62-Year-Old Man With Abdominal Pain and Cloudy Peritoneal Dialysate.

A 62-year-old man presented to the emergency department for evaluation for abdominal pain. He has a history of end-stage renal disease (ESRD) secondary to lithium toxicity, now on peritoneal dialysis (PD) for 2 years. His past medical history was also notable for hypertension, obstructive sleep apnea (OSA) adherent to continuous positive airway pressure (CPAP) ventilation, heart failure with reduced ejection fraction caused by idiopathic dilated cardiomyopathy, bipolar disorder, and ongoing tobacco use. Home medications were amlodipine 10 mg daily, aspirin 81 mg daily, cinacalcet 30 mg twice daily, metoprolol succinate 200 mg daily, sevelamer 3200 mg 3 times daily, and torsemide 100 mg twice daily. That morning, the patient felt progressively worsening nausea, with several episodes of postprandial nonbloody and nonbilious emesis. He endorsed diffuse "nagging" abdominal pain and mild confusion but no fever or chills. He denied dysuria, migratory pain, hematemesis, or melena. He reported a 30-pack-a-year smoking history but no consumption of alcoholic beverages. He had no allergies. On arrival to the floor, blood pressure was 102/73 mm Hg, pulse 112, respiratory rate 16, temperature 37 °C, oxygen saturation (SpO2) of 94%. On examination, the patient was alert and oriented. Results of a heart and lung examination were unremarkable. He had diffuse abdominal tenderness with guarding and rebound. There was no abdominal distention, bowel sound abnormalities, fluid wave, or jaundice. Assessment of Murphy's sign and McBurney's point were negative. Laboratory evaluation (reference ranges provided parenthetically) revealed hemoglobin of 11.4 g/dL (13.5 g/dL-17.5 g/dL), white blood cell count 6.5×109/L (3.5-10.5×109/L), sodium 131 mmol/L (135 mmol/L-145 mmol/L), potassium 3.8 mmol/L (3.6 mmol/L-5.2 mmol/L), anion gap 16 mmol/L (7 mmol/L-15 mmol/L), bicarbonate 26 mmol/L (22 mmol/L-29 mmol/L), creatinine 10.6 mg/dL (0.8 mg/dL-1.3 mg/dL, patient’s baseline 10 mg/dL-12 mg/dL), blood urea nitrogen 43 mg/dL (8 mg/dL-24 mg/dL), alanine aminotransferase 24 U/L (7 U/L-55 U/L), aspartate aminotransferase 20 U/L (8 U/L-48 U/L), alkaline phosphatase 70 U/L (45 U/L-115 U/L), phosphorus 7.2 mg/dL (2.5 mg/L-4.5 mg/dL), albumin 2.8 g/dL (3.5 g/dL-5.0 g/dL), and lactate 0.9 mmol/L (0.9 mmol/L-1.7 mmol/L). In the emergency department, computed tomography (CT) of the abdomen and pelvis with and without intravenous contrast material was performed, revealing abdominal omental and mesenteric fat edema and inflammation with perceptible smooth peritoneal enhancement. Peritoneal dialysis catheter fluid was subsequently collected.1.Which one of the following laboratory findings most strongly supports the suspected diagnosis in this patient?a)Serum-ascites albumin gradient of 0.8b)Peripheral blood white blood cell count of 18,000 109/Lc)Serum aspartate aminotransferase of 250 U/Ld)Peritoneal fluid total white blood cell count of 125/uLe)60% lymphocytes in peritoneal fluid white count The most likely diagnosis for our patient is peritoneal dialysis-related peritonitis (PDrP). The serum-ascites albumin gradient has no role in diagnosis of PDrP.1Li P.K. Szeto C.C. Piraino B. et al.ISPD peritonitis recommendations: 2016 update on prevention and treatment.Perit Dial Int. 2016; 36: 481-508Crossref PubMed Scopus (666) Google Scholar Serum white blood cell count can be normal in PDrP, such as in our patient’s case, and cannot be relied upon. Rather, elevated white blood cell count warrants investigation of possible secondary cause of peritonitis. Similarly, hepatic function tests can be normal in the setting of PDrP. An ascitic fluid total white blood cell count of 125/uL supports the diagnosis of PDrP. Peritoneal fluid lymphocyte count has no role in diagnosis of PDrP; rather, it would be helpful for diagnosis of tuberculosis or carcinomatosis. PDrP is diagnosed by the presence of any 2 of the following: consistent clinical features such as abdominal pain or cloudy dialysis effluent, peritoneal fluid total white blood cell (WBC) count greater than 100 cells/mm3 with greater than 50% of them neutrophils, or positive dialysis effluent culture.1Li P.K. Szeto C.C. Piraino B. et al.ISPD peritonitis recommendations: 2016 update on prevention and treatment.Perit Dial Int. 2016; 36: 481-508Crossref PubMed Scopus (666) Google Scholar This criterion contrasts with the diagnosis of spontaneous bacterial peritonitis, which requires