Peritoneal dialysis patient selection: characteristics for success

Multiple Complications of Crohn's Disease and the Need for Early and Continuous Multidisciplinary Undertaking

Crohn's disease is an inflammatory disease that typically affects the bowels but can also have many different extraintestinal manifestations. One of those complications is immunoglobulin A nephropathy (IgAN), which is one of the most encountered renal lesions in the setting of Crohn's disease. Another point of focus for Crohn's patients is the risk of cancer, with a higher risk of colorectal cancer but also extraintestinal neoplasia such as hepatobiliary, hematological, and urinary tract neoplasia. We present the case of a young patient suffering from long-term Crohn's disease and subsequent IgAN leading to end-stage kidney disease and hemodialysis. The patient was diagnosed young and had undergone multiple surgeries and different treatments in various countries. He then presented in our center already with advanced chronic renal failure from IgAN that was unknown due to poor multidisciplinary follow-up. Shortly after starting hemodialysis, he developed a large abdominal mass, first thought to result from Crohn's-related fistula. This mass turned out to be a urachal adenocarcinoma, a rare type of bladder cancer with an especially poor prognosis. It is not known whether this type of cancer is associated with either Crohn's disease or IgAN, and no such association has been previously described. The treatment of urachal cancer usually relies on surgery, with the addition of chemotherapy in some cases. Unfortunately for our patient, his case was already so advanced at the moment of diagnosis that he was excluded from curative treatment and quickly passed away thereafter. This case illustrates many important aspects of the rigorous follow-up that is needed for Crohn's patients, with regular check-ups, screening investigations, and the need for multidisciplinary evaluation. Furthermore, it describes the development of a rare type of cancer in the setting of Crohn's disease and IgAN, with no prior established link between these different pathologies.

Peritoneal dialysis outcomes in a tertiary-level state hospital in Johannesburg, South Africa: Ethnicity and HIV co-infection do not increase risk of peritonitis or discontinuation

BACKGROUND

Peritoneal dialysis (PD) is a valuable means to increase access to kidney replacement therapy in South Africa (SA). An increased rate of modality discontinuation related to an increased risk of peritonitis in patients of black African ethnicity, in those with diabetes and in those living with HIV has previously been suggested, which may lead to hesitancy in adoption of 'PD first' programmes.

OBJECTIVES

To analyse the safety of a PD-first programme in terms of 5-year peritonitis risk and patient and modality survival at the outpatient PD unit at Helen Joseph Hospital, Johannesburg.

METHODS

After exclusions, clinical data from 120 patients were extracted for analysis. The effects of patient age at PD initiation, ethnicity, gender, diabetes mellitus and HIV infection on patient and modality survival and peritonitis risk were analysed using Cox proportional hazards modelling and logistic regression analysis. Five-year technique and patient Kaplan-Meier survival curves for peritonitis and comorbidity groups were compared using the Cox-Mantel test. The Mann-Whitney U-test and Fisher's exact test were used to compare continuous and categorical variables where appropriate.

RESULTS

Five-year patient survival was 49.9%. Black African ethnicity was associated with reduced mortality hazard (hazard ratio (HR) 0.33; 95% confidence interval (CI) 0.15 - 0.71; p=0.004), and patients with diabetes had poorer 5-year survival (19.1%; p=0.097). Modality survival at 5 years was 48.1%. Neither Black African ethnicity nor HIV infection increased the risk of PD discontinuation. Peritonitis was associated with increased modality failure (HR 2.99; 95% CI 1.31 - 6.87; p=0.009). Black African ethnicity did not increase the risk of peritonitis. HIV was not independently associated with an increased risk of peritonitis. Patient and PD survival were generally similar to other contemporaneous cohorts, and the peritonitis rate in this study was within the International Society for Peritoneal Dialysis acceptable range.

