The Impact Of Remote Monitoring On Standardized Clinical Outcomes Of Peritoneal Dialysis in The Department Of Nephrology

With the increasing demand and economic burden of renal replacement therapy worldwide. Updated data from the "ISN Global Kidney Health Atlas" (ISN-GKHA) shows that the global median incidence rate of renal failure is 146/million people and the median prevalence rate is 823/million people. At the same time, peritoneal dialysis and hemodialysis treatment costs are US$18,959/year and US$19,380/year respectively [1].

Click to Cistanche for kidney disease

Compared with hemodialysis, peritoneal dialysis has unique advantages such as home treatment, simple operation, lower cost, protection of residual renal function, and better quality of life and early survival rate for patients. Worldwide, peritoneal dialysis accounts for 9% of all renal replacement therapies and 11% of all dialysis treatments. The global median prevalence of peritoneal dialysis is 38.1/1 million people, with a regional variation of more than 5000 times. Half of all patients receiving peritoneal dialysis come from China, the United States, Mexico, and Thailand [2].

Data released by the United States Renal Registration System (USRDs) in 2022 show that among patients with end-stage renal disease, the proportion of peritoneal dialysis treatment reached 12.7%, an increase of 1.2% from 2019 (11.5%). Data from the China National Renal Data System (CNRDS) at the end of 2022 show that the total number of dialysis patients in mainland China has exceeded 1 million, including 140,544 patients undergoing peritoneal dialysis [3-4].

01 Research progress on standardized clinical outcomes of peritoneal dialysis

Based on the global epidemiological status of peritoneal dialysis, standardized clinical outcomes of peritoneal dialysis are divided into four categories: clinical outcomes, patient-reported outcomes, surrogate outcomes and other outcomes, of which clinical outcomes and patient-reported outcomes are the main outcomes. Clinical outcome advantages of peritoneal dialysis include better preservation of residual renal function, improved patient satisfaction, improved quality of life, better kidney transplant outcomes (transplant recipients), delayed need for vascular access (especially in young children) , strengthened anemia management, and reduce the risk of blood-borne and respiratory viral infections (including new SARS-CoV-2) [5].

The 2019 Standardized Outcomes in Nephrology-Peritoneal Dialysis (SONG-PD) initiative determines the hierarchy of peritoneal dialysis outcomes and the priority of reporting based on their level of importance to stakeholders: the core layer is the most important core outcome and should be included in all studies Reported; middle and outer layers are important to some or some groups and reported in some studies. Among them, core outcomes include peritoneal dialysis-related infections, cardiovascular disease, mortality, technical failure, and life participation [6-9].

Recently, a British scholar published a review titled "Delivering Person-Centered Peritoneal Dialysis" in CJASN, the top international journal of nephrology, summarizing the implementation of "person-centered" high-quality peritoneal dialysis prescription practice based on the latest ISPD recommendations. Methods of dialysis treatment, including remote patient monitoring (RPM) [9].

02 Automated peritoneal dialysis RPM (APD-RPM)

RPM refers to the use of various communication means such as telephones, mobile phones, and the Internet to transmit personal information of long-distance patients to relevant monitoring centers. After analysis by medical staff, patients or related personnel are notified in a timely manner and corresponding medical services are provided. The application of remote monitoring in chronic disease management has been used in recent years [10-12].

The new generation of APD machines has realized RPM functions to a certain extent: RPM usually consists of cloud servers, APD machines, and medical terminals to facilitate doctor-patient interaction, acquisition and integration of more complete information. The RPM system can also add patient-side application software and other peripheral devices that can automatically upload health information, such as blood pressure monitors, weight scales, etc. At the same time, it has functions such as information management, prescription adjustment, data transmission, automatic analysis, and online monitoring [13].

The implementation of telemonitoring includes data collection and transmission, as well as telephone or video-based support, although most of the evidence relates primarily to dialysis-related telemonitoring. Data-based patient remote monitoring mainly includes biometric data (blood pressure, pulse rate, weight) and treatment-related data (dialysate type, treatment duration, number of peritoneal dialysis fluid changes, cumulative ultrafiltration volume, machine alarms), which are stored on the remote server. Some of the data is collected automatically by APD machines, while some relies on patients or caregivers entering it using specialized devices or mobile apps. The data is then reviewed by healthcare professionals, which may trigger actions such as changing dialysis prescriptions remotely or directly supporting peritoneal dialysis patients over the phone or in person [14]. In the management of peritoneal dialysis, the management of complications is particularly important (Figure 3). Smart APD-RPM has obvious advantages in the following aspects [15]:

Volume overload: Remote intelligent APD treatment can assess the patient's volume status (blood pressure, weight, edema) in real time, guide the patient's dietary management, dialysis plan, drug treatment, etc., promptly correct the volume load, and reduce the occurrence of cardiovascular and cerebrovascular events.

