Nephrol Dial Transplant (2007) 22: 3601–3605
doi:10.1093/ndt/gfm416
Advance Access publication 30 June 2007
Original Article
Analysis of the factors conditioning the diffusion of peritoneal
dialysis in Italy
Giusto Viglino1, Loris Neri1, Sandro Alloatti2, Gianfranca Cabiddu3, Roberto Cocchi3,
Aurelio Limido3, Giancarlo Marinangeli3, Roberto Russo3, Ugo Teatini3 and
Francesco Paolo Schena4
1
Renal and Dialysis Unit, San Lazzaro Hospital, Alba (CN), Via Pierino Belli 26, 12051 Alba (CN) 2Renal and Dialysis
Unit, Regional Hospital, Aosta 3Scientific Committee of Peritoneal Dialysis Study Group of Italian Society of
Nephrology and 4Renal, Dialysis and Transplant Unit, University of Bari, Policlinico, Bari, Italy
Abstract
Background. The diffusion of peritoneal dialysis (PD)
in Italy is lower than expected on the basis of indications and contraindications reported in literature.
Methods. To analyse the factors influencing the use of
PD in Italy, we used data from the first National
Census of the Italian Society of Nephrology relating to
9773 incident patients (IncidHD þ PD) in 2004 and
43 293 prevalent patients dialysed in 658 centres at
31/12/2004 (337 public centres, 286 private centres, 12
paediatric centres, 15 research or religious institutions
and 8 unspecified).
Results. The percentages on PD of total incident
(IncPD%) and prevalent dialysis patients (PrevPD%)
were 15.9% and 10.3%, respectively with considerable
variations from region to region and from centre to
centre. The IncPD% was higher in regions with fewer
patients on dialysis in private centres. In the private
centres, the IncPD% was 0.4%. Of the 325 nonpaediatric public centres, 116 (35.7%) do not use PD:
compared with the 209 centres which do, these centres
have a lower mean IncHD þ PD and PrevHD þ PD per
centre (13.0 12.3 vs 28.6 18.0 51.8 35.7 vs
117.3 66.4 patients, P < 0.0001), and more haemodialysis (HD) stations available (3.0 vs 3.5 patients per
HD station, P < 0.0001). However, the significant
influence of cultural and motivational factors on the
use of this method is demonstrated by the fact that it is
used by 34% of the smaller non-paediatric public
centres, and is not used by 19% of the larger nonpediatric public centres.
Keywords: end stage renal disease; haemodialysis;
healthcare; modality selection; patient preferences;
Correspondence and offprint requests to: Giusto Viglino, S.O.C. di
Nefrologia e Dialisi, Ospedale San Lazzaro, Via Pierino Belli 26,
12051 Alba (CN), Italy. Email: [email protected]
peritoneal dialysis; patient education; renal
replacement therapy; survival
Introduction
The diffusion of peritoneal dialysis (PD) varies
extremely from country to country, with haemodialysis
(HD) clearly predominating in most cases [1,2].
Since data from registers and various studies show
no significant differences in survival rates between HD
and PD [1,3–9], the differences in the diffusion of PD
may be due to factors associated with the choice of
modality and/or drop out rates. The technique-related
drop out rate is known to be higher in PD than in HD
[1,3,4,10]. However, the importance of the choice of
modality in influencing the lower penetration of PD
is confirmed by a parallel trend in the incidence and
prevalence of PD, which—in most countries—are
lower than those of HD [1,2,11].
One treatment may be preferred to another on
clinical grounds, or for non-clinical reasons such
as psychological, social and aptitude factors,
which are more significant where a home-based, selfadministered treatment such as PD is concerned.
According to the data reported in literature [12–16],
indications to PD are clinical in 1–15% of patients, and
non-clinical in 0–3% of cases. Contraindications to
PD, on the other hand, are represented by clinical
factors in 4–17% of cases, and non-clinical factors in
1–21% of cases. The balance between indications
and contraindications to PD varies between þ1.4%
[12] and –14.3% [13] for clinical factors, and between –
1.3% [13] and –20.0% [12] for non-clinical factors.
Considering both clinical and non-clinical factors,
as well as indications and contraindications,
a choice against PD may occur in at most 23.5% of
cases [12–16].
