Peritoneal Dialysis in Croatia

Objective To present the state of renal replacement therapy (RRT) in Croatia, assess the quality of dialytic treatment, verify the value of peritoneal dialysis (PD), and promote expansion of PD in Croatia based on results attained locally. According to the integrative care concept, PD is the best way to start life-long RRT. Croatian nephrologists have adopted the policy of increasing the use of PD. However, evidence for recommendations were obtained in specific circumstances and might not be relevant elsewhere. The aim of this observational study is to compare the outcome of PD with that of hemodialysis (HD), as practiced in Croatia. Methods Since 2000, the Croatian Registry for Renal Replacement Therapy has been collecting individual patient data for all patients on RRT, with complete coverage. Results As of 31 December 2004, there were 251 prevalent patients on PD (continuous ambulatory PD and automated PD) in Croatia, accounting for 7% of all patients on RRT and giving a prevalence of 57 patients per million population. From 1 January 2000 to 31 December 2004, 377 patients started PD and were followed from the first day of RRT. For 80% of them, PD was the first mode of RRT. The probability of staying on PD for 5 years was 31% [95% confidence interval (CI) 29 - 32]. Five-year technique survival (excluding transplanted, recovered, and deceased patients) was 68% (95%CI 65 - 70). For survival analysis and comparison between PD and HD, only patients on the same method from the start of their RRT were included. Patients changing treatment were censored after 60 days (intention-to-treat analysis). Unadjusted 5-year survival in the PD-first group (301 patients) was 60% (95%CI 54 - 65), which is significantly better than in the 2789 HD-first patients (42%, 95%CI 40 – 44; log-rank p < 0.0001). When data were stratified for age and diabetes, 5-year mortality rates on HD were higher in all strata. Only in patients ≥ 70 years old was the advantage of PD less impressive. Standardized mortality ratio was 1.85 ( p < 0.01) in favor of PD. Hazard ratio of HD versus PD was 2.1 (95%CI 1.6 – 2.8). After adjustments for age, gender, diabetes, and nephroangiosclerosis, the hazard ratio settled at 1.5 (95%CI 1.1 – 1.9). Conclusion In Croatia, PD is used mostly as the first RRT. Almost one third of patients continue PD for 5 years due to good patient and technique survival. Starting RRT with PD offers 50% superior 5-year survival in comparison to HD. Dialysis patients in Croatia would benefit from an expanded PD program.