Peritoneitis and catheter-related infections: Through the peritoneal dialysis filtrate, peritoneal dialysis catheter, and outlet images, the images are transmitted back to the medical terminal, which can promptly evaluate the situation and treatment effect of peritoneal dialysis-related peritonitis and catheter infections; for suspected infection cases, daily Follow up, find the cause, and treat it as soon as possible once diagnosed.

Catheter dysfunction: When the extraction volume is reduced, the extraction time is prolonged, or the extraction obstruction occurs, the remote intelligent APD machine will display a red alarm prompt on the medical terminal, especially for several consecutive days. Medical personnel should analyze all data and images in a timely manner. , contact the patient to inquire about the condition, and if necessary, use imaging examinations to check for catheter end displacement, catheter blockage or other dysfunction, early detection, and timely treatment.

The 2020 ISPD Guidelines point out a direction for clinical practice, that is, RPM is an important measure for closed-loop management of peritoneal dialysis prescriptions, which is helpful for the practice and achievement of high-quality peritoneal dialysis [16].

03 Effect of RPM on clinical outcomes of peritoneal dialysis

Regarding the clinical outcomes of patients with APD-RPM, there are relevant reports in many studies from various countries.

1. Case fatality rate and technical survival

Several studies have shown that the survival rate of peritoneal dialysis patients is not inferior to that of hemodialysis [17]. Studies have shown that APD treatment, especially APD treatment with RPM function, has a survival advantage. In 2023, a Spanish multicenter retrospective observational cohort study was published at the American Society of Nephrology Kidney Week, which included 232 patients from 16 hospitals and used propensity score matching to reduce baseline shifts to improve APD-RPM and APD- There was no comparability between patients treated with RPM. The results showed that before PAM, APD-RPM was associated with lower mortality and higher technical survival compared with APD-no RPM; after PSM, APD-RSM was still associated with higher technical survival [18]. 1 study conducted a meta-analysis and systematic review on the outcomes of remote management of peritoneal dialysis patients (RPM-PD) during the COVID-19 epidemic. The study searched PubMed, Embase and Cochrane databases, and a total of 22 studies were included. Quantitative analysis of the study showed that compared with traditional peritoneal dialysis management, RPM-PD patients had lower technical failure rates (log RR = -0.32; 95% CI, -0.59 to -0.04) and lower hospitalization rates (standardized mean difference =-0.84; 95%CI, -1.24～-0.45) and lower case fatality rate (log RR=-0.26; 95%CI, -0.44～-0.08). This result confirms that RPM-PD is superior to traditional management in various outcomes and may improve risk resistance during medical service interruptions [19].

At the ASN2021 conference, a Mexican randomized controlled study included 417 RPM-APD and 398 APD patients. The results showed that through competing risk analysis, APD treatment with RPM can reduce the risk of all-cause death (APDvs. APD-RPM: sHR 1.79, 95%Cl, 1.15～2.81, P=0.01), cardiovascular-related death risk (APDvs.APD-RPM: sHR 1.74, 95%Cl, 1.34～2.25, P=0.01), while prolonging the time to the first AE. [20].

2. Hospitalization rate and length of hospitalization

A multicenter, retrospective cohort study in Colombia included 360 patients using APD, divided into 65 patients in the APD-RPM cohort and 295 patients in the APD-no RPM cohort. The patients were followed up for 1 year after APD treatment, and the hospitalization rate and length of stay were recorded. After patients were matched by 1:1 propensity score (63 patients in each cohort), the hospitalization rate and length of stay in the two groups were evaluated. The results showed that the annual hospitalization rate of patients in the APD-RPM group was reduced by 39%, and the annual hospitalization days were reduced by nearly 1 week [21].

3. Optimize treatment plans and improve patient outcomes

A multicenter retrospective observational cohort study in Colombia included 49 patients with end-stage renal disease in 46 clinics from October 2016 to May 2017. Compare APD with RPM and APD without RPM (RPM platform is Sharesource) to analyze the impact of RPM exposure and clinical treatment effects. The results showed that compared with APD without RPM, the APD with RPM group had more prescription adjustments, more preventive consultations, and lower diastolic blood pressure [22].

