Original investigation: dialysis therapy
The effect of contraindications and patient preference on dialysis modality selection in ESRD patients in The Netherlands

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Abstract

Background: Patients with end-stage renal disease (ESRD) who are about to start long-term dialysis therapy are faced with the question of modality choice. The aim of the current study is to determine the influence of different factors on long-term dialysis modality choice. Methods: As part of a large Dutch prospective multicenter study, the Netherlands Cooperative Study on the Adequacy of Dialysis, we consecutively included all new patients with ESRD. Nephrologists indicated the most important reason for the modality selection. Results: Of 1,347 included patients, 36% (n = 483) had a contraindication to either peritoneal dialysis (PD) or hemodialysis (HD) therapy. Eighty percent (n = 386) of all contraindications were directed to PD therapy. The most frequently mentioned contraindication was a social one; ie, the expected incapability of patients to perform PD exchanges themselves. Patients with contraindications were older, had more comorbidity, and lived alone more often compared with patients without contraindications. In patients without contraindications (64%), modality choice was based on patient preference. Older age increased the odds of choosing HD, whereas receipt of predialysis care was associated with a lower preference for HD. Conclusion: Older age was associated with more contraindications to PD therapy and stronger patient preference for HD therapy. An elderly patient therefore was more likely to start with HD therapy. Results from the current study suggest that an increase in provision of predialysis care, in combination with a reduction in social contraindications to PD therapy, may be associated with an increase in likelihood of starting with PD therapy. In a time of an aging population, increasing demand on dialysis capacity, and limited amount of financial supplies, we may reconsider current strategies to provide future patients with ESRD the possibility to start with the dialysis modality they prefer.

Section snippets

Methods

All consecutive new patients with ESRD from 38 Dutch dialysis centers were invited to participate in the Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD), a large, multicenter, prospective study. The aim of the NECOSAD study is to monitor the quality and adequacy of dialysis treatment in The Netherlands. Eligibility criteria were age of 18 years or older, and dialysis had to be the first renal replacement therapy. All patients gave their informed consent before inclusion.

The

Patients and contraindications

Thirteen hundred forty-seven patients were included 3 months after the start of dialysis therapy. Patient characteristics at the start of long-term dialysis treatment are listed in Table 1. Mean age was 59 years, 39% of patients were women, and 62% were treated with HD. As shown in Fig 1, the percentage of patients starting on HD therapy increased with age. In the group of patients aged 18 to 40 years, 40% received HD as long-term therapy, whereas in patients older than 70 years, 81% received

Discussion

In this study, we present an analysis of factors associated with long-term dialysis modality choice based on information on the decision process provided by the nephrologist for each individual patient at the start of dialysis therapy, as well as on patient characteristics. In one third of patients, the modality choice was the consequence of having a contraindication to 1 of the modalities. Contraindications were present more often in elderly patients, those with comorbid conditions, and

Acknowledgements

The authors thank the nursing staff of the 38 different dialysis units, who collected most of the data, and the staff of the NECOSAD trial office for their assistance in the logistics of this study.

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    Supported in part by grant no. E.018 from The Dutch Kidney Foundation; and grant no. OG97/005 from the Dutch National Health Insurance Board.

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    The NECOSAD Study Group: A.J. Apperloo, J.N.M. Barendregt, R.J. Birnie, M. Boekhout, W.H. Boer, E.F.H. van Bommel, H.R. Büller, F.Th. de Charro, C.J. Doorenbos, W.T. van Dorp, A. van Es, W.J. Fagel, G.W. Feith, C.F.M. Franssen, L.A.M. Frenken, J.A.C.A. van Geelen, W. Geerlings, P.G.G. Gerlag, J.P.M.C. Gorgels, W. Grave, R.M. Huisman, M.A. Jansen, K. Jie, W.A.H. Koning-Mulder, M.I. Koolen, T.K. Kremer Hovinga, A.T.J. Lavrijssen, A.W. Mulder, K.J. Parlevliet, J.B. Rosman, J.L.C.M. van Saase, M.J.M. Schonk, M.M.J. Schuurmans, P. Stevens, J.G.P. Tijssen, R.M. Valentijn, G. Vastenburg, C.A. Verburg, V.M.C. Verstappen, H.H. Vincent, and P. Vos.

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    Copyright © 2004 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.