Peritoneal Dialysis Versus Hemodialysis: Risks, Benefits,

and Access Issues

Ramapriya Sinnakirouchenan and Jean L. Holley
Peritoneal dialysis (PD) and hemodialysis (HD) are dialysis options for end-stage renal disease patients in whom preemptive
kidney transplantation is not possible. The selection of PD or HD will usually be based on patient motivation, desire, geographic
distance from an HD unit, physician and/or nurse bias, and patient education. Unfortunately, many patients are not educated on
PD before beginning dialysis. Most studies show that the relative risk of death in patients on in-center HD versus PD changes
over time with a lower risk on PD, especially in the first 3 months of dialysis. The survival advantage of PD continues for 1.5-2
years but, over time, the risk of death with PD equals or becomes greater than with in-center HD, depending on patient factors.
Thus, PD survival is best at the start of dialysis. Patient satisfaction may be higher with PD, and PD costs are significantly lower
than HD costs. The new reimbursement system, including bundling of dialysis services, may lead to an increase in the number
of incident patients on PD. The high technique failure of PD persists, despite significant reductions in peritonitis rates. Infection
also continues to be an important cause of mortality and morbidity among HD patients, especially those using a central venous
catheter as HD access. Nephrologists efforts should be focused on educating themselves and their patients about the oppor-
tunities for home modality therapies and reducing the reliance on central venous catheter for long-term HD access.
Q 2011 by the National Kidney Foundation, Inc. All rights reserved.
Key Words: Tunneled catheters, End-stage renal disease, Chronic kidney disease

Risks and Benefits of PD Versus HD

I ntegrated care models of chronic kidney disease
(CKD) and end-stage renal disease (ESRD) emphasize
transitions between treatment modalities (hemodialysis
Table 1 shows some of the primary benefits of each mo-
dality. We are not specifically considering home HD,
[HD], peritoneal dialysis [PD], and kidney transplanta-
but many of the general benefits of PD listed in the table
tion) and the possibility that a specific patient will, in
also apply to home HD. Initial modality selection should
his or her lifetime with CKD/ESRD, experience more
in most cases be patient/family directed, with primary
than one of these modalities. For most patients, success-
considerations focused on lifestyle and social issues
ful kidney transplantation is the best treatment for
such as patient autonomy, geographic locationas it
ESRD. However, the lack of available donor organs, co-
affects transportation to and from the dialysis center, liv-
morbid conditions, and patient choice preclude trans-
ing situation, patient motivation, and patient and family
plantation in many patients, thereby making chronic
employment. Patient education about modality options is
dialysis the only option for some beginning renal re-
required for informed decision making and, in most cases,
placement therapy. Medical and social conditions as
will be somewhat dependent on physician input and en-
well as geographic considerations and patient choice
couragement. Unfortunately, US nephrologist training in
should dictate the selection of PD (continuous ambula-
PD is often inadequate,5 and although most nephrologists
tory PD or continuous cycling PD) or hemodialysis
believe at least 40% of ESRD patients should be on PD,6
(HD), but patient choice should always be the primary
less than 10% of current US dialysis patients are on PD.7
factor in that decision. However, patient choice requires
Bundling of dialysis services and reimbursement for pre-
adequate modality education, which, unfortunately, is
dialysis education may increase the numbers of patients
not always the case. As a consequence, physician prefer-
on PD over the next few years.4 In general, when patients
ence and experience and reimbursement issues may also
are required to be seen regularly before dialysis and
influence modality choice.1-4 Implicit in the decision to
educated about PD, up to 45% of patients choose PD.8
initiate HD or PD is a consideration of the risks and ben-
Distance from an HD center is a primary factor in the
efits of each modality, and those issues will be the focus
choice of PD, accounting for 25% of the variability of dial-
of this discussion.
ysis modality choice in a 1996 to 1997 study of 3793 inci-
dent dialysis patients.1 Younger, white, employed, more
educated patients in this study were likely to choose PD
over in-center HD.1 Because patient survival and accept-
From Department of Internal Medicine, University of Illinois, Urbana- able quality of life are the ultimate goals of renal replace-
Champaign, Champaign, IL; and Carle Physician Group, University Avenue, ment therapies, it is important to compare mortality and
Urbana, IL. morbidity in patients on PD and HD.
Address correspondence to Jean L. Holley, MD, Carle Physician Group,
The influence of dialysis modality on patient survival
Nephrology, S2S2, 602 West University Avenue, Urbana, IL 61801. E-mail:
jholley@illinois.edu is somewhat controversial, with early studies showing
2011 by the National Kidney Foundation, Inc. All rights reserved. a 19% higher adjusted mortality rate in PD patients.9
1548-5595/$36.00 However, subsequent studies demonstrated similar
doi:10.1053/j.ackd.2011.09.001