CONCLUSION

PD is a safe and appropriate therapy in a low socioeconomic setting with a high prevalence of HIV infection. Consideration of home circumstances and training in sterile technique reduce peritonitis risk and improve PD modality survival. Patients with diabetes may be at risk of poorer outcomes on PD.

A Comparison of US Medicare Expenditures for Hemodialysis and Peritoneal Dialysis

BACKGROUND

Observations that peritoneal dialysis (PD) may be an effective, lower-cost alternative to hemodialysis for the treatment of ESKD have led to policies encouraging PD and subsequent increases in its use in the United States.

METHODS

In a retrospective cohort analysis of Medicare beneficiaries who started dialysis between 2008 and 2015, we ascertained average annual expenditures (for up to 3 years after initiation of dialysis) for patients ≥67 years receiving in-center hemodialysis or PD. We also determined whether differences in Medicare expenditures across dialysis modalities persisted as more patients were placed on PD. We used propensity scores to match 8305 patients initiating PD with 8305 similar patients initiating hemodialysis.

RESULTS

Overall average expenditures were US$108,656 (2017) for hemodialysis and US$91,716 for PD (proportionate difference, 1.11; 95% confidence interval [CI], 1.09 to 1.13). This difference did not change over time (P for time interaction term=0.14). Hemodialysis had higher estimated intravenous (iv) dialysis drug costs (1.69; 95% CI, 1.64 to 1.73), rehabilitation expenditures (1.35; 95% CI, 1.26 to 1.45), and other nondialysis expenditures (1.34; 95% CI, 1.30 to 1.37). Over time, initial differences in total dialysis expenditures disappeared and differences in iv dialysis drug utilization narrowed as nondialysis expenditures diverged. Estimated iv drug costs declined by US$2900 per patient-year in hemodialysis between 2008 and 2014 versus US$900 per patient-year in PD.

CONCLUSIONS

From the perspective of the Medicare program, savings associated with PD in patients ≥67 years have remained unchanged, despite rapid growth in the use of this dialysis modality. Total dialysis expenditures for the two modalities converged over time, whereas nondialysis expenditures diverged.

How To Build a Successful Urgent-Start Peritoneal Dialysis Program

In-center hemodialysis (HD) remains the predominant dialysis therapy in patients with ESKD. Many patients with ESKD present in late stage, requiring urgent dialysis initiation, and the majority start HD with central venous catheters (CVCs), which are associated with poor outcomes and high cost of care. Peritoneal dialysis (PD) catheters can be safely placed in such patients with late-presenting ESKD, obviating the need for CVCs. PD can begin almost immediately in the recumbent position, using low fill volumes. Such PD initiations, commencing within 2 weeks of the catheter placement, are termed urgent-start PD (USPD). Most patients with an intact peritoneal cavity and stable home situation are eligible for USPD. Although there is a small risk of PD catheter-related mechanical complications, most can be managed conservatively. Moreover, overall outcomes of USPD are comparable to those with planned PD initiations, in contrast to the high rate of catheter-related infections and bacteremia associated with urgent-start HD. The ongoing coronavirus disease 2019 pandemic has further exposed the vulnerability of patients with ESKD getting in-center HD. PD can mitigate the risk of infection by reducing environmental exposure to the virus. Thus, USPD is a safe and cost-effective option for unplanned dialysis initiation in patients with late-presenting ESKD. To develop a successful USPD program, a strong infrastructure with clear pathways is essential. Coordination of care between nephrologists, surgeons or interventionalists, and hospital and PD center staff is imperative so that patient education, home visits, PD catheter placements, and urgent PD initiations are accomplished expeditiously. Implementation of urgent-start PD will help to increase PD use, reduce cost, and improve patient outcomes, and will be a step forward in fostering the goal set by the Advancing American Kidney Health initiative.

