“Peritoneal Dialysis” Strikes Back
In the United States, the number of patients who are offered peritoneal dialysis (PD) has declined over the last decade. The newer generation of Nephrologists may not feel as comfortable with this dialysis modality, and shy away from referring patients towards PD. Dr. Arshia Ghaffari (AG) from the Keck School of Medicine discussed his recent article in AJKD on urgent start PD with Dr. Kenar Jhaveri, eAJKD Blog Editor. The study was a pilot project of using PD as an urgent start form of dialysis when chronic kidney disease stage 5 patients present with uremia and no prior plan for dialysis modality. Patients were offered PD as the initial modality of dialysis.
eAJKD: What interested you in the topic of urgent start PD?
AG: At our center, the number of PD patient was declining. PD is under utilized in the United States. Recent studies have shown that PD is equal, or even better, to HD in terms of outcomes. It offers an improved lifestyle for many patients. Another reason was that the interest in PD among our attending Nephrologists and fellows has started to decline. To energize the faculty, and for the benefit of our trainees, we need to practice more PD. Some of these things got me excited, and from there this project unfolded.
eAJKD: Do you feel the younger nephrologists have less experience and comfort level to even offer PD to patients?
AG: It is unfortunate, but you are correct. There are training programs within the country that don’t have any PD patients and hence can’t provide their fellows with outpatient PD exposure. They may have to send their fellows to other centers or PD Universities for training, which is not enough. The experience one gets by seeing a sizable PD population cannot be replaced by few lectures. I think that PD is an outstanding modality with good clinical outcomes and an improved lifestyle than what hemodialysis (HD) offers.
eAJKD: How do you make PD appeal to patients in an urgent setting?
AG: This is a challenge. We developed questionnaires to give out to patients. We would go over the questions with them help them understand the lifestyle implications of HD compared with PD. But most importantly, we would make a firm recommendation that PD may be the right modality for them. I think it is very difficult for patients to make an acute informed decision on modality.
eAJKD: Setting up a program like this must have had many administrative hurdles, including nursing availablity and catheter insertion. What can other centers learn from your project?
AG: The first thing one needs is good access to a support services (ie, surgery or radiology). We went to our interventional radiology department and they were supportive of the idea. The key is to have someone who is experienced in radiology available to place the catheters. Not many radiologists are comfortable with the procedure. As you know, the nursing staff is another very important aspect of PD. We involved the nursing staff in the protocol development, and they were an integral part of starting the program. Once the catheter was working, our goal was to get the new patients out of the hospital as soon as possible and have PD continued in an outpatient setting.
eAJKD: Do you have any final thoughts on this topic?
AG: Our clinical endpoints are impressive when compared with the standard way of starting PD. We had no catheter-related problems other than what we usually see in nonurgent PD patients. Additionally, I want to make a pitch for PD to the nurses, physicians, and fellows on the front lines in the hospitals to think about PD and consider it as an acute option for maintenance dialysis patients. If they don’t think about it, it won’t be offered. I think the future of PD is very bright.
To view the entire article please visit AJKD.
I have a huge bias for PD and my six years on PD were my best among those with CKD. PD, I feel offers the best quality of life among all dialysis modalities. The few diet and fluid restrictions, the possibility of unhindered travel and not having to go to the hospital thrice a week all make this modality very appealing.
The nephrologist community has historically been step-motherly towards this therapy. There are multiple reasons for this. Some of these are due to the doctors, some due to the patients. From a patient’s perspective, introducing PD first rather than hemodialysis allows patients to settle into a therapy that is less violent, offers more independence and fewer problems. The switch to hemodialysis, from then on, would pose the same challenges as does the switch to PD from hemodialysis currently.
This initiative is very welcome. PD as a successful first line of therapy and that too without any prior preparation should at the very least, reduce an excuse from the list of excuses for not recommending this modality.
I really liked this article – just even to help improve awareness that less prepared starts can still do peritoneal dialysis from day 1. It is such an important option for many people.
thanks for your info
Thank you for the info… very helpful as I am considering my options