The Current State of Peritoneal Dialysis

Abstract

Technical innovations in peritoneal dialysis (PD), now used widely for the long-term treatment of ESRD, have significantly reduced therapy-related complications, allowing patients to be maintained on PD for longer periods. Indeed, the survival rate for patients treated with PD is now equivalent to that with in-center hemodialysis. In parallel, changes in public policy have spurred an unprecedented expansion in the use of PD in many parts of the world. Meanwhile, our improved understanding of the molecular mechanisms involved in solute and water transport across the peritoneum and of the pathobiology of structural and functional changes in the peritoneum with long-term PD has provided new targets for improving efficiency and for intervention. As with hemodialysis, almost half of all deaths on PD occur because of cardiovascular events, and there is great interest in identifying modality-specific factors contributing to these events. Notably, tremendous progress has been made in developing interventions that substantially reduce the risk of PD-related peritonitis. Yet the gains have been unequal among individual centers, primarily because of unequal clinical application of knowledge gained from research. The work to date has further highlighted the areas in need of innovation as we continue to strive to improve the health and outcomes of patients treated with PD.

Keywords: Life-threatening dialysis complications; cardiovascular disease; end-stage renal disease; peritoneal dialysis; peritoneal membrane.

Figure 1.

Major landmarks in the development of PD as a treatment for ESRD (1923–1978).

Figure 2.

Secular trends in the number of patients treated with PD in the United States (1996–2013). (A) The number of patients treated with PD by 90 day of start of maintenance dialysis; (B) Point prevalent counts of the number of patients treated with PD as of December 31 of each calendar year.

Figure 3.

Secular trends in the proportion of patients undergoing maintenance dialysis treated with PD in the United States (1996–2013). The blue line represents the proportion of all patients undergoing maintenance dialysis treated with PD 90 days from the date of first dialysis and the red line represents the proportion of all patients undergoing maintenance dialysis on December 31 of any calendar year.

Figure 4.

Overview of interrelationships between modality-specific factors that may contribute to the cardiovascular risk of patients undergoing PD.

Figure 5.

Center-specific PD-related peritonitis rates (incidence rate ratios) in Australia during the periods 2004–2008 (open triangles) and 2009–2013 (solid circles).