Multicenter registry analysis of center characteristics associated with technique failure in patients on incident peritoneal dialysis

Abstract

Background and objectives Technique failure is a major limitation of peritoneal dialysis. Our study aimed to identify center- and patient-level predictors of peritoneal dialysis technique failure. Design, setting, participants, & measurements All patients on incident peritoneal dialysis in Australia from 2004 to 2014 were included in the study using data from the Australia and New Zealand Dialysis and Transplant Registry. Center- and patient-level characteristics associated with technique failure were evaluated using Cox shared frailty models. Death-censored technique failure and cause-specific technique failure were analyzed as secondary outcomes. Results The study included 9362 patients from 51 centers in Australia. The technique failure rate was 0.35 (95% confidence interval, 0.34 to 0.36) episodes per patient-year, with a sevenfold variation across centers that was mainly associated with center-level characteristics. Technique failure was significantly less likely in centers with larger proportions of patients treatedwith peritoneal dialysis (>29%; adjusted hazard ratio, 0.83; 95%confidence interval, 0.73 to 0.94) andmore likely insmaller centers (<16newpatientsper year; adjustedhazard ratio, 1.10; 95% confidence interval, 1.00 to 1.21) and centers with lower proportions of patients achieving target baseline serum phosphate levels (<40%; adjusted hazard ratio, 1.15; 95% confidence interval, 1.03 to 1.29). Similar results were observed for death-censored technique failure, except that center target phosphate achievement was not significantly associated. Technique failure due to infection, social reasons, mechanical causes, or death was variably associated with center size, proportion of patients on peritoneal dialysis, and/or target phosphate achievement, automatedperitoneal dialysis exposure, icodextrin use, andantifungal use. The variation of hazards of technique failure across centerswas reducedby 28%after adjusting forpatient-specific factors andan additional 53% after adding center-specific factors. Conclusions Technique failurevarieswidelyacross centers inAustralia.Asignificantproportionof thisvariationis related to potentially modifiable center characteristics, including peritoneal dialysis center size, proportion of patients on peritoneal dialysis, and proportion of patients on peritoneal dialysis achieving target phosphate level.