Kalantar-Zadeh, Kamyar

Sy, John

English

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UC IrvineUC Irvine Previously Published WorksTitleCombining Peritoneal and Hemodialysis in the Same Patient: Furthering Precision Medicine in Dialysis Transitions.Permalinkhttps://escholarship.org/uc/item/9t63x118JournalKidney international reports, 5(4)ISSN2468-0249AuthorsSy, JohnKalantar-Zadeh, KamyarPublication Date2020-04-01DOI10.1016/j.ekir.2020.01.025Copyright InformationThis work is made available under the terms of a Creative Commons Attribution License, availalbe at https://creativecommons.org/licenses/by/4.0/ Peer reviewedeScholarship.org Powered by the California Digital LibraryUniversity of CaliforniaCOMMENTARYCombining Peritonealand Hemodialysisin the Same Patient:Furthering Precision Medicinein Dialysis TransitionsJohn Sy1 and Kamyar Kalantar-Zadeh11University of California Irvine, Orange, California, USAKidney Int Rep (2020) 5, 389–391; https://doi.org/10.1016/j.ekir.2020.01.025ª 2020 International Society of Nephrology. Published by Elsevier Inc. This is an openaccess article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).See Clinical Research on Page 468Despite decades of experiencewith both peritoneal dialysis(PD) and hemodialysis (HD), ne-phrologists around the worldcontinue to debate sthe optimaldialysis modality. Widegeographic variations exist, withHong Kong, the pioneer of PDfirst, having the highest preva-lence of PD patients at approxi-mately 70%. In contrast, theUnited States is currently at 10%to 12%, and Japan stands atapproximately 5% PD prevalence.1Lately, the U.S. president’s execu-tive order has mandated increasingthe use of home dialysis modalitiesover the next 5 years, includingthe use of PD, necessitatingU.S.-based nephrologists to bemore cognizant of PD, its outcomes,and its complications.Recent research has shown thatdialysis staff with less training andenthusiasm for PD are associatedwith lower rates of PD initiation,Correspondence: Kamyar Kalantar-Zadeh,Division of Nephrology and Hypertension,University of California Irvine MedicalCenter, 101 The City Drive, Suite 400, Or-ange, California 92868-3217, USA. E-mail:kkz@uci.eduKidney International Reports (2020) 5, 389–391reflecting possibly a negative biasregarding its suitability for pa-tients.2 Regardless, the incidencerates of PD have risen over the pastseveral years, at least in the UnitedStates, possibly reflecting patientpreferences for home-based modal-ities or our increasing awarenessand comfort regarding this modal-ity. In addition, the U.S. govern-ment has increased reimbursementrates for PD since 2011, which alsomay have helped hasten the rise ofPD. Whether by governmentmandate, patient preference,physician competence, or changingreimbursement models, the numberof PD patients is expected tocontinue to rise over time. Keepingin mind our own limitations andbiases, striving for a more completeunderstanding of PD will un-doubtedly improve outcomes,decrease our own partiality againstthis modality, and align our treat-ments to patient preferences.The fundamental question ofwhether the PD modality inher-ently has better outcomes than HDwhen controlling for patient fac-tors has not yet been answered byrandomized trials, despite severalattempts to do so and a recent389study suggesting that there are nodifferences in mortality out-comes.3,4 In both attempted ran-domized controlled trials in theUnited States and the Netherlands,investigators failed to randomizeappropriately due to patient pref-erences for modality type, high-lighting that patient preferencesremain the driver for selecting thedialysis modality. It is also knownthat incident PD patients aregenerally healthier and havehigher residual kidney function atbaseline compared with HD pa-tients, possibly leading toimproved mortality and morbidityoutcomes in observational studies.Attempts to overcome randomiza-tion issues, including the use ofsophisticated statistical modelingtechniques as propensity score orinstrumental variable analyseshave been pursued with somedegree of success, but the inherentissue of nonrandomization withresidual confounding still persistsas a methodological flaw of theobservational study design.4Notwithstanding the limitationsof observational studies, the questto improve our understanding ofPD outcomes should continue,especially in understanding thecomplications of this modality andthe reasons for its technique fail-ure. In the United States, PDtechnique failure rates areapproximately 20%, 40%, and55% at 1, 2, and 3 years, respec-tively.5 Although PD failure oc-curs for a variety of reasons,because of peritonitis, inadequatedialysis, catheter malfunction, orpsychosocial