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Renal Patients Prefer At-Home Dialysis

They're more informed about their care, study suggests

TUESDAY, Feb. 10, 2004 (HealthDayNews) -- Patients with kidney failure who begin a type of dialysis they can perform at home are more likely to rate their care excellent than people who go to a dialysis center several times a week for hemodialysis, a new study finds.

The U.S. study is the first to compare patients' satisfaction with hemodialysis vs. the do-it-yourself type of treatment, called peritoneal dialysis.

"The people who are more fully informed end up choosing peritoneal dialysis," says study author Dr. Haya Rubin, a professor at the Johns Hopkins School of Medicine in Baltimore who specializes in quality assessment.

The report appears in the Feb. 11 issue of the Journal of the American Medical Association.

About 300,000 Americans have chronic kidney disease and require dialysis or a kidney transplant to stay alive, according to the National Kidney Foundation. Dialysis removes waste, salt and extra water from the body.

There are two main types of dialysis. In hemodialysis, a patient's blood is pumped through a machine that acts like an artificial kidney. Surgery is required to create an entryway into a patient's blood vessels. After that, hemodialysis is typically performed three times a week for four hours at a stretch.

Peritoneal dialysis, by contrast, uses the patient's own abdomen to cleanse the blood. A special catheter is inserted into the abdominal cavity, allowing dialysis solution to be pumped in and flushed out. Patients can do it themselves at home or work. The process is repeated four or five times a day.

So which treatment option works better? Clinically, it appears to be a toss-up. Previous studies found either no difference in patient survival rates between the two methods or better survival with peritoneal dialysis, especially in the first two years after starting dialysis.

With no clear difference in survival, the authors of the new study decided to measure patient preferences. A survey was given to 736 patients who started dialysis at 37 centers across the country from October 1995 to June 1998. A total of 656 returned a satisfaction questionnaire after receiving dialysis an average of seven weeks.

When patients rated their care, a clear preference emerged. People on peritoneal dialysis were 1.5 times more likely to give excellent ratings of their overall dialysis care than those receiving hemodialysis.

Those patients rated their experience more highly on many individual aspects of care, the survey found. One clear difference was the amount of dialysis information peritoneal patients received from staff and the amount of information they were given to help choose between the options, the survey found.

"They do get a lot of information, and information tends to make people happier," Rubin says.

And because patients can perform peritoneal dialysis at home and decide when to do the fluid exchanges, it can be more convenient and gives them greater control over their care, she explains.

There are drawbacks, of course. Patients sometimes skip recommended exchanges or entire treatment days, increasing their risk of hospitalization and death, says the National Kidney and Urologic Diseases Information Clearinghouse.

"Not every patient is suitable for peritoneal dialysis," adds Dr. T. Alp Ikizler, a nephrologist at Vanderbilt University Medical Center in Nashville. Elderly patients, particularly those with more than one medical condition, may not be the best candidates, for example.

"In general, my own experience is if the patients are given enough information and you take enough time preparing the patient for renal dialysis therapy, I think they can make an appropriate choice," Ikizler says.

Considering the similarity in clinical benefits of the two options, primary care physicians and nephrologists ought to give greater consideration to peritoneal dialysis, the study's authors conclude.

Peritoneal dialysis isn't as common in the United States as it is elsewhere in the world. "When docs from the U.K. visit, they're always surprised at how little we do it here," Rubin observes.

While home dialysis may be less costly to provide, clinicians have an economic incentive to refer patients for hemodialysis, the authors suggest. That's because Medicare pays for the facility and equipment costs to run a hemodialysis center. After that up-front expense is covered, the extra cost of treating a hemodialysis patient is probably lower than the cost for a new peritoneal patient, they say.

In an accompanying editorial, Dr. James Heaf of Herlev University Hospital in Herlev, Denmark, says peritoneal dialysis is underused, representing just 8.4 percent of all dialysis patients. He suggests ways to increase peritoneal dialysis in the United States, including better physician training, early patient referral, shorter waiting times for catheter placement and rational financial incentives.

For patients now facing a dialysis choice, Rubin advises: "Ask for a lot of information about both modalities and make sure you're finding out about both of them."

More information

Learn more about dialysis from the National Kidney Foundation, while the National Institute of Diabetes and Digestive and Kidney Diseases has an overview of kidney disorders.

SOURCES: Haya Rubin, M.D., Ph.D., professor, medicine, Johns Hopkins School of Medicine, Baltimore; T. Alp Ikizler, M.D., associate professor, medicine, division of nephrology, Vanderbilt University Medical Center, Nashville; Feb. 11, 2004, Journal of the American Medical Association
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