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Key Points Peritoneal dialysis is a high quality and cost-effective dialysis modality In the past decade the greatest increases in peritoneal dialysis utilization have occurred in China, Thailand and the USA; peritoneal dialysis utilization has decreased in parts of Europe and in Oceania Asia has experienced the largest absolute growth in patients on dialysis, and is characterized by the largest regional variation in peritoneal dialysis utilization Reimbursement schemes and government policy are important determinants of peritoneal dialysis epidemiology Peritoneal dialysis first policies (Hong Kong and Thailand), the peritoneal dialysis favoured policy (China) and the home dialysis first model (Australia and New Zealand) have resulted in increased utilization of peritoneal dialysis Major challenges to increased utilization of peritoneal dialysis — particularly in developing countries — include prohibitive costs, lack of trained medical personnel, disparities in health-care provision and a lack of infrastructure In many countries, patient outcomes with peritoneal dialysis are comparable or superior to those with haemodialysis. Here, the authors discuss the changing epidemiology of peritoneal dialysis worldwide, including the remaining country-specific challenges that must be overcome to improve utilization of this cost-effective therapy. As the global burden of chronic kidney disease continues to increase, so does the need for a cost-effective renal replacement therapy. In many countries, patient outcomes with peritoneal dialysis are comparable to or better than those with haemodialysis, and peritoneal dialysis is also more cost-effective. These benefits have not, however, always led to increased utilization of peritoneal dialysis. Use of this therapy is increasing in some countries, including China, the USA and Thailand, but has proportionally decreased in parts of Europe and in Japan. The variable trends in peritoneal dialysis use reflect the multiple challenges in prescribing this therapy to patients. Key strategies for facilitating peritoneal dialysis utilization include implementation of policies and incentives that favour this modality, enabling the appropriate production and supply of peritoneal dialysis fluid at a low cost, and appropriate training for nephrologists to enable increased utilization of the therapy and to ensure that rates of technique failure continue to decline. Further growth in peritoneal dialysis use is required to enable this modality to become an integral part of renal replacement therapy programmes worldwide.

The selection of a specific dialysis modality can have important consequences in terms of survival and quality of life. In this Review, Lameire and Van Biesen compare the epidemiology of peritoneal dialysis with that of hemodialysis and describe some of the major differences that exist in the global utilization of these two dialysis modalities. The authors describe a number of medical and nonmedical factors, including economic, educational and psychological factors that influence dialysis modality choice. In 2008, an estimated 1.77 million patients worldwide received dialysis. Of these patients, 1.58 million were treated with hemodialysis and approximately 190,000 received peritoneal dialyisis. In a global comparison of treatment methods for renal failure, therefore, hemodialysis clearly dominates. In this Review, we compare the epidemiology of peritoneal dialysis with that of hemodialysis and describe some of the major differences in the global utilization of the two dialysis modalities. These differences can largely be explained by a number of nonmedical, mainly economic factors, but also by educational and psychological factors. To reverse the current trends, the implementation of suitable reimbursement strategies for peritoneal dialysis is needed as well as increased investment in the training of young nephrology fellows and in education programs for patients and other non-nephrological health-care providers. To achieve these goals, academic and nonacademic training centers, which often consider peritoneal dialysis to be a low-level priority, must invest in research and training related to peritoneal dialysis. Key Points The prevalence of peritoneal dialysis differs substantially between regions; these differences cannot solely be explained by medical factors; economic factors and dogmatic beliefs are also believed to have an important role In regions or centers with a high prevalence of peritoneal dialysis, the outcome for patients on peritoneal dialysis is at least as good as for those on hemodialysis Patient choice of dialysis modality is an important predictor of outcome; as such, each center should offer both peritoneal dialysis and hemodialysis to their patients in an unbiased way The prevalence of automated peritoneal dialysis use is increasing worldwide, although continuous ambulatory peritoneal dialysis and automated peritoneal dialysis perform equally well in terms of survival Automated peritoneal dialysis can be beneficial in patients with a fast transport status, but again, patients should be free to choose the dialysis modality used The education of patients and trainee nephrologists on all aspects of peritoneal dialysis is a prerequisite for promoting peritoneal dialysis; scientific societies should stimulate educational and research activities related to peritoneal dialysis

