Perit Dial Int
29(Supplement_2):
59-61
2009
© 2009 International Society for Peritoneal Dialysis
Part 3: Clinical Experiences |
CLINICAL ADVANTAGES OF PERITONEAL DIALYSIS
Bulent Tokgoz
Erciyes University School of Medicine, Department of Nephrology, Kayseri,
Turkey
Correspondence to: B. Tokgoz, Erciyes Universitesi, Tip Fakultesi, Nefroloji
Bilim Dali, 38039 Kayseri, Turkey.
bulentto{at}gmail.com
 |
ABSTRACT
|
|---|
Chronic peritoneal dialysis (PD) continues to be an option in the
treatment of end-stage renal disease (ESRD). Medical, social, and logistic
considerations are needed to determine the most suitable dialysis option for
an ESRD patient. Peritoneal dialysis has been advancing in terms of technique,
new exchange systems, and a new generation of solutions. A survival advantage
for PD patients has been noted over the first 1 – 2 years after the
onset of the dialysis. Most patients may need both dialytic modalities in
time, and therefore the sequence of the treatment options is important.
Compared with hemodialysis patients, PD patients seem much more satisfied in
most of the studies that evaluate quality of life during treatment. A
preference for PD may be more advantageous in the pre-transplantation period.
Moreover, much lower doses of erythropoietin have been shown to be sufficient
for PD patients. Also, PD has been reported to protect residual renal
functions better in many studies.
KEY WORDS: Survival; residual renal function.
Chronic peritoneal dialysis (PD) is one of the treatments used in end-stage
renal disease (ESRD). Since the early 1980s, PD has been overwhelmingly used
all over the world (1). As a
treatment option, PD has some advantageous aspects; however, whether it is
superior to intermittent hemodialysis (HD) is still controversial.
Today, ESRD is becoming a major public health problem, and if no form of
renal replacement treatment (RRT) is applied for a patient with end-stage
renal failure, that patient may be very close to death. There is no doubt that
the best treatment for a patient who is very close to ESRD is pre-emptive
transplantation, but transplantation generally does not happen because of an
insufficient number of donors. Therefore, most patients have to choose a
dialysis type, meaning that dialysis continues to be the main treatment for
most patients. The two major dialysis types—HD and PD—are not only
different from one another technically, but also with regard to the
expectations of patients pertaining to the effort involved.
|
CHOOSING A DIALYSIS TYPE
|
|---|
In choosing the most suitable dialysis option for the patient, medical,
social, and logistic conditions are considered. "Which dialysis method
is the best?" seems to be the most critical question. Advantageous
aspects of PD are described here, but the disadvantageous aspects should not
be disregarded when choosing the dialysis type. Physicians and patients should
both be sufficiently informed about the risks and benefits of the dialysis
options.
As mentioned earlier, PD has been applied worldwide for more than 25 years
(1). During this period, both
the technical and the non-technical aspects of PD have been improved.
Peritoneal dialysis can be very advantageous for many aspects such as clinical
effectiveness, social circumstances, and tolerance of the patient for the
treatment, among others.
|
PATIENT OUTCOME: MORTALITY AND MORBIDITY RATES
|
|---|
Early studies observed that mortality and morbidity rates were lower in HD
patients (2). However, further
studies discovered that PD could achieve patient survival that was the same or
better than that with HD. The key reason for this remarkable change was that
both the technical and the non-technical aspects of PD had been
improved—for example, PD technique was better, new exchange systems had
been developed, and new solutions had been introduced. Most interestingly, the
data suggested that during the first 1 – 2 years after the onset of
ESRD, PD actually appears to hold a slight survival advantage for patients
using the technique
(3–5).
This advantage is seen in all age groups except for elderly white women with
diabetes, who seem to do worse on PD
(6).
In the recently published Choices for Healthy Outcomes in Caring for ESRD
(CHOICE) study, a significant risk increase was observed in PD patients by
year 2 (7). Patients were
monitored for nearly 7 years, and during follow-up, 25% of patients in the PD
group and 5% of those in the HD group switched dialysis modality, and a
significant risk increase was observed in PD patients as of the 2nd year. When
corrections were made to take into account comorbid conditions and residual
renal function (RRF), outcomes did not change. However, the pitfall of the
CHOICE study was that, at the beginning of treatment, PD patients had a higher
incidence of cardiovascular diseases.
