Historical Reasons for Underuse of Peritoneal Dialysis in the United States

Improvements in the delivery of peritoneal dialysis in the 1980s using plastic dialysate bags rather than bottles, Y-sets for continuous ambulatory peritoneal dialysis, improved catheter design, and the development of easy-to-use automated peritoneal dialysis cyclers have made peritoneal dialysis an effective option to treat patients with ESRD. In addition, the peritoneal membrane removed toxic “middle molecules” better than earlier-generation hemodialysis filters made with cupraphan. In the 1980s, in our center and in some dialysis centers in the United States, up to 35 percent of all ESRD patients were receiving peritoneal dialysis, but this percentage has recently dropped to under 10 percent. The use of peritoneal dialysis in the United States lags far behind that of other countries. Several reasons may explain the underuse of peritoneal dialysis in the United States.

Over the past two decades, U.S. physicians have developed a bias against and lack of enthusiasm for peritoneal dialysis. Early studies suggested that the mortality of peritoneal dialysis patients was greater than that of similar patients receiving hemodialysis, and even recent studies suggest that the mortality of peritoneal dialysis patients older than 45 years may be greater than that in similar patients on hemodialysis. These studies may have biased some nephrologists against offering peritoneal dialysis to their patients. However, newer registry and epidemiologic studies in the United States, Canada, and Denmark have shown that mortality is lower with peritoneal dialysis in the early years of therapy compared with similar patients receiving hemodialysis. When these data are taken together, there is no clear evidence that survival is better in ESRD patients with hemodialysis than in those receiving peritoneal dialysis. Thus, any apparent survival difference is not great enough between modalities to warrant physicians offering either method over the other for patients approaching ESRD. Rather, psychosocial issues, complex medical problems, and patient choice should determine who can successfully perform peritoneal dialysis.

Physicians’ bias favoring hemodialysis over peritoneal dialysis may also be due to recent improvements in biocompatible hemodialyzers, which now have better middle molecule clearance. In addition, the rise of interventional radiologists placing temporary or longer-term dialysis catheters allows easier management of the initial uremic state with hemodialysis. Annually, approximately 15 percent of patients receiving peritoneal dialysis transfer to hemodialysis because of severe peritonitis, peritoneal membrane failure, or catheter malfunction. Difficulty in achieving dialysis adequacy in patients with a large body mass index and insufficient training of nephrology fellows in the management of peritoneal dialysis patients are additional reasons why nephrologists have shifted away from peritoneal dialysis as an important therapy for ESRD.

In the past two decades, most academic centers that train nephrology fellows no longer provide peritoneal dialysis education and training in their hospital-owned peritoneal dialysis programs. Rather, hospitals have divested their nonprofitable dialysis units to one of several national dialysis companies that primarily focus on hemodialysis patients, with few resources or champions devoted to peritoneal dialysis. However, the new bundled payment schedule for ESRD patients offered by the Centers for Medicare and Medicaid Services financially favors the use of peritoneal dialysis and should help increase the numbers of ESRD patients receiving it. The ease and focus on hemodialysis rather than on peritoneal dialysis has diminished the use of the latter. However, developing the expertise of physicians and nurses could enhance the use of peritoneal dialysis as an effective therapy for ESRD.

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Notes

[1] Gregory L. Braden, MD, is fellowship director and chief of the nephrology division at Baystate Medical Center/Tufts University School of Medicine in Springfield, MA.

Suggested Reading

1.Bloembergen WE, Port FK, Mauger EA, et al. A comparison of cause of death between patients treated with hemodialysis and peritoneal dialysis. J Am Soc Nephrol 1995; 6:184–191.

2.Vonesh EF, Moran J. Mortality in end-stage renal disease: a reassessment of difference between patients treated with hemodialysis and peritoneal dialysis. J Am Soc Nephrol 1999; 10:354–365.

3.Stack AG, Molony DA, Rahman NS, et al. Impact of dialysis modality on survival of new ESRD patients with congestive heart failure in the United States. Kidney Int 2003; 64:1071–1079.

4.Ganesh SK, Hulbert-Shearon T, Port FK, et al. Mortality difference by dialysis modality among incident ESRD patients with and without coronary artery disease. J Am Soc Nephrol 2003; 14:415–424.

5.Vonesh EF, Snyder JJ, Foley RN, et al. Mortality studies comparing peritoneal dialysis and hemodialysis: what do they tell us? Kidney Int 2006, 70:S3–S11.

6.Murphy SW, Foley RN, Barrett BJ, et al. Comparative mortality of hemodialysis and peritoneal dialysis in Canada. Kidney Int 2000; 57:1720–1726.

7.Mehrotra R, Kermah D, Fried L, et al. Chronic peritoneal dialysis in the United States: declining utilization despite improving outcomes. J Am Soc Nephrol 2007; 18:2781–2788.

8.Mehrotra R, Chiu Y, Kalantar-Zadeh K, et al. Similar outcomes with hemodialysis and peritoneal dialysis in patients with end-stage renal disease. Arch Intern Med 2011; 171:110–118.

9.Blake PG, Suri RS. Peritoneal dialysis vs. hemodialysis: time to end the debate? Nat Rev Nephrol 201; 7:308–310.

August 2012 (Vol. 4, Number 8)