Peritoneal Dialysis: Does It Have a Brighter Future?

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In the 1960s and through the 1970s, intermittent peritoneal dialysis (PD) was used for the long-term treatment of uremia. The results, however, were disappointing.1

Three major advances have made continuous treatment with PD possible now for more than 30 years: an indwelling intraperitoneal catheter (Tenckhoff), description of continuous ambulatory PD (Popovich and Moncrief), and introduction of disposable, plastic containers for the dialysate (Oreopoulous).2-4

Starting from the 1980s, an increasing number of end-stage renal disease (ESRD) patients are being treated with PD around the world. As of 2010, it is estimated that almost one half of these patients reside in one of three countries (Mexico, United States, and China). However, in many developed countries, but particularly in the United States, the number of patients treated with PD has remained largely unchanged over the last 15 years while the total dialysis population has almost doubled in size.5

Hence, the proportion of ESRD patients treated with PD in countries like the United States, Canada, United Kingdom, Australia, and New Zealand has progressively declined.6 So, what does the future hold for PD as renal replacement therapy? More importantly, should the nephrology community care about the future of PD?

PD: Why should we care? 

A diagnosis of ESRD has a profound impact on patients' emotional well-being. In a German study, more than 10% of hemodialysis (HD) patients reported the presence of symptoms compatible with post-traumatic stress disorder attributable to the need for dialysis.7 Studies also suggest that up to a quarter or more of dialysis patients have depression.

Furthermore, the need for dialysis requires patients to make major lifestyle changes. For some patients, the ability to dialyze at home allows them to preserve their dignity and independence better than coming to a dialysis unit for their treatments.8 Indeed, PD patients report greater satisfaction with their treatment. This is due largely to the education and support they are provided before and after they start maintenance dialysis.9

Yet, much too often, patients in the United States are not aware of or offered the choice of dialyzing at home.10 When given a choice, many more patients choose to dialyze at home than would be predicted based upon PD utilization in the United States.11 These lines of evidence suggest that the current low rate of PD utilization in the United States does not reflect patient choice. This is unfortunate given how large the impact of a diagnosis of ESRD and need for dialysis is on patients' well-being.

There is also a strong economic argument to be made for a greater use of PD. The costs of dialysis in the United States are almost entirely borne by the taxpayers. The annual per-patient Medicare payments for patients treated with PD are about $20,000 lower than for patients treated with HD.5

The annual costs are lower even when one accounts for the lower age and burden of co-existing diseases and a higher rate of transfer to HD for patients who begin treatment with PD.12 Medicare provides equal reimbursement for the delivery of both dialysis modalities; the higher costs for patients treated with HD are driven by a greater use of injectable medications and expenses related to maintaining vascular access.

Given the lower costs to the payer, it is not surprising that the Centers for Medicare and Medicaid Services (CMS) has offered financial incentives to promote a greater use of home dialysis, with Medicare coverage starting on day 1 rather than day 90 of dialysis for Medicare-eligible but previously uncovered patients. CMS also provides reimbursement for both the dialysis facility and physician for training a patient for home dialysis. In addition, physicians are not required to have a face-to-face visit with a patient in order to receive the monthly capitated payment.

PD Outcomes

Many studies evaluating the outcomes of patients treated in the 1990s showed a lower early risk of death but a higher long-term risk for patients treated with PD when compared with those treated with in-center HD.6 Since then, outcomes of PD patients have improved significantly more than those of patients treated with in-center HD6

Hence, in the most recent cohorts, the adjusted five-year survival of PD patients in the United States is no different from that of patients treated with in-center HD.13 Equally importantly, similar long-term survival of patients treated with either of the two dialysis modalities has been reported from countries like Canada, Australia, and New Zealand, where PD is used by a substantially larger proportion of ESRD patients than in the United States.14 This provides reassurance that one could expect similar long-term survival even if a larger proportion of patients were to be treated with PD in the United States.

A greater need to change dialysis modalities is another challenge for patients treated with PD. However, in the most recent cohorts, fewer patients need to transfer to HD than they did in the 1990s.15 Moreover, the more PD patients in a dialysis unit, the lower the need for the patients to transfer to HD.15 This suggests that the risk of transfer to HD is modifiable and can be reduced with continuous quality improvement programs.

