Controversial Aspects of Peritoneal Dialysis in Italy. Results of the First National Audit of PD

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Gruppo di Progetto Dialisi Peritoneale

DOI: 10.69097/42-05-2025-11

Stefania Maxia1, Anna Giuliani2, Marco Heidempergher3, Mathias Zeiler4, Claudio Mastropaolo5, Giusto Viglino6, Giancarlo Marinangeli7, Gianfranca Cabiddu1 and Loris Neri8 on behalf of the Peritoneal Dialysis Project Group of the Italian Society of Nephrology

1. Nephrology, Dialysis and Transplantation Unit, ARNAS “G. Brotzu”, Cagliari, Italy
2. Nephrology Dialysis and Transplantation, AULSS8 Berica, Ospedale “San Bortolo”, Vicenza, Italy
3. Nephrology and Dialysis Unit, ASST “Fatebenefratelli – Sacco”, Milan, Italy
4. Nephrology and Dialysis Unit, Peritoneal Dialysis Section, "C. e G. Mazzoni" Hospital, Ascoli Piceno, Italy
5. Visionage SRL
6. Telemedicine Service, ASLCN2, Italy and Past Director of (8)
7.Past Director of Nephrology and Dialysis Unit, Ospedale Maria SS dello Splendore, Giulianova, Teramo, Italy.
8. Nephrology and Dialysis, ASLCN2 – Ospedale “Michele e Pietro Ferrero”, Verduno (CN), Italy

Corresponding author:
Loris Neri
SOC Nefrologia e Dialisi - Ospedale “Michele e Pietro Ferrero”, Via Tanaro 7 – Verduno (CN)
Telefono 0172-140-8271
E-mail: lorisneri1960@gmail.com

 

Abstract

The Census carried out by the Italian Society of Nephrology’s Peritoneal Dialysis (PD) Project Group has been following the evolution of PD for 20 years. For the first time, the latest edition in 2024 was followed up by an on-line audit conducted between 28/04/2025 and 09/05/2025.
With 185 of the 228 Centers which used PD in 2024 taking part, the Audit investigated a number of questions which are controversial or relatively unexplored: 1) the incremental dialysis prescription in CAPD; 2) empiric peritonitis therapy; 3) the prophylaxis of exit site infections (ESI); 4) types of peritoneal catheter used; 5) the use of telemedicine.
There is no consensus on the incremental prescription in CAPD. Most start with a single exchange, and in the event of two exchanges the majority keep the abdomen empty for part of the day. However, 37.4% of the 162 Centers using incremental PD begin from 2+ exchanges, while 26.5% in two-exchange CAPD keep the abdomen always full. A fair degree of variation was also observed regarding the type of catheter used, although 75.7% of the Centers use only one type in their Center.
Almost all the Centers follow ISPD recommendations on empiric peritonitis therapy and ESI/TI prophylaxis, the validity of which is confirmed by the constant reduction in the drop-out rate for peritonitis recorded over the last 20 years.
Finally, Telemedicine data show the ever-increasing use of this tool, notably Telemonitoring, whereas only a minority of the Centers use Teleassistance – in particular Televisits – which is particularly useful in Assisted PD.

Keywords: Peritoneal Dialysis, Incremental Dialysis, Peritonitis, Exit Site Infections, Peritoneal Catheter, Telemedicine

Background

The Census by the Italian Society of Nephrology’s Peritoneal Dialysis Project Group (GPDP-SIN) collects data on various aspects of Peritoneal Dialysis (PD); launched in 2005, it has essentially been following the evolution of PD for 20 years, with the ninth edition relating to 2024 being the latest [1].

The most significant data observed by the Census over these 20 years have been: 1) a continuous and constant reduction in the incidence of peritonitis and drop-outs for peritonitis, 2) an increasingly widespread use of the incremental prescription, with CAPD (Continuous Ambulatory Peritoneal Dialysis) always being associated with incremental prescription and APD (Automated Peritoneal Dialysis) with full dialysis, 3) an ever more extensive use of 3.86% PET in the evaluation of the peritoneal membrane, 4) an increasingly minor role of the Nephrologist in the placement of the peritoneal catheter, 5) a constant reduction – still under discussion – in the incidence of EPS. Despite these results, the number of Centers using PD, its prevalence and mean duration, overall drop-out rates and the percentage of patients on Assisted PD have remained largely unchanged.

In order to attempt to clarify some of these aspects, the latest edition of the Census was followed up with an on-line Audit, the results of which are reported in this paper.

 

Materials and methods

Methodology and implementation

A questionnaire was sent to all the contacts in the 228 Centers which took part in the 2024 Census following the rule “only one response per Center”. The subject areas investigated in the Audit were drawn from a preliminary analysis of the Census data. The issues were selected and the questions were formulated by all the Authors during videoconferencing meetings, and the Audit was conducted between 28/04/2025 and 09/05/2025. The results of preliminary processing were presented at the XXII National Peritoneal Dialysis Conference held in Brescia from 15 to 17 May 2025. In order to facilitate their reading, the results on each subject will be followed by their discussion.

The subjects of the Audit

The issues investigated by the Audit were incremental prescription, empiric peritonitis therapy, orifice infection (ESI/TI) prevention, type of catheter used and telemedicine.

The questions are given in the Figures where appropriate. The results were broken down into the above-mentioned subject areas, which are discussed one by one. Statistical analysis was limited to chi-square testing for differences between groups.

 

Results

The 185 Centers which responded to the questionnaire represent 81% of the Centers which took part in the Census.

Incremental dialysis prescription in CAPD

Results. Of the 185 Centers which responded, 23 (12.4%) do not prescribe Incremental CAPD and 7 (3.8%) only take it into consideration in the case of heart failure. Of the remaining 155 Centers (83.8%), it is prescribed starting from one exchange by 97 (52.4%), while 58 (31.4%) only from 2 or more exchanges (Figure 1).

Whilst with only 1 exchange it is natural to keep the abdomen empty, this may not be true with 2 exchanges. Indeed, of the 162 Centers which prescribe Incremental CAPD, on reaching 2 exchanges 43 Centers (26.5%) keep the abdomen always full in all (10 Centers) or most patients on 2-exchange Incremental CAPD (33 Centers). Conversely, 119 Centers (73.5%) keep the abdomen always empty for part of the day in all (68 Centers) or most cases (51 Centers) (Figure 2).

There are no differences in relation to keeping the abdomen empty between those who begin with one exchange and those who begin with two.

Use of the incremental prescription
Figure 1. Use of the incremental prescription, with breakdown of Centers according to initial number of exchanges (HF: heart failure).
Keeping the abdomen empty
Figure 2. Keeping the abdomen empty for part of the day in the prescription of 2-exchange CAPD.

Discussion. In Italy, incremental PD is predominantly prescribed in CAPD. Incremental PD is only possible starting from a GFR >4 ml/minute. For lower values, the renal Kt/V is generally less than 1.0 Unit/week and the difference for reaching the minimum target (1.70 Units/week) is hard to achieve with only two exchanges a day. One of the advantages of the incremental prescription is a better Quality of Life due to the lower number of dialysis procedures required [2].

The majority of the Centers prescribe Incremental PD starting from one exchange, and when two are used seek to keep the abdomen empty during the day. However, 37.4% of the Centers using the incremental prescription only start with two exchanges, while only a minority (26.5% of the Centers) considers the abdomen always full in all or most cases. Finally, cross-checking the Audit with the 2024 Census data [1] the Centers which start using the incremental prescription from one exchange have a higher average number of incident patients (7.65 vs 5.77 pts/Center) and use the incremental prescription more (46.1% vs 29.7% – p<0.000005) than the Centers which prescribe it only starting from two exchanges.

The incremental prescription is subject to clearance- and Quality of Life-related factors. The main clearance factors are the Glomerular Filtration Rate (GFR) at the start of dialysis (incremental prescription starting from just one exchange is only possible with a GFR of over 6 ml/minute) and the clearance of middle molecules (many of the uremic toxins) which, as is known, depends on the dwell time rather than the volumes used [3]. For the non-clearance factors, the Quality of Life is inversely proportionate to the number of exchanges, in particular if more than two; furthermore, an abdomen which is always full entails greater mechanical risk and a reduction in appetite.

The results of the Audit therefore suggest that, while the choice between clearance and Quality of Life is not yet clear for the starting of Incremental CAPD, once PD has begun considerations relating to the preservation of the peritoneal membrane and the fear of mechanical complications prevail.

Finally, a comment on Incremental APD, which is still seldom used today. The Audit highlights a further difficulty in its use associated with the intermittence of the treatment. As a matter of fact, for logistical reasons the sample for the calculation of the clearances is taken by most Centers (85.4%) in the morning (Figure 3). This leads to an overestimation of adequacy indicators, which increases further in Incremental APD. Being less used than incremental CAPD, incremental APD may seem to be not only less suitable in terms of Quality of Life, but also more difficult to evaluate.

Figure 3. Time of blood sampling for the calculation of dialysis clearances in APD.
Figure 3. Time of blood sampling for the calculation of dialysis clearances in APD.

Empiric peritonitis therapy

Results. As per ISPD guidelines [4], 172 Centers (93.0%) use two antibiotics, one active on Gram-positive bacteria and one active on Gram-negative bacteria. Of the remaining 13 Centers (7%), only 5 use a IV generation Cephalosporin (Cefepime), an alternative to the dual antibiotic recognized by the guidelines [4], while 3 Centers use only Vancomycin and 5 Centers use antibiotics which are only active on Gram-negative bacteria (Figure 4).

Percentage of Centers using dual coverage
Figure 4. Percentage of Centers using dual coverage (2 antibiotics) in empiric peritonitis therapy. In the column, the percentage of Centers using only one antibiotic and the type.

Considering the Centers which use two antibiotics, the most widely used for Gram-positive bacteria is 1st-generation Cephalosporin (55.8%) followed by Vancomycin (43.0%), while the use of Teicoplanin is negligible (1.2%). For Gram-negative bacteria the most widely used antibiotic is III generation Cephalosporin (68.6%) followed by an Aminoglycoside (27.9%), while recourse to other antibiotics such as Carbapenems, IV generation Cephalosporin and unspecified is negligible (3.5%) (Figure 5). As regards the combination, the most widely-used is 1st-generation/III generation Cephalosporin (37.8%), followed by Vancomycin/III generation Cephalosporin (30.8%) and 1st-generation Cephalosporin/Aminoglycoside (17.4%), while the most nephrotoxic and ototoxic association – represented by Vancomycin/Aminoglycoside – is only used by 10.5% of the Centers (Figure 6).

Discussion. The vast majority of the Centers follow the ISPD guidelines [4] for empiric therapy, as regards both dual coverage and the antibiotics. In particular, the recommendations on the prevention of the ototoxicity and nephrotoxicity of Aminoglycosides – even more so if they are associated with Vancomycin – seem to be carefully followed, with this combination being used by only 10% of the Centers. According to the PDOPPS study [5], 15.9% of cases of peritonitis end in drop-out to HD (Figure 7). The Census data [1] show that for a total of 647 cases of peritonitis in the 213 Centers which provided the data there were 104 transfers to hemodialysis (HD) in 2024. This corresponds to 16.1% of cases of peritonitis, which is practically superimposable with the value reported by the PDOPPS study which involved only large Centers in “western” countries” [5].

