Both continuous ambulatory peritoneal dialysis (CAPD) and hemodialysis (HD) have their advantages regarding the treatment of patients with renal failure. In CAPD, solute removal is sometimes insufficient in patients who have a relatively large muscle mass that produces high levels of creatinine. To compensate for this deficiency, frequent exchanges and large peritoneal dialysate volumes are required. Alternatively, CAPD and HD as a combined modality of treatment for patients needing dialysis therapy has been proposed. Our experiences with three groups of patients are described. First, in 2003, 7 cases (6 males and 1 female; average age 54.3 ± 4.5 years; mean duration of CAPD therapy 4.3 ± 1.1 years; average weekly creatinine clearance (WCC) was 45.2 ± 1.7 l/1.73 m(2)) were treated with once-a-week HD therapy (3.5 h; 200 ml/h). Addition of once-a-week HD therapy improved WCC to 66 ± 7.1 liters/1.73 m(2). This improvement was due not only to the addition of HD therapy but also to an increase in creatinine clearance for 3 consecutive days after the completion of once-a-week HD therapy. Both creatinine clearance and ultrafiltration were significantly increased. Other clinical parameters such as blood pressure control, weight control, and dosage of erythropoietin were significantly improved after introducing this therapy. Second, we followed 9 CAPD patients who underwent an additional weekly HD for more than 3 years. Similar improvements were obtained in this long-term study as seen in the short-term study. Besides, the incidence of peritonitis decreased dramatically from 0.13 to 0.09 episodes/patient-year (p < 0.05) during the 3-year study. These data suggest that the combined use of CAPD and HD improves solute clearance in CAPD patients who are insufficiently dialyzed. Third, based on these data, we examined the efficacy of an early start of combination therapy and found that it stabilized dialysis therapy and prolonged the duration of CAPD. Combined with several of the previous several reports and our present experience, it is suggested that an early start of HD therapy will prolong the survival rate in patients on CAPD with physically stable conditions.

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Background: Various reasons for "Peritoneal Dialysis (PD) First" rather than hemodialysis (HD) have been presented, such as better preservation of residual renal function (RRF), longer survival, and lower incidence of hospitalization. In spite of these advantages for "PD First", in Japan as well as in the United States the annual rate of patients receiving PD has been reduced to less than 10%. One of the major reasons against selecting PD is that a large proportion of PD patients are transferred from PD to HD in less than 5 years. Our "PD First" policy is based on the diversity of modalities available after discontinuing PD therapy. The purpose of this study was to examine the follow-up of patients who selected "PD First" as the initial treatment of end-stage renal disease (EDRD) between April 1997 and December 2010.Methods: Sex, age, primary underlying diseases and selection of modalities were collected retrospectively. Results:A total of 377 (59.2 ± 8.3 years old; female/male: 255/122) patients were introduced to PD therapy as "PD First." Patients who were very old, with cardiovascular problems, senile dementia, and neoplasms that were forced to select PD were excluded. One hundred and sixty patients started HD as complementary dialysis therapy and then continued with PD + HD in combination until transfer to HD, transplantation or home HD. Among them, 10 patients received transplants and 22 patients were transferred to home HD. One hundred and twenty eight patients were switched from PD to HD for various reasons. Overall patients' survival after 5 and 10 years was 84.8% and 55.8%, respectively. Conclusion:Our data shows a diversity of modalities for selection after discontinuing PD therapy alone, as well as providing a rationale to support PD as the initial renal replacement modality for end-stage renal disease patients.