428 Advances in Chronic Kidney Disease, Vol 18, No 6 (November), 2011: pp 428-432
 PD Versus HD 429

survival in PD and HD patients and emphasized that pa- in peritonitis rates, infection remains the primary reason
tient comorbidity, age, and cause of ESRD were the pri- for transfer to HD. In one prospective study of 28 dialysis
mary factors affecting survival.10 More recent studies centers, 25% of PD patients transferred to HD, with 70%
have described improved survival in PD patients, espe- of those transferring within 2 years of starting PD.20 Re-
11,12
cially in the first 1 to 2 years of ESRD. After 1.5 to 2 current peritonitis may also lead to membrane failure,
years on dialysis, the risk of death in PD patients becomes and ultrafiltration failure is the cause of 2% to 14% of
equivalent to or greater than that in HD patients, depend- transfers from PD.21 An analysis of USRDS data suggests
ing on patient factors such as age, diabetes, and other co- improved technique survival in recent cohorts of PD pa-
morbidities. Two recent studies showed the negative tients.22 Additional risks of PD are shown in Table 1 and
effects of central venous catheter (CVC) on patient sur- include weight gain, caregiver and patient burnout, and,
vival.13,14 Perl and colleagues demonstrated similar sur- with the loss of residual kidney function, possible inade-
vival in PD and HD patients who began with an quate small solute clearance.
arteriovenous fistula (AVF) or arteriovenous graft Dialysis adequacy is assessed on a routine basis in
(AVG) (90-day survival: 7.4% for PD and 6.1% for HD- both HD and PD patients. Although the daily small
AVF/AVG), but significantly worse survival for HD pa- urea clearance on PD is significantly less than the urea
tients beginning dialysis with a CVC (15.6% survival, clearance of a single HD treatment, the continuous nature
13). Another small study of 123 patients starting dialysis of PD provides adequate overall clearance as measured
in an unplanned fashion showed equivalent 6-month sur- by weekly kt/V. Some would suggest that the more fre-
vival for HD and PD patients quent physician visits of
but a higher relative risk of CLINICAL SUMMARY
HD patients (PD patients
bacteremia in the HD pa- are generally seen monthly
tients, suggesting acute  A PD survival advantage is seen early in the course of renal
and HD patients up to 4
start PD is a viable option replacement therapy, but after 1 to 2 years, patient survival times per month) is a benefit
for late referral patients.14 on PD or HD is equivalent and influenced by comorbidity of HD over PD. However,
The observed early PD sur- and age. there are no data showing
vival advantage may in part  The high rate of technique failure in PD remains primarily improved patient survival
be due to improving survival a function of infectious complications although peritonitis or reduced morbidity asso-
of PD patients in general, rates are now low in experienced PD programs. Infection ciated with the frequency
perhaps due to technical ad- and access issues are the most common problems for of physician visits. For
patients on HD, and, especially for HD patients using CVC,
vances and increasing expe- high mortality and morbidity are to be expected.
some patients, HD provides
rience of nurses and an opportunity for sociali-
nephrologists with PD.4 PD  Recent changes in reimbursement for dialysis education as zation and development of
well as bundling of dialysis services may lead to a renewed
program experience remains interest in PD in the United States. Nephrologists efforts
a caring community of
an influence on patient and should be focused on educating themselves and their friends and caretakers inter-
technique success in PD, patients about the opportunities for home modality ested in the patient and his
with more experienced therapies and reducing the reliance on catheters for long- or her welfare. For many
(large programs with more term HD access. PD patients, the support of
patients) programs reporting the home dialysis nurses
lower rates of technique fail- may provide a similar expe-
ure and patient mortality.15 In addition, maintenance of re- rience. Caregiver burnout and depression are less with
sidual kidney function may contribute to reduced HD patients.23 As the dialysis population is increasingly
mortality, and most studies report better preservation of older and less functionally independent, caregiver needs
residual kidney function in patients on PD compared and response assume an important consideration in dial-
with patients on HD.16 Some studies have reported higher ysis outcomes and deserve more attention and study.
mortality in PD patients with underlying heart dis- A few studies have shown less delayed graft function
ease.17,18 Other studies have noted a higher incidence of after kidney transplantation in PD patients compared
hemorrhagic stroke in patients on HD although a USRDS with HD patients.24,25 Factors involved may include pa-
analysis concluded that the risk of death from stroke was tient volume status and residual kidney function at the
greater in PD patients despite a lower prevalence of preex- time of transplantation. A recent study showed a 10%
isting cerebrovascular disease.19 Patient comorbidity, in- lower (P .014) all-cause mortality in patients on PD
cluding diabetes and age, influences mortality. compared with those on HD before transplantation.26
Although mortality may be lower in PD patients dur-
ing the first 1 to 2 years of dialysis, technique failure with
Access in PD and HD
PD remains fairly high and negatively affects patients
quality of life owing to the need for interventions (new Table 1 illustrates the risks of HD and PD, and among the
access) and transfer to HD. Despite significant reductions most common are access-related issues. HD is virtually
430 Sinnakirouchenan and Holley

