Nephrology Hypertension

Peritoneal Dialysis: Patient Selection

Does this patient have advanced chronic kidney disease and an indication for peritoneal dialysis support?

There are only two absolute contra-indications for peritoneal dialysis - the lack of a functional peritoneal membrane, and the lack of a stable residence. Every other medical or psychosocial contraindication is relative - whether these other conditions, as discussed below, should determine the selection of dialysis modality should be left to the judgment of each individual patient and if appropriate, their family members and/or care-givers under the guidance and support of a multi-disciplinary healthcare team.

Thus, the overwhelming majority of patients with advanced chronic kidney disease do not have any medical or psycho-social contraindication for peritoneal dialysis. Since there are few therapies that have as profound an impact on a patient's life-style as dialysis therapy has on patients with end-stage renal disease, it is essential to engage patients to determine which dialysis modality will allow them to lead what they believe to be fulfilling lives.

It is equally important to reassure the patients that the decision that they will make now about a dialysis modality is not permanent - under most circumstances, they can switch to an alternative dialysis modality if their medical or social condition changes or the burden of the selected therapy differs from what their expectations were. This can sometimes relieve the pressure on patients considering different dialysis therapies.

There are several medical and social issues that may potentially be important when considering peritoneal dialysis for a given patient. It is important that these be elucidated when talking to the patient (medical history) and upon physical examination. These include patient age, cause of end-stage renal disease (diabetes, polycystic kidney disease, scleroderma), other medical history (previous cardiovascular disease), surgical history (previous abdominal surgery, aortic prosthetic grafts in patients with abdominal aortic aneurysm), body size, presence of ascites, hernia, and living conditions and lifestyle considerations of a patient.

Elderly

Peritoneal dialysis has successfully been performed by octagenarians and nanogenarians; the risk of infectious or non-infectious complications with the therapy are no different than seen in younger age groups. Hence, chronological age is insufficient to deny a patient the choice in selecting their dialysis modality.

Advancing age, however, is often associated with a decrease in manual dexterity and visual acuity, frailty, cognitive decline, and chronic arthritis. Furthermore, many elderly patients live alone and home dialysis may accentuate social isolation. Others may be reluctant to impose the additional burden of home dialysis on their elderly partners. Conversely, family members of many patients may be willing to provide support to allow them to perform self-care dialysis at home.

Yet, peritoneal dialysis performed at home may offer several advantages to some elderly patients - even the frail elderly. Peritoneal dialysis obviates the need for frequent travel to and from a health-care facility - this may be as important to a care-giver as to the patient. The life-plan of many elderly individuals may include recreational travel - it is easier for patients to travel if they were to do peritoneal dialysis. Creating and maintaining a vascular access and the need for anti-coagulation during the hemodialysis procedure are more likely to pose challenges for the elderly and should prompt consideration of peritoneal dialysis as an alternative. The continuous nature of peritoneal dialysis also offers greater hemodynamic stability that may allow better tolerance of the dialysis procedure.

What can facilitate peritoneal dialysis for a frail patient?

The use of peritoneal dialysis in frail individuals, irrespective of age, can be facilitated by connection-assist devices and assisted therapy. Connection-assist devices can overcome the challenges posed by decreased manual dexterity and/or visual acuity, are available from both major manufacturers of peritoneal dialysis supplies, and for both continuous ambulatory and automated therapies.

Another strategy that has been successfully applied in different health care systems around the world is "assisted peritoneal dialysis" - assistance is provided to the patient for their dialysis treatment by either a family member or a healthcare provider (nurse or healthcare aide). In most such reports, the risk for infectious complications in patients performing assisted peritoneal dialysis is no different than seen with unassisted therapy. Assisted peritoneal dialysis is best performed using a cycler and the prescription can be designed such that a patient requires assistance only twice during any 24-hour period (at the time of connection to the cycler at night and disconnection in the morning).

