The role of APD in the improvement of outcomes in an ESRD program.

We review the role of automated peritoneal dialysis (APD) in improving outcomes of an end-stage renal disease (ESRD) program. As the "integrated care approach" becomes accepted as the preferred strategy for treatment of ESRD patients, we looked for the potential place of APD in such an approach. APD has probably the same advantages as CAPD as a first-line renal replacement modality in suitable patients willing to perform PD. There is currently no hard evidence that residual renal function (RRF) should decline more rapidly in APD than in CAPD, at least if a dry abdomen during the day is avoided. The detection of peritonitis is probably more delayed in APD, but the frequency of peritonitis is lower, and there is no hard evidence pointing to a poorer outcome of peritonitis in APD as compared to CAPD. Quality of life is at least as good in APD, which is mostly related to the increased possibilities for adapting the exchange pattern to employment-related time frames. APD also has the potential to prolong technique success in patients failing CAPD rather than transferring them to hemodialysis. Nevertheless, APD remains more expensive and technically complicated, thereby missing the beauty of CAPD's simplicity. Therefore we believe that APD has its role in an integrated approach and that all patients should be informed of its potential. It would, however, not be correct to present APD as the preferred PD method for all patients, as it also has some drawbacks that make it less suitable for some categories of patients. In all cases, patients should have a free and informed choice.