Do patients feel better with peritoneal dialysis or hemodialysis (HD)?

Peritoneal Dialysis vs. Hemodialysis: Impact on Patient Well-Being

Peritoneal dialysis generally provides better patient satisfaction and quality of life compared to hemodialysis, with patients reporting higher overall ratings of care and greater autonomy, though clinical outcomes are largely similar between modalities. 1

Patient Experience and Quality of Life

Patient Satisfaction

• PD patients are significantly more likely to give excellent ratings of their dialysis care compared to HD patients (85% vs 56%) 2
• The greatest differences in satisfaction ratings are in the domain of information provided (69% excellent for PD vs 30% for HD) 2
• Home dialysis modalities (including PD) are associated with greater patient autonomy and treatment satisfaction compared to in-center modalities 1

Quality of Life Considerations

• PD patients typically report better quality of life in specific domains:
  • Fewer dietary restrictions
  • More flexible schedule
  • Greater travel ability
  • Better control over treatment environment 3
• HD patients may experience greater improvements in physical functioning and general health perception over time 3
• PD patients may experience better financial outcomes but worse sleep quality compared to HD patients 3

Clinical Outcomes and Survival

• Mortality rates are generally comparable between PD and HD modalities 4
• The relative risk of death changes over time:
  • PD shows lower mortality risk in the first 3 months of dialysis
  • PD's survival advantage continues for 1.5-2 years
  • Over time, the risk of death with PD equals or becomes greater than with in-center HD, depending on patient factors 5

Specific Considerations for Different Patient Groups

Cardiovascular Disease Patients

• PD may be better tolerated in patients with cardiovascular disease due to:
  • Better hemodynamic control
  • Less acute electrolyte shifts that could cause arrhythmias
  • Better control of anemia (important for coronary artery disease patients) 1

Heart Failure Patients

• Peritoneal dialysis represents an attractive alternative for patients with left ventricular assist devices (LVADs) due to:
  • Smaller hemodynamic shifts
  • No need for venous catheters
  • More patient-centric approach
  • Better chance of renal recovery with fewer ischemic insults to kidneys 1

Malnourished Patients

• PD may not be suitable for severely malnourished patients due to:
  • Peritoneal protein losses
  • Potential inability to comply with the dialysis regimen 1

Complications and Pitfalls

Peritoneal Dialysis Pitfalls

• Technique failure remains high despite reductions in peritonitis rates 5
• Peritonitis risk is higher in patients with frequent episodes of diverticulitis 1
• Protein losses through the peritoneum can worsen malnutrition 1
• Abdominal pain may occur, requiring management strategies such as:
  • Reducing dialysate fill volume by 25-50%
  • Switching to more frequent exchanges with smaller volumes
  • Adjusting PD modality (CAPD to APD) 6

Hemodialysis Pitfalls

• Infection remains an important cause of mortality and morbidity, especially with central venous catheter access 5
• Rapid shifts in solute transport and volume can cause hemodynamic instability 1
• Transportation to and from dialysis centers 3-4 times weekly can be challenging for patients in certain locations 1

Cost Considerations

• PD costs are significantly lower than HD costs 5
• From a societal perspective, PD is the most cost-effective dialysis alternative 4
• Increasing the proportion of patients receiving PD could result in significant healthcare savings 4

Decision Algorithm for Modality Selection

1. Assess patient preference and autonomy desires

   • If patient strongly values independence and flexible schedule → Consider PD
   • If patient prefers healthcare professional supervision → Consider HD

2. Evaluate cardiovascular status

   • If severe cardiac disease or LVAD present → PD may be preferable
   • If hemodynamically stable → Either modality suitable

3. Consider nutritional status

   • If severely malnourished → HD may be preferable
   • If normal nutritional status → Either modality suitable

4. Assess abdominal status

   • If frequent diverticulitis, extensive abdominal adhesions, or mechanical defects → HD recommended
   • If normal abdominal status → Either modality suitable

5. Evaluate home situation and support

   • If capable of self-care or has suitable assistant → PD feasible
   • If physically/mentally incapable without assistant → HD recommended

6. Consider long-term planning

   • If transplantation expected within 2 years → PD may offer survival advantage
   • If long-term dialysis expected → Consider starting with PD and transitioning to HD later if needed

The evidence suggests that PD should be offered as the first dialysis modality when feasible, with HD as a complementary therapy that patients can transition to if needed, keeping in mind their long-term treatment goals 7.