Figure 5. Antibiotics used for coverage against Gram positives (left) and Gram negatives (right) in the Centers using dual coverage.
Figure 6. Breakdown of percentages of the Centers using dual coverage according to the combinations of Gram positive- and Gram negative-active antibiotics used. The most frequently used combination – used in 37.8% of the Centers – associates a 1st-generation Cephalosporin with a 3rd-generation Cephalosporin.
Figure 7. Peritonitis outcomes observed in the PDOPPS study.

ESI (Exit Site Infection) / TI (Tunnel Infection) prophylaxis

Results. At least one nasal swab is performed to detect Staphylococcus aureus carriers by 71.9% of the Centers which took part. For the prophylaxis of ESI/TI, 59.5% of the Centers use an antiseptic (chlorhexidine, argentum, amuchina), 7.6% use an antibiotic cream and 2.7% an antiseptic and an antibiotic cream in turn. Nothing is used by 30.3% of the Centers (Figure 8-A). Those who do not perform a nasal swab use an antiseptic or a cream more frequently (80.8%) than those who do (65.4% – p<0.05) (Figure 8-B).

Figure 8. Performance of nasal swab (A) and type of medication used, overall (pie chart) and depending on whether the nasal swab is performed or not (bar chart) (B).

Regarding the frequency of dressing the peritoneal catheter exit site, most of the Centers indicate every other day (54.6%) while only 18.9% medicate on a daily basis (Figure 9-A). There are no significant differences regarding frequency of medication between those who use nothing and those who use an antiseptic and/or a cream (Figure 9-B). Finally, ultrasound scans are performed by 65.5% of the 174 Centers which responded to the question in order to monitor a catheter emergency (Figure 10).

Figure 9. In A, breakdown of the 185 Centers which took part according to the frequency with which the orifice is medicated; in B, the frequency of medication according to type of medication performed.
Figure 10. Percentages of Centers using ultrasound scanning to monitor exit site.

Discussion. The Audit shows how ESI/TI prevention remains controversial. This is also reflected by the guidelines [4, 6, 7]. In particular, while antibiotic cream was recommended previously as the best prophylaxis, in the latest version this has been downgraded. On the other hand, only 10.3% of the Centers use it.

Another controversial point, in particular with antibiotic cream, is the frequency of medication, which should be daily in order to avoid the onset of resistance. Clearly, the choice to medicate every other day is influenced by a need to avoid overloading the patient. Unfortunately, the Census does not investigate orifice infections as a cause of drop-out or peritonitis. However, the constant reduction in the incidence of peritonitis puts the importance of the specific measures taken into perspective.

Peritoneal dialysis catheter

Results. Only one type of catheter is used by 75.7% of the Centers, while 21.1% use mainly one (more than 50% of cases) and the remaining 3.2% use several types with no preference (Figure 11).

Figure 11. Number and types of peritoneal catheter used.
Figure 11. Number and types of peritoneal catheter used.

With regard to the type of catheter, the traditional Tenckhoff is used exclusively or predominantly in 49.7% of the Centers, followed by the self-locating Di Paolo and Swan Neck catheters used by identical percentages (20.1%), and finally the Vicenza catheter (8.4% of the Centers) (Figure 12).

Discussion. The majority of the Centers have a go-to catheter, which in around half of the Centers is still the traditional Tenckhoff (straight, two cuffs). This partly reflects the need to simplify the activity, as better outcomes have never been demonstrated [6, 7], except in the case of dislocation with the self-locating catheter which is only used, however, by 1/5 of the Centers, as is the swan neck.

Figure 12. Percentages of use of the various types of peritoneal catheter and breakdown based on sole or predominant (> 50%) use.

Telemedicine

Results. Telemonitoring is performed by 69.5% of the Centers, most of whom use commercial Remote Patient Management platforms (Figure 13). Teleassistance is practiced in 47.1% of the Centers (Figure 14) and finally Televisits in just 23.2% (Figure 16).

Figure 13. Percentages of the Centers using Telemonitoring platforms.
Figure 13. Percentages of the Centers using Telemonitoring platforms.

In particular, of the 87 Centers which use Teleassistance, the most frequently performed activity in the 60 Centers which specified those carried out in Teleassistance is compliance checks, followed by retraining, inventories and checks, patient and/or caregiver education and information. Training and videocaregiver activities (a nurse in the Center guiding the patient/caregiver at home in performing the dialysis procedures) are less frequently performed using Telemedicine (Figure 15).

Figure 14. Percentages of the Centers performing Teleassistance.
Figure 15. Main Teleassistance activities carried out.

Discussion. The average age and frailty of incident dialysis patients have increased over the years. The average age of incident patients on PD remains lower than that of incident patients on HD [1], so over the years the use of Assisted PD has remained largely unchanged, or even diminished, although the difficulty of starting on Assisted PD is likely to be the cause of the reduced use of PD in the elderly. If, however, the reason is the limited availability of caregivers, this could be overcome by the introduction of Telemedicine. The results of the Audit show how Telemedicine is mainly used in the form of Telemonitoring, while nurse-conducted Teleassistance and doctor-conducted Televisits are still performed in a minority of the Centers, though more than shown in a previous investigation [8].

Figure 16. Percentages of the Centers carrying out Televisits.

 

Conclusions

There is virtually total compliance with the guidelines on empiric therapy, with the most widely used association being two cephalosporins, though other combinations are also relatively frequent. Antibiotic creams are used for the prevention of ESI and TI by only a minority of the Centers. While drop-out for peritonitis trends over the last 20 years confirm the validity of empiric therapy, the behavior of the Centers confirms the uncertainty surrounding ESI TI prophylaxis. For the choice of catheter, considerations are mainly of a practical nature.

As regards the incremental prescription, the Audit highlighted how the opposing needs of clearance and preservation of Quality of Life make it less simple than generally considered.

Finally, Telemedicine. The Audit shows how Telemedicine has become part of everyday reality in Dialysis Centers, in particular in the form of Telemonitoring. In Teleassistance, various activities are performed by nurses in half of the Centers which use it. Televisits and involvement of doctors still apply to a minority of the Centers.

 

Acknowledgements

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

Albrizio Paolo (Voghera)
Alessandrello Ivana (Modica)
Alfano Gaetano (Modena)
Amar Karen (Cernusco sul Naviglio)
Ambrogio Antonina (Rovigo)
Ancarani Paolo (Sestri Levante)
Angela Maria Dinnella (Anzio)
Angelo Maria Letizia (Camposampiero)
Ansali Ferruccio (Civitavecchia)
Apponi Francesca (Frosinone)
Argentino Gennaro (Napoli)
Barattini Marina (Massa)
Barbera Vincenzo (Colleferro)
Basso Anna (Padova)
Bellizzi Vincenzo (Caserta)
Bellotti Giovanni (Sapri)
Benozzi Luisa (Borgomanero)
Bermond Francesca (Torino)
Bianco Beatrice (Verona)
Bigatti Giada (Desio)
Bilucaglia Donatella (Torino)
Boccadoro Roberto (Rimini)
Bonesso Cristina (San Dona’ di Piave)
Bonincontro Maria Luisa (Bolzano)
Bonvegna Francesca (Verbania)
Borettaz Ilaria (Vizzolo Predabissi)
Borrelli Silvio (Napoli)
Bosco Manuela (Gorizia Monfalcone)
Bottai Anna (Pisa)
Braccagni Beatrice (Poggibonsi)
Brocca Jessica (Cinisello Balsamo)
Bruno Paolo Ferdinando (Cesena)
Budetta Fernando (Eboli)
Cabibbe Mara (Milano)
Cabiddu Gianfranca (Cagliari)
Cadoni Maria Chiara (San Gavino Monreale)
Cannarile Daniela Cecilia (Bologna)
Cannavo’ Rossella (Firenze)
Canonici Marta (Fabriano)
Cantarelli Chiara (Parma)
Capistrano Maria (Montichiari)
Caponetto Carmelo (Siracusa)
Cappadona Francesca (Genova)
Cappelletti Francesca (Siena)
Capurro Federica (Novara)
Capurso Domenico (Putignano)
Caria Simonetta (Cagliari)
Carta Annalisa (Nuoro)
Caselli Gian Marco (Firenze)
Casuscelli di Tocco Teresa (Messina)
Cataldo Emanuela (Altamura)
Centi Alessia (Roma)
Cerami Caterina (Pavullo)
Cernaro Valeria (Messina)
Cerroni Franca (Rieti)
Ciabattoni Marzia (Savona)
Cianfrone Paola (Catanzaro)
Cimolino Michele (Pordenone)
Ciurlino Daniele (Sesto San Giovanni)
Comegna Carmela (Tivoli)
Congiu Giovanni (Asti)
Consaga Marina (Livorno)
Contaldo Gina (Monza)
Conti Paolo (Arezzo)
Cornacchia Flavia (Cremona)
Cosa Francesco (Lodi)
Cosentini Vincenzo (San Bonifacio)
Costantino Ester Grazia Maria (Manerbio)
D’Alonzo Silvia (Roma)
D’Altri Christian (Martina Franca)
D’Amico Maria (Erice Casa Santa)
De Mauri Andreana (Pavia)
D’Elia Filomena (Bari)
Della Gatta Carmine (Nola)
Della Rovere Francesca Romana (Civita Cast)
Di Franco Antonella (Barletta)
Di Liberato Lorenzo (Chieti)
Di Loreto Ermanno (Atri)
Di Pietro Fabio (Caltanissetta)
Di Renzo Brigida (Brindisi)
Di Somma Agnese (San Marco Argentano)
Di Stante Silvio (Fano)
Dian Silvia (Schiavonia)
Domenici Alessandro (Roma)
Esposito Samantha (Grosseto)
Esposito Vittoria (Pavia)
Fancello Sabina (Tempio Pausania)
Fantinati Concetta (Imola)
Feliciani Annalisa (Seriate)
Ferrando Carlo (Cuneo)
Ferrara Gaetano (Foggia – SGiovanni Rotondo)
Fiederling Barbara (Latina)
Figliano Ivania (Vibo Valentia)
Figliola Carmela (Gallarate)
Filiberti Olivierio (Vercelli)
Filippini Armando (Roma)
Finazzi Silvia (Rozzano)
Finocchietti Daniela (Chieri)
Gabrielli Danila (Aosta)
Gai Massimo (Torino)
Galderisi Cristina (Albano Laziale – Ariccia)
Garofalo Donato (Fermo)
Gazo Antonietta (Vigevano)
Gennarini Alessia (Bergamo)
Gherzi Maurizio (Ceva)
Giancaspro Vincenzo (Molfetta)
Gianni Glauco (Prato)
Giozzet Morena (Feltre)
Giozzet Morena (Belluno)
Giuliani Anna (Vicenza)
Giunta Federica (Macerata)
Grazi Francesca (Montepulciano)
Graziani Romina (Ravenna)
Grullo Maurizio (Lamezia Terme)
Guizzo Marta (Castelfranco Veneto)
Heidempergher Marco (Milano)
Iadarola Gian Maria (Torino)
Iannuzzella Francesco (Reggio Emilia)
Iannuzzi Maria Rosaria (Napoli)
Incalcaterra Francesca (Palermo)
Kalikatzaros Ileana (Ciriè)
Kanaki Angeliki (Pontedera)
La Milia Vincenzo (Lecco)
Laudadio Giorgio (Bassano Del Grappa)
Lenci Federica (Ancona)
Leonardi Sabina (Trieste)
Lepori Gianmario (Olbia)
Lidestri Vincenzo (Chioggia)
Lisi Lucia (Vimercate)
Lo Cicero Antonina (San Daniele)
Lommano Nicola (Civitanova Marche)
Luciani Remo (Roma)
Lupica Rosaria (Taormina)
Maggio Milena (Crema)
Magnoni Giacomo (Bologna)
Malandra Rosella (Teramo)
Mancuso Verdiana (Agrigento)
Mangano Stefano (Tradate)
Mannucci Claudia (Pescia)
Marchetti Valentina (Lucca)
Martelli Luca (Pinerolo)
Masa Alessandra (Sondrio)
Mastrippolito Silvia (Lanciano)
Mastrosimone Stefania (Treviso)
Mazzola Giuseppe (Mantova)
Messina Antonella (Catania)
Miglio Roberta (Busto Arsizio)
Miniello Vincenzo (Pistoia)
Mollica Agata (Cosenza)
Montemurro Vincenzo (Firenze)
Nardelli Luca (Milano)
Nava Elisa (Varese)
Neri Loris (Alba)
Nicolai Giuli Adriana (Conegliano)
Nicosia Valentina (Formia)
Ocello Alessandra (Sciacca)
Oliva Barbara (Palermo)
Olivi Laura (Trento)
Paganizza Luca (Roma Tor Vergata)
Palmiero Giuseppe (Napoli)
Pani Alessandra (Acireale)
Panuccio Vincenzo (Reggio Calabria)
Panzino Antonio (Catanzaro)
Paola Nazzaro (Campobasso)
Papantonio Domenico (Foggia)
Paribello Giuseppe (Napoli)
Parodi Denise (Genova – Arenzano)
Pastorino Nadia (Novi Ligure)
Perez Giuseppina (Dolo)
Perilli Angela (Vasto)
Pezone Ilaria (Legnano)
Pieracci Laura (Imperia)
Pignone Eugenia (Rivoli)
Piraina Valentina (Ivrea)
Piscitani Luca (Avezzano – Sulmona – L’Aquila)
Piscopo Giovanni (Bari)
Pogliani Daniela Rosa Maria (Garbagnate)
Porcedda Claudia (Oristano)
Portale Grazia (Catania)
Previti Antonino (Santorso)
Puliatti Daniela (Catania)
Puliti Marialaura (Palestrina)
Re Sartò Giulia Vanessa (Milano)
Restivo Giuseppe (Enna)
Ria Paolo (Lecce)
Ricciatti Anna Maria (Ancona)
Rocca Anna (Roma)
Roccetti Stefano (La Spezia)
Romano Paolo (Venezia Mestre)
Romano Giuseppina (Avellino)
Romano Paolo (Venezia)
Rossi Natalia (Casale Monferrato)
Sabatino Stefania (Udine)
Sacco Colombano (Biella)
Sammartino Fulvio Antonio (Pescara)
Sansone Gennaro (Lauria)
Santarelli Stefano (Jesi)
Santese Domenico (Taranto)
Santinello Irene (Piove di Sacco)
Santirosi Paola (Foligno)
Santoni Stefania (Todi)
Saraniti Antonello (Milazzo)
Savignani Claudia (Citta’ di Castello)
Scarfia Rosalia Viviana (Caltagirone)
Serriello Ilaria (Roma)
Silvestri Simona (San Benedetto del Tronto)
Somma Giovanni (Castellamare di Stabia)
Sorice Mario (Senigallia)
Spissu Valentina (Sassari)
Stacchiotti Lorella (Giulianova)
Stanzione Giovanna (Salerno)
Stucchi Andrea (Milano)
Taietti Carlo (Treviglio)
Tettamanti Maria Giulia (Como)

