Peritoneal Dialysis: Turning Choice Into Reality

BACKGROUND:Peritoneal dialysis (PD) utilization rates vary widely between UK renal centers. Currently there are only limited data available on how many patients choose PD but subsequently fail to start their chosen modality. In the current analysis we sought to explore the outcomes of patients who chose PD in our center where all PD catheters are inserted via a mini-laparotomy with no acute-start PD service. METHODS:We retrospectively analyzed the outcomes of 658 patients over a 12-year period who, following predialysis education had chosen PD as their preferred renal replacement therapy (RRT) modality. Data were collected on patient demographics, start modality, transplantation, patient survival, and the reasons patients failed to start PD. RESULTS:Predialysis education was given to 2,749 patients, and 658 (24%) chose PD. Of the 566 (86%) who either started RRT or died, less than half started PD (n = 273, 48%). The commonest reason to start hemodialysis (HD) was an acute decline in kidney function leading to an effective 'unplanned' start on RRT. As a result, despite adjusting for older age and higher comorbidity, the transplant-censored survival at 3 years from the time of start of RRT was predictably worse in patients starting HD. Less than half the patients who started HD went on to commence PD later. CONCLUSION:Unanticipated decline in kidney function leading to unplanned start on HD contributes to the worse outcomes associated with failing to start PD. How and when we insert PD catheters appears to be key, and we have identified ways to improve our service.