4 to hyperglycemia, weight gain, and hyperlipidemia. Fur- thermore, chronic exposure to hypertonic solutions which degrade into AGEs may alter peritoneal membrane trans- port characteristics, converting a low transporter into high transporter [32]. In two diﬀerent PD cohorts—one from Netherlands and one from Japan—failure of ultraﬁltration was the biggest reason for withdrawal from CAPD [33, 34]. However, in these both cohorts the major modality was CAPD and Icodextrin was not used. Icodextrin is a glucose polymer that may be used as an osmotic alternative to dextrose in PD solutions. In a Japanese cohort of greater than 7000 patients, Kuriyama et al, showed that the dropout rate in patients who used Icodextrin (8.9%), was signiﬁcantly lower than those using dextrose (14.5%), (P < .0001) [35]. Newer biocompatible solutions without dextrose, and having a more physiologic pH have been associated with better preservation of peritoneal membrane; however, most human studies done with biocompatible solutions had short followup duration and clear evidence of beneﬁt is lacking [36, 37]. Mechanical complications like catheter malposition or malfunction are also known to cause failure of ultraﬁltration. Many causes of catheter malfunction such as occlusion by bladder or bowels can be corrected with use of laxatives or emptying the bladder. Obstruction due to clots can be dislodged with injecting heparinized saline; and if unsuccessful, by instillation of TPA or urokinase in the catheter. Common mechanical problems of omental trapping, adhesion formation, and so forth can be corrected through laparoscopic means by performing omentopexy, adhesiolysis, resection of epiploic appendices, colopexy, and so forth [38]. 11. Education Is Important Adequate understanding and education of patient and nephrologists are key to improve utilization rates of PD. In dialysis centers with limited knowledge and experience in performing PD, the recommendation “PD ﬁrst” can lead to poor outcomes. Along with the education of physicians and medical staﬀ, patients with chronic kidney disease approaching ESRD should be educated about kidney failure and renal replacement therapies. The National Pre-ESRD Education Initiative involved 15,000 patients from 932 refer- ring nephrologists between 1997 and 2001. Upon completion of the program 55% chose hemodialysis, while 45% chose peritoneal dialysis, suggesting important inﬂuence of pre- dialysis education on selection of modality of treatment [39]. Low prevalence of PD leads to inadequate exposure of in-training fellows to this modality. This in turn leads to vicious cycle in which uncomfortable nephrologists not oﬀering PD to their patient and further reducing its use. To oﬀset these concerns, the training programs must provide fellows adequate exposure to PD. Programs with limited access should oﬀer fellows elective rotation in centers with larger PD population and have a core curriculum for PD including text and visual aids. In conclusion, there is suﬃcient evidence to support the initiative of PD ﬁrst and with improving PD techniques, greater use of biocompatible solutions, improved patient and International Journal of Nephrology physician education, and the bundling of dialysis services, providers will be more receptive towards the PD ﬁrst initiative. References [1] “USRDS data system: USRDS annual data report,” Bethesda MD, 2009. [2] P. G. Blake and F. O. Finkelstein, “Why is the proportion of patients doing peritoneal dialysis declining in North America?” Peritoneal Dialysis International, vol. 21, no. 2, pp. 107–114, 2001. [3] R. Mehrotra, D. Kermah, L. 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