Peritoneal dialysis (PD) is an established form of renal replacement therapy that is performed primarily at home. The concept of continuous ambulatory peritoneal dialysis (CAPD) was first described by Popovich and Moncrief in 1976. During the 1980s there was rapid growth in the utilization of CAPD in the United States with the development of chronic indwelling PD catheters and the introduction of peritoneal dialysis solution in sterile, disposable plastic bags. The early 1990s witnessed an increase in the number of patients on automated peritoneal dialysis (APD) with the increased interest in dialysis adequacy and the development of simplified, automated cycler machines. Starting in the mid-1990s there was a decrease in the number of incident and prevalent PD patients, and this marked the beginning of a relatively stagnant period for PD growth in the United States. The cause of this decreased PD utilization was likely multifactorial, including lack of infrastructure and provider expertise, inadequate predialysis education, and lower reimbursement rates. More recently there has been a resurgence in PD utilization in the United States. According to the 2016 USRDS annual data report (ADR), the use of PD in 2013 was 72% higher than in 2007, with 9.5% of prevalent dialysis patients in the United States being treated with PD. This increase in PD utilization is thought to be largely due to economic incentives created by changes in reimbursement policy and the adoption of a bundled payment system. Internationally, hemodialysis (HD) still remains the most common form of treatment for end-stage renal disease (ESRD); however, the utilization of PD remains quite high in some countries such as Hong Kong (72%) and Mexico (45%), where “PD first” policies are in effect.
The selection of dialysis modality is influenced by a number of considerations such as availability and convenience, medical factors, and socioeconomic and dialysis center factors. Patients who receive predialysis education are more likely to select peritoneal dialysis. In general, the one absolute contraindication to chronic PD is an unsuitable peritoneum due to the presence of extensive adhesions, fibrosis, or malignancy. Other relative contraindications do exist (Table 50–1). PD continues to be the preferred dialysis modality for infants and young children, patients with severe hemodynamic instability on hemodialysis, and patients with difficult vascular access.
Table 50–1.Contraindications to performance of peritoneal dialysis. |Favorite Table|Download (.pdf) Table 50–1. Contraindications to performance of peritoneal dialysis.
Extensive abdominal adhesions or documented loss of peritoneal function
Presence of colostomy, ileostomy, nephrostomy, or ileal conduit
Recurrent chronic backache with preexisting disc disease
Severe psychological and social problems
Severe diverticular disease of the colon
Severe neurological disease, movement disorder or severe arthritis preventing self care. (Caregivers can be trained to perform peritoneal dialysis.)
Severe chronic obstructive pulmonary disease
Studies investigating differences in patient mortality between PD and in-center hemodialysis have been conflicting. Variable results ...