International Journal of Nephrology occurrence of both S Aureus and gram negative infections, including pseudomonas, and should be applied as a best practice [19]. 6. Quality of Life and Patient Satisfaction PD oﬀers home-based therapy, thus there is no need to go to dialysis unit three times per week and no time spending in dialysis unit. Most PD patients pay visit to see their physician once a month. PD oﬀers a ﬂexible schedule with opportunities to travel and participate in other activities. Patient satisfaction is better amongst PD patients as com- pared those on HD [20]. In CHOICE cohort researchers surveyed 736 new dialysis patients from 37 centers regarding their satisfaction with treatment. Patients receiving PD were much more likely than those receiving HD to give excellent ratings of dialysis care overall and signiﬁcantly more likely to give excellent ratings for each speciﬁc aspect of care rated. The diﬀerences between peritoneal dialysis and hemodialysis patient satisfaction persisted even after adjustment for patient age, race, education, health status, marital status, employment status, distance from the center, and time since starting dialysis [21]. 7. Better Graft Survival in Transplant Patient It would be preferable to start ESRD patients waiting for renal transplant on PD; especially ones with live donors. In a case-control study the incidence of delayed graft function was less, and the drop in serum creatinine was faster in continuous ambulatory peritoneal dialysis (CAPD) patients compared to HD patients. No diﬀerences in surgical com- plications or infections were observed between CAPD and HD patients [22]. One study reported high graft thrombosis with PD and high acute rejection episodes in HD patients but overall graft survival was similar [23]. While another study reported that the choice of pretransplant dialysis modality did not inﬂuence waiting time for transplant or the results of transplantation [24]. A study from the United States suggested that the use of PD immediately before transplantation predicts a 3% lower risk for graft failure (P < .05) and 6% lower risk for recipient death (P < .001). Better recipient and graft survival was noted when patient received at least 50% of their pretransplant RRT time as PD [25]. 8. Economic Issues Per Center for Medicare and Medicaid, the cost diﬀerence between HD and PD was $13,900 in 2001. Though the costs of both modalities have increased over years, the diﬀerence in cost has also increased to $20,000 in 2009 [1]. Per person, per year cost for HD was $73,008 versus $53,446 for PD [1]. Until recently in the US, there was a ﬁxed “composite rate” for dialysis-related services and in addition providers were also reimbursed for “injectable” medications (such as erythrocyte stimulating agents, intravenous iron, and vitamin D analogues) on an “as used” basis. On an average, 3 PD patient uses less intravenous medications than in-center HD patient which contributes to higher cost of HD. Shih et al. evaluated the impact of initial dialysis modality choice and subsequent modality switches on Medicare expenditure in a 3-year period involving 3423 patients with new initiation of dialysis. After adjusting for patient charac- teristics, the annual Medicare expenditure was signiﬁcantly lower for patients with peritoneal dialysis as the initial modality (56,807 dollars versus 68,253 dollars) (P < .001). “Peritoneal dialysis, with at least one switch” and “hemodial- ysis, with at least one switch” had a lower or similar annual expenditure of $66,639 and $72,335, respectively [26]. In a recent cost comparison study of 463 dialysis patient with 12% of PD patients, the rate of hospitalization was less in PD patients compared to HD patients in the year following initiation of dialysis and had signiﬁcantly lower health care cost over 12 month period. ($173,507 versus $129,997, P = .03) [27]. 9. Achieving Solute Clearance As with HD, the clearance of small solutes has been thought to be an important predictor of survival in PD patients. The Canada-USA (CANUSA) study examined the relationship between dialysis adequacy and mortality, hospitalization, and technique failure in PD patients. According to this study results, a decrease of 5 L/1.75 m2 in creatinine clearance per week was associated with a 7% increase in relative risk of death. Also, a decrease of 0.1 units Kt/V per week was asso- ciated with a 5% increase in the relative risk of death. Based on these results, NKF-DOQI guidelines suggested a weekly Kt/V of 2.0 and weekly creatinine clearance of 60 L/1.73 m2 for PD patients. These Kt/V and creatinine clearance were diﬃcult to achieve in large and anuric patients. However, the CANUSA study assumed that renal and peritoneal clearances were similar and additive [28]. The ADEMEX study showed that increasing peritoneal small solute clearance achievable in clinical practice did not improve survival in PD patients [29]. In a study from Hong Kong, Lo et al. showed that there was no diﬀerence in outcome for patients with Kt/Vurea maintained above 2.0 versus Kt/Vurea between 1.7 and 2.0 [30]. Reanalysis of CANUSA data showed no association between peritoneal clearance and the relative risk of death. Based on these results, the 2006 NKF-DOQI guidelines suggested a minimum weekly Kt/Vurea target of 1.7 for PD. These lower adequacy targets are easier to achieve in practice and have not translated in inferior outcomes. 10. Adequate Ultraﬁltration and Volume Control Inability to achieve adequate ultraﬁltration and failure to maintain volume homeostasis is another cause of technique failure in PD patients. Prevalence of ultraﬁltration failure is reported to be between 1.7% and 13.7% [31]. Failure to follow ﬂuid and dietary sodium restrictions necessi- tates use of more hypertonic solution to achieve adequate ultraﬁltration. Use of hypertonic glucose solution can lead