factors, traditionallymany patients had no choice but toconvert to thrice-weekly in-centerhemodialysis. This is in sharpcontrast to the fast-emergingconcept of incremental dialysis,whereby incident dialysis patientswith adequate residual kidneyStop PD and Transion to Thrice-Weekly HD Dialysis WithdrawalIncremental PD Transion:Peritoneal Dialysis + Once-Weekly HDIncremental PD Transion:Peritoneal Dialysis + Twice-Weekly HDTradional ApproachesNovel ApproachesDecreasing kidney funconDecreasing kidney funconPD Technique FailureFigure 1. Traditional and novel options to transition from peritoneal dialysis (PD) to hemo-dialysis (HD).COMMENTARY J Sy and K Kalantar-Zadeh: Combining HD and PDfunction (i.e., native urea clearance>3 ml/min) who meet certaincriteria are nowadays expected totransition to twice-weekly HD forthe first several months.6 Over thepast several years, the concept ofincremental dialysis has gainedsubstantial acceptance in theUnited States and abroad, given itsnature of patient-centeredness andits alliance with the basic princi-ples of precision medicine.7 TheUniversity of California Irvine in-cremental dialysis model that isalso practiced at the Veterans Af-fairs Medical Center in LongBeach, California, has emerged asthe prevailing model of twice-weekly HD transition throughoutthe nation and beyond.8 Based onour unpublished data, no patientshave died out of more than 100incident dialysis patients whoinitiated twice-weekly HD since2014 and maintained this infre-quent HD regimen between 3months to 3 years before theytransitioned to thrice-weekly HD.This is in contrast to the highmortality rate during the first yearafter dialysis transition that hasbeen described relatively consis-tently on outright initiation ofconventional thrice-weekly HD.6Nevertheless, the use of incre-mental dialysis is not quite clear.390More unclear is the utility of otherprecision medicine–based ap-proaches in dialysis therapyrealms, including combining HDand PD. In a recent concept model,Gedney (who is a dialysis patient)and Kalantar-Zadeh9 proposedtranslating the incremental modelto incident PD patients usingshorter dwell times, less daily so-lution volume, or fewer than 7dialysis treatment days per week.A gradual transition to morefrequent or more intense dialysistherapy over several months canthen be used to counter worseningfluid retention and uremia.9 Theseauthors also suggest that if lessfrequent PD is desired, PD may becombined with sporadic HD treat-ments, although there are few dataabout the benefits and challengesof such combination approaches.To that end, if PD appears to beinadequate on further reduction inresidual kidney function, sporadicHD therapies in addition to back-ground PD, such as once-weeklyHD, can be considered (Figure 1).In the current edition of KI Re-ports, Tanaka et al.10 have investi-gated hospitalization outcomes inpatients converted to a combinationof PD and HD, a modality that israrely heard of in the United Statesor Western Europe. Investigatorsmatched prevalent HD patients with42 combined PD and HD patients,most (37, or 88% of the combinedPD-HD cohort) of whom were con-verted from PD due to inadequatedialysis or volume overload. Theredid not appear to be any significantdifferences in hospitalization ratesbetween the combination PD-HDcohort versus the HD cohort, butinvestigators unsurprisingly notedan increase in hospitalizations fordialysis access-related issues in thecombined PD-HD cohort, includingvascular complications and PD-related infections of 21.7 per 100patient-years versus 7.2 per 100patient-years, respectively.Many readers may take theseinteresting results to suggest thatthe combined modality should notbe offered and that patients shouldbe switched directly to HD whenPD failure occurs given theincreased risk of dialysis accesscomplications. However, the factthat total hospitalization rates didnot differ between the 2 groupsmay suggest an alternativeapproach whereby patients main-tain the independence of PD whileslowly, instead of abruptly, tran-sitioning to HD (Figure 1). Qualityof life, maintenance of indepen-dence, and the ability to perform alife-sustaining treatment on one’sown schedule is an importantconsideration. This is especiallytrue in the era of precision medi-cine, incremental transitions indialysis, and more intense focus onpatient-reported outcomes. Ourexperience with transitioning pa-tients from chronic kidney disease5 to dialysis via the University ofCalifornia Irvine twice-weekly in-cremental dialysis model for pa-tients who meet eligibility criteria6has improved compliance, main-tained residual kidney function,and improved long-term out-comes.11 The transition from fullPD to combined PD-HD can belikened