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Need for evidence on long-term prognosis of PD+HD: a commentary

Abstract

Combination therapy with peritoneal dialysis and hemodialysis (PD+HD) is an alternative dialysis method for patients with end-stage kidney disease (ESKD). The complementary use of once-weekly HD expedites to achieve adequate dialysis and enables to prolong PD duration. Although PD+HD has been widely employed among Japanese PD patients, it is much less common outside Japan. Clinical evidences are still not enough, especially in long-term prognosis and appropriate treatment duration, suitable patients, and generalizability. A retrospective cohort study by Chung et al. (BMC Nephrol 21:348, 2020) compared the risk of mortality and hospitalization between PD patients who were transferred to PD+HD and those who were transferred to HD in Taiwan. Because the mortality and hospitalization rates did not differ between the groups, the authors concluded that, PD+HD may be a rational and cost-effective treatment option. It should be noted that the effects of PD+HD on long-term prognosis are still unknown due to too-short PD+HD duration. However, the study identified the high-risk patient population and showed the generalizability of PD+HD. PD+HD is a treatment of choice in patients with ESKD who prefer PD lifestyles even after decline in residual kidney function.

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Background

Combination therapy with peritoneal dialysis and hemodialysis (PD+HD) has been widely used in Japan (Fig. 1). Currently, one-fifth of Japanese PD patients are on PD+HD, and 87.9% of those are treated with 5 to 6 days of PD and once-weekly HD (Japanese Society for Dialysis Therapy, unpublished data), which is covered by the national health insurance as a maintenance dialysis. Since the complementary use of HD ameliorates underdialysis and overhydration and enables significant prolongation of PD, PD+HD is preferred by PD patients who wish to maintain PD lifestyles after decline in residual kidney function [1, 2]. In fact, health-related quality of life for PD+HD was close to that for PD but was better than HD in role and social functions [3]. In this cohort, hospitalization risk was similar between PD+HD and HD, although PD+HD may have a higher hospitalization risk of dialysis access-related complications than HD [4]. However, many of these findings were from low quality studies, and several important arguments, such as long-term prognosis and appropriate treatment duration, and suitable patients, have not been determined. The generalizability of PD+HD was also unclear, since there have been few reports from outside Japan so far.

Fig. 1
figure1

Treatment patterns of each dialysis modality. Shown are examples of treatment schedule in a week among PD, PD+HD, and HD. For each modality, the frequency of treatment can be modified based on patient characteristics. PD+HD may be used as either a bridging therapy or a maintenance therapy. Complementary use of HD increases dialysis doses and fluid removal in PD patients after decline in residual kidney function. PD+HD may also allow “PD-holiday” that mitigates excessive exposure to glucose dialysate. Abbreviations: HD, hemodialysis; PD, peritoneal dialysis; PD+HD, combination therapy with peritoneal dialysis and hemodialysis

PD+HD compared to HD

Chung et al. recently reported a retrospective cohort study comparing the risk of mortality and hospitalization (including emergent hospital visits) between PD+HD group (transfer from PD to PD+HD) and HD group (transfer from PD to HD) using a health insurance database in Taiwan [5]. An intention-to-treat analysis revealed that both risks were similar between the two groups, although peritonitis was a strong risk factor for hospitalization in PD+HD. The authors concluded that PD+HD is a safe, rational, and may be a cost-effective treatment for patients with end-stage kidney disease (ESKD), and the larger number of patients and longer observation period than previous studies may strengthen the present study conclusion.

However, long-term prognostic effects of PD+HD have not been clarified yet. In the present study, about 58% of patients were transferred from PD+HD to HD within a year. Too-short PD+HD duration makes it difficult to understand the crude effects of the combined dialysis in a 12-year follow-up. In addition, it remains unclear whether patients with ESKD can be treated adequately with PD+HD for a long period. A multivariate analysis including PD+HD duration may help to understand the long-term prognostic impacts and appropriate treatment period of this combined modality.

Nevertheless, the present study provided an important finding that PD+HD had a similar prognosis to HD, which was compatible with a recent Japanese study [4]. The consistency of the results from different regions suggested the feasibility and generalizability of PD+HD. There may be some differences in health insurance policies and the treatment strategies for additional HD between Japan and Taiwan. While once-weekly HD is routinely performed in most Japanese PD+HD patients, the study showed that a half of PD+HD patients in Taiwan were treated with only two HD sessions per month, and in such patients, HD was sometimes used as a rescue treatment. This biweekly HD regimen of PD+HD may increase the generalizability in developing countries.

The present study also suggested that PD+HD can be prescribed as an individualized, bridging dialysis modality. The flexibility may enable a smooth and appropriate transition of dialysis modality, and it may be of help during disastrous situations, such as recent COVID-19 pandemic [6]. On the other hand, dialysis access-related complications [4] and peritonitis [5] were risk factors of hospitalization for PD+HD, and technique survival rate was poor in those who required high ultrafiltration volume by additional HD [7]. It is necessary to identify suitable patients and establish the optimal indication for PD+HD.

