Is the Declining Use of Long-Term Peritoneal Dialysis Justified by Outcome Data?

Abstract

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.

Dialysis Modality and Outcomes in Kidney Transplant Recipients

“…A large number of studies have examined the relationship of dialysis modality to patient survival with or without transplantation (1,27,28). Although there is no significant difference in 5-year survival of patients in contemporary cohorts, many of the earlier studies have shown a lower risk for death in the first 1-3 years after the start of dialysis.…”

Association of Dialysis Modality and Cardiovascular Mortality in Incident Dialysis Patients

“…Both of these studies were limited by lack of statistical power, lack of consideration of nonproportional hazards and competing risks, and uncertain relevance of outcomes observed over a decade ago to contemporary dialysis practice. The relevance to current practice is particularly important in view of observations that outcomes in PD patients have improved over time relative to those in HD patients (18,28).…”

The impact of the peritoneal glucose load index on hydration status and inflammation in peritoneal dialysis patients

“…[4][5][6][7][8] Poor glycaemic control (glycosylated haemoglobin [HbA 1c ] !8%) in PD patients appears to be associated with higher mortality. 9 Glucose absorption from PD solutions also contributes to the harmful effects on the metabolic profile and hydration status. [10][11][12] Some observational studies showed a higher risk for death in older diabetic PD patients compared with those on haemodialysis.…”