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PD vs.
HD
Background
 PD vs HD has always been a controversial topic among patient who are receiving renal
replacement therapy, as the two carries both risk and reward, depending on the situation
and timing.
 In HD, blood is pumped counter-currently to a dialysis solution within an
extracorporeal membrane. This can be performed intermittently (3-4 hrs during the
day) or in a continuously (24 hrs) fashion depending on hemodynamic stability goals.
 While PD uses the patients peritoneal membrane as the selective filter, and dialysis
fluid containing dextrose is instilled into the peritoneal cavity, therefore, glycemic
control is crudial in PD patient.
Advantages and disadvantages of PD vs. HD
PD HD
 More control over schedule.  Care given by trained professionals.
 The luxury to stay at home while given care.  More efficient than PD.
 Ability to travel with limited preparation. (Though
this advantage is questionable during times of an
 Rapid correction of hemodynamic stabilities.
ongoing pandemic)  Clinical visit ~3 times a week.
 Clinical visit 1~2 times a month.  Potential risk of infections like bacteremia
 No “off” days. (especially when using catheters).
 Potential risk of infection and/or peritonitis  Less schedule flexibility.
 Protruding access point, aesthetically obnoxious.  Depressing atmosphere in HD centers.
 Requires self-monitoring care.
 Vascular access surgery required.
 Risk of weigh gain from glucose solution.
PICO
 P: PD vs HD in patient with renal failure

 I: Peritoneal dialysis (PD)
 C: Hemodialysis (HD)
 O: Whether PD is better than HD in terms of:
Mortality
Quality of life
Renal function recovery
Metabolic control
The differential impact of risk factors on mortality in
hemodialysis and peritoneal dialysis
EDWARD F. VONESH, JON J. SNYDER, ROBERT N. FOLEY, and ALLAN J. COLLINS
Baxter Healthcare Corporation, Applied Statistics Center, Round Lake, Illinois; and Nephrology Analytical Services,Minneapolis, Minnesota
Introduction
 Data of 398,940 patients on dialysis across the US is collected, and further divided into
12 groups by:
→ Age: 18-44, 45-64, >65

→ Cause of ESRD: DM vs. non-DM
→ Presence of baseline comorbidity: None vs. one or more
 Studies the mortality rates between PD vs. HD among these patients

Result
Mortality Non-DM <45 Non-DM >45 DM<45 DM 45-64 DM > 65
No HD 24% HD 13% higher HD 22% PD 8% PD 14%

comorbid higher higher higher higher
Yes - - - PD 18% 20%
comorbid higher higher
Discussion and problems with the study
Discussion Problems with the study

 A survival advantage for PD is maintained for these  There were no adjustments were made
patients throughout the 3-year follow-up period,
despite death rates are comparable to HD after 1 year. for factors that directly relate to
 Older (age≥55) female DM patients on PD were at an dialysis modality selection, such as:
increased risk of death due to infection compared to those
on HD, and suggests that continued improvements in →length of time patients were aware of
PD connectology may help lower the risk. kidney failure
 A higher rate of mortality due to infection among DM
patients on PD may also reflect a degree of negative → timing of nephrology referral
selection bias associated with diabetes.
→ modality options education
 Younger DM patients on PD have equal or better
survival compared to HD may reflect their ability to
better metabolize and utilize glucose loads.
→patient attitude to the management
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2615722/
Result
Younger patients without comorbidities had a mortality advantage with PD treatment in 90

to 365 day, but other groups did not. After 12 month, the use of PD at day 90 was
associated with significantly increased mortality in all groups.
Result
There was a statistically and clinically significant interaction among PD risk, age, and comorbidity: The benefit
of PD in the first 12 month was particularly great in the <60-yr group without comorbidities.
Result
 Outcomes among Modality “Switchers”
Mortality of D90-D365 → The group with the lowest mortality during the 90- to 365-d period
were those who were treated with PD at both day 0 and day 90.
Mortality of > 1 year → Compared with those who were on HD treatment both at 90 and 365 d, all other
groups had an increased risk, particularly those who changed from HD at 90 d to PD by 365 d
 120 patients with acute tubular necrosis (ATN) were assigned to HVPD or DHD
 Primary end points :

　　 hospital survival rate
　　 renal function recovery
 Secondary end point ：

　　 metabolic control
14
 HVPD and DHD groups were similar for :
　 Age
　 Gender 　
　 Sepsis
　 Hemodynamic instability
　 Severity of AKI (APACHE II)
　 Pre-dialysis BUN
　 Creatinine
　 Cause of AKI
Etiology of ATN
Indication of dialysis
 Exclusion :
＜ 18 ys
functional azotemia
urinary tract obstruction
acute interstitial nephritis
rapidly progressive glomerulonephritis
history of chronic renal insufficiency
renal transplantation
pregnancy 15
severe hypercatabolism 　
Result
 PD vs HD were similar in :
Metabolic control
-BUN
-Serum creatinine
-Bicarbonate levels
-Sodium
-Potassium
-Glucose
-Evolution of plasma
albumin level
Infection
Mechanical complications
16
 Mortality rate and renal function recovery were similar
 PD was associated with a significantly shorter time to the recovery of renal function
 Therapy duration was significantly longer in DHD group
17
Conclusion
 HVPD and DHD are effective methods for treating AKI patients,
allowing satisfactory metabolic control and similar patient outcome
 Adequate prescription of high volume CPD with a flexible PD catheter and an

