Division of Nephrology-Hypertension, University Hospital, Bern, Switzerland
Correspondence and offprint requests to: Professor J.-P. Wauters, Abteilung Nephrologie-Hypertonie, Inselspital, CH 3010 Bern, Switzerland. Email: Jean-Pierre.Wauters{at}insel.ch
Keywords: chronic dialysis; chronic kidney disease; end-stage renal failure; medical decision; peritoneal dialysis
![]() |
Introduction |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
Some facts about PD utilization |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
These observations suggest that the choice of a dialysis treatment modality is based on factors other than the medical superiority of one technique over the other. Some of the non-medical factors have been identified, in particular within the USA [2,10]. In a survey covering most European countries, the USA and Japan, Gokal et al. [1] have shown that large differences exist in the incidence and prevalence of ESRF and in the distribution of the different treatment modalities. The differences were attributed mostly to the type of social security system: public systems with a low prevalence and incidence of ESRD and a homogeneous distribution between HD, PD and renal transplantation; private systems with a high prevalence, incidence and a main development of HD; and the so-called mixed systems with an intermediate distribution pattern.
The existing regional and centre disparities, however, indicate that the distribution between HD and PD therapies does not exclusively depend on the type of social security system. Changes may also occur over time as illustrated by the evolution in the number of patients treated by chronic dialysis over the last 5 years in Switzerland (Figure 1): the slow increase in the total number of dialysis patients is almost exclusively due to centre HD, while the PD patient numbers stabilized but with more and more automated PD (APD) treatments. While in 1993 PD was used in 18% of the total Swiss dialysis population, this percentage has declined and now stabilized at 11%; in the meantime the proportion of APD has increased from 9 to 43% of all the PD patients. A recent survey made among the 19 dialysis units in the French-speaking part of Switzerland revealed that only eight of those units practice PD and that the percentage of PD patients varied between 0 and 23% of their population treated by dialysis [11].
|
Interestingly, even within the PD treatment modalities, the use of automated PD (APD) vs CAPD seems to be centre- and/or region-dependent. While the French-speaking part of Switzerland has largely moved to APD, used in >60% of the PD patients, this trend is less marked and more recent in the German-speaking part (Table 1). This difference is most probably explained by patient attitudes towards autonomous dialysis and preferences concerning daytime activities.
|
![]() |
Which factors influence the use of PD? |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
|
As a consequence, the vast majority of the Swiss PD patients are treated in public centres, with only around 10 patients being treated in private centres (Table 3). Among the 70 Swiss dialysis units, 32 practice PD (46%), but when subdivided according to their structure, 30 out of 51 public units (59%) and only 2 out of 19 private units (11%) practice PD.
|
Along the same lines, HD will be systematically favoured when insufficient professional experience in the PD technology is at hand. This will be even more the case when a HD centre structure and trained staff are available: the marginal cost of a new additional patient will automatically favour the technique most at hand. With 70 centres for a population of 7.5 million inhabitants, Switzerland has one of the highest dialysis centre densities in the world. The unexpected increase in CAPD patient numbers seen in 2002 was probably due to the fact that two large dialysis units were overcrowded and faced with an acute problem of unavailable haemodialysis posts.
Patient factors
Even when objectively oriented by the nephrology staff, some pre-existing patient factors may also influence their final choice. Previous information given by the primary care physician or another nephrologist might play a fundamental role, but other factors must also be considered: travel distance to the unit, socio-familial factors such as presence of a spouse or housing facilities, and more individual factors such as age, education, profession and co-morbidities [18]. Patient preferences may also be influenced by totally dialysis-free days, daytime activities or body image. Within a group of 150 consecutive patients starting dialysis, Prichard [7] illustrated that among the 84 who were not treated by one of the techniques for preferential medical or social reasons, 37 chose PD and 37 HD; among the latter, 15 finally performed self- or home-therapy, 7 had previously been treated by HD, 4 refused PD and 11 were late referrals to the dialysis unit.
The deleterious effect of late referral on the preferential choice of HD has been demonstrated repeatedly [1921]. Blake [10] has shown that, in his unit, of 161 consecutive new ESRF patients, 22% were treated by PD, but this percentage rose to 32% for those who had received previous information, and was only 4% when this information could not have been given.
