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Patient Candidacy

Prioritize PD for the majority of ESKD patients

At least 78% of patients have no absolute medical or social contraindication for PD1,2

This includes diabetic, elderly & obese patients who are often excluded from PD3-6

78%

Data suggests that Diabetic, Elderly and Obese patients may do well on PD7-9

Diabetic patient icon

Diabetic Patients

Data shows overall patient survival was significantly higher compared  with PD than HD in incident dialysis patients with diabetes10

Elderly patient icon

Elderly Patients

Older patients reported significantly better kidney disease-specific quality of life compared to younger patients9

Obese patient icon

Obese Patients

Single-center retrospective cohort study, obesity also conferred a survival advantage in their PD population compared to non-obese patients7

Evidence shows that patients with diabetes may do well on PD8,11,12

Based on the review of nine mortality studies comparing PD and HD12:

Younger patients

Among younger patients without and with diabetes in the United States, Canada, and Denmark, PD is associated with survival equivalent to or better than that for HD12

Older patients

In patients with diabetes over 45 years of age, there is no survival benefit for those on HD vs PD, although in the US, HD is associated with better survival12

Modifying factors

Diabetes, age, and comorbidity all significantly modify the effect of treatment modality on patient survival*12

*Data analysis (as-treat and intent to treat) also modifies the effect of treatment modality on patient survival  

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Regardless of the reported differences in mortality between diabetics on PD and HD, the early initiation of an adequate chronic PD program may ensure higher long-term outcome in PD diabetic patients.11

Passadakis PS, Oreopoulos DG. Diabetic patients on peritoneal dialysis. Semin Dial. 2010;23(2):191-197.

Diabetic patients should be considered for PD

Survival of patients from a Korean cohort study, comparing mortality risk in diabetic PD and HD matched for glycemic control10

Chart showing survival of patients from a Korean cohort study

Kaplan–Meier analysis of all-cause mortality according to dialysis modality in the (A) whole cohort of 902 patients and (B) 773 patients who had available HbA1c.

Patients treated with HD showed significantly higher all-cause mortality than those with PD in the whole cohort (log-rank test, P = 0.009) and in 773 patients (log-rank test, P = 0.012). HbA1c = hemoglobin A1c, HD = hemodialysis, PD = peritoneal dialysis.

Adapted from Lee MJ  et al. Medicine (Baltimore). 2016; 95(11): e3118.

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…the overall patient survival of PD was significantly higher compared with that of HD in incident dialysis patients with diabetes. In addition, better patient survival with PD was influenced by the degree of glycemic control.10

Lee MJ et al. Medicine (Baltimore). 2016; 95(11): e3118

Survival rates in patients with good glycemic control

Chart showing comparison of good and poor control of sugar

In patients with good glycemic control (HbA1c <8%), the cumulative survival rate was significantly higher in patients on PD than in patients on HD (P=0.021). 

However, there was no statistically significant difference in survival in patients with poor glycemic control (HbA1c ≥8%). 

  1. Diabetics with good glycemic control do better on PD than on HD
  2. Those with poor glycemic control do as well on PD as on HD

Elderly patients should be considered for PD

Graph showing Patients on PD in the United States from 2001 - 2021

Adapted from 2018 USRDS Annual Data Report Reference Tables, Table D.8, Counts of point prevalent ESRD patients, by mode of therapy: peritoneal dialysis

Given the recent outcome data of PD versus HD, older data showing worse outcomes on PD are no longer relevant17,18

Elderly patients with end-stage renal disease are appropriate candidates for peritoneal dialysis 

  • Most elderly patients possess the manual and cognitive skills necessary to perform PD14
  • Elderly patients on PD exhibit excellent compliance with their treatment regimen and display no increase in the rate of infectious complications, though they may have a slight increase in hospital days14. These patients:
    • Easily achieve adequacy targets
    • Experience good technique survival
    • Have nutritional status that is at least as good as that of their hemodialysis counterparts14
  • Patient survival varies around the world but is overall comparable to that of age-matched patients on hemodialysis14
  • Quality of life may be somewhat superior to that of older hemodialysis patients14

It is not medically justifiable to exclude them from consideration for this therapeutic modality14