automated PD cycler leads to outcomes comparable to those of DHD performed
six times per week
 HVPD and DHD can be considered as alternative forms of RRT in AKI
03/28/2023 18
Careful investigations in recent years suggest that PD patient survival
equals or is slightly shorter than that of patients who undergo HD.
It is now widely accepted that health-related quality of life (HRQOL) is an important outcome of health care rather than
considering only the mortality and also one on which patients base treatment decisions.
• National, prospective cohort study,

Choices for Healthy Outcomes in Caring for ESRD (CHOICE) Study
• Participants completed the Choice Health Experience Questionnaire (CHEQ)
that included information on generic and dialysis specific HRQOL
• Of 1041 patients, 89% (698 HD patients and 230 PD patients)
completed a baseline CHEQ
• Of the 928 patients who completed a baseline
CHEQ, 585 also completed a CHEQ 1 yr. later
https://doi.org/10.1097/01.ASN.0000113315.81448.CA
PD HD
Healthier at Beginning Greater Health Improvement

General (Exclude Mental Health)
Less Bodily Pain Physical Function Improvement
Less Finance Burden

Sleep Improvement
Easy to Access
Dialysis-specific
Diet
Less Loss of Quality of Sex
Travel Free
Result
Change in overall health status was
determined by increases (improved)
or decreases (worsened) in domain
scores during 1 yr. after baseline.
HD patients improved more in some aspects, such as sleep

(which for PD patients actually became worse over time) and
body image. At the end of 1 yr., patients on HD reported
significantly better sexual functioning than those on PD.
PD patients improved more on other dialysis-specific aspects

of life, such as financial well-being, and continued to have
higher scores for ability to travel, diet, and dialysis access.
Discussion
 Many studies have shown a changing risk over time, with an increase in the
mortality risk of PD compared with HD. Several factors may influence this.
 Better preservation of residual renal function

→ Residual renal function has been associated with a lower risk
for death among PD and HD patients.
 Catheter usage
→ Using of both tunneled and non-tunneled catheters is associated
with a higher mortality rate.
 The start point of the cohort

→ Exclusion of patients who did not survive 90 d may exclude patients
at risk for early mortality; if this group is more likely to be treated
with HD, then this would tend to advantage HD.
Discussion Adjusted odds ratios for improvement in overall health status on PD versus HD
The good news for patients on both modalities is that

health and general well-being should improve during
the first year of dialysis.
There do seem to be distinct advantages and

disadvantages to each of the two modalities that should
be explored with patients who are choosing between
them.
Physicians should be as explicit as possible in
describing specific tradeoffs and attempt to elicit
individual preferences for these aspects of quality of
life.
Conclusion
研究顯示在療程早期， PD 基於某些原因死亡率會較選擇 HD
的族群低，但若是長遠來看 HD 患者的生存率則會略高於 PD 的患者，
在健康狀態、生理功能的改善方面也是 HD 略勝一籌，然而不論是採取
PD 或 HD ，其實都能很好的改善這些患者們的生活品質。
而兩者因為其療程進行方式的特色，對病患生活型態的影響也
有所不同，其背後影相因素甚為錯綜複雜，並不能以單一項目的差異就
斷言哪種治療較優，病患必須要對自己已經失去健康的事實有所認知，
且要依據自身所處環境、生活習慣等面向綜合考量，選擇對自己影響較
小、較能接受的療程，如此不論是生理或是心理上，都能回歸相對健康
的狀態，而身為醫療提供者所該做到，就是在這個過程協助病患、提供
正確和完整的醫療諮詢，並從專業角度了解病患的狀況和需求。

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PD vs.

 P: PD vs HD in patient with renal failure

→ Age: 18-44, 45-64, >65

 Studies the mortality rates between PD vs. HD among these patients

Mortality Non-DM <45 Non-DM >45 DM<45 DM 45-64 DM > 65

No HD 24% HD 13% higher HD 22% PD 8% PD 14%

Discussion Problems with the study

Younger patients without comorbidities had a mortality advantage with PD treatment in 90

 Primary end points :

 Secondary end point ：

 Therapy duration was significantly longer in DHD group

 Adequate prescription of high volume CPD with a flexible PD catheter and an

 HVPD and DHD can be considered as alternative forms of RRT in AKI

• National, prospective cohort study,

Healthier at Beginning Greater Health Improvement

Less Finance Burden

HD patients improved more in some aspects, such as sleep

PD patients improved more on other dialysis-specific aspects

 Better preservation of residual renal function

 The start point of the cohort

The good news for patients on both modalities is that

There do seem to be distinct advantages and

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