Peritoneal Dialysis Called Underused
SEATTLE—Peritoneal dialysis (PD) is underused in the United States even though it offers a number of advantages over hemodialysis (HD), according to a speaker at the 30th Annual Dialysis Conference here.
For example, in the first three years of dialysis treatment, PD is associated with better survival than HD, said Jack Moncrief, MD, Medical Director of the DaVita/Jack Moncrief Dialysis Center in Austin, Tex. Survival rates are similar after that. Moreover, PD patients need less erythropoietin than HD patients.
“The big problem is that there are too many myths,” Dr. Moncrief said. “Also, people don't realize that when they go on dialysis, they still have some remaining kidney function. However, when you put them on hemodialysis that remaining kidney function quickly disappears. That is not the case with peritoneal dialysis.”
Dr. Moncrief, who spoke on the barriers to the use of PD, said many physicians and their patients falsely believe that infections are more common in PD than in HD. Yet, studies show that PD patients experience fewer episodes of peritonitis than HD patients experience sepsis.
Other myths include the mistaken beliefs that all PD patients need vascular access back-up, PD is difficult to manage in the hospital setting, PD is not adequate for large patients, and survival rates are not as good on PD as they are on HD.
As to why PD is not more widely used, Dr. Moncrief noted that “nephrologists have been poorly trained in peritoneal dialysis. They simply are not familiar with how to manage a peritoneal dialysis program.”
In addition, patients are afraid of having a tube stuck in their abdomen, he said, adding that they are more willing to have something to put in their arm. They also do not want the responsibility of performing PD at home. Other barriers to PD use include discomfort among medical staff when it comes to PD and a general lack of information about PD and its costs.
“About one-third of patients on peritoneal dialysis don't need erythropoietin at all,” Dr. Moncrief pointed out. “That is a big economic advantage.” Additionally, PD patients need fewer phosphate binders “because phosphate is removed better with peritoneal dialysis,” he said.
Patients need to be trained and empowered to do their own dialysis, he said. “A lot of times patients come to dialysis and they don't even know there is more than one way to do dialysis,” Dr. Moncrief said. “There is a fundamental bias by the medical staff against teaching the patient to do it themselves and sending the patient out. That is because the medical staff is no longer in control.”
Dr. Moncrief predicts that, as a result of economics, PD will become more widely accepted. In his view, 20% to 30% of dialysis patients should be on PD.
David Goodkin, MD, of Goodkin Biopharma Consulting in Bellevue, Wash., said PD offers patients autonomy and much more freedom compared to HD. For patients who are relatively young and still working, PD allows them to keep normal work hours.
Patients can do their PD exchanges on their own schedule, using a cycling machine while they sleep. “Peritoneal dialysis offers a desirable alternative to patients who wish to continue to be employed, because it frees them from having to visit a hemodialysis center three days each week and allows them autonomy in scheduling their dialysis exchanges,” Dr. Goodkin said.