Importance of lifestyle

In Dr. Mehrotra’s view, virtually all patients with end-stage renal disease (ESRD) are candidates for PD. “I think most physicians don’t do much PD because they believe there’s a certain candidate who’s optimally suited to it, and I couldn’t disagree more,” he stated. “The social setup in which an individual lives is a far more important determinant of the best dialysis modality than is the severity of the person’s kidney or other co-existing disease.”

According to Dr. Mehrotra, a young, employed, educated individual may appear to be the perfect medical and social candidate for PD, “but if this person hates the idea of doing dialysis at home, he or she would be a disaster at home therapy.”

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Conversely, an older, infirm patient who can’t get transportation to the dialysis unit and would rather be dialyzed at home may be just fine using the PD cycler.

“There are very few medical conditions that would prevent someone from being able to do PD—for example, having a scarred peritoneal cavity due to multiple surgeries,” Dr. Mehrotra said. “And somebody who is homeless and can’t have supplies delivered to them also couldn’t do PD. But in the absence of those two circumstances, everything else depends on the patient and the physician.”

Physician bias

A study by Haya R. Rubin, MD, PhD, and colleagues revealed that PD patients rated their care much higher than HD patients (JAMA. 2004;291:697-703). Specifically, 85% of PD patients versus 56% of HD patients considered their care “excellent” based largely on “information given to help choose modality” and “the amount of dialysis information from staff.”

The investigators concluded: “These findings indicate that clinicians should give patients more information about the option of peritoneal dialysis.”

“Ideally, the patient should be told about all modalities—all the aspects of hemodialysis, peritoneal dialysis, transplantation, and no treatment,”  said nephrologist Susan Bray, MD, clinical associate professor of medicine at Philadelphia’s Drexel University College of Medicine and a member of the medical advisory board of the American Association of Kidney Patients.

“There is no blanket recommendation for the type of dialysis a patient should undergo at any particular point in treatment. It’s a very individual decision, not an across-the-board thing. Unfortunately, generally speaking it’s what the particular medical group chooses to do.”

Dr. Bray’s opinion is seconded by Marcos Rothstein, MD, a professor of medicine in the division of renal diseases at Washington University School of Medicine and medical director of dialysis services at Barnes-Jewish Hospital, both in St. Louis. “You have places like Hong Kong, where the prevalence rate of PD is as high as 80%, and then you have other countries like Japan, where it’s only 3%,” he says. he says. “This tells you that this is society and physician bias more than anything to do with the technique.”

As to possible reasons providers might not present all dialysis options as thoroughly as they should, Dr. Bray observed: “It’s probably a lack of time more than anything, or not having a team of nurses and social workers and dietitians to sit and teach the patient. It takes a lot of time to teach patients what the choices are because they are frightened and aren’t absorbing everything you’re saying. So you really need to have a program for teaching patients what’s out there in terms of their dialysis options.”

But the information bottleneck on home-dialysis treatments often can be traced back even further to insufficient education on the provider’s end. Nephrology training programs have traditionally emphasized acute care that takes place in the hospital, frequently in the intensive care unit. “Nephrology fellows only see the rejects of PD, the people who fail,” Dr. Rothstein said. “The ones who are doing well don’t show up in the hospital.”

“Many nephrology fellows don’t have a comfort level with peritoneal dialysis simply because they haven’t been exposed to much of it,” Dr. Bray noted.

Anjali Bhatt Saxena, MD, director of PD at the Santa Clara Valley Medical Center in San Jose, Calif., corroborates this assertion by recalling a study in which nephrology fellows were asked how comfortable they were with PD. “Their comfort level was much lower than you would want it to be.”

Dr. Saxena pointed to research showing that more than 40% of patients who undergo intensive education about their dialysis choices would choose PD. “That’s a big difference compared to what we see in actuality, where fewer than 10% of patients are on PD, said Dr. Saxena, clinical assistant professor of medicine at Stanford University in California. “Other industrialized countries—for instance, Canada, Denmark, Netherlands, England, New Zealand—have much higher prevalence of peritoneal dialysis.”

Furthermore, she said polls of U.S. nephrologists have revealed that they thought approximately 30% of their patients should be on PD. “That’s so different than what we actually have. There’s some kind of disconnect.”