Patients in kidney failure don’t necessarily have to visit a dialysis clinic several times weekly to filter the toxins from their blood. Many can opt for peritoneal dialysis, an approach that enables them to self-administer dialysis at home. Research has shown that the survival rates are similar to conventional dialysis, and the treatment costs are lower.
Yet peritoneal dialysis has been slow to catch on in this country. In 2015, just 9.6% of the 124,114 Americans newly diagnosed with kidney failure started treatment with peritoneal dialysis, according to the most recent annual report from the United States Renal Data System (USRDS), published in 2017. Other countries that have emphasized trying the at-home method first have achieved much higher rates, including as many as 80% of kidney failure patients in Hong Kong, according to a 2007 study.
Number of patients (in thousands)
ESRD=end-stage renal disease
Source: United States Renal Data System Annual Data Report 2017
At this point, there don’t seem to be any added financial incentives for clinic-based dialysis. CMS officials implemented a new bundled payment system in 2011 in part to standardize reimbursement between hemodialysis and peritoneal dialysis. The USRDS report says that in 2015, peritoneal dialysis was about $13,000 less expensive per year than clinic-based dialysis ($75,140 vs. $88,750), so a shift to peritoneal dialysis might result in some real savings.
But researchers and kidney specialists say there are many obstacles in the way: a lack of doctors and nurses with training in how to instruct patients, the sunk costs of existing dialysis clinics, and the reluctance of patients and their families. Dialysis in the United States is geared so much toward dialysis centers that it is difficult to persuade clinicians that peritoneal treatment might be better for some of their patients, says Arshia Ghaffari, DO, a peritoneal dialysis researcher who directs dialysis services at the University of Southern California in Los Angeles. “You sort of hear grumblings that ‘We don’t have the staff. We don’t have the space. We don’t have the experience.’”
In conventional dialysis at a clinic, the patient’s blood is cleaned outside the body by pumping it through a dialysis machine before it is returned to the body. With peritoneal dialysis, a dialysis solution is pumped through a catheter inserted through the abdominal wall into the patient’s peritoneal cavity. The solution absorbs waste products from blood vessels in the peritoneum and is then pumped out through a drainage tube that is inside the same catheter used to pump the fluid into the cavity. When the fluid is pumped manually, the process takes about half an hour or a bit longer and has to be done several times daily. But if a machine is used to pump the fluid, patients are “essentially able to sleep through the treatments and get up in the morning and go on about their way,” says Ghaffari.
Once the catheter is in place and the patient has been trained, peritoneal dialysis can be done at home (so can normal dialysis but only a small fraction of patients go that route). The training time of at least 20 hours for patients to learn the procedure and related sterile techniques is not insignificant, notes Rajnish Mehrotra, MD, section head of nephrology for Seattle’s Harborview Medical Center. Because of all the supplies involved—the dialysis solution is typically shipped in large boxes—Ghaffari makes it a practice to ask patients about how much storage space they have in their homes.
Figuring out whether there is any mortality differences between conventional and peritoneal dialysis patients has been complicated by a lack of data from randomized trials; understandably, people are unwilling to let their dialysis future be decided by a figurative flip of a coin. One such study was halted because it failed to enroll sufficient patients. But a frequently cited observational study that Mehrotra and other researchers conducted found that median life expectancy for conventional dialysis patients was only slightly longer than peritoneal dialysis patients (38.4 months vs. 36.6 months).
Mehrotra believes that too often patients don’t learn about peritoneal treatment until they’ve already rearranged their lives around thrice-weekly trips to the dialysis clinic. “The biggest challenge,” he says, “is that most of the patients that are not choosing peritoneal dialysis often do not even know that they have a choice.”
Education about the choice has been shown to increase the number of people who choose peritoneal dialysis. After completing a program that explained the treatment options, 24% of the study subjects choose peritoneal compared with just 4% who didn’t go through the program, according to findings published in 2011 in the American Journal of Kidney Diseases.
Clinicians may not even mention the peritoneal option to their patients, says Ghaffari, who is a speaker and consultant for Baxter and DaVita: “If you’re not comfortable, you’re not going to make that a therapy that you offer patients as a preferred modality.”
Peritoneal dialysis is underutilized in the U.S. even though it can be more cost effective for payers like Medicare, says Martin Schreiber Jr., MD, of DaVita Kidney Care.
Martin Schreiber Jr., MD, with DaVita Kidney Care, agrees that “peritoneal dialysis is really underutilized in the United States.” The company, which has slightly more than 2,500 dialysis clinics, is striving to boost its current peritoneal dialysis rate from nearly 11% to at least 16% and ideally 20% in the next five-plus years, says Schreiber, who is DaVita’s chief medical officer for home modalities.
But Schreiber doesn’t agree with Ghaffari that dialysis clinics play a role in steering patients away from peritoneal dialysis. His take: Better education is needed to make sure each patient gets the optimal treatment, which isn’t necessarily peritoneal. For instance, he notes, someone with Crohn’s disease or another inflammatory bowel condition might not be a good candidate, as the inflammation involved might boost the risk of infection.
Along those lines, DaVita is piloting an approach called transitional care dialysis in a few clinic sites. Kidney failure patients are started on conventional dialysis but educated about the peritoneal version in the event they want to transition, Schreiber says. “We truly believe that patients that are intensively educated and get positioned on the correct therapy to start with, tend to do better long run-wise.”
Too often, though, patients don’t have the luxury of foresight. Roughly half are considered “crashers into dialysis,” with little to no warning of their kidney failure, Ghaffari says.
Mehrotra and Ghaffari are among those kidney specialists who have been promoting peritoneal dialysis for even those unexpected cases. At the Los Angeles County+USC Medical Center, kidney failure patients who need to start dialysis right away can get a temporary catheter, Ghaffari says. Once they’re stable, they are educated about the peritoneal option. If they can wait for even a few days, they start a fast-track peritoneal education and evaluation process. Patients who agree to try peritoneal dialysis begin the treatment in the clinic under the supervision of a specially trained nurse, Ghaffari says.
Ghaffari cites cost data, published in 2014 in the journal Medicine, showing that the first 90 days of urgent-start peritoneal dialysis costs less than conventional dialysis ($16,398 vs. $19,352). Plus, says Ghaffari, the running costs in an efficiently run peritoneal dialysis unit are considerably lower because it doesn’t require as much infrastructure and staffing costs as clinic-based dialysis, although, he adds, some peritoneal programs might not be large enough to reap those kind of cost savings.
Schreiber agrees that peritoneal dialysis can be more cost effective. Any savings, by preventing hospitalizations and other complications, would benefit payers like Medicare, he says. If providing the dialysis itself proves to be less costly, then those savings would primarily go to the clinics, he says. Mehrotra, who didn’t disclose any financial conflicts, describes himself as cautiously optimistic that peritoneal treatment will gain traction, particularly if clinicians emphasize that their decision is not carved in stone. “I can see the tension breaking when I say this to the patients—that you are not making a permanent decision,” he says.