Growing a peritoneal dialysis program: A single-center experience

The population of the United States is experiencing rapid growth of end-stage renal disease (ESRD) requiring renal replacement therapy (RRT). There were more than 548,000 ESRD patients in 2008, consuming 7% of the Medicare budget and $39.5 billion in total costs. With an annual growth of 6%, the ESRD population is projected to grow to more than 775,000 dialysis patients in 2020.1 RRT options include hemodialysis (HD), peritoneal dialysis (PD), and renal transplant. While renal transplant remains the RRT of choice, the proportion of ESRD patients receiving renal transplant has not changed in the past decade. With the increasing numbers of ESRD patients requiring dialysis, one would expect a proportionate growth of all dialysis modalities. However, while utilization of HD has progressively increased, there has been a steady decline in PD usage in the United States. Currently less than 7% of the U.S. dialysis patients use PD as their RRT modality.1

PD is associated with patient survival advantages when compared with HD during the first 2 years on dialysis.2-9 Unlike saw-tooth treatment with HD, PD delivers a more steady-state treatment, avoiding fluctuations in plasma volume and solutes, and is generally better tolerated by the patients with cardiovascular compromise. PD provides flexible schedules, thus allowing patients to work, travel, and participate in daytime activities. As PD does not involve needlesticks, patient anxiety is mitigated, arteriovenous access sites for future HD are preserved, and the risk of acquiring blood-borne infections such as hepatitis C and HIV are minimized. Additionally, residual renal function (RRF) is better preserved on PD than HD7-13 and is associated with improved outcomes. Furthermore, patients on PD have better long- and short-term transplant outcomes. Recent data suggest that compared with HD, PD patients have significantly lower incidence of delayed graft function, significantly lower requirement of dialysis in the post-transplant period, and better long-term transplant survival.7, 14-16 Moreover, PD is less expensive than HD on a per-patient per-year basis, with the difference estimated to be more than $20,000 based on the 2010 U.S. Renal Data System (USRDS) annual data report.1

Despite these advantages and lower costs, the number of patients on PD in the United States has progressively declined over the past 10 years17, 18 to below 7% of the total U.S. dialysis population, compared with other developed countries, where PD is being utilized in a much larger (15-30%) proportion of the dialysis population.1

The reasons for low utilization of PD in the United States are complex, but seem to be influenced by psychosocial and economic factors, lack of physician, surgeon, and nursing training, physician bias, and inadequate pre-ESRD education to the patients (Table I). Several of these factors are modifiable, and with a concerted effort PD utilization can be significantly increased.

PD continues to be underutilized in the United States for non-medical reasons such as complex psychosocial and economic factors, lack of physician training, physician bias, and inadequate pre-ESRD education to the patients. Modification of several of these factors can significantly improve PD utilization (Table II). Patient and physician education and comfort with using PD are critical. Minimizing episodes of PD-related infections, preserving the peritoneal membrane by using more biocompatible solutions and drugs such as angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, and careful management of volume status can reduce loss of PD patients to HD. Timely surgical interventions can prevent the malfunction and loss of PD catheters. Consolidating smaller PD facilities in a given geographical area into a single large PD center can further improve PD outcomes and PD growth. Finally, with the introduction of bundled payment for dialysis services, PD may emerge as a cost-effective therapy and interest may be rekindled in the dialysis community to consider PD as a viable RRT option.