Despite their advantages, peritoneal dialysis and home hemodialysis remain unpopular modalities

By the end of 2006, approximately 355,000 individuals were undergoing dialysis in the United States. Only 8.2% of them were on peritoneal dialysis (PD). The rest were on hemodialysis (HD), according to a 2008 U.S. Renal Data System (USRDS) report. After a high of 9,407 new patients in 1995, the number of new PD users every year has fallen to 6,725 and accounts for just 6.2% of new dialysis patients—a number that continues to decline from a 1982-1985 peak of 15%, the report noted.

“Fundamentally there's very limited enthusiasm among providers and companies for the use of peritoneal dialysis,” observes Rajnish Mehrotra, MD, associate professor of medicine at the David Geffen School of Medicine, University of California-Los Angeles (UCLA) and associate chief and director for peritoneal dialysis in the division of nephrology and hypertension at Harbor-UCLA Medical Center.

For Dr. Mehrotra, four main issues limit the use of PD:
  1. Inadequate training. Most programs are not set up to provide sufficient home-dialysis education to trainees, preventing them from offering such alternatives to dialysis candidates.
  2. Concerns about outcomes. PD is perceived to have worse outcomes than HD.
  3. Lack of infrastructure. The infrastructure is not in place to provide PD therapy as seamlessly as HD therapy.
  4. Financial considerations. The Centers for Medicare & Medicaid Services (CMS) has created incentives for a greater use of home dialysis treatment—for example, waiving the 90-day waiting period for Medicare eligibility for patients who choose PD or home HD (www.homedialysis.org/resources/medicarefaq/). However, some providers are not aware of these incentives. For the most part, in-center HD has been the most lucrative treatment, at least in part because of the profit margin tied to the greater use of injectable medications such as erythropoietin and vitamin D. (Patients who are dialyzed at home do not require as many injectables; they are more likely to have pills than shots.) Also, increases in HD capacity has put more pressure on providers to fill those chairs, as unfilled hemodialysis capacity is quite costly.

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