Background Serum albumin predicts mortality in dialysis patients and is used to assess their health status and the quality of delivered care. Whether the threshold level of serum albumin at which mortality risk increases in peritoneal dialysis (PD) patients is the same as for hemodialysis (HD) patients has not been studied. Study Design Observational cohort study of dialysis patients undertaken to determine the survival-predictability of serum albumin in PD patients, and to compare it with that in HD patients. Setting and Participants 130,052 dialysis patients (PD, 12,171; HD, 117,851) who received treatment in any of the 580 dialysis units owned by DaVita Inc. between 7/1/2001 through 6/30/2006, followed through 6/30/2007 Predictor Baseline and time-averaged serum albumin (assayed by bromcresol green), and change in serum albumin over six months Outcome Measures All-cause, cardiovascular, and infection-related mortality. Results PD patients with baseline serum albumin < 3.0 g/dl had an over three-fold higher adjusted risk for all-cause and cardiovascular mortality, and 3.4-fold higher risk for infection-related mortality (reference group: serum albumin 4.00–4.19 g/dl). The adjusted all-cause mortality was significantly lower in PD patients with ≥ 0.3 g/dl increase in serum albumin over six months, and significantly higher in whom it decreased by ≥ 0.2 g/dl (reference group: serum albumin change, +0.1 to −0.1 g/dl). Significant increase in death risk was evident for HD patients with serum albumin < 4.0 g/dl but at < 3.8 g/dl for PD patients. For each albumin category, the overall death risk for PD patients was lower than of HD patients (reference group: HD patients with serum albumin, 4.00–4.19 g/dl). Limitations Study can only identify associations without attribution of causality and residual confounding cannot be excluded. Conclusions To conclude, serum albumin predicts all-cause, cardiovascular, and infection-related mortality in both PD and HD patients. However, the threshold at which risk for death increases varies by dialysis modality and this difference should be considered by agencies or organizations that set quality standards.

Evidence-based cinical practice guidelines improve delivery of uniform care to patients with and at risk of developing kidney disease, thereby reducing disease burden and improving outcomes. These guidelines are not well-integrated into care delivery systems in most low- and middle-income countries (LMICs). The KDIGO Controversies Conference on Implementation Strategies in LMIC reviewed the current state of knowledge in order to define a road map to improve the implementation of guideline-based kidney care in LMICs. An international group of multidisciplinary experts in nephrology, epidemiology, health economics, implementation science, health systems, policy, and research identified key issues related to guideline implementation. The issues examined included the current kidney disease burden in the context of health systems in LMIC, arguments for developing policies to implement guideline-based care, innovations to improve kidney care, and the process of guideline adaptation to suit local needs. This executive summary serves as a resource to guide future work, including a pathway for adapting existing guidelines in different geographical regions.

The number of dialysis patients continues to grow. In many parts of the world, peritoneal dialysis (PD) is a less expensive form of treatment. However, it has been questioned whether patients treated with PD can have as good a long-term outcome as that achieved with hemodialysis (HD). This skepticism has fueled ongoing comparisons of outcomes of patients treated with in-center HD and PD using data from national registries, or prospective cohort studies. There are major challenges in comparing outcomes with two therapies when the treatment assignment is nonrandom. Furthermore, many of the inter-modality comparisons include patients who started dialysis therapy in the 1990s. In many parts of the world, improvements in PD outcome have outpaced those seen with in-center HD. It is not surprising, then, that virtually all the recent observational studies from different parts of the world consistently show that long-term survival of HD and PD patients is remarkably similar. These studies support the case for a greater use of PD for the treatment of end-stage renal disease -this, in turn, could allow more patients to be treated for any given budgetary allocation to long-term dialysis.Ever since the initial successful experience with continuous ambulatory peritoneal dialysis (PD), a large number of studies have tried to determine if the outcomes of PD patients are comparable to those achieved with hemodialysis (HD). A controlled clinical trial in which patients were randomly assigned to treatment with either PD or HD would be the best way to obtain unbiased estimates of the independent effects of dialysis modality on patient outcomes. However, the two dialysis modalities have disparate effects on patients' daily lives. It is not surprising then that when patients are educated about their modality options, they often want to have a say in the choice and refuse to be randomized. The last attempt to conduct a randomized, controlled clinical trial was made under the auspices of the Netherlands Cooperative Study of Dialysis (NECOSAD). Only 38 (5%) of the 773 eligible subjects agreed to be randomized and hence, the study was substantially underpowered to allow any meaningful conclusions 1 . The most recent attempt is currently being undertaken