NTUH · Yunlin Branch
Nephrology Grand Rounds
For Nephrologists · 40 min
Benefits of PD
for the Elderly
老年人適合腹膜透析嗎？ — A Shared Decision
Agenda02 / 36
Outline
A forty-minute conversation,
in eight movements.
01IntroductionTaiwan's dialysis landscape · TWRDS 2024
02ASN Geriatric CurriculumWhat the canonical reference still tells us
03From Survival to Quality of LifeThree decades of HD vs PD comparisons
04Recent EvidenceCheng 2023 meta-analysis & companion studies
05The Case for PD in the ElderlyHemodynamics · independence · assisted PD
06Shared Decision MakingA four-step model for the dialysis choice
07My PD ExperienceNTUH Yunlin Branch · 6-year cohort
08Closing ThoughtsA teacher's lesson, a patient's verdict
Part One03 / 36
PART · 01
Introduction.
The Taiwanese landscape.
Before we ask whether the elderly should choose PD, it helps to see how few of them actually do — and to ask why.
Introduction04 / 36
TWRDS · prevalent dialysis population
Dialysis in Taiwan — an HD-dominated ecology.
| Year | HD (n) | PD (n) | PD share |
|---|
| 2019 | 73,044 | 6,971 | 8.7 % |
| 2020 | 75,332 | 6,857 | 8.3 % |
| 2021 | 77,831 | 6,886 | 8.1 % |
| 2022 | 79,994 | 6,904 | 7.9 % |
| 2023 | 81,938 | 6,942 | 7.8 % |
HD grows by ~ 9,000 patients over five years.
PD stays effectively flat.
Taiwan's PD share — already among the lowest in Asia — is trending downward as new HD prescriptions outpace new PD starts.
Taiwan Renal Registry Data System (TWRDS) · 2019 – 2023 prevalent figures.
Introduction05 / 36
TWRDS · age structure
Our dialysis population is aging quickly.
54%
of prevalent dialysis patients in Taiwan are ≥ 65 years old — and the median age continues to drift upward year on year.
≥ 75
years is the fastest-growing band; this is precisely the group most likely to be frail and most likely to benefit from a gentler modality.
< 10%
of incident patients aged ≥ 65 are started on PD — far below comparable healthcare systems in Hong Kong, France, or the UK.
TWRDS 2024 annual report; ASN Geriatric Nephrology Curriculum, Ch. 22.
Introduction06 / 36
TWRDS · PD utilisation by age band
PD utilisation falls sharply with age.
| Age band | Share on PD | Notes |
|---|
| < 40 | > 20 % | peak adoption |
| 40 – 65 | ~ 10 % | working-age plateau |
| ≥ 65 | < 10 % | under-offered |
| ≥ 75 | < 5 % | rare in practice |
HK · 80% PD
France · >50% > 70y
UK · 17%
Canada · 12%
“PD is rare and probably underused in elderly patients.”
— ASN Geriatric Nephrology Curriculum, Ch. 22.
TWRDS · USRDS · ERA-EDTA registries, latest available.
Part Two07 / 36
PART · 02
The ASN Geriatric
Nephrology Curriculum.
Wright & Danziger's Chapter 22 has been our anchor reference since 2009. Its conclusions, surprisingly, have aged well — let's walk through them.
ASN Curriculum08 / 36
International comparison
PD penetration is a policy choice, not a clinical limit.
United States
12 %
→ 4 %
USRDS: 12 % PD in patients 20–55 y; collapsing to roughly 4 % once patients pass 75. Mirrors Taiwan's curve.
Hong Kong
PD-first
~ 80 %
A policy mandate, not a clinical recommendation — yet median age on PD is 62, with elderly patients well represented.
France
> 50 % PD
in age ≥ 70
Assisted PD reimbursement made PD the dominant modality in the elderly — the cleanest natural experiment we have.
United Kingdom
17 %
National framework recommends modality choice through structured pre-dialysis education and SDM.
Canada
12 %
Steady, with home-dialysis incentives driving slow PD growth in seniors via assisted programmes.
Taiwan
< 10 %
≥ 65 y
No assisted-PD reimbursement. Most pre-dialysis education is HD-default. Patients rarely hear PD presented as equal.
Wright & Danziger, ASN Geriatric Nephrology Curriculum, Ch. 22 — Peritoneal Dialysis in Elderly Patients.