Timio Francesca (Perugia)
Tomaselli Martine (Roma Ostia)
Toriello Gianpiero (Polla)
Torre Aristide (Nocera Inferiore)
Trepiccione Francesco (Napoli)
Trubian Alessandra (Legnago)
Vaccaro Valentina (Alessandria)
Valsania Teresa (Piacenza)
Vecchi Luigi (Terni)
Veronesi Marco (Ferrara)
Visciano Bianca (Magenta)
Viviana Finato (San Miniato)
Vizzardi Valerio (Brescia)
Zambianchi Loretta (Forlì)
Zeiler Matthias (Ascoli Piceno)

 

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Peritoneal Dialysis in Italy: the 9th GPDP-SIN Census 2024. Twenty Years of Monitoring Peritoneal Dialysis

Posted on Scarica PDF

Gruppo di Progetto Dialisi Peritoneale

DOI: 10.69097/42-04-2025-02

Loris Neri1, Anna Giuliani2, Marco Heidempergher3, Mathias Zeiler4, Stefania Maxia5, Claudio Mastropaolo6, Giusto Viglino7, Giancarlo Marinangeli8 e Gianfranca Cabiddu5 on behalf of the Peritoneal Dialysis Project Group of the Italian Society of Nephrology

1. Nephrology and Dialysis, ASLCN2 – Ospedale “Michele e Pietro Ferrero”, Verduno (CN), Italy
2. Nephrology Dialysis and Transplantation, AULSS8 Berica, Ospedale “San Bortolo”, Vicenza, Italy
3. Nephrology and Dialysis Unit, ASST “Fatebenefratelli-Sacco”, Milan, Italy
4. Nephrology and Dialysis Unit, Peritoneal Dialysis Section, "C. e G. Mazzoni" Hospital, Ascoli Piceno, Italy
5. Nephrology, Dialysis and Transplantation Unit, ARNAS “GiuseppeBrotzu”, Cagliari, Italy
6. Visionage SRL
7. Past Director (1) and Telemedicine Service, ASLCN2, Italy
8. Past Director of Nephrology and Dialysis Unit, Ospedale Maria SS dello Splendore, Giulianova, Teramo, Italy

Corresponding author:
Loris Neri
SOC Nefrologia e Dialisi - Ospedale “Michele e Pietro Ferrero”, Via Tanaro 7 – Verduno (CN)
Telefono 0172-140-8271
E-mail: lorisneri1960@gmail.com

 

Abstract

Objectives. We report here the results of the 9th National Census (Cs-24) of Peritoneal Dialysis in Italy, carried out in 2025 by the Italian Society of Nephrology’s Peritoneal Dialysis Project Group and relating to 2024.
Methods. The Census was conducted in the 228 non pediatric centers which performed Peritoneal Dialysis (PD) in 2024. The results have been compared with previous Censuses carried out since 2005.
Results. Incidence: in 2024, 1,398 patients (CAPD = 55.1%) started on PD (1st treatment for ESRD). PD was started incrementally by 40.2% of these in 155 Centers. The catheter was positioned exclusively by a Nephrologist in 19.2% of known cases. Prevalence: of the 4,322 patients on PD at 31/12/2024 (CAPD=43.7%), 21.4% were on assisted PD (family member caregiver: 86.2%). Out: in 2024 the PD dropout rate (ep/100 pt-yrs) was: 12.7 to HD; 9.7 death; 8.5 Tx. The main cause of transfer to HD remains peritonitis (21.8%), although it is still decreasing (Cs-05: 37.9%). Peritonitis/EPS: the incidence of peritonitis in 2024 was 0.164 ep/pt-yr (647 episodes). The incidence of new cases of EPS in 2023-24 (9 cases) was unchanged. Other results: 3.86%-PET remains the most widely-used test (58.1%); most of the Centers do not carry out Home Visits (54.1%); training is mainly carried out in-Center (49.1% of the Centers).
Conclusions. Cs-24 confirms the good results PD is having in Italy, where it is experiencing a slight upturn.

Keywords: Peritoneal Dialysis, technique failure, incremental Peritoneal Dialysis, peritonitis, assisted PD

Introduction

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 [1–7]. The last edition, relating to 2022 [7], showed a reduction in the incidence and prevalence of PD compared to 2016 (the 2019 edition was incomplete, conducted as it was at the height of the COVID pandemic).

As with the previous 2022 edition, all the Centers using PD took part in the current edition – the Ninth – relating to 2024. 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 [8] and by the Questionnaire conducted by the GPDP in 2007 [9], and though they are likely to partly still be the same, new factors seem to be hindering a more widespread use of PD.

The current edition raises several points of interest and new aspects. First of all, it is the second “post COVID” edition. The number of Centers taking part increased significantly with the use of a new data collection system introduced during the pandemic [6], allowing for greater precision in the data collected. For the second time, not only the incidence, but also the etiology of peritonitis were investigated thoroughly, as well as certain structural aspects of PD Centers, such as the dedicated personnel and training, while a full analysis was possible for the first time of the patients who were started on PD due to cardiopathy rather than ESRD, and this will be the subject of a forthcoming detailed analysis.

This report presents the results of the 9th edition, conducted over the first few months of 2025 and relating to 2024, compared with those of the previous years.

Completing the report are the results of the first National Peritoneal Dialysis Audit in which some of the more discussed PD practices have been considered (in preparation).

 

Materials and methods

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

Data collection

As for 2022 [7], 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. This system has several limitations in terms of logistics and calculation, the main one being the need to update the software – version 4.0 in 2024 – to the information to be “extracted”.

The number of Centers using this system in 2024 remained substantially unchanged from 2022 (Cs-19: 110 Centers; Cs-22: 175 Centers; Cs-24: 170 Centers). The method used by the remaining 58 Centers was the traditional collection of data by filling in the online questionnaire used for previous editions.

In total, the Census reports data from 228 Centers, which is 100% of Italian PD Centers. Of the 9 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 [8] has been updated over the years through attendances at Congresses, Conferences and subsequent SIN Censuses, with a further verification carried out for 2024 by GDPD’s regional contacts based on local knowledge.

The number of Centers which treated at least 1 patient with PD in 2024 was 228. While all the Centers responded to the questions on the incidence and prevalence of PD, 46 Centers provided no data on the incidence and prevalence of HD (Figure 1).

Centers which treated at least 1 patient with PD in 2024.
Figure 1. Centers which treated at least 1 patient with PD in 2024. They all sent the data relating to PD, while 46 of them did not send HD incidence and prevalence data. The traditional system was still used for sending this data, with the entry of aggregate data for 58 Centers.

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, which was first used in 2019 and has been improved in this edition, information is available on the causes of Renal Insufficiency, causes of death, certain organizational aspects such as training methods and available resources, and the etiology of peritonitis, and for the first time it has been possible to fully analyze the patients started on PD on non-renal grounds separately.

Data verification and comparison

The data collected were initially subjected to 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 01/01/2024 to 31/12/2024 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 refers to patients on dialysis at December 31st. For these, a need for assistance refers to the involvement of a caregiver in the performance of the dialysis procedures. For the first time it was possible to analyze the patients started on PD on non-renal grounds separately, though as mentioned only for the Centers which used the analytical system to send the data. Non-renal reasons for PD were heart and liver conditions.

The calculation of the follow-up to relate events to 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 2024) 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 [10]. 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 170 Centers which used the “4.0” program. In these Centers, the comparison between the two methods showed that “traditional” follow-up underestimates the “actual” follow-up by 1.7%, so it overestimates by an equivalent amount the incidence of the events considered. As the data collection system was still mixed for 2024, the traditional method was used to calculate follow-up for all 228 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 2023-24 two-year period.