Table 1. Risks and Benefits of PD and HD

Benefits Risks
PD Survival years 12 High technique failure (membrane failure, infection)
Patient autonomy Weight gain
Patient satisfaction Patient and caregiver burnout
Maintenance of RRF
Less delayed graft function post transplant
Lower cost
HD Less patient responsibility Infection (bacteremia, sepsis)
Community/socialization Access complications
Higher mortality in the period just before and 12 hours after treatment, possibly
due to electrolyte issues

Abbreviation: RRF, residual renal function.

always used as initial therapy when patients present with
acutely discovered CKD, primarily because of the avail-
ability and suitability of CVC for immediate HD access.
However, the risks associated with CVC are significant,
with a 2- to 3-fold increase in mortality, a 5- to 10-times
increase in serious infection, and increased rates of hospi-
talization in HD patients using CVC for HD access.27 In
addition, long-term CVC use is associated with a higher
number of vascular procedures and higher incidence of
inadequate dialysis.28,29 Some researchers have sug-
gested that catheters may also contribute indirectly to
high patient mortality by acting as an instigator of
a chronic inflammatory condition that predisposes to
morbidity and mortality.30,31 The finding of higher CRP
levels in HD patients without overt infection but with
CVC has raised this possibility and concern.30,31 More-
over, long-term CVC access for HD is associated with os-
teomyelitis, septic arthritis, endocarditis, poor quality of
life, and central vein stenosis that may limit future op-
tions for arteriovenous access.27-29 Efforts to reduce the
risk of catheters for HD access have focused on early ne-
phrology referral, creation of a multidisciplinary dialysis
access team, and patient and nephrologist education,27,32
but CVC use remains high in the United States. Some
have suggested that patients who refuse creation of an ar-
teriovenous fistula or graft and choose to continue using
a CVC as HD access should be required to sign an in-
formed refusal of AVF form and ultimately be referred
to another nephrologist for care.27 In such instances,
a quality care issue is cited as the reason for refusing on-
going care of a patient who declines AVF or AVG place-
ment.27 Although such action may be more drastic than
many nephrologists are willing to consider, it is incum-
bent on nephrologists as a group to make all efforts to re-
duce the use of dialysis catheters.
Although a variety of PD catheters are available, the
differences among them are minor, and the decision to
use one catheter over another depends primarily on the
preferences of the physician inserting the catheter. Func-
tion and infection rates are generally similar for all avail-
able PD catheters although relatively small studies may
advocate for certain catheters or implantation techniques
(eg, Tenckhoff vs swan-neck catheters, surgical vs lapa-
roscopically implanted, buried vs nonburied).33-35 The
lack of surgical training in PD catheter placement may
be an issue for some programs.36 PD catheters are placed
in the abdomen, but for some patients (obese, those with
ostomies, children), the presternal catheter exit site loca-
tion may be preferable.37 Complications associated with
PD catheters may include poor drainage and infection.
Infection remains the most common cause for transfer
to HD, but in successful PD programs, peritonitis rates
are now 1 every 20 to 37 mo/patient.4,38 Moreover, com-
pared with CVC-associated infections, PD-associated
catheter infections rarely lead to death and are less fre-
quently associated with hospitalization.4 Quality im-
provement programs to examine infection rates, causes,