Background The use of peritoneal dialysis (PD) has declined in the United States over the past decade and technique failure is also reportedly higher in PD compared to hemodialysis (HD), but there are little data in the United States addressing the factors and outcomes associated with switching modalities from PD to HD. Methods In a prospective cohort study of 262 PD patients enrolled from 28 peritoneal dialysis clinics in 13 U.S. states, we examined potential predictors of switching from PD to HD (including demographics, clinical factors, and laboratory values) and the association of switching with mortality. Cox proportional hazards regression was used to assess relative hazards (RH) of switching and of mortality in PD patients who switched to HD. Results Among 262 PD patients, 24.8% switched to HD; with more than 70% switching within the first 2 years. Infectious peritonitis was the leading cause of switching. Patients of black race and with higher body mass index were significantly more likely to switch from PD to HD, RH (95% CI) of 5.01 (1.15–21.8) for black versus white and 1.09 (1.03–1.16) per 1 kg/m 2 increase in BMI, respectively. There was no difference in survival between switchers and non-switchers, RH (95% CI) of 0.89 (0.41–1.93). Conclusion Switching from PD to HD occurs early and the rate is high, threatening long-term viability of PD programs. Several patient characteristics were associated with the risk of switching. However, there was no survival difference between switchers and non-switchers, reassuring providers and patients that PD technique failure is not necessarily associated with poor prognosis.

The numbers of older patients requiring dialysis therapy is rising, reflecting the ageing of the general population. Older dialysis patients have a tendency to present later for dialysis, have a higher number of comorbid conditions, are at higher risk of cognitive dysfunction and have increased levels of frailty. These are all barriers to home dialysis therapy so hospital haemodialysis (HD) is the predominant dialysis modality for older patients. Evidence suggests, however, that home treatment with peritoneal dialysis (PD) intrudes less into the life of older patients than hospital HD. Assisted PD is available in some countries and this enables more older patients to be treated in their own homes. Adjustments to patient education also need to be made to accommodate the barriers to learning and decision-making that often exist in older people. Copyright © 2011 S. Karger AG, Basel [PUBLICATION ABSTRACT]

Introduction: Dialysis access should be timely, minimise complications and maintain functionality. Good functional access is required for renal replacement therapy (RRT) to be successful. The aim of the combined vascular and peritoneal dialysis access audit was to examine practice patterns with respect to dialysis access and highlight variations in practice between renal centres. Methods: The UK Renal Registry collected centre-specific information on vascular and peritoneal access outcome measures including patient demographics, dialysis access type (at start of dialysis and three months after start of dialysis), surgical assessment and access functionality. The combined access audit covered incident haemodialysis (HD) and peritoneal dialysis (PD) patients in 2012 from England, Northern Ireland and Wales. Centres who had reported data on incident PD patients for the previous audit in 2011 were additionally asked to provide one year follow up data for this group. Results: Fifty-one centres in England, Wales and Northern Ireland (representing 82% of all centres) returned data on first access from 3,720 incident HD patients and 1,018 incident PD patients. A strong relationship was seen between surgical assessment and the likelihood of starting HD with an arteriovenous fistula (AVF). Type of first access was related to the length of time known to renal services with higher numbers of AVFs and PD catheters used in patients known to renal services for at least one year. Three month and one year outcomes of HD and PD access were poorly reported. Conclusions: This audit provides information on important patient related outcome measures with the potential to lead to an improvement in access provision. This represents an important advance, however data collection remains suboptimal. There is wide practice variation across the England, Wales and Northern Ireland in provision of both HD and PD access which requires further exploration. © 2014 S. Karger AG, Basel [PUBLICATION ABSTRACT]

Background The increasing prevalence of treated end-stage renal disease and low transplant rates in Africa leads to longer durations on dialysis. Dialysis should not only be aimed at prolonging lives but also improve quality of life (QOL). Using mixed methods, we investigated the QOL of patients on chronic haemodialysis (HD) and peritoneal dialysis (PD). Methods We conducted a cross-sectional study at Tygerberg Hospital in Cape Town, South Africa. All the PD patients were being treated with continuous ambulatory peritoneal dialysis. The KDQOL-SF 1.3 questionnaire was used for the quantitative phase of the study. Thereafter, focus-group interviews were conducted by an experienced facilitator in groups of HD and PD patients. Electronic recordings were transcribed verbatim and analysed manually to identify emerging themes. Results A total of 106 patients completed questionnaires and 36 of them participated in the focus group interviews. There was no difference between PD and HD patients in the overall KDQOL-SF scores. PD patients scored lower with regard to symptoms ( P  = 0.005), energy/fatigue ( P  = 0.025) and sleep ( P  = 0.023) but scored higher for work status ( P  = 0.005) and dialysis staff encouragement ( P  = 0.019) than those on HD. Symptoms and complications were verbalised more in the PD patients, with fear of peritonitis keeping some housebound. PD patients were more limited by their treatment modality which impacted on body image, sexual function and social interaction but there were less dietary and occupational limitations. Patients on each modality acknowledged the support received from family and dialysis staff but highlighted the lack of support from government. PD patients had little opportunity for interaction with one another and therefore enjoyed less support from fellow patients. Conclusions PD patients experienced a heavier symptom burden and greater limitations related to their dialysis modality, especially with regards to social functioning. The mixed-methods approach helped to identify several issues affecting quality of life which are amenable to intervention.