ASN Curriculum09 / 36
Considerations specific to older patients
Real concerns — and what the evidence actually says.
The legitimate worries
- Peritoneal aging — chronic inflammation, fibrosis, accelerated membrane failure.
- Higher prevalence of diverticular disease and prior abdominal surgery.
- Visual, manual, and cognitive demands of exchanges.
- In patients > 80 y, more than 60 % may require some form of assistance.
What the data has shown
- Accelerated membrane aging has not been confirmed in clinical cohorts.
- Catheter placement is safe even after prior abdominal surgery in experienced hands.
- Assistive devices (APD cyclers) and trained caregivers reliably bridge the gap.
- Overall mortality in elderly PD is broadly similar to HD.
Wright & Danziger, ASN Geriatric Nephrology Curriculum, Ch. 22.
ASN Curriculum10 / 36
Peritonitis & infection
Peritonitis risk in the elderly: conflicting evidence.
2008
Szeto et al., PDI — no difference in 12-month peritonitis-free probability (76.6 % vs 76.5 %, ≥ 65 vs < 65).
Hong Kong cohort, n ≈ 800.
2016
Duquennoy et al., PDI — peritonitis risk not increased in elderly when assisted PD is available.
French RDPLF registry — assistance neutralises the age penalty.
2020
Wu et al., PDI — elderly PD patients carry higher prevalence of peritonitis and peritonitis-related mortality.
Multi-centre Asian cohort, n > 1,200.
2022
Jiang et al., PLOS ONE — elderly PD has higher mortality vs younger PD; technique survival unchanged.
Meta-analysis of 21 cohorts.
Synthesis: assistance + training appear to be the dominant moderators — not age itself.
ASN Curriculum11 / 36
Quality of life
In the elderly, QoL is similar — and that is the whole point.
- In younger patients PD is generally associated with better HRQoL than HD — partly self-selection.
- In older patients the published data are sparse, but consistently report no QoL difference between HD and PD.
- For an older patient who places a high value on independence, on not travelling three times a week, or on night-time dialysis, PD remains the obviously appropriate first choice.
“If two paths give the same outcome,
the right path is the one the patient would choose.”
— A working principle for SDM.
Wright & Danziger, ASN Geriatric Nephrology Curriculum, Ch. 22.
ASN Curriculum12 / 36
Take-home points
Five take-home points
from the ASN curriculum.
01
Underused
PD is rare and probably underused in elderly patients — in the US, and even more so in Taiwan.
02
Mortality parity
No substantial mortality difference between PD and HD in elderly patients eligible for both.
03
QoL parity
Quality of life is not reported to differ between elderly patients on PD and HD.
04
Infection parity
Infection rates are not higher in elderly versus younger PD patients, when assistance is available.
05
Assistance helps
Assistants and commercially available cyclers make PD accessible to many more elderly patients.
Wright & Danziger, ASN Geriatric Nephrology Curriculum, Ch. 22 — Take Home Points.
Part Three13 / 36
PART · 03
From Survival
to Quality of Life.
For thirty years the field litigated a single question: which modality keeps patients alive longer? It was the wrong question — or at least, the wrong only question.
HD vs PD14 / 36
Three decades, one debate
The survival war: no winner declared.
1995
Bloembergen et al., JASN — USRDS analysis concludes HD survival is better.
Foundational, but observational; severe selection bias.
2003
Korevaar et al., KI — the only randomised trial of PD vs HD failed to recruit.
A field-defining null result. The RCT will not be done.
2005
Jaar et al., Ann Intern Med — the CHOICE study finds no difference.
Prospective US cohort, modern era.
2015
Han et al., CJASN — Korean ≥ 65 meta-analysis: HD better, but did not adjust for frailty.
The frailty omission is the single most important caveat in this literature.
FR
In France, frail elderly (≥ 75) preferentially receive assisted PD; median survival ≈ 24 months — comparable to HD.
Natural experiment: assistance closes the gap.
Lee & Bargman, "Survival by Dialysis Modality — Who Cares?" Semin Dial.
HD vs PD15 / 36
The hidden variable
Most "HD wins" studies are really measuring frailty.
In real-world cohorts, PD recipients in the elderly are often self-selected for frailty — the patient who cannot tolerate centre HD, who is bedbound, who comes from a nursing home.
When studies fail to adjust for frailty, performance status, and comorbidity load, the modality variable absorbs the frailty signal.
