SAGE-Hindawi Access to Research International Journal of Nephrology Volume 2011, Article ID 239515, 5 pages doi:10.4061/2011/239515 Review Article In Peritoneal Dialysis, Is There Sufﬁcient Evidence to Make “PD First” Therapy? Pranav Dalal,1 Harbaksh Sangha,1 and Kunal Chaudhary2, 1 1 Division of Nephrology, Department of Internal Medicine, University of Missouri, Columbia, Mo 65212, USA 2 Division of Nephrology, Harry S Truman Veterans’s Hospital, Columbia, Mo 65201, USA Correspondence should be addressed to Kunal Chaudhary, chaudharyk@health.missouri.edu Received 19 January 2011; Revised 6 April 2011; Accepted 20 April 2011 Academic Editor: Hulya Taskapan Copyright © 2011 Pranav Dalal et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Since its introduction more than 3 decades ago, the use of peritoneal dialysis (PD) has increased greatly due to its simplicity, convenience, and low cost. Advances in technique, antibiotic prophylaxis, and the introduction of newer solutions have improved survival, quality of life, and reduced rate of complications with PD. In Hong Kong, approximately 80% end-stage renal disease (ESRD) patients perform PD; in others, that is, Canada, Australia, and New Zealand, 20%–30% patients use PD. However, in the United States, the annual rate of prevalent patients receiving PD has reduced to 8% from its peak of 15% in mid-1980s. PD as the initial modality is being oﬀered to far less patients than hemodialysis (HD), resulting in the current annual incidence rate of less than 10% in USA. There are many reasons preventing the PD ﬁrst initiative including the increased numbers of in-center hemodialysis units, physician comfort with the modality, perceived superiority of HD, risk of peritonitis, achieving adequate clearances, and reimbursement incentives to providers. Patient fatigue, membrane failure, and catheter problems are other reasons which discourage PD utilization. In this paper, we discuss the available evidence and provide rationale to support PD as the initial renal replacement modality for ESRD patients. 1. Introduction Over half million Americans were undergoing renal replace- ment therapy (RRT) for ESRD at the end of year 2008. In-center Hemodialysis (HD) and home PD are the two common forms for dialysis therapy. Only about 8% of patients with ESRD are receiving PD as RRT in the United States compared to Canada and Europe, where PD is much more common [1]. The percentage PD patients has declined signiﬁcantly from the peak of 15% in the mid- eighties to 5.8% in 2007 [1]. There are numerous factors contributing to the low incidence and prevalence of PD in this country [2, 3]. Concerns regarding achievement of adequate clearance with PD, especially in patient with no residual renal function and a perception of better patient survival on HD compared to PD amongst US nephrologists impact selection of dialysis modality. Risk of infectious complications, specially PD peritonitis and catheter-related problems contribute to the selection bias. Systemic factors such as the easy accessibility to HD, ﬁnancial incentives, and ownership of dialysis units, including units owned by large dialysis organization (LDOs), as well as physician education and exposure to PD during training also play an important role in the selection of RRT for ESRD patients. Strategies to prevent peritonitis, ultraﬁltration failure, managing catheter- related complications, and improving adequacy of dialysis as well as education of patients and medical staﬀ may all help with increasing PD utilization. 2. Why PD before HD? Along with improved survival, other long-term goals of ESRD patients are to improve quality of life, preserve residual renal function, and reduce morbidity. Many young ESRD patients will likely receive PD, HD, and renal transplantation at diﬀerent points over their lifetime. Better survival on PD compared to HD during ﬁrst two years of dialysis treatment is one of the compelling reasons to start patient on PD ﬁrst. In the last decade, infection-related complications are higher and appear to be increasing in HD patients, whereas such complications are steadily declining in PD patients [1]. Preservation of residual renal function and vascular access