Peritoneal dialysis patient selection from a comorbidity perspective

Despite many medical and socioeconomic advantages, peritoneal dialysis (PD) is an underutilized dialysis modality that in most countries is used by only 5%-20% of dialysis patients, while the vast majority are treated with in-center hemodialysis. Several factors may explain this paradox, such as lack of experience and infrastructure for training and monitoring of PD patients, organizational issues, overcapacity of hemodialysis facilities, and lack of economic incentives for dialysis centers to use PD instead of HD. In addition, medical conditions that are perceived (rightly or wrongly) as contraindications to PD represent barriers for the use of PD because of their purported potential negative impact on clinical outcomes in patients starting PD. While there are few absolute contraindications to PD, high age, comorbidities such as diabetes mellitus, obesity, polycystic kidney disease, heart failure, and previous history of abdominal surgery and renal allograft failure, may be seen (rightly or wrongly) as relative contraindications and thus barriers to initiation of PD. In this brief review, we discuss how the presence of these conditions may influence the strategy of selecting patients for PD, focusing on measures that can be taken to overcome potential problems.

Foreign Perspective on Achieving a Successful Peritoneal Dialysis-First Program

Podcast

This article contains a podcast at https://www.asn-online.org/media/podcast/K360/2020_07_30_KID0000712019.mp3.

Tenckhoff Catheter Insertion by Nephrologists: Open Dissection Technique

Background

The practice of Tenckhoff catheter insertion by nephrologists remains uncommon in most countries.

Methods

We report our single-center experience of Tenckhoff catheter insertion by nephrologists using the open dissection surgical technique in a dedicated ward-based procedure room.

Results

Between November 2005 and September 2008, 250 peritoneal catheters were inserted by 6 nephrologists with varying levels of experience. Surgical dissection followed by exposure of the peritoneum under direct vision was performed under local anesthesia. Primary catheter failure, as defined by catheters that failed to function within 1 month after insertion, occurred in 2.8% of cases. Within 1 month of catheter insertion, 20 patients developed infectious complications: 9 (3.6%) peritonitis, and 11 (4.4%) exit-site infections; none of these complications led to catheter removal. Mean technique survival for the catheters was 41.2 months (95% confidence interval: 39.5 months to 42.9 months). Catheter survival rates at 1 and 2 years were 92.7% and 87.2% respectively.

Conclusions

We reported an encouraging outcome for Tenckhoff catheters inserted by nephrologists in an open surgical manner, with a 2-year catheter survival of 87.2% and a good safety profile.

Home Dialysis in the Prospective Payment System Era

The ESRD Prospective Payment System introduced two incentives to increase home dialysis use: bundling injectable medications into a single payment for treatment and paying for home dialysis training. We evaluated the effects of the ESRD Prospective Payment System on home dialysis use by patients starting dialysis in the United States from January 1, 2006 to August 31, 2013. We analyzed data on dialysis modality, insurance type, and comorbidities from the United States Renal Data System. We estimated the effect of the policy on home dialysis use with multivariable logistic regression and compared the effect on Medicare Parts A/B beneficiaries with the effect on patients with other types of insurance. The ESRD Prospective Payment System associated with a 5.0% (95% confidence interval [95% CI], 4.0% to 6.0%) increase in home dialysis use by the end of the study period. Home dialysis use increased by 5.8% (95% CI, 4.3% to 6.9%) among Medicare beneficiaries and 4.1% (95% CI, 2.3% to 5.4%) among patients covered by other forms of health insurance. The difference between these groups was not statistically significant (1.8%; 95% CI, -0.2% to 3.8%). Conversely, in both populations, the training add-on did not associate with increases in home dialysis use beyond the effect of the policy. The ESRD Prospective Payment System bundling, but not the training add-on, associated with substantial increases in home dialysis, which were identical for both Medicare and non-Medicare patients. These spill-over effects suggest that major payment changes in Medicare can affect all patients with ESRD.

