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Underutilization of peritoneal dialysis.

CONSIDERABLE PROGRESS HAS BEEN MADE DURING THE past decade in the practice and theory of peritoneal dialysis for end-stage renal disease (ESRD). One previous major concern was whether peritoneal dialysis could deliver enough clearance to meet targets for adequacy of dialysis. Patients can be divided into low and high peritoneal transport categories depending on measured clearance rates. Anuric “low transporters” were considered at particular risk for underdialysis. However, epidemiological studies showed paradoxically lower morbidity and mortality in this group. High transporters, while easily achieving conventional dialysis targets, were characterized by ultrafiltration failure (due to rapid loss of glucose, and thereby osmotic pressure, from the dialysis fluid), hypertension, excess peritoneal loss of albumin, and excess mortality. Two solutions to this problem have been discovered. First, the widespread introduction of automated peritoneal dialysis, whereby dialysis fluid is exchanged frequently while the patient is asleep, improves ultrafiltration and reduces even further the time that the patient needs to devote to dialysis procedures, since daytime exchanges are often not required. Most patients, even those who are anuric, are suited to automated peritoneal dialysis. Second, the introduction of icodextrin dialysis fluid, containing a polyglucose that maintains a long-term osmotic pressure gradient, has reduced the problem of negative ultrafiltration during the night exchange or long day exchanges. On another front, improvements in connector technology and training techniques have reduced peritonitis frequency, such that episodes per patient of less than 1 per 24 months are now the norm. The introduction of biocompatible peritoneal dialysis fluids has reduced dialysis discomfort and promises further reduction in peritonitis frequency and better long-term preservation of peritoneal function. Some epidemiological studies have shown an adjusted survival advantage for peritoneal dialysis compared with hemodialysis during the first 2 years of dialysis. This may be real, possibly due to better preservation of residual renal function, or may be an artifact due to differences in patient selection. However, a recently published randomized controlled trial found a significant survival advantage for patients who received peritoneal dialysis. A reasonable conclusion therefore is that peritoneal dialysis is at least as good an initial therapy as center or satellite hemodialysis for all patient groups, with the possible exception of elderly diabetic patients. Home hemodialysis is a special case, but since it requires higher intellectual functioning, more time, greater training requirements, and frequent home assistance, it is infrequently used in most centers since the advent of peritoneal dialysis. Technique failure rates for peritoneal dialysis at 7% to 11% per year are generally higher than for hemodialysis, either due to patient “burn-out” (reduced motivation due to increasing morbidity), recurrent peritonitis, or peritoneal membrane failure. The “integrated care” approach to ESRD does not consider this relatively higher failure rate to be a contraindication. This concept advocates that hemodialysis, peritoneal dialysis, and renal transplantation should all be offered to the patient in an unbiased way, and that all 3 modalities may be a part of treatment during the patient’s lifetime. For many, peritoneal dialysis will be a reasonable initial choice, hopefully followed by renal transplantation, but otherwise with timely conversion to hemodialysis should complications arise from peritoneal dialysis. Peritoneal dialysis is an efficient and less expensive dialysis modality that can be tailored to the individual patient’s clinical and social requirements. It permits a high degree of social rehabilitation and travel freedom. Given an informed choice, approximately half of patients will choose peritoneal dialysis. However, some 20% of patients will a priori be unsuitable for peritoneal dialysis either due to abdominal problems (eg, hernias, multiple operations), physical disabilities (eg, hemiparesis), or psychological problems (eg, dementia, noncompliance), so overall rates of newly initiated peritoneal dialysis cannot be expected to be as high. In this issue of THE JOURNAL, Rubin et al present findings from their study showing that peritoneal dialysis patients rate their care higher than hemodialysis patients do. After adjusting for case mix, patients receiving peritoneal