnover calculated as the ratio of prevalent patients to the total of new patients on PD in 2022 was 31.6 months, substantially unchanged compared to previous years (it was 32.9 months in 2008). The trend in turnover over the years is given in detail in Figure 16.

Table III: Prevalent patients at 31/12/2022 and PD method in the non-pediatric Centers
Table III: prevalent patients at 31/12/2022 and PD method in the non-pediatric Centers which used PD in 2022 compared with previous years. The number of Centers not sending HD incidence data has increased constantly since 2016. * the values of the First SIN Census carried out in 2004 are given since data relating to HD were not requested in the first GPDP Census in 2005.
Figure 14: Number of patients treated with PD at December 31st of each year (prevalent) in the years surveyed.
Figure 14: number of patients treated with PD at December 31st of each year (prevalent) in the years surveyed. The percentage prevalence was calculated on total prevalent patients (PD + HD). Since 2016 a number of Centers have not sent HD prevalence data, so the PD percentage is only calculated for the Centers which have sent the data (light blue, value in italics). The total number of prevalent patients is given at the top of each column. It is to be remembered that the 2019 data are incomplete. In 2005 the HD prevalence data were not requested, so those of the 2004 SIN Census are considered.
Figure 15: Breakdown of incident and prevalent patients between CAPD and APD.
Figure 15: breakdown of incident and prevalent patients between CAPD and APD.
Figure 16: Duration of PD calculated by multiplying the NEW/PREVALENCE ratio by 12.
Figure 16: duration of PD calculated by multiplying the NEW/PREVALENCE ratio by 12. This is obviously valid in steady state conditions, while for 2022 this may not be the case, although the lower incidence was partly offset by the rise in patients from HD.

Assisted PD

In Cs-22 the number of prevalent patients requiring a caregiver (assisted PD) was 878 (21.15% of all prevalent patients on PD) (Figure 17). Compared to 2019 (976 patients on Assisted PD in an incomplete Census), this is a significant reduction (p<0.005).

The caregiver is a family member in 86.3% of cases, a live-in carer in 7.4%, a home nurse in 1.7%; finally, 4.6% (40 patients) perform PD in facilities for the elderly. A reduction was recorded for 2022 in the number of live-in carers, with an increased involvement of family members. The number of patients treated with PD in residential care homes was unchanged (Figure 18).

Figure 17: Assisted PD in the prevalent patients on 31/12/2022 and type of caregiver involved.
Figure 17: assisted PD in the prevalent patients on 31/12/2022 and type of caregiver involved. Given inside the graphic for the latter are the percentages referred to the total of prevalent patients, and near every single component the percentages in relation to the total number of patients on assisted PD.
Figure 18: Trend over time in caregivers involved in assisted PD.
Figure 18: trend over time in caregivers involved in assisted PD.

Change of method and drop-out

Figure 19 shows overall drop-out and drop-out due to transfer to HD, death, and transplant, expressed as both number of patients and events/100 pt-years.

The number of deaths recorded in 2022 was 400 (10.1 ep/100 pt-years), 464 patients transferred to HD (11.7 ep/100 pt-years) and 296 to transplants (7.5 ep/100 pt-years). A reduction in mortality was confirmed for 2022 compared to 2016.

Other causes of drop-out from PD in 2022 were voluntary refusal to continue dialysis (burn out) for 21 patients, Recovery of Residual Renal Function (RFRR) in 14 patients and on “other” grounds for 6 patients. Burn out was proposed for the first time in 2022, and may have been attributed in the past to death or “other” grounds.

With regard to drop-out to HD (Figure 20), the single main cause remains peritonitis (23.5%), but its reduction over the course of the years was confirmed (2005: 37.9%; 2008: 36.7%; 2010: 30.4%; 2012: 28.2%; 2014: 24.8%; 2016: 23.8%). The second cause – significantly on the increase – is the impossibility to continue on PD (22.4%). Traditionally this refers to events that render the patient no longer suitable for the performance of the dialysis procedures due to the onset of barriers to independence (physical, psychological, cognitive) in the event of absence or loss – if already on Assisted PD – of the caregiver. Other clinical events may also be attributed to this cause however. Finally, catheter is increasing as cause of drop-out (14.0%).

The main cause of death is heart disease (42.3%), while peritonitis represents 1.9% of deaths (Figure 21).

Figure 19: Causes of drop-out from PD over the years. In 2019 the Census was incomplete.
Figure 19: causes of drop-out from PD over the years. In 2019 the Census was incomplete.
Figure 20: Causes of transfer to HD over the years. In 2019 the Census was incomplete.
Figure 20: causes of transfer to HD over the years. In 2019 the Census was incomplete.
Figure 21: Causes of death in the Centers that used the dedicated 2.2. program to send the data.
Figure 21: causes of death in the Centers that used the dedicated 2.2. program to send the data.

Peritonitis

The number of episodes of peritonitis recorded in 2022 was 696 in 226 Centers, which for a total follow-up of 3943.5 years (47.322 months) is equivalent to 0.176 episodes per patient-year, or in other terms 1 episode every 68.0 patient-months, a lower incidence than recorded in previous years. As far as the percentage of negative cultures is concerned (134 episodes, equaling 19.3% of the total), the data is not significantly different to previous years (Table IV).

The peritonitis trend is given in both Table IV and Figure 22.

The etiology was analyzed for 627 cases of peritonitis reported in 211 Centers. One Center did not report the data, and 15 reported a higher number defined by the etiological agents than the cases of peritonitis reported overall (+18). However, as 8 Centers reported a lower number of etiological agents for peritonitis than the total declared (-17), the net difference was only 1 episode, confirming the validity of the overall data.

Half (50.1%) were caused by Gram positives, 27.9% by Gram negatives and 2.7% by unspecified germs (Figure 23). Cases of culture-negative peritonitis in these Centers were lower (17.9%) than those declared overall by all the Centers (134 episodes, 19.3%). Figure 24 details the different isolated microorganisms.

Of the episodes of peritonitis recorded in 2022, 323 (46.4%) occurred during CAPD and 373 (53.6%) APD, reflecting the breakdown of the 2 methods in prevalent patients.

Table IV: The episodes of peritonitis recorded by 73% of surveyed Centers are given for 2005, while not all recorded them in 2019 (and 4 did not report the data).
Table IV: the episodes of peritonitis recorded by 73% of surveyed Centers are given for 2005, while not all recorded them in 2019 (and 4 did not report the data). For 2022 the data refer to all the Centers, except 1 which was unable to retrieve the data. The calculation is taken from the overall number. Any discrepancy with the number of etiological agents has not been taken into account for standardization with the previous years (in which the etiology was not investigated).
Figure 22: Incidence of peritonitis in 2022. The peritonitis reported for 2005 was recorded by 73% of the Centers surveyed, while not all were surveyed in 2019
Figure 22: incidence of peritonitis in 2022. The peritonitis reported for 2005 was recorded by 73% of the Centers surveyed, while not all were surveyed in 2019 (and 4 did not report the data). For 2022 the data refer to all the Centers, except 1 due to impossibility to retrieve the data. The count is taken from the total number. Any discrepancy with the number of etiological agents was not taken into account for standardization with the previous years (in which the etiology was not investigated).
Figure 23: Etiology of peritonitis – breakdown based on the main categories.
Figure 23: etiology of peritonitis – breakdown based on the main categories.
Figure 24: Etiology of peritonitis in detail.
Figure 24: etiology of peritonitis in detail.

Encapsulating peritoneal sclerosis (EPS)

Of the 7 new episodes of EPS reported during the period 2020-22, 5 were diagnosed in the course of PD and 2 following transfer to HD. No cases were reported following a transplant (Figure 25).

A separate paper in this number is dedicated to discussing this finding, which is similar to 2019, but in constant decline.

Figure 25: Sclerosing peritonitis over time. For 2022 only the number of extracted cases is reported.
Figure 25: sclerosing peritonitis over time. For 2022 only the number of extracted cases is reported.

PET

Peritoneal permeability is assessed by most of the Centers (88.1%). although the number of Centers which do not consider it has grown further (2.2% in 2010 vs 11.9% in 2022).

For some time now the most widely-used method is 3.86%-PET rather than Twardowski’s 2.27%-PET (Figure 26). The number of Centers measuring peritoneal permeability using more sophisticated techniques or in another way increased.

The Centers using 3.86%-PET are larger, with a lower drop-out due to UFF/insufficient clearance (Figure 27).

Figure 26: Assessment of peritoneal permeability with the various methods.
Figure 26: assessment of peritoneal permeability with the various methods.
Figure 27: Characteristics of the Centers divided on the basis of assessment of peritoneal permeability adopted and incidence of drop-out due to UFF or poor clearance.
Figure 27: characteristics of the Centers divided on the basis of assessment of peritoneal permeability adopted and incidence of drop-out due to UFF or poor clearance.

PD for heart failure

The Census considers separately new patients to PD on NON renal grounds (GFR > 15 ml/min/1.73m2). The main non-renal reason remains treatment for heart failure (PUF), which regarded 66 patients in 44 Centers in 2022. The data is unchanged with respect to 2010 (Figure 28). In these Centers, with a larger PD program and greater use of Assisted PD, PUF represents 15% of new patients to PD (Figure 29).

Figure 28: Use of PUF (PD in refractory heart failure (HF) at GFR > 15 ml/min/1.73m2) compared with 2010.
Figure 28: use of PUF (PD in refractory heart failure (HF) at GFR > 15 ml/min/1.73m²) compared with 2010.
Figure 29: Characteristics of the Centers which use PD for refractory heart failure (HF).
Figure 29: characteristics of the Centers which use PD for refractory heart failure (HF).

Analysis of the Centers

Mean incidence was 5.9 patients per Center and mean prevalence 18.3 patients per Center, with considerable variability between one Center and another (Figure 30). Most of the Centers involved and of the prevalent patients are concentrated in the North (102 Centers, 45%). Figure 31 shows the geographical distribution.

The 2022 Census considered various aspects which characterize PD Centers. The data is being analyzed and will be published soon.

Figure 30: Distribution of centers and patients by Macro area.
Figure 30: distribution of centers and patients by Macro area.
Figure 31: Breakdown by incidence and prevalence of the PD Centers which took part in the 2022 Census.
Figure 31: breakdown by incidence and prevalence of the PD Centers which took part in the 2022 Census.

 

Discussion

Limitations and new features

The PD Census – at its 8th edition counting 2022 – represents the result of a constant organizational effort by GPDP-SIN and all the PD points of contact in the Centers in Italy using PD. Following the difficulties of the last edition caused by the pandemic, PD Center participation in 2022 was once again 100%.

As has been reiterated several times, its main limitation lies in the fact that it is a photograph of the Centers which perform PD alone, though this is also its raison d’être.

A second limitation results from the growing difficulty the PD points of contact have in sending even the most basic information relating to patients on HD in their Centers. Found for the first time in 2016, the number of Centers not sending HD data reached 22% in 2022.

A third limitation is the calculation of follow-up. With the data available, prevalence at the end of the year, new patients to PD and drop-outs the follow-up has always been calculated by subtracting from and adding to end-of-year prevalence half of the new patients to PD and half of the drop-outs recorded in the year respectively. This system has been preferred to considering the mean between current prevalence and prevalence recorded at the time of the previous Census (a system only used in calculating the incidence of EPS) due both to the interval in between, at times 3 or more years, and – at least initially – the lack of historical data. As usual, however, we report the absolute patient and event values so that anyone who wishes to perform recalculations can do so. It should be remembered only that the system adopted is the most “anti-economic” in that it leads to an underestimation of the follow-up, and therefore an overestimation of the incidence of events. Despite this, it has been shown that the results of PD in Italy are more than valid.

