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Increasing PD Utilization: Should Suitable Patients be Forced?

144 This issue of Peritoneal Dialysis International includes an article by Portolés et al. that suggests, based on a large Spanish experience, that lack of a patient’s free choice of modality is associated with worse peritoneal dialysis (PD) outcomes, including early mortality (1). The fundamental question of whether patients should be forced into less expensive dialysis modalities is a controversial ethical dilemma for nephrologists. However, like so many other clinical studies in nephrology, this study is imperfect and really only shines some murky light on the fate of patients that fail hemodialysis (HD) and are therefore obliged to do PD for medical reasons. It seems clear that patients approaching end-stage renal disease can be grouped into several broad categories. Some choose conservative therapy; others are eligible for early transplantation. Of those that wish to live on dialysis, there are some patients that have contraindications to PD and a few with contraindications to HD, but the great majority can do either method. It is this last group that generates the question of whether to force a home dialysis option. In contrast, the group described by Portolés et al. is different. It seems that these patients were unable to start or continue on HD, and so were obligated to do PD, but to say they were forced (with the implication that this was against their will) is just not correct. The title, the body of the article, the tables, and the figures would be more accurate if the authors had consitently labeled the group as “manditory (or obligatory) referral to PD,” as the authors have done in the abstract. It is important to point out that the analysis by forced choice may or may not have been a prespecified research question. Indeed, the criteria for assigning patients to the forced choice group are not precisely defined at all. Thus, the association described should be considered hypothesis-generating only. Nonetheless, it is not surprising that patients that are unable to do HD, or that have failed it, do relatively poorly. They are a self-selected subgroup with many negative characteristics that are different from their younger colleagues who have all options open to them. Thus, the real question is, How did they fare when compared to the only other option that was available, which was the discontinuation of dialysis? The blunt truth is INCREASING PD UTILIZATION: SHOULD SUITABLE PATIENTS BE FORCED?