The John F. Maher Award Recipient Lecture 2006. The continuum of chronic kidney disease and end-stage renal disease: challenges and opportunities for chronic peritoneal dialysis in the United States.
End-stage renal disease (ESRD) patients undergoing renal replacement therapy have a high mortality rate and suffer from considerable morbidity. Degree of nutritional decline, disordered mineral metabolism, and vascular calcification are some of the abnormalities that predict an adverse outcome for ESRD patients. All these abnormalities begin early during the course of chronic kidney disease (CKD), long before the need for maintenance dialysis. Thus, CKD represents a continuum of metabolic and vascular abnormalities. Treatment of these abnormalities early during the course of CKD and a timely initiation of dialysis have the potential of improving patient outcomes. However, the thesis that successful management of these abnormalities will favorably modify the outcomes of dialysis patients remains untested. The proportion of incident USA ESRD patients starting chronic peritoneal dialysis (CPD) has historically been low. Limited physician training and inadequate predialysis patient education appear to underlie the low CPD take-on in the USA. Furthermore, two key changes have occurred in the USA: steep decline in CPD take-on and progressive increase in the use of automated peritoneal dialysis. The decline in CPD take-on has afflicted virtually every subgroup examined and has occurred, paradoxically, when the CPD outcomes in the country have improved. Understanding the reasons for historically low CPD take-on and recent steep declines in utilization may allow the development of plans to reverse these trends.
Mehrotra
Rajnish
R
Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California, USA. rmehrotra@labiomed.org
D006801:Humans; D015994:Incidence; D007676:Kidney Failure, Chronic / Q000453:epidemiology / Q000628:therapy*; D010530:Peritoneal Dialysis / Q000706:statistics & numerical data*; D051436:Renal Insufficiency, Chronic / Q000150:complications* / Q000628:therapy; D014481:United States / Q000453:epidemiology