Combination therapy with hemodialysis and peritoneal dialysis

Both continuous ambulatory peritoneal dialysis (CAPD) and hemodialysis (HD) have their advantages regarding the treatment of patients with renal failure. In CAPD, solute removal is sometimes insufficient in patients who have a relatively large muscle mass that produces high levels of creatinine. To compensate for this deficiency, frequent exchanges and large peritoneal dialysate volumes are required. Alternatively, CAPD and HD as a combined modality of treatment for patients needing dialysis therapy has been proposed. Our experiences with three groups of patients are described. First, in 2003, 7 cases (6 males and 1 female; average age 54.3 ± 4.5 years; mean duration of CAPD therapy 4.3 ± 1.1 years; average weekly creatinine clearance (WCC) was 45.2 ± 1.7 l/1.73 m(2)) were treated with once-a-week HD therapy (3.5 h; 200 ml/h). Addition of once-a-week HD therapy improved WCC to 66 ± 7.1 liters/1.73 m(2). This improvement was due not only to the addition of HD therapy but also to an increase in creatinine clearance for 3 consecutive days after the completion of once-a-week HD therapy. Both creatinine clearance and ultrafiltration were significantly increased. Other clinical parameters such as blood pressure control, weight control, and dosage of erythropoietin were significantly improved after introducing this therapy. Second, we followed 9 CAPD patients who underwent an additional weekly HD for more than 3 years. Similar improvements were obtained in this long-term study as seen in the short-term study. Besides, the incidence of peritonitis decreased dramatically from 0.13 to 0.09 episodes/patient-year (p < 0.05) during the 3-year study. These data suggest that the combined use of CAPD and HD improves solute clearance in CAPD patients who are insufficiently dialyzed. Third, based on these data, we examined the efficacy of an early start of combination therapy and found that it stabilized dialysis therapy and prolonged the duration of CAPD. Combined with several of the previous several reports and our present experience, it is suggested that an early start of HD therapy will prolong the survival rate in patients on CAPD with physically stable conditions.