Restrict to patients eligible for both modalities, and the survival difference largely disappears.
“Survival of the fittest,
not survival of the modality.”
— Lee & Bargman, on how to read the literature honestly.
Wong et al., AJKD — survival similar among incident patients eligible for both modalities; effect of modality on survival does not change over time.
HD vs PD16 / 36
Morton et al., 2012 · AJKD
When asked, patients say QoL — not months.
15 – 23 mo
of life expectancy patients were willing to trade away for greater freedom to travel.
7 mo
of life expectancy patients were willing to trade for fewer hospital visits.
“If we measure success only in months,
we are not measuring what our patients came here for.”
Morton et al., AJKD 2012 — discrete-choice experiment, n ≈ 100 dialysis-eligible patients.
Part Four17 / 36
PART · 04
Recent Evidence.
The 2023 meta-analysis.
Cheng et al. assembled thirty-one studies and 770,000 patients to revisit the survival question one more time — with the modern era, diabetes, and dialysis duration as the moderators.
Recent Evidence18 / 36
Cheng et al., 2023 · Updated systematic review & meta-analysis
Mortality of PD vs HD in older adults — study design.
Studies
31
Observational cohorts, 1998 – 2017 publication window.
Patients
~ 774k
Approximately 74,000 PD and 680,000 HD, all aged ≥ 65 at incidence.
Outcome
All-cause mortality
Hazard ratios pooled with random-effects; stratified by era, DM, age, RRT duration.
Quality
Moderate
No RCT in the pool; residual confounding for frailty and dialysis access remains.
Cheng et al., "Mortality of Peritoneal Dialysis versus Hemodialysis in Older Adults: An Updated Systematic Review and Meta-Analysis." PMID 37742209.
Recent Evidence19 / 36
Cheng et al., 2023 · overall mortality
Overall, PD carries a 17 % higher mortality.
HR 1.17
95 % CI 1.10 – 1.25 · PD vs HD, all-cause mortality, age ≥ 65.
The headline number is real — but it is a population average across three decades and many health systems.
As we will see, the average dissolves once you stratify by era, comorbidity, and dialysis vintage.
For most contemporary elderly patients eligible for both modalities, the choice is not between living and dying — it is between two ways of living.
Cheng et al., 2023 · PMID 37742209.
Recent Evidence20 / 36
Cheng et al., 2023 · subgroup analysis
The average dissolves on subgroup analysis.
| Subgroup | Result | HR (PD vs HD) | Interpretation |
|---|
| RRT < 2 years | No difference | ~ 1.00 | Most elderly do not survive past 2 y. |
| RRT 4 y / 5–10 y | PD > HD mortality | 1.14 / 1.16 | Membrane failure begins to bite. |
| Non-diabetic | No difference | ~ 1.00 | PD is fully competitive. |
| Diabetic | PD > HD mortality | 1.22 | The most important stratum to scrutinise. |
| Age ≥ 75 | No difference | ~ 1.00 | The very-elderly do equally well on PD. |
| Studies before 2010 | PD > HD mortality | 1.18 | Older PD prescription practices. |
| Studies after 2010 | No difference | ~ 1.00 | Modern PD has closed the gap. |
Cheng et al., 2023 · PMID 37742209. Bold rows are the clinically actionable signals.
Recent Evidence21 / 36
Cheng et al., 2023 · what to do on Monday
What this means in clinic.
Time horizon
Match modality to expected vintage
For patients whose realistic horizon is < 2 years, PD and HD are equivalent for survival — and PD is gentler.
Diabetes
Diabetic patients need closer follow-up
DM elderly carry the largest excess risk on PD. Tight glycaemic and volume control; revisit modality at 2-year mark.
Era effects
Contemporary PD has closed the gap
Pre-2010 data should no longer dominate counselling. We have biocompatible fluids, APD, telemonitoring, assisted PD.
Cheng et al. conclude: modality choice should weigh diabetes status, comorbidity burden, expected RRT duration — and incorporate patient preference and quality of life through shared decision making.
Cheng et al., 2023 · PMID 37742209.
Part Five22 / 36
PART · 05
The case for PD
in the elderly.
If survival is parity-class, the conversation shifts to fit. Three reasons recur in every careful review — and one operational answer to the "but who will do the exchanges?" objection.
The case for PD23 / 36
Reason one
PD is a kinder haemodynamic option.