In a report of assisted peritoneal dialysis from Canada, many patients required assistance for some but not all connections/disconnections; a significant minority graduated to complete independence after a short period of assisted peritoneal dialysis. Thus, the availability of assistance may increase the confidence of selected individuals about their ability to undertake home dialysis and serve as a bridge to independent home care dialysis.

Diabetes mellitus

The effect of peritoneal dialysis on glycemic control, potential for weight gain, and patient longevity are important issues in the context of selection of dialysis modality for a patient with diabetes mellitus. Glucose absorption from the peritoneal dialysate and increased nutrient intake after the amelioration of uremic anorexia with the start of dialysis treatment undoubtedly affects glycemic control. In most patients, this can be readily managed with appropriate adjustment of medical therapy.

In a recent clinical trial, glucose-sparing peritoneal dialysis prescriptions (that use icodextrin for the long overnight dwell and day dwell respectively for continuous ambulatory and automated peritoneal dialysis patients) were associated with a significant improvement in glycemic control and dyslipidemia and should be considered for selected patients. A recent study showed that significant weight gain in patients who begin treatment with peritoneal dialysis is no more frequent than those who start in-center hemodialysis and this consideration should not dissuade patients from considering the therapy either.

Finally, care should be exercised before using survival data from observational studies in making decisions about dialysis modality for a given patient. It remains unclear if differences in survival, if any, between patients treated with different dialysis modalities are attributable to the therapy or to unmeasured differences in characteristics of patients who select the therapy. Thus, notwithstanding the purported challenges with peritoneal dialysis, most diabetics can choose the dialysis modality that fits best with their goals and expectations in life.

Polycystic kidney disease

The ability of patients to tolerate instillation of peritoneal dialysate in the presence of enlarged kidneys, and reports suggesting a higher risk of hernias and diverticulitis have raisedsome question as to whether peritoneal dialysis is appropriate for treatment of end-stage renal disease in patients with polycystic kidney disease. Three recent case-control studies - one each from the United Kingdom, France, and Hong Kong - have shown the risk for infectious of peritoneal dialysis in patients with polycystic kidney disease is no different from that of other patients with end-stage renal disease from non-diabetic kidney disease. While hernias may be more common, they are readily treatable and peritoneal dialysis can be successfully performed. Hence, a diagnosis of polycystic kidney disease generally should have no bearing on selection of dialysis modality.

Scleroderma

In patients with systemic sclerosis, concern has been sometimes raised that peritoneal fibrosis - if present - may preclude successful performance of peritoneal dialysis. Scleroderma is a rare disease and the published clinical experience in the form of case-reports and case-series show that peritoneal dialysis can be successfully performed in these patients. Peritoneal dialysis can be initiated if a patient with scleroderma believes it is the best therapy for him/her.

Previous cardiovascular disease (coronary artery disease or congestive heart failure)

Several observational studies have demonstrated that patients with previous cardiovascular disease treated with peritoneal dialysis have a higher mortality risk than those treated with hemodialysis. The risk is more pronounced for older individuals. However, studies also indicate that the magnitude of elevation of risk in such patients treated with peritoneal dialysis has diminished over time.

Observational studies are insufficient to deny patients a choice in selecting their dialysis modality but they do draw attention to the importance of individualizing prescription to every patient's medical condition. Peritoneal dialysis offers continuous ultrafiltration allowing for greater hemodynamic stabilitiy. Furthermore, since the peritoneal dialysate contains no potassium, hyperkalemia is virtually never a problem in patients treated with peritoneal dialysis - this makes it safer to initiate or maintain cardio-protective drugs like angiotensin-converting-enzyme inhibitors, angiotensin receptor blockers, or aldosterone antagonists.

On the other hand, the nature of therapy places a greater burden on the healthcare team to educate the patient on how to quickly adjust the dialysis prescription in response to day-to-day changes in salt and water intake. It also highlights the importance of ensuring that prescriptions are designed such that they mitigate the metabolic effects of peritoneal dialysis like dyslipidemia and to preferentially use glucose-sparing regimens in such patients. These considerations could inform decision-making about the most appropriate dialysis modality for any given patient.

