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Wednesday, January 26, 2011

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Bruce Carter

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.

Tray Mark

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

Peter Laird, MD

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.

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