as a similar transitionKidney International Reports (2020) 5, 389–391J Sy and K Kalantar-Zadeh: Combining HD and PD COMMENTARYperiod between chronic kidneydisease and HD, one which canpotentially avoid the constant he-modynamic changes seen in HDand its associated poor outcomes.There are inherent limitations tothis small, nonrandomized studyfrom Japan,10 including the lack ofindividual dialysis PD prescriptiondetails before transition and indi-vidual patient characteristics thatmake it difficult to ascertain ifadjusting the PD prescription mayhave prevented them fromswitching to the combination mo-dality. The small study in a limitedgeographical area with a homoge-neous patient population will alsoaffect generalizability of thesefindings to other non-Asian coun-tries, especially because most dial-ysis centers around the world arenot capable (logistically or other-wise) of performing such combi-nation dialysis treatments.Furthermore, mortality outcomesin this study and optimal dialysisadequacy targets for combinationmodality patients overall remainsunknown. Although larger studiesthat investigate the feasibility andoutcomes of the combined PD-HDdialysis modality over the long-term are needed, this small butimportant study points to anavenue to assist patients with thetransition from PD to HD.Ultimately, modality selectionmust remain the patient’s decision,but having an improved under-standing of the modalities and itscomplications, in addition to con-siderations when transitioningKidney International Reports (2020) 5, 389–391patients to and from various mo-dalities, will undoubtedly improvethe education of our patients,remove our personal biases againstthe PD modality, and enhanceoutcomes both here in the UnitedStates and abroad. There are manyadvantages to using precisionmedicine tools to institute incre-mental dialysis and combined HD-PD protocols. These include longerpreservation of residual kidneyfunction, avoidance of the abrupttransition from PD to thrice-weekly HD on PD technique fail-ure, improved adherence to patientpreference, and allowance for agreater patient-centeredness.Although we are uncertain that acombined HD-PD will ultimatelybecome a favorable treatmentchoice globally, we remain highlyenthusiastic of innovative dialysisand nondialysis options andcombinations.DISCLOSUREAll the authors declared nocompeting interests.REFERENCES1. United States Renal Data System.2018 USRDS annual data report:epidemiology of kidney disease inthe United States. Bethesda, MD:National Institutes of Health, NationalInstitute of Diabetes and Digestiveand Kidney Diseases; 2018.2. Shen JI, Schreiber MJ, Zhao J, et al.Attitudes toward peritoneal dialysisamong peritoneal dialysis and he-modialysis medical directors: are wepreaching to the right choir? Clin JAm Soc Nephrol. 2019;14:1067–1070.3. Zhou H, Sim JJ, Bhandari SK, et al.Early mortality among peritonealdialysis and hemodialysis patientswho transitioned with an optimaloutpatient start. Kidney Int Rep.2019;4:275–284.4. Chiu Y-W, Jiwakanon S, Lukowsky L,et al. An update on the comparisonsof mortality outcomes of hemodialy-sis and peritoneal dialysis patients.Semin Nephrol. 2011;31:152–158.5. Shen JI, Mitani AA, Saxena AB, et al.Determinants of peritoneal dialysistechnique failure in incident USpatients. Perit Dial Int. 2013;33:155–166.6. Kalantar-Zadeh K, Unruh M, Zager PG,et al. Twice-weekly and incrementalhemodialysis treatment for initiationof kidney replacement therapy. Am JKidney Dis. 2014;64:181–186.7. RheeCM,Obi Y,MathewAT, Kalantar-Zadeh K. Precision medicine in thetransition to dialysis and personalizedrenal replacement therapy. SeminNephrol. 2018;38:325–335.8. Ghahremani-GhajarM,Rojas-BautistaV,Lau W-L, et al. Incremental hemodialy-sis: the University of California Irvineexperience. Semin Dial. 2017;30:262–269.9. Gedney N, Kalantar-Zadeh K. Dialysispatient-centeredness and precisionmedicine: focus on incrementalhome hemodialysis and preservingresidual kidney function. SeminNephrol. 2018;38:426–432.10. Tanaka M, Ishibashi Y, Hamasaki Y,et al. Hospitalization for patients oncombination therapy with peritonealdialysis and hemodialysis comparedwith hemodialysis. Kidney Int Rep.2020;5:468–474.11. Mathew AT, Obi Y, Rhee CM, et al.Incremental dialysis for preservingresidual kidney function: does onesize fit all when initiating dialysis?Semin Dial. 2018;31:343–352.391

Combining Peritoneal and Hemodialysis in the Same Patient: Furthering Precision Medicine in Dialysis Transitions.

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Combining Peritoneal and Hemodialysis in the Same Patient: Furthering Precision Medicine in Dialysis Transitions.

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