Background A previous cohort study indicated a significant association of lower baseline level of physical activity in hemodialysis patients with elevated risks of mortality. However, there have been no reports regarding the association between changes in physical activity over time and mortality in hemodialysis patients. This study was performed to examine the prognostic significance of physical activity changes in hemodialysis patients. Methods This retrospective cohort study was performed in 192 hemodialysis patients with a 7-year follow-up. The average number of steps taken per non-dialysis day was used as a measure of physical activity. Forty (20.8%) patients had died during the follow-up period. The percentage change in physical activity between baseline and 12 months was determined, and patients were divided into three categories according to changes in physical activity. A decrease or increase in physical activity > 30% was defined as becoming less or more active , respectively, while decrease or increase in physical activity < 30% were classified as stable . Results Forty seven (24.5%), 51 (26.6%), and 94 (49.0%) patients were classified as becoming less active , becoming more active , and stable , respectively. The hazard ratio on multivariate analysis in patients with decreased physical activity was 3.68 (95% confidence interval, 1.55–8.78; P  < 0.01) compared to those with increased physical activity. Conclusions Reductions in physical activity were significantly associated with poor prognosis independent of not only patient characteristics but also baseline physical activity. Therefore, improved prognosis in hemodialysis patients requires means of preventing a decline in physical activity over time.

Background: The central paradigm of effective peritoneal dialysis (PD) is an appropriate standard of PD catheter function. Aim: The aim of the project was to develop an effective national PD access audit which would identify an 'appropriate standard' of PD catheter function. Methods: The UK Renal Registry collected centre specific information on various PD access outcome measures including catheter functionality and post-insertion complications. The first PD access audit covering England, Northern Ireland and Wales was conducted during April to June 2012 looking at incident dialysis patients in 2011. Results: Forty three data collection spreadsheets were returned from a total of 65 centres describing 917 PD catheter placements. The median age of PD patients was 61 years and 61.5% were male. The proportion of patients initiated on PD in comparison to HD was lower in socially deprived areas. There was a relationship between the timing of nephrology referral and the likelihood of surgical assessment regarding PD catheter placement. Patients with diabetes did not have higher rates of PD catheter failure or of early peritonitis. Conclusions: A comparative PD catheter audit has the potential to provide valuable information on an important patient related outcome measure and lead to an improvement in patient experience. There was wide variation between centres of PD catheter use for late presenting patients. Overall patients were more likely to get a PD catheter if they had been known to the service for more than 1 year. The percutaneous insertion technique was associated with a higher early (less than 2 week) peritonitis rate and more catheter flow problems. Copyright © 2013 S. Karger AG, Basel [PUBLICATION ABSTRACT]

Automated peritoneal dialysis (PD) is the dominant mode of delivery of PD in the US. Information about actual prescribing patterns has been limited. The present study examines cycler prescription use in large cohorts during the years 1997, 2000, and 2003. We observed trends consisting of increasing fill volumes, increasing time on cycler, lowering of the number of cycles, and a shift in the reason for utilization of tidal therapy. Monitoring of practice patterns is beneficial in identifying opportunities for practice enhancement. The findings of the present survey demonstrate trends that approach standard recommendations of the benefits of increasing fill volume whereas paying close attention to dwell time as a balance between cycle number and therapy duration. Furthermore, this survey shows that the cycler represents a flexible method to personalize PD therapy.

The 1996 annual report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) summarizes data submitted from 130 centers on 2,208 patients in whom 2,787 independent courses of dialysis were performed between 1 January 1992 and 16 January 1996. Approximately two-thirds of the dialysis population were maintained on peritoneal dialysis (PD), with automated PD remaining the preferred modality. There were 964 episodes of peritonitis in 1,018 patient years, yielding an overall peritonitis rate of 1 episode every 13 patient months. More PD patients attended school full time than hemodialysis (HD) patients at baseline (77% vs. 45%), which continued at 6, 12, and 24 months of followup. There were fewer Hispanic patients who were full-time students, whether on HD or PD, compared with white or black patients; 18% of Hispanic patients did not attend school, even though they were medically capable. The majority of dialysis courses terminated due to transplantation (54%), with change in dialysis modality the next most-common reason (28%). Early dialysis termination for any reason was seen more often in HD than PD (40% vs. 23% at 6 months), but by 24 months similar percentages of PD and HD courses had been terminated (75% HD, 72% PD). The most-common PD access was a Tenckhoff catheter with a single cuff, a straight tunnel and lateral exit site. The majority of HD accesses were external percutaneous catheters, with the sublcavian vein the most-common site. Erythropoietin was administered in 93% of HD and PD patients at 24 months.