polymorphonuclear cell count greater than 250 cells/mm3. Importantly, for patients undergoing PD who have cloudy dialysis fluid and greater than 50% polymorphonuclear cells in peritoneal fluid, empiric treatment is indicated regardless of the total cell count. The patient's ascitic fluid appeared cloudy and peritoneal fluid studies drawn from his peritoneal dialysis catheter revealed 25,516 nucleated cells per μL with 88% neutrophils, 2% lymphocytes, and 10% monocytes. Fluid was cultured and gram-positive cocci were noted on the gram stain of the effluent. He was started empirically on intraperitoneal vancomycin and cefepime consistent with local guidelines. Cultures revealed Staphylococcus epidermidis as the cause of peritonitis, and antibiotics were de-escalated to intraperitoneal vancomycin monotherapy. By the following day, our patient endorsed that his abdominal pain was significantly improved.2.What is the best next step in management of this patient?a)Start fluconazoleb)Obtain a transthoracic echocardiogramc)Addition of gentamicind)Obtain daily blood culturese)Start rifampin Exposure to antibiotics in patients on PD increases risk for fungal peritonitis. It is hypothesized that antibiotic exposure shifts flora toward yeast species or that patients requiring antibiotics have a baseline-elevated risk of fungal infection. Thus, antifungal prophylaxis is recommended by professional societies, including the International Society of Peritoneal Dialysis (ISPD) guidelines, for any antibiotic duration greater than a single dose with either nystatin or fluconazole.1Li P.K. Szeto C.C. Piraino B. et al.ISPD peritonitis recommendations: 2016 update on prevention and treatment.Perit Dial Int. 2016; 36: 481-508Crossref PubMed Scopus (666) Google Scholar It is typically prescribed for the duration of antibiotic therapy, with particular attention paid to altered pharmacokinetics in patients on PD. Although infection with catheter-associated blood stream infections caused by S. aureus in patients on hemodialysis requires catheter removal and testing for endocarditis, this is not the case for our patient on peritoneal dialysis with S. epidermidis.1Li P.K. Szeto C.C. Piraino B. et al.ISPD peritonitis recommendations: 2016 update on prevention and treatment.Perit Dial Int. 2016; 36: 481-508Crossref PubMed Scopus (666) Google Scholar Although an aminoglycoside can be given as empiric therapy for gram-negative coverage of PDrP, our patient is clinically improving on vancomycin, so the addition of gentamicin is not necessary.1Li P.K. Szeto C.C. Piraino B. et al.ISPD peritonitis recommendations: 2016 update on prevention and treatment.Perit Dial Int. 2016; 36: 481-508Crossref PubMed Scopus (666) Google Scholar Clinical course should not be monitored with blood cultures but through daily assessments of clinical improvement and visual appearance of PD effluent.1Li P.K. Szeto C.C. Piraino B. et al.ISPD peritonitis recommendations: 2016 update on prevention and treatment.Perit Dial Int. 2016; 36: 481-508Crossref PubMed Scopus (666) Google Scholar By 48 hours, most patients with PDrP should significantly improve.1Li P.K. Szeto C.C. Piraino B. et al.ISPD peritonitis recommendations: 2016 update on prevention and treatment.Perit Dial Int. 2016; 36: 481-508Crossref PubMed Scopus (666) Google Scholar If at 48 hours the clinical picture or effluent appearance does not improve, then peritoneal fluid studies and cultures should be repeated.1Li P.K. Szeto C.C. Piraino B. et al.ISPD peritonitis recommendations: 2016 update on prevention and treatment.Perit Dial Int. 2016; 36: 481-508Crossref PubMed Scopus (666) Google Scholar Rifampin may benefit patients with S. aureus peritonitis who show no improvement by 48 hours.1Li P.K. Szeto C.C. Piraino B. et al.ISPD peritonitis recommendations: 2016 update on prevention and treatment.Perit Dial Int. 2016; 36: 481-508Crossref PubMed Scopus (666) Google Scholar However, rifampin has no role in PDrP caused by S. epidermidis. The patient was started on fluconazole 200 mg every other day while intraperitoneal antibiotics continued. He was discharged the day after admission on intraperitoneal vancomycin for 14 days with close outpatient follow-up. Guidelines recommend repeating dialysis effluent cell count and culture to assess response to therapy in all patients at 3 to 5 days into therapy.1Li P.K. Szeto C.C. Piraino B. et al.ISPD peritonitis recommendations: 2016 update on prevention and treatment.Perit Dial Int. 2016; 36: 481-508Crossref