Friday, April 16, 2010

PD vs HD in the elderly

Patients over 65 tend not to choose peritoneal dialysis for a host of reasons, not the least of which is PD is underutilized in the US in general. However, a recent study suggests that PD may be preferable to HD in the elderly, at least for those with the cognitive and functional ability to perform PD.

The BOLDE (Broadening Outcomes for Long-term Dialysis in the Elderly) trial out of the UK looked at health-related quality of life measures in PD vs HD patients over 65. Results have not yet been published but were recently presented at the Annual Dialysis Conference in Seattle in March. Using a cross-sectional design, the study matched PD and HD patients (age, gender, time on dialysis) and compared health related quality of life via several validated assessment tools. Mean age was 73, most were men (70%), and ~25% lived alone in both groups. Patients in both groups were on dialysis for on average about 2.5 years. Education level was similar in both groups. Disease intrusiveness scores were lower in PD than in HD patients (22.0 in PD vs. 26.0 in HD) as assessed by the Illness and Intursiveness Rating Scale. The study also found that depressive symptoms were less common in the PD group, as were common dialysis-associated symptoms (headaches, dry mouth, taste changes, dizziness, and unsteadiness), with the exception of lower extremity edema, which was more common in patients with PD. For more details see the author's presentation data here and a review article here.

With the aging of the population, modality choice in the elderly will be a decision encountered more frequently, and at the very least this study should lead us to seriously entertain, if not encourage, PD in the elderly population. Further, as many of you know, Centers for Medicare and Medicaid Services (CMS) will be implementing the bundle payment system in January 2011. In short, dialysis treatments in the US will be reimbursed with one lump some that will cover all the costs of the treatment, including labs, medications etc. Reimbursement for home dialysis will be comparable to in-center dialysis, providing some incentive to increase the use of home modalities which are generally cheaper. Taken in this context, PD enthusiasm in general should increase, both for quality of life and, for better or worse, financial, reasons.

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