ß The Author [2007]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.
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3602
If, therefore, the choice of treatment is influenced by
the above factors alone, and not by a preference of
patients or doctors for one type of modality, we should
expect a PD incidence of at least 35–40%. Since a
similar percentage is only found in certain countries,
while in the others the incidence of PD is decidedly
lower, there are grounds for assuming a negative
attitude on the part of patients and/or family members
towards this modality.
This negativity seems to be associated fundamentally
with inadequate information on the various dialysis
options during pre-dialysis. Indeed, published data
seem to confirm that PD is chosen by 48–58% of
patients who are not conditioned by clinical and nonclinical factors, and who have been provided adequate
information on the dialysis treatment [13,14,17]. This is
more likely in early-referral patients, although adequate information supplied following the commencement of the dialysis treatment seems to nullify the
negative effect of late referral [13]. On the other hand,
insufficient or a complete lack of information also
results in less likelihood of PD being chosen in earlyreferral patients too [18]. In the end, the different
diffusion rate for PD is conditioned by the choice of
doctors on whether to inform, propose and use this
modality.
According to Nissenson et al. [19], their attitude can
be conditioned by economic and cultural factors.
Of importance among the economic factors are both
the country’s wealth and availability of resources, and
the benefits for the doctor or for the facility in terms
of reimbursements and the utilization of investment
made for the setting up of a dialysis centre. Significant
among the cultural factors are educational aspects
relating to health workers, and the customs, social
conditions and cultural traditions of the patients and
their families. Furthermore, Nissenson et al. observed
how PD diffusion in Italy varied considerably among
different regions, and was low not only in private
centres, but also in public facilities, suggesting that
the use of PD is conditioned by non-economic factors.
The purpose of this study was to analyse the factors
that affect the variability in the penetration of PD in
Italy among different geographical areas and centres.
G. Viglino et al.
public
others
private
Campania
Sicilia
Lazio
Puglia
Lombardia
Trentino
Abruzzo
Molise
Sardegna
Emilia
Basilicata
Calabria
Marche
Veneto
Val d'aosta
Umbria
Toscana
Piemonte
Liguria
Friuli
0%
20%
40%
60%
80%
100%
Fig. 1. Distribution of public, private and other centres in each
region. Public centres: 348 (337 adult centres – 11 paediatric centres)
private centres: 287 (286 adult centres – 1 paediatric centre) other
centres: 23 (15 institutes of a research or religious nature – 8
unspecified).
the Italian regions of the different types of centres. These
centres were supplemented by 303 satellite centres which were
taken into account in the evaluation of the overall number
of HD stations.
To assess the use of PD, the number of new patients
admitted to this renal replacement therapy during 2004
(IncidPD) was compared with the total number of admissions
to PD and HD (IncidPD þ HD) over the same period
([IncidPD% ¼ (IncidPD/IncidPD þ HD) 100]). In addition,
the total number of patients on PD at 31/12/2004 (PrevPD)
was compared with the total number of patients on renal
replacement therapy (PrevPD þ HD) as of the same date
([PrevPD% ¼ (PrevPD/PrevPD þ HD) 100]).
The occupancy of HD stations was assessed by relating
prevalent patients at 31/12/2004 (PrevHD) to available HD
stations (StHD) in centres, including their satellite services,
(PrevHD/StHD). The ratio between incident and prevalent
patients in PD (IncidPD/PrevPD) was used as an indirect
drop-out index.
The statistical analysis was applied to evaluate difference
between groups by means of the Chi-square test.
Materials and methods
The data collected by the First National Census organized
by the Italian Society of Nephrology were used for this study.
This census gathers aggregate data, for all Italian centres,
on structural and human resources, organizational aspects
and activities which are not taken into consideration by
the Italian Dialysis and Transplant Register (RIDT).
The incidence data relate to 2004, and the prevalence data
to 31/12/2004.
