The role for nursing in the increasing use of urgent peritoneal dialysis

ANAHEIM—Individuals who end up in the hospital emergency room after months, maybe years, of ignoring the signs of kidney failure usually have a fairly standard course of treatment: dialysis delivered via a temporary hemodialysis catheter. Once stabilized, the newly diagnosed ESRD patient is transferred to an outpatient facility for maintenance dialysis.

At that point, says Arshia Ghaffari, DO, MA, MBA, there is a high likelihood that the individual will stay on in-center hemodialysis. “Once they are on in-center hemodialysis, it is rare that a patient moves to peritoneal dialysis,” Ghaffari said at the 45^th annual symposium of the American Nephrology Nurses Association here. Even with pre-dialysis care and counseling up to one year with a nephrologist, 85% of all patients start with a temporary hemodialysis catheter, he said. That’s not always the fault of the nephrologist––patients can be in denial about the seriousness of their kidney disease and will cancel appointments set up by nephrologists for a permanent access because of the fear of the surgery. “Even if we do our best to get these patients prepared, there is a certain percentage who will crash” and end up in the ER needed dialysis immediately. That usually means a temporary hemodialysis catheter, and studies show that increases the patient's risk for infection and death.

One solution that may reverse this tide, which is partly responsible for close to 90% of patients being on in-center dialysis, is urgent peritoneal dialysis. The idea that such patients, who have ignored their deteriorating kidney condition and are forced to seek help in an emergency room, would be ideal candidates for self-care seems odd. But after becoming medical director at his Los Angeles-based clinic, Ghaffari began looking into why his percentage of PD patients was not growing. “Most referrals were coming from my county hospital – patients who were underinsured, had little or no experience with primary care–– and coming in late in the disease process." But Ghaffari told nurses that if patients are presented with PD as the best therapy at the onset, they take on the responsibility. “We need to give these patients the option to do self-care,” he told his staff.

Urgent PD is placing the patient on peritoneal dialysis right from the start of therapy. Patients may get a temporary hemodialysis catheter and have several hemodialysis sessions to reduce fluid overload and help stabilize the patients’ condition if they are highly uremic, but the HD catheter is removed before the patient leaves the hospital.

Some of the benefits of choosing urgent PD over traditional in-center hemodialysis include:

Preservation of the vasculature. “Those of us who are PD advocates recognize that it is a modality with a finite time,” said Ghaffari. “Going with PD from the start preserves the patient’s vasculature for hemodialysis in the future.”
Preserving residual renal function. PD is superior to HD for doing this for patients who still have some kidney function left.
Lower cost. Dialysis providers acknowledge that PD is a more cost-effective modality because of lower overhead and fewer hospitalizations for patients.
Patient satisfaction. Ghaffari said this is usually higher among PD patients because of the freedom and flexibility offered by home therapy and a more liberal diet
Transplant outcomes. These are better for PD patients vs. HD patients.

PD has had limited penetration as a modality choice because seasoned nephrologists are still remembering complications from the 1980s and 1990s, namely high peritonitis rates. Among new nephrologists, a lack of knowledge is the problem. “ Forty percent of nephrologists coming out of training today say they are not comfortable taking care of PD patients,” Ghaffari said. That discomfort may increase if you are asking nephrologist to consider starting patients on PD right away without the traditional patient education and preparation.

The keys to success for urgent start PD, says Ghaffari, are:

Rapid PD catheter placement. The catheter needs to be implanted immediately in the OR as soon at the patient is evaluated and confirmed as a candidate. The patient needs to be stabilized and get discharged as quickly as possible so they can begin training on long-term PD.
Education. For both patients and staff, education is key.
Administrative support. Clinics need to be prepared for taking in patients who are suddenly starting on a home therapy and need some sessions in the clinic. Space and staff need to be dedicated to handle these new patients, who may be on hours of low-volume, intermittent PD in the clinics for up to two weeks before they can finalize needed training.

Ghaffari believes there may now be over 1,000 patients in the U.S. that have been initiated on dialysis via urgent PD. “Almost every other week I’m seeing something new about clinics starting an urgent start PD program,” he said. -by Mark Neumann