Peritoneal Dialysis Versus Hemodialysis: Risks, Benets, and Access Issues

Ramapriya Sinnakirouchenan and Jean L. Holley

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 rst 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 signicantly 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 signicant 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. Q 2011 by the National Kidney Foundation, Inc. All rights reserved. Key Words: Tunneled catheters, End-stage renal disease, Chronic kidney disease

ntegrated care models of chronic kidney disease (CKD) and end-stage renal disease (ESRD) emphasize transitions between treatment modalities (hemodialysis [HD], peritoneal dialysis [PD], and kidney transplantation) and the possibility that a specic patient will, in his or her lifetime with CKD/ESRD, experience more than one of these modalities. For most patients, successful kidney transplantation is the best treatment for ESRD. However, the lack of available donor organs, comorbid conditions, and patient choice preclude transplantation in many patients, thereby making chronic dialysis the only option for some beginning renal replacement therapy. Medical and social conditions as well as geographic considerations and patient choice should dictate the selection of PD (continuous ambulatory PD or continuous cycling PD) or hemodialysis (HD), but patient choice should always be the primary factor in that decision. However, patient choice requires adequate modality education, which, unfortunately, is not always the case. As a consequence, physician preference and experience and reimbursement issues may also inuence modality choice.1-4 Implicit in the decision to initiate HD or PD is a consideration of the risks and benets of each modality, and those issues will be the focus of this discussion.

Risks and Benets of PD Versus HD

Table 1 shows some of the primary benets of each modality. We are not specically considering home HD, but many of the general benets of PD listed in the table also apply to home HD. Initial modality selection should in most cases be patient/family directed, with primary considerations focused on lifestyle and social issues such as patient autonomy, geographic locationas it affects transportation to and from the dialysis center, living situation, patient motivation, and patient and family employment. Patient education about modality options is required for informed decision making and, in most cases, will be somewhat dependent on physician input and encouragement. Unfortunately, US nephrologist training in PD is often inadequate,5 and although most nephrologists believe at least 40% of ESRD patients should be on PD,6 less than 10% of current US dialysis patients are on PD.7 Bundling of dialysis services and reimbursement for predialysis education may increase the numbers of patients on PD over the next few years.4 In general, when patients are required to be seen regularly before dialysis and educated about PD, up to 45% of patients choose PD.8 Distance from an HD center is a primary factor in the choice of PD, accounting for 25% of the variability of dialysis modality choice in a 1996 to 1997 study of 3793 incident dialysis patients.1 Younger, white, employed, more educated patients in this study were likely to choose PD over in-center HD.1 Because patient survival and acceptable quality of life are the ultimate goals of renal replacement therapies, it is important to compare mortality and morbidity in patients on PD and HD. The inuence of dialysis modality on patient survival is somewhat controversial, with early studies showing a 19% higher adjusted mortality rate in PD patients.9 However, subsequent studies demonstrated similar

From Department of Internal Medicine, University of Illinois, UrbanaChampaign, Champaign, IL; and Carle Physician Group, University Avenue, Urbana, IL. Address correspondence to Jean L. Holley, MD, Carle Physician Group, Nephrology, S2S2, 602 West University Avenue, Urbana, IL 61801. E-mail: jholley@illinois.edu 2011 by the National Kidney Foundation, Inc. All rights reserved. 1548-5595/$36.00 doi:10.1053/j.ackd.2011.09.001