4. Intervention for Catheter Problems

A case report from Switzerland reported that a 23-year-old patient with end-stage renal disease had abnormal drainage during treatment with APD-RPM (dialysate injection time was normal, drainage time was significantly prolonged, and drainage volume was significantly reduced). After the medical staff discovered the problem, they judged that the catheter might be displaced and promptly contacted the patient for further examination. It was confirmed that the catheter was displaced and conservative treatment was ineffective. The problem of catheter displacement was finally solved through laparoscopy. The patient was followed up for 6 months and the phenomenon did not reappear [23].

5. Quality of life score

The results of an Italian retrospective cohort study in 2020 showed that compared with APD treatment without RPM, APD-RPM treatment can significantly improve patient's quality of life scores during treatment (APD-RPM vs. APD 100.00 vs. 87.50, P=0.018) [ twenty four].

04 Summary and Outlook

The ideal peritoneal dialysis remote monitoring platform should take into account both practicality and ease of use. It should be composed of a video call function, vital signs and peritoneal dialysis treatment parameter monitoring function, data management and analysis system, etc. It can provide regular health education, remote guidance, and standardized operations, and It helps to reduce the occurrence of related complications such as peritonitis and volume overload, and reduces the readmission rate to improve the prognosis.

"Person-centered" dialysis treatment goes beyond a simple dialysis prescription but is a personalized, collaborative, and empowering treatment and care model for kidney disease patients. By implementing RPM and evaluating patient-reported clinical outcomes, we can ensure that the focus of peritoneal dialysis care shifts from treating the disease to treating the people with the disease.

How Does Cistanche Treat Kidney Disease?

Cistanche is a traditional Chinese herbal medicine used for centuries to treat various health conditions, including kidney disease. It is derived from the dried stems of Cistanche deserticola, a plant native to the deserts of China and Mongolia. The main active components of cistanche are phenylethanoid glycosides, echinacoside, and acteoside, which have been found to have beneficial effects on kidney health.

Kidney disease, also known as renal disease, refers to a condition in which the kidneys are not functioning properly. This can result in a buildup of waste products and toxins in the body, leading to various symptoms and complications. Cistanche may help treat kidney disease ase through several mechanisms.

Firstly, cistanche has been found to have diuretic properties, meaning it can increase urine production and help eliminate waste products from the body. This can help relieve the burden on the kidneys and prevent the buildup of toxins. By promoting diuresis, cistanche may also help Reduce high blood pressure, a common complication of kidney disease.

Moreover, cistanche has been shown to have antioxidant effects. Oxidative stress, caused by an imbalance between the production of free radicals and the body's antioxidant defenses, plays a key role in the progression of kidney disease. ies help neutralize free radicals and reduce Oxidative stress, thereby protecting the kidneys from damage. The phenylethanoid glycosides found in cistanche have been particularly effective in scavenging free radicals and inhibiting lipid peroxidation.

Additionally, cistanche has been found to have anti-inflammatory effects. Inflammation is another key factor in the development and progression of kidney disease. Cistanche's anti-inflammatory properties help reduce the production of pro-inflammatory cytokines and inhibit the activation of inflammation mandatory pathways, thus alleviating inflammation in the kidneys.

Furthermore, cistanche has been shown to have immunomodulatory effects. In kidney disease, the immune system can be dysregulated, leading to excessive inflammation and tissue damage. Cistanche helps regulate the immune response by modulating the production and activity of immune cells, such as T cells and macrophages. This immune regulation helps reduce inflammation and prevent further damage to the kidneys.

Moreover, cistanche has been found to improve renal function by promoting the regeneration of renal tubes with cells. Renal tubular epithelial cells play a crucial role in the filtration and reabsorption of waste products and electrolytes. In kidney disease, these cells can be damaged, leading to damaged renal function. Cistanche's ability to promote the regeneration of these cells helps restore proper renal function and improve overall kidney health.

In addition to these direct effects on the kidneys, cistanche has been found to have beneficial effects on other organs and systems in the body. This holistic approach to health is particularly important in kidney disease, as the condition often affects multiple organs and systems. che has been shown to have protective effects on the liver, heart, and blood vessels, which are commonly affected by kidney disease. By promoting the health of these organs, cistanche helps improve overall kidney function and prevent further complications.

In conclusion, cistanche is a traditional Chinese herbal medicine used for centuries to treat kidney disease. Its active components have diuretic, antioxidant, anti-inflammatory, immunomodulatory, and regenerative effects, which help improve renal function and protect the kidneys from further damage. , cistanche has beneficial effects on other organs and systems, making it a holistic approach to treating kidney disease.