The most important new feature is represented by the new system for collecting the data by means of a dedicated program that can be used to send it in aggregate form. This system has greatly reduced data incongruence and has increased the information available, enabling increasingly detailed processing. As it is not yet used by all the Centers, however, traditional calculation and processing methods have been applied in this edition to all the Centers.

Use of PD

The number of incident and prevalent patients on PD is decreasing: compared to 2016, in 2022 there was a fall in the total number of incident patients of 15.4%, and in the number of prevalent patients of 9.9%. Percentage incidence and prevalence – calculated only for the Centers which sent HD data – are also dropping: compared to 2016, incidence fell from 24.0% to 19.8% and prevalence from 17.4% to 14.9%. It should be remembered furthermore that these percentage values refer only to the Centers using PD. If the number of prevalent patients on PD in 2022 is related to dialysis (HD + PD) prevalence data in Italy (estimated by the Italian Dialysis and Transplant Register to be 811 patients per million inhabitants (pmp) for 2019 [9]), then PD prevalence in Italy is 8.7% (Figure 32), which is disheartening in comparison with other Western countries (Figure 33) (Figure 36 – A) [1013], where the percentage prevalence is higher, not diminishing, and at times continuously increasing, as in the USA.

The reduction in prevalence has involved different regions and macro-areas to a variable degree (Figure 34) (Figure 35).

Figure 32: PD pmp prevalence in relation to the total (HD + PD) reported by the Italian Dialysis and Transplant Register.
Figure 32: PD pmp prevalence in relation to the total (HD + PD) reported by the Italian Dialysis and Transplant Register. The percentages show the relationship between the two prevalences. It is to be remembered that, unlike RIDT, the Census does NOT include pediatric patients.
Figure 33: Trend in percentage PD prevalence reported by the main international registers.
Figure 33: trend in percentage PD prevalence reported by the main international registers.
Figure 34: Comparison between 2022 and 2016 of prevalence referred to the resident populations in the various Italian Macro areas.
Figure 34: comparison between 2022 and 2016 of prevalence referred to the resident populations in the various Italian Macro areas.
Figure 35: Comparison between 2022 and 2016 of absolute value prevalence and referred to the resident populations in the various Italian Regions.
Figure 35: comparison between 2022 and 2016 of absolute value prevalence and referred to the resident populations in the various Italian Regions.
Figure 36: International comparisons.
Figure 36: international comparisons. In A absolute value and percentage prevalence reported by several registers. Canada includes Québec since 2020. Scandinavia includes Denmark, Iceland, Sweden, Norway, Finland. In B the outcome data reported by the Registers in France and ANZ.

Incremental Dialysis

Incremental Dialysis has been investigated ever since the first edition, documenting its characteristics and evolution over time in a manner which is detailed, and still unique – in terms of national Registers – in literature [14]. In 2022 this method grew further due to its greater use in the Centers that already prescribed it, and it seems to increasingly affect the choice of PD method: CAPD for the incremental prescription and APD for full-dose PD. Its use associated with a higher percentage use of PD is confirmed, while an important – but not yet resolved – aspect remains its role in the constant decrease observed in the incidence of peritonitis. Dr. Valerio Vizzardi of the Brescia Center, who has extensive experience in the use of this prescription, examines its importance and limitations in a dedicated annex to this report.

Assisted PD

This aspect will also be considered separately, though a significant reduction in recourse to Assisted PD is seen for 2022.

As is the case with other aspects, assisted PD is used more in larger Centers. The most common caregiver by far is a family member. In this, the situation in Italy is consistent with that in other countries, except – as is well-known and has already been extensively discussed previously – for France.

Drop-out from PD

The improvement seen in mortality is confirmed in 2022, while transfer to HD and transplant remain substantially unchanged. Excluding 2019, the year in which the Census was conducted at the height of the pandemic and was as a result incomplete in terms of both number of Centers taking part and information received, it is the first time drop-outs from PD have fallen below 30 episodes per 100 patient years.

Very little register data is available. Compared with ANZ and France, the Italian rate of turnover is the lowest, and mortality is comparable if not better, although burn-out (voluntary withdrawal from dialysis) is significantly lower than in other countries (Figure 36 – B).

Highlighted in terms of causes of drop-out to HD is an increase in catheter malfunction and the impossibility to continue PD. The fact that the data for the latter differ from France and ANZ is likely to be due to their more limited definition of the category.

A possible association with the lesser role of the Nephrologist in placement and the less frequent recourse to Assisted PD recorded in 2022, however appealing, remains to be established.

The reduction over the years in drop-out due to peritonitis is confirmed, consistent with the decrease observed in the incidence of peritonitis.

Finally, if drop-outs due to insufficient clearance and UFF are considered together, they are superimposable with the situation in other countries (Figure 36 – B).

Peritonitis

The incidence of peritonitis fell in 2022 to 0.176 episodes/patient year. Essentially, it has dropped from 5 episodes per patient-year in the 80s to less than 1 episode every 5 years. In particular, the incidence of peritonitis has almost halved from the first Census in 2005 (1 episode every 36 months) to today (1 episode every 68 months). This value is among the lowest recorded in the West, and is markedly lower than the maximum target recommended by the 2022 ISPD guidelines [15] and consistent with world trends for this complication (Figure 37) [16].

As regards the etiology too, which was investigated in a complete manner for the first time, the Census data are consistent with what has been observed in other Registers and multi-center studies [1719].

Andamento delle peritoniti nel tempo. Dati di Registro ricavato da Marshall et al [16].
Figure 37: trend in peritonitis over time. Register data sourced from Marshall et al [16]. The maximum ISPD – 2022 guideline targets are reported, along with the comparison with the GPDP Census data.
EPS

The 2022 data seem to confirm the major reduction in this PD complication, limited as it was to just a few cases in PD and in HD. This data is controversial – and in certain respects dangerous – because it could lead to less attention being given to the complication in PD to be feared most, so it was worthy of the in-depth analysis carried out by Prof. Guido Garosi and Dr. Nicoletta Mancianti attached to the Report.

Assessment of peritoneal permeability

The monitoring of peritoneal permeability, and the way in which it is done, is an important PD program quality indicator. The Census data show a constant increase over the years in the use of 3.86%-PET, from 15.6% of the Centers in 2010 to 57.7% in 2022. Contributing to this success has certainly been the research carried out by Dr. Vincenzo La Milia, who has examined the reasons in an annex to the Report.

PD due to refractory heart failure

When terminal-stage heart failure is reached, treatment of congestion by means of PD represents a possible solution which was already proposed many years ago. The experience reported in literature [2021] shows clear positive effects on symptomatology, quality of life and admissions to hospital. Indications on when to start the therapy still remain uncertain, and a real comparison with HD is practically impossible, although the data do not show significant differences. The Census highlights an important aspect associated with this therapy. Over a period of more than 10 years, its use in Italy remains relegated to the same number of Centers and for the same number of patients. The Centers that use it are larger and make greater use of assisted PD. 

Center Effect

The number of Centers which use PD has remained substantially the same over the years. In various aspects of PD examined (Incr-PD, drop-out to HD, assisted PD, non-renal PD, PET), it seems that the so-called “Center effect” – in short, size of PD program (prevalent patients) – is important: the larger the program, the better the use and results of PD seem to be. The 2022 Census investigated in greater detail the characteristics of Centers, such as the presence of dedicated doctors and nurses, the availability of dedicated premises and of a home visit program, training methods. A detailed analysis of this important aspect is underway for forthcoming publication.

 

Conclusions

The PD Census relating to 2022 confirms the quality of PD in Italy in terms of prescription elasticity, reduction in mortality, reduction in peritonitis and EPS, the still extensive recourse to Assisted PD, although this is on the decrease, and monitoring of the peritoneal membrane. However, the use of PD seems to be diminishing. Limited as it is to PD Centers, the Census does not make it possible to identify the reasons for this fall. It just highlights its contrast with the results obtained. Thanks to the active participation of the PD contacts in the individual Centers, the Census confirms itself as a valid, constantly-developing tool for knowing the actual situation.

 

Acknowledgements

Special thanks to the contacts in the Centers taking part in the Census, whose commitment has made the collection of the data and this report possible.