In the present study, the authors proposed PD+HD as a part of an integrated dialysis care and mentioned that dialysis staff should be familiar with this combined modality. A patient-centered dialysis prescription by the shared decision-making is desired [8], however, many patients are feeling that they had not been sufficiently explained about dialysis modalities at the start of dialysis [9]. An increased awareness of PD+HD would provide patients more treatment choices in the precision medicine era.

Conclusions

A recent study by Chung et al. suggested that mortality and hospitalization risks were similar between PD patients who were transferred to PD+HD and those who were transferred to HD in Taiwan [5]. However, the effects of PD+HD on long-term prognosis was unclear, since the treatment duration of PD+HD was too-short in the study. Nevertheless, this interesting paper provided several important findings. Firstly, PD+HD may be a safe, feasible, and flexible dialysis modality which is generalizable both in Japan and Taiwan. Secondary, patients with recent peritonitis were at a high risk of hospitalization. Clinicians and nurses should have a good understanding of PD+HD to apply precision medicine in clinical practice.

Availability of data and materials

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Abbreviations

PD+HD:

Combination therapy with peritoneal dialysis and hemodialysis

ESKD:

End-stage kidney disease

COVID-19:

Coronavirus disease 2019

References

  1. 1.

    Kawanishi H, Hashimoto Y, Nakamoto H, Nakayama M, Tranaeus A. Combination therapy with peritoneal dialysis and hemodialysis. Perit Dial Int. 2006;26(2):150–4.

    Article  Google Scholar 

  2. 2.

    Kawanishi H, Moriishi M. Clinical effects of combined therapy with peritoneal dialysis and hemodialysis. Perit Dial Int. 2007;27(Suppl 2):126–9.

    Article  Google Scholar 

  3. 3.

    Tanaka M, Ishibashi Y, Hamasaki Y, Kamijo Y, Idei M, Kawahara T, Nishi T, Takeda M, Nonaka H, Nangaku M, et al. Health-related quality of life on combination therapy with peritoneal dialysis and hemodialysis in comparison with hemodialysis and peritoneal dialysis: a cross-sectional study. Perit Dial Int. 2020;40(5):462–9. https://doi.org/10.1177/0896860819894066.

    Article  PubMed  Google Scholar 

  4. 4.

    Tanaka M, Ishibashi Y, Hamasaki Y, Kamijo Y, Idei M, Kawahara T, Nishi T, Takeda M, Nonaka H, Nangaku M, et al. Hospitalization for Patients on Combination Therapy With Peritoneal Dialysis and Hemodialysis Compared With Hemodialysis. Kidney Int Rep. 2020;5(4):468–74.

    Article  Google Scholar 

  5. 5.

    Chung MC, Yu TM, Wu MJ, Chuang YW, Muo CH, Chen CH, Chang CH, Shieh JJ, Hung PH, Chen JW, et al. Is combined peritoneal dialysis and hemodialysis redundant? A nationwide study from Taiwan. BMC Nephrol. 2020;21(1):348.

    Article  Google Scholar 

  6. 6.

    Matsuo N, Yokoyama K, Tanno Y, Yamamoto I, Yokoo T. Combined therapy using peritoneal dialysis and hemodialysis may increase the indications for peritoneal dialysis in the United States. Kidney Int. 2015;87(6):1259–60.

    Article  Google Scholar 

  7. 7.

    Tanaka M, Ishibashi Y, Hamasaki Y, Kamijo Y, Idei M, Nishi T, Takeda M, Nonaka H, Nangaku M, Mise N. Ultrafiltration volume by once-weekly hemodialysis is a predictor of technique survival of combination therapy with peritoneal dialysis and hemodialysis. Ther Apher Dial. 2020. https://doi.org/10.1111/1744-9987.13509.

    Article  PubMed  Google Scholar 

  8. 8.

    Blake PG, Brown EA. Person-centered peritoneal dialysis prescription and the role of shared decision-making. Perit Dial Int. 2020;40(3):302–9.

    Article  Google Scholar 

  9. 9.

    Dahlerus C, Quinn M, Messersmith E, Lachance L, Subramanian L, Perry E, Cole J, Zhao J, Lee C, McCall M, et al. Patient Perspectives on the Choice of Dialysis Modality: Results From the Empowering Patients on Choices for Renal Replacement Therapy (EPOCH-RRT) Study. Am J Kidney Dis. 2016;68(6):901–10.

    Article  Google Scholar 

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MT conceived and wrote the first draft of the manuscript. NM supervised the manuscript. Both authors read and approved the final manuscript.

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Correspondence to Mototsugu Tanaka.

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Tanaka, M., Mise, N. Need for evidence on long-term prognosis of PD+HD: a commentary. BMC Nephrol 22, 10 (2021). https://doi.org/10.1186/s12882-020-02212-x

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Keywords

  • Peritoneal dialysis
  • Hemodialysis
  • Combined dialysis
  • End-stage kidney disease
  • End-stage renal disease
  • Residual kidney function
  • Technique failure
  • Precision medicine