Peritoneal Dialysis and the Psychosocial Benefits – Do They Really Exist?

Do the psychosocial benefits offered by peritoneal dialysis (PD) truly exist in the everyday lives of our PD patients? In a thematic synthesis of qualitative studies recently published in AJKD, Tong et al attempt to investigate these issues. Corresponding author Dr. Allison Tong (AT) discusses the study with Dr. Sean Kalloo (eAJKD), eAJKD Contributor.

eAJKD: Please describe your study.

AT: We synthesized 39 qualitative studies on patients’ experiences and beliefs about PD. Patients receiving PD gained a sense of control, independence, self-efficacy, and freedom. However, they also reported an impaired self-esteem, physical incapacitation, and limited social functioning. To promote treatment satisfaction and optimal psychosocial outcomes, implementation of targeted strategies to strengthen social support, patient resilience, and confidence is integral in clinical care.

eAJKD: The concept of “major themes” is mentioned in the manuscript. Can you briefly describe these themes and how they relate to the PD population, both in a positive and negative manner?

AT: We identified seven themes which reflected patients’ experiences and perspectives of PD: 1) “resilience and confidence”; 2) “support network” described the patients’ relationships with their healthcare providers, family and friends, and other dialysis patients, and how they influenced the patients’ capacