Why is Peritoneal Dialysis Underutilized in the US Compared to Hemodialysis?

Use of peritoneal dialysis in patients with chronic kidney disease is declining due to lack of physician training and awareness, financial disincentives, and other factors. However, with proper patient and provider education, it is possible to grow a successful peritoneal dialysis program.

Physicians who are interested in starting and/or growing a peritoneal dialysis program for treating patients with chronic kidney disease face a range of challenges, but there are several strategies they can employ to increase patient and provider adherence and satisfaction, said Ramesh Saxena, MD, at Kidney Week 2012 in San Diego, an event sponsored by the American Society of Nephrology.

Dialysis cleans the body of harmful substances that build up when kidneys fail. But some patients with kidney failure, especially US residents, may not even be aware that there is another option besides hemodialysis, which uses a machine to filter blood outside of the body.

Saxena, who is a professor of internal medicine, division of nephrology, at the University of Texas Southwestern, in Dallas, noted that a study published in 2002 revealed that among patients with end-stage renal disease who initiated hemodialysis, only 25% said that peritoneal dialysis was discussed as an option and 32% did not even know what it was. Patients are much more likely to start on peritoneal dialysis if they are provided appropriate education on dialysis modality choice, Saxena said.

Peritoneal dialysis, which filters the blood within the body, is underutilized in the United States compared to Canada and other parts of the world, and its use has steadily declined over the past 15 years, said Saxena. Some contributing factors to reduced enrollment of patients with chronic kidney disease may be infrastructure and physician bias that favors hemodialysis, financial disincentives from funding agencies, and late patient referrals to nephrologists, he said.

Lack of education and exposure to peritoneal dialysis during nephrology training in the United States also reduces the likelihood of its use, Saxena said. According to 2002 data presented at the Annual Dialysis Conference, a full 70% of fellows were less comfortable with peritoneal dialysis than hemodialysis and 38% felt that they were inadequately trained for it.

Other challenges to growing a program are age-old perceptions about peritoneal dialysis, Saxena said. Though there are studies to the contrary, some in the medical field hold on to beliefs that patients are not interested in or have been unsatisfied with peritoneal dialysis, that the modality is not suitable for patients who are obese or have had abdominal surgeries, or that it is rife with complications, he said.

Reducing the number of patient dropouts will keep a program on track. Reasons for patient drop-out of peritoneal dialysis vary but some result from complications such as catheter mechanics that if modified could improve the number of patients who stick with the therapy, Saxena said. Consolidating small peritoneal dialysis centers in nearby geographical areas to improve efficiency and reduce staff burnout is another strategy to growing a peritoneal dialysis program, he said.

Saxena offered several additional suggestions to help improve growth and outcomes of a peritoneal dialysis center or program. He said the most important is to improve the training and awareness of nephrologists when it comes to this modality and to educate patients and their families with timely and quality information about end-stage renal disease that includes dialysis treatment options. In addition, physicians and staff in peritoneal dialysis programs should take swift action to prevent and treat related complications, and adopt measures to preserve peritoneal membrane function.

Saxena said his institution, the UT Southwestern Medical Center, adopted a multi-step process to educate patients facing dialysis that has led to significant growth of the peritoneal program. Patients are first counseled and educated about dialysis options; if they choose peritoneal dialysis they are sent to the center where they receive comprehensive education about the process before the catheter is surgically placed for dialysis.

Additional Information

Peritoneal dialysis versus hemodialysis: risks, benefits, and access issues.

“Peritoneal dialysis (PD) and hemodialysis (HD) are dialysis options for end-stage renal disease patients in whom preemptive kidney transplantation is not possible. The selection of PD or HD will usually be based on patient motivation, desire, geographic distance from an HD unit, physician and/or nurse bias, and patient education. Unfortunately, many patients are not educated on PD before beginning dialysis. Most studies show that the relative risk of death in patients on in-center HD versus PD changes over time with a lower risk on PD, especially in the first 3 months of dialysis. The survival advantage of PD continues for 1.5-2 years but, over time, the risk of death with PD equals or becomes greater than with in-center HD, depending on patient factors. Thus, PD survival is best at the start of dialysis. Patient satisfaction may be higher with PD, and PD costs are significantly lower than HD costs. The new reimbursement system, including bundling of dialysis services, may lead to an increase in the number of incident patients on PD. The high technique failure of PD persists, despite significant reductions in peritonitis rates. Infection also continues to be an important cause of mortality and morbidity among HD patients, especially those using a central venous catheter as HD access. Nephrologists' efforts should be focused on educating themselves and their patients about the opportunities for home modality therapies and reducing the reliance on central venous catheter for long-term HD access.”

For Patients: A Comparison of Dialysis Options

Hemodialysis

Peritoneal Dialysis

Advantages

• Performed by trained health professionals
• Opportunities for support and networking with other patients during treatment
• Shorter treatment duration, fewer days per week

• Treatment done at home, not at a treatment center.
• Treatment self-administered (can even be done while sleeping)
• Fewer dietary restrictions
• No needles

Disadvantages

• Fatigue following treatment
• Increased risk of hypotension and blood clots at dialysis access point
• Increased risk of blood infections

• Procedure may be difficult for some patients to properly administer
• Increased risk of peritonitis

Source: eMedicineHealth