Changes in the worldwide epidemiology of peritoneal dialysis

As the global burden of chronic kidney disease continues to increase, so does the need for a cost-effective renal replacement therapy. In many countries, patient outcomes with peritoneal dialysis are comparable to or better than those with haemodialysis, and peritoneal dialysis is also more cost-effective. These benefits have not, however, always led to increased utilization of peritoneal dialysis. Use of this therapy is increasing in some countries, including China, the USA and Thailand, but has proportionally decreased in parts of Europe and in Japan. The variable trends in peritoneal dialysis use reflect the multiple challenges in prescribing this therapy to patients. Key strategies for facilitating peritoneal dialysis utilization include implementation of policies and incentives that favour this modality, enabling the appropriate production and supply of peritoneal dialysis fluid at a low cost, and appropriate training for nephrologists to enable increased utilization of the therapy and to ensure that rates of technique failure continue to decline. Further growth in peritoneal dialysis use is required to enable this modality to become an integral part of renal replacement therapy programmes worldwide.

Introduction of Renal Key Performance Indicators Associated with Increased Uptake of Peritoneal Dialysis in a Publicly Funded Health Service

♦ BACKGROUND: Increased demand for treatment of end-stage kidney disease has largely been accommodated by a costly increase in satellite hemodialysis (SHD) in most jurisdictions. In the Australian State of Victoria, a marked regional variation in the uptake of home-based dialysis suggests that use of home therapies could be increased as an alternative to SHD. An earlier strategy based solely on increased remuneration had failed to increase uptake of home therapies. Therefore, the public dialysis funder adopted the incidence and prevalence of home-based dialysis therapies as a key performance indicator (KPI) for its health services to encourage greater uptake of home therapies. ♦ METHODS: A KPI data collection and bench-marking program was established in 2012 by the Victorian Department of Health and Human Services, with data provided monthly by all renal units in Victoria using a purpose-designed website portal. A KPI Working Group was responsible for analyzing data each quarter and ensuring indicators remained accurate and relevant and each KPI had clear definitions and targets. We present a prospective, observational study of all dialysis patients in Victoria over a 4-year period following the introduction of the renal KPI program, with descriptive analyses to evaluate the proportion of patients using home therapies as well as home dialysis modality survival. ♦ RESULTS: Following the introduction of the KPI program, the net growth of dialysis patient numbers in Victoria remained stable over 4 years, at 75 - 80 per year (approximately 4%). However, unlike the previous decade, about 40% of this growth was through an increase in home dialysis, which was almost exclusively peritoneal dialysis (PD). The increase was identified particularly in the young (20 - 49) and the elderly (> 80). Disappointingly, however, 67% of these incident patients ceased PD within 2 years of commencement, 46% of whom transferred to SHD. ♦ CONCLUSIONS: Introduction of a KPI program was associated with an increased uptake of PD but not home HD. This change in clinical practice restricted growth of SHD and reduced pressure on satellite services. The effect was offset by a modest PD technique survival. Many patients in whom PD was unsuccessful were subsequently transferred to SHD rather than home HD.

Home dialysis-an international perspective

Background. There is strong evidence from a range of long-term conditions of improved outcomes where patients are involved in self-management. Against this background, the international trend for home dialysis continues to decline, with centre-based haemodialysis continuing its dominance.

Methods. An opinion-based commentary exploring practice patterns and drivers for home dialysis internationally. Data are drawn from a number of sources including the 2010 United States Renal Data System report.

Results. Drivers behind the use of home dialysis are complex including factors relating to the patient and their carers, health care team, health care system, geography and cultural factors. There are important examples where local champions or public health initiatives have had a positive impact on the use of home dialysis; however, in many settings significant barriers remain. Better systems for giving patient information, shared decision making and involving patients in their own care may have the potential to act as a driver for change.

Conclusion. Centre-based haemodialysis continues to dominate renal replacement therapy internationally with notable exceptions. Such dominance suggests that most patients worldwide do not get much choice when it comes to modality selection.

A modified open surgery technique for peritoneal dialysis catheter placement decreases catheter malfunction

BACKGROUND

This retrospective study was conducted to evaluate the effect of a new, modified open surgery technique on catheter-related malfunction.

