Chronic Peritoneal Dialysis in the United States

Abstract

In the United States, chronic peritoneal dialysis take-on has declined among incident ESRD patients. Although increasing age, co-morbidity, and body size may explain part of this decline, other factors likely contribute. Among incident ESRD patients in the United States, we found that peritoneal dialysis take-on significantly decreased from 11% in 1996 to 1997 to 7% in 2002 to 2003 (P Ͻ 0.001 for the trend). This decrease remained after adjusting for patient demographics, case-mix, and laboratory data, suggesting the involvement of other factors. This decline in utilization occurred during a time of improving outcomes for incident peritoneal dialysis patients, measured as reduced hazards for death or for the need to transfer to hemodialysis. In contrast, among patients initially treated with hemodialysis, the 12-month adjusted hazards for death or transfer to peritoneal dialysis slightly worsened or were unchanged over this same period. Therefore, the decline in peritoneal dialysis take-on cannot be entirely explained by increasing age, co-morbidity and body size of incident ESRD patients. The decline in utilization has occurred at a time when the early outcomes of CPD patients have improved.

Association of Dietary Phosphorus Intake and Phosphorus to Protein Ratio with Mortality in Hemodialysis Patients

“…The medical chart of each MHD patient was thoroughly reviewed by a collaborating physician, and data pertaining to underlying kidney disease and other comorbid conditions were extracted. A modified version of the Charlson comorbidity index was used to assess the severity of comorbidities (25,26).…”

Is the Declining Use of Long-Term Peritoneal Dialysis Justified by Outcome Data?

“…Against this background of low use, the proportion of patients who undergo PD has declined further in the past decade in the United States ( Figure 1) (2,18), and a Ͼ50% decline in the proportion of incident patients who commence treatment with PD has occurred (24). The United States is not the only country with declining use of PD.…”

“…Of the proposed hypotheses, only the relationship of increasing age, body size, and comorbidity burden of incident dialysis patients has been studied. During an 8-yr period, starting from 1996, the age and body size of the incident dialysis patient in the United States increased, but the burden of coexisting illnesses did not change (24). Furthermore, PD use declined in every age group and strata of body size and coexisting illnesses (24); therefore, the change in age, body size, and coexisting disease burden are insufficient to explain the decrease in PD use in the United States.…”

“…During an 8-yr period, starting from 1996, the age and body size of the incident dialysis patient in the United States increased, but the burden of coexisting illnesses did not change (24). Furthermore, PD use declined in every age group and strata of body size and coexisting illnesses (24); therefore, the change in age, body size, and coexisting disease burden are insufficient to explain the decrease in PD use in the United States. The systematic decline in use is likely a result of system-wide factors in the delivery of care (Table 1).…”

“…A review of Table 2 also demonstrates that most of the studies included cohorts largely from the 1980s and 1990s; only one included patients who were incident after 2000. There are data to suggest that the outcomes of MHD and PD patients may have differentially changed during this period (24). In an analysis of the US Renal Data System data during an 8-yr period (1996 to 2003), the 12-mo outcomes of 606,777 incident patients were studied.…”