What is the importance of peritoneal dialysis in treating end-stage renal disease (ESRD)?

The Importance of Peritoneal Dialysis in End-Stage Renal Disease

Peritoneal dialysis represents an attractive alternative dialysis option for patients with end-stage renal disease due to smaller hemodynamic shifts, lack of need for venous catheters, a more patient-centric approach, and potentially better chance at renal recovery compared to hemodialysis. 1

Advantages of Peritoneal Dialysis

• Peritoneal dialysis offers greater autonomy and flexibility for patients as it can be performed at home, allowing for improved quality of life and independence compared to in-center hemodialysis 2, 3
• PD provides more hemodynamic stability with fewer cardiovascular fluctuations compared to conventional hemodialysis, making it particularly beneficial for patients with cardiovascular instability 1
• Home-based peritoneal dialysis eliminates transportation challenges associated with traveling to dialysis centers 3-4 times weekly, which is especially important for patients in remote geographic locations 1
• PD may be more cost-effective than in-center hemodialysis in many healthcare systems 2
• For patients with left ventricular assist devices (LVADs), peritoneal dialysis may decrease hospitalization days and lead to symptomatic improvement even in the absence of kidney failure 1

Special Clinical Scenarios Where Peritoneal Dialysis Excels

• In patients with advanced heart failure requiring mechanical circulatory support, PD offers advantages over hemodialysis due to smaller hemodynamic shifts and reduced risk of ischemic insults to kidneys 1
• For patients with hemodynamic instability who cannot tolerate the rapid fluid shifts of conventional hemodialysis, PD provides a gentler alternative with continuous ultrafiltration 1
• In tumor lysis syndrome management, while PD is less efficient than hemodialysis for removing solutes and fluid, it may still be considered in patients with hemodynamic instability who cannot tolerate hemodialysis 1

Limitations and Contraindications

• Body size can be a relative contraindication when patients are either too small to tolerate prescribed dialysate volumes or too large to achieve adequate dialysis 1
• Inflammatory or ischemic bowel disease, frequent diverticulitis, abdominal wall infections, and morbid obesity may be relative contraindications to peritoneal dialysis 1
• PD is generally less efficient than hemodialysis at removing solutes and fluid, which limits its usefulness in patients requiring significant solute removal 1
• The presence of peritoneal leaks into subcutaneous tissues, pleural space, or genitalia can cause complications and may necessitate switching to hemodialysis 1

Survival Outcomes

• Most studies show that the relative risk of death in patients on peritoneal dialysis versus hemodialysis changes over time, with PD showing a survival advantage in the first 1.5-2 years of dialysis 2, 4
• Recent data from multiple countries including the United States, Brazil, Spain, Australia, and New Zealand show significant improvements in PD patient survival 5
• However, long-term survival rates on PD remain a concern, with some studies showing that over time, the risk of death with PD may equal or exceed that of hemodialysis, depending on patient factors 2, 5

Integration into ESRD Care Planning

• An individualized ESRD Life-Plan should be developed for each patient, considering their medical situation, life goals, preferences, social support, and functional status 6
• While kidney transplantation remains the preferred treatment option for eligible ESRD patients, peritoneal dialysis should be considered as an important alternative to hemodialysis 6, 7
• For patients who choose conservative management without renal replacement therapy, comprehensive palliative care should be provided for symptom management 6, 1

Common Pitfalls and Considerations

• High technique failure of PD persists despite significant reductions in peritonitis rates, which may necessitate switching to hemodialysis over time 2
• Patient education about peritoneal dialysis is often inadequate before beginning dialysis, limiting informed choice between modalities 2
• Special attention should be paid to patients with diabetes, coronary artery disease, or congestive heart failure when they choose PD as their first dialysis modality to reduce mortality risk 5
• The evidence supporting guideline-directed medical therapy in ESRD is generally of very low quality, with most recommendations being conditional rather than strong 8