and preventive protocols are integral to any PD program
and are increasingly being adapted by HD programs to
lower infection rates.
Costs and Patient Satisfaction in PD and HD
Although there are few studies examining dialysis pa-
tients satisfaction, PD patients usually report higher sat-
isfaction than in-center HD patients.39,40 Explanations for
this may relate to the patients themselves and their per-
ceived quality of life and independence (generally higher
among PD patients) but may also reflect inherent quali-
ties in patients that lead them to choose a home-based
modality. Interestingly, PD patients are also more satis-
fied with their medical care providers (nurse and physi-
cian) despite less direct exposure to nephrologists than
that experienced by in-center HD patients who are com-
monly seen weekly. The availability of the PD nurse and
the close relationship that often develops between PD
nurses and their patients may foster patient confidence
and support in a way that leads to more satisfaction
than that experienced by in-center HD patients. The
lack of controlled studies examining patient satisfaction
and the confounding issue of selection bias suggests ad-
ditional study of this issue is needed.
Because dialysis is a Medicare benefit in the United
States, the cost of treatment to society is relevant. PD
 PD Versus HD
remains less expensive than in-center HD, with per year
patient costs of $53,446 and $73,008, respectively, as re-
vealed by Medicare data.7 Under private insurance cov-
erage, PD was also significantly less expensive than HD
($173,507 vs $129,997, P .03) in the first year after start-
ing dialysis in 463 dialysis patients, in part because hos-
pitalization rate was lower among PD patients.41
However, before January 2011, the cost of medications
administered during dialysis was typically higher for
HD patients. With the inception of dialysis services bun-
dling, costs of intravenous medications given during HD
will likely fall, and thus, the total treatment cost of HD
should also fall. Owing to the costs of equipment and, im-
portantly, staff needed in the HD unit, PD treatment costs
are likely to remain lower than HD costs, but the overall
cost difference between the 2 modalities may narrow.
There is a specific payment for professional services pro-
vided during training for home dialysis that can be billed
by nephrologists and may act as a financial incentive to
build home dialysis programs. There is no similar pay-
ment for in-center HD.
Summary
The selection of PD or HD will usually be based on
patient motivation, desire, geographic distance from an
HD unit, physician and/or nurse bias, and patient educa-
tion. A PD survival advantage is seen early in the course
of renal replacement therapy, but after 1 to 2 years, pa-
tient survival on PD or HD is equivalent and influenced
by comorbidity and age. The high rate of technique fail-
ure in PD remains primarily a function of infectious com-
plications although peritonitis rates are now low in
experienced PD programs. Infection and access issues
are the most common problems for patients on HD,
and, especially for HD patients using CVC, high mortal-
ity and morbidity are to be expected. Consideration of PD
as a bridge for access maturation and initial treatment in
late referral patients should be entertained in an effort to
avoid CVC. Recent changes in reimbursement for dialysis
education as well as bundling of dialysis services may
lead to a renewed interest in PD in the United States. Ne-
phrologists efforts should be focused on educating them-
selves and their patients about the opportunities for
home modality therapies and reducing the reliance on
catheters for long-term HD access.
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