When your kidneys fail, the job of dialysis is to help you live longer, feel well, and have a good quality of life. You may have one or more transplants in your life with kidney failure, and try more than one type of dialysis. You can also switch treatments if one you choose does not fit your life. So, which one should you try first?

With peritoneal dialysis (PD), you can:

• Keep your remaining kidney function longer
• Improve your chance of getting a transplant
• Keep your job more easily
• Start Medicare coverage right away
• Care for your children
• Learn the treatment quickly—and regain control of your life
• Get a fistula placed so you’re ready for hemodialysis if you ever need it

You should be very involved in the decision of which type of dialysis to do, as it has a huge impact on your lifestyle. In this article, we’ll explain each of these reasons why PD may be a good first choice treatment—if it will otherwise suit your needs, health, and lifestyle.

How PD works

PD is a self-care treatment. It uses the sac that lines the abdomen, called the peritoneum, as a filter to clean your blood. In training, you learn to put dialysate (cleansing fluid) into your peritoneum through a soft, plastic catheter (tube) that is placed in your abdomen or chest¹ by a surgeon. Wastes and excess water slowly flow into the dialysate.

You drain out used dialysate and replace it with fresh a few times each day. This process is called an exchange. You can do exchanges by hand—at breakfast, lunch, dinner, and bedtime—or with a cycler machine at night while you sleep. Since your blood never leaves your body, no needles are used for PD.

Most people can do PD. You may not be able to if you have had abdominal surgeries, or if you don’t have a clean, dry place in your home to store the bags of dialysate. You will need to come for clinic visits once a month for a check up and blood tests. You’ll need to keep pets out of the room and control the air flow when you do an exchange. And, you must care for your catheter and do each exchange with care to avoid infection.

Preserve kidney function longer with PD

In most cases, kidneys don’t lose 100% of their function when they fail—at least not right away. Having some residual kidney function (RKF) can help you to feel better², have fewer diet and fluid limits¹, and live longer^3,4. In fact, one study found that each 1% of glomerular filtration rate (GFR) (kidney filtering) you keep cuts your risk of death in half.²

PD may help you maintain RKF longer than standard hemodialysis (HD)*.^5,6,7 It is vital to do CAPD just as you are taught and avoid peritonitis infection, though. Peritonitis can cause a faster loss of RKF.⁸

RKF does tend to drop over time. If you choose PD, your RKF will be checked with a 24 hour urine test quite often until you don’t make urine any more. Your PD dose will need to be adjusted as your RKF drops.

* HD should be done with biocompatible dialyzer membranes and ultrapure dialysate to maintain RKF.⁴

PD improves chance of transplant

If you plan to get a kidney transplant, PD may be good news for you. A study of more than 252,000 adult U.S. dialysis and transplant patients found that people on PD were about 50% more likely to get a transplant than people on in-center HD. This was true even though the same number of people in both groups were listed for transplant.⁹

PD is an excellent ‘bridge’ to transplant, because you do the treatments yourself. With a transplant, you will need to take a number of drugs correctly. Doing PD shows the transplant team that you can handle responsibility and will care for a transplant well.

PD is work-friendly

How old are you? Each year, half of all new dialysis patients are under 65, or “working-age.” Yet, fewer than 1 in 4 keep a job after they start treatment.¹⁰ For many, this means taking Social Security Disability, which pays only about 35% of what they earned before.

Job loss can push a family into poverty. But standard in-center HD, which is done by 91% of U.S. patients, is not work-friendly. To keep a job on in-center HD, you need a very understanding boss, a flexible work schedule, and a dialysis slot that fits your work times. You may miss work because you feel “washed out” for hours after a treatment or have other symptoms.

PD is work-friendly. You can do an exchange at work or use a cycler at night, so your days are free for work. Some patients do not even tell their employers that they are on dialysis, and they live a rather normal life. It is easy to travel on PD. And, because PD is very gentle and going on most or all of the time, you won’t have ups-and-downs in how you feel from day to day—so you may miss less work. Among more than 163,000 working-age people with kidney failure, people who chose PD or had a transplant were significantly more likely to keep their jobs than those who did in-center HD.⁹

Keeping a job may also mean keeping an employer group health plan (EGHP). An EGHP will pay first for your first 33 months of PD. This means you should have fewer out-of-pocket costs to pay for (and more income to do it with).

Medicare starts sooner with PD

There is another plus of PD—or any form of home dialysis. You can get Medicare to cover your treatments in the first month if you start home training before the 3rd month. With in-center HD, on the other hand, Medicare will not kick in until the first day of your third month of treatment. The dialysis bills can really add up for you in those first three months, especially if you don’t have other insurance.

PD makes parenting easier

If you have very young or even school-aged children, there will be days when an in-center HD schedule will simply not fit your life. A child can become ill in the middle of the night and need to stay home from school or daycare. There may be a play, band concert, or sports event that you would have to miss because it’s on a treatment day. It can be hard—and costly—to find child care for school days off, vacations, and summer break.

The beauty of PD is the flexibility to fit with your needs. With PD, you can shift your exchange times a bit if you need to, so you can go to those special events with your child. If you use a cycler at night, an extra-long tubing set will allow you to reach your child if he or she has a bad dream or a stomach ache.

