By Peter Laird
In the last several weeks, there have been several medical journal reports on the benefits of peritoneal dialysis (PD) for patients and for the American ESRD program. Patients on PD have similar outcomes to patients treated with standard in-center hemodialysis at a much reduced cost to the tax payers funding the ESRD program. Many are advocating that PD become the default dialysis modality of choice.
The Path Not Taken On Dialysis
If half the new dialysis patients in the U.S. chose PD over HD, Medicare could save more than $5 billion a year. The additional counseling needed to get to those rates might even jump-start the long overdue conversation about why so many people do so poorly once they’re on dialysis; why so many have failing kidneys in the first place; and what preventive measures can be taken to deal with this burgeoning public health fiasco.
The "news" that PD has similar outcomes to HD is not really a new report at all. Similar outcomes have been documented for more than two decades. What is new according to the latest study is that the 5 year survival remained equal instead of dropping off after two years in prior reports. While this is good news for those that choose PD as their primary dialysis modality, the grim news is that the median survival for PD patients on average is only three years.
Similar Outcomes With Hemodialysis and Peritoneal Dialysis in Patients with End-Stage Renal Disease
Results There was progressive attenuation in the higher risk fo death seen patients treated with PD in earlier cohorts; for the 2002-2004 cohort, there was no significant difference in the risk of death for HD and PD patients through 5 years of follow-up. THe median life expectancy of HD and PD patients was 38.4 and 36.6 months, respectively. Analysis in 8 subgroups based on age (<65 and 
65 years), diabetic status and baselinecomorbidity (none and 1) showed greater improvement in surval among patients treated with PD relative to HD at all follow-up periods.
Once again, while this is good news, it is not the same level of improved survival that we see with the recent short daily hemodialysis report in the FHN, nor is it at the level of cadaveric transplant survival that we have seen with nocturnal hemodialysis on a daily basis that Pauly reported on in 2009 where median survival is greater than 10 years.
Survival among nocturnal home haemodialysis patients compared to kidney transplant recipients
Results. The total study population consisted of 177 NHD patients matched to 1062 DTX and LTX recipients (total 1239 patients) followed for a maximum of 12.4 years. During the follow-up period, the proportion of deaths among NHD, DTX and LTX patients was 14.7%, 14.3% and 8.5%, respectively (P = 0.006). We found no difference in the adjusted survival between NHD and DTX (HR 0.87, 95% CI 0.50–1.51; NHD reference group), while LTX survival was better (HR 0.51, 95% CI 0.28–0.91).
Conclusions. These results indicate that NHD and DTX survival is comparable, and suggest that this intensive dialysis modality may be a bridge to transplantation or even a suitable alternative in the absence of LTX in the current era of growing transplant waiting lists and organ shortage.
In addition, home hemodialysis compares very favorably with home PD for cost savings benefits when the direct and indirect costs of care such as preventable hospitalizations is utilized in the analysis.
Cost savings of home nocturnal versus conventional in-center hemodialysis
HNHD provides about three times as many treatment hours at nearly a one-fifth lower cost, with savings evident even when only program and funding-specific costs are considered.
Dr. Victoria Kumar, et al, at Kaiser Permanente in Southern California reported a direct comparison of observational results of their home PD and home SDHD patients showing a significant benefit to the home hemodialysis cohort in reduced hospitalizations and over all complication rates.
Costs of Home Hemodialysis Offset by Better Health, Fewer Hospitalizations
Daily hemodialysis administered in patients’ homes is associated with better health outcomes compared with peritoneal dialysis, according to an article in the October issue of the American Journal of Kidney Diseases, the official journal of the National Kidney Foundation. . .
Dr. Kumar’s group treated the 22 patients in the daily hemodialysis group and the 64 in the peritoneal dialysis group for at least 6 months between 2003 and 2007. The groups were comparable in age, the number of patients with diabetes, and causes of kidney failure..
Despite these similarities, patients treated by peritoneal dialysis spent nearly twice as many days each year in the hospital compared with patients treated with home hemodialysis (average 5.6 days/patient-year versus 3.3 days/patient-year).
Those treated by daily home hemodialysis were also able to reduce the number of medications required to keep their blood pressure under control, and had better nutritional status than they did prior to starting treatment, as shown by higher serum albumin levels.
In addition, there are certain patient groups who do substantially worse on PD than on HD. These include morbidly obese patients and patients with CHF, which is the number one complication noted in hospitalized ESRD patients.