- Continuous, gentle ultrafiltration — fluid is removed minute by minute, not in a 4-hour bolus.
- No intradialytic hypotension, no post-HD stunning of brain and myocardium.
- Steady blood-pressure control; less reliance on IV inotropes and reactive volume management.
- Particularly attractive in older patients with heart failure, autonomic dysfunction, or labile blood pressure.
- Preserves residual kidney function longer — a meaningful survival and QoL signal.
“For a frail elderly heart, three weekly shocks are not therapy. They are a stressor we have learned to tolerate.”
— A working argument for PD-first in the elderly.
Established physiologic argument; supported by multiple registry analyses of intradialytic hypotension and cardiac stunning.
The case for PD24 / 36
Reason two
PD is performed at home — and at home is where older people heal.
Time
No 3× weekly transit
Eliminates the four- to six-hour day spent on transport, waiting, and recovery — the hidden cost of centre HD.
Autonomy
Schedule on patient terms
Day-time CAPD or overnight APD allows for family meals, religious schedules, grandchildren, travel — the texture of late life.
Safety
Lower infection exposure
Avoids the dialysis-unit waiting room — relevant in respiratory-virus seasons and for immunocompromised patients.
Cognition
No dialysis-day stunning
Less post-HD fatigue and cognitive fog; older patients report more usable hours per day.
Economics
Lower system cost
PD is consistently less expensive than centre HD across health systems — at parity outcomes, that matters.
Dignity
A patient, not a slot
Home dialysis preserves the social role of the older adult inside the family, rather than as a tri-weekly outpatient.
Synthesis of registry, QoL, and cost-effectiveness literature 2010 – 2024.
The case for PD25 / 36
Reason three · operational
"But who will do the exchanges?" — assisted PD.
The three operational models
- Family-assisted PD — spouse, adult child, or live-in caregiver trained by the PD nurse.
- Home-care assisted PD — visiting nurse performs CAPD exchanges or sets up overnight APD.
- APD with telemonitoring — cycler does the work overnight; clinic reads compliance and ultrafiltration remotely.
In France, where assisted PD is reimbursed, more than half of dialysis patients aged ≥ 70 are on PD — with survival equivalent to HD.
“The risk of peritonitis is not increased in elderly patients on PD — in a country where assisted PD is available.”
— Duquennoy et al., PDI 2016.
FR · Reimbursed
UK · Available
HK · Routine
TW · Not yet
The single largest unaddressed policy gap for PD in the Taiwanese elderly population.
Part Six26 / 36
PART · 06
Shared Decision
Making.
When the survival curves overlap, the decision is no longer a medical fact — it is a personal one. Our job is to make sure the patient is the one making it.
SDM27 / 36
Charles, Gafni & Whelan · Soc Sci Med, 1997
What we mean when we say shared decision making.
Criterion 01
Two participants
At minimum, both the physician and the patient are actively involved in the decision-making process.
Criterion 02
Information flows both ways
The physician shares evidence; the patient shares values, preferences, and life circumstances.
Criterion 03
Deliberation is shared
Both parties take steps to build a treatment preference — neither imposes nor abdicates.
Criterion 04
A decision is agreed
An explicit decision is reached, jointly owned by patient and physician. Documentation matters.
“SDM is the meeting of two experts — one in evidence,
one in the life that will live with the consequences.”
Charles, Gafni & Whelan, 1997 — the foundational four-criterion definition.
SDM28 / 36
A four-step model for the dialysis modality choice
SDM in practice — four steps, two voices.
Step 01 · 醫
Present the options
The nephrologist lays out HD, PD, conservative care, and transplantation — fairly, with personalised survival and QoL framing.
Step 02 · 病
Explore values
The patient — and family — names what matters: independence, travel, family role, fear of needles, fear of operations.
Step 03 · 病
Make the choice
A decision is articulated by the patient, supported by the physician. Reversibility is named explicitly.
Step 04 · 醫
Create the access
The nephrologist plans and executes the chosen access — PD catheter, AVF, AVG, or tunnelled catheter (Permcath).
Adapted for dialysis modality decision-making from Charles et al., 1997; consistent with KDIGO and ASN SDM frameworks.
SDM · Step 0129 / 36
STEP · 01
01
醫師The physician presents
Present all options — honestly, evenly.
- HD, PD, kidney transplantation, and conservative kidney management — name all four.