METHODS

During the period from January 1997 to June 2009, 216 patients received initial peritoneal catheters. For the present study, patients were divided into four groups according to the catheter types and the surgery techniques: TO-S: traditional open surgery, straight Tenckhoff catheter TO-C: traditional open surgery, coiled Tenckhoff catheter TO-SN: traditional open surgery, swan-neck catheter MO-S: modified open surgery, straight Tenckhoff catheter The modified surgery was characterized by a low incision site, a short intra-abdominal catheter segment and an additional upward straight subcutaneous tunnel. All patients were followed up for 2 years or until death. Survival rates, complications caused by catheter placement, and the probability of malfunction-free catheter survival were compared between the groups.

RESULTS

Catheter malfunction was the most frequent mechanical complication, found in 31 patients (14.4%), who experienced 38 malfunctions. Only 2 episodes of catheter malfunction were found in the MO-S group, representing a rate significantly less than those in the TO-S and TO-C groups (both p < 0.05). Kaplan-Meier curves for malfunction-free PD catheter survival showed a significantly different malfunction-free probability for the various groups (p = 0.009). After 2 years of follow-up, 136 patients (63.0%) survived with their initial PD catheter. The initial catheter survival rate was 76.8% in the MO-S group. Kaplan-Meier curves for initial catheter survival showed that the highest survival rate was found in the MO-S group (p = 0.001).

CONCLUSIONS

The modified open surgery technique is a reliable method for catheter placement.

The dynamic process of adherence to a renal therapeutic regimen: perspectives of patients undergoing continuous ambulatory peritoneal dialysis

BACKGROUND

The nature of end-stage renal disease and the need for continuous ambulatory peritoneal dialysis require patients to manage various aspects of the disease, its symptoms and treatment. After attending a training programme, patients are expected to adhere to the renal therapeutic regimen and manage their disease with the knowledge and skills learned. While patients are the stakeholders of their health and related behaviour, their perceptions of adherence and how they adhere to their renal therapeutic regimen remains unexplored.

AIMS

To understand adherence from patients' perspectives and to describe changes in adherence to a therapeutic regimen among patients undergoing continuous ambulatory peritoneal dialysis.

DESIGN

This study used a mixed methods design with two phases - a survey in phase I and semi-structured interviews in phase II. This paper presents phase II of the study.

SETTINGS

The study was conducted at a renal unit of an acute hospital in Hong Kong.

PARTICIPANTS

Based on the phase I survey results, maximum variation sampling was employed to purposively recruit 36 participants of different genders (18 males, 18 females), ages (35-76 years), and lengths of dialysis experience (11-103 months) for the phase II interviews.

METHODS

Data were collected by tape-recorded semi-structured interviews. Content analysis was employed to analyse the transcribed data. Data collection and analysis were conducted simultaneously.

FINDINGS

Adherence was a dynamic process with three stages. At the stage of initial adherence, participants attempted to follow instructions but found that strict persistent adherence was impossible. After the first 2-6 months of dialysis, participants entered the stage of subsequent adherence, when they adopted selective adherence through experimenting, monitoring and making continuous adjustments. The stage of long-term adherence commenced after 3-5 years of dialysis, when participants were able to assimilate the modified therapeutic regimen into everyday life.

CONCLUSIONS

The process of adherence was dynamic as there were fluctuations at each stage of the participants' adherence. With reference to each stage identified, nursing interventions can be developed to help patients achieve smooth transition throughout all the stages.

Outcomes in older adults with stage 5 chronic kidney disease: comparison of peritoneal dialysis and conservative management

BACKGROUND

Data on the outcomes of older adults receiving peritoneal dialysis (PD), especially those who are dependent and have multiple comorbidities, are scarce.