Planning for the future

As previously mentioned, the long-term survival of PD patients now is no different from that of patients treated with in-center HD. Furthermore, even though it is probably likely that more PD patients will need to change dialysis modality than those treated with in-center HD, a significant proportion of transfers can be prevented by better training of physicians and a stronger infrastructure to support patients. It follows that offering PD to all patients who begin dialysis will allow them to choose the therapy that best fits their lifestyle without having a meaningful impact on their morbidity or mortality. Our ability to offer PD has been enhanced by two major regulatory changes.

First, reimbursement is now available for providing pre-dialysis education for Medicare patients with stage 4 CKD. Second, the final rules for the “expanded bundle” for the provision of dialysis services further incentivizes the use of home dialysis. Hence, the “expanded bundled” payment for in-center HD and PD will be identical, although the reduced need for injectable drugs in PD patients provides a financial incentive for providers to use PD for a larger proportion of patients.

Moreover, additional reimbursement will be available for training home dialysis patients if such training was to occur after the first four-months of the start of dialysis treatment. During the first four months, a “new patient add-on” payment is expected to cover the costs of training. We hope that the reports of improvements in outcomes of PD patients and greater financial incentives to the providers will lead to wider use of PD in the United States. If such an increase occurs, this is expected to translate into greater cost-savings for the taxpayers and allow more patients to be treated for a given budgetary allocation for dialysis.

Dr. Mehrotra is Professor of Medicine in the Division of Nephrology and Hypertension at Harbor UCLA Medical Center in Torrance, Calif., where he is Associate Chief of the division and Director of the Peritoneal Dialysis Program.

References

  1. Ahmad S, Gallaher N, Shen F. Intermittent peritoneal dialysis: status reassessed.   Trans m Soc Artif Int Org. 1979;25:86-88.           
  2. Tenckhoff H, Schechter H. A bacteriologically safe peritoneal access device. Trans Am Soc Artif Int Org. 1973;10:181-187.
  3. Popovich RP, Moncrief JW, Nolph KD, et al. Continuous ambulatory peritoneal dialysis. Ann Intern Med. 1978;88:449-456.
  4. Karanicolas S, Oreopoulos DG, Pylypchuk G,  et al. Home peritoneal dialysis: 3 years' experience in Toronto. Can Med Assoc J. 1977;116:266-269.
  5. United States Renal Data System. US Department of Public Health and Human Services, Public Health Service, National Institutes of Health, Bethesda,  2009.
  6. Khawar O, Kalantar-Zadeh  K, Lo WK, et al. Is the declining use of long-term peritoneal dialysis justified by outcome data? Clin J Am Soc Nephrol. 2007;2:1317-1328.
  7. Tagay S, Kribben A, Hohenstein A, et al. Posttraumatic stress disorder in HD patients. Am J Kidney Dis. 2007;50:594-601.
  8. Morton RL, Tong A, Howard K, et al. The views of patients and carers in treatment decision making for chronic kidney disease: systematic review and thematic synthesis of qualitative studies. BMJ. 2010;340:c112.
  9. Rubin HR, Fink NE, Plantinga LC, et al. Patient ratings of dialysis care with peritoneal dialysis vs HD. JAMA. 2004;291:697-703.
  10. Mehrotra R, Marsh D, Vonesh E, et al. Patient education and access of ESRD patients to renal replacement therapies beyond in-center HD. Kidney Int. 2005;68: 378-390.
  11. Golper TA, Vonesh EF, Wolfson M, et al. The impact of pre-ESRD education on dialysis modality selection. J Am Soc Nephrol. 2000;11:231A.
  12. Shih YC, Guo A, Just, PM, Mujais S. Impact of initial dialysis modality and modality switches on Medicare expenditures of end-stage renal disease patients. Kidney Int. 2005;68:319-329.
  13. Mehrotra R, Chiu YW, Kalantar-Zadeh K, et al. Similar outcomes with HD and peritoneal dialysis in patients with end-stage renal disease. Arch Intern Med. 2011 (in press).
  14. Jiwakanon S, Chiu YW, Kalantar-Zadeh K, Mehrotra R. Peritoneal dialysis: an underutilized modality. Curr Opin Nephrol Hypertens. 2010; Jul 15 Epub.
  15. Mehrotra R, Chiu YW, Kalantar-Zadeh K, Vonesh E. The outcomes of continuous ambulatory and automated peritoneal dialysis are similar. Kidney Int. 2009;76:97-107.
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