2 sites, lower cost of therapy, convenience of home therapy, a ﬂexible schedule, and increased freedom from the patient’s perspective are other reasons to oﬀer PD as the ﬁrst choice modality. 3. Survival Advantage Comparisons of mortality outcomes in HD and PD patients in studies have yielded conﬂicting results. Vonesh et al. analyzed the Medicare data of 398,340 patients initiating dialysis between 1995 and 2000. They showed survival diﬀerences between HD and PD varied substantially accord- ing to the underlying cause of ESRD, age, and level of baseline co morbidity. The adjusted mortality rates were either the same or higher for HD as compared to PD in most patient groups except in older diabetic patients [4]. Heaf and colleagues reported survival beneﬁt for PD during the ﬁrst two years of dialysis treatment from the Danish Terminal Uremia registry data [5]. Similar survival beneﬁts were reported from Canadian cohort of dialysis patients initiating dialysis between 1990–1994 [6]. However, among CHOICE cohort, Jaar et al. reported no diﬀerence in the mortality risk during ﬁrst year but signiﬁcantly higher mortality risk for patients undergoing PD relative to HD during second year [7]. The CHOICE study has been criticized for collection of data after dialysis initiation, recruitment bias and data analysis. Mehrotra et al. examined the US Renal Data System (USRDS) for secular trends in survival among patients treated with HD and PD on day 90 of ESRD (HD 620, 020 patients; PD 64 406 patients) in three 3-year cohorts (1996–1998, 1999–2001, and 2002–2004) for up to 5 years of follow up. Authors reported higher risk of death seen with PD in earlier cohorts which improved with time and there was no signiﬁcant diﬀerence in the risk of death for PD and HD patients for the 2002–2004 cohorts during 5-year followup. Subgroups analysis based on age, diabetes status, and baseline comorbidity showed greater improvement in survival among patients treated with PD relative to HD at all follow-up periods [8]. In a separate study of 66,381 PD patients, comparing 1996–1998 cohorts to 2002–2004 cohorts, the risk of death and switch to HD were 45% and 38% lower, respectively, in the later cohort [9]. Researchers compared mortality rates between patients treated with PD and HD (including home HD) using data from 27,015 patients in the Australia and New Zealand Dialysis and Transplant Registry. Overall mortality rates were signiﬁcantly lower during the 90- to 365-d period among those being treated with PD at day 90 (adjusted hazard ratio [HR] 0.89; P .001) [10]. Five-year survival on dialysis has improved signiﬁcantly in last one decade. However, survival probabilities were improved more for patients on PD compared to HD. For incident patients on hemodialysis or peritoneal dialysis, survival probabilities in 1998–2002 were 7.2 and 14.8 percent higher, respectively, than in 1993– 1997 [1]. The improvement in survival for diabetics was 12.9 and 21.8 percent for HD and PD, respectively. Similarly for patients with hypertension, the improvement was 4.0 and 13.2 percent for HD and PD, respectively [1]. In contrast to a common belief that survival on PD is inferior as compared International Journal of Nephrology to HD, the converse is actually the case for most patient groups, particularly in the ﬁrst few years of dialysis. Although the rates of native AVF are lower in PD patients, it has not translated into inferior survivals and it would be prudent to protect the veins of a PD patient specially those who are not a transplant candidate [11]. 4. Preservation of Residual Renal Function Residual renal function (RRF) is clinically important as it contributes to adequacy of dialysis, quality of life, and mortality in dialysis patients. Rate of decline in RRF is a more powerful prognostic factor than baseline RRF associated with all-cause mortality in PD patients [12]. Loss of RRF reduces small and middle molecular weight toxin clearance, decreased erythropoietin synthesis and increase sodium, phosphorus, and water retention [13]. These can lead to anemia, malnutrition, congestive heart failure, cardiac hype- rtrophy, atherosclerosis, vascular, and valvular calciﬁcation; and overall increase in cardiovascular morbidity and mor- tality [13]. In a study Moist et al. showed that PD had 65% lower risk of loss of RRF compared to HD during ﬁrst year of RRT in incident ESRD patients [14]. Maintenance of RRF has shown direct correlation with patient survival. In a prospective observational study involving 231 chronic PD patients, Wang and colleagues reported 50% reduction in all- cause mortality and cardiovascular death for every 1 ml/min increase in residual GFR [15]. It is imperative to periodically measure both the delivered dose of PD and RRF and make necessary adjustments to the dialysis prescription as RRF is lost. Eﬀorts to maintain RRF with use of biocompatible PD solutions and treatment with ACE inhibitors should be considered [16]. 5. Lower Infection and Hospitalization Rates After cardiovascular disease, infection is the most common cause of death in dialysis patients accounting for 33 deaths per 1000 patient years in the USRDS cohort of 2001– 2003 [1]. In a single-center observational cohort of dialysis patients (n = 181; HD 119 and PD 62) from 1999 to 2005, as expected only HD patients had bacteremia (0.16/year) and PD patients had peritonitis (0.24/year), the investigators however did not ﬁnd any diﬀerence (P = .24) in the rates of overall infection between HD and PD patients [17]. According to USRDS data from 2007, the rates of admission for bacteremia/septicemia were 1.5–2.3 times higher in HD patients reaching 102 per 1000 patient years compared to 66.7 per 1000 patient years in PD patients [1]. Comparing HD to PD as initial RRT modality, HD patients are at twice as higher risk of hospitalization from septicemia than PD patients. In another longitudinal cohort of incident dialysis patients with seven years of followup, the adjusted risk of death from septicemia was almost double in HD patients compared to PD patients (9.79 versus 4.81, P < .01) [18]. Since the introduction of twin bags and Y set system and use of “ﬂush before ﬁll” technique, the rates of PD peritonitis have gone down signiﬁcantly over the last few years. Use of Gentamicin cream application at exit site reduces the