 The Past Decade I began my tenure as President of ISPD over 10 years ago. During this past decade, two other Past-Presidents have died ( Dr. John Maher and Dr. Jonas Bergström ). Their insight and guidance will be missed. In many parts of the world the percentage of incident and prevalent patients on PD has declined since 1990. I will mention some of the many factors that have contributed to this. The survivals on PD and HD have been compared in many studies. There were initial suggestions that PD survivals were not as good as with HD in comparable populations. Recent studies, however, suggest that survivals on PD are as good or (in some groups) better with PD. Definitions of PD adequacy targets and whether these could be met in large, low transporter and/or anephric patients raised concerns. Now, we are going through re-examination of these targets and establishing prescription techniques for reaching reasonable adequacy targets in most patients based on their transport status, size and residual renal function. The cycler has assumed an increased role over the years. Another reason for the decline in the percentage of patients on PD is the fact that the dialysis population is older and more infirm year by year and lower percentages are able to do a self dialysis treatment. In addition, there are still the economic and bias influences on the choice of dialysis therapy. Increasing evidence shows that many patients are given little or no information about PD and have little say in the choice of their dialysis mode. Informed patients choose PD in much higher percentages than are the percentages from the USRDS Registry of new patients starting PD. Late referrals and/or late starts of dialysis often lead to chronic HD therapy in these patients who are too uremic or too poorly nourished to undergo education or PD training once the HD has been started, the patients remain on HD. Dr. Rajnish Mehrotra , Dr. Peter Blake and I have recently surveyed nephrology training programs in Canada and the USA. In many nephrology fellow training programs (especially in the USA), there is inadequate exposure to PD core knowledge and PD patients. Too many young nephrologists are not properly trained to manage PD patients. During the past decade, the ISPD has been a strong voice demanding fair comparisons of survivals; innovative prescriptions to meet PD adequacy targets; better care of the pre-dialysis patients with early dialysis education and referral; initiation of dialysis before uremia and malnutrition exact their tolls; and consideration of PD in patients where lifestyle and/or medical advantages are likely. The ISPD has also challenged biases in the choice of therapy. The ISPD has worked through its outstanding journal (PDI) and by promoting education and science in PD at many meetings, including its own Congress. ISPD Guidelines for treating ultrafiltration failure, infections and catheter problems have advanced the quality of care on PD. Travel grants for trainees and needy scientists have been invaluable. Special programs for nephrology fellows have been organized and sponsored. The Future of PD In my opinion, the next decade will see many advances in PD and increasing percentages of incident and prevalent PD patients. The ISPD will continue to play a major role in advancing PD science and know-how and in defining the roles of PD in chronic dialysis. I will mention some of the attractive features of PD that will help foster PD growth in the coming years. There is increasing interest in starting chronic dialysis while the patient still has good nutritional status and some residual renal function and increasing the dialysis dose incrementally as residual renal function declines. PD lends it self to incremental dialysis with less demands on life style than HD and may be associated with better preservation of residual renal function in many patients than is seen with HD.
The comparisons of survivals between PD and HD have recently suggested PD advantages in the early years of chronic dialysis. These findings also favor PD as an initial therapy. New dialysis solutions will be very important. Glucose polymers as osmotic agents are already widely used for nightly long dwells in CAPD or the daytime long dwells in APD. Such solutions have enhanced the means of generating adequate ultrafiltration and the need for transfer from PD for ultrafiltration failure will be reduced in incidence. More biocompatible solutions and bicarbonate solutions will have their advantages more clearly defined and will most likely reduce the problems with membrane alterations over time that can be seen with repeated exposure to high glucose concentrations. Peritonitis and exit site infections are still challenges. The Y-sets and improved exit site care have decreased the incidences of these infections compared to earlier decades and the coming decade will most likely yield even better results. Economic studies usually show that PD is cheaper than HD considering the costs of supplies, monitoring and complications mainly because of the high costs of blood access maintenance in HD. Economic pressures may favor increased use of PD. PD is a daily therapy and daily dialysis treatment is being increasingly shown to have many advantages in dialysis patients. There is a move towards more frequent HD. Growth in this type of HD and growth of PD may be expected while thrice weekly HD may become a smaller portion of new and prevalent patients. PD offers the opportunity to train patients for self home therapy in a very efficient and safe manner. Home therapy training with HD is more prolonged and demanding on staff and patients. As long as there are patients suitable for and interested in home dialysis therapy, there will be an important role for PD. Concluding Remark PD therapy has been and continues to evolve. I have every hope that the best is still to come. PD life style advantages over HD are compelling and will have an increasing impact on choice of therapy as the evolution of PD results in reduced incidences of catheter and exit infections, membrane alterations, and ultrafiltration failure. PD could become the initial mode of chronic dialysis in the majority of patients with later transfers to HD when, and if, such becomes necessary in some patients to achieve adequacy after renal function declines. The ISPD through meetings, PDI and other educational and scientific endeavors will play a major role in guiding PD therapy to become the best it can be. |