In recent cohort research at our center in Turkey, the mortality rate was
found to be higher in patients who underwent HD before PD
(8). Patients who started PD as
a second renal replacement therapy had a higher risk of death [risk ratio
(RR): 1.84; 95% confidence interval (CI): 1.06 to 3.19].
According to the results of all dialysis outcome studies, no convincing
evidence shows that one method is superior to the other. A randomized
prospective design study is necessary to clearly determine the dialysis method
that has better patient survival. But such a study is almost impossible,
because most patients will not accept randomization. Of course, what
practitioners have to do is inform patients about the available dialysis
methods and focus on the improvement of patient outcome whether under HD or
PD. In this circumstance, the important question to be answered is
"Which treatment sequence is the best?" rather than "Which
treatment is the best?" The options of PD, HD, and renal transplantation
can be considered together, because HD and PD are not competing treatments,
they are complementary. Many patients may need both methods in time. Transfer
from one method to another should not be considered to be
"failure" of the previous method.
|
PATIENT SATISFACTION AND LIFE QUALITY
|
|---|
Lately, awareness of patient satisfaction and quality of life has been
increasing. There is no doubt that good medical care does not only mean
achieving optimal biomedical results; psychological outcomes should also be
considered. Some recent studies have evaluated this subject. Special
questionnaires designed to measure customer satisfaction ask patients to
determine their treatment satisfaction level. In most of these studies, PD
patients seem to be much happier than HD patients are
(9–11).
These results do not change after adjustment for age, ethnicity, education
level, marital status, employment status, distance from the treatment center,
and treatment duration
(10).
|
PERITONEAL DIALYSIS AS A PRE-TRANSPLANTATION RRT
|
|---|
In many studies, a preference for PD has been shown to possibly be more
advantageous during the pre-transplantation period
(12–14).
Selecting PD as a RRT method at that time shows some possible positive effects
on graft function after the transplantation process. For example, a study by
Van Biesen and colleagues showed that PD treatment might have independent
positive effects on graft function in addition to the situation of cold
ischemia and volume (12). The
most likely cause of this condition has been speculated to be
bioincompatibility seen in HD patients. On the other hand, no long-term
difference has been shown.
|
ADVANTAGES OF PD IN RENAL ANEMIA TREATMENT
|
|---|
Anemia is a well-known complication of ESRD. It is also well known that
cardiovascular events are the primary cause of death in this patient group,
and anemia causes progress of left ventricular hypertrophy
(15). Fortunately, treating
the anemia avoids this deterioration. It has been documented that
erythropoietin (EPO) is required in much lesser amounts to treat renal anemia
in PD patients, and much reduced doses are sufficient for PD patients who take
EPO (16).
|
PERITONEAL DIALYSIS AND PRESERVATION OF RRF
|
|---|
Currently, the importance of RRF for patients on chronic dialysis treatment
is strongly emphasized. The patient's remaining glomerular filtration rate
(GFR) is considered to represent the patient's RRF. It also reflects the
remaining endocrine functions of the kidney such as EPO production. From a
clinician's point of view, RRF is very important because it directly affects
the required dialysis dose. There is also a close relationship between RRF and
mortality: the CANUSA study found that every 0.5 mL/min increase in GFR is
associated with a 9% reduction in the risk of death
(17). Many studies have looked
at the better protection of RRF in PD patients
(17–19).
|
REFERENCES
|
|---|
- Grassmann A, Gioberge S, Moeller S, Brown G. End-stage renal
disease: global demographics in 2005 and observed trends. Artif
Organs 2006; 30:895
-7.[Medline]
- Bloembergen WE, Port FK, Mauger EA, Wolfe RA. A comparison of
mortality between patients treated with hemodialysis and peritoneal dialysis.
J Am Soc Nephrol 1995;6
: 177-83.[Abstract]
- Fenton SS, Schaubel DE, Desmeules M, Morrison HI, Mao Y, Copleston
P, et al. Hemodialysis versus peritoneal dialysis: a comparison of
adjusted mortality rates. Am J Kidney Dis1997; 30:334
-42.[Medline]
- Heaf JG, Løkkegaard H, Madsen M. Initial survival advantage
of peritoneal dialysis relative to haemodialysis. Nephrol Dial
Transplant 2002; 17:112
-17.[Abstract/Free Full Text]
- Termorshuizen F, Korevaar JC, Dekker FW, Van Manen JG, Boeschoten
EW, Krediet RT, on behalf of the Netherlands Cooperative Study on the Adequacy
Dialysis Study Group. Hemodialysis and peritoneal dialysis: comparison of
adjusted mortality rates according to the duration of dialysis: analysis of
the Netherlands Cooperative Study on the Adequacy of Dialysis 2. J
Am Soc Nephrol 2003; 14:2851
-60.[Abstract/Free Full Text]
- Collins AJ, Hao W, Xia H, Ebben JP, Everson SE, Constantini EG,
et al. Mortality risks of peritoneal dialysis and hemodialysis.
