Our study demonstrated that the overall risks of developing the first episode of peritonitis, technique failure, and mortality between the MDPC group and the non-MDPC group were not significant. However, diabetic PD patients receiving MDPC had a lower risk of mortality compared to those receiving the usual care.
MDPC for pre-dialysis CKD patients has been shown to be associated with a lower risk of all-cause mortality, a slower estimated glomerular filtration decline, and a decreased risk of progression to ESRD, a lower risk of hospitalization, more planned dialysis starts and a higher proportion of patients initiating dialysis with PD [10, 12, 14, 17]. A retrospective cohort study in the US evaluating 6978 elderly patients with CKD stage 3–5 not yet on dialysis demonstrated that MDPC was associated with a 50% reduction in the risk of death . An open-label, controlled cohort study from Taiwan also revealed that MDPC may decrease the risk of all-cause mortality and reduce the hazard of progression to ESRD for stage 3–5 pre-dialysis CKD patients . Similarly, a recent meta-analysis based on 21 studies also revealed that MDPC reduced the risk of all-cause mortality for patients with stage 4–5 pre-dialysis CKD .
The beneficial effects of MDPC might extend to the post-dialysis periods. A small prospective study in Canada including both HD and PD patients revealed that MDPC was associated with a lower risk of deaths after the initiation of dialysis independent of residual renal function, medication use, and laboratory data . A prospective study evaluated the effectiveness of MDPC for patients initiating dialysis at two tertiary care institutions in Vancouver of Canada and in Cremona of Italy . Patients in the MDPC group initiated dialysis at a higher estimated glomerular filtration rate, and had higher hemoglobin, albumin, and calcium compared to those in the non-MDPC group. The non-MDPC group were at an elevated risk of death with a HR of 2.17, compared to the MDPC group. A prospective study from Taiwan found that MDPC was significantly associated with a lower risk of getting the first episode of peritonitis in PD patients . A prospective study in Brazil compared the outcomes between early pre-dialysis care (90 days of follow-up by a nephrology team) and late pre-dialysis care (absent or less than 90 days) in a national cohort of 4107 incident PD patients . The results showed that early pre-dialysis care was associated with better patient survival, but the time to the first episode of peritonitis and technique survival were similar . However, this study failed to adjust residual renal function . In our study, patients in the MDPC group had a higher residual renal function than patients in the non-MDPC group. Thus, patients in the MDPC group were more likely to initiate dialysis earlier than those in the non-MDPC group. In our study, there was no significant difference in laboratory data of albumin, phosphate, hemoglobin, and glycated hemoglobin, distribution of comorbidities, and duration of break-in period between the two groups. In a model without adjustment for residual renal function, MDPC was associated with a lower risk of mortality. However, there was no significant difference between the two groups in risks of mortality after adjustment for residual renal function.
Diabetes is a major risk factor for peritonitis, technique failure, and mortality in PD patients [19, 20]. In other words, PD patients with diabetic have a worse prognosis than those without diabetes. In our study, the subgroup analysis demonstrated that PD patients with diabetes under the care of MDPC program had a much lower risk of mortality than those in the non-MDPC group.
Although care of PD patients after dialysis initiation are also multidisciplinary approach with involvement of nephrologists, dietitians, and nurses, there might be a legacy effect of MDPC. The positive effects of MDPC include selecting healthier PD candidate, adaptation of positive attitude toward illness, enablement of self-care technique, improvement in patient compliance with treatment, maintenance of a healthier lifestyle and greater understanding of PD complications.
The strength of this study is the use of a well-organized database of medical records collected in a recent decade with the sample size large enough to evaluate outcomes after a long follow-up period. There are limitations in this study. This study was observational and retrospective in design. In addition, the assignment of MDPC was up to the preference of physicians and patients. There might be a selection bias. However, multivariate analyses were preformed to reduce the bias.
In conclusion, patients in the MDPC group were more likely to initiate dialysis earlier than those in the non-MDPC group. There were no significant differences in time to the first episode peritonitis, and risks of technique failure and mortality between the MDPC group and the non-MDPC group. The MDPC program could reduce the risk of death for patients with diabetes, compared to those under the usual care.