Quality of Life by Age Group

Table 2 Mean (SD) of QoL and Emotional distress outcomes by Age Group

Adapted from Griva K, et al. J Adv Nurs. 2014;70(8):1902-1914. *Statistically significant in ANOVA tests. †Statistically significant when analyses were repeated using ANCOVA tests with adjustment for case-mix differences. KDQOL-SF, Kidney Disease Quality

Clinical advice on PD and the elderly patient15

KDIGO in collaboration with the European Renal Best Practice (ERBP) Advisory Board issued clinical advice which states:

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“Older age should not be considered a contra-indication for PD”

KDIGO in collaboration with the European Renal Best Practice (ERBP) Advisory Board

Obese patients should be considered for PD

Overweight and obese peritoneal dialysis patients have longer survival than those with lower BMI – a difference that is not adequately explained by lower transplantation and technique survival rates.7 

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“It is impossible to prove, but tempting to speculate, that overweight patients receive narrower treatment choices than those with normal BMI. If such a bias exists, it appears to be in direct contradiction to survival estimates.”7

Snyder JJ, et al. Body size and outcomes on peritoneal dialysis in the United States. Kidney Int. 2003;64(5):1838-1844.

A single-center observational study, obesity also conferred a significant survival advantage in their PD population16

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“Obese patients should therefore not be discouraged from receiving PD purely on the basis of BMI.”16

Johnson DW, et al. Is obesity a favorable prognostic factor in peritoneal dialysis patients? Perit Dial Int. 2000;20(6):715-721.

Explore the evidence with our PD Candidacy Resource Guide on our PD Management Tools page

PD Management Tools
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PD Management Tools

Related Pages

Previous page

Prioritize PD for the majority of patients, regardless of age, race or socio-economic background, by offering equal access to treatment options and patient support services

Equal Access

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Eliminating barriers to PD by addressing health disparities

Addressing Health Disparities
References

  1. Mendelssohn DC, et al. A prospective evaluation of renal replacement therapy modality eligibility. Nephrol Dial Transplant. 2009;24(2):555-561.

  2. Oliver MJ, et al.. Impact of contraindications, barriers to self-care and support on incident peritoneal dialysis utilization. Nephrol Dial Transplant. 2010; 25(8): 2737-2744.

  3. Passadakis PS, Oreopoulos DG. Diabetic patients on peritoneal dialysis. Semin Dial. 2010;23(2):191-197. 

  4. Teitelbaum I. Peritoneal dialysis is appropriate for elderly patients. Contrib Nephrol. 2006;150:240-246.

  5. Snyder JJ, et al. Body size and outcomes on peritoneal dialysis in the United States. Kidney Int. 2003;64(5):1838-1844

  6. United States Renal Data System. 2023 USRDS Annual Data Report: Epidemiology of kidney disease in the United States: End Stage Renal Disease: Chapter 1. Incidence, Prevalence, Patient Characteristics, and Treatment Modalities. National Institutes of Health

  7. Chung SH, et al. Optimal use of peritoneal dialysis in patients with diabetes. Perit Dial Int. 2009;29(2):132-S134. 

  8. Griva K, et al. Age is not a contraindication to home-based dialysis – Quality-of-Life outcomes favour older patients on peritoneal dialysis regimes relative to younger patients. J Adv Nurs. 2014;70(8):1902-1914.

  9. Lee MJ, et al. Glycemic Control Modifies Difference in Mortality Risk Between Hemodialysis and Peritoneal Dialysis in Incident Dialysis Patients With Diabetes: Results From a Nationwide Prospective Cohort in Korea. Medicine (Baltimore). 2016;95(11):1-9.

  10. Vonesh EF, et al. Mortality studies comparing peritoneal dialysis and hemodialysis: what do they tell us? Kidney Int Suppl. 2006;70:3-11.

  11. Covic A, et al. Educating end-stage renal disease patients on dialysis modality selection: a clinical advice from the European Renal Best Practice (ERBP) Advisory Board. Nephrol Dial Transplant. 2010;3(3):1757–1759

  12. Johnson DW, et al. Is obesity a favorable prognostic factor in peritoneal dialysis patients? Perit Dial Int. 2000;20(6):715-721.

  13. Marshall MR. The benefit of early survival on PD versus HD—why this is (still) very important. Perit Dial Int. 2020;40(4):405-418.