Am J Kidney Dis 1999;34
: 1065-74.[Medline]
- Astor BC, Eustace JA, Powe NR, Klag MJ, Fink NE, Coresh J on behalf
of the CHOICE Study. Type of vascular access and survival among incident
hemodialysis patients: the Choices for Healthy Outcomes In Caring for ESRD
(CHOICE) Study. J Am Soc Nephrol 2005;16
: 1449-55.[Abstract/Free Full Text]
- Sipahioglu MH, Aybal A, Unal A, Tokgoz B, Oymak O, Utas C. Patient
and technique survival and factors affecting mortality on peritoneal dialysis
in Turkey: 12 years' experience in a single center. Perit Dial
Int 2008; 28:238
-45.[Abstract/Free Full Text]
- Barendse SM, Speight J, Bradley C. The Renal Treatment Satisfaction
Questionnaire (RTSQ): a measure of satisfaction with treatment for chronic
kidney failure. Am J Kidney Dis 2005;45
: 572-9.[Medline]
- Rubin HR, Fink NE, Plantinga LC, Sadler JH, Kliger AS, Powe NR.
Patient ratings of dialysis care with peritoneal dialysis vs hemodialysis.
JAMA 2004; 291:697
-703.[Abstract/Free Full Text]
- Juergensen E, Wuerth D, Finkelstein SH, Juergensen PH, Bekui A,
Finkelstein FO. Hemodialysis and peritoneal dialysis: patients' assessment of
their satisfaction with therapy and the impact of the therapy on their lives.
Clin J Am Soc Nephrol 2006;1
: 1191-6.[Abstract/Free Full Text]
- Van Biesen W, Veys N, Vanholder R, Lameire N. The impact of the
pre-transplant renal replacement modality on outcome after cadaveric kidney
transplantation: the Ghent experience. Contrib Nephrol2006; 150:254
-8.[Medline]
- Goldfarb–Rumyantzev AS, Hurdle JF, Scandling JD, Baird BC,
Cheung AK. The role of pretransplantation renal replacement therapy modality
in kidney allograft and recipient survival. Am J Kidney
Dis 2005; 46:537
-49.[Medline]
- Pérez Fontán M, Rodríguez–Carmona A,
Bouza P, García Falcón T, Adeva M, Valdés F, et
al. Delayed graft function after renal transplantation in patients
undergoing peritoneal dialysis and hemodialysis. Adv Perit
Dial 1996; 12:101
-4.[Medline]
- Levin A, Thompson CR, Ethier J, Carlisle EJ, Tobe S, Mendelssohn D,
et al. Left ventricular mass index increase in early renal disease:
impact of decline in hemoglobin. Am J Kidney Dis1999; 34:125
-34.[Medline]
- Snyder JJ, Foley RN, Gilbertson DT, Vonesh EF, Collins AJ.
Hemoglobin levels and erythropoietin doses in hemodialysis and peritoneal
dialysis patients in the United States. J Am Soc
Nephrol 2004; 15:174
-9.[Abstract/Free Full Text]
- Churchill DN, Taylor DW, Keshaviah PR, and the CANUSA Peritoneal
Dialysis Study Group. Adequacy of dialysis and nutrition in continuous
peritoneal dialysis: association with clinical outcomes. J Am Soc
Nephrol 1996; 7:198
-207.[Abstract]
- Misra M, Vonesh E, Van Stone JC, Moore HL, Prowant B, Nolph KD.
Effect of cause and time of dropout on the residual GFR: a comparative
analysis of the decline of GFR on dialysis. Kidney Int2001; 59:754
-63.[Medline]
- Lang SM, Bergner A, Töpfer M, Schiffl H. Preservation of
residual renal function in dialysis patients: effects of
dialysis-technique–related factors. Perit Dial
Int 2001; 21:52
-7.[Abstract/Free Full Text]
TOP
ABSTRACT
CHOOSING A DIALYSIS TYPE