Previous abdominal surgery

A history of previous abdominal surgery in and of itself is not a contra-indication for peritoneal dialysis but does increase the likelihood that the patient has intra-peritoneal adhesions. It is only the presence of extensive adhesions that precludes the successful performance of peritoneal dialysis. The more complicated the abdominal surgery or greater the intra-peritoneal bleeding or inflammation at the time of surgery, greater is the likelihood of extensive adhesions.

Yet, neither the surgical records nor any non-invasive imaging test can reliably predict the presence or absence of such extensive intra-peritoneal adhesions that will preclude successful performance of peritoneal dialysis. The optimal approach in a patient who has a history of significant abdominal surgery in the past and who prefers peritoneal dialysis is for the surgeon to inspect the peritoneal cavity using a laparascope- in many patients a peritoneal dialysis catheter can be successfully placed with or without selective adhesiolysis. In those patients where extensive adhesions preclude the placement of a peritoneal dialysis catheter, the surgeon can place a vascular access at the same sitting.

Aortic prosthetic grafts in patients with abdominal aortic aneurysm

The initiation of peritoneal dialysis should be delayed by 4-6 weeks in patients who have had surgical repair of abdominal aortic aneurysm. After the initial post-operative period, peritoneal dialysis may be safer than starting hemodialysis with a central venous catheter. Since the aorta is retro-peritoneal, the prosthetic graft is unlikely to be infected if the patient was to develop peritoneal dialysis-related peritonitis. On the other hand, the graft is significantly more likely to be infected in the setting of bacteremia - not an uncommon complication in patients with central venous catheters.

Large body size

Large body size is, in most cases, not a contraindication for peritoneal dialysis. As in all patients treated with hemodialysis, there is an inverse relationship between body size and risk for death among US peritoneal dialysis patients. However, the risk of transfer to hemodialysis increases with increasing body size.However, it is generally not because of difficulty in achieving solute clearance targets, as the burden of uremic toxins in obese individuals is not much larger than the non-obese. Ability to achieve solute clearance targets is even less of a problem in a patient with significant native kidney function.

The most important challenge in performing peritoneal dialysis in obese patients is obtaining a trouble-free peritoneal dialysis catheter exit site. A catheter exit-site that is placed under the abdominal pannus would be at a very high risk of recurrent exit-site and tunnel infection. To obviate this problem, extended abdominal or pre-sternal catheters should be used to ensure that the exit-site is located at a place where the patient can keep it dry and readily perform daily exit-site care.

The concern that peritoneal dialysis will be associated with greater weight gain which, in turn, could further limit the possibility of renal transplantation has not been borne out in recent observational studies. Not only was the possibility of significant weight gain no different between patients treated with hemodialysis or peritoneal dialysis, for every strata of body size the adjusted odds of renal transplantation were significantly higher in patients treated with peritoneal dialysis. Thus, peritoneal dialysis can be successfully performed in obese patients; our program has successfully performed peritoneal dialysis in patients weighing up to 400 lb.

Presence of ascites

Patients with right heart failure and/or chronic liver disease with co-existing end-stage renal disease can present with large ascites. Placement of an indwelling catheter will allow for daily removal of "ascitic" fluid with each dialysis exchange, obviating the need for periodic paracentesis. Moreover, peritoneal dialysis affords greater hemodynamic stability than intermittent hemodialysis.

There are several challenges that also need to be appreciated - wound healing may be delayed in patients with tense ascites with/without abdominal wall edema. Furthermore, in patients with very large ascites, it may be advantageous to ensure that initial complete drainage of ascitic fluid is done over a few days.

