In the United States, chronic peritoneal dialysis take-on has declined among incident ESRD patients. Although increasing age, co-morbidity, and body size may explain part of this decline, other factors likely contribute. Among incident ESRD patients in the United States, we found that peritoneal dialysis take-on significantly decreased from 11% in 1996 to 1997 to 7% in 2002 to 2003 (P Ͻ 0.001 for the trend). This decrease remained after adjusting for patient demographics, case-mix, and laboratory data, suggesting the involvement of other factors. This decline in utilization occurred during a time of improving outcomes for incident peritoneal dialysis patients, measured as reduced hazards for death or for the need to transfer to hemodialysis. In contrast, among patients initially treated with hemodialysis, the 12-month adjusted hazards for death or transfer to peritoneal dialysis slightly worsened or were unchanged over this same period. Therefore, the decline in peritoneal dialysis take-on cannot be entirely explained by increasing age, co-morbidity and body size of incident ESRD patients. The decline in utilization has occurred at a time when the early outcomes of CPD patients have improved.

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In the past decade, peritoneal dialysis use among patients with end-stage renal disease has declined in many countries. Studies from the United States indicate that many academic centers do not have adequate resources to train fellows, most incident dialysis patients are not offered peritoneal dialysis, and more than half of dialysis clinics do not have the infrastructure to support peritoneal dialysis. Some are concerned that the outcomes of peritoneal dialysis and maintenance hemodialysis patients may not be equivalent, a notion that is not supported by outcome studies. Given the effect of modality selection on patients' lifestyle, attempts to conduct a randomized, controlled comparison of maintenance hemodialysis and peritoneal dialysis have been unsuccessful. Most observational studies showed that peritoneal dialysis is associated with a survival advantage that diminishes over time; it is unclear whether any of the differences over time are attributable to the modality. Between 1996 and 2003, the early outcomes of peritoneal dialysis patients further improved, whereas those for maintenance hemodialysis patients remained unchanged. Differences in outcomes may be due to residual statistical confounding; however, several biologic mechanisms can be postulated: The early survival advantage may be related to the better preservation of residual renal function with peritoneal dialysis, and the diminution of the survival advantage may be related to worsened volume control. There is a need for large observational and interventional studies among peritoneal dialysis patients to sustain and enforce the improvements in both dialysis therapies.