METHODS

In a retrospective cohort study, we compared older adults (≥65 years) with stage 5 chronic kidney disease receiving PD (PD group) with those receiving conservative management (conservative group). Baseline characteristics (demographics and clinical, functional, socioeconomic, and laboratory parameters) were collected, and study outcomes (patient survival, emergency hospitalization, institutionalization, and palliative and end-of-life care) were compared between groups.

RESULTS

We included 199 eligible participants aged 65-90 years (mean ± standard deviation 73.8 ± 5.4 years; 157 in the PD group and 42 in the conservative group). The PD group had a longer survival (median [interquartile range]: 3.75 [2.49-5.25] vs 2.35 [1.13-3.71] years, p < .001), lower emergency hospitalization rates (1.63 [0.82-2.92] vs 3.51 [1.06-7.16] per person-year, p < .01) and hospital days (16.17 [6.29-43.32] vs 38.01 [6.75-76.56] days per person-year, p = .03), and no increased risk of institutionalization compared with the conservative group. Age (hazard ratio [HR] for 1-year increase 1.06, 95% confidence interval [CI] 1.02-1.10), modified Charlson's Comorbidity Index (HR 1.36, 95% CI 1.18-1.56), impairment in basic activities of daily living (HR 2.11, 95% CI 1.28-3.46), and emergency dialysis (HR 1.67, 95% CI 1.11-2.53) were independent predictors of mortality in the PD group.

CONCLUSION

PD is a viable treatment option in older adults with stage 5 chronic kidney disease. Age alone should not preclude dialysis. Comprehensive geriatric assessment can prognosticate and facilitate shared decision making to commence dialysis in older adults.

Socio-economic impact in CKD

BACKGROUND

Socio-economic status (SES) may be conceptualized as an individual's position in society, as determined by their income, occupation, education, wealth, and housing situation. This review summarizes the current literature regarding associations of these markers of SES with both chronic kidney disease (CKD) and associated poor outcomes.

METHODS

Literature searches were conducted in the US National Library of Medicine, National Institutes of Health, PubMed database using the search terms "chronic kidney disease" and "chronic renal insufficiency," combined with "socio-economic status," "income," "occupation," "employment," "education," "social class," "wealth," and "housing." Articles not in the English language, using non-human subjects, or primarily concerning subjects with ESRD or acute kidney injury were excluded.

RESULTS

Income is the most-studied aspect of SES in relation to CKD, but there is increasing literature involving occupation and education as well. Additionally, the associations of CKD and its outcomes with area-level and life course SES are both burgeoning areas of research. There are several research areas that remain mostly unexplored, including the roles of wealth and housing in defining SES-related risk in CKD. Additionally, none have explored the relative utility of composite versus individual indicators of SES in predicting risk of CKD and outcomes.

CONCLUSION

Given the overwhelming evidence that SES plays an important role in the development and progression of disease, the development and testing of more targeted interventions should be a top priority in CKD research. Continuing examination of these factors, with increased rigor and focus on potentially modifiable intermediate pathways, is needed.

The Singapore General Hospital Peritoneal Dialysis Programme from 2000–2008

Introduction:

There is lack of data regarding outcomes of peritoneal dialysis (PD) in Singapore. The aim of this study is to retrospectively evaluate the patient characteristics, technique survival, and patient survival in a single centre.

Methods:

The retrospective review included 1,015 adults (47.3% female, 72.6% Chinese, mean age 58±12.4 years, mean follow-up 39.7±27.7 months) initiated on PD at the Singapore General Hospital from January 2000 to December 2008. Baseline characteristics, including cause of end-stage renal disease (ESRD), comorbid conditions, and endpoints (ie. death, transfer to HD or transplantation, renal recovery or until last follow-up on 31 December 2010) were collected. Demographic variables and patient and technique survival rates were analysed.

