This paper reviews the rationale behind the proposed policy of using peritoneal dialysis (PD) as the initial treatment modality in patients with end-stage renal disease (ESRD). The better preservation of residual renal function associated with PD is emphasized along with its potential cardiovascular bene®ts. The superior patient survival on PD, relative to hemodialysis, during the ®rst 2 years on dialysis in both the United States and Canada is discussed, as are the potential advantages of PD

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... terms of hepatitis C prevention, anaemia management and quality of life. The lower cost of PD in association with these clinical advantages lead to the modality being more cost-effective in the early years on dialysis. The relatively high technique failure rate on PD, however, subsequently leads to an increasing need for haemodialysis. A policy of integrated dialysis care with PD ®rst and then haemodialysis, as required, is advocated as a more cost-effective approach to ESRD in suitable patients.