In their European multi-centre survey, Lameire et al. [22] demonstrated that in patients referred late, HD is chosen much more often than among those who are referred early. This observation, however, was not made in 4 of the 13 centres, illustrating again that this therapeutic choice is a multi-factorial process.
Socio-economic factors
The structure of the dialysis program within any given country or region and/or the dialysis infrastructure and staffing at hand in any particular centre may also influence the development of any given technique. In most units, it is easier to start an additional patient on an existing HD post than to go through the more time- and staff-consuming procedure of PD training.
Cultural factors
Finally, the place of an autonomous therapy may also be influenced by persistent or changing cultural attitudes towards the chronic disease state. This factor explains why home therapy is almost non-existent in Japan and may also partly elucidate the changing pattern observed in Europe [23].
![]() |
Some proposals towards a more homogeneous use |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Social security measures
The reimbursement rate of the autonomous dialysis treatment modalities should not penalize those therapies. While a financial profit can be made today with most of the present reimbursement rates for centre dialysis, autonomous therapies usually result in a loss of money for the dialysis unit. A fee for the setting-up and running of an autonomous dialysis program in addition to the patient regular consultations and back-up should be implemented. On the other hand, reimbursement of the workload assumed by the patient or his eventual dialysis partner should also be taken into account.
An evaluation of the global costs (instead of the dialysis technique costs) will also provide better comparative data: the inclusion of hospitalization costs, travel time to the unit, additional costs of surgery and drugs, paying-off of dialysis equipment, personnel salaries, etc will allow a more precise comparison than the net dialysis reimbursement rates [24].
Educational measures
In order to better inform their patients about all existing ESRD therapeutic possibilities, primary care physicians as well as nephrologists should receive a more detailed education at the pre-, post- and continuous-education level. As yet, the advantages, indications and contra-indications of ESRD therapy options are seldom part of the general medical teaching programs. The same applies to most of the nurses training programs. In several units, PD prescription is done mostly by the PD nurses with little involvement of the nephrologist; and the increased complexity of the newer PD techniques [25] will not necessarily facilitate more medical commitment. Recently, Schaubel et al. [26] have shown that a centre's experience and degree of specialization toward PD strongly impact on PD outcome. Therefore, the PD curriculum set-up by the International Society for Peritoneal Dialysis should become an integrated part of all nephrological training programs at the postgraduate level [27]. It might also be questioned whether nephrologists should receive an education in health economics, taking into account the tremendous but difficult to evaluate expenses necessitated by the ESRF programs in each country [24,28].
Patient information measures
An integrated collaboration between primary care physicians and nephrologists should be set up to prevent the late referral pattern and allow not only better treatment of the progressing CKD and its complications but also more complete and objective informing of the patients and their families [20,21,29,30]. This information should be adapted to the patient and his family at all levels of progressive CKD depending on their level of understanding and also on the progression rate of their CKD: patients do not need to be informed about the respective advantages of dialysis therapies when they have an almost stable or still very moderate decline in their kidney function.
The advantages of a multidisciplinary approach involving other para-medical professions and other patients have already been demonstrated [29].
PD logistics measures
PD utilization should not be hampered by barriers such as insufficient stockpiling space from infrequent material delivery or transient partner unavailability. The availability of para-medical personnel at home or in nursing homes for transient help and advice has proven very useful [31]. The development of efficient and easy-to-use APD cyclers may also convince more patients to tackle the burden of autonomous therapy by not spending much day time for exchanges and making training and daily use less demanding. Finally, better prevention or treatment of the side-effects or complications of PD therapy (peritonitis prevention, more biocompatible dialysis solutions, etc) will also provide better long-term use.
![]() |
Conclusions |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Steps towards a more homogeneous PD utilization have been identified. Their implementation necessitates measures to be implemented at three levels: national (social security measures, reimbursement rates), regional (pre- and post-graduate education) and centre stage (education and communication, logistics).
![]() |
Acknowledgments |
---|
Conflict of interest statement. None declared.
![]() |
References |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|