Combined Peritoneal Dialysis and Hemodialysis: Our Experience Compared to Others

Abstract

Objective To determine the clinical experience of using combined-modality [simultaneous hemodialysis (HD) and peritoneal dialysis (PD)] treatment in patients with end-stage renal disease. Design We reviewed data on 4 patients from our center that were treated with “combined-mode therapy.” We then conducted a retrospective survey by sending questionnaires to nephrologists in the US and Canada by mail and by posting the survey on the Internet. Data queried included number of patients on combined modality, solute clearances, albumin levels pre and post combined therapy, reasons for using combined therapy, duration and success of combined therapy, and reimbursement issues. Setting and Participants Ours is a tertiary-care center. Patients that were not doing well on PD alone were put on combined modality of treatment between 1992 and 1998. Main Outcome Measures Clinical improvement in the indication for which the participant was started on combined modality. Results In response to the survey, data on 27 patients were collected. These data were combined with data on 4 patients from our unit that had previously been treated with combined HD and PD. Most patients were reported to have more than one clinical reason for changing from PD to combined therapy. The main clinical reason for offering combined treatments was inadequate solute clearance (34%), followed by ultrafiltration problems (16%) and neuropathy (11%). Mean duration of time followed on combined treatment was 8.5 ± 0.12 months. Most patients tolerated combined treatment well and were reported to show improvement in the clinical reasons for which they needed the combined modality. Dual access and reimbursement issues were not a problem. There was no single method used for calculating total (HD, PD, and residual renal) solute clearance. No universal total solute clearance goal was reported. Conclusion Hemodialysis and PD are not mutually exclusive. They can be used in combination to achieve targeted solute clearances, to improve certain clinical conditions, and to control volume and blood pressure in a subset of patients. Further evaluation is needed to better establish the long-term outcomes of using combined modality. Total solute clearance goals and methods for determining total solute clearance need to be standardized.

The Risks of High Ultrafiltration Rate in Chronic Hemodialysis: Implications for Patient Care

“…Potential interventions in this regard include use of wearable UF devices, which are currently under development, and institution of non-HD-day peritoneal UF (66,67). To our knowledge, adjuvant PD has not been applied to HD patients previously, but there has been successful report of combination PD ⁄ HD among PD patients unable to achieve clearance or fluid removal goals (66,(68)(69)(70)(71). Intensification of salt restriction (and thus fluid intake) is another potential strategy; however, past data and clinical experience indicating poor patient compliance are cause for pessimism (59)(60)(61)(62).…”

Health-related quality of life on combination therapy with peritoneal dialysis and hemodialysis in comparison with hemodialysis and peritoneal dialysis: A cross-sectional study

“…In particular, 40.9% of patients with a PD history of more than 6 years underwent this combination therapy. 23 Several benefits of PDþHD have been reported [24][25][26][27][28][29][30] such as improvement of uremic symptoms, hypertension, renal anemia, left ventricular mass index, peritoneal permeability, and technique survival. However, most of these results were in before-after studies on PD patients with a decreased RRF.…”

Assessing the Adequacy of Small Solute Clearance for Various Dialysis Modalities, with Inclusion of Residual Native Kidney Function

“…Most reported combinations have occurred in the setting of failing adequacy in long‐term PD patients whose clearances of both urea and creatinine have fallen below target, with evidence of clinical decline. One to three HD treatments per week have been added to CAPD treatments in this setting as well as in the setting of early start PD . In the late PD setting, K RU is usually negligible so the caregiver is mainly interested in the total of CAPD and HD clearances.…”