Abdulsattar Giamila (Oristano)
Alberghini Elena (Cinisello Balsamo)
Albrizio Paolo (Voghera)
Alessandrello Maria Grazia Ivana (Modica)
Alfano Gaetano (Modena)
Amar Karen (Cernusco sul Naviglio)
Ambrogio Antonina (Rovigo)
Ancarani Paolo (Sestri Levante)
Angelini Maria Laura (forlì)
Ansali Ferruccio (Civitavecchia)
Apponi Francesca (Frosinone)
Argentino Gennaro (Napoli)
Avella Alessandro (Varese)
Barattini Marina (Massa)
Barbera Vincenzo (Colleferro)
Basso Anna (Padova)
Bellotti Giovanni (Sapri)
Benozzi Luisa (Borgomanero)
Bermond Francesca (Torino)
Bianco Beatrice (Verona)
Bigatti Giada (Sesto San Giovanni)
Bilucaglia Donatella (Torino)
Boccadoro Roberto (Rimini)
Boito Rosalia (Crotone)
Bonesso Cristina (San Donà di Piave)
Bonincontro Maria Luisa (Bolzano)
Bonvegna Francesca (Verbania)
Borettaz Ilaria (Melegnano – Vizzolo Predabissi)
Borrelli Silvio (Napoli)
Bosco Manuela (Gorizia)
Braccagni Beatrice (Poggibonsi)
Budetta Fernando (Eboli)
Cabibbe Mara (Milano)
Cabiddu Gianfranca (Cagliari)
Cadoni Maria Chiara (San Gavino Monreale)
Campolo Maria Angela (Lamezia Terme)
Cannarile Daniela Cecilia (Bologna)
Cannavo’ Rossella (Firenze)
Canonici Marta (Fabriano)
Cantarelli Chiara (Parma)
Caponetto Carmelo (Siracusa)
Cappadona Francesca (Genova)
Cappelletti Francesca (Siena)
Caprioli Raffaele (Pisa)
Capurro De Mauri Federica Andreana (Novara)
Caria Simonetta (Quartu Sant’ Elena)
Carta Annalisa (Nuoro)
Caselli Gian Marco (Firenze)
Casuscelli di Tocco Teresa (Messina)
Cataldo Emanuela (Altamura)
Cernaro Valeria (Messina)
Cerroni Franca (Rieti)
Ciabattoni Marzia (Savona)
Cianfrone Paola (catanzaro)
Cimolino Michele (Pordenone)
Comegna Carmela (Tivoli)
Consaga Marina (Livorno)
Contaldo Gina (Monza)
Conti Paolo (Arezzo)
Cornacchia Flavia (Cremona)
Cosa Francesco (Legnano)
Cosentini Vincenzo (San Bonifacio)
Costantini Luigia (Vercelli)
Costantino Ester Grazia Maria (Manerbio)
Costanza Giuseppa (Gela)
D’Alonzo Silvia (Roma)
D’Altri Christian (Martina Franca)
D’Amico Maria (Erice)
De Blasio Antonietta (Caserta)
Del Corso Claudia (Pescia)
Della Gatta Carmine (Nola)
D’Ercole Martina (La Spezia)
Di Franco Antonella (Barletta)
Di Liberato Lorenzo (Chieti)
Di Loreto Ermanno (Atri)
Di Renzo Brigida (Brindisi)
Di Somma Agnese (San Marco Argentano)
Di Stante Silvio (Pesaro – Fano)
Dinnella Angela Maria (Anzio)
Distratis Cosimo (Manduria)
Dodoi Diana Teodora (Chieri)
Domenici Alessandro (Roma)
Esposito Samantha (Grosseto)
Esposito Vittoria (Pavia)
Farina Marco (Lodi)
Ferrando Carlo (Cuneo)
Ferrannini Michele (Roma)
Ferrara Gaetano (San Giovanni Rotondo)
Figliano Ivania Maria (Vibo Valentia)
Figliola Carmela (Gallarate)
Filippini Armando (Roma)
Finato Viviana (San Miniato)
Fiorenza Saverio (Imola)
Frattarelli Daniele (Roma Ostia)
Gabrielli Danila (Aosta)
Gai Massimo (Torino)
Garofalo Donato (Fermo)
Gazo Antonietta (Vigevano)
Gennarini Alessia (Bergamo)
Gherzi Maurizio (Ceva)
Giancaspro Vincenzo (Molfetta)
Gianni Glauco (Prato)
Giovannetti Elisabetta (Camaiore)
Giovannetti Elisabetta (Lido di Camaiore)
Giozzet Morena (Feltre)
Giuliani Anna (Vicenza)
Giunta Federica (Macerata)
Graziani Romina (Ravenna)
Guizzo Marta (Castelfranco Veneto)
Heidempergher Marco (Milano)
Iacono Rossella (Civita Castellana)
Iadarola Gian Maria (Torino)
Iannuzzella Francesco (Reggio Emilia)
Incalcaterra Francesca (Palermo)
La Milia Vincenzo (Lecco)
Laudadio Giorgio (Bassano del Grappa)
Laudon Alessandro (Trento)
Lenci Federica (Ancona)
Leonardi Sabina (Trieste)
Lepori Gianmario (Olbia)
Leveque Alessandro (Citta’ di Castello)
Licciardello Daniela (Acireale)
Lidestri Vincenzo (Chioggia)
Lisi Lucia (Vimercate)
Lo Cicero Antonina (San Daniele del Friuli )
Luciani Remo (Roma)
Maffei Stefano (Asti)
Magnoni Giacomo (Bologna)
Malandra Rossella (Teramo)
Manca Rizza Giovanni (Pontedera)
Mancuso Verdiana (Agrigento)
Manfrini Vania (Seriate)
Manini Alessandra (Crema)
Marcantoni Carmelita (Catania)
Marchetti Valentina (Lucca)
Marini Alvaro (Popoli)
Martella Vilma (Lecce)
Masa Maria Alessandra (Sondrio)
Mastrippolito Silvia (Lanciano)
Mastrosimone Stefania (Treviso)
Matalone Massimo (Catania)
Mauro Teresa (Corigliano Rossano)
Mazzola Giuseppe (Mantova)
Melfa Gianvincenzo (Como)
Messina Antonina (Catania)
Miglio Roberta (Busto Arsizio)
Miniello Vincenzo (Pistoia)
Mollica Agata (Cosenza)
Montalto Gaetano (Taormina)
Montanari Marco (Ariccia)
Montemurro Vincenzo (Firenze)
Musone Dario (Formia)
Nardelli Luca (Milano)
Neri Loris (Alba)
Orani Maria Antonietta (Milano)
Palmiero Giuseppe (Napoli)
Palumbo Roberto (Roma)
Panuccio Vincenzo Antonio (Reggio Calabria)
Panzino Antonio Rosario (Catanzaro)
Parodi Denise (Arenzano)
Pastorino Nadia Rosa (Novi Ligure)
Pellegrino Cinzia (Cetraro)
Perilli Luciana (Vasto)
Perna Concetta (Cerignola)
Perosa Paolo (Pinerolo)
Pieracci Laura (Imperia)
Pietanza Stefania (Putignano)
Pignone Eugenia (Torino)
Pinerolo Maria Cristina (Milano)
Piraina Valentina (ivrea)
Pirrottina Maria Anna (San Benedetto del Tronto)
Pisani Antonio (Napoli)
Pogliani Daniela Rosa Maria (Garbagnate Milanese)
Porreca Silvia (Bari)
Pozzi Marco (Desio)
Prerez Giuseppina (Dolo)
Previti Antonino (Santorso)
Puliti Maria Laura (Palestrina)
Randone Salvatore (Avola)
Ricciardi Daniela (Castiglione del Lago)
Ricciatti Annamaria (Ancona)
Rocca Anna Rachele (Roma)
Rubini Camilla (Venezia Mestre)
Russo Francesco Giovanni (Scorrano)
Russo Roberto (Bari)
Sabatino Stefania (Udine)
Sacco Colombano (Biella)
Sammartino Fulvio Antonio (Pescara)
Santarelli Stefano (Jesi)
Santese Domenico (Taranto)
Santinello Irene (Piove di Sacco)
Santirosi Paola Vittori (Foligno-Spoleto)
Santoferrara Angelo (Civitanova Marche)
Saraniti Antonello (Milazzo)
Savi Umberto (Belluno)
Scalso Berta Ida (Cirie’)
Scarfia Rosalia Viviana (Caltagirone)
Serriello Ilaria (Roma)
Signorotti Sara (Cesena)
Silvana Baranello (Campobasso)
Somma Giovanni (Castellamare di Stabia)
Sorice Mario (Senigallia)
Spissu Valentina (Sassari)
Stacchiotti Lorella (Giulianova)
Stucchi Andrea (Milano)
Taietti Carlo (Treviglio)
Tata Salvatore (Venezia)
Teri Antonino (Foggia)
Tettamanzi Fabio (Tradate)
Timio Francesca (Perugia)
Todaro Ignazio (Piazza Armerina)
Toriello Gianpiero (Polla)
Torraca Serena (Salerno)
Trepiccione Francesco (Napoli)
Trubian Alessandra (Legnago)
Turchetta Luigi (Cassino)
Vaccaro Valentino (Alessandria)
Valsania Teresa (Piacenza)
Vecchi Luigi (Terni)
Veronesi Marco (Ferrara)
Visciano Bianca (Magenta)
Viscione Michelangelo (Avellino)
Vizzardi Valerio (Brescia)
Zanchettin Gianantonio (Conegliano)
Zeiler Matthias (Ascoli Piceno)

 

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Peritoneal Dialysis in Italy: the 7th GSDP-SIN census 2019

Abstract

Objectives: Analysis of the results of the 7th National Census (Cs-19) of Peritoneal Dialysis in Italy, conducted in 2020-21 by the Peritoneal Dialysis Project Group of the Italian Society of Nephrology, for the year 2019.
Materials and methods: The data was initially collected using specially designed software, which after entering the data of individual patients allows the aggregate extraction of the necessary information. The difficulties due to the COVID pandemic made it necessary to also use the traditional on-line questionnaire used previously. Of the 237 Centers envisaged, 198 responded, of which 177 with complete data for HD also in 2016.
Results: Overall incidence and prevalence (31/12/2019) were respectively 1,363 (CAPD/APD = 741/622) and 3,922 (CAPD/APD = 1,857 / 2,065) patients. The percentage incidence and prevalence (177 Centers) decreased compared to 2016, respectively, from 23.8% to 22.1% and from 17.3% to 16.6%. 31.4% started PD incrementally in 60.3% of the Centers. The catheter is placed by the Nephrologist alone in 19.7%. Assisted PD is used by 24.5% of the prevalent patients, mostly (83.8%) by a family member. In 2019, the exit from PD (ep/100 years-pts: 11.6 in HD; 8.9 death; 6.0 Tx) is decreasing for all causes. The main cause of transfer to HD remains peritonitis (26.8%). The incidence of peritonitis in 2019 dropped further to 0.190 ep/year-pts as well as the incidence of new cases of EPS (0.103 ep/100 years-pts).
Conclusions: The Cs-19 confirms the good results of the DP in Italy.

Keywords: Peritoneal Dialysis, technique failure, incremental Peritoneal Dialysis, peritonitis, home visits, peritoneal equilibration test (PET)

Sorry, this entry is only available in Italian.

Introduzione

L’utilizzo della Dialisi Peritoneale (DP) viene rilevato dal Gruppo di Progetto di Dialisi Peritoneale della Società Italiana di Nefrologia (SIN) mediante un Censimento, condotto ogni 2-3 anni, dei Centri che utilizzano la DP. In questo report sono presentati i risultati della 7° edizione, condotta nel 2020-21 e relativa all’anno 2019 (Cs-19), confrontandoli con quelli degli anni precedenti: 2005 (Cs-05), 2008 (Cs-08) [1], 2010 (Cs-10) [2], 2012 (Cs-12) [3], 2014 (Cs-14) [4] e 2016 (Cs-16) [5].

Per quest’ultima edizione era stato introdotto un nuovo sistema di raccolta dati ma la coincidenza con la pandemia COVID-19 ha impedito il raggiungimento dell’obiettivo principale del Censimento, la copertura del 100% dei Centri DP.

 

Materiali e metodi

Il Censimento del GPDP consiste nella raccolta di dati aggregati relativi alla DP ed è rivolto a tutti i Centri Pubblici, non pediatrici, che hanno utilizzato la DP nell’anno censito.

Raccolta dati

Nell’edizione attuale i dati aggregati sono stati raccolti in due modi diversi.

La prima modalità, analitica, è stata effettuata attraverso un software sviluppato appositamente per il progetto, una sorta di cartella clinica in cui inserire sistematicamente i singoli pazienti e, quando necessario, esportare i dati aggregati utili al Censimento lasciando al programma l’onere dei conteggi. Le informazioni richieste erano i dati anagrafici, quelli relativi all’inizio della DP (nefropatia di base, motivazioni all’inizio della DP, referral, tecnica di inserzione del catetere, tipo di caregiver in caso di DP assistita) ed al follow up della DP limitato alle peritoniti e all’eventuale cambio di modalità di DP o sua interruzione. Per motivi di privacy il programma è stato sviluppato senza una componente cloud quindi tutti i dati inseriti erano conservati in locale e la possibilità di backup su server era demandata all’operatore. La riorganizzazione delle strutture operative e del personale avvenuta a causa del COVID-19 ha comportato per diversi Centri lo spostamento dei computer o la loro riformattazione con la conseguente perdita dei dati inseriti. A questo si sono aggiunti lo stato di emergenza degli ospedali, il sottodimensionamento dell’organico nelle strutture e il pensionamento di molti dei referenti, fattori che hanno ulteriormente compromesso la raccolta dei dati. Infine, in alcuni Centri l’invio dei dati aggregati è stato bloccato dal firewall dell’ospedale.

A questi problemi si è posto parzialmente rimedio ricorrendo alla modalità tradizionale di raccolta dati mediante la compilazione del questionario on-line utilizzato per le edizioni precedenti.

Per tutte queste ragioni, nonostante gli sforzi compiuti, non è stato raggiunto l’obiettivo principale del Censimento, ovvero la copertura del 100% dei Centri che hanno utilizzato la DP nel 2019.

Centri partecipanti e livelli di analisi

L’elenco dei Centri pubblici che utilizzano la DP ha il suo punto di partenza nell’elenco del Censimento della SIN condotto per l’anno 2004 [6], aggiornato negli anni ed integrato con altri dati raccolti in occasione di Convegni e Congressi, fino all’ultimo Censimento SIN del 2018 [7].