The obligatory generation of ascitic fluid from increased hydrostatic pressure secondary to portal hypertension can result in large effluent volumes with peritoneal dialysis that may complicate hemodynamic management. Some have raised concern that daily peritoneal albumin losses may worsen hypoalbuminemia. These issues should allow for informed decision making for an occasional patient with end-stage renal disease who has a large ascites burden.

Hernia

Increase of intra-peritoneal pressure with instillation of dialysate can lead to an increase in the size of a pre-existing hernia. Careful physical examination of the patient at the time of initial evaluation can allow for simultaneous repair of the hernia at the time of placement of peritoneal dialysis catheter. This will preclude the need to repair the hernia after the patient has been established on peritoneal dialysis therapy.

Larger hernias are best treated with tension-free herniorraphy with a polypropolene mesh. Since the mesh is pre-peritoneal, it is unlikely to be infected even in the setting of peritoneal dialysis-associated peritonitis and peritoneal dialysis can be safely performed in such patients.

Living conditions of a patient

The patient has to have sufficient space at home to store supplies for performing peritoneal dialysis. In the United States, manufacturers generally ship supplies to a patient's home once a month; in patients with space constraints at home, the frequency of delivery of supplies can be increased to once every 15 days.

The patient needs to have a large night stand or an elevated structure equivalent to a large night stand to place the cycler if they choose to use automated peritoneal dialysis. It is also important for the patients to understand that it is desirable for toddlers or pets not to be in the room when they are performing a peritoneal dialysis exchange. It is also important for patients to ensure that pets don't sleep in their bed, particularly if they use a cycler at night.

Other lifestyle considerations

Patients are discouraged from lifting weights or objects that are heavier than 20 lb. In addition, those with abdominal exit-sites are strongly discouraged from soaking in a bath-tub. If this is an important consideration, it is advantageous to use a pre-sternal catheter.

Patients can engage in physical activities that lead to significant sweating or soaks the dressing over the exit site (like swimming). Under such circumstances, it is best to cover the exit-site with a colostomy bag and useful for the patients to shower and perform exit-site care promptly. Swimming in fresh water is safer than in public pools. These additional considerations may be relevant for some patients when selecting their dialysis modality.

What tests to perform?

There are no laboratory tests that are useful in helping a patient decide which dialysis modality is most appropriate. Imaging tests are not very useful in determining the presence or extent of adhesions or whether a patient will be able to tolerate the volume of dialysate that is necessary for the successful performance of peritoneal dialysis.

How should patients with advanced chronic kidney disease, who are trying to determine an appropriate dialysis modality, be managed?

All patients with advanced and progressive chronic kidney disease should be referred for multi-disciplinary patient education. The "education team" should consist of a "lead patient educator" with components taught by dietitians, and social workers. The value of such education can be enhanced if it includes either group or one-on-one interaction with patients treated with different dialysis modalities and visits to both an in-center hemodialysis and a home program. The nature of instruction should be a mix of didactic instruction, interactive discussion, and visuals provided by videos and/or DVDs.

The goal of the education program should be to educate patients about chronic kidney disease, its natural history and complications, the different renal replacement therapies, their advantages and complications, impart an understanding of the importance of making dietary selections consistent with the presence of kidney disease, and financial/insurance issues. The education program should offer support to the patient and facilitate the decision-making regarding their dialysis modality.

One of the key measures of success of such an education program should be the timely placement of the dialysis access - whether it is vascular access for hemodialysis or catheter for peritoneal dialysis. This would require timely referral for multi-disciplinary education.

In 2008, 44% of patients who started maintenance dialysis in the United States had no prior care from a nephrologist. It is critical that even the late-referred patients undergo multi-disciplinary chronic kidney disease education.

Timing of placement of peritoneal dialysis access

Optimally, one should wait about 2 weeks from the time of placement of the catheter before it is used for full-volume peritoneal dialysis ('break-in' period). This allows for adequate healing of the tunnel tract and minimzes the risk for leaks. However, peritoneal dialysis can be started within hours of placement of a catheter if needed; it is best to perform perform low-volume, supine peritoneal dialysis during early break-in.

