Impact of telemedicine on metabolic control and hospitalization of peritoneal dialysis patients during the COVID-19 pandemic: a national multicentric cohort study

Abstract Introduction: The coronavirus-19 pandemic threatens the lives of all people, but results in higher mortality rates for patients with end-stage kidney disease (ESKD) including those on peritoneal dialysis (PD). Telemedicine was the main alternative to reduce exposure to the virus, but it was introduced in the Brazil without proper training. Objective: To investigate the impact of telemedicine on metabolic control, peritonitis rates, and hospitalization in PD patients during the pandemic. Methods: This was a retrospective multicenter cohort study. We included all adult patients on chronic PD from 9 clinics selected by convenience during the pandemic. The outcomes of interest were measured and compared between before and after switching to telemedicine using repeated measure analysis and multilevel Poisson regression. Results: The study included 747 patients with a mean age of 59.7±16.6 years, of whom 53.7% were male and 40.8% had diabetes. Biochemical parameters including hemoglobin, potassium, phosphate, calcium, and urea serum levels did not change significantly after transition to telemedicine. There was no association between telemedicine and peritonitis rates. In contrast, hospitalization rates increased significantly in the telemedicine period. The incidence rate ratio (IRR) for hospitalization in the telemedicine period was 1.54 (95%CI 1.10-2.17; p 0.012) and 1.57 (95%CI 1.12-2.21; p 0.009) in the mixed-effects Poisson regression before and after adjustment for the presence of confounders. Admissions for hypervolemia and infections not related to PD doubled after transition to telemedicine. Conclusion: The implementation of telemedicine without proper training may lead to an increase in adverse events in PD patients.

摘要
引言：新型冠状病毒（COVID-19）大流行威胁全人类生命健康，终末期肾病（end-stage kidney disease, ESKD）患者（包括接受腹膜透析（peritoneal dialysis, PD）者）的死亡率更高。远程医疗（telemedicine）是减少病毒暴露的主要替代方案，但巴西在推行该模式时未开展规范培训。
研究目的：探究大流行期间，远程医疗对腹膜透析患者代谢控制、腹膜炎发生率及住院率的影响。
研究方法：本研究为回顾性多中心队列研究。于疫情期间通过便利抽样选取9家诊所的全部慢性腹膜透析成年患者作为研究对象。采用重复测量分析与多层泊松回归，对比切换至远程医疗前后的目标结局指标。
研究结果：本研究共纳入747例患者，平均年龄为59.7±16.6岁，其中53.7%为男性，40.8%合并糖尿病。切换至远程医疗后，患者的血清血红蛋白、钾、磷、钙及尿素水平等生化指标无显著变化；远程医疗与腹膜炎发生率无显著关联。与之相反，远程医疗阶段的住院率显著升高。经混合效应泊松回归分析，校正混杂因素前后，远程医疗阶段的住院发病风险比（incidence rate ratio, IRR）分别为1.54（95%置信区间：1.10~2.17；P=0.012）和1.57（95%置信区间：1.12~2.21；P=0.009）。切换至远程医疗后，因高血容量及与腹膜透析无关的感染所致的住院人次翻倍。
研究结论：未经规范培训即推行远程医疗，可能会增加腹膜透析患者的不良事件发生风险。