Is PD a suitable treatment after an unsuccessful transplant?

An update on absolute and relative indications for dialysis treatment modalities

Background

Choosing a dialysis modality is an important decision for people to make as their kidney failure progresses. In doing so, their options should be informed by any absolute or relative indications that may favour one modality over another.

Methods

In creating this update, we reviewed literature using a framework that considered first, high-level outcomes (survival and modality transition) from large registry data and cohort studies when considering optimal patient pathways; second, factors at a dialysis provider level that might affect relative indications; and third, specific patient-level factors. Both main types of dialysis modality, peritoneal (PD) and haemodialysis (HD), and their subtypes were considered.

Results

For most people starting dialysis, survival is independent of modality, including those with diabetes. Better survival is seen in those with less comorbidity starting with PD or home HD, reflecting continued improvements over recent decades that have been greater than improvements seen for centre HD. There are provider-level differences in the perceived relative indications for home dialysis that appear to reflect variability in experience, prejudice, enthusiasm, and support for patients and carers. Absolute contraindications are uncommon and, in most cases, where modality prejudice exists, e.g. obesity, Adult Polycystic Kidney Disease, and social factors, this is not supported by reported outcomes.

Conclusion

Absolute contraindications to a particular dialysis modality are rare. Relative indications for or against particular modalities should be considered but are rarely more important than patient preferences.

Clinical outcomes after failed renal transplantation-does dialysis modality matter?

Patients returning to dialysis after graft loss (DAGL) are an increasing segment of the end-stage renal disease (ESRD) population. It is unclear whether patients with previous graft loss have equivalent or reduced survival from the time of restarting dialysis when compared with ESRD patients initiating dialysis for the first time. Moreover, the impact of dialysis modality on the survival of patients returning to DAGL is not known. Studies of patients with transplant graft failure returning to hemodialysis (HD) have suggested decreased survival when compared with transplant-naïve dialysis patients, yet some studies of patients with graft failure returning to peritoneal dialysis (PD) have demonstrated equivalent survival. Based on these data, it is unclear whether survival differences may exist between the dialysis modalities, and if they do, whether they can be attributed to either differences in patient characteristics or to factors related to the dialysis modalities. For patients starting back onto dialysis, in whom preservation of residual renal function is important, it is also unclear how immunosuppression reduction or transplant nephrectomy may affect survival. In this review, we will summarize the available literature on survival rates of patients returning to DAGL; compare and contrast survival after initiation of HD and PD and discuss what is known about the impact of transplant nephrectomy and the different approaches to immunosuppression reduction. Practical considerations will be discussed with a specific emphasis on patients treated by PD.