Why Peritoneal Dialysis is Underutilized in the United States: A Review of Inequities

Abstract

Given a choice, most patients with end-stage renal disease prefer home dialysis over in-center hemodialysis (HD). Peritoneal dialysis (PD) is a home dialysis method and offers benefits such as absence of central venous access and therefore preservation of veins, low cost, and decreased time per dialysis session, as well as convenience. Survival rate for patients on PD has increased to levels comparable to in-center HD. Despite endorsement by leaders in the medical field, professional societies, and those in government, PD has reached only 11% adoption among incident patients according to the 2019 United States Renal Data System Annual Data Report. This figure is dwarfed in comparison to rates as high as 79% in other countries. In addition, research has shown that inequities exist in PD access, which are most pronounced in rural, minority, and low-income regions as demonstrated by trends in regional PD supplies. To complicate things further, technique failure has been implicated as a major determinant of poor PD retention rates. The low initiation and retention rates of PD in the United States points to barriers within the healthcare system, many of which are in the early phases of being addressed.

Peritoneal Dialysis Catheter Complications after Insertion by Surgeons, Radiologists, or Nephrologists

“…As PD demand increases with the implementation of the ESKD Treatment Choices and Kidney Care Choices models in the United States, 16 it is critical to identify limitations to the United States' ability to facilitate the use of PD. Patients who are subjected to follow-up procedures and operators who are faced with nonfunctional catheters may lose interest in pursuing PD, 9 or clinical conditions may eventually require some patients to start hemodialysis before a functional PD catheter becomes available. 17 Theoretically, interventional nephrologists and radiologists may be more readily available to insert PD catheters given that these procedures do not require an operating room and anesthesia team to be available, and an approach that does not require anesthesia may be preferred for patients with multiple comorbidities.…”

“…18 In other nations where PD use is highly prevalent, interventional nephrologists have become the primary operators who place PD catheters. 9,[19][20][21] A previous trial demonstrated that catheter complication-free survival was higher (42.5%) in those receiving catheter implantation with radiology as opposed to general surgeons (18.1%). 22 Other studies have varied in their findings, with some showing that exit site leak was more common in catheters placed percutaneously as opposed to a surgical approach and other studies showing low complication rates with radiology-placed percutaneous catheters.…”

“…8 PD catheter placement complications have been implicated as a cause of low PD retention rates. 9 In current practice, PD catheter insertion can be performed by operators who have different training backgrounds, experience, and volume of procedures including interventional radiologists, interventional nephrologists, and general and vascular surgeons. Our objective was to determine whether the probability of needing a follow-up procedure within 90 days of placement of a PD catheter varied by the type of operator inserting these catheters using data from the national ESKD registry, the United States Renal Data System (USRDS).…”

Trends in Automated Peritoneal Dialysis Prescriptions in a Large Dialysis Organization in the United States

“…2,3 Although most (approximately 85%) patients requiring KRT qualify for PD, uptake in the United States remains low. 3 As of 2020, 64,406 patients with prevalent kidney failure were receiving PD (12% of all dialysis among patients with kidney failure). 4 Changes in health care policies have contributed to recent increases in home-based dialysis, including PD utilization.…”

Multi-institutional audit of outcomes after peritoneal dialysis catheter placement in Japan: What are the takeaways?

“…Despite these successes in improving catheter outcomes and reducing technique failure, the utilisation of PD in Japan has remained flat over the past decade, 1,27,28 implicating the influence of other globally recognised government, physician and patient barriers that must be addressed to effectively grow PD. [29][30][31] On a final note, throughout the manuscript, Sakurada and company used mixed terminologies of catheter patency failure and survival and technique failure and survival, but they were clear in how the terms were applied. However, it has been suggested by the SONG-PD (Standardized Outcomes in Nephrology-Peritoneal Dialysis) consensus workshop to use positively framed terminology, therefore, survival instead of failure, in reporting patient outcomes to convey a more appropriate perception of PD therapy.…”