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Peritoneal dialysis offers patients a life unplugged


When Melvin Cureton's kidneys failed 10 months ago, he started on dialysis, visiting a Baltimore clinic three times a week for several hours at a stretch. But the procedure didn't fit with his schedule; Cureton, a truck driver, spends his days driving between Florida and Massachusetts.

So Cureton's doctor, Johns Hopkins kidney specialist Bernard Jaar, suggested he try an alternative treatment that he could perform himself - peritoneal dialysis, which allows patients to purify their own blood by injecting a mineral solution into their abdomen.

Cureton says the process has been a godsend, allowing him much more freedom. "It seems like I'm not even on dialysis," said Cureton, 39, who lives in Baltimore and has a less-common kidney disease. "I can hook up any time."

Instead of spending several hours hooked up to a machine at a clinic, he simply injects the solution before going to sleep or starting a trip. Several hours later, he removes the liquid - which has collected the toxins from his bloodstream - through a tube inserted into his abdomen.

Cureton is an anomaly: Only 10 percent of the 400,000 Americans on dialysis use the peritoneal method. But many more should be using it, suggests a new study by Johns Hopkins University researchers.

The study, which appeared in yesterday's issue of the Journal of the American Medical Association, found that patients using peritoneal dialysis were more satisfied with their care than those using the more common treatment, which is known as hemodialysis. Overall, the two treatments are considered equally effective.

"Peritoneal dialysis patients rated their care much higher than hemodialysis patients," said one of the study's authors, Dr. Neil Powe, an epidemiologist at the Johns Hopkins School of Public Health.

The researchers were surprised by the results. "I didn't realize there would be such a big difference," said the study's lead author, Dr. Haya Rubin, a researcher at Johns Hopkins Medical School. "People really do think it's better."

Dr. James Heaf, a professor at the University of Herlev in Copenhagen, Denmark, said as many as 30 percent of American dialysis patients should probably be using the peritoneal method. "It was a very interesting paper," said Heaf, who wrote an accompanying editorial.

Proponents of the do-it-yourself treatment say it often offers advantages over hemodialysis, which requires patients - who are sometimes already weakened by their disease - to travel to a clinic and spend several hours connected to a machine that removes and then purifies their blood before returning it to their bodies.

Peritoneal dialysis, by contrast, can be done almost anywhere. Patients are surgically fitted with a tube that extends into their peritoneum, a membrane inside the abdomen. This membrane comes into close contact with several large blood vessels, allowing toxins to be leached from the blood.

Three to four times a day, patients inject about two liters of solution into their peritoneum, then remove the liquid several hours later.

"They have more freedom, and they don't have to change their lifestyle as much," said Dr. John Burkart, a professor of medicine at Wake Forest University. Burkart, a strong proponent of peritoneal dialysis, is the medical director for the school's 10 dialysis centers.

Not all kidney failure patients can use the peritoneal method, however. For those who have had abdominal surgery, hemodialysis is much safer. And patients with mental disabilities may not be able to take on the treatments.

But because the overall mortality rate for each method is about the same, Burkart and others argue that many more U.S. patients should use peritoneal dialysis. In countries with comparable health systems, such as England, Scandinavia and the Netherlands, about a third of kidney failure patients use the method.

In the United States, the use of peritoneal dialysis is actually dropping, and has fallen by almost half in the past decade.

There are many reasons for this low rate, researchers say. Powe says some doctors and clinics may not be giving patients enough information about peritoneal dialysis. Many doctors don't receive enough training in the method, and aren't comfortable prescribing it.

"Patients ought to be more informed up front," Powe said. Rubin said that studies have shown that the more informed patients are, the more likely they are to choose peritoneal dialysis.

And some dialysis centers have an economic incentive to steer patients to hemodialysis, critics say. The federal government currently covers the cost of dialysis, and pays doctors and clinics the same amount for both kinds of treatment. After excluding fixed costs such as building construction, a hemodialysis treatment costs less than a peritoneal treatment, so providers generally stand to make more from the former.

Rubin said this profit difference may subtly influence some doctors' decisions about treatment.

Patients are also a factor: Some simply don't want the added responsibility. "They have to be committed to the treatment," said Jaar, Cureton's doctor.

On this point, Cureton is an ideal peritoneal patient, Jaar said: "He's a very independent person. He likes to be taking care of himself."

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