The census covered all the 658 Italian centres, including
337 public, 286 private, 12 paediatric centres (one of which
was private, giving a total of 287 private centres), 15 others
with different legal status (research or religious institutions),
and eight unspecified. Figure 1 shows the distribution among
Results
Over the course of 2004, 9773 patients were
admitted to dialysis treatment, including 1557
(IncidPD% ¼ 15.9%) on PD; the patients on renal
replacement therapy (HD þ PD) at 31/12/2004 were
43 293, of whom 4461 were on PD (PrevPD% ¼10.3%)
(Table 1). However the use of PD varies considerably
from region to region (Figure 2).
Figure 3 shows the IncidPD% and the PrevPD þ HD in
the different Italian regions; the width of each column
represents the percentage of PrevPD þ HD in a given
region compared with the total number of Italian
Factors conditioning PD diffusion
3603
patients on dialysis. In the seven regions in which there
are no private centres, and in the eight regions in which
<10% (mean 4.6%) of the patients on dialysis are in
private centres, the IncidPD% is 23.2% and 18.0%,
respectively. In the remaining five regions, in which
>10% (mean 54.1%) of the patients on dialysis are in
private centres, the IncidPD% drops to 9.5%.
There was extreme variability in the use of PD also
among centres. Indeed, IncidPD% in the 286 nonpaediatric private centres was 0.4%, while in the 12
paediatric centres it was 55.8%. Excluding these
centres, which had special reasons for using PD or
not, and both the 23 centres classified as others or
unspecified and the 12 centres with IncidPD þ HD ¼ 0, in
the remaining 325 non-paediatric public centres the
IncidPD% and PrevPD% were 19.3% and 13.8%,
respectively (Table 1). However, in these centres too
there was considerable variability in the IncidPD%,
with 116 centres (35.7%) not using this modality at all
(Figure 4). In the remaining 209 centres, the IncidPD%
and PrevPD% were 24.1% and 16.9%, respectively
(Table 1).
Table 1. Numbers of incident and prevalent patients and PD
incidence and prevalence rates based on type of centre
Total centres
Non-paediatric
private centres
Non-paediatric
public centres
Non-paediatric
public centres
with PD
%
Centres
Incident patients Prevalent patients
Num %
Total IncPD% Total
PrevPD%
658
286
100.0 9773
43.5 1624
15.9
0.4
43 293 10.3
10 833 0.2
325
49.4 7495
19.3
30 530 13.8
209
31.8 5988
24.1
24 522 16.9
PrevPD%
Factors distinguishing centres not using PD were
smaller in size in terms of both mean IncidPD þ HD per
centre (13.0 12.3 patients vs 28.6 18.0; P < 0.0001)
and mean PrevPD þ HD per centre (51.8 35.7 patients
vs 117.3 66.4; P < 0.0001), and more availability of
HD stations (PrevHD/StHD ratio 3.0 vs 3.5 patients per
station; P < 0.0001). These data were then used to
assess the influence of centre size on the choice of PD.
Small centres (SC) were defined as those with an
IncidPD þ HD 13 patients, and big centres (BC) those
with an IncidPD þ HD > 13 patients. The IncidPD%
in SC and BC was 12.7% and 20.2% (P < 0.0001),
respectively, while the PrevHD/StHD was 2.78% and
3.52% (P < 0.0001) Furthermore, patients were
admitted to PD in 34% of SC and 81% of BC.
The 209 public centres which performed PD were
divided on the basis of their mean PrevPD (19.83 15.1
patients) into two groups, with PrevPD <20 or 20
patients. The IncidPD/PrevPD ratio was significantly
higher in the centres with a lower PrevPD (0.39 vs 0.33;
P < 0.01).
Discussion
The IncidPD% (15.9%) and PrevPD% (10.3%) show
low diffusion of this renal replacement therapy in Italy.