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survival in PD and HD patients and emphasized that pain peritonitis rates, infection remains the primary reason tient comorbidity, age, and cause of ESRD were the prifor transfer to HD. In one prospective study of 28 dialysis mary factors affecting survival.10 More recent studies centers, 25% of PD patients transferred to HD, with 70% have described improved survival in PD patients, espeof those transferring within 2 years of starting PD.20 Re11,12 After 1.5 to 2 current peritonitis may also lead to membrane failure, cially in the rst 1 to 2 years of ESRD. years on dialysis, the risk of death in PD patients becomes and ultraltration failure is the cause of 2% to 14% of equivalent to or greater than that in HD patients, dependtransfers from PD.21 An analysis of USRDS data suggests improved technique survival in recent cohorts of PD paing on patient factors such as age, diabetes, and other cotients.22 Additional risks of PD are shown in Table 1 and morbidities. Two recent studies showed the negative include weight gain, caregiver and patient burnout, and, effects of central venous catheter (CVC) on patient surwith the loss of residual kidney function, possible inadevival.13,14 Perl and colleagues demonstrated similar survival in PD and HD patients who began with an quate small solute clearance. arteriovenous stula (AVF) or arteriovenous graft Dialysis adequacy is assessed on a routine basis in (AVG) (90-day survival: 7.4% for PD and 6.1% for HDboth HD and PD patients. Although the daily small AVF/AVG), but signicantly worse survival for HD paurea clearance on PD is signicantly less than the urea tients beginning dialysis with a CVC (15.6% survival, clearance of a single HD treatment, the continuous nature 13). Another small study of 123 patients starting dialysis of PD provides adequate overall clearance as measured in an unplanned fashion showed equivalent 6-month surby weekly kt/V. Some would suggest that the more frevival for HD and PD patients quent physician visits of but a higher relative risk of HD patients (PD patients CLINICAL SUMMARY bacteremia in the HD paare generally seen monthly tients, suggesting acute and HD patients up to 4  A PD survival advantage is seen early in the course of renal start PD is a viable option times per month) is a benet replacement therapy, but after 1 to 2 years, patient survival for late referral patients.14 of HD over PD. However, on PD or HD is equivalent and inuenced by comorbidity and age. The observed early PD surthere are no data showing vival advantage may in part improved patient survival  The high rate of technique failure in PD remains primarily be due to improving survival or reduced morbidity assoa function of infectious complications although peritonitis rates are now low in experienced PD programs. Infection of PD patients in general, ciated with the frequency and access issues are the most common problems for perhaps due to technical adof physician visits. For patients on HD, and, especially for HD patients using CVC, vances and increasing expesome patients, HD provides high mortality and morbidity are to be expected. rience of nurses and an opportunity for sociali Recent changes in reimbursement for dialysis education as nephrologists with PD.4 PD zation and development of well as bundling of dialysis services may lead to a renewed program experience remains a caring community of interest in PD in the United States. Nephrologists efforts an inuence on patient and friends and caretakers intershould be focused on educating themselves and their technique success in PD, ested in the patient and his patients about the opportunities for home modality therapies and reducing the reliance on catheters for longwith more experienced or her welfare. For many term HD access. (large programs with more PD patients, the support of patients) programs reporting the home dialysis nurses lower rates of technique failmay provide a similar expeure and patient mortality.15 In addition, maintenance of rerience. Caregiver burnout and depression are less with sidual kidney function may contribute to reduced HD patients.23 As the dialysis population is increasingly mortality, and most studies report better preservation of older and less functionally independent, caregiver needs residual kidney function in patients on PD compared and response assume an important consideration in dialwith patients on HD.16 Some studies have reported higher ysis outcomes and deserve more attention and study. mortality in PD patients with underlying heart disA few studies have shown less delayed graft function ease.17,18 Other studies have noted a higher incidence of after kidney transplantation in PD patients compared hemorrhagic stroke in patients on HD although a USRDS with HD patients.24,25 Factors involved may include patient volume status and residual kidney function at the analysis concluded that the risk of death from stroke was time of transplantation. A recent study showed a 10% greater in PD patients despite a lower prevalence of preexlower (P .014) all-cause mortality in patients on PD isting cerebrovascular disease.19 Patient comorbidity, including diabetes and age, inuences mortality. compared with those on HD before transplantation.26 Although mortality may be lower in PD patients during the rst 1 to 2 years of dialysis, technique failure with Access in PD and HD PD remains fairly high and negatively affects patients Table 1 illustrates the risks of HD and PD, and among the quality of life owing to the need for interventions (new most common are access-related issues. HD is virtually access) and transfer to HD. Despite signicant reductions

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Table 1. Risks and Benets of PD and HD Benets PD Survival years 12 Patient autonomy Patient satisfaction Maintenance of RRF Less delayed graft function post transplant Lower cost Less patient responsibility Community/socialization Risks High technique failure (membrane failure, infection) Weight gain Patient and caregiver burnout

HD

Infection (bacteremia, sepsis) Access complications Higher mortality in the period just before and 12 hours after treatment, possibly due to electrolyte issues

Abbreviation: RRF, residual renal function.