PubMed Scopus (666) Google Scholar Unfortunately, our patient was only able to follow up with the outpatient dialysis team 2 weeks after his antibiotic course was completed because of work obligations. Despite reporting the absence of symptoms, peritoneal fluid remained cloudy and displayed persistent elevation of total nucleated cells at 129 per μL. Peritoneal fluid cultures were collected.3.At this time, 2 weeks after completion of his antibiotic course, which of the following peritoneal fluid culture findings would permit retreatment of our patient without removal of the PD catheter?a)C. albicansb)S. epidermidisc)No growth in this set, but S. epidermidis 2 weeks laterd)E. colie)M. tuberculosis In certain circumstances, such as infection by certain organisms or specific types of reinfections, the PD catheter must be temporarily removed to eradicate infection. Not doing so may damage the peritoneal membrane, reducing its ability to perform PD. Fungal peritonitis necessitates immediate catheter removal because of increased mortality and infection recurrence; it can lead to death in up to 25% of episodes.1Li P.K. Szeto C.C. Piraino B. et al.ISPD peritonitis recommendations: 2016 update on prevention and treatment.Perit Dial Int. 2016; 36: 481-508Crossref PubMed Scopus (666) Google Scholar Persistent peritoneal cultures positive for S. epidermidis despite completion of antibiotic therapy meets the diagnosis for refractory peritonitis, defined by failure of peritoneal fluid clearance despite at least 5 days of antibiotic therapy. This would necessitate catheter removal.1Li P.K. Szeto C.C. Piraino B. et al.ISPD peritonitis recommendations: 2016 update on prevention and treatment.Perit Dial Int. 2016; 36: 481-508Crossref PubMed Scopus (666) Google Scholar In contrast, if our patient were to clear his initial infection, but within a month were to develop another episode of PDrP with the same organism, he would meet criteria for relapsing peritonitis. Relapsing peritonitis is also an indication for catheter removal. If our patient were to have an episode of E. coli PDrP within a month of resolution of his S. epidermidis PDrP, he would have recurrent peritonitis, which is infection by a different organism within a month of therapy completion. Recurrent peritonitis is not an indication for catheter removal nor is PDrP that is caused by E. coli, a common causative organism in PDrP, typically from touch contamination.1Li P.K. Szeto C.C. Piraino B. et al.ISPD peritonitis recommendations: 2016 update on prevention and treatment.Perit Dial Int. 2016; 36: 481-508Crossref PubMed Scopus (666) Google Scholar As with fungal peritonitis, mycobacterial peritonitis warrants catheter removal given high rates of antibiotic therapy failure without catheter removal.1Li P.K. Szeto C.C. Piraino B. et al.ISPD peritonitis recommendations: 2016 update on prevention and treatment.Perit Dial Int. 2016; 36: 481-508Crossref PubMed Scopus (666) Google Scholar Our patient’s peritoneal cultures ultimately grew gram-positive cocci resembling S. epidermidis after 2 days, meeting criteria for refractory peritonitis, so he was started on another 21-day course of intraperitoneal vancomycin and fluconazole. His PD catheter was removed, and he was started on hemodialysis (HD) while he completed this second course.4.When our patient was originally deciding on dialysis modality, which of the following factors would favor PD over HD?a)Unsafe home environmentb)Inflammatory bowel disease with an ostomyc)Large abdominal herniad)Upcoming renal transplante)Peritoneal scarring or adhesions As with many other therapies administered at home, a safe and supportive home environment is a critical factor for success for patients on PD. There are concerns that ostomy maintenance may increase exit-site infection risk and that inflammatory bowel disease may increase risk of peritonitis from migration of enteric bacteria across inflamed bowel.2Saxena R. Peritoneal dialysis: misperceptions and reality.Am J Med Sci. 2014; 348: 250-261Abstract Full Text Full Text PDF PubMed Google Scholar Although an abdominal hernia is not an absolute contraindication, it could sequester dialysate, leading to unpredictable dialysis sessions, and PD may increase risk of hernia expansion.3Balda S. Power A. Papalois V. Brown E. Impact of hernias on peritoneal dialysis technique survival and residual renal function.Perit Dial Int. 2013; 33: 629-634Crossref PubMed Scopus (40) Google Scholar Several studies have found PD superior to HD as pretransplantation therapy, with reduced mortality and risk of graft failure.4Jain D. Haddad D.B. Goel N. Choice of dialysis modality prior to kidney transplantation: does it matter?.World J Nephrol. 