How to Have a Successful Peritoneal Dialysis Program

The proportion of end-stage renal disease patients on continuous ambulatory peritoneal dialysis (CAPD) has increased by twofold in Hong Kong over last two decades, accounting for 80% of the entire dialysis population. Our encouraging outcome results—a 2-year actuarial patient survival of 83%, and a 2-year technique survival of 72.8%—further testify to the success of CAPD in our territory. A relatively constant successful outcome has been achieved despite an increasing prevalence of diabetes mellitus and an aging population. The present review postulates the reasons behind our success. Apart from reimbursement policy, technique-related factors, and center effects, inherent patient factors—including baseline survival advantage of Chinese patients, genetic difference, cardiovascular risk factors, and possibly lower dialysis volume requirement and compliance—are thought to be contributory. As for the future, more efforts are needed to further improve the technique survival rate and the nutritional status, psychosocial well-being, and rehabilitation of CAPD patients. Judicious assessment of peritoneal dialysis adequacy and preservation of residual renal function should be constantly exercised to tailor treatment to the needs of Chinese CAPD patients.

Is there a survival advantage in Asian peritoneal dialysis patients?

Over the last decade, epidemiological surveys and qualitative research literature have demonstrated and validated a better survival in the Asian peritoneal dialysis population. This review summarizes the current understanding of Asian peritoneal dialysis patient survival and attempts to scrutinize the supposed survival advantage of this population group. We outlined the published peritoneal dialysis survival data from a literature search, with reference to dialysis patient cohorts from 1983 through 2002 for prevalent cases and 1980 through 2002 for incident patients. Two-year and 5-year patient survival rates in excess of 80% and 60% respectively were demonstrated in Asian countries, which compared favorably with the CANUSA, ADEMEX and most Caucasian series. Better end-stage renal disease patient survival is apparent despite a dialysis adequacy disadvantage, for reasons yet to be identified. As is the case of other racial disparities in medical care, such a difference is a product of more than biological differences and include budgetary barrier, health care system and geographic variation, physician bias and statistical pitfalls. Particular efforts should therefore be made to explore the underlying reason(s) for the Asian peritoneal dialysis patient survival advantage. Alternative approach and guidelines to peritoneal dialysis delivery in Asia might be warranted.

Peritoneal dialysis in anuric patients: concerns and cautions

Most recent studies have found an equivalent survival for patients on peritoneal dialysis (PD) and hemodialysis (HD); evidence even suggests that PD might be the preferred modality during the first 3-4 years of renal replacement therapy. This is probably related to the continuous and minimally invasive character of PD as compared to HD, resulting in better preservation of residual renal function (RRF) and less cardiovascular strain. On the other hand, blood pressure control, fluid balance, and adequacy targets may be difficult to obtain in long-term PD patients. The question arises whether PD is a feasible option in anuric patients. It is clear that the answer depends on the body size and the peritoneal membrane transport characteristics of the patient, so that PD will be feasible in some anuric patients, whereas in others it will not be. Evaluation of the peritoneal transport characteristics and adaptation of the PD prescription is warranted. A constant evaluation of the fluid balance, nutritional, and cardiovascular status is needed. This article reviews the physiologic insights and clinical evidence necessary for a good PD prescription in anuric patients.