科研之友
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摘要
Since its introduction more than 3 decades ago, the use of peritoneal dialysis (PD) has increased greatly due to its simplicity, convenience, and low cost. Advances in technique, antibiotic prophylaxis, and the introduction of newer solutions have improved survival, quality of life, and reduced rate of complications with PD. In Hong Kong, approximately 80% end-stage renal disease (ESRD) patients perform PD; in others, that is, Canada, Australia, and New Zealand, 20%每30% patients use PD. However, in the United States, the annual rate of prevalent patients receiving PD has reduced to 8% from its peak of 15% in mid-1980s. PD as the initial modality is being offered to far less patients than hemodialysis (HD), resulting in the current annual incidence rate of less than 10% in USA. There are many reasons preventing the PD first initiative including the increased numbers of in-center hemodialysis units, physician comfort with the modality, perceived superiority of HD, risk of peritonitis, achieving adequate clearances, and reimbursement incentives to providers. Patient fatigue, membrane failure, and catheter problems are other reasons which discourage PD utilization. In this paper, we discuss the available evidence and provide rationale to support PD as the initial renal replacement modality for ESRD patients. 1. Introduction Over half million Americans were undergoing renal replacement therapy (RRT) for ESRD at the end of year 2008. In-center Hemodialysis (HD) and home PD are the two common forms for dialysis therapy. Only about 8% of patients with ESRD are receiving PD as RRT in the United States compared to Canada and Europe, where PD is much more common [1]. The percentage PD patients has declined significantly from the peak of 15% in the mid-eighties to 5.8% in 2007 [1]. There are numerous factors contributing to the low incidence and prevalence of PD in this country [2, 3]. Concerns regarding achievement of adequate clearance with PD, especially in patient with no residual renal function and a perception of better patient survival on HD compared to PD amongst US nephrologists impact selection of dialysis modality. Risk of infectious complications, specially PD peritonitis and catheter-related problems contribute to the selection bias. Systemic factors such as the easy accessibility to HD, financial incentives, and ownership of dialysis units, including units owned by large dialysis organization (LDOs), as well as physician education and exposure to PD during training also play an important role in the selection of RRT for ESRD patients. Strategies to
