What are the factors to consider when choosing between Peritoneal Dialysis (PD) and Haemodialysis (HD) for patients with Impaired renal function?

Factors to Consider When Choosing Between Peritoneal Dialysis (PD) and Hemodialysis (HD)

The choice between Peritoneal Dialysis (PD) and Hemodialysis (HD) should be based on patient-specific factors including medical contraindications, lifestyle considerations, and residual kidney function, with PD offering advantages as first-line therapy for suitable patients due to better preservation of residual renal function and comparable early survival outcomes. 1

Medical Factors

Medical Contraindications for PD

• Abdominal Conditions:

  • Inflammatory or ischemic bowel disease increases risk of transmural contamination by enteric organisms 2
  • Frequent episodes of diverticulitis significantly increase peritonitis risk 2
  • Severe lumbo-sacral disk disease may limit tolerance of peritoneal fluid volumes 2
  • Advanced polycystic kidney disease may restrict intraperitoneal volumes 2

• Respiratory Issues:

  • Advanced lung disease may limit tolerance of peritoneal fluid volumes 2
  • Recurrent hydrothorax is a contraindication due to fluid management challenges 2

• Skin and Abdominal Wall Integrity:

  • Abdominal wall or skin infections increase risk of catheter site contamination 2
  • Presence of colostomy/ileostomy requires individualized assessment 2

• Nutritional Status:

  • Severe malnutrition is a relative contraindication due to:
    • Compromised wound healing
    • Inability to tolerate peritoneal protein losses
    • Potential compliance issues with self-dialysis regimen 2

• Body Habitus:

  • Morbid obesity presents challenges in catheter placement, healing, and achieving adequate dialysis 2
  • Increased caloric absorption from dialysate may exacerbate weight gain 2

Transport Characteristics

• Peritoneal Equilibration Test (PET) results should guide modality selection:
  • High transporters may experience poor ultrafiltration and excessive protein losses on PD 2
  • Low transporters may have inadequate peritoneal clearance of creatinine 2

Residual Kidney Function

• PD better preserves residual kidney function compared to HD 1
• Residual function significantly contributes to solute clearance and fluid removal 1
• Patients with substantial residual function may particularly benefit from PD 3

Patient-Centered Factors

Quality of Life Considerations

• Lifestyle Flexibility:

  • PD offers greater independence and flexibility for travel 4
  • Home-based therapy eliminates need for thrice-weekly center visits 1

• Employment Opportunities:

  • PD patients have increased chances of maintaining employment 1

• Patient Satisfaction:

  • Patient satisfaction may be higher with PD compared to in-center HD 4

Patient Education and Decision-Making

• Structured Education Process:

  • Patient decision aid tools (PDAs) significantly improve concordance between chosen and definitive treatment modality 5
  • When properly educated, patients choose PD and HD in approximately equal proportions (45% PD, 43% HD) 5

• Timing of Education:

  • Early education before dialysis initiation leads to higher rates of PD selection 5
  • Patients without proper education before dialysis start are less likely to choose PD 5

Clinical Outcomes

Survival Outcomes

• Early Survival Advantage:

  • PD shows lower relative risk of death in the first 1.5-2 years of dialysis 4
  • This advantage is particularly pronounced in the first 3 months 4

• Long-Term Outcomes:

  • Over time (>2 years), risk of death with PD equals or exceeds that of HD 4
  • Survival advantage depends on patient factors including age and comorbidities 4

Technique Survival

• PD Technique Failure:
  • High technique failure rates persist despite reductions in peritonitis 4
  • Patients often need to switch from PD to HD over time 1

Complications

• Infection Risk:
  • PD: Peritonitis remains a significant complication 4
  • HD: Infection risk is high with central venous catheters 4

Economic and System Factors

• Cost Considerations:
  • PD costs are significantly lower than HD costs 4, 3
  • Cost advantage is particularly relevant for healthcare systems with limited resources 3

Indications for Switching from PD to HD

• Consistent failure to achieve target Kt/Vurea and creatinine clearance 2
• Inadequate solute transport or fluid removal 2
• Unmanageably severe hypertriglyceridemia 2
• Unacceptably frequent peritonitis or other PD-related complications 2
• Development of technical/mechanical problems with catheter 2
• Severe malnutrition resistant to aggressive management 2

Decision Algorithm

1. Initial Assessment:

   • Evaluate for absolute contraindications to either modality 2
   • Assess residual kidney function 1
   • Consider patient's lifestyle, employment, and support system 1

2. For New Patients with No Contraindications:

   • Consider PD as first-line therapy due to:
     • Better preservation of residual kidney function 1
     • Early survival advantage 4
     • Comparable quality of life 1
     • Lower healthcare costs 4, 3

3. For Patients with Specific Conditions:

   • Cardiovascular disease: Consider PD to avoid hemodynamic instability associated with HD 4
   • Vascular access problems: PD may be preferable 6
   • Morbid obesity or severe malnutrition: HD may be more appropriate 2
   • Inflammatory bowel disease or frequent diverticulitis: HD is preferable 2

4. Long-term Planning:

   • Consider PD as initial therapy with transition to HD if technique failure occurs 1
   • Prepare for potential modality changes during the patient's dialysis career 3

Common Pitfalls to Avoid

• Inadequate Patient Education: Failure to properly educate patients about all modality options often leads to default selection of HD 5
• Ignoring Peritoneal Transport Characteristics: Not considering PET results when prescribing PD can lead to inadequate dialysis 2
• Overlooking Residual Kidney Function: Failing to account for the contribution of residual function to overall clearance 1
• Not Planning for Technique Failure: Not preparing patients for potential need to switch modalities over time 3
• Physician/Nurse Bias: Healthcare provider preference influencing patient choice rather than objective assessment 4