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The Status of Peritoneal Dialysis in Europe – An Update
The long-awaited results of the Choices for Healthy Outcomes in Caring long dwells have all improved the results of PD. In the meantime, these
for ESRD (CHOICE) study have now been published, accompanied by a concerns were partly responsible, or were at least used as arguments, in
very thoughtful editorial
9;15
and commentary.
16
The CHOICE study was some European countries, for reluctance to start PD and for unnecessary
a collaboration between a non-profit dialysis chain and investigators at technique failure where PD was applied.
1
Johns Hopkins University, with the addition of PD patients from the
Yale New Haven Group. This study started a decade ago and Finally, as survival is not the only applicable outcome, it is equally
prospectively collected a host of important and pertinent data near the important to consider hospitalisations and health-related quality of life
start of dialysis in PD and HD patients, and the outcome was evaluated (QoL). In this regard, a recent study
20
confirmed a previous report
21
that
over up to seven years. In general, it was found that the risk of death the overall satisfaction score for PD patients was higher than for HD
is increased on PD relative to HD after the first year on dialysis. In patients. PD patients indicated that there was less overall impact of the
addition, 25% of patients undergoing PD and only 5% of HD patients dialysis treatment on their lives in at least 14 of the 15 domains
switched type of dialysis. After adjustment, the risk of death did not examined. With the use of a proportional odds model analysis, the only
differ between patients undergoing PD and those undergoing HD significant predictor of overall satisfaction and impact of therapy was
dialysis modality. Patients were also asked to comment freely on the
positive and negative effects of the dialysis treatments on their lives, and
a taxonomy of patient perceptions and concerns was developed. This
With the use of a proportional odds
study suggests that PD patients in general are more satisfied with their
overall care and believe that their treatment has less impact on their lives
model analysis, the only significant
than HD patients.
predictor of overall satisfaction and
Non-medical Factors in the Selection of Peritoneal
impact of therapy was dialysis modality.
Dialysis as Renal Replacement Therapy Modality
As pointed out,
1
medical factors alone cannot explain why the wide
differences in PD utilisation are still present, particularly in Europe, and
why PD is even declining in some European countries. It is clear that,
during the first year, but the risk became significantly higher among beyond medical and scientific factors, equally important non-medical
those undergoing PD in the second year. After stratification, the survival factors must be involved in the wide variety in utilisation of PD in some
rate was not different for patients who had the highest propensity of areas of the world and possibly in the further decline in its utilisation over
being initially treated with PD. The results were consistent with the last years.
14,22
These factors include lack of pre-ESRD patient
adjustment based on a propensity score model and in sensitivity education, late patient referral, limited presentation of dialysis modality
analyses that used as-treated models and models in which changes in choice to the patient and a poor infrastructure of PD training, research
type of dialysis were regarded as treatment failures. The results were and physician experience in many renal replacement programmes.
23,27
also similar but stronger in analyses that were restricted to patients who These considerations suggest that nephrologists and primary care
were treated only in clinics offering both types of dialysis. The major physicians should give greater attention to PD when patients are eligible
limitations of this study were that the patients were not randomly for either modality, especially in light of no clear superiority of one
assigned to their initial type of dialysis and that more patients modality over the other in patient survival.
undergoing PD than HD switched type of dialysis over time: the reason
for switching was often a consequence of the technique (for a critical
commentary on the CHOICE study, see references 16 and 17).
…we believe that financial and
Although the experience with the recently introduced, more
reimbursement issues are the most
biocompatible (being low in glucose degradation products) PD solutions
is too preliminary to evaluate, these solutions have further reduced
important non-medical determinants of
dialysis discomfort. They may possibly lead to a further reduction in
the choice of dialysis modalities in any
peritonitis frequency, and to a better long-term preservation of peritoneal
given country.
structure and function. At least one study has shown improved patient
survival with these new solutions compared with the conventional
fluids.
18,19
Besides the apparently less favourable survival results compared
with HD, additional medical concerns of PD are related to the The importance of patient education in the overall pre-ESRD processes
achievement of sufficient dialysis. This is mainly based on small solute was recently corroborated by Mehrotra et al.
25
using data on incident
removal targets and on adequate peritoneal ultrafiltration, particularly in ESRD patients admitted to 229 dialysis units in the ESRD Network in the
anuric patients. These topics were discussed in our previous paper,
1
US. The majority of ESRD patients were not exposed to chronic PD, home
where it was concluded that at least some of these medical concerns HD or renal transplantation as options (66, 88 and 74%, respectively).
formulated in the early years of PD were appropriate but that, over the Using multivariate analysis, variables significantly associated with
last 10 years, most of them have been countered by improvements in the selection of chronic PD as modality were the fact that chronic PD was
understanding of PD physiology and technological progress. The presented as a treatment option and the time spent on patient education.
realisation of the importance of the preservation of residual renal It thus appears that an incomplete presentation of treatment options is
function and the introduction of automated PD and of icodextrin for the an important reason for underutilisation of home dialysis therapies,
EUROPEAN RENAL DISEASE 2007 59