I Centri che hanno partecipato sono stati 198. Nelle precedenti edizioni si trattava della totalità dei Centri che avevano utilizzato la DP per almeno 1 paziente, con dati completi sia per la DP ma anche per la Emodialisi (HD) (tranne nell’ultima edizione del 2016 in cui su 237 Centri i dati completi per HD erano stati forniti da 230 Centri). Ciò consentiva di effettuare il confronto con gli anni precedenti sui dati globali.

Nell’attuale edizione la mancanza di diversi Centri e/o la mancanza dei dati relativi alla HD, ha complicato l’analisi, che, per includere il maggior numero di informazioni possibile, è stata quindi condotta tra gruppi diversi secondo le informazioni analizzate.

In sintesi sono stati registrati (Figura 1):

  1. 198 Centri con dati completi di incidenza e prevalenza e drop out per la DP
    • Centri nuovi = 5 (e quindi 193 presenti anche nel 2016)
    • Centri esclusi per cessata DP od altro (non censibili) = 7
    • Centri che non hanno inviato i dati e che presumibilmente utilizzano la DP = 39
    • I Centri che hanno risposto rappresentano quindi l’83,5% dei Centri DP (198/237)
  2. 186 Centri dei 198 censiti con dati completi per incidenza e prevalenza della HD nel 2019
  3. 177 Centri dei 198 censiti con dati completi per la HD anche nel 2016.
Fig. 1: Centri partecipanti alle diverse edizioni dei Censimento del GSDP.
Fig. 1: Centri partecipanti alle diverse edizioni dei Censimento del GSDP. Per il 2019 i Centri che non hanno inviato i dati sono 39 anche se, proprio per questo, non è certo che tutti abbiano utilizzato la DP nel 2019.

L’analisi della DP è stata condotta su tutti i Centri censiti. Dal momento che non tutti i Centri hanno risposto a tutte le domande, il numero dei Centri con dati disponibili è specificato nelle singole sottoanalisi. Il confronto per la DP con l’anno precedente (2016) è stato effettuato sui 193 Centri presenti anche nel 2016, mentre il confronto con il 2016 degli indici che richiedono anche i dati relativi alla HD (incidenza e prevalenza percentuali) è stato effettuato sul sottogruppo di 177 Centri che hanno inviato anche i dati relativi alla HD sia nel 2016 che nel 2019.

Informazioni

La struttura del Censimento prevede un gruppo di informazioni ripetute, rimaste invariate dalla prima edizione (Cs-05), relative ad incidenza, prevalenza, cambio o interruzione di metodica, peritoniti e DP non renale. A queste, dal 2008 [1], è stata aggiunta la peritonite sclerosante incapsulante (EPS); dal 2010 [2], le visite domiciliari ed il test di equilibrio peritoneale (PET).  Dall’edizione del 2016 [5], sono state riprese le domande sui cateteri. Inoltre con la modalità analitica di raccolta dati sono state disponibili per la prima volta informazioni sui germi coinvolti negli episodi di peritonite e sulle modalità del training.

Verifiche dei dati e confronti

I dati inizialmente raccolti sono stati sottoposti ad una prima analisi di congruenza. Quelli incoerenti sono stati corretti, ove possibile, attraverso un recall telefonico oppure considerati mancanti o incompleti, a seconda dei casi. Le eventuali correzioni ed il numero di Centri coinvolti sono riportati in dettaglio nella presentazione dei singoli risultati.

Definizioni e calcoli

Sono stati considerati pazienti incidenti tutti quelli immessi come primo trattamento in DP ed in HD nel periodo 01/01/2019-31/12/2019. Tra questi, sono stati considerati in DP incrementale (Incr-DP) con CAPD (Incr-CAPD) e APD (Incr-APD) i pazienti che effettuavano rispettivamente ≤2 scambi/die o ≤4 sedute/settimana. La prevalenza è stata riferita ai pazienti in trattamento dialitico al 31 dicembre. Tra i prevalenti la necessità di assistenza è riferita al coinvolgimento di un caregiver nell’esecuzione delle procedure dialitiche. I pazienti trattati con DP per cause non renali (GFR ≥15 ml/min/1,73) sono stati considerati a parte ed esclusi dal calcolo dell’incidenza e della prevalenza.

Gli episodi di peritonite sono riferiti al 2019 mentre quelli di peritonite sclerosante si riferiscono a tutto il biennio 2018-9 per la raccolta tradizionale ed al triennio per quella analitica.

L’overall rate per morte, trapianto e per cambio di metodica da PD ad HD è stato espresso in numero di episodi per 100 anni-paziente (ep/100anni-pz) secondo la formula:

Overall rate = [N° episodi / (anni di follow up)] x 100

A loro volta, gli anni di follow up sono stati calcolati sottraendo ed aggiungendo ai prevalenti del 31/12/2019 rispettivamente la metà dei pazienti che hanno iniziato la DP (incidenti e da altre metodiche) e la metà quelli usciti (per drop out in HD, decesso o trapianto) durante il 2019.

Per le peritoniti l’incidenza è stata calcolata come episodi/mesi-paziente (ep/mesi-pz) riferita all’anno censito.

Per la EPS, essendo i dati richiesti su base pluriennale e, per la prima rilevazione, quinquennale, è stata applicata la seguente formula:

ep/100 aa/pz = [(casi nel periodo) / (N° anni del periodo) / (prevalenza media del periodo)] x 100

ove la prevalenza media del periodo è stata calcolata come la media della prevalenza attuale (per il Cs-19 quella al 31/12/2019) e quella del censimento precedente (Cs-16, prevalenza al 31/12/2016).

L’analisi statistica è stata limitata alla ricerca di eventuali differenze con il test Chi quadro.

 

Risultati

Centri partecipanti e rappresentatività del campione

I Centri che hanno trattato almeno 1 paziente in DP nel 2019 e che hanno partecipato al Cs-19 sono stati 198 di cui 5 non presenti (Centri “nuovi”) e 193 presenti nell’edizione precedente (Cens-16).

Rispetto al 2016 sono inoltre stati esclusi 7 Centri per cessato utilizzo della DP mentre 39 Centri che, presumibilmente, hanno continuato a utilizzare la DP, non hanno inviato alcun dato. Complessivamente i Centri che hanno inviato i dati rappresentano quindi almeno l’83,5% dei Centri che hanno utilizzato la DP nel 2019.

La rappresentatività dei Centri partecipanti è stata valutata mediante il numero di pazienti trattati in questi Centri, rispetto il totale, nel 2016. Per quanto riguarda i 193 Centri presenti in entrambi i Censimenti, l’incidenza e la prevalenza della DP in questi Centri nel 2016 erano rispettivamente l’82,9% (1322 / 1595) e l’84,7% (3903 / 4607) del totale (237 Centri).

Per il confronto degli indici che richiedono anche i dati della HD (incidenza e prevalenza) si è dovuto tenere conto che sia nel Cs-16 che nel Cs-19 alcuni Centri non hanno inviato i dati relativi alla HD (incidenza, prevalenza o entrambe). Per il calcolo di incidenza/prevalenza percentuali nel 2019 sono stati esclusi quindi 12 Centri (186 Centri) mentre per il confronto con il 2016 sono stati esclusi anche i 5 Centri “nuovi” e 4 Centri che non avevano inviato i dati relativi alla HD nel 2016 (Centri considerati per il confronto = 177). La rappresentatività di questi Centri, calcolata sempre allo stesso modo, è riportata in Figura 2. Come si vede, le percentuali di pazienti incidenti e prevalenti e quelli dei Centri sostanzialmente coincidono, ad indicare una buona rappresentatività del “campione”.

Fig.2: Percentuale di pazienti in DP + HD (incidenza e prevalenza) Censiti nel 2016 nei 177 Centri che hanno partecipato con dati completi per l’HD ad entrambe le edizioni.
Fig.2: Percentuale di pazienti in DP + HD (incidenza e prevalenza) Censiti nel 2016 nei 177 Centri che hanno partecipato con dati completi per l’HD ad entrambe le edizioni.

Incidenza e prevalenza

Complessivamente i pazienti che hanno iniziato la DP nel 2016 come primo trattamento nei 198 Centri sono risultati 1.363 (CAPD/APD = 741/622) e quelli in trattamento al 31/12/2019 sono risultati 3.922 (CAPD/APD = 1.857/2.065 pazienti).

Considerando solo i 186 Centri con dati completi per l’HD i pazienti che hanno iniziato la DP come primo trattamento sono stati 1.272 (CAPD/APD = 689/583) e la HD 4.582 con un’incidenza percentuale del 21,7%, mentre i pazienti in trattamento in DP ed in HD al 31/12/2019 sono stati rispettivamente 3.613 (CAPD/APD = 1.685/1.928 pazienti) e 18.671 per una prevalenza percentuale della DP del 16,2% (Figura 3).

Infine considerando solo i 177 Centri presenti anche nel C-16 e con dati disponibili per l’HD l’incidenza è scesa dal 23,8% nel 2016 al 22,1% (Figura 4) nel 2019 mentre la prevalenza dal 17,3% del 2016 al 16,6% del 2019 (Figura 5).

Come già riportato si tratta di Centri pubblici (tranne uno) che utilizzano la DP; perciò i dati di incidenza e prevalenza percentuale della DP sono superiori a quelli del RIDT, che riporta invece i dati di tutti i Centri dialisi, sia pubblici che privati, sia che utilizzino la DP oppure no. Questi ultimi, come noto, sono la maggioranza [6].

Fig. 3.  Incidenza e prevalenza della DP nel 2019 in tutti i Centri (1° trattamento) in valori assoluti e nei Centri con dati disponibili anchde per la HD in valori percentuali.
Fig. 3.  Incidenza e prevalenza della DP nel 2019 in tutti i Centri (1° trattamento) in valori assoluti e nei Centri con dati disponibili anche per la HD in valori percentuali.
Fig. 4.  Incidenza della DP (1° trattamento) in valori assoluti e percentuali rispetto al totale
Fig. 4.  Incidenza della DP (1° trattamento) in valori assoluti e percentuali rispetto al totale dei pazienti in trattamento dialitico. In A negli anni delle precedenti edizioni (2005, 2008, 2010, 2012, 2014, 2016); in B nel 2019 confrontato con il 2016 negli stessi Centri con dati disponibili per entrambe le metodiche.
Fig. 5.  Prevalenza della DP in valori assoluti e percentuali
Fig. 5.  Prevalenza della DP in valori assoluti e percentuali rispetto al totale dei pazienti in trattamento dialitico. In A negli anni delle precedenti edizioni (2005, 2008, 2010, 2012, 2014, 2016); in B nel 2019 confrontato con il 2016 negli stessi Centri con dati disponibili per entrambe le metodiche.
CENTRI CENSITI CENTRI CON DATI COMPLETI PER HD
ANNO CENTRI PAZIENTI DP CENTRI PAZIENTI DP PAZIENTI HD % DP
2005 222 1.443 222 1.443 4.502 24,3
2008 223 1.379 223 1.379 4.646 22,9
2010 224 1.429 224 1.429 4.695 23,3
2012 224 1.433 224 1.433 4.700 23,4
2014 225 1.652 225 1.652 4.442 27,1
2016 237 1.595 230 1.549 4.907 24,0
2019 198 1.363 186 1.272 4.582 21,7
   
2016 177 1.201 3.840 23,8
2019 177 1.243 4.384 22,1
Tabella I: Incidenza nel tempo. Per il 2019 è riportato il confronto con il 2016 per gli stessi Centri con dati disponibili anche per la HD.
CENTRI CENSITI CENTRI CON DATI COMPLETI PER HD
ANNO CENTRI PAZIENTI DP CENTRI PAZIENTI DP PAZIENTI HD % DP
2004 * 4.234 4.234 20.921 16,8
2008 223 4.094 223 4.094 20.478 16,7
2010 224 4.222 224 4.222 21.175 16,6
2012 224 4.299 224 4.299 20.844 17,1
2014 225 4.480 225 4.480 21.716 17,1
2016 237 4.607 230 4.484 21.286 17,4
2019 198 3.922 186 3.613 18.671 16,2
   
2016 177 3.559 16.965 17,3
2019 177 3.542 17.774 16,6
Tabella II: Prevalenza nel tempo. Per il 2019 è riportato il confronto con il 2016 per gli stessi Centri con dati disponibili anche per la HD.
* Il 2004 è riferito ai dati del Censimento SIN [6] mentre nel 2005 la prevalenza non è stata indagata.

