NDT Advance Access published online on July 1, 2008
Nephrology Dialysis Transplantation, doi:10.1093/ndt/gfn374
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PD underutilization in Europe: a call to action
Correspondence and offprint requests to: E-mail: cfourt{at}usa.net
Sir,
We read with interest the editorial comment by Van Biesen et al. [1] regarding the detailed list of factors leading to peritoneal dialysis (PD) underutilization in Europe. However, as we ‘cannot teach an old dog new tricks’, all our effort should focus on the training of the renal fellows around Europe. Most of them can easily say by heart all the contraindications (haemodialysis has none!) and complications (mainly peritonitis!) of PD, but rarely a few of its advantages.
More than two-thirds of incident ESRD patients do not have medical contraindications for either haemodialysis (HD) or PD, but the vast majority starts HD [2] and this situation will become worse, as young nephrologists usually do not feel very confident with the modality. Not only in the USA [3], but also in many European countries and Greece, a lot of medical centres with nephrology training programs do not treat enough (or have no PD patients!), or devote not enough time for renal fellows in order to develop expertise in the care of PD patients. Most of the PD training is based mainly on the complications the fellow will face in the nephrology wards. So, the new nephrologist will remain with the bad experiences of resistant, or sclerosing encapsulating peritonitis and severe fluid overload. Successful PD and patients’ real satisfaction with the modality can be appreciated only in the PD outpatient clinic.
Selecting PD is a complex situation for the ESRD patient, who might be aware of HD or transplantation of course, but almost never of PD! The ‘hidden curriculum’ in the society and the ‘hidden persuaders’ in the medical community will always be in favour of HD. The fake dilemma regarding the best modality for ESRD (HD or PD?) should be terminated as soon as possible. The modern nephrologist should be wise enough to recognize the possible contraindications of each modality and confident enough to offer both of them to the right patient. Offering HD to a patient who stays 100 km away from the nearest HD unit sounds equally ridiculous to offering PD in an obese, anuric octogenarian without any assistance at home.
Our association ERA/EDTA, in collaboration with the ISPD, must focus on all these educational issues and take action to offer more adequate training and exposure to PD, in order to equip the young nephrologists in the future with the appropriate knowledge, regarding the best therapeutic options for the individualized ESRD patient.
Conflict of interest statement. None declared.
Department of Internal Medicine-Nephrology, Patras University Hospital, Patras, Greece
Notes
Editorial note: Prof. Van Biesen et al. declined the opportunity to reply to this letter.
References
- Van Biesen W, Lameire N, Vanholder R. Why less success of the peritoneal dialysis programmes in Europe? Nephrol Dial Transplant (2008) 23:1478–1481.
[Free Full Text] - Mehrotra R, March D, Vonesh E, et al. Patient education and access of ESRD patients to renal replacement therapies beyond in-center hemodialysis. Kidney Int (2005) 68:378–390.[Web of Science][Medline]
- Khawar O, Kalantar-Zadeh K, Lo WK, et al. Is the declining use of long-term peritoneal dialysis justified by outcome data? Clin J Am Soc Nephrol (2007) 2:1317–1328.
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