always used as initial therapy when patients present with acutely discovered CKD, primarily because of the availability and suitability of CVC for immediate HD access. However, the risks associated with CVC are signicant, with a 2- to 3-fold increase in mortality, a 5- to 10-times increase in serious infection, and increased rates of hospitalization in HD patients using CVC for HD access.27 In addition, long-term CVC use is associated with a higher number of vascular procedures and higher incidence of inadequate dialysis.28,29 Some researchers have suggested that catheters may also contribute indirectly to high patient mortality by acting as an instigator of a chronic inammatory condition that predisposes to morbidity and mortality.30,31 The nding of higher CRP levels in HD patients without overt infection but with CVC has raised this possibility and concern.30,31 Moreover, long-term CVC access for HD is associated with osteomyelitis, septic arthritis, endocarditis, poor quality of life, and central vein stenosis that may limit future options for arteriovenous access.27-29 Efforts to reduce the risk of catheters for HD access have focused on early nephrology referral, creation of a multidisciplinary dialysis access team, and patient and nephrologist education,27,32 but CVC use remains high in the United States. Some have suggested that patients who refuse creation of an arteriovenous stula or graft and choose to continue using a CVC as HD access should be required to sign an informed refusal of AVF form and ultimately be referred to another nephrologist for care.27 In such instances, a quality care issue is cited as the reason for refusing ongoing care of a patient who declines AVF or AVG placement.27 Although such action may be more drastic than many nephrologists are willing to consider, it is incumbent on nephrologists as a group to make all efforts to reduce the use of dialysis catheters. Although a variety of PD catheters are available, the differences among them are minor, and the decision to use one catheter over another depends primarily on the preferences of the physician inserting the catheter. Function and infection rates are generally similar for all available PD catheters although relatively small studies may advocate for certain catheters or implantation techniques

(eg, Tenckhoff vs swan-neck catheters, surgical vs laparoscopically implanted, buried vs nonburied).33-35 The lack of surgical training in PD catheter placement may be an issue for some programs.36 PD catheters are placed in the abdomen, but for some patients (obese, those with ostomies, children), the presternal catheter exit site location may be preferable.37 Complications associated with PD catheters may include poor drainage and infection. Infection remains the most common cause for transfer to HD, but in successful PD programs, peritonitis rates are now 1 every 20 to 37 mo/patient.4,38 Moreover, compared with CVC-associated infections, PD-associated catheter infections rarely lead to death and are less frequently associated with hospitalization.4 Quality improvement programs to examine infection rates, causes, and preventive protocols are integral to any PD program and are increasingly being adapted by HD programs to lower infection rates.

Costs and Patient Satisfaction in PD and HD

Although there are few studies examining dialysis patients satisfaction, PD patients usually report higher satisfaction than in-center HD patients.39,40 Explanations for this may relate to the patients themselves and their perceived quality of life and independence (generally higher among PD patients) but may also reect inherent qualities in patients that lead them to choose a home-based modality. Interestingly, PD patients are also more satised with their medical care providers (nurse and physician) despite less direct exposure to nephrologists than that experienced by in-center HD patients who are commonly seen weekly. The availability of the PD nurse and the close relationship that often develops between PD nurses and their patients may foster patient condence and support in a way that leads to more satisfaction than that experienced by in-center HD patients. The lack of controlled studies examining patient satisfaction and the confounding issue of selection bias suggests additional study of this issue is needed. Because dialysis is a Medicare benet in the United States, the cost of treatment to society is relevant. PD

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remains less expensive than in-center HD, with per year patient costs of $53,446 and $73,008, respectively, as revealed by Medicare data.7 Under private insurance coverage, PD was also signicantly less expensive than HD ($173,507 vs $129,997, P .03) in the rst year after starting dialysis in 463 dialysis patients, in part because hospitalization rate was lower among PD patients.41 However, before January 2011, the cost of medications administered during dialysis was typically higher for HD patients. With the inception of dialysis services bundling, costs of intravenous medications given during HD will likely fall, and thus, the total treatment cost of HD should also fall. Owing to the costs of equipment and, importantly, staff needed in the HD unit, PD treatment costs are likely to remain lower than HD costs, but the overall cost difference between the 2 modalities may narrow. There is a specic payment for professional services provided during training for home dialysis that can be billed by nephrologists and may act as a nancial incentive to build home dialysis programs. There is no similar payment for in-center HD.

Summary
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. A PD survival advantage is seen early in the course of renal replacement therapy, but after 1 to 2 years, patient survival on PD or HD is equivalent and inuenced by comorbidity and age. The high rate of technique failure in PD remains primarily a function of infectious complications although peritonitis rates are now low in experienced PD programs. Infection and access issues are the most common problems for patients on HD, and, especially for HD patients using CVC, high mortality and morbidity are to be expected. Consideration of PD as a bridge for access maturation and initial treatment in late referral patients should be entertained in an effort to avoid CVC. Recent changes in reimbursement for dialysis education as well as bundling of dialysis services may lead to a renewed interest in PD in the United States. Nephrologists efforts should be focused on educating themselves and their patients about the opportunities for home modality therapies and reducing the reliance on catheters for long-term HD access.

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