Factors Involved in the Choice of Type of Dialysis



Chronic hemodialysis can be performed in the home, if the patient has a dialysis partner, or in an outpatient dialysis facility. Chronic peritoneal dialysis is usually a homebased, rather than a facility-based, treatment. The morbidity and mortality of ESRD patients treated with either hemodialysis or peritoneal dialysis are ap­proximately the same. The choice of one mod­ality versus the other, therefore, is often predi­cated on nonmedical considerations, such as the patient’s desire to directly participate in his or her care, the home and work situation of the patient, and the proximity of the patient to a kidney treat­ment center. In certain acute and chronic circum­stances, however, one modality may be the pre­ferred treatment option.

Cardiovascular instability is more common in patients treated with hemodialysis than in those treated with peritoneal dialysis. Peritoneal dialysis does not require an extracorporeal lowresistance blood circuit. In addition, by virtue of the fact that peritoneal dialysis is a less efficient modality on a per minute basis, the changes in blood chemistries and in the extracellular fluid volume occur more slowly. In a patient who is experiencing instability or intolerance to hemo­dialysis, peritoneal dialysis may be the preferred treatment option.

In the patient with diabetes mellitus, peri­toneal dialysis is the preferred choice of dialytic therapy. Peritoneal dialysis avoids the require­ment for heparin, with the attendant risk of blind­ness in the diabetic patient with retinopathy. There is a significant increase in the incidence of blindness in diabetic patients treated with chronic hemodialysis. In addition, patients with diabetes mellitus who reach ESRD have a high in­cidence of associated cardiac disease and auto­nomic neuropathy and, as a consequence, are less tolerant of hemodialysis.

The presence of intra-abdominal adhesions, communications between the pleural and peri­toneal spaces, or abdominal wall hernias is a con­traindication to institution or continuation of per­itoneal dialysis. Obesity and abnormalities in serum lipids may be exacerbated by the glucose absorbed from the peritoneal dialysis fluid. The presence or worsening of these conditions is a rel­ative contraindication to peritoneal dialysis.