Ongoing team approach may improve odds of choosing, staying on peritoneal dialysis
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When a multidisciplinary team provides appropriate education and ongoing support, patients may be more likely to initiate kidney replacement therapy with peritoneal dialysis, according to a speaker at the virtual ASN Kidney Week.
Further, Matthew Oliver, MD, MS, of the University of Toronto, told the audience that this approach may also improve the odds of retaining patients on PD, rather than transitioning to other modes of therapy.
“Patients who are considering peritoneal dialysis first undergo an assessment and a process of education in order to determine if they're eligible for PD and if they’d like to choose PD,” he said. “If the patient wishes to choose PD, then a PD catheter is inserted. After a break-in period, there is a period of PD training and, hopefully, the patient initiates PD at home without any problems.”
However, Oliver acknowledged patients can experience complications which may result in them never starting PD or failing PD within the first 3 to 6 months after catheter insertion.
“Even if patients do not fail therapy, they can still experience complications, which can make their start of PD unpleasant, reduce their quality-of-life and lead to what I’m terming ‘a rocky start,’” he added.
Citing results from a study conducted in Canada and the United States, Oliver noted 19% of patients never started PD — even after undergoing PD catheter insertion — because they felt PD would present too much of a burden for them or their families; psychosocial reasons were also linked to early technique failure and transition to hemodialysis in an analysis of patients who initiated PD in France.
“This data emphasizes the role of patient assessment and education in successful early PD therapy,” he said. “It is important that patients and families are adequately educated about peritoneal dialysis.”
According to Oliver, there are many ways to deliver this education, including content which is developed by individual programs and available through PowerPoint presentations online.
Alternatively, he said, education can be delivered directly by a multidisciplinary team of nurses and physicians; this allows family members to be a part of the process.
He also highlighted the importance of peer support programs, indicating that patients seem to appreciate the opportunity to speak with other patients who have been on PD as it gives them a better understanding of the potential impact of the therapy on their own lives.
The chances that a patient will choose PD increases through education regardless of how the content is delivered, Oliver said.
“There isn’t a lot of information to say which is the better way of delivering the information because there's such a wide variety of methods,” he said. “It is therefore extremely important to do an interdisciplinary team assessment for all new patients starting dialysis. We use a team approach to evaluate the patients. The first thing we’re looking for is contraindications to PD and this would be defined as either medical or social.”
More specifically, he noted that a medical contraindication might be if the patient had active inflammatory bowel disease, while a social contraindication would be if the patient resides in a space where PD therapy was not permitted (eg, some nursing homes).
Oliver said it is also necessary to consider barriers to self-care, which can be classified as medical, physical, cognitive or social.
Reiterating that patients and families can sometimes find PD too burdensome and, thus, transition to hemodialysis soon after initiation, Oliver concluded: “PD choice is a dynamic process requiring ongoing coaching to maintain a commitment to [the therapy].”
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Oliver M. Avoiding a rocky start to peritoneal dialysis. Presented at: ASN Kidney Week. Oct. 22-25, 2020 (virtual meeting).
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