Children can and do get used to a parent doing dialysis—it just becomes another part of life.

PD is easy to learn

PD is easy to learn and to do. In most cases, you can learn it in a week or two, with a PD nurse on call 24 hours a day for your questions. You don’t need a partner for PD, unless you can’t lift the bags of dialysate. If your hands or eyes don’t work well, you may also prefer to do PD with a helper. There are assist devices, though, and people who are blind can and do perform PD alone.

Learning to do your own treatments puts you in charge of your life—it gives you back the control you lost when you found out you had kidney failure. And, feeling in control improves quality of life for people on dialysis.^11,12,13 A study of more than 4,000 patients found that a sense of personal control also significantly increased the chance of living longer and of getting a kidney transplant.¹⁴

Fistula first

Even if you choose PD, a day may come when you must switch to HD. To do HD, you will need a vascular access—a way to get the blood to the artificial kidney and back to your body. The “gold standard” type of access is called a fistula. It is a direct link between your own artery and vein, made by a surgeon. Fistulas are best because they are your own tissue; they are least likely to get blood clots or infections, and they can work well for decades.

Choosing PD first can allow you time to get a fistula placed and have it ready to go, just in case. This is important, because it means you may be able to avoid a central venous catheter (CVC)—a tube placed into a central vein in your neck or chest. It’s best to not to have a CVC; they have a very high risk of blood infection. In fact, a study of more than 5,500 people on dialysis found that patients who had a CVC were 54%-70% more likely to die than people who had a fistula.¹⁵

Medicare believes that fistulas are so vital to the health and quality of life of people on dialysis that they started a “Breakthrough Initiative” called Fistula First, in which the whole kidney community has come together to be sure that more fistulas are done.

Conclusion

You need to choose a treatment that will fit into your life, and allow you to feel your best. If it will work for you, PD can be a good choice as a first treatment for kidney failure.

References

1. The “Bathtub” (Presternal) PD Catheter.
2. Chandna SM, Farrington K. Residual renal function: Considerations on its importance and preservation in dialysis patients. Sem Dial May-June;17(3):196-201, 2004.
3. Maiorca R, Brunori G, Zubani R, Cancarini GC, Manili L, Camerini C, Movilli E, Pola A, d’Avolio G, Gelatti U. Predictive value of dialysis adequacy and nutritional indices for mortality and morbidity in CAPD and HD patients. A longitudinal study. Nephrol Dial Transplant. Dec;10(12):2295-305, 1995.
4. Termorshuizen F, Korevaar JC, Dekker FW, van Manen JG, Boeschoten EW, Krediet RT. The relative importance of residual renal function compared with peritoneal clearance for patient survival and quality of life: An analysis of the Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD)-2. Am J Kidney Dis;June 41(6):1293-1302, 2003.
5. Horinek A, Misra M. Does residual renal function decline more rapidly in hemodialysis than in peritoneal dialysis? How good is the evidence? Adv Perit Dial; 20:137-40, 2004.
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7. Misra M, Vonesh E, Van Stone JC, Moore HL, Prowant B, Nolph KD. Effect of cause and time of dropout on the residual GFR: A comparative analysis of the decline of GFR on dialysis. Kidney Int; Feb;59(2):754-63, 2001.
8. Shin SK, Noh H, Kang SW, Seo BJ, Lee IH, Song HY, Choi KH, Ha SK, Lee HY, Han DS. Risk factors influencing the decline of residual renal function in continuous ambulatory peritoneal dialysis patients. Perit Dial Int;Mar-Apr;19(2):138-42, 1999.
9. Snyder JJ, Kasiske BL, Gilbertson DT, Collins AJ. A comparison of transplant outcomes in peritoneal and hemodialysis patients. Kidney Int;Oct;62(4):1423-30, 2002.
10. Witten B, Schatell DR, Becker BN. Relationship of ESRD working-age patient employment to treatment modality. Poster presented at the American Society of Nephrology meeting, St. Louis, MO, October 31, 2004. (Abstract) J Am Soc Nephrol. 2004; 15:633A.
11. Tsay SL, Hung LO. Empowerment of patients with end-stage renal disease—a randomized controlled trial. Int J Nurs Stud; Jan;41(1):59-65, 2004.
12. Tovbin D, Gidron Y, Jean T, Granovsky R, Schneider A. Relative importance and interrelations between psychosocial factors and individualized quality of life of hemodialysis patients. Qual Life Res; Sept;12(6):709-17, 2003.
13. Tsay SL, Healstead M. Self-care self-efficacy, depression, and quality of life among patients receiving dialysis in Taiwan. Int J Nurs Stud;Mar;39(3):245-51, 2002.
14. Stack AG, Martin DR. Association of patient autonomy with increased transplantation and survival among new dialysis patients in the United States. Am J Kidney Dis;Apr; 45(4):730-42, 2005.
15. Dhingra RK, Young EW, Hulbert-Shearon TE, Leavey SF, Port FK. Type of vascular access and mortality in U.S. hemodialysis patients. Kidney Int;Oct;60(4):1443-51, 2001.

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