Opinion: Patients can benefit from staff-assisted peritoneal dialysis
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“You need dialysis!”
That is how life changes for more than 150,000 people every year in the United States alone. That is the moment a person has to adapt to a life of coming to a dialysis center for 4 hours a session, three times a week to have that person’s blood run through a machine to remove toxins and excess water – replacing the function of failing kidneys.
The patient has to follow a strict schedule and bears the burden of travelling back and forth to the dialysis center. Moreover, in-center hemodialysis (HD) is associated with drops in blood pressure and hemodynamic instability. The diet is restrictive as is fluid intake.
In-center HD leaves people exhausted after the dialysis treatment, frequently for several hours, making them unable to work or participate in their family or social lives.
Current routines are also the reason we have what is known as the “killer gap”: Patients have a 2-day gap in which they don’t get dialysis. This gap is associated with increased risk of death. The killer gap can be eliminated by dialyzing at least four times a week, but this is hard to accommodate for in-dialysis centers.
Home dialysis
A better option is home dialysis, either as home HD or peritoneal dialysis (PD). No rigid schedules. No travelling to centers. People who self-care can avoid the many clinical and lifestyle disadvantages of in-center HD.
There is a growing population of patients who are good candidates for home dialysis but have physical, mental and psychosocial limitations that make self-care difficult. In a Canadian study, for example, 81% of patients starting chronic dialysis had at least one medical or social condition that could potentially be a barrier to self-care.
Not all patients have family members who can help with dialysis, forcing many to rely on in-center HD. Among caregivers, chronic diseases, anxiety and stress are common, and the burden of providing care increases significantly after dialysis initiation.
Assisted PD
Assistance to perform PD can be provided by family or staff (in this article, we refer to assisted PD as staff-assisted PD, which can be provided by a health care technician or a registered nurse).
Assistants receive training to enable PD support. For instance, in one program, this consisted of 2.5 hours theoretical training in the local home program followed by 2.5 hours of practical training in the patient's residence.
Programs from around the world are structured to support continuous cycler-assisted PD, continuous ambulatory PD, or both, by providing a single or multiple daily visits. Assistants help with cycler setup, moving and hanging dialysis bags, discarding dialysis waste, and measuring blood pressures and weights, among other tasks.
Outcomes
Several studies reported favorable outcomes of assisted PD. These studies showed comparable quality of life and physical function, favorable technique survival, similar or lower peritonitis risk, and similar hospitalization risk. Assisted home dialysis is an integral part of dialysis care in countries with higher utilization of home therapies, but is not typically available in the United States, mainly because of regulatory reasons. In recognition of multiple advantages of home dialysis, the Advancing American Kidney Health initiative has set ambitious goals to promote home dialysis. To enable scoring on that goal, a recent bipartisan bill has been introduced in Congress to support adoption of assisted home dialysis in the United States.
Providing staff assistance will enable us to deliver person-centered care by supporting many people to choose home dialysis and alleviating some of the burden on patients and families.
Pilot project
While awaiting regulatory changes, our nephrology group at Satellite Health Care conducted a pilot project by offering staff-assisted PD at six of our home dialysis programs. Our objective was to explore patient needs and evaluate the logistics of providing staff assistance for this modality. The results were positive, and we hope to continue the study and expand to other programs.
Staff assistance for home therapies not only can help attract more patients to the therapy but offers a strongly likelihood that they will “stick with it.” That is key if we want to expand our home programs in the future.
References:
Béchade C, et al. Peri Dial Int. 2015; doi:10.3747/pdi.2014.00344.
Benabed A, et al. Nephrology, Dialysis, Transplantation. 2016; doi:10.1093/ndt/gfw011.
Bevilacqua MU, et al. Peri Dial Int. 2017; doi:10.3747/pdi.2016.00201.
Boyer A, et al. Clin Kidney J. 2020; doi:10.1093/ckj/sfaa051.
Executive Order on Advancing American Kidney Health. The White House. www.whitehouse.gov/presidential-actions/executive-order-advancing-american-kidney-health/. Published 2019. Accessed Dec. 31, 2020.
Flythe JE, et al. J Am Soc Nephrol. 2014; doi:10.1681/asn.2014020222.
Giuliani A, et al. Peri Dial Int. 2017; doi:10.3747/pdi.2016.00214.
Guilloteau S, et al. American Journal of Nephrology. 2018; doi:10.1159/000494664
Hussein WF, et al. Am J of Neph. 2017; doi:10.1159/000476076.
Iyasere OU, et al. Clin J Am Soc Nephrol. 2016; doi:10.2215/cjn.01050115.
Maierean SM, et al. Blood Purification. 2021; doi:10.1159/000512839.
Oliver MJ, et al. Clin J Am Soc Nephrol. 2016; doi:10.2215/cjn.10130915.
Oliver MJ, et al. Kidney Int. 2007; doi:10.1038/sj.ki.5002107.
Rayner HC, et al. Am J Kidney Dis. 2014; doi:10.1053/j.ajkd.2014.01.014.
Rush introduces bipartisan legislation to expand home dialysis, ensure kidney patients are educated about full range of treatment options. https://rush.house.gov/media-center/press-releases/rush-introduces-bipartisan-legislation-expand-home-dialysis-ensure. Published Jan. 21, 2022. Accessed Jan. 21, 2022.
USRDS Annual Data Report: Epidemiology of kidney disease in the United States. NIH, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md, 2021.
For more information
Wael Hussein, MD, is vice president of research and development at Satellite Healthcare and an adjunct assistant professor at Stanford School of Medicine. He can be reached at husseinw@satellitehealth.com. His Twitter handle is @Teknofiliac.
Editor’s Note: On March 4, Hussein will share his experience using assisted PD in a session at the virtual Annual Dialysis Conference entitled, “Alleviating patient and care partner burden: Experience from the first U.S,-based staff assisted program.” For more information on the session and to register for the Annual Dialysis Conference, taking place March 4-6, visit https://annualdialysisconference.org/program-2022/.
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