Ingressi in Dialisi Peritoneale

Oltre ai 1.363 pazienti incidenti nei 198 Centri censiti sono entrati in Dialisi Peritoneale 125 pazienti (8,2% degli ingressi) provenienti dalla HD e 44 pazienti (2,9% degli ingressi) provenienti dal Trapianto, per un totale di 1.532 pazienti, senza variazioni significative rispetto gli anni precedenti (Figura 6). In particolare considerando tutti i pazienti rientrati dal Tx in dialisi la percentuale di quelli che rientrano in DP rimane significativamente inferiore e stabile al 14,0% (Figura 7). I pazienti trasferiti da altri Centri sono stati 33.

L’indice di ricambio (pazienti prevalenti/totale ingressi), stima approssimativa della durata media della DP, è risultato 2,56 anni (30,7 mesi), analoga a quella degli anni precedenti.

Fig. 6: Percentuale sul totale degli ingressi in DP di pazienti provenienti dalla HD
Fig. 6: Percentuale sul totale degli ingressi in DP di pazienti provenienti dalla HD e dal Tx in tutti i Centri censiti (198 per il 2019).
Fig. 7: Rientro in dialisi da trapianto. Percentuali di pazienti che hanno
Fig. 7: Rientro in dialisi da trapianto. Percentuali di pazienti che hanno ripreso la dialisi in DP ed in HD negli anni dei Censimenti. Nel 2016 non considerati 7 Centri che non hanno fornito gli ingressi in HD mentre nel 2019 i Centri con dati disponibili per la HD sono stati 186.

Modalità di Dialisi Peritoneale

Tra i pazienti incidenti la CAPD rappresenta la modalità più utilizzata (54,4%) mentre tra i prevalenti lo è la APD (52,7%) (Figura 8). Il dato non sembra essersi modificato negli anni (Figura 9).

Fig. 8: Modalità di DP nei pazienti incidenti e prevalenti nel 2019.
Fig. 8: Modalità di DP nei pazienti incidenti e prevalenti nel 2019.
Fig. 9: Modalità di DP nei pazienti incidenti e prevalenti negli anni.
Fig. 9: Modalità di DP nei pazienti incidenti e prevalenti negli anni.
  PAZIENTI INCIDENTI PAZIENTI PREVALENTI
  CAPD APD TOT CAPD/APD CAPD APD TOT CAPD/APD
2005 794 649 1443 1,22 nd nd 4432 nd
2008 759 620 1379 1,22 1926 2168 4094 0,89
2010 763 666 1429 1,15 1929 2293 4222 0,84
2012 778 655 1433 1,19 1981 2318 4299 0,85
2014 945 707 1652 1,34 2099 2381 4480 0,88
2016 895 700 1595 1,28 2147 2460 4607 0,87
2019 741 622 1363 1,19 1857 2065 3922 0,90
177 CENTRI
2016 685 516 1201 1,33 1680 1879 3559 0,89
2019 671 572 1243 1,17 1653 1889 3542 0,88
Tabella III: Modalità di DP nei pazienti incidenti e prevalenti negli anni

Dialisi peritoneale incrementale

Il dato sulla dialisi incrementale nel 2019 è risultato disponibile in 194 Centri dei 198 Censiti. Nel 2019 i pazienti che hanno iniziato la DP con modalità incrementale nei 194 Centri (Incr-DP) sono stati 414, pari al 31,4% del totale dei pazienti incidenti in tali Centri (1.317); il numero dei Centri che l’hanno utilizzata sono stati 117, pari al 60,3% dei 194 Centri. Tra i pazienti Incr-DP la metodica più utilizzata è risultata sempre la CAPD (86,2%) al contrario di quelli “full dose” in cui è significativamente più utilizzata l’APD (59,7% – p<0,0001) (Figura 10).

Negli anni il numero dei Centri (Figura 11) ed il numero e la percentuale di pazienti in Incr-DP sono andati costantemente aumentando fino al 2012 per rimanere sostanzialmente stabili fino al 2019 (Figura 12).

Si conferma inoltre il numero limite di pazienti in Incr-DP: nei Centri che vi ricorrono infatti la percentuale di pazienti in Incr-DP è risultata nel 2019 (44,9%) praticamente sovrapponibile a quella degli anni precedenti (Figura 13).

Nei Centri che hanno prescritto Incr-DP almeno per 1 paziente l’incidenza percentuale della DP (23,6%) è risultata significativamente superiore a quella degli altri (18,6% – p <0,005) (Figura 14-A). Ciò è in accordo con quanto osservato in tutte le edizioni precedenti (Figura 14-B).

Fig. 10: Inizio incrementale nei 1.317 pazienti incidenti nel 2019
Fig. 10: Inizio incrementale nei 1.317 pazienti incidenti nel 2019 (194 Centri). Nelle colonne ai lati è riportata la ripartizione APD / CAPD dei pazienti che iniziano in modo incrementale (sinistra) e full dose (destra).
Fig. 11: Percentuale di Centri, sul totale di tutti i Centri, che hanno immesso almeno un paziente in Incr-PD nei diversi anni del Censimento. La percentuale è riferita ai Centri con incidenza diversa da zero.
Fig. 11: Percentuale di Centri, sul totale di tutti i Centri, che hanno immesso almeno un paziente in Incr-PD nei diversi anni del Censimento. La percentuale è riferita ai Centri con incidenza diversa da zero.
Fig. 12: Utilizzo della DP incrementale negli anni.
Fig. 12: Utilizzo della DP incrementale negli anni. A sinistra il numero assoluto di pazienti incidenti che hanno iniziato in modo incrementale in CAPD ed in APD (A) ed in percentuale sul totale dei pazienti per modalità di DP (B). A destra le percentuali rispetto al totale dei pazienti incidenti in DP.
Fig. 13: Percentuale di pazienti in Incr-DP nei Centri che utilizzano tale modalità di inizio.
Fig. 13: Percentuale di pazienti in Incr-DP nei Centri che utilizzano tale modalità di inizio.
Fig. 14: Probabilità di iniziare la dialisi con la DP rispetto alla HD nei Centri
Fig. 14: Probabilità di iniziare la dialisi con la DP rispetto alla HD nei Centri che fanno ricorso alla Incr-DP rispetto ai Centri che non la utilizzano nel 2019 (%, A) e nei diversi anni in cui è stato condotto il Censimento del GPDP (OR, B).

Cambio di modalità di Dialisi Peritoneale

Nel 2019 i pazienti, dei 194 Centri che hanno fornito i dati, passati dalla CAPD alla APD sono stati 172 (Figura 15-A) mentre quelli passati dalla APD alla CAPD sono stati 37 (Figura 15-B), rispettivamente il 3,6% e lo 0,8% dei pazienti trattati con la DP. Ciò spiega ulteriormente come tra i pazienti prevalenti la metodica più utilizzata sia l’APD. La ragione principale del cambio di metodica rimane la scelta del paziente: 43,0% per il passaggio da CAPD ad APD e 27,0% per quello da APD a CAPD. Per il passaggio dalla CAPD alla APD l’adeguatezza e l’UF sono ragioni altrettanto importanti, mentre per il trasferimento inverso lo è anche il malfunzionamento del catetere (Figura 15-B). Non sono stati registrati cambiamenti significativi negli anni.

Fig. 15: Pazienti che hanno cambiato metodica di DP
Fig. 15: Pazienti che hanno cambiato metodica di DP (dalla CAPD alla APD e viceversa) nel 2019 e motivazioni al cambio. Come si vede il flusso dalla CAPD alla APD (172 pazienti) è nettamente superiore rispetto al flusso inverso (37 pazienti).

Dialisi Peritoneale assistita

Nel Cs-19 i pazienti prevalenti con necessità di caregiver (assisted PD) sono risultati 962 (24,5% di tutti i prevalenti in DP) nei 198 Centri. Il caregiver era un familiare nel 83,8% dei casi, un badante nel 5,6%, un infermiere a domicilio nel 6,1%; infine, il 4,4% (42 pazienti) effettuava la DP in strutture per anziani (RSA) (Figura 16). Rispetto il 2016 è diminuito il ricorso al caregiver retribuito (“badante”) mentre è aumentato quello all’Infermiere a domicilio ed il coinvolgimento di un familiare (Figura 17).

Fig. 16: DP assistita nel 2019.
Fig. 16: DP assistita nel 2019. Confronto con gli anni precedenti (valori percentuali riportati nel riquadro grigio) e ripartizione dei pazienti in funzione del tipo di caregiver.
Fig. 17: Caregiver nel 2019 a confronto con il 2016 nei 193
Fig. 17: Caregiver nel 2019 a confronto con il 2016 nei 193 Centri presenti in entrambi i Censimenti. Nel riquadro la percentuale di pazienti in RSA in HD ed in DP nel 2019.

Uscita dalla Dialisi Peritoneale e trasferimento alla Emodialisi

In Figura 18 sono riportate le uscite dalla DP, per trasferimento alla HD, per morte e per trapianto, espresse sia come numero di pazienti che come numero di eventi/100 anni-pz, nei 193 Centri presenti anche nel 2016 e confrontati con gli anni precedenti.

In tali Centri sono stati registrati 324 decessi (8,9 ep/100 anni-pz), 421 trasferimenti alla HD (11,6 ep/100 anni-pz) e 220 trapianti (6,0 ep/100 anni-pz). Il numero complessivo di uscite dalla DP si è ridotto da 30,9 ep/100 anni-pz del 2016 a 26,5 ep/100 anni-pz per una riduzione di tutte le modalità di uscita ma in particolare della mortalità.

Per quanto riguarda il dropout alla HD (Figura 19), la singola causa principale rimane la peritonite (26,8% nel 2019), in lieve aumento rispetto il 2016 (da 2,98 a 3,11 ep/100 anni-pz) dopo il costante calo registrato negli anni precedenti. In riduzione il drop out per scelta ed impossibilità a proseguire la DP (23,5% dei casi) passato da 3,04 a 2,72 ep/100 anni-pz. Sostanzialmente invariate le altre cause di trasferimento alla HD (Figura 20).

Per completezza ricordiamo che il Censimento raccoglie anche i dati sui trasferimenti da un Centro all’altro, sulla ripresa della FR e altre uscite dalla DP: rispetto ai 31 pazienti entrati da altri Centri quelli trasferiti ad altri Centri sono stati 43 mentre 22 risultano aver interrotto la DP per ripresa della FRR od altro motivo.