- Personalise survival and QoL framing using patient age, frailty, comorbidities — not pooled hazard ratios.
- Acknowledge what the evidence shows and what it does not — the residual uncertainty is the patient's to weigh.
- Avoid the default-HD framing ("we'll just put in a Permcath") that is endemic in Taiwanese nephrology practice.
- Where possible, use a visual decision aid (Option Grid, NKF tools, KDIGO leaflets).
"Honestly and enthusiastically offer PD to all ESRD patients based on clinical appropriateness." — Prof. 黃政文.
SDM · Step 0230 / 36
STEP · 02
02
病人The patient explores
Surface the values beneath the question.
- How important is staying at home?
- Is there a trained family member or willing caregiver?
- What is the patient's relationship to needles, to operations, to hospitals?
- Travel, religious obligations, work, grandchildren — which of these is non-negotiable?
- Family dynamics: who will the decision actually fall to in 12 months, when fatigue sets in?
- What does the patient (and family) understand the prognosis to be?
This is where the nephrologist must listen more than speak. The PD nurse and social worker are essential collaborators.
SDM · Step 0331 / 36
STEP · 03
03
病人The patient decides
The patient names the choice — not us.
- The articulation should come from the patient's own mouth: "I want PD" / "I want HD".
- Acknowledge that the decision is reversible — modality switches are common and acceptable.
- Set a clear re-decision point: a planned conversation at 12 months, or sooner if circumstances change.
- Document the SDM process — not just the outcome — in the chart.
- Affirm the choice without subtle disapproval. Patients sense ambivalence and over-correct toward what they think the physician wants.
A decision documented in the chart as the product of SDM is also the legally and ethically strongest position for the team.
SDM · Step 0432 / 36
STEP · 04
04
醫師The physician creates access
Now — and only now — plan the access.
For PD
Tenckhoff catheter
Open or laparoscopic; plan 2 – 4 weeks before anticipated start; consider rectus-sheath tunnelling in obese or elderly patients.
For HD
AVF / AVG / Permcath
AVF preferred where vessels permit; AVG in elderly with poor venous quality; tunnelled cuffed catheter (Permcath) as planned bridge or by patient choice.
In the elderly, a tunnelled Permcath is not a moral failure — it is sometimes the right access for a defined horizon.
Access planning belongs after the decision, never before it. Pre-emptive AVF in a patient who will choose PD is a system failure, not a clinical victory.
Part Seven33 / 36
PART · 07
My PD experience
at NTUH Yunlin.
Numbers from a six-year cohort in a real Taiwanese county hospital — not a referral centre, not a registry, just what happened.
My PD experience34 / 36
NTUH Yunlin Branch · 2020 – 2026
A small cohort, honestly reported.
Catchment
Yunlin 659k
Changhua 1.21m
Taichung 2.87m
A largely rural population with the oldest age structure in Taiwan.
Centre HD
~ 4,000 /mo
HD volume in the county, distributed across multiple clinics.
PD on programme
60 → 50
Slow decline across the catchment, consistent with the national trend.
My patients
38 in 6 y
Started since my return from NTUH Taipei.
Currently active
15
Mean PD vintage 40 months. Mean current age 49.
Transferred
1 + 1 + 8
1 transplanted · 1 relocated · 8 transitioned to HD.
Deceased
13
Mean age at death 74 — a population we did not surrender to HD.
Mentor
"Trained at NTUH
under Prof. 黃政文."
460+ PD patients across 2 fellows.
A real-world programme. Not a registry, not selection-corrected — what came through the door.
Closing35 / 36
My thoughts on PD for the elderly
What I have learned, in one paragraph.
“No patient is unfit for PD
— only the physician untrained in it.”
— Prof. 黃政文, my teacher.
- Practise shared decision making; centre quality of life, not modality preference.
- Honestly and enthusiastically offer PD to every ESRD patient who is clinically appropriate — and that includes the elderly.
- Embrace technology, embrace AI — let it draft, let us decide.
- Above all: the rest of this, too, I learned from my patients.
A summary of six years of practice, three iterations of this talk, and many evenings reviewing peritoneal effluent.
End36 / 36
Thank you.
Q & A
紀竣議 醫師 Chun-Yi Chi, MD
Division of Nephrology · NTUH Yunlin Branch
2026 · 04 · 30
“To PD or not to PD —
let the patient decide, with us beside them.”