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Peritoneal dialysis (PD) is an established form of renal replacement therapy that is used around the world. The concept of continuous ambulatory peritoneal dialysis (CAPD) was first described 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 PD solution in sterile, disposable plastic bags. In the 1990s there was a rapid 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. In more recent years, however, the growth of PD has decreased in the United States. United States Renal Data System (USRDS) data from 1998 to 2002 indicate that the prevalent PD population decreased by 3.5% per year, with only 8% of prevalent dialysis patients being treated with PD in 2002. In contrast to the experience in the United States, the prevalent number of patients with end-stage renal disease receiving PD has exceeded 60% in other countries, such as in Mexico and Hong Kong. The cause for these differences is likely multifactorial and is related to access to PD, physician expertise, patient mix, and reimbursement.

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. 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 51–1). 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. Studies investigating differences in patient mortality between PD and hemodialysis (HD) have been conflicting. Most reports have shown no significant difference in survival between PD and nondiabetic HD patients. Survival by dialysis modality among diabetic patients may vary with age. Some series have found lower survival for older diabetic patients on PD compared to HD. Variable results in these mortality studies have been affected by differences in patient comorbidities, inclusion of prevalent versus incident patients, and the types of analytical methods utilized. Real differences in mortality between PD and HD can be assessed only in prospective, randomly controlled trials that will be very difficult and therefore unlikely to be performed. Technique survival is shorter in PD compared to HD due to peritonitis, peritoneal membrane failure, and patient burnout.

Table 51–1. Contraindications to Performance of Peritoneal Dialysis.

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