The break-in may need to be longer in patients in whom there is concern about impairment in wound-healing (for example, patients who have been treated with steroids for long periods of time like those with a failed kidney transplant). Given these considerations, it is best to place a peritoneal dialysis catheter only 2-4 weeks before the anticipated need for dialysis.

Role of "buried" peritoneal dialysis catheters

If the patient has determined which dialysis modality is most appropriate for them, the peritoneal dialysis catheter can be placed electively and the external limb of the peritoneal dialysis catheter can be buried in the subcutaneous tissue. This takes away the need for the patient to perform daily exit-site care for prolonged periods of time before the need for dialysis and relieves the pressure from the healthcare team about determining precisely when the patient will require maintenance dialysis.

The external limbs of peritoneal dialysis catheters have been successfully buried for up to 3 years; however, it is preferable to bury the external limb of the catheter only if the anticipated interval between the time of placement of the catheter and the need for dialysis is between 6 weeks and 6 months. As and when dialysis is necessary, a small incision is made at the desired location for the exit-site, and the catheter limb is exteriorized.

This is a low-risk procedure that can be performed in either the nephrologist's or surgeon's office under local anesthesia. Since the tunnel track would have healed completely, full-volume peritoneal dialysis can be started on the same day as the exteriorization of the catheter.

How do patients who choose peritoneal dialysis do as compared to those who choose in-center hemodialysis?

At least two randomized, controlled clinical trials have been attempted to compare the outcomes of patients with end-stage renal disease treated with in-center hemodialysis and peritoneal dialysis. The most recent attempt was made in the Netherlands under the auspices of the NECOSAD study. Once the patients learnt about the disparate effects of different dialysis modalities on their lifestyle, over 90% of eligible patients refused to be randomized. It is unlikely that another randomized controlled trial of dialysis modalities will be attempted in any of the developed countries. There is a clinical trial that is presently underway in China with the goal of comparing in-center hemodialysis with peritoneal dialysis.

Currently, one has to depend upon observational clinical studies. A large number of such studies have been undertaken from different parts of the world. One has to exercise great caution in using data from such observational studies to make decisions about which dialysis modality would be appropriate for any given patient. There is no certitude that differences in survival between patients in such are indeed attributable to the dialysis modality with which they are treated. It is equally likely that the survival differences stem from the patients who choose the therapy rather than the specific effects of the dialysis modality ("residual confounding").

Given the uncertainty, it is inappropriate to use data from observational studies to deny a choice in selection for dialysis modality. Moreover, in patients with as limited a life-expectancy as that of individuals with end-stage renal disease, there are outcomes that may be more relevant to a patient than survival (including health-related quality of life or satisfaction with care).

Early studies indicated that patients who start treatment with peritoneal dialysis had a lower risk for death early during the course of end-stage renal disease but a higher long-term risk. However, over the last decade, the outcomes of peritoneal dialysis patients have improved considerably more than of patients treated with in-center hemodialysis in different parts of the world.

Analysis of data from more recent cohorts, thus, shows that there is no neither an early survival advantage nor a long-term risk with peritoneal dialysis as had been shown in earlier studies. Thus, there is no significant difference in 4-, 5-, or 10-year survival of end-stage renal disease patients treated with either hemodialysis or peritoneal dialysis in the United States, Canada, and Australia and New Zealand.

Many studies have examined the relative outcomes with the two dialysis modalities in different sub-groups of patients. The preponderance of published evidence indicates that survival of younger patients with few, if any, other co-existing medical conditions is superior to that observed for patients treated with in-center hemodialysis. Conversely, the survival of older patients with other co-existing medical conditions treated with peritoneal dialysis is inferior to that of patients treated with in-center hemodialysis.

