Identifying ‘mistakes,’ speaker suggests ways to make peritoneal dialysis patient-friendly
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A speaker at the virtual ASN Kidney Week discussed what she termed the “top five mistakes” clinicians make when prescribing peritoneal dialysis, highlighting that many current approaches do not fully consider patient preferences.
According to Joanne M. Bargman, MD, professor of medicine at the University of Toronto, these mistakes include defining adequate dialysis primarily using the measure of Kt/V urea, ignoring the contribution of residual kidney function, assuming more cycles are better than fewer cycles, not using hypertonic dialysis solutions and not consulting with patients and their caregiver prior to prescribing the treatment regimen.
“As you know, there is not one fixed measure that defines adequate dialysis and there are several aspects to think of in terms of adequate dialysis for our patients,” Bargman said, touching on the reliance on Kt/V urea. “The [International Society for Peritoneal Dialysis] ISPD guidelines now talk about adequate dialysis as being related to multiple factors, of which toxin removal is only one.”
Bargman recommends tailoring dialysis treatments to each patient which, she noted, consists of having conversations about patient goals and ensuring patients have a sense of “well-being and satisfaction.” Related considerations of dialysis adequacy include symptom management and maintaining appropriate nutritional status.
Bargman also addressed residual kidney function.
“We know that most peritoneal dialysis starts are elective and associated with significant residual kidney function,” she said, suggesting incremental dialysis might better serve certain patients. She pointed to various studies that have shown incremental dialysis (defined here as one to two exchanges per day) may be related to reduced symptom burden and reduced risk of peritonitis, as well as a lower risk of losing residual kidney function. Survival rates between patients who receive standard PD vs. incremental PD are also similar, according to Bargman.
Again, focusing on patients’ sense of well-being and sense of control over their lives, Bargman argued more cycles do not necessarily provide more benefits.
“I think that our patients go through enough in life that they need to have a good night’s sleep,” she said, referencing the burden of a greater number of exchanges.
She said it is crucial to discuss the prescription of cyclic dialysis with patients and to determine how many hours they are willing to undergo.
“Don’t start with 9 [hours] every night,” she said. “We have some patients who are on 6 hours overnight. Some were on 10 hours overnight. It depends on the patient. So, this has to be a discussion.”
According to Bargman, being flexible with the prescription — and developing a PD schedule based on direct consultations with the patients — is the most important factor to consider. She even suggests allowing patients to “skip a day once in a while,” to live their lives more fully.
Concluding her talk, Bargman posed the question of how to fix these mistakes, summarizing how more optimal care may be provided.
“First of all, don’t be a slave to Kt/V urea,” she recommended. “It certainly is not a good index of dialysis dose, especially in peritoneal dialysis.
“Secondly, consider kidney function and design a patient-friendly incremental regimen. In the vast majority of our patients who start on peritoneal dialysis with significant residual kidney function, more is not better.
“Lastly, let me emphasize: Prescribe a regimen that is suitable and is going to be sustainable for the patient and their family.”
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Bargman JM. Top five mistakes in prescribing peritoneal dialysis. Presented at: ASN Kidney Week. Oct. 22-25, 2020 (virtual meeting).
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