Alloatti S, Manes M, Paternoster G, Gaiter A M, Molino A, Rosati C
Nephrology and Dialysis Unit, Ospedale Regionale, Aosta, Italy.
J Nephrol. 2000 Sep-Oct;13(5):331-42.
Whether to use peritoneal dialysis (PD) or hemodialysis (HD) is a major decision in terms of clinical outcome and management implications; the final choice is difficult because of the conflicting results of comparisons reported in the literature. A review of studies comparing survival shows either superiority of HD, or superiority of PD, or equivalence of the two techniques, but an analysis of the comparisons as a whole brings to light two clear phases in the survival curves. In the first, residual renal function (RRF) gives PD an advantage, or at least puts it on the same level as HD. In the second phase, the reduction in Kt/V as RRF declines gives PD a potential risk. After a few years of PD treatment a sharp watch is therefore necessary to detect signs of under-dialysis promptly and to shift the patient to HD. In patients without RRF it is more difficult to control hypertension with PD and they are more prone to hyperhydration. Despite a widespread belief in the Eighties that PD was the treatment modality of election for diabetics, HD is in fact preferable in these patients, except younger ones. High-turnover and low-turnover bone lesions are more frequent respectively in HD and PD patients. Anemia is better controlled with PD. Blood lipids and nutritional indices are less well controlled with PD. Despite poor technical survival, the "pool" of patients treated with PD frequently reaches 20-30% because it is indicated as first treatment in a large proportion. PD preserves renal function better than HD and is useful while awaiting renal transplantation, with faster postoperative restoration of diuresis. The quality of life with PD as home treatment is usually better than with HD. In conclusion, dialytic centers should establish an integrated PD/HD programme as the two methods are not competitive but are different tools for the treatment and rehabilitation of uremic patients.
在临床结局和管理影响方面，选择腹膜透析（PD）还是血液透析（HD）是一个重大决策；由于文献报道的比较结果相互矛盾，最终选择颇具难度。一项对比较生存率的研究综述显示，HD具有优势，或PD具有优势，或两种技术相当，但对这些比较进行整体分析会发现生存曲线存在两个明显阶段。在第一阶段，残余肾功能（RRF）使PD具有优势，或至少使其与HD处于同一水平。在第二阶段，随着RRF下降，Kt/V降低使PD存在潜在风险。因此，在进行几年的PD治疗后，必须密切观察，以便及时发现透析不充分的迹象并将患者转为HD治疗。对于没有RRF的患者，用PD控制高血压更困难，且他们更容易出现水潴留。尽管在20世纪80年代普遍认为PD是糖尿病患者的首选治疗方式，但实际上除了年轻患者外，HD对这些患者更合适。高转换型和低转换型骨病变分别在HD和PD患者中更常见。PD对贫血的控制更好。PD对血脂和营养指标的控制较差。尽管技术生存率较低，但接受PD治疗的患者“群体”常常达到20% - 30%，因为在很大比例的患者中它被作为首选治疗方法。PD比HD能更好地保留肾功能，在等待肾移植期间很有用，术后利尿恢复更快。作为家庭治疗方式，PD的生活质量通常比HD更好。总之，透析中心应建立一个综合的PD/HD项目，因为这两种方法并非相互竞争，而是治疗和康复尿毒症患者的不同手段。