Over the last decade, the differences in survival in different sub-groups have all moved in favor of peritoneal dialysis in the United States. Thus, the relatively better survival of younger and otherwise healthy patients treated with peritoneal dialysis has gotten even better while the relatively worse survival of older and sicker patients treated with peritoneal dialysis has become less so.

Technique Survival (or time-on-therapy)

Technique survival (or time-on-therapy) is often used as an outcome measure for patients treated with peritoneal dialysis. While each individual patient has many different vascular access sites, they have only one peritoneal membrane. Hence, the probability of a peritoneal dialysis patient developing a complication that necessitates the transfer to hemodialysis is significantly greater than the other way round.

There have been at least two notable issues highlighted by recent studies. First, the technique survival of peritoneal dialysis patients is directly related to unit census - the risk of transfer to hemodialysis is considerably lower for patients treated in larger units than the smaller ones. This implies that many of the causes of transfer to hemodialysis are potentially preventable. Second, the technique survival of peritoneal dialysis patients in the United States has improved in parallel with the improvement in patient survival. This is probably largely secondary to a significant reduction in infection risk of patients treated with peritoneal dialysis.

Other relevant measures

Numerous studies have compared the health-related quality of life of patients treated with in-center hemodialysis and peritoneal dialysis and the preponderance of evidence suggests that there is no difference. At least two studies have demonstrated a significantly higher satisfaction with care in patients treated with peritoneal dialysis than those with in-center hemodialysis.

How to utilize team care?

Patients with advanced chronic kidney disease should undergo multi-disciplinary education that is delivered by a lead educator and is supported by dietitians, social workers, and current patients.

Once patients are established on peritoneal dialysis, their care should be delivered by multi-disciplinary teams that consist of physicians, nurses, dietitians, and social workers.

Are there clinical practice guidelines to inform decision making?

  • International Society for Peritoneal Dialysis Guidelines on peritoneal dialysis access and peritoneal dialysis training available at http://www.ispd.org/lang-en/treatmentguidelines/guidelines

  • National Kidney Foundation KDOQI guidelines available at http://www.kidney.org/professionals/KDOQI/guideline_upHD_PD_VA/pd_guide1.htm

  • Caring for Australasians with Renal Impairment (CARI) available at http://www.cari.org.au/dialysis_accept_published.php

  • UK Renal Association Guidelines for peritoneal dialysis available at http://www.renal.org/Libraries/Guidelines/Peritoneal_Dialysis_FINAL_DRAFT_-_09_May_2010.sflb.ashx.

What is the evidence?

Mendelssohn, DC, Mujais, SK, Soroka, SD, Brouillette, J, Takano, T, Barre, PE, Mittal, BV, Singh, A, Firanek, C, Story, K, Finkelstein, F. "A prospective evaluation of renal replacement therapy modality eligibility". Nephrol Dial Transplant. vol. 24. 2009. pp. 555-561.

(This is one of the largest studies in which the eligibility of patients with advanced chronic kidney disease was assessed for peritoneal dialysis and transplantation by healthcare providers. The authors reported that 78% of patients neither had medical nor psychosocial contraindications for peritoneal dialysis.)

Korevaar, JC, Feith, GW, Dekker, FW, van Manen, JG, Boeschoten, E, Bossuyt, PMM, Krediet, RT. "Effect of starting hemodialysis compared with peritoneal dialysis in patients new on dialysis treatment: a randomized controlled trial". Kidney Int. vol. 64. 2006. pp. 2222-2228.

(This is the last randomized controlled trial meant to compare the outcomes of patients treated with hemodialysis or peritoneal dialysis attempted in Netherlands. More than 90% of eligible patients refused to be randomized, indicating rather strongly patients' preference to have a say in the selection of their dialysis modality.)

Oliver, MJ, Quinn, RR, Richardson, EP, Kiss, AJ, Lamping, DL, Manns, BJ. "Home care assistance and the utilization of peritoneal dialysis". Kidney Int. vol. 71. 2007. pp. 673-678.

