Guest Blog: John Moran, MD, FRACP, FACP

The question of relative mortality of incident patients commencing PD versus those starting conventional thrice-weekly in-center HD is one I am often asked. In the words of the great American philosopher, Yogi Berra,“I wish I had an answer for that, because I’m tired of answering that question.”

The 2010 USRDS report  shows an equal five-year survival in the Medicare population, with a higher survival on PD for the first two or three years. These results are confirmed by many other observational studies. The only randomized trial reported in 2003 from the Netherlands, showed a significantly better survival for patients on PD. However, of 773 eligible patients only 38 agreed to be randomized, so the results need to be interpreted with caution. The vast majority refused to be randomized because, after a full modality education, they wanted either in-center HD (52%) or PD (48%). The clearest outcome of this study is that a randomized prospective trial will never be done. I also attempted such a study –but abandoned it because over 90% of the patients refused randomization after modality education.

Two recent papers address this question again. The first, from Canada, (J Am Soc Nephrol 22: 1113–1121, 2011) examines an interesting idea –that the early higher mortality in incident HD patients may be due to the use of central venous catheter (CVC) as vascular access. The data supports this, compared with the 7,412 PD patients, one-year mortality was similar for the 6,663 HD-AVF/AVG patients but was 80% higher for the 24,437 HD-CVC patients (adjusted HR, 1.8; 95% CI, 1.6 to 1.9). Of course this result does not rule out patient selection as an explanation for these results, and indeed the HD-CVC patients were older and had more documented comorbidities than the PD patients.

The second paper, also from Canada (J Am Soc Nephrol 22: 1534–1542, 2011) examines a different potential explanation for the observed differences in mortality between PD and HD. They hypothesize that the difference is seen because patients with emergent starts on maintenance dialysis are usually treated with HD. They analyzed the survival in patients who commence dialysis electively as outpatients and who also have at least four months of predialysis care. In this group there was no difference in survival between PD and HD.

So how do I translate all the literature into practice? First, home should be the default option. Second, for the individual patient, the one sitting across the desk in the office, the choice between PD and in-center HD is one that should be very largely based on lifestyle. PD offers simplicity, ease of travel, freedom from facility schedules, and at least equivalent outcomes to HD. I believe the only absolute contraindication to PD is not having a peritoneal membrane! Third, while all patients need to be educated on all options, my experience is that patients new to dialysis almost all choose PD rather than home HD as the home modality.

John Moran, MD FRACP FACP
VP, Clinical Affairs – Home Modalities

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