Results The overall prevalence of CHF was 33% at ESRD initiation. There were 27,149 deaths (25.2%), 5423 transplants (5%), and 3753 (3.5%) patients lost to follow-up over 2 years. Adjusted mortality risks were significantly higher for patients with CHF treated with peritoneal dialysis than hemodialysis [diabetics, relative risk (RR) = 1.30, 95% confidence interval (CI) 1.20 to 1.41; nondiabetics, RR = 1.24, 95% CI 1.14 to 1.35]. Among patients without CHF, adjusted mortality risk were higher only for diabetic patients treated with peritoneal dialysis compared with hemodialysis (RR = 1.11, 95% CI 1.02 to 1.21) while nondiabetics had similar survival on peritoneal dialysis or hemodialysis (RR = 0.97, 95% CI 0.91 to 1.04).
Conclusion New ESRD patients with a clinical history of CHF experienced poorer survival when treated with peritoneal dialysis compared with hemodialysis. These data suggest that peritoneal dialysis may not be the optimal choice for new ESRD patients with CHF perhaps through impaired volume regulation and worsening cardiomyopathy.
When cost savings and survival benefits are fitted into the same discussion, home nocturnal hemodialysis is very comparable to PD for overall costs at the same time it is also very comparable to cadaveric renal transplant survival. Looking at the issue of what should be America's default dialysis treatment modality when patients are not able to do a preemptive transplant, in my opinion, that default standard of care should be first line home nocturnal hemodialysis.
Home nocturnal hemodialysis is not the treatment of choice for all patients due to underlying factors including the ability to self cannulate and having supportive family resources available, but as many as 30% of patients starting dialysis could utilize this life saving technology by many estimates. New Zealand has over 25% of its ESRD population on home hemodialysis as proof that high numbers of people can be helped in this manner.
When comparing all aspects of renal replacement therapy, although PD is an excellent and right choice for many, using it as the default standard of care in America is not going to correct our high mortality rate that home nocturnal dialysis does address at a significant cost savings to the system and significant health benefits to the patient. In my opinion, home, nocturnal hemodialysis is the firstline treatment that should be the gold standard of care offered to all eligible patients at the onset of renal replacement therapy for ESRD when transplant is not an immediate option.
Excellent post - lays it out quite clearly. In terms of survival, PD is clearly not "optimal" - at least compared to daily home HD. However the studies do make the case that PD is not inherently worse than traditional in-center dialysis. PD arguably improves quality-of-life during those three or so years of median survival, with fewer ups/downs and washouts, compared to in-center.
Therefore, perhaps advocating PD is at least a step in the right direction, if it helps home dialysis of all kinds to gain acceptance. So, perhaps home PD can be thought of as a "bridge to home HD" by changing perceptions and nurturing this emerging market.
Perhaps wearable near-continuous PD and long-term dialysate regeneration technology (some soon starting human trials) will improve PD survival, or at least quality of life.
However, for patients to benefit from advances in PD or home HD on the horizon, it still seems in everyone's interest to help incubate the home dialysis market in general.
Charles Lindbergh wasn't actually the first person to fly across the Atlantic--but he changed how everyone thought about how the Atlantic should be crossed. Better airplanes soon followed.
Keep up the good work.
Posted by: Bruce Carter | Friday, January 28, 2011 at 08:26 PM
Don't know what to make of this new statistical analysis below (Jan 10, 2013). It is well known that patients on PD has better control of their metabolic acidosis than HD and perhaps that improves their residual renal function and mortality rate.
"Comparing survival of PD and HD among 23,718 incident dialysis patients during their first 2 years of dialysis treatment in a nationally representative cohort using statistical techniques that account for time-varying confounding and differential censorships, we found that incident PD patients had 48% greater survival."
Clin J Am Soc Nephrol 8: ccc–ccc, 2013. doi: 10.2215/CJN.04810512
Posted by: Tray Mark | Wednesday, January 16, 2013 at 08:33 PM
Dear Tray, I find it quite phenomenal that DaVita finds such a benefit now that they have a significant financial incentive to place patients on PD when you compare PD to historical records. Under the bundle, PD is the least expensive treatment option. I am not sure what new methods of PD DaVita has discovered to account for such an astounding improvement in mortality.
I must take many of the new studies since the bundle with a grain of salt recognizing the potential financial bias of such outcomes. The USRDS data does not show anywhere near a 48% improved mortality.
Posted by: Peter Laird, MD | Wednesday, January 16, 2013 at 09:10 PM