Fig. 18: Cause di trasferimento dalla DP alla HD negli anni.
Fig. 18: Cause di trasferimento dalla DP alla HD negli anni. Si osserva un significativo (p <0,001) trend alla riduzione della peritonite come causa di dropout mentre è aumentata l’insufficiente depurazione. Si conferma inoltre l’aumento registrato nel 2014 dell’impossibilità a proseguire/scelta.
Fig. 19: Cause di trasferimento dalla DP alla HD negli anni in percentuale sul totale dei trasferimenti.
Fig. 19: Cause di trasferimento dalla DP alla HD negli anni in percentuale sul totale dei trasferimenti.
Fig. 20: Cause di trasferimento dalla DP alla HD negli anni in valore assoluto espresso come episodi per 100 anni-pz.
Fig. 20: Cause di trasferimento dalla DP alla HD negli anni in valore assoluto espresso come episodi per 100 anni-pz.

Peritoniti

L’analisi delle peritoniti è stata condotta sui 193 Centri presenti in entrambi i Censimenti. Di questi, 4 non hanno fornito i dati sulle peritoniti per cui il dato si riferisce a 189 Centri. Nel 2019 sono stati registrati 666 episodi di peritonite che, per un totale di 42.120 mesi di follow up, equivalgono a 0,190 episodi per anno-paziente o, in altri termini, ad 1 episodio ogni 63,2 mesi-pz, un’incidenza inferiore a quelle registrate negli anni precedenti (Figura 21).

Delle peritoniti registrate nel 2019, 331 (49,7%) si sono verificate in corso di CAPD e 335 (50,3%) in corso di APD. Per quanto riguarda la percentuale di colture negative (125 episodi, pari al 18,8% del totale), il dato non è significativamente diverso da quello degli anni precedenti (Figura 21).

Per la prima volta è riportata l’etiologia delle peritoniti per i 110 Centri che hanno inviato i dati raccolti in modalità analitica (Figura 22): i germi Gram positivi rappresentano la principale causa di peritonite e tra questo lo SA è il più coinvolto mentre tra i Gram negativi lo è Escherichia Coli.

Fig. 21: Incidenza delle peritoniti nel 2019 a confronto con gli anni precedenti.
Fig. 21: Incidenza delle peritoniti nel 2019 a confronto con gli anni precedenti.
Fig. 22: Etiologia delle peritoniti nei 110 Centri indagati in modalità “analitica”.
Fig. 22: Etiologia delle peritoniti nei 110 Centri indagati in modalità “analitica”.

Peritonite sclerosante (EPS)

Dal Censimento del 2016 sono stati riportati 8 nuovi episodi di EPS, per un’incidenza di 0,103 ep/100 anni-pz (Figura 23). Al momento della diagnosi 6 pazienti erano in DP e 2 in HD (Figura 23).

Fig. 23: Casi di EPS nel quinquennio 2004-2008 e nei periodi 2009-10, 2011-12, 2013-14, 2015-16, 2016-2019.
Fig. 23: Casi di EPS nel quinquennio 2004-2008 e nei periodi 2009-10, 2011-12, 2013-14, 2015-16, 2016-2019.

Indagini speciali

Il catetere peritoneale. La tecnica e modalità di posizionamento più frequente è quella chirurgica, in anestesia locale, cui partecipano in collaborazione chirurgo e nefrologo (29,3%) (Figura 24) seguita da quella chirurgica, sempre in anestesia locale, ma con operatore il solo chirurgo (23,0%). Il nefrologo opera da solo nel 19,7% dei casi (in calo rispetto il 2016), sempre in anestesia locale e prevalentemente con tecnica chirurgica (18,3%), sempre più raramente con tecnica semi-chirurgica (1,4% dei casi). La video-laparoscopia è utilizzata nel 8,2% dei posizionamenti come nel 2016.

Complessivamente, il chirurgo è coinvolto nel 80,3% dei casi e il nefrologo nel 54,1%, anche se è probabile che partecipi a parte degli interventi effettuati in VLS (Figura 25).

Fig. 24: Tecnica, operatore e tipo di anestesia per il posizionamento
Fig. 24: Tecnica, operatore e tipo di anestesia per il posizionamento del catetere peritoneale nei pazienti incidenti. Il dato è riferito ai 180 Centri con dati inviati e congruenti. TECNICA: C = chirurgica; SC = semichirurgica; Videolaparoscopia; Altro = non comprende i casi mancanti. OPERATORE: C = chirurgo; N = nefrologo; C e N = chirurgo e nefrologo. ANESTESIA: AL = locale; AG = generale
Fig. 25: Ripartizione del numero di interventi di posizionamento riusciti per tipo di operatore.
Fig. 25: Ripartizione del numero di interventi di posizionamento riusciti per tipo di operatore. Legenda come in Fig. 24.

Il PET. La permeabilità peritoneale viene valutata dalla quasi totalità dei Centri (92,8%) (Figura 26).

Il metodo più utilizzato si conferma non essere più il PET secondo Twardowski con il 2,27%, ma il PET con il 3,86% (57,9%), in costante e significativo aumento (p <0,001) dal 2010 al 2019 (Figura 26). Solo il 7,7% dei Centri misurano la permeabilità peritoneale con altre tecniche (PDC, doppio miniPET e miniPET, altro non specificato).

Fig. 26: Tipo di valutazione della membrana peritoneale: confronto 2019 vs 2016
Fig. 26: Tipo di valutazione della membrana peritoneale: confronto 2019 vs 2016 vs 2014 vs 2012 vs 2010. Nel 2019 è ulteriormente aumentato il numero di Centri che utilizza il 3,86% per il PET.

Le visite domiciliari. Nel 2019 le visite domiciliari non sono previste nel programma di DP del 46,2% dei Centri (Figura 27), numero sostanzialmente invariato rispetto gli anni precedenti (Figura 28). Solo il 9,7% dei Centri le programma di routine, percentuale in lieve aumento rispetto il 2016 (8,0%), mentre il 33,3% dei Centri le utilizza solo se necessario ed il 10,8% solo all’inizio del trattamento (Figura 27). La figura maggiormente coinvolta nelle visite domiciliari rimane l’infermiere, che le svolge da solo nel 44,7% dei 103 Centri che le prevedono; nei casi restanti la visita è svolta in varia misura insieme al medico (Figura 29).

Fig. 27: Frequenza con cui sono state effettuate le viste domiciliari dai Centri partecipanti nel 2019.
Fig. 27: Frequenza con cui sono state effettuate le visite domiciliari dai Centri partecipanti nel 2019.
Fig. 28: Percentuale di Centri che non effettuano visite domiciliari e che le effettuano regolarmente negli anni censiti.
Fig. 28: Percentuale di Centri che non effettuano visite domiciliari e che le effettuano regolarmente negli anni censiti.
Fig. 29: Operatore sanitario che effettua le visite domiciliari nei Centri che le prevedono.
Fig. 29: Operatore sanitario che effettua le visite domiciliari nei Centri che le prevedono. MD > Inf = medico e occasionalmente l’infermiere; Inf. > MD = infermiere e occasionalmente il medico; MD – Inf. = medico e infermiere insieme.

Il Training. Il Training è stato indagato solo per i 110 Centri in modalità analitica per un totale di 771 ingressi in DP nel 2019. In questi Centri (Figura 30) (Figura 31) è effettuato prevalentemente in Centro (58,2%) e solo in una minoranza di Centri completamente a domicilio (6,4%) mentre nel 35,5% dei Centri è avviato in Ospedale e proseguito a domicilio (in proporzione non specificata). Il personale coinvolto è prevalentemente quello del Centro (63,6% dei Centri) mentre personale esterno è coinvolto in una qualche misura nei rimanenti Centri (Figura 31), in particolare nel Training domiciliare: considerando il numero di ingressi registrati nel 2019 in questi 110 Centri, personale esterno potrebbe essere stato coinvolto per 255 training (33,1%) (Figura 31).

Fig. 30: Sede del training ed operatore che lo effettua nei 110 Centri con dati disponibili.
Fig. 30: Sede del training ed operatore che lo effettua nei 110 Centri con dati disponibili.
Fig. 31: Operatore sanitario che effettua il training in funzione della sede del training.
Fig. 31: Operatore sanitario che effettua il training in funzione della sede del training. Personale esterno è coinvolto principalmente nei training effettuati completamente od in parte al domicilio del paziente.

 

Discussione

Limiti

Il Censimento della DP, giunto nel 2016 alla 7° edizione, rappresenta il risultato di un costante sforzo organizzativo del GSDP-SIN e di tutti i referenti DP dei Centri che utilizzano la DP in Italia.

Come ribadito più volte, al limite principale di essere una fotografia dei soli Centri che fanno la DP, che d’altra parte sarebbe anche la sua ragione d’essere, si aggiunge per l’edizione 2019 il non essere riuscito a censire tutti i Centri DP.

Le ragioni sono state ampiamente illustrate nei “Materiali e metodi”, ma è importante ribadire che si è svolto in piena pandemia COVID che ha reso difficoltoso anche l’abituale lavoro di verifica e correzione/recall telefonico preliminare all’analisi dei dati e necessario per ridurne l’imprecisione.

Utilizzo della DP

Tra i paesi occidentali, nonostante una copertura del 83,5% dei Centri DP, l’Italia si è confermata, per numero di pazienti prevalenti in DP, ai primi posti [812].

I valori percentuali di incidenza e prevalenza, rispettivamente del 21,7% e del 16,2%, non ne rappresentano la realtà percentuale, essendo riferiti ai soli Centri che hanno utilizzato la DP nel 2019 e con dati disponibili anche per la HD (186 Centri). Se consideriamo tutti i pazienti anche dei Centri privati e dei Centri pubblici che non fanno la DP, le percentuali riportate dal Registro Italiano di Dialisi e Trapianto [13] sono ovviamente molto inferiori, con un’incidenza globale del 14,5% (dati riferiti a 13 regioni) ed una prevalenza globale della DP nel 2019 del 12,6% (dati relativi a 10 Regioni). Per quanto riguarda il trend, abbiamo fatto riferimento ai 177 Centri con dati completi anche per la HD e anche per il 2016. In questi Centri, dopo anni di sostanziale stabilità si registra un lieve calo dell’incidenza e della prevalenza in accordo con la sostanziale stabilità dei dati riportati dai Registri Internazionali ad eccezione degli USA, in cui la DP è in lieve ma costante aumento per i noti provvedimenti adottati (Figura 32).

Fig. 32: Prevalenza della DP riportata nei diversi registri di dialisi e trapianto del mondo occidentale nel tempo.
Fig. 32: Prevalenza della DP riportata nei diversi registri di dialisi e trapianto del mondo occidentale nel tempo.

Dialisi Peritoneale Incrementale

Si conferma che la Incr-DP coinvolge una percentuale di pazienti incidenti significativa ed è associata ad un maggior utilizzo della DP, in particolare della CAPD. Il trend sembra essersi arrestato da alcuni anni sia per quanto riguarda il numero di Centri che la praticano che per il numero di pazienti per la quale viene prescritta in questi Centri, riscontro atteso e che potrebbe essere correlato alla percentuale di late referral (non indagata in questa edizione). In assenza di dati di Registro internazionali, il Censimento del GSDP rimane una fonte di dati disponibile sull’argomento. Non sono purtroppo disponibili i dati del GFR di inizio dialisi.

CAPD/APD

All’inizio della DP la modalità più utilizzata è la CAPD mentre tra i pazienti prevalenti quella più utilizzata è la APD. A ciò contribuiscono verosimilmente due fattori, la dialisi incrementale prima ed il maggiore utilizzo dell’APD al ridursi della FRR e all’aumentare della permeabilità peritoneale. Infatti, se all’inizio del trattamento la DP incrementale è prevalentemente effettuata come CAPD, il trasferimento dalla CAPD alla APD rispetto all’inverso è significativamente superiore (e motivato dalla scelta del paziente/caregiver) e, per i pazienti trasferiti dalla HD e dal Tx alla DP, la metodica preferita è l’APD [1]. Il dato del 2019 è sostanzialmente invariato rispetto gli anni precedenti.