2019; 8: 1-10Crossref Google Scholar,5Shahab I. Khanna R. Nolph K.D. Peritoneal dialysis or hemodialysis? A dilemma for the nephrologist.Adv Perit Dial. 2006; 22: 180-185PubMed Google Scholar Peritoneal scarring or adhesions affecting the peritoneal membrane would reduce the surface area available for dialysis. At his follow-up appointment with nephrology, our patient discussed the risks and benefits of staying on HD vs attempting PD again. Ultimately, our patient decided to remain on HD.5.Which one of the following would best characterize the long-term impact for our patient by transitioning to HD?a)HD has decreased rates of infection compared with PDb)HD has worse survival outcomes compared with PD at 10 yearsc)HD provides comparable quality of life compared with PDd)HD is associated with a lower rate of loss of employmente)HD tends to be more costly than PD Multiple studies have found comparable rates of infection when comparing HD and PD.6Aslam N. Bernardini J. Fried L. Burr R. Piraino B. Comparison of infectious complications between incident hemodialysis and peritoneal dialysis patients.Clin J Am Soc Nephrol. 2006; 1: 1226-1233Crossref PubMed Scopus (112) Google Scholar PD has improved short-term survival outcomes compared with HD, although this decreases to a comparable level after 1 or 2 years.7Sinnakirouchenan R. Holley J.L. Peritoneal dialysis versus hemodialysis: risks, benefits, and access issues.Adv Chronic Kidney Dis. 2011; 18: 428-432Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar Overall, studies have found that patients on PD tend to be more satisfied than those on HD.2Saxena R. Peritoneal dialysis: misperceptions and reality.Am J Med Sci. 2014; 348: 250-261Abstract Full Text Full Text PDF PubMed Google Scholar Several studies have found that when compared with PD, HD is associated with an up to 5 times greater risk of loss of employment.8Nakayama M. Ishida M. Ogihara M. et al.Social functioning and socioeconomic changes after introduction of regular dialysis treatment and impact of dialysis modality: a multi-centre survey of Japanese patients.Nephrology (Carlton). 2015; 20: 523-530Crossref PubMed Scopus (17) Google Scholar In most developed countries, the annual cost per patient on HD is 1.25 to 2.35 times more expensive than PD because of higher staffing costs and overhead costs. Medicare data reveal per-year patient costs of $73,008 and $53,446 for HD and PD, respectively.7Sinnakirouchenan R. Holley J.L. Peritoneal dialysis versus hemodialysis: risks, benefits, and access issues.Adv Chronic Kidney Dis. 2011; 18: 428-432Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar At follow-up, our patient noted that HD had a more significant impact than PD on his day-to-day activities, such as needing to end several sessions earlier for work obligations. He also had occasional nausea and hypotension with HD, a complication he had not had with PD. Peritonitis is a severe complication for patients undergoing peritoneal dialysis. Approximately 18% of the infection-related mortality for these patients can be attributed to peritonitis, and it remains the primary cause of transfer to HD.7Sinnakirouchenan R. Holley J.L. Peritoneal dialysis versus hemodialysis: risks, benefits, and access issues.Adv Chronic Kidney Dis. 2011; 18: 428-432Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar Fortunately, with improvements in technique, training, and prophylaxis, successful PD programs have peritonitis rates as low as 1 episode every 20 to 37 months.7Sinnakirouchenan R. Holley J.L. Peritoneal dialysis versus hemodialysis: risks, benefits, and access issues.Adv Chronic Kidney Dis. 2011; 18: 428-432Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar A strong candidate for PD should have minimal abdominal surgery to reduce the risk of adhesions that decrease surface area available for dialysis. Having more residual kidney function and smaller total body volume reduce dialysis volume requirements, making PD dialysis duration more manageable. Environmental factors such as adequate space available to store PD supplies, a commonly noted inconvenience, should also be considered.8Nakayama M. Ishida M. Ogihara M. et al.Social functioning and socioeconomic changes after introduction of regular dialysis treatment and impact of dialysis modality: a multi-centre survey of Japanese patients.Nephrology (Carlton). 