The Census is a “photograph” of the current situation, so statistical analysis was limited to looking for any differences with the Chi square test. Incremental PD and PD for heart failure will be the subjects of two forthcoming analyses.

 

Results

Incidence and initial method

In 2024, PD was started on as first treatment by 1398 patients, with 770 using CAPD and 628 APD. The Centers with no incidence in PD in 2024 numbered 18.

HD incidence and prevalence data were provided by 182 Centers, where 1132 patients started on PD as first treatment, and 4734 on HD, giving a percentage PD incidence of 19.3% (19.8% in 2022) (Table I) (Figure 2).

Incident patients and initial PD method in the non-pediatric Centers which used PD in 2024 compared with previous years.
Table I. Incident patients and initial PD method in the non-pediatric Centers which used PD in 2024 compared with previous years. The number of Centers not sending HD incidence data has increased constantly since 2016.

This PD incidence percentage is clearly overestimated, because it refers to the minority of public and private Italian dialysis Centers which use the method. To attempt to estimate the actual incidence of PD in Italy correctly, we have used the Italian Dialysis and Transplant Registry (RIDT) incidence per million population (pmp), which was 168 pmp for 2023 (data kindly provided in advance by Dr. Maurizio Nordio). As a proportion of the population of Italy as of 31/12/2023 (available National Institute of Statistics ISTAT data), 23.7 pmp of patients therefore started on PD, in other words 14.1% of all incident Dialysis patients (Figure 3). This can be considered stable compared to previous years.

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, asterisk). 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.
Figure 3. Nationwide incidence and prevalence of PD.
Figure 3. Nationwide incidence and prevalence of PD. The value is estimated from the incidence and prevalence per million population of all patients on dialysis, provided by RIDT (Dr. Nordio).

The most widely-used initial PD method remains CAPD (55.1%), closely related to incremental prescription (Figure 4).

Figure 4. Peritoneal Dialysis modality in incident and prevalent patients (A), and in patients when starting PD from HD and Tx (B).
Figure 4. Peritoneal Dialysis modality in incident and prevalent patients (A), and in patients when starting PD from HD and Tx (B).

For the second time, basic nephropathy data are available, though only for the 170 Centers which sent data using the 4.0 system. The conditions in which PD is most used are Nephroangiosclerosis (24.2%) and chronic Glomerulonephritis (21.7%). The cause of ESRD is diabetic nephropathy in 14.4% of cases and ADPKD in 7.6% of cases, while in 17.2% it is not known (Figure 5).

Type of nephropathy in incident PD patients.
Figure 5. Type of nephropathy in incident PD patients. The information was not requested by the traditional system used to send data, so the breakdown reported in the Figure refers to 1,068 incident patients in 170 Centers.

The mean age of incident patients on PD, calculated as the weighted average of the aggregate average of the 165 Centers which provided congruent data, was 64.3 years (Figure 5).

Finally, for the first time it was possible to estimate the number of patients who were incident for non-renal causes (heart and liver failure). Out of the 1398 incident patients, 72 (5.2%) started on PD due to heart failure and 3 (0.2%) liver failure.

Placement of the peritoneal catheter

All insertions were considered for the placement of the catheter. Excluding 49 patients due to incongruent or no data, in the 1349 patients who started on PD in 2024, 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 6) (Figure 7).

VLS was used in 9.5% of cases (Figure 7).

Operator, insertion technique, type of anesthesia used for the 1398 catheters of the incident patients.
Figure 6. Operator, insertion technique, type of anesthesia used for the 1398 catheters of the incident patients. The percentages in the table refer to the 1349 catheters with data available.
Figure 7. Operators involved in placement of catheter, 2024 vs 2016. The percentages were also calculated excluding catheters for which an “other” or not specified response was given.
Figure 7. Operators involved in placement of catheter, 2024 vs 2016. The percentages were also calculated excluding catheters for which an “other” or not specified response was given. The percentage of catheters placed by the Nephrologist alone has diminished significantly (p<0.001). 

Initial dialysis dose – incremental peritoneal dialysis

PD was started on in 2024 using the incremental method (Incr-PD) by 562 patients, equalling 40.2% of total incident patients (Figure 8); it was used for at least 1 patient by 155 Centers, equalling 68.0% of the 228 Centers (73.8% when excluding the 18 Centers with no incidence), increasing compared to previous years.

Figure 8. Incremental dialysis in 2024
Figure 8. Incremental dialysis in 2024. The lateral columns show the PD method (CAPD and APD) used for “incremental” (on the left) and “full dose” patients (on the right). As can be seen, the PD modality is significantly different for incremental and full-dose prescription.

For the patients who started PD with an incremental dose, the most widely-used method – as in previous years – was CAPD (84.5%), as opposed to the patients who started with a full-dose prescription, for whom APD is significantly more widely-used (66.3% – p<0.0001) (Figure 8). CAPD is a PD method which 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 rising constantly, from the 11.9% of 2005 to the current 40.2% (Figure 9). The increase recorded in 2024 can be attributed to both a rise in the number of Centers prescribing it (73.8% in 2024 and 63.0% in 2022, while in 2005 it was 29.2%), and the increased number of patients for whom it is prescribed in those Centers (50.9% in 2024 vs 47.8% in 2022). The incremental prescription will be the subject of a forthcoming detailed analysis.

Figure 9. 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) over time.
Figure 9. 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) over time.

Patients from other treatments

In 2024, 201 patients transferred from HD to PD (Table II) (Figure 10).

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
2024 1398 201 57 1656 12.1 3.4
Table II. Patients (absolute value and percentage of all new patients to PD) from HD and return post-Transplant.
Figure 10. Admissions to PD, sum of Incident patients, transfers from HD and returns post-Tx.
Figure 10. Admissions 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 (527 drop-outs in 2024), but higher in both absolute and percentage terms: indeed, in 2024 it represents 12.1% of all new patients to PD, compared to 5.7% in 2005 (Figure 11). While for every 100 patients who transferred from PD to HD in 2005 there were 17 took the reverse path, in 2024 the latter figure was 38.

Figure 11. Trend over time in the percentage of patients who started on PD from HD and Tx out of the total number of admissions.
Figure 11. Trend over time in the percentage of patients who started on PD from HD and Tx out of the total number of admissions.

As regards a return to PD post-Transplant, the numbers and percentages have remained substantially unchanged over time (Figure 12), although the percentage value compared to return to HD is made more uncertain by the increasingly low number of Centers sending the data (66.2% in 2024, Figure 12). As expected, for the probable lower RRF the most widely-used PD modality used initially in these patients is APD, contrary to what is observed in incident patients (Figure 4).

Figure 12. Percentages of patients returning post-Transplant on HD (red) and on PD (blue).
Figure 12. Percentages of patients returning post-Transplant on HD (red) and on PD (blue). Only Centers with complete data for HD as well are considered: as shown at the bottom, since 2016 the number of Centers not sending the data relating to return to HD from Tx has increased constantly.

Change of PD method

Information on the change of method was available for 221 Centers. In these Centers, 203 patients transferred from CAPD to APD in 2024, while 41 transferred from APD to CAPD (Figure 13).

Figure 13. Change of PD method in 2024. Seven Centers did not provide the data.
Figure 13. Change of PD method in 2024. Seven Centers did not provide the data.

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.

Prevalence and PD method

At December 31st 2024 there were 4322 patients on PD, with 1890 on CAPD and 2432 on APD. Compared with 2022, an increase of 4.1% was recorded in the prevalent population (Figure 14) (Table III).

Prevalent patients at 31/12/2024 and PD method in the non-pediatric Centers which used PD in 2024 compared with previous years.
Table III. Prevalent patients at 31/12/2024 and PD method in the non-pediatric Centers which used PD in 2024 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.

In the 182 Centers with complete incidence and prevalence data for HD as well, there were 3526 patients on PD and 19,397 on HD, with a 15.4% PD prevalence. Like the incidence, in Figure 3 is reported the “real” PD prevalence in Italy.

The most widely-used PD method among prevalent patients is APD (56.3%) (Figure 4), 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 2024 was 31.3 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 15.

Patients treated with PD at December 31st of each year in the years surveyed.
Figure 14. Patients treated with PD at December 31st of each year in the years surveyed. The percentage prevalence is 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 (red, asterisk). The total number of prevalent patients is given at the top of each column. It is to be remembered that the 2019 data were incomplete. In 2005 the HD prevalence data were not requested, so those of the 2004 SIN Census are considered.
Duration of PD calculated by multiplying the ADMISSIONS/PREVALENCE ratio (“turnover” index) by 12.
Figure 15. Duration of PD calculated by multiplying the ADMISSIONS/PREVALENCE ratio (“turnover” index) by 12. This is obviously valid in steady state condition.

Assisted PD

In Cs-24 a caregiver (assisted PD) was required by 904 prevalent patients in the 221 Centers with data available (21.4% of all prevalent patients on PD in these Centers) (Figure 16), almost identical to the data recorded in 2022. Compared to 2019 (976 patients on Assisted PD in an incomplete Census), this confirms a significant reduction (p<0.005).

The caregiver is a family member in 86.2% of cases (Figure 17), a live-in carer in 8.1% and a home nurse in 3.0%; finally, 2.8% (25 patients) perform PD in facilities for the elderly (Figure 18).

Assisted PD in prevalent patients at 31/12/2022 and type of caregiver involved.
Figure 16. Assisted PD in prevalent patients at 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 – alongside each single component – the percentages in relation to the total number of patients on assisted PD.
Figure 17. Trend over time in family caregivers involved in assisted PD.
Figure 17. Trend over time in family caregivers involved in assisted PD.
Figure 18. Trend over time of other forms of assisted PD (excluding “family members”)(“other” in yellow).
Figure 18. Trend over time of other forms of assisted PD (excluding “family members”)(“other” in yellow).

Change of method and drop-out

Figure 19 shows both 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.

Figure 19. Drop out from Peritoneal Dialysis. In 2019 the Census was incomplete.
Figure 19. Drop out from Peritoneal Dialysis. In 2019 the Census was incomplete.

The number of deaths recorded in 2024 was 400 (9.7 ep/100 pt-years), with 527 patients transferring to HD (12.7 ep/100 pt-years) and 351 to transplants (8.5 ep/100 pt-years). A reduction in mortality was confirmed for 2024 compared to 2022 and 2016. Other causes of drop-out from PD in 2022 were voluntary refusal to continue dialysis (burn out) for 7 patients, Recovery of Residual Renal Function (RFRR) in 12 patients and “other” grounds for 22 patients.

With regard to drop-out to HD (Figure 20), the single main cause remains peritonitis (21.8%), 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%; 2022: 23.5%). The second cause – on the increase constantly since 2016 (8.5%) – is the catheter (16.9%), followed by UFF (13.5%) and dialysis adequacy (13.1%), while impossibility to continue on PD (9.5%) – which represented 22.4% of all drop-outs in 2022 – is falling sharply. This is most probably because the definition of “impossibility to continue” was limited in 2024 to cases of self-management of PD (loss of independence or caregiver), whereas in the past it referred to events that rendered the patient no longer suitable for the performance of 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. In the past, in the absence of a precise indication other clinical events – such as mechanical (pleuroperitoneal communication, for example) or surgical complications – may also have been attributed to this cause. The increase in other causes of interruption” from 3.0 to 17.6% confirms this interpretation.

