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Peritoneal Dialysis: PD: A Viable Renal Replacement Therapy Option (Lecture)

The number of patients with end stage renal disease requiring dialysis has increased markedly over the last decade and continues to grow at an alarming rate in the United States. Of the currently available dialysis options for end stage renal disease (hemodialysis and peritoneal dialysis), peritoneal dialysis (PD) is underutilized in the USA for non-medical reasons. Early recognition of CKD and timely referral to nephrologist when glomerular filtration rate approaches 30 ml/min/1.73m is extremely important to improve ESRD outcome and appropriate selection of dialysis modality. Peritoneal dialysis (PD) remains a viable treatment option for ESRD patients. PD is the less expensive dialysis modality and may provide a survival advantages over hemodialysis in first 2-4 years of treatment, but that advantage is not as robust with increasing age and with presence of diabetes. Preserving residual renal function is of paramount importance to prolong the survival outcomes in PD patients. Judicial use of prophylactic antibiotics to prevent peritonitis would help to reduce morbidity from PD. The initial survival advantage is lost in long-term PD mainly due to changes in peritoneal membrane from long-term toxic and metabolic effects of the conventional glucose-based solutions. Current data suggests that not many patients continue on PD beyond ten years. Recent development of more biocompatible PD solution should help to preserve membrane function, promote ultrafiltration, improve nutritional status and hopefully prolong the survival advantage of PD. Identification of molecular mechanisms involved in cellular responses leading to peritoneal fibrosis and angiogenesis, evoke new therapeutic strategies that might protect peritoneal membrane against the consequences of long-term PD. References 1. United States Renal Data System, Annual Data Report 2003, Bethesda. MD. 2. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification and stratification. Kidney disease outcome quality initiative. Am J Kidney Dis 2002; 39: S1-246. 3. Jansen MA, Hart AA, Korevaar, JC, Dekker FW, Boeschoten EW, Krediet RT. Predictor of rate of decline of residual renal function in incident dialysis patients. Kidney Int 2002; 62: 1046-53. 4. Keane WF, Bailie GR, Boeschoten E, Gokal R, Golper TA, Holmes CJ, et al. Adults peritoneal dialysis-related peritonitis treatment recommendations: 2000 update. Perit Dial Int 2000; 20: 396-411. 5. Bargman JM, Thorpe KE, Churchill DN. Relative contribution of residual renal function and peritoneal clearance of adequacy of dialysis: A reanalysis of the CANUSA study. J Am Soc Nephrol 2001; 12: 2158-62. 6. Collins, AJ, Hao W, Xia H, Ebben JP, Everson SF, Constantini EG, Ma JZ. Mortality risks of peritoneal dialysis and hemodialysis. Am J Kidney Dis 1999; 34: 1065-74. 7. Fenton, SSA, Schaubel DE, Desmeules, M, Morrison HI, Mao Y, Copleston P, et al. Hemodialysis versus peritoneal dialysis: A comparison of adjusted mortality rates. Am J Kidney Dis 1997; 30: 334-42. 8. Vonesh EF, Snyder JJ, Foley RN, Collins AJ. The differential impact of risk factors on mortality in hemodialysis and peritoneal dialysis. Kidney Int 2004; 66: 2389-401. 9. Stack AG. Impact of timing of nephrology referral and pre-ESRD care on mortality risk among new ESRD patients in the United States. Am J Kidney Dis 2003; 41: 310-8. 10. Mortier S, Faict D, Schalkwijk CG, Lameire NH, Vriese ASD. Long-term exposure to new peritoneal dialysis solutions: Effects on the peritoneal membrane. Kidney Int 2004; 66: 1257-65.