Editor’s Note: The articles in this section offer readers a variety of highlights on programming for the upcoming National Kidney Foundation’s Spring Clinicals meeting.
Modality options: Should nephrologists promote peritoneal dialysis as a bridge to and from transplantation?
Despite having comparable medical outcomes as hemodialysis, peritoneal dialysis is underutilized in the United States as a modality of renal replacement therapy compared to other developed countries.1 One of the multiple factors leading to this underutilization of peritoneal dialysis is that almost a quarter of patients who need renal replacement therapy do not receive adequate pre-dialysis care and are not even offered peritoneal dialysis or transplantation as an option.2 This lack of education needs to be highlighted specifically in patients who go on to receive a transplant.
It has been shown that use of peritoneal dialysis (PD) as a pre-transplant modality is associated with a lower risk of delayed graft rejection (DGF) and primary allograft failure.3, 4 The mechanism by which DGF is prevented in patients on PD has not been completely elucidated. However the most likely reason is that residual kidney function is better preserved in patients on PD, which likely contributes to maintenance of homeostatsis post transplant.3 As DGF is associated with a higher risk of death and death-censored graft failure,5 it seems logical that use of PD prior to transplant will be associated with favorable outcomes overall. This was demonstrated in a recent metanalysis in which PD was associated with a lower all-cause mortality compared to hemodialysis (HD adjusted hazard ratio of mortality: 0.89) in addition to a lower rate of DGF (pooled odds ratio: 0.5).6 Therefore, as practicing nephrologists, we should share these results with patents while educating them regarding renal replacement therapy options and encourage the use of PD prior to tranplantation.
In addition, patients with a failing allograft (DAGF) account for a significant number of patients starting dialysis.2 Some reasons for the growth of this population has been improved short-term kidney allograft survival and greater sensitization of patients with a failed transplant, reducing their chances of retransplanation and increasing time on the waitlist.7,8 Moreover, patients with DAGF tend to be younger and have fewer comorbidities than the general end-stage renal disease (ESRD) population and these factors are associated with favorable outcomes in PD and general incident dialysis.9,10 However, despite these factors and most of these patients being under care of a nephrologist, they still have a low rate of PD utilization comparable to the general ESRD population.8 One of the reasons for the low rate of PD utilization in DAGF might be the concern for peritonitis in the setting of ongoing immunosuppression, but none of the studies have consistently shown a higher rate of peritonitis in these patients. This raises the important question of whether mortality in patients with DAGF is dependent on the dialysis modality and this has been addressed in several studies, most of which have shown that overall survival of patients with DAGF on PD is comparable to patients on HD.8,11 Moreover, there is some evidence that there is a time-dependent survival trend in the association between dialysis modality and risk of death, with PD being associated with a greater survival in the first 2 years and poorer survival after 2 years.8 Given this early survival benefit, it seems prudent to support PD as initial dialysis modality after transplant failure with transition to HD at a later date.
In summary, nephrologists should discuss and highlight the potential benefits of PD as a dialysis modality to patients who are on their way to receiving a transplant and with those who are transitioning to dialysis after allograft failure. However, ultimately the decision regarding which dialysis modality to use should be based on patient preference rather than physician preference.
This topic will be presented during the session “Peritoneal dialysis first” on Friday, April 13, from 4:00 p.m. to 5:00 p.m. in the Austin Convention Center.
National Kidney Foundation Spring Clinicals meeting, will be held at the Austin Convention Center from April 10-14 in Austin, Texas. For more information, visit www.kidney.org/spring-clinical.
- Liu FX, et al. Perit Dial Int. 2015;doi:10.3747/pdi.2013.00204.
- USRDS annual data report: Epidemiology of kidney disease in the United States. NIH, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md., 2017.
- Freitas C, et al. Transplant Proc. 2011;doi:10.1016/j.transproceed.2010.12.008.
- Tang M, et al. Blood Purif. 2016;doi:10.1159/000446272.
- Snyder JJ, et al. Kidney Int. 2002;doi:10.1046/j.1523-1755.2002.00563.x.
- Joachim E, et al. Perit Dial Int. 2017;doi:10.3747/pdi.2016.00011.
- Lamb KE, et al. Am J Transplant. 2011;doi:10.1111/j.1600-6143.2010.03283.x.
- Perl J, et al. Perit Dial Int. 2013;doi:10.3747/pdi.2012.00280.
- Rao PS, et al. Am J Kidney Dis. 2007;doi:10.1053/j.ajkd.2006.11.022.
- Vonesh EF, et al. Kidney Int Suppl. 2006;doi:10.1038/sj.ki.5001910.
- Perl J, et al. Clin J Am Soc Nephrol. 2011;doi:10.2215/CJN.06640810.
For more information: Micah R. Chan, MD, is clinical chief and an associate professor of nephrology and Sana Waheed, MD, is an assistant professor of nephrology at the University of Wisconsin School of Medicine and Public Health, based in Madison, Wisconsin. Disclosures: The authors report no relevant financial disclosures.