Peritoneal Dialysis as an option for unplanned initiation of chronic dialysis
Chronic kidney disease (CKD) is a matter of global public health. Data from the United States have shown a steady increase in the number of patients on renal replacement therapy (RRT) In 1983, there were 86,354 patients on RRT program in the United States, which rose to more than 615,000 patients in 2011. The census of the Brazilian Society of Nephrology (SBN) showed 65,121 patients on a dialysis program in 2005, while in 2011 there were 91,314 and in 2013 more than 112,000 patients on dialysis in Brazil. The rate of incident dialysis patients was 119 patients per million (ppm) in 2005, 149 ppm in 2011, and 161 ppm in 2013. Nephrologists have two methods of dialysis at their disposal: peritoneal dialysis (PD) and hemodialysis (HD) the latter being the most commonly used method worldwide. Although, historically, PD has been widely used in nephrology, for reasons which are not completely clear, it has been underutilized in recent years. Possible reasons for its underutilization are the perception that it is inferior to HD, which appears technologically advanced, and fear of the infectious, mechanical and metabolic complications associated with PD, along with preferential financial reimbursement with HD use and difficulties with peritoneal catheter insertion. In the United States, in 2007, there were 368,000 patients on RRT, and 92.8% of them were on HD. In Brazil, data from 2013 showed that 90.6% of chronic patients underwent HD and only 9.4% were treated with PD. Several studies have compared the differences between the two types of dialysis, i.e. PD vs. HD, in incident patients on RRT. There is no evidence of the superiority of one method over the other with regards to general mortality within the first two years of therapy. Some studies have shown better results with PD in the group of young patients with no comorbidities, while other studies have shown lower mortality after two years of dialysis in elderly patients with comorbidities treated with HD. Recently, some authors have pointed out the impact of the vascular access used in the mortality of incident patients on HD. These studies found that central venous catheter (CVC) use is associated with reduced survival, especially in the first 90 days of RRT. Furthermore, there is a greater risk of bacteremia, sepsis and hospitalizations in patients using CVC when compared to patients using an arteriovenous fistula (AVF) graft or PD. In this scenario, the PD appears to be an option in cases with an urgent start to chronic dialysis. It can offer the advantage of not using a CVC, thereby preserving vascular access and residual renal function, which can reduce the morbidity and mortality of these patients. Most patients with end stage CKD start unplanned RRT. Unplanned dialysis may be defined as the start of HD without a functioning definitive vascular access (AVF) i.e. using a CVC, or as the start of PD within less than 7 days after its implantation. Ivarsen et al. retrospectively reviewed the Danish Nephrology Registration from 2008 to 2011 and found that 50% of incident patients on RRT started it in an unplanned manner. In Brazil, approximately 60% of incident patients on RRT have no definitive access and need to be treated through CVC. In the dialysis unit of the University Hospital of the Botucatu Medical School, the reality is worse than elsewhere in the world: more than 90% of incident patients start unplanned dialysis and 60% of Correspondence to: D. Ponce, PhD, Botucatu School of Medicine, Distrito de Rubi~ao Junior, S~ao Paulo 18600090, Brazil. E mail: dponce@fmb.unesp.br Conflict of Interest: DBD, VB, MLM, PB declare that there is no conflict of interest. Disclosure of grants or other funding: DP has received research grant from Baxter Healthcare Corporation.
Hemodialysis international. International Symposium on Home Hemodialysis