Figure 20. Causes of drop-out from PD over the years.
Figure 20. Causes of drop-out from PD over the years. In 2019 the Census was incomplete. Shown at the top of each column is the absolute value of patients who transferred to HD for each year surveyed.

The main cause of death is heart disease (42.3%), while peritonitis represents 0.9% of deaths (Figure 21).

Figure 21. Causes of death in the Centers which used the dedicated 4.0. program to send the data.
Figure 21. Causes of death in the Centers which used the dedicated 4.0. program to send the data.

Peritonitis

The number of episodes of peritonitis recorded in 2024 was 647 in 213 Centers (93.4% of Centers with data available), which for a total follow-up of 3937.5 years is equivalent to 0.164 episodes per patient-year, or in other terms 1 episode every 73.0 patient-months, a lower incidence than recorded in previous years (Table IV). The peritonitis trend is given in both Table IV and Figure 22.

INCIDENCE
PERITONITIS ep/pt-year pt-month/ep NEGAT (%)
2005 1026 0.329 36.5 17.1
2008 1171 0.292 41.1 17.1
2010 1209 0.296 40.5 18.5
2012 1179 0.282 42.5 15.9
2014 953 0.224 53.5 19.9
2016 939 0.212 56.6 17.3
2019 667 0.189 63.5 18.7
2022 696 0.176 68.0 19.3
2024 647 0.164 73.0 17.9
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 it. 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). For 2024 the data were provided by 93.4% of the Centers (213).
Figure 22. Trend over the years in the incidence of peritonitis. The constant reduction recorded over the years is striking.
Figure 22. Trend over the years in the incidence of peritonitis. The constant reduction recorded over the years is striking.

As regards the etiology, around half (46.8%, 303 episodes) of the 116 negative cultures (17.9%) were caused by Gram positives and 28.6% (185 episodes) by Gram negatives (Figure 23).

SA (30.7%), SE/CoNS (24.8%) and Streptococcus (19.1%) are the most frequently isolated Gram positive bacteria (Figure 24), while PA, Escherichia and Klebsiella represent 53%  of Gram negative etiological agents (Figure 25).

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. Gram positives.
Figure 24. Etiology of peritonitis in detail. Gram positives.
Figure 25. Etiology of peritonitis in detail. Gram negatives.
Figure 25. Etiology of peritonitis in detail. Gram negatives.

Encapsulating peritoneal sclerosis (EPS)

Of the 9 new episodes of EPS reported during the period 2023-24 (0.106 ep/100 pt-year), 6 were diagnosed in the course of PD and 3 following transfer to HD. No cases were reported following a transplant (Figure 26).

Sclerosing peritonitis over time.
Figure 26. Sclerosing peritonitis over time. Only the number of extracted cases is reported for 2022, as the 2019 data were incomplete. Ep/100 yrs-pts = [(Number of EPS in the period considered)/(years of the period)]/(Mean Prevalence) Mean Prevalence = average prevalence recorded at the beginning and end of the period considered
PET

Peritoneal permeability is assessed by most of the Centers (97.4%). PET with 3.86% is the preferred modality (58.1% of Centers) (Figure 27). Most centers assess peritoneal permeability as needed (48.6%) or once a year (38.9%) (Figure 28).

Assessment of peritoneal permeability with the various methods over the years.
Figure 27. Assessment of peritoneal permeability with the various methods over the years. Note – 7 Centers did not respond – the number of Centers using 3.86% was 131 in 2022 and is 132 in 2024 – the Centers not assessing permeability are 6 (27 in 2022).
Figure 28. Frequency of assessment of peritoneal permeability. Note – see Figure 27.
Figure 28. Frequency of assessment of peritoneal permeability. Note – see Figure 27.

PD for heart failure

For the first time, in the 170 “4.0 Centers” it has been possible to consider separately the use of PD for heart failure defined by diuretic therapy-resistant hydrosaline retention (the classic “single exchange”) or by type II cardiorenal syndrome. Overall, 72 (5.2%) of the 1398 incident patients started on PD for heart failure. This could only be fully analyzed however for the 170 Centers which sent aggregate data using the 4.0 system. In these Centers, the number of incident and prevalent patients for heart failure were 47 and 72 respectively, with 38 (22.4%) treating at least 1 patient for heart failure with PD in 2024. The mean age on admission was 74.4 years (decidedly higher than that of the overall population), and the most widely-used method was CAPD (79%), in incremental modality in 57% of cases  (Figure 29).

Use of PD in refractory heart failure (GFR > 15 ml/min/1.73) – incident patients.
Figure 29. Use of PD in refractory heart failure (GFR > 15 ml/min/1.73) – incident patients. To be noted are the higher mean age, extended incremental prescription and CAPD as most used modality. The analysis is limited to the Centers which sent the data using the new system. The 25 patients reported by the Centers which sent the data in the traditional manner should be added to the 47 incident patients. However, only the incidence was available for these Centers, so they were not considered other than that.

Of the 72 prevalent patients, 62% were on assisted PD, and the mean duration of the PD was 18.4 months, with a mortality rate of 38.7 ep/100 pt-yrs. The incidence of peritonitis was 0.097 episodes/patient-year (Figure 30).

Use of PD in refractory heart failure – prevalent patients.
Figure 30. Use of PD in refractory heart failure – prevalent patients. To be noted are the widespread use of assisted PD, the mean duration on PD of 18.4 months (32.3 in the global population), and the high cardiovascular mortality rate, but low rate of peritonitis or UFF.

Training and Home Visits

For the 220 Centers (96.5%) which responded to the questions on Training, the trainer was in-Center in 56.4%, external in 12.7%, and in the remainder either internal or external (Figure 31-A) in forms which were not investigated further.

Figure 31. Training for PD. Trainers (A) and venues (B).
Figure 31. Training for PD. Trainers (A) and venues (B).

As regards the venue for the training, in 49.1% of cases it was performed in-Center, in 11.4% of the Centers only at home, and in 39.5% of  the Centers partly in-Center and partly at home (Figure 31-B). When the trainer is internal, in 83.8% of cases it is performed in-Center, when the trainer is external it is performed in 64.3% of cases at home, and when the training is performed by either an internal or an external trainer in 85.3% of cases it takes place partly in-Center and partly at home (Figure 32).

Figure 32. Venue of training in relation to trainer.
Figure 32. Venue of training in relation to trainer.

Following the start of PD, home visits are only carried out by a minority of the Centers (101 Centers = 45.7% of the 221 Centers which responded), confirming the 2022 proportion but less than in the previous years (59.4% in 2010). The number of Centers performing them regularly – already small – has declined slightly (7.2%). The remainder only carry out home visits during the first few months (7.2%) or in case of necessity (31.2%) (Figure 33).

Figure 33. Frequency of home visits over the years. Only a minority of Centers performed them.
Figure 33. Frequency of home visits over the years. Only a minority of Centers performed them.

In all cases, the nurse is involved, either alone (45.5% of cases) or with a doctor in varying ways, but it is never the doctor alone (Figure 34-A). The involvement of a doctor increases as the VD program becomes more intense (Figure 34-B).

Figure 34. Who makes the home visits (A) and the relationship between intensity of the home visit program and the operator involved (B).
Figure 34. Who makes the home visits (A) and the relationship between intensity of the home visit program and the operator involved (B).

Analysis of the Centers

Mean prevalence was 19.0±16.9 patients per Center, with considerable variability between one Center and another (Figure 35).

Figure 35. Breakdown by number of prevalent pts in the PD Centers which took part in the Cs-24.
Figure 35. Breakdown by number of prevalent pts in the PD Centers which took part in the Cs-24.

Most of the Centers involved and of the prevalent patients are concentrated in the North (46.5% of Centers, 55.8% of PD patients) (Figure 36). Figure 37 shows the geographical distribution of prevalence pmp.

Figure 36. Distribution of Centers and patients by Macro area.
Figure 36. Distribution of Centers and patients by Macro area.
Figure 37. PD prevalence per million population in the various regions.
Figure 37. PD prevalence per million population in the various regions.

 

Discussion

The limitations of the Census

Launched in 2005, over these 20 years the PD Census has represented the result of a constant organizational effort by GPDP-SIN and all its PD contacts in the Centers using PD in Italy. Following the difficulties in the 7th edition due to the pandemic, as in 2022 100% of PD Centers took part once again in this 9th edition in 2024.

The real limitation of the Census lies in its very nature of being simply a “snapshot” – however detailed it may be – of just the Centers that use PD, which – as is known – are a minority of the Dialysis Centers in Italy. This limitation has been accentuated in the last few editions by the growing difficulty for Center contacts to send even basic information relating to patients on HD in their Centers. Recorded for the first time in 2016, the percentage of Centers not sending HD data is similar in 2024 to 2022 (21.8%).

The most important new feature is represented by the new system for collecting the data by means of a dedicated program that facilitates the sending of the data in aggregate form alone. This system has greatly reduced data incongruence and has increased the information available. However it is still not used by a sizeable number of Centers, so traditional calculation and processing methods have been applied to all the Centers in this edition too, in particular in regard to the follow-up to relate events to. Assessed in this way, the follow-up is an underestimation, and as a result overestimates the incidence of events.

The use of PD

The number of incident and prevalent patients on PD has increased slightly: +3.6% and +4.1% respectively. The number of patients on PD at 31/12/2024 remains the highest in Europe [11]. For the Centers which also provided HD data, compared to 2022 the percentage incidence and prevalence (compared to total number of patients on dialysis) were slightly lower (from 19.6% to 19.3%) and slightly higher (from 14.9% to 15.4%) respectively. Considered in relation to the population in Italy, the percentage incidence and prevalence of PD remain limited to 14.1% and 9.5%  of the patients on dialysis.

Incremental Dialysis has been investigated since the first edition of the Census [1, 12], and increased further in 2024 in terms of both number of Centers prescribing it and greater use in the single Centers. The advantages of this prescriptive modality are increasingly clear [13, 14], and it will be subject to more in-depth processing.

The reduced use recorded in 2022 of assisted PD – strictly linked to the support of family members (in over 80% of cases) – is confirmed for 2024.

In short, in Italy PD concerns patients who are younger, mostly early referral and started on the incremental modality using CAPD.

Drop-out from PD and peritonitis

The improvement in the mortality rate was confirmed in 2024, while drop-out for transfer to HD and transplant increased. Overall, the mean duration of a patient on PD remained unchanged (31.3 months). Peritonitis is falling constantly for transfer to HD, while catheter malfunction is increasing. The reduction in “interruptions due to impossibility to continue” recorded in 2024 compared to 2022 (from 22.4% to 9.5%) is due to the redefinition of this cause, limiting it to loss of suitability for self-management alone.

The incidence of peritonitis dropped further in 2024 to 0.164 episodes/patient year. Essentially, the reduction in peritonitis from the 5 episodes per patient-year of the ‘80s to less than 1 episode every 6 year represents the method’s most notable success. In particular, from the first Census in 2005 (1 episode every 36.5 months) to today (1 episode every 73.0 months) the incidence of peritonitis has halved. This is one of the lowest recorded in the western world, and decidedly less than the maximum target value recommended by the ISPD guidelines in 2022 [15], and it is in line with the worldwide trend for this complication [16].

The reduction in the incidence of peritonitis is confirmed by the reduction in drop-out for peritonitis.

