The title for this article is a bit odd. No, this is not a current events thriller. The 2010 National Kidney Foundation Spring Clinical Meetings include a two-hour workshop entitled, "Debate on Peritoneal Dialysis (PD) versus Hemodialysis (HD)." All three speakers-Zip Krishnasami from the University of Alabama, Birmingham; John Burkart from Wake Forest University, and I-are staunch advocates of the right renal replacement therapy (RRT) at the right time.

None of us would argue against transplantation as the RRT of choice for most patients. But the availability of transplantation is limited by the scarcity of donor organs. So for RRT when transplantation is not imminent, there may well be a "debate."

American nephrologists have already gone on record to state that about one third of dialysis patients should be utilizing PD (Mendelsohn et al., Am J. Kid Dis 37:22, 2001) while current counts indicate only one-fourth of that potential patient group actually perform PD (USRDS Annual Data Report, 2009, Figure 4.2 Vol. 2). Compare that to countries like Mexico and New Zealand where there is much more prevalence of PD (USRDS Annual Data Report, 2007, Table 12.d).

Dr. Burkhart is to discuss ethics, and I'm curious as to whose ethics will get the attention: the PCPs, nephrologists, transplant surgeons, large dialysis organization chief executives, insurance company executives-or perhaps the family members of the patients.

What is really behind the debate over modality choice in the United States? What is missing in the "debate" theme is the concept of making it part of a life plan.  A life plan is a road map to achieve quality years of life. It does not preclude emphasizing length over quality, but most patients will argue for quality as the dominating factor if the concepts are explained in a manner that they understand. A life plan may actually move away from focusing on RRT options, and towards a more integrated approach of utilizing all options at some point with harmonious transitions from one modality to another. This is called integrative care. Nephrologists with experience only in performing in-center HD can not practice it without further training in the other modalities, or joining practices with subspecialty associates who can.

Offering the modality of choice
No one should question that a transplant is really the first choice in a life plan. In my practice at Vanderbilt, I aggressively pursue pre-emptive transplants as often as feasible. Nonetheless, 50% of my incident dialysis patients start on home dialysis and 35% of my prevalent patients are on home dialysis.

The probability of a patient with chronic kidney disease seeing a nephrologist within a year of a diagnosis is less than 50% (USRDS Annual Data Report, 2009, Figure 4.4.i). So it is easy to argue that patients are referred too late for lengthy discussions on a life plan and treatment options.

However, I am not confident that we do as much as we can. Effective communication is given a low priority. Furthermore, we dislike discussing uncomfortable topics such as end-of-life care and conservative management of progressive chronic kidney disease. Sometimes, we feel threatened by well-informed patients and sometimes we simply lack communications skills. Likewise, I think that sometimes we resent the time this all takes. We deny these situations and prefer to blame the managed care system or late referrals.

Be a detective
To create the life plan, you need to do some fact finding. I enjoy performing the family and social history of the initial work-up. I probe. I am looking for levers as to what will motivate patients, because difficult decisions are going to come up soon. I am not uncomfortable telling patients what I would do, about my parents and their illnesses and how life can be extended or shortened by the choices we make. I ask them about their living situation, their short and long-term goals, and how long and well they plan to live. This is a critical issue because it defines the commitment that they will make. I point out that my commitment will parallel theirs. I have no obligation for making more of a commitment than they make. That is a wake-up call for some patients. After this wake-up call, we can effectively discuss their priority perspectives, which may include simply feeling better, getting to some upcoming event such as a wedding or graduation, to have a quality of life defined by the patient and their family, or even to simply live as long as possible. Getting patients to verbalize their goals and priorities is important for them. But it is also crucial for me so that I can advise them as to how to achieve these goals. Here is an example:

• A polycystic father of two is in pain and has no room for his impending transplant. His discomfort is so severe that in stage 4 CKD, a bilateral nephrectomy is mandatory. He will perform in-center HD for six weeks with a central line catheter and then receive his live donor transplant. Again, he will perform in-center HD with a catheter. Is this a failure or ideal management? His immediate goal was to get transplanted. I agreed. That's the goal and we planned for the catheter and his dialysis in-center. The point here is that a life plan was made by all the parties involved and it may not conform to certain "guidelines" that advise against starting dialysis with a catheter.

Making a decision
This patient is a married, working father of two. So for him the first decision was easy. The first decision is conservative care for progressive kidney disease (no RRT) with ultimate death related to terminal kidney failure versus RRT.

Once that decision is made, the second decision is what form of RRT to begin with (i.e. modality options). The phrase "to begin with" is key, because in a patient's lifetime, almost all RRT modalities will be utilized. As stated above, this can be done harmoniously if there is a life plan. The modality options in the second decision are transplantation (and then options within that modality) versus dialysis (and the options within that modality).

The third decision then is a review of modalities. For transplantation that could be living donor pre-emptive transplant, living donor after temporary dialysis, or deceased donor preemptive (large degree of uncertainty here for timing), or deceased donor after dialysis initiated. For choosing dialysis in the second decision, the third decision is home versus in-center dialysis. Many clinicians apply HD versus PD as the third decision. That is why so few patients dialyze at home. If the clinicians took the position that the third decision is home dialysis versus in-center dialysis, then more patients would be aware of home dialysis as a decision. If patients choose home dialysis, then the fourth decision is HD versus PD. By the failure to emphasize the third decision and jumping straight to the fourth decision, a critical philosophy is nullified. Because too many in our community think the only decision is PD versus HD, I have titled this article "The fourth decision" because that is where the concept of PD versus HD belongs.

Other options
I have no experience with nocturnal HD and this may soon be more broadly available. There are nocturnal programs at home and in-center and I accept that a decision to perform nocturnal, in-center HD may alter my decision numbering. This is important because the fifth decision in my tree is what type of home HD or home PD is practiced. Within home HD, we offer traditional thrice weekly HD with very high dialysate flow rates and ultrafiltration rates and short daily home HD. For home PD, we offer cycler, manual PD, or combinations. So this becomes the fifth decision.

To take patients through this decision tree requires patience and an interest in working with motivated patients, and then helping with the education to allow their decisions to be adequately informed.

There are many decisions, but the life plan will help keep them in the right order.


Dr. Golper is a nephrologist at Vanderbilt University Medical Center in Nashville, Tenn.