Results:

The main causes of ESRD were diabetes mellitus (DM) (58.0%), glomerulonephritis (GN) (23.3%) and hypertension (15.4%). The 1, 2, 5 and 10-year patient survival rates were 88.7%, 77.7%, 39.8% and 15.4%, respectively. Causes of death were related to infection (43.1%) and cardiac (37.8%). Patient survival rates were significantly better in PD patients with ESRD due to GN, compared with DM (5-year survival rates of 70.2% versus 22.3%, P <0.001). Patients aged 65 years and older had lower survival rates compared with those aged less than 65 years ( P <0.001). The 1, 2, 5 and 10-year technique survival rates were 92.9%, 85.0%, 64.8% and 32.9%, respectively. Peritonitis was the main cause of technique failure (63.5%), and caused 13.8% of deaths. Technique survival rates were better in patients with ESRD due to GN, compared with DM (5-year survival rates of 70.9% versus 62.0%, P <0.05).

Conclusion:

In our single-centre retrospective review, technique survival was comparable to other East Asian centres. The poorer patient survival observed in this study may be due to older age and higher comorbidity.

Peritoneal Dialysis Drop-out: Causes and Prevention Strategies

Peritoneal dialysis (PD) as a renal replacement therapy (RRT) has become wide spread since its inception more than twenty-five years back. Since then, several advances have been made and PD has been accepted as an alternative therapy to hemodialysis (HD), with excellent survival, lower cost, and improved quality of life. In spite of comparable survival of HD and PD, improved PD techniques over the last few years, and lower health care costs with PD, PD prevalence remains low in many countries. An important reason for the low PD prevalence is patient dropouts, that is, transfer to HD. The reasons for dropouts are multifactorial, that is, modality related, system related, and patient related. These include episodes of peritonitis, catheter-related problems, ultrafiltration failure, patient fatigue, and provider comfort. This review discusses the various factors that contribute to PD dropout and the strategies to prevent it.

Peritoneal dialysis first: rationale

The use of peritoneal dialysis (PD) has become wide spread since the introduction of continuous ambulatory PD more than 25 years ago. Over this time, many advances have been made and PD is an alternative to hemodialysis (HD), with excellent comparable survival, lower cost, and improved quality of life. The percentage of prevalent PD patients in the United States is approximately 7%, which is significantly lower compared with the 15% PD prevalence from the mid-1980s. Despite comparable survival of HD and PD and improved PD technique survival over the last few years, the percentage of patients performing PD in the United States has declined. The increased numbers of in-center HD units, physician comfort with the modality, perceived superiority of HD, and reimbursement incentives have all contributed to the underutilization of PD. In addition to a higher transplantation rate among patients treated with PD in the United States, an important reason for the low PD prevalence is the transfer to HD. There are various reasons for the transfer (e.g., episodes of peritonitis, membrane failure, patient fatigue, etc.). This review discusses the various factors that contribute to PD underutilization and the rationale and strategies to implement "PD first" and how to maintain it. The PD first concept implies that when feasible, PD should be offered as the first dialysis modality. This concept of PD first and HD second must not be seen as a competition between therapies, but rather that they are complementary, keeping in mind the long-term goals for the patient.

Epidemiology of peritoneal dialysis: a story of believers and nonbelievers

In 2008, an estimated 1.77 million patients worldwide received dialysis. Of these patients, 1.58 million were treated with hemodialysis and approximately 190,000 received peritoneal dialyisis. In a global comparison of treatment methods for renal failure, therefore, hemodialysis clearly dominates. In this Review, we compare the epidemiology of peritoneal dialysis with that of hemodialysis and describe some of the major differences in the global utilization of the two dialysis modalities. These differences can largely be explained by a number of nonmedical, mainly economic factors, but also by educational and psychological factors. To reverse the current trends, the implementation of suitable reimbursement strategies for peritoneal dialysis is needed as well as increased investment in the training of young nephrology fellows and in education programs for patients and other non-nephrological health-care providers. To achieve these goals, academic and nonacademic training centers, which often consider peritoneal dialysis to be a low-level priority, must invest in research and training related to peritoneal dialysis.