Also as regards the etiology, which has been fully investigated for the first time, the Census data are in line with what has been observed by other Registers and multi-center papers [17, 18]: a half gram positive, a fourth gram negative and a fifth culture negative. The last are in any case down compared with 2022.

Finally, the 2024 data on EPS confirm the major reduction in this complication in PD, which is limited to just a few cases occurring in PD and HD.

As in the previous edition, it is be underlined that while on the one hand it is likely that the incidence of EPS is underestimated (not communicated following transfer to HD or Tx), there are several factors which may have contributed to its actual reduction, including greater biocompatibility of the solutions used for years, incremental dialysis and the reduction in peritonitis.

Particular aspects

The monitoring of peritoneal permeability, and the way in which it is performed, 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 the 15.6% of Centers in 2010 to the 58.1% in 2024, but above-all a reduction in 2024 in the Centers not assessing peritoneal permeability to just 2.6% of the total number.

For the first time it was possible to analyze PD for heart failure separately. The results seem to be positive, both in terms of survival and of complications linked to dialysis. This is the first nationwide investigation of this issue, and is to be the subject of a dedicated detailed analysis.

Training is performed with the contribution of “external” personnel in 43.6% of the Centers, in-Center only in half of cases (49.1%). In alignment with training is the observation that home visits following the start of PD are still only carried out in a minority of the Centers.

The number of PD Centers and their characteristics have remained substantially the same, in particular the lower use of PD in the South of the country, though with extreme variability between regions and from Center to Center.

 

Conclusions

The PD Census relating to 2024 confirms the quality of PD in Italy in terms of elasticity of the prescription, reduction in the mortality rate, reduction in peritonitis and EPS, widespread – though diminishing – use of assisted PD, and monitoring of the peritoneal membrane.

Nevertheless, overall it is still used for less than 10% of prevalent patients undergoing dialysis treatment in Italy. The 2024 Census allows us to posit some of the reasons underlying the limited use of PD. In particular, the age of the patients, which is significantly lower than the mean age of the patients being admitted today to dialysis with an increasing number of particularly cardiovascular comorbidities and care needs. On the other hand, the use of assisted PD (limited to one-fifth of patients and largely assisted by family members), the difficulty involved in starting a home follow-up program and the need for external trainers are likely to be organizational issues which need to be addressed to enable more widespread use of the method.

 

Appendix 1: 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.

Albrizio Paolo (Voghera)
Alessandrello Ivana (Modica)
Alfano Gaetano (Modena)
Amar Karen (Cernusco sul Naviglio)
Ambrogio Antonina (Rovigo)
Ancarani Paolo (Sestri Levante)
Angela Maria Dinnella (Anzio)
Angelo Maria Letizia (Camposampiero)
Ansali Ferruccio (Civitavecchia)
Apponi Francesca (Frosinone)
Argentino Gennaro (Napoli)
Barattini Marina (Massa)
Barbera Vincenzo (Colleferro)
Basso Anna (Padova)
Bellizzi Vincenzo (Caserta)
Bellotti Giovanni (Sapri)
Benozzi Luisa (Borgomanero)
Bermond Francesca (Torino)
Bianco Beatrice (Verona)
Bigatti Giada (Desio)
Bilucaglia Donatella (Torino)
Boccadoro Roberto (Rimini)
Bonesso Cristina (San Dona’ di Piave)
Bonincontro Maria Luisa (Bolzano)
Bonvegna Francesca (Verbania)
Borettaz Ilaria (Vizzolo Predabissi)
Borrelli Silvio (Napol)
Bosco Manuela (Gorizia Monfalcone)
Bottai Anna (Pisa)
Braccagni Beatrice (Poggibonsi)
Brocca Jessica (Cinisello Balsamo)
Bruno Paolo Ferdinando (Cesena)
Budetta Fernando (Eboli)
Cabibbe Mara (Milano)
Cabiddu Gianfranca (Cagliari)
Cadoni Maria Chiara (San Gavino Monreale)
Cannarile Daniela Cecilia (Bologna)
Cannavo’ Rossella (Firenze)
Canonici Marta (Fabriano)
Cantarelli Chiara (Parma)
Capistrano Maria (Montichiari)
Caponetto Carmelo (Siracusa)
Cappadona Francesca (Genova)
Cappelletti Francesca (Siena)
Capurro Federica (Novara)
Capurso Domenico (Putignano)
Caria Simonetta (Cagliari)
Carta Annalisa (Nuoro)
Caselli Gian Marco (Firenze)
Casuscelli di Tocco Teresa (messina)
Cataldo Emanuela (Altamura)
Centi Alessia (Roma)
Cerami Caterina (Pavullo)
Cernaro Valeria (Messina)
Cerroni Franca (Rieti)
Ciabattoni Marzia (Savona)
Cianfrone Paola (Catanzaro)
Cimolino Michele (Pordenone)
Ciurlino Daniele (Sesto San Giovanni)
Comegna Carmela (Tivoli)
Congiu Giovanni (Asti)
Consaga Marina (Livorno)
Contaldo Gina (Monza)
Conti Paolo (Arezzo)
Cornacchia Flavia (Cremona)
Cosa Francesco (Lodi)
Cosentini Vincenzo (San Bonifacio)
Costantino Ester Grazia Maria (Manerbio)
D’Alonzo Silvia (Roma)
D’Altri Christian (Martina Franca)
D’Amico Maria (Erice Casa Santa)
De Mauri Andreana (Pavia)
D’Elia Filomena (Bari)
Della Gatta Carmine (Nola)
Della Rovere Francesca Romana (Civita Cast)
Di Franco Antonella (Barletta)
Di Liberato Lorenzo (chieti)
Di Loreto Ermanno (Atri)
Di Pietro Fabio (Caltanissetta)
Di Renzo Brigida (Brindisi)
Di Somma Agnese (San Marco Argentano)
Di Stante Silvio (Fano)
Dian Silvia (Schiavonia)
Domenici Alessandro (Roma)
Esposito Samantha (Grosseto)
Esposito Vittoria (Pavia)
Fancello Sabina (Tempio Pausania)
Fantinati Concetta (Imola)
Feliciani Annalisa (Seriate)
Ferrando Carlo (Cuneo)
Ferrara Gaetano (Foggia – S Giovanni Rotondo)
Fiederling Barbara (Latina)
Figliano Ivania (Vibo Valentia)
Figliola Carmela (Gallarate)
Filiberti Olivierio (Vercelli)
Filippini Armando (Roma)
Finazzi Silvia (Rozzano)
Finocchietti Daniela (Chieri)
Gabrielli Danila (Aosta)
Gai Massimo (Torino)
Galderisi Cristina (Albano Laziale – Ariccia)
Garofalo Donato (Fermo)
Gazo Antonietta (Vigevano)
Gennarini Alessia (Bergamo)
Gherzi Maurizio (Ceva)
Giancaspro Vincenzo (Molfetta)
Gianni Glauco (Prato)
Giozzet Morena (Feltre)
Giozzet Morena (Belluno)
Giuliani Anna (Vicenza)
Giunta Federica (Macerata)
Grazi Francesca (Montepulciano)
Graziani Romina (Ravenna)
Grullo Maurizio (Lamezia Terme)
Guizzo Marta (Castelfranco Veneto)
Heidempergher Marco (Milano)
Iadarola Gian Maria (Torino)
Iannuzzella Francesco (Reggio Emilia)
Iannuzzi Maria Rosaria (Napoli)
Incalcaterra Francesca (Palermo)
Kalikatzaros Ileana (Ciriè)
Kanaki Angeliki (Pontedera)
La Milia Vincenzo (Lecco)
Laudadio Giorgio (Bassano Del Grappa)
Lenci Federica (Ancona)
Leonardi Sabina (Trieste)
Lepori Gianmario (Olbia)
Lidestri Vincenzo (Chioggia)
Lisi Lucia (Vimercate)
Lo Cicero Antonina (San Daniele)
Lommano Nicola (Civitanova Marche)
Luciani Remo (Roma)
Lupica Rosaria (Taormina)
Maggio Milena (Crema)
Magnoni Giacomo (Bologna)
Malandra Rosella (Teramo)
Mancuso Verdiana (Agrigento)
Mangano Stefano (Tradate)
Mannucci Claudia (Pescia)
Marchetti Valentina (lucca)
Martelli Luca (Pinerolo)
Masa Alessandra (Sondrio)
Mastrippolito Silvia (Lanciano)
Mastrosimone Stefania (Treviso)
Mazzola Giuseppe (Mantova)
Messina Antonella (Catania)
Miglio Roberta (Busto Arsizio)
Miniello Vincenzo (Pistoia)
Mollica Agata (Cosenza)
Montemurro Vincenzo (Firenze)
Nardelli Luca (Milano)
Nava Elisa (Varese)
Neri Loris (Alba)
Nicolai Giuli Adriana (Conegliano)
Nicosia Valentina (Formia)
Ocello Alessandra (Sciacca)
Oliva Barbara (palermo)
Olivi Laura (Trento)
Paganizza Luca (Roma Tor Vergata)
Palmiero Giuseppe (Napoli)
Pani Alessandra (Acireale)
Panuccio Vincenzo (Reggio Calabria)
Panzino Antonio (Catanzaro)
Paola Nazzaro (Campobasso)
Papantonio Domenico (Foggia)
Paribello Giuseppe (Napoli)
Parodi Denise (Genova – Arenzano)
Pastorino Nadia (Novi Ligure)
Perez Giuseppina (Dolo)
Perilli Angela (Vasto)
Pezone Ilaria (Legnano)
Pieracci Laura (Imperia)
Pignone Eugenia (Rivoli)
Piraina Valentina (Ivrea)
Piscitani Luca (Avezzano – Sulmona – L’Aquila)
Piscopo Giovanni (Bari)
Pogliani Daniela Rosa Maria (Garbagnate)
Porcedda Claudia (Oristano)
Portale Grazia (Catania)
Previti Antonino (Santorso)
Puliatti Daniela (Catania)
Puliti Marialaura (Palestrina)
Re Sartò Giulia Vanessa (Milano)
Restivo Giuseppe (Enna)
Ria Paolo (Lecce)
Ricciatti Anna Maria (Ancona)
Rocca Anna (Roma)
Roccetti Stefano (La Spezia)
Romano Paolo (Venezia Mestre)
Romano Giuseppina (Avellino)
Romano Paolo (Venezia)
Rossi Natalia (Casale Monferrato)
Sabatino Stefania (Udine)
Sacco Colombano (Biella)
Sammartino Fulvio Antonio (Pescara)
Sansone Gennaro (Lauria)
Santarelli Stefano (Jesi)
Santese Domenico (Taranto)
Santinello Irene (Piove di Sacco)
Santirosi Paola (Foligno)
Santoni Stefania (Todi)
Saraniti Antonello (Milazzo)
Savignani Claudia (Città di Castello)
Scarfia Rosalia Viviana (Caltagirone)
Serriello Ilaria (Roma)
Silvestri Simona (San Benedetto del Tronto)
Somma Giovanni (Castellammare di Stabia)
Sorice Mario (Senigallia)
Spissu Valentina (Sassari)
Stacchiotti Lorella (Giulianova)
Stanzione Giovanna (Salerno)
Stucchi Andrea (Milano)
Taietti Carlo (Treviglio)
Tettamanti Maria Giulia (Como)
Tomaselli Martine (Roma Ostia)
Toriello Gianpiero (Polla)
Torre Aristide (Nocera Inferiore)
Trepiccione Francesco (Napoli)
Trubian Alessandra (Legnago)
Vaccaro Valentina (Alessandria)
Valsania Teresa (Piacenza)
Vecchi Luigi (Terni)
Veronesi Marco (Ferrara)
Visciano Bianca (Magenta)
Viviana Finato (San Miniato)
Vizzardi Valerio (Brescia)
Zambianchi Loretta (Forlì)
Zeiler Matthias (Ascoli Piceno)
Figure 38. A sincere thank you to the contacts whose contribution made the Census possible.
Figure 38. A sincere thank you to the contacts whose contribution made the Census possible.