(This is one of several reports of successful application of assisted peritoneal dialysis.)

Paniagua, R, Ventura, MD, Avila-Diaz, M, Cisneros, A, Vicente-Martinez, M, Furlong, MD, Garcia-Gonzalez, Z, Villanueva, D, Orihuela, O, Prado-Uribe, MD, Alcantara, G, Amato, D. "Icodextrin improves metabolic and fluid management in high and high-average transport diabetic patients". Perit Dial Int. vol. 29. 2009. pp. 422-432.

(This randomized controlled clinical study tested the effect of "glucose-sparing" peritoneal dialysis prescriptions on a variety of metabolic parameters. These regimens were associated with lower cumulative glucose exposure, a reduced need for insulin, an improvement in fasting blood glucose and glycosylated hemoglobin, and improvement in dyslipidemia.)

Kumar, S, Fan, SL, Raftery, MJ, Yaqoob, MM. "Long-term outcome of patients with autosomal dominant polycystic kidney diseases receiving peritoneal dialysis". Kidney Int. vol. 66. 2004. pp. 2389-2401.

(This is one of two recent studies that compared the outcome of non-diabetic patients with and without autosomal polycystic kidney disease and report no difference in any infectious or non-infectious complications of peritoneal dialysis.)

Vonesh, EF, Snyder, JJ, Foley, RN, Collins, AJ. "The differential impact of risk factors on mortality in hemodialysis and peritoneal dialysis". Kidney Int. vol. 66. 2004. pp. 2389-2401.

(This is one of the most comprehensive comparisons of the outcomes of hemodialysis and peritoneal dialysis patients in the United States and used data from the United States Renal Data System. It illustrates the importance of interaction with time, age, diabetic status, and cardiovascular co-morbidity in determining the inter-modality comparison.)

Mehrotra, R, Kermah, D, Fried, L, Kalantar-Zadeh, K, Khawar, O, Norris, K, Nissenson, A. "Chronic peritoneal dialysis in the United States: declining utilization but improving outcomes". J Am Soc Nephrol. vol. 18. 2007. pp. 2781-2788.

(This is the first study, using data from the United States Renal Data System, to demonstrate that improvements in outcomes of peritoneal dialysis patients have outpaced those seen for in-center hemodialysis patients.)

Mehrotra, R, Chiu, YW, Kalantar-Zadeh, K, Bargman, J, Vonesh, E. "Similar outcomes with hemodialysis and peritoneal dialysis in patients with end-stage renal disease". Arch Intern Med. vol. 171. 2011. pp. 110-118.

(This study, using data from the United States Renal Data System, demonstrates that for patients who started dialysis between 2002 and 2004 in the United States, there is no significant difference in the 5-year survival of patients treated with in-center hemodialysis or peritoneal dialysis.)

Mehrotra, R, Chiu, YW, Kalantar-Zadeh, K, Vonesh, E. "The outcomes of continuous ambulatory and automated peritoneal dialysis are similar". Kidney Int. vol. 76. 2009. pp. 97-107.

(This study, using data from the United States Renal Data System, demonstrates the dependence of technique survival on the number of patients treated with peritoneal dialysis in a given unit. Furthermore, it demonstrates the progressive improvement in technique survival over time for US peritoneal dialysis patients.)

Crabtree, JH. "Extended peritoneal dialysis catheters for upper abdominal wall exit sites". Perit Dial Int. vol. 24. 2004. pp. 292-294.

(This paper is a useful resource to plan the placement of upper abdominal wall catheters in obese patients with a large pannus.)

McCormick, BB, Brown, PA, Knoll, G, Yelle, JD, Page, D, Biyani, M, Lavoie, S. "Use of embedded peritoneal dialysis catheter: experience and results from a North American center". Kidney Int. 2006. pp. S38-S34.

(This paper is a useful resource for how and when to bury and exteriorize peritoneal dialysis catheters.)
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