Assisted PD

Circa un quarto dei pazienti in DP necessita di assistenza per le procedure dialitiche. Tale percentuale, dopo il lieve calo registrato nel 2016 sembra essere tornata in linea con gli anni precedenti.

I dati internazionali sulla Assisted PD sono ancora scarsi e limitati a Paesi come la Francia ed altri Paesi del Nord Europa in cui, come noto, è effettuata prevalentemente dall’infermiera/personale sanitario/volontari a domicilio [5]. In Italia al contrario il caregiver maggiormente coinvolto rimane quello familiare. Per le altre figure si segnala un diminuito ricorso alle badanti ed uno aumentato al personale sanitario del Centro.

La DP in RSA rimane limitata ad un trascurabile numero di pazienti, in particolare se paragonato al numero dei pazienti in RSA che sono in HD.

Dropout e fallimento della tecnica

Le uscite dalla DP sembrano essersi ridotte, in particolare quelle per morte. In mancanza di altri dati non è possibile analizzarne le ragioni. Il sistema di calcolo del follow up cui rapportare gli eventi è rimasto lo stesso e come per le peritoniti è verosimile che sia sottostimato piuttosto che il contrario.

Il trasferimento alla HD rimane la causa principale di interruzione della metodica.

La principale causa di fallimento della tecnica è ancora la peritonite, in lieve aumento rispetto il 2016 così come in aumento sembra essere il malfunzionamento del catetere mentre in calo depurazione/UFF e scelta/impossibilità a proseguire la DP.

Peritoniti e Peritonite Sclerosante

In contrasto con l’aumento del drop out per peritonite è l’incidenza delle peritoniti, ben al di sotto dell’incidenza auspicabile indicata dalle linee guida ISPD 2022 di 0,40 ep/anno-pz [14], secondo un trend al costante calo negli anni peraltro in accordo con i dati di una recentissima analisi internazionale [15], cui il Censimento del GPDP ha contribuito. Rimane maggior del valore limite indicato dalle linee Guida la percentuale di colture negative (<15%), seppur costante negli anni [14].

A fronte di una riduzione dell’incidenza delle peritoniti, il dato etiologico mostra l’importanza di quelle da SA e da Gram Negativi rispetto a quelle “tradizionali” da SE, dato che potrebbe giustificare la mancata riduzione del drop-out da peritonite registrata nel 2019. L’incidenza di EPS continua a diminuire. È possibile che il dato sia stato ancora più sottostimato in epoca pandemica, in particolare per quanto riguarda l’EPS insorta dopo il Tx, soprattutto nel caso di pazienti trasferiti ad altri Centri per il follow up post Tx.

Aspetti particolari della DP

Catetere peritoneale. Rispetto il 2016 si registra un’ulteriore riduzione del ruolo del Nefrologo nel suo posizionamento ed il conseguente aumento di quello del Chirurgo, da solo o in collaborazione con il Nefrologo. Invariato il ricorso alla Videolaparoscopia.

Valutazione della permeabilità peritoneale. La diffusa valutazione della permeabilità peritoneale e soprattutto il costante incremento nell’utilizzo del 3,86% per il PET (dal 15,6% di tutti i Centri nel 2010 al 57,9% del 2019) osservati in questi anni suggeriscono attenzione all’ottimizzazione del trattamento dialitico e alla conservazione della membrana peritoneale.

Visite domiciliari. Invariato e sempre elevato il numero di Centri che non effettua le visite domiciliari (il 46,2%), mentre in lieve incremento quelli che le effettuano regolarmente (8,0% nel 2016 – 9,7% nel 2019) anche se sempre meno di un Centro su dieci. Il limitato ricorso a questa importante forma di monitoraggio, invariato se non peggiorato negli anni, è forse un indice delle difficoltà organizzative di molti Centri dialisi italiani. L’infermiere rimane il protagonista delle visite a domicilio.

Training. Indagato per la prima volta, solo con la modalità analitica di raccolta dei dati, il training è effettuato prevalentemente in Centro dal personale del Centro stesso nonostante i vantaggi noti del condurlo a domicilio del paziente. Quando effettuato a domicilio interviene personale esterno, da solo o in collaborazione con quello del Centro, indice di difficoltà organizzative.

 

Conclusioni

Il Censimento 2019 ha coinciso con la pandemia COVID ma nonostante questa, grazie all’impegno dei Referenti DP, la copertura raggiunta è risultata, anche se non completa, comunque significativa.

L’utilizzo della DP sembra essere in lieve riduzione nonostante i risultati della DP in Italia si siano confermati di buon livello, come indicato dall’incidenza costantemente in riduzione delle peritoniti, dalla riduzione della mortalità e dalla riduzione del drop out in HD.

 

Ringraziamenti

Si ringraziano i Referenti dei Centri che hanno aderito al Censimento e che con il loro impegno hanno reso possibile la raccolta dati ed il presente lavoro.

Abdulsattar Giamila (Oristano)
Agostini Barbara (Biella)
Alberghini Elena (Cinisello Balsamo)
Alessandrello Ivana (Modica)
Alfano Gaetano (Modena)
Ambrogio Antonina (Rovigo)
Ancarani Paolo (Sestri Levante)
Angelini Maria Laura (Forlì)
Angelo Maria Letizia (Camposampiero)
Ansali Ferruccio (Civitavecchia)
Autuly Valerie Marie (Città di Castello)
Basso Anna (Padova)
Benozzi Luisa (Borgomanero)
Bermond Francesca (Torino)
Bianco Beatrice (Verona)
Bilucaglia Donatella (Torino)
Bisello Walter (Urbino)
Boccadoro Roberto (Rimini)
Bonesso Cristina (San Donà di Piave)
Bonvegna Francesca (Verbania)
Borettaz Ilaria (Lodi)
Borrelli Silvio (Napoli)
Bosco Manuela (Gorizia)
Braccagni Beatrice (Poggibonsi)
Brigante Maurizio (Campobasso)
Budetta Fernando (Eboli)
Caberlotto Adriana (Treviso)
Cabibbe Mara (Milano)
Cabiddu Gianfranca (Cagliari)
Cadoni Maria Chiara (San Gavino Monreale)
Cannarile Daniela Cecilia (Bologna)
Cantarelli Chiara (Parma)
Capistrano Mariano (Montichiari)
Cappelletti Francesca (Siena)
Capurro Federica (Novara)
Caria Simonetta (Quartu Sant’ Elena)
Carta Annalisa (Nuoro)
Caselli Gian Marco (Firenze)
Caselli Ada (Ascoli Piceno)
Casuscelli di Tocco Teresa (Messina)
Centi Alessia (Roma)
Cerroni Franca (Rieti)
Ciabattoni Marzia (Savona)
Cianfrone Paola (Catanzaro)
Cimolino Michele (Pordenone)
Ciurlino Daniele (Sesto San Giovanni)
Colombo Patrizia (Vercelli)
Colucci Giuseppina (Putignano)
Comegna Carmela (Tivoli)
Contaldo Gina (Monza)
Cornacchia Flavia (Cremona)
Cosa Francesco (Legnano)
Costa Silvano (Voghera)
Costantino Ester Maria Grazia (Manerbio)
D’Alonzo Silvia (Roma)
D’Altri Christian (Martina Franca)
D’Amico Maria (Trapani)
Del Corso Claudia (Pescia)
D’Elia Filomena (Bari)
Della Gatta Carmine (Nola)
Di Daniele Nicola (Roma)
Di Franco Antonella (Barletta)
Di Liberato Lorenzo (Chieti)
Di Loreto Ermanno (Atri)
Di Somma Agnese (San Marco Argentano)
Di Stante Silvio (Pesaro – Fano)
Distratis Cosimo (Manduria)
Domenici Alessandro (Roma)
Esposito Samantha (Grosseto)
Esposito Vittoria (Pavia)
Fancello Sabina (Tempio Pausania)
Fattori Laura (Senigallia)
Ferrando Carlo (Cuneo)
Ferrara Gaetano (San Giovanni Rotondo)
Figliola Carmela (Gallarate)
Filippini Armando (Roma)
Fiorenza Saverio (Imola)
Fischer Maria Stephanie (Bolzano)
Flavio Scanferla (Venezia)
Frattarelli Daniele (Roma)
Gabrielli Danila (Aosta)
Gai Massimo (Torino)
Gammaro Linda (Verona)
Gangeri Fabio (Roma)
Garofalo Donato (Fermo)
Gazo Antonietta (Vigevano)
Gherzi Maurizio (Ceva)
Glauco Gianni (Prato)
Giozzet Morena (Feltre)
Giudicissi Antonio (Cesena)
Giuliani Anna (Vicenza)
Graco Angelo (La Spezia)
Grill Anna (Asti)
Gullo Maurizio (Lamezia Terme)
Guzzo Daniela (Livorno)
Heidempergher Marco (Milano)
Iacono Rossella (Civita Castellana)
Iadarola Gian Maria (Torino)
Iannuzzella Francesco (Reggio Emilia)
Isola Elisabetta (Ravenna)
La Milia Vincenzo (Lecco)
Laudadio Giorgio (Bassano del Grappa)
Laudon Alessandro (Trento)
Lenci Federica (Ancona)
Leonardi Sabina (Trieste)
Lepori Gianmario (Olbia)
Libetta Carmelo (Pavia)
Licciardello Daniela (Acireale)
Lidestri Vincenzo (Chioggia)
Lisi Lucia (Vimercate)
Lo Cicero Antonina (San Daniele)
Luciani Remo (Roma)
Magnoni Giacomo (Bologna)
Malandra Rosella (Teramo)
Manca Rizza Giovanni (Pontedera)
Manfrini Vania (Seriate)
Mangano Stefano (Varese)
Manini Alessandra (Piacenza)
Mariani Roberta (Vasto)
Marini Alvaro (Popoli)
Martella Vilma (Lecce)
Masa Maria Alessandra (Sondrio)
Mastrippolito Silvia (Lanciano)
Matalone Massimo (Catania)
Mauro Teresa (Rossano)
Mazzola Giuseppe (Mantova)
Mazzotta Antonio (Casale Monferrato)
Messina Antonina (Catania)
Michelassi Stefano (Firenze)
Migotto Clara (Vizzolo Predabissi)
Miniello Vincenzo (Pistoia)
Mollica Agata (Cosenza)
Montalto Gaetano (Taormina)
Montanari Marco (Albano Laziale)
Montemurro Vincenzo (Firenze)
Neri Loris (Alba)
Nicolai Giulia Adriana (Conegliano)
Nicosia Valentina (Formia)
Orani Maria Antonietta (Milano)
Panuccio Vincenzo (Reggio Calabria)
Panzino Antonio Rosario (Catanzaro)
Parodi Denise (Genova)
Pastorino Nadia (Novi Ligure)
Pellegrino Cinzia (Cetraro)
Perna Concetta (Cerignola)
Perosa Paolo (Pinerolo)
Pignone Eugenia (Rivoli)
Pinerolo Cristina (MIlano)
Piraina Valentina (Ivrea)
Piredda Maria (Sassari)
Pirrottina Maria Anna (San Benedetto del Tronto)
Pogliani Daniela Rosa Maria (Garbagnate Milanese)
Porreca Silvia (Altamura)
Pozzi Marco (Desio)
Previti Antonino (Santorso)
Puliti Maria Laura (Palestrina)
Randone Salvatore (Avola)
Rapisarda Francesco (Catania)
Ratto Elena (Genova)
Ricciardi Daniela (Castiglione del Lago)
Rocca Anna Rachele (Roma)
Russo Roberto (Bari)
Russo Domenico (Napoli)
Russo Francesco Giovanni (Scorrano)
Sabatino Stefania (Udine)
Santarelli Stefano (Jesi)
Santese Domenico (Taranto)
Santinello Irene (Piove di Sacco)
Santirosi Paola Vittoria (Spoleto)
Santoferrara Angelo (Civitanova Marche)
Santoro Domenico (Messina)
Saraniti Antonello (Milazzo)
Savi Umberto (Belluno)
Scalamogna Antonio (Milano)
Scalzo Berta Ida (Cirie’)
Scarfia Rosalia Viviana (Caltagirone)
Somma Giovanni (Castellamare di Stabia)
Stacchiotti Lorella (Giulianova)
Stramignoni Emanuele (Chieri)
Stucchi Andrea (Milano)
Taietti Carlo (Treviglio)
Tartaglia Luciano (Foggia)
Tata Salvatore (Mestre)
Timio Francesca (Perugia)
Todaro Ignazio (Piazza Armerina)
Toriello Gianpiero (Polla)
Torraca Serena (Salerno)
Totaro Erica (Dolo)
Tramontana Domenico (Vibo Valentia)
Trepiccione Francesco (Napoli)
Trubian Alessandra (Legnago)
Turchetta Luigi (Cassino)
Vaccaro Valentina (Alessandria)
Vecchi Luigi (Terni)
Visciano Bianca (Magenta)
Viscione Michelangelo (Avellino)
Vizzardi Valerio (Brescia)