 

Bibliografia

  1. Marinangeli G, Cabiddu G, Neri L et al; Italian Society of Nephrology Peritoneal Dialysis Study Group. Old and new perspectives on peritoneal dialysis in Italy emerging from the Peritoneal Dialysis Study Group Census. Perit Dial Int 2012; 32:558-65.
  2. Marinangeli G, Cabiddu G, Neri L et al; Italian Society of Nephrology Peritoneal Dialysis Study Group. Andamento della DP in Italia nei Centri pubblici non pediatrici. Risultati del censimento GSDP-SIN 2010 e confronto con i censimenti 2008 e 2005. G Ital Nefrol 2014; 31(4).
  3. Marinangeli G, Cabiddu G, Neri L et al; Italian Society of Nephrology Peritoneal Dialysis Study Group. Peritoneal Dialysis in Italy: the fourth GSDP-SIN census 2012. G Ital Nefrol 2017; 34(2).
  4. Marinangeli G, Neri L, Viglino G; Peritoneal Dialysis Study Group of Italian Society of Nephrology.PD in Italy: the 5th GSDP-SIN Census 2014. G Ital Nefrol 2018;35(5).
  5. Neri L, Viglino G, Marinangeli G, et al; Peritoneal Dialysis Study Group of the Italian Society of Nephrology. [Peritoneal Dialysis in Italy: the 6th GSDP-SIN census 2016]. G Ital Nefrol. 2019 Jun 11;36 (3).
  6. Neri L, Viglino G, Vizzardi V, et al; Peritoneal Dialysis Study Group of the Italian Society of Nephrology. [Peritoneal Dialysis in Italy: the 7th GPDP-SIN census 2019]. G Ital Nefrol. 2022 May 11;36 (3).
  7. 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.
  8. Viglino G, Neri L, Alloatti S et al. Analysis of the factors conditioning the diffusion of peritoneal dialysis in Italy. Nephrol Dial Transpl 2007; 22:3601-5.
  9. Neri L, Viglino G, Vizzardi V, Porreca S, Mastropaolo C, Marinangeli G, Cabiddu G. Role of the Opinions of the Nephrologist and Structural Factors in Dialysis Modality Selection. Results of a Peritoneal Dialysis Study Group Questionnaire. G Ital Nefrol. 2024 Feb 28;41(1):2024-vol1. PMID: 38426674.
  10. Marshall MWG and Verger C. Peritoneal dialysis associated peritonitis rate – validation of a simplified formula. Bull Dial Domic 2012; 4(4): 245–257.
  11. Rianne Boenink, Marjolein Bonthuis, Brittany A Boerstra et al. The ERA Registry Annual Report 2022: Epidemiology of Kidney Replacement Therapy in Europe, with a focus on sex comparisons, Clinical Kidney Journal, 2024; https://doi.org/10.1093/ckj/sfae405.
  12. Neri L, Viglino G, Marinangeli G, et al; Peritoneal Dialysis Study Group of Italian Society of Nephrology. Italian Society of Nephrology Peritoneal Dialysis Study Group. Incremental start to PD as experienced in Italy: results of censuses carried out from 2005 to 2014. J Nephrol. 2017; 30:593-599.
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  14. Cheetham MS, Cho Y, Krishnasamy R, et al. Multicentre registry analysis of incremental peritoneal dialysis incidence and associations with patient outcomes. Peritoneal Dialysis International. 2023;43(5):383-394. doi:1177/08968608231195517
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News on Peritoneal Dialysis

Posted on Scarica PDF

DOI: 10.69097/41-s83-2024-14

Gianfranca Cabiddu, Antonello Pani, Nicola Lepori

A.R.N.A.S. Brotzu- Ospedale San Michele
Department of Medical Science and Public Health; University of Cagliari; Italy

Corresponding author:
Gianfranca Cabiddu
UO Nefrologia e Dialisi, A.R.N.A.S. Brotzu-Ospedale San Michele
Piazzale Ricchi, 1
09134 Cagliari, Italia
Telefono: 070539496
E-mail: cabiddugianfranca@gmail.com

 

Abstract

Among the recent advancements in Peritoneal Dialysis, the guidelines on the prevention and treatment of peritonitis, published in March 2022 by the International Society for Peritoneal Dialysis (ISPD), are of particular importance.
The ISPD periodically updates these guidelines, with the previous update dating back to 2016.
Peritonitis, despite its decreased incidence, remains a significant challenge in PD as it continues to be a major cause of morbidity, mortality, and dropout from the modality.
The 2022 ISPD guidelines update the previous recommendations and introduce new ones.
These recommendations are evidence-based where evidence is available.

Keywords: Guidelines, Peritoneal Dialysis, Peritonitis

Sorry, this entry is only available in Italiano.

Una tra le novità in tema di Dialisi Peritoneale (DP) è rappresentata dalla pubblicazione delle raccomandazioni sulla prevenzione e trattamento delle peritoniti. Nel 2022 la Società Internazionale di Dialisi Peritoneale (ISPD) ha pubblicato l’aggiornamento di tali raccomandazioni (la precedente pubblicazione risaliva al 2016).

Benché infatti l’incidenza della peritonite in DP sia diminuita, questa rimane tuttora una ‘spina nel fianco’ della metodica perché costituisce una importante causa di morbilità, mortalità e di drop out.

Come ci dimostrano anche i dati del censimento 2022 del Gruppo di Progetto di Dialisi Peritoneale della SIN (Figura 1).

Figura 1
Figura 1

 

Novità con l’aggiornamento 2022 delle linee guida ISPD sulle peritoniti  

Incidenza delle peritoniti. Vengono riviste ed aggiornate le raccomandazioni del 2016. L’incidenza di peritonite (riportata come episodi per paziente/anno) dovrebbe essere < 0,4 episodi per paziente/anno (1C). Si tratta di un miglioramento dello standard di 0,5 episodi/paziente/anno raccomandato nelle linee guida del 2016 (Figura 2).

Figura 2
Figura 2

Peritoniti a coltura negativa. Nel 2016 si suggeriva di rivedere i metodi di campionamento e coltura se più del 15% degli episodi di peritonite erano coltura negativa (2C). Nel 2022 si raccomanda una percentuale di peritoniti con coltura negativa < al 15% di tutti gli episodi di peritonite (1C).

Prevenzione delle peritoniti. Oltre alle già note misure di prevenzione ne vengono riviste ed introdotte delle nuove.
Vengono riviste precedenti raccomandazioni:

  1. Gestione della contaminazione dei sistemi PD. Viene suggerita la profilassi antibiotica dopo una wet contamination, riferito alla contaminazione con un sistema aperto (2D). Nel 2016 tale misura era not graded.
  2. Procedure invasive. Viene confermato il suggerimento circa la profilassi antibiotica prima della colonscopia (2C) e delle procedure invasive ginecologiche (2D). Si introduce il suggerimento che tali procedure vengano effettuate ad addome vuoto (2D).
  3. Training alla DP. Le linee guida del 2016 raccomandavano che il training fosse effettuato da personale infermieristico con adeguata esperienza (1C). Le nuove linee guida raccomandano che la tecnica di scambio e le conoscenze siano regolarmente rivalutate e aggiornate, con un’enfasi sull’ispezione diretta della pratica (1C).

Vengono introdotte nuove raccomandazioni:

  1. Animali domestici. Si raccomanda ai pazienti che posseggono animali domestici, di adottare precauzioni aggiuntive per prevenire la peritonite (1C). Si suggerisce, inoltre, che gli animali non siano ammessi nella stanza in cui ha luogo lo scambio dialitico e dove è stoccato il materiale di dialisi (2A).
  2. Fattori di rischio modificabili di peritonite (ipokaliemia, antagonisti dei recettori dell’istamina-2). Si suggerisce che evitare e trattare l’ipokaliemia possa ridurre il rischio di peritonite (2C). Si suggerisce che evitare o limitare l’uso degli antagonisti dei recettori dell’istamina-2 può prevenire la peritonite enterica (2C).

Terapia empirica delle peritoniti. Vengono aggiornate le raccomandazioni riguardanti la terapia antibiotica empirica.  Si conferma la terapia empirica raccomandata nel 2016. Per i Gram-positivi: cefalosporina di prima generazione o vancomicina; per i Gram-negativi: cefalosporina di terza generazione o aminoglicosidi (1B). Le linee guida del 2022 introducono il suggerimento che la monoterapia con cefepime possa essere un’alternativa accettabile per i regimi antibiotici empirici (2B). A proposito di tale opzione è importante comunque sottolineare che si tratta ancora di un suggerimento con un grado di evidenza 2B.

N-acetilcisteina.  Viene introdotto il suggerimento che l’aggiunta orale di N-acetilcisteina può aiutare a prevenire l’ototossicità degli aminoglicosidi (2B).

Successiva terapia delle peritoniti.  Vengono aggiornate le raccomandazioni per il trattamento della peritonite da determinati microrganismi:
Corynebacterium. Si suggerisce che la peritonite da Corynebacterium sia trattata con antibiotici efficaci per 2 settimane (2D). Le linee guida del 2016 suggerivano tre settimane di trattamento. Si suggerisce, inoltre, che la peritonite dovuta a ceppi beta-lattamasi resistenti come il Corynebacterium jeikeium sia trattato con vancomicina (2C).
Enterococcus Species. Le Linee guida 2022 rivedono le precedenti raccomandazioni e suggeriscono di trattare la peritonite enterococcica per 3 settimane con amoxicillina orale (per enterococchi sensibili all’ampicillina) o vancomicina intraperitoneale (2C).
Pseudomonas. Rispetto alle precedenti raccomandazioni si suggerisce che, se non c’è risposta clinica dopo 5 giorni di trattamento antibiotico appropriato, la peritonite da Pseudomonas deve essere trattata con la rimozione del catetere(2D).
Stenotrophomonas maltophilia. Vengono introdotte nuove indicazioni. Si suggerisce di trattare tale peritonite con due diverse classi di antibiotici, uno dei quali trimetoprim-sulfametossazolo, per almeno 3 settimane (2D).
Acinetobacter. Vengono introdotte nuove indicazioni. Si suggerisce che la peritonite da Acinetobacter resistente ai carbapenemi deve essere trattata con aminoglicosidi e un agente contenente sulbactam (2C).
Peritonite refrattaria. Viene rivista la raccomandazione riguardante la gestione della peritonite refrattaria (definita come mancata risposta dopo 5 giorni di terapia antibiotica appropriata). Rimane la raccomandazione che nella peritonite refrattaria il catetere sia rimosso (1D). Nelle precedenti linee guida il livello di evidenza era 1C. Si introduce infatti il suggerimento che un’osservazione più lunga di 5 giorni è appropriata se la conta dei globuli bianchi nell’effluente dialitico sta diminuendo verso la normalità (2C).

