Clinical efficacy of combined therapy with peritoneal dialysis and hemodialysis

Abstract

Combined therapy with peritoneal dialysis (PD) and hemodialysis (HD) represents a treatment option for PD patients who cannot maintain adequate solute and fluid removal. It has rapidly gained popularity in Japan, and 15 years of accumulated experiences is available. Serum creatinine, serum β2 microglobulin (β2m), body weight, and blood pressure decreased, whereas hemoglobin increased after initiating combined therapy. These results indicated that both adequacy of dialysis and hydration status were significantly improved. In addition, dialysate-to-plasma ratio of creatinine (D/P Cr) as obtained from peritoneal equilibration test (PET) was decreased, probably due to the functional and histological improvements of the peritoneal membrane. Combined therapy may have a good impact on the prevention of cardiovascular disease through reduction of blood pressure, correction of fluid overload, and improvement of left ventricular hypertrophy. Quality of life may improve as a result of decreases in uremic symptomatology and freedom from bag exchanges. On the other hand, combined therapy with PD and HD has some concerns. A reduction in urine volume during combined therapy indicates a decline in residual renal function, and may have potential negative impacts on life expectancy. Furthermore, induction of combined therapy would increase the overall duration of PD treatment and susceptibility to peritonitis. We have to pay attention to the development of encapsulating peritoneal sclerosis, as the most serious complication of PD, because both prolonged PD duration and increased number of peritonitis episodes are independent risk factors. Here, we propose criteria for the indication and discontinuation of combined therapy. Under these criteria, Kt/V, serum β2m, and uremic symptoms including nutritional status, erythropoiesis-stimulating agent-hyporesponsive anemia, and restless legs syndrome were used as markers of dialysis adequacy. On the other hand, higher blood pressure, heart enlargement or pleural effusion on chest X-ray, and persistent peripheral edema were used as markers of hydration status. Further studies, particularly prospective cohort studies with a large group of cases, are needed to confirm the clinical efficacy of combined therapy with PD and HD.

Predictors of outcomes in patients on peritoneal dialysis: A 2-year nationwide cohort study

“…In the present cohort, the duration of PD was significantly longer in the patients receiving combination therapy than in those receiving PD alone (72 months vs. 38 months, P < 0.0001). On the day of HD and on the following day, patients on combination therapy have a PD holiday, that is, they are released from bag exchange for PD 28,29 , which might lead to a decrease in the D/P Cr ratio obtained from the peritoneal equilibration test, suggesting improved functioning of the peritoneal membrane. PD + HD combination therapy is widely used in Japanese patients on PD in view of its known effectiveness for solute clearance and fluid management 30,31 .…”

Intra-Atrial Tunneled Dialysis Catheter as Vascular Access: Ultimate Choice in a Hemodialysis Patient

“…Combination of once-weekly hemodialysis with peritoneal dialysis, as in our case, reduce manipulation of the IATDC which can lower related risks and enhance median survival, but not indicated often although it has proven efficiency. [23,24] In fact, bimodal dialysis is associated with lower vascular access infection, and lower all-cause mortality compared with PD [25][26][27] This therapy is widely used in Japan (20% of all PD patients) [27]. Our experience with bimodal dialysis lasted for nine months before switching patient to exclusive hemodialysis.…”