 

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  11. Canadian Institute for Health Information. Canadian Organ Replacement Register. Annual Report: Treatment of End-Stage Organ Failure in Canada, Canadian Organ Replacement Register.
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  13. Registro Italiano di Dialisi e Trapianto, https://ridt.sinitaly.org/.
  14. Li PK, Chow KM, Cho Y et al.ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment. Perit Dial Int. 2022; 42(2):110-153, https://doi.org/1177/08968608221080586.
  15. Marshall MR. A systematic review of peritoneal dialysis-related peritonitis rates over time from national or regional population-based registries and databases. Perit Dial Int. 2022; 42(1): 39-47, https://doi.org/1177/0896860821996096.

Peritoneal Dialysis in Italy: the 6th GSDP-SIN census 2016

Abstract

Objectives. We report here the results of the 6th National Census (Cs-16) of Peritoneal Dialysis in Italy, carried out in 2017-18 by the Italian Society of Nephrology’s Peritoneal Dialysis Study Group and relating to 2016.

Methods. The Census was conducted using an on-line questionnaire administered to the 237 non pediatric centers which did perform Peritoneal Dialysis (PD) in 2016. The results have been compared with the previous Censuses carried out since 2005.

Results. Incidence: In 2016, 1,595 patients (CAPD=56.1%) started on PD (1st treatment for ESRD) and 4,607 on hemodialysis (HD). PD was started incrementally by 32.5% in 144 Centers. 15.6% were late referrals, and 5.1% began within 48-72 hours of insertion. The catheter was positioned exclusively by a Nephrologist in 24.3% of cases. Prevalence: Patients on PD on 31/12/2016 were 4,607 (CAPD=46.6%), with 22.2% of prevalent patients on assisted PD (family member caregiver: 80.5%). Out: In 2016, PD dropout rate (ep/100 pt-yrs: 12.5 to HD; 11.8 death; 7.0 Tx) has not changed. The main cause of transfer to HD remains peritonitis (23.8%), although it is still decreasing (Cs-05: 37.9%). Peritonitis/EPS: The incidence of peritonitis in 2016 was 0.211 ep/pt-yr (939 episodes). The incidence of new cases of EPS in 2015-16 is diminishing too (16 cases=0.176 ep/100 pt-yrs). Other results: In 2016 the number of Centers using 3.86% for the peritoneal equilibration test (PET) (49.8%) increased, and the Centers carrying out home visits diminished (51.5%).

Conclusions. Cs-16 confirms that PD in Italy is having good results.

Keywords: Peritoneal Dialysis, technique failure, incremental Peritoneal Dialysis, peritonitis, home visits, peritoneal equilibration test (PET)

Sorry, this entry is only available in Italian.

Introduzione

L’utilizzo della dialisi peritoneale (DP) in Italia nel 2015 è ancora limitato ad una prevalenza del 9,5%, con un ulteriore calo nel 2016 [1], se si considerano tutti i Centri Dialisi, anche quelli che non utilizzano la metodica. Sempre presente anche la notevole variabilità da regione a regione e da Centro a Centro [26]. 

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PD in Italy: the 5th GSDP-SIN Census 2014

Abstract

OBJECTIVES

To know PD modalities and results in Italy.

METHODS

The Census was carried out by means of an on-line questionnaire in ALL the 225 non-pediatric public centers which PERFORMED PD in 2014. The results were compared with those of previous Censuses (2005:Cs-05; 2008:Cs-08; 2010:Cs-10; 2012:Cs-12).

RESULTS

Incidence. In 2014 PD was begun (first treatment for ESRD) by 1,652 pts (CAPD: 57.2%) and HD by 4,442 pts (%PD-incidence= Cs-14: 27,1%; Cs-12: 23.4%; Cs-10: 23.3%; Cs-08: 22.8%; Cs-05: 24.2%). For the first time Incremental PD does not increase (Cs-14: 27,5%; Cs-12: 28,8%; Cs-10: 22,8%; Cs-08: 18,3%; Cs-05: 11,9%).

Prevalence. At 31/12/2014 there were 4,480 patients on PD (CAPD: 46.9%) (%PD-prevalence= Cs-14: Cs-12: 17.1%; Cs-10: 16.6%; Cs-08: 16.7%; Cs-05:16.8%; p=NS), 24.3% of whom were on assisted PD (family members: 83.6%; paid caregivers: 11.5%; nurses: 1.1%; NH: 2.8%).

Out. In 2014 there was no change in the PD drop-out rate (32.0 ep/100yrs-pt) (death: 502; transplant: 329; switch to HD: 528 pts). The main reason for transferring to HD remained peritonitis (24.8%). Choice (9.3%) and impossibility to continue PD (15.2%) are increasing.

Peritonitis. The peritonitis rate (953 episodes) was 0.224 ep/yrs-pt. The incidence of new cases of EPS in 2013-14 (39 cases=0.444 ep/100yrs-pt) is decreasing (2011-12= 0.505; 2009-10= 0.529; 2004-08= 0.701 ep/100-yrs-pt).

Other results. Compared to 2012, in 2014 the number of Centers using 3.86% for PET increased (41.3%) (Cs-12: 30.8%; Cs-10: 15.6%; p<0.001), while the number carrying out home visits (59.6%) remained unchanged (56.3% in 2012, 59.4% in 2010). CONCLUSIONS

Cs-14 confirms the extensive use, stability and good results of PD in Italy. Incremental PD and assisted PD are unchanged, peritonitis are decreased and EPS remains a rare event. PET-3.86% is increasingly used.

Keywords: Peritoneal Dialysis, Technique failure, Incremental peritoneal dialysis, assisted PD, peritonitis, home visit, PET (peritoneal equilibration test)

Sorry, this entry is only available in Italian.

INTRODUZIONE

L’utilizzo della dialisi peritoneale (PD) in Italia nel 2013 è risultato sostanzialmente stabile e limitato ad una incidenza del 13,2% ed una prevalenza inferiore al 9,6% (1) se si considerano tutti i Centri Dialisi, anche quelli che non utilizzano la metodica. Invariata anche la notevole variabilità da regione a regione e da centro a centro (25). L’utilizzo della DP viene rilevato dal Gruppo di Studio della DP (GSDP) della Società Italiana di Nefrologia (SIN) mediante un Censimento, condotto ogni 2 anni, di tutti i Centri che utilizzano la DP.

In questo report sono presentati i risultati della 5° edizione condotta nel 2016 e relativa all’anno 2014 (Cens-14) confrontandoli con quelli degli anni precedenti: 2005 (Cens-05), 2008 (Cens-08) (3), 2010 (4), 2012 (Cens-12) (5).

  

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PD in Italy: The 4th GSDP-SIN census 2012

Abstract

OBJECTIVES To know PD modalities and results in Italy.

METHODS The Census was carried out by means of an on-line questionnaire in all the 224 non-pediatric public centers which performed PD in 2012. The results were compared with those of previous Censuses.

RESULTS

Incidence. In 2012 PD was begun (first treatment for ESRD) by 1,433 pts (CAPD: 54.3%) and HD by 4,700 pts (%PD-incidence= Cs-12: 23.4%; Cs-10: 23.3%; Cs-08: 22.8%; Cs-05: 24.2%; p=NS), with a further increase in incremental PD (Cs-12: 28.8%; Cs-10: 22.8%; Cs-08: 18.3%; Cs-05: 11.9%; p<0.001).

Prevalence. At 31/12/12 there were 4,299 patients on PD (CAPD: 46.1%) (%PD-prevalence= Cs-12: 17.1%; Cs-10: 16.6%; Cs-08: 16.7%; Cs-05:16.8%; p=NS), 24.5% of whom were on assisted PD (family members: 82.3%; paid caregivers: 12.4%; nurses: 0.7%;  NH: 3.0%).

Out. In 2012 there was no change in the PD drop-out rate (30.9 ep/100yrs-pt) (death: 481; transplant: 290; switch to HD: 511 pts). The main reason for transferring to HD remained peritonitis (28.2%).

Peritonitis. The peritonitis rate (1,179 episodes) was 0.284 ep/yrs-pt.

EPS. The incidence of new cases of EPS in 2011-12 (43 cases=0.505 ep/100yrs-pt) remained unchanged (2009-10= 0.529; 2004-08= 0.701 ep/100-yrs-pt).

Other results. Compared to 2010, in 2012 the number of Centers using 3.86% for PET increased (30.8% vs 15.6%-p<0.001), while the number carrying out home visits remained unchanged (56.3 vs 59.4%).

CONCLUSIONS Cs-12 confirms the extensive use, stability and good results of PD in Italy. Incremental PD is on the increase. EPS remains a rare event.

Key words: Assisted Pd, Home Visit, Incremental Peritoneal Dialysis, Peritoneal Dialysis, Peritonitis, Technique Failure

Sorry, this entry is only available in Italian.

INTRODUZIONE

L’utilizzo della dialisi peritoneale (DP) in Italia è risultato confinato, nel 2012, ad una incidenza del 12,8% ed una prevalenza del 9,8% (1) se si considerano tutti i Centri Dialisi, anche quelli che non utilizzano la metodica, ed è rimasta sostanzialmente stabile negli ultimi anni, sempre comunque con una notevole variabilità da regione a regione e da centro a centro (2). L’utilizzo della DP viene rilevato dal Gruppo di Studio della DP (GSDP) della Società Italiana di Nefrologia (SIN) mediante un Censimento, condotto ogni 2 anni, di tutti i Centri che utilizzano la DP.

In questo report sono presentati i risultati dell’edizione condotta nel 2013-14 e relativa all’anno 2012 (Cens-12), confrontati con quelli degli anni precedenti: 2005 (Cens-05) e 2008 (Cens-08) (3), 2010 (4) e con i dati internazionali.
 

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