 

Bibliografia

  1. Li PK, et al. ISPD peritonitis recommendations: 2016 update on prevention and treatment. Perit Dial Int 36: 481–508, 2016
  2. Li PK, et al. ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment. Perit Dial Int. 2022;42(2):110–53.

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

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Loris Neri1, Giusto Viglino2, Valerio Vizzardi3, Silvia Porreca4, Claudio Mastropaolo5, Giancarlo Marinangeli6 e Gianfranca Cabiddu7 a nome del Gruppo di Progetto della Dialisi Peritoneale della Società Italiana di Nefrologia

1 Nefrologia e Dialisi, Ospedale “Michele e Pietro Ferrero”, Verduno, Cuneo, Italy
2 Referente per la Telemedicina dell’ASLCN2, Italy
3 Nefrologia e Dialisi, Spedali Civili, Brescia, Italy
4 Nefrologia e Dialisi, Policlinico Università A. Moro, Bari, Italy
5 Visionage SRL
6 UOC di Nefrologia e Dialisi, Ospedale di Giulianova, Teramo, Italy
7 ARNAS Brotzu, Università degli Studi di Cagliari, Italy

Corresponding author:
Loris Neri
SOC Nefrologia e Dialisi - Ospedale “Michele e Pietro Ferrero”, Via Tanaro 7 – Verduno (CN)
Telefono: 0172-140-8271
E-mail: lorisneri1960@gmail.com

 

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 [1–6]. 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) [10–13], 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 [17–19].

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 [20–21] 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

Posted on Scarica PDF

Gruppo di studio di dialisi peritoneale

Loris Neri1, Giusto Viglino1, Valerio Vizzardi2, Roberto Russo3, Carlo Taietti4, Silvia Porreca5, Antonino Ragusa6, Caudio Mastropaolo7, Giancarlo Marinangeli8, Gianfranca Cabiddu9, on behalf of the Peritoneal Dialysis Project Group of the Italian Society of Nephrology

1 Nefrologia e Dialisi, Ospedale “Michele e Pietro Ferrero”, Verduno, Cuneo, Italy
2 Nefrologia e Dialisi, Spedali Civili, Brescia, Italy
3 Nefrologia e Dialisi, Policlinico Università “Aldo Moro”, Bari, Italy
4 Nefrologia e Dialisi, ASST Bergamo Ovest – Treviglio, Bergamo, Italy
5 Nefrologia e Dialisi, Ospedale della Murgia “Fabio Perinei”, Bari, Italy
6 Nefrologia e Dialisi, Ospedale “San Vincenzo”, Taormina, Italy
7 Visionage SrL, Italy
8 Nefrologia e Dialisi, Ospedale “Maria SS dello Splendore”, Giulianova, Teramo, Italy
9 Dipartimento Scienze mediche e sanità pubblica - Università di Cagliari - ARNAS Brotzu - Cagliari

Corrispondenza a:
Loris Neri
Nefrologia e Dialisi - Ospedale “Michele e Pietro Ferrero”, Via Tanaro 7-9, Verduno (CN), Italy
Telefono 0172-140-8271
Email: lorisneri1960@gmail.com

 

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 Italiano.

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 [8–12].

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)

 

Bibliografia

  1. Marinangeli G, Cabiddu G, Neri L et al; Italian Society of Nephrology Peritoneal Dialysis Study Group. Old and new perspectives on peritoneal dialysis in Italy emerging from the Peritoneal Dialysis Study Group Census. Perit Dial Int 2012; 32:558-65, https://doi.org/3747/pdi.2011.00112.
  2. Marinangeli G, Cabiddu G, Neri L et al; Italian Society of Nephrology Peritoneal Dialysis Study Group. Andamento della DP in Italia nei Centri pubblici non pediatrici. Risultati del censimento GSDP-SIN 2010 e confronto con i censimenti 2008 e 2005. G Ital Nefrol 2014; 31(4), http://www.nephromeet.com/web/procedure/protocollo.cfm?List=WsIdEvento,WsIdRisposta,WsRelease&c1=00194&c2=14&c3=1
  3. Marinangeli G, Cabiddu G, Neri L et al; Italian Society of Nephrology Peritoneal Dialysis Study Group. Peritoneal Dialysis in Italy: the fourth GSDP-SIN census 2012. G Ital Nefrol 2017; 34(2), https://giornaleitalianodinefrologia.it/en/2017/04/la-dp-in-italia-il-censimento-del-gsdp-sin-2012-cs-12/.
  4. Marinangeli G, Neri L, Viglino G et al; Peritoneal Dialysis Study Group of Italian Society of Nephrology.PD in Italy: the 5th GSDP-SIN Census 2014. G Ital Nefrol 2018;35(5), https://giornaleitalianodinefrologia.it/en/2018/09/la-dialisi-peritoneale-in-italia-il-5-censimento-del-gsdp-sin-2014/.
  5. Neri L, Viglino G, Marinangeli G et al; Peritoneal Dialysis Study Group of the Italian Society of Nephrology. Peritoneal Dialysis in Italy: the 6th GSDP-SIN census 2016. G Ital Nefrol. 2019 Jun 11;36(3):2019-vol3.
  6. Viglino G, Neri L, Alloatti S et al. Analysis of the factors conditioning the diffusion of peritoneal dialysis in Italy. Nephrol Dial Transpl 2007; 22:3601-5, https://giornaleitalianodinefrologia.it/en/2019/05/la-dialisi-peritoneale-in-italia-il-6-censimento-del-gsdp-sin-2016/.
  7. Quintaliani G, Di Luca M, Di Napoli A et al. Census of the renal and dialysis units by Italian Society of Nephrology: structure and organization for renal patient assistance in Italy (2014-2015). G Ital Nefrol 2016; 33(5), https://giornaleitalianodinefrologia.it/en/2016/10/censimento-a-cura-della-societa-italiana-di-nefrologia.
  8. ERA-EDTA Registry Annual Report 2019. Academic Medical Center, Department of Medical Informatics, Amsterdam, the Netherlands, 2021, https://www.era-online.org/registry/AnnRep2019.pdf.
  9. USRDS Annual Data Report. Volume 2 – ESRD in the United States, https://www.usrds.org/media/2283/2018_volume_2_esrd_in_the_us.pdf.
  10. Ikuto Masakane, Masatomo Taniguchi, Shigeru Nakai et al. Annual Dialysis Data Report 2016, JSDT Renal Data Registry (JRDR). Renal Replacement Therapy 2018; 4:45, https://rrtjournal.biomedcentral.com/articles/10.1186/s41100-018-0183-6.
  11. Canadian Institute for Health Information. Canadian Organ Replacement Register. Annual Report: Treatment of End-Stage Organ Failure in Canada, Canadian Organ Replacement Register.
  12. ANZDATA – Australia and New Zealand Dialysis and Transplant Registry – Annual ANZDATA Report – Adelaide, South Australia, https://www.anzdata.org.au/anzdata/publications/reports/.
  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

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Loris Neri1, Giusto Viglino2, Giancarlo Marinangeli3, Annamaria D’Ostilio4, Massimo Matalone5, Antonio Ragusa6, Valerio Vizzardi7, Roberto Russo8, Gianfranca Cabiddu9, a nome del Gruppo di Studio Dialisi Peritoneale della Società Italiana di Nefrologia (on behalf of the Peritoneal Dialysis Study Group of the Italian Society of Nephrology)

1 Nefrologia e Dialisi, Ospedale San Lazzaro, Via Pierino Belli 26, Alba, Cuneo, Italy
2 Nefrologia e Dialisi, Ospedale San Lazzaro, Via Pierino Belli 26, Alba, Cuneo, Italy
3 Nefrologia e Dialisi, Ospedale Maria SS dello Splendore, Giulianova, Teramo, Italy
4 Nefrologia e Dialisi, Ospedale Maria SS dello Splendore, Giulianova, Teramo, Italy
5 Nefrologia e Dialisi, Azienda Ospedaliera Cannizzaro, Catania, Italy
6 Nefrologia e Dialisi, Ospedale San Vincenzo, Taormina, Italy
7 Nefrologia e Dialisi, Policlinico Università A. Moro, Bari, Italy
8 Nefrologia e Dialisi, Spedali Civili, Brescia, Italy
9 Nefrologia e Dialisi, Azienda Ospedaliera Brotzu, Cagliari, Italy

Corrispondenza a:
Loris Neri
SOC Nefrologia e Dialisi - Ospedale San Lazzaro, Via Pierino Belli 26 – Alba (CN)
Telefono 0173-316579
Fax 0173-316574
Email: lorisneri1960@gmail.com

 

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 Italiano.

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 [2–6].

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

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Giancarlo Marinangeli

Giancarlo Marinangeli1, Loris Neri2, Giusto Viglino3, Anna Rachele Rocca4, Alessandro Laudon5, Antonio Ragusa6, Gianfranca Cabiddu7. On behalf of Peritoneal Dialysis Study Group of Italian Society of Nephrology

1 Nefrologia e Dialisi, Ospedale Maria SS dello Splendore, Giulianova, Teramo, Italy.
2 Nefrologia e Dialisi, Ospedale San Lazzaro, Via Pierino Belli 26, Alba, Cuneo, Italy.
3 Nefrologia e Dialisi, Ospedale San Lazzaro, Via Pierino Belli 26, Alba, Cuneo, Italy.
4 Nefrologia e Dialisi, Policlinico Umberto I, Roma, Italy.
5 Nefrologia e Dialisi, Azienda Provinciale Servizi Sanitari, Trento, Italy.
6 Nefrologia e Dialisi, Ospedale San Vincenzo, Taormina, Italy.
7 Nefrologia e Dialisi, Azienda Ospedaliera Brotzu, Cagliari, Italy.

Autore Corrispondente:
Dott. Loris Neri
SOC Nefrologia e Dialisi
Ospedale San Lazzaro, Via Pierino Belli 26 – Alba (CN)
Telefono 0173-316579
Fax 0173-316574
E-mail: lorisneri1960@gmail.com

 

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 Italiano.

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 (2–5). 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

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Giancarlo Marinangeli

Giancarlo Marinangeli1, Gianfranca Cabiddu2, Loris Neri3,
Giusto Viglino3, Roberto Corciulo4, Anna Rachele Rocca5,
Alessandro Laudon6, Viviana Finato7. A nome del Gruppo di Studio Dialisi Peritoneale della SIN

(1) Ospedale Maria SS dello Splendore, Giulianova
(2) Azienda Ospedaliera Brotzu, Cagliari
(3) Ospedale San Lazzaro, Alba
(4) Università di Bari, Bari
(5) Policlinico Umberto I, Roma
(6) Azienda Provinciale Servizi Sanitari, Trento
(7) Ospedale degli Infermi, San Miniato

AUTORE CORRISPONDENTE
Loris Neri
Ospedale San Lazzaro,
SOC Nefrologia, Dialisi e Nutrizione Clinica
Via Pierino Belli 26 – Alba (CN)
Telefono 0173-316579
Telefono 333-3935557
Fax 0173-316574
Email: lorisneri1960@gmail.com

 

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 Italiano.

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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