Considerable regional disparity existed within this
national report, with IncidPD% varying between 2.4%
(Basilicata) and 36.8% (Val d’Aosta), while PrevPD%
ranged from 1.4% (Basilicata) to 19.5% (Liguria). One
factor which seems to strongly influence this variability
is the presence of private centres, especially when
it exceeds 10% of the centres in the region. In fact, of
the 286 HD private centres in the census, only five
performed PD. This result is caused by legal provisions, in terms of both accreditation criteria and
IncidPD%
40
35
30
25
20
15
10
5
gl
ia
al
ab
r
To ia
sc
Lo ana
m
ba
rd
ia
Pi
em
on
te
M
ar
ch
e
Ve
Va
ne
lle
to
d'
Ao
st
a
Ab
ru
zz
o
Li
gu
ria
Pu
C
Ba
si
lic
at
Tr
C
en
am a
tin
pa
oni
Al
a
to
-A
di
ge
M
ol
is
e
Si
ci
lia
La
zi
o
Em Sar
d
e
i
l
ia
gn
Fr
-R
iu
om a
liVe
ne agn
a
zi
a
G
iu
lia
U
m
br
ia
0
Fig. 2. Incidence and prevalence of PD in the various regions of Italy.
G. Viglino et al.
Sicilia
Lazio
Puglia
Sardegna
Calabria
Marche
70
Lombardia
80
Emilia Romagna
Toscana
Piemonte
90
Liguria
Veneto
Umbria
Trentino A.A.
Molise
Val d’Aosta
Friuli V.G.
Basilicata
Abruzzo
%
100
Campania
3604
60
50
40
30
20
10
0
%
0
10
20
IncidPD%
30
40
50
60
70
80
90
100
PrevPD+HD% in private centres
PrevPD+HD% in public centres
Fig. 3. Relationship between the patients on dialysis in private centres and the incidence of PD in the different Italian regions. The percentage
of patients on dialysis in a given region with respect to the total number of patients on dialysis in Italy is given on the X-axis.
100
90
80
70
%
Non-PD
116 centres
35.7%
PD
209 centres
64.3%
60
50
40
30
20
10
0
centres
Fig. 4. Percentage PD incidence in the 325 Italian non-paediatric
public centres, 116 of which do not use PD.
reimbursement rates making PD less economically
favourable than HD for private centres. This finding
also confirms previous results on the inverse ratio in
different countries between the greater importance of
private centres in the health system and a lower
diffusion of PD [20].
The use of PD also varies considerably from centre
to centre, with size being an influential factor. In fact,
the IncidPD þ HD and PrevPD þ HD were lower in centres
which did not perform PD than in centres where this
therapy was made most use of.
In the SC, there was a lower occupancy of HD
stations in terms of PrevHD/StHD. Other authors
[10,11,21,22] have pointed out how an increase in
StHD leads to less use of PD, as it entails the need to
utilize the investment carried out to create them [19].
Within the Italian context, an IncidPD þ HD of lower
than 13 patients seems to be a discriminantly critical
measure for the use of PD. In this respect, it is quite
clear that even where the admission rate to PD is not
particularly high, a higher IncidPD þ HD caters to a PD
prevalence rate which is capable of amortizing the
employment of sufficient human resources to guarantee optimal management of the PD programme. On the
other hand, it has been found how the PD drop-out
rate can be reduced by having a programme which is
more extensive in terms of either overall number of
patients treated [23] or PrevPD [24,25]. As reported by
other authors [24,25], in this study it was also found
that a PrevPD of around 20 patients is able to
distinguish centres with a higher or lower PD dropout rate. The cultural and motivational input of health
workers is a further important element which may
influence the choice of a centre to use PD. This study
found that 36% of all public centres and 19% of the
BC in Italy did not use this modality, while 34% of
SC did. This cultural and motivational factor may
be attributed to a lack of familiarity with this therapy.
This cultural gap results in turn in inadequate
information to patients about PD during pre-dialysis.
[18,26,27]. This lack of information contradicts the
deontological principle of informed consent and the
willingness of patients to take part in the choice of
the dialysis treatment, as shown by the fact that only
4.9% of 773 patients without indications or contraindications to PD or HD accepted that the dialysis
modality was established by randomization [28].
In conclusion, PD diffusion in Italy is limited, but
varies considerably in different geographical areas.
The reasons for this variability can be attributed to the
characteristics of the centres and to cultural factors.
The use of PD is more limited in private and SC, where
there is greater availability of HD stations. Besides
these structural elements however, the use of PD in
individual centres is also significantly influenced by
Factors conditioning PD diffusion
cultural and motivational factors relating to health
workers.
3605
14.
Conflict of interest statement. None declared.
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Received for publication: 22.5.07
Accepted in revised form: 4.6.07