2015; 20: 523-530Crossref PubMed Scopus (17) Google Scholar Modifiable risk factors for PDrP include constipation, smoking, and obesity.9Cho Y. Johnson D.W. Peritoneal dialysis-related peritonitis: towards improving evidence, practices, and outcomes.Am J Kidney Dis. 2014; 64: 278-289Abstract Full Text Full Text PDF PubMed Google Scholar Risk for PDrP is also higher for patients with diseases that increase risk of bacterial translocation, such as recurrent diverticulitis, inflammatory bowel disease, or abdominal cancer.10Yip T. Tse K.C. Lam M.F. et al.Risks and outcomes of peritonitis after flexible colonoscopy in CAPD patients.Perit Dial Int. 2007; 27: 560-564Crossref PubMed Scopus (62) Google Scholar Similarly, invasive gastrointestinal, genitourinary, or urologic procedures, such as colonoscopy or hysteroscopy, increase the risk of PDrP. To reduce this risk, peritoneal fluid should be drained before these procedures.10Yip T. Tse K.C. Lam M.F. et al.Risks and outcomes of peritonitis after flexible colonoscopy in CAPD patients.Perit Dial Int. 2007; 27: 560-564Crossref PubMed Scopus (62) Google Scholar Obesity, although not a contraindication, does require special consideration. It typically requires an increased volume of dialysate and duration of PD. As patients with obesity are already at higher risk of concurrent metabolic disorders, dialysate can further exacerbate this risk because of its high glucose load. However, despite these considerations, obesity has not been associated with a significant difference in efficacy or survival between HD and PD, provided that the more complicated dialysate regimen needed for obese patients is well implemented.2Saxena R. Peritoneal dialysis: misperceptions and reality.Am J Med Sci. 2014; 348: 250-261Abstract Full Text Full Text PDF PubMed Google Scholar Visual impairment or blindness are not contraindications for PD. Studies have shown that visually impaired patients on PD had comparable outcomes for rates of peritonitis and life expectancy compared with those without visual impairment when resources were provided to support them.11Chandran P.K. Lane T. Flynn C.T. Patient and technique survival for blind and sighted diabetics on continuous ambulatory peritoneal dialysis: a ten-year analysis.Int J Artif Organs. 1991; 14: 262-268Crossref Scopus (7) Google Scholar PDrP should be highly considered in patients undergoing PD with abdominal pain. Cloudy effluent is also highly suggestive of PDrP. Other common symptoms include fever, nausea, and diarrhea. In cases with signs and symptoms suggestive of PDrP, PD effluent should be sent for cell count, differential, Gram stain, and culture.1Li P.K. Szeto C.C. Piraino B. et al.ISPD peritonitis recommendations: 2016 update on prevention and treatment.Perit Dial Int. 2016; 36: 481-508Crossref PubMed Scopus (666) Google Scholar Concurrent exit-site or tunnel infection is associated with 30% of PDrP cases and increases the likelihood of catheter removal for definitive management. For this reason, purulent drainage from the exit site of the dialysis catheter should be cultured.1Li P.K. Szeto C.C. Piraino B. et al.ISPD peritonitis recommendations: 2016 update on prevention and treatment.Perit Dial Int. 2016; 36: 481-508Crossref PubMed Scopus (666) Google Scholar It is important to differentiate PDrP from secondary peritonitis in the PD patient population, which would require addressing the underlying cause. Secondary causes include cholecystitis, bowel perforation, and appendicitis. Typically, these patients have systemic manifestations of sepsis, localization of pain, and findings such as feculent material in dialysate and peritoneal fluid cultures with enteric or polymicrobial organisms.1Li P.K. Szeto C.C. Piraino B. et al.ISPD peritonitis recommendations: 2016 update on prevention and treatment.Perit Dial Int. 2016; 36: 481-508Crossref PubMed Scopus (666) Google Scholar Empiric antibiotic treatment is critical as untreated peritonitis can scar the peritoneum and reduce PD efficacy. Empiric antibiotics must cover both gram-positive and gram-negative organisms.1Li P.K. Szeto C.C. Piraino B. et al.ISPD peritonitis recommendations: 2016 update on prevention and treatment.Perit Dial Int. 2016; 36: 481-508Crossref PubMed Scopus (666) Google Scholar As infection is often localized to the peritoneum, intraperitoneal antibiotics are preferred to intravenous administration unless the patient appears septic. Patients with PDrP should have significant improvement within 48 hours of initiating therapy, defined by clearer PD effluent appearance, reduced cell counts in PD fluid studies, and improving clinical symptoms. If these metrics are not met, switching to continuous dosing of antibiotics can be considered, and if by 5 days improvement is still not noted, guidelines recommend catheter removal.1Li P.K. Szeto C.C. Piraino B. et al.ISPD peritonitis recommendations: 2016 update on prevention and treatment.Perit Dial Int. 2016; 36: 481-508Crossref PubMed Scopus (666) Google Scholar Overall, the mortality of PDrP ranges from 2% to 6% and depends primarily on the pathogen. Mortality rates are highest with fungal pathogens, gram-negative organisms, and S. aureus, estimated at 28%, 19%, and 15%, respectively.1Li P.K. Szeto C.C. Piraino B. et al.ISPD peritonitis recommendations: 2016 update on prevention and treatment.Perit Dial Int. 2016; 36: 481-508Crossref PubMed Scopus (666) Google Scholar Ultimately, in approximately 20% of PDrP cases, the catheter may need to be removed temporarily, with 5% to 20% of patients requiring a switch to HD.1Li P.K. Szeto C.C. Piraino B. et al.ISPD peritonitis recommendations: 2016 update on prevention and treatment.Perit Dial Int. 2016; 36: 481-508Crossref PubMed Scopus (666) Google Scholar In comparing PD and HD, the former provides several significant advantages, including greater patient satisfaction, short-term survival benefits, and lower costs.2Saxena R. Peritoneal dialysis: misperceptions and reality.Am J Med Sci. 2014; 348: 250-261Abstract Full Text Full Text PDF PubMed Google Scholar,7Sinnakirouchenan R. Holley J.L. Peritoneal dialysis versus hemodialysis: risks, benefits, and access issues.Adv Chronic Kidney Dis. 2011; 18: 428-432Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar In certain situations, such as comorbid heart failure or pulmonary hypertension, pediatric populations, and for those patients who must avoid anticoagulation or preserve vasculature, PD may be superior to HD.12Flanagin E.P. Chivate Y. Weiner D.E. Home dialysis in the United States: a roadmap for increasing peritoneal dialysis utilization.Am J Kidney Dis. 2020; 75: 413-416Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar PD has also been associated with reduced risks of graft failure in renal transplant patients, making it the preferred pretransplant dialysis modality.5Shahab I. Khanna R. Nolph K.D. Peritoneal dialysis or hemodialysis? A dilemma for the nephrologist.Adv Perit Dial. 2006; 22: 180-185PubMed Google Scholar Despite these benefits, the prevalence of PD in the United States remains low. It represents only 10% of the approximately 580,000 Americans requiring renal replacement therapy. This is far from the Centers for Medicare and Medicaid Services (CMS) proposed goal of 80% home dialysis or renal transplantation, the latter of which remains the modality of choice for patients with ESRD.12Flanagin E.P. Chivate Y. Weiner D.E. Home dialysis in the United States: a roadmap for increasing peritoneal dialysis utilization.Am J Kidney Dis. 2020; 75: 413-416Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Several factors have been identified that drive this underuse. Up to two-thirds of patients report not receiving sufficient information about PD when initially choosing a dialysis modality.12Flanagin E.P. Chivate Y. Weiner D.E. Home dialysis in the United States: a roadmap for increasing peritoneal dialysis utilization.Am J Kidney Dis. 2020; 75: 413-416Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar In general, PD tends to be more difficult to initiate than HD, and many facilities for patients with chronic conditions are unable to care for patients on PD. Transfer from PD to HD is common, and approximately one-half of the patients started on PD will require transition to HD within 2 years.5Shahab I. Khanna R. Nolph K.D. Peritoneal dialysis or hemodialysis? A dilemma for the nephrologist.Adv Perit Dial. 2006; 22: 180-185PubMed Google Scholar Causes for this transition range from clinical concerns such as peritonitis or reduced peritoneal filtration, patient or support burnout, and provider discomfort with troubleshooting PD-related concerns.12Flanagin E.P. Chivate Y. Weiner D.E. Home dialysis in the United States: a roadmap for increasing peritoneal dialysis utilization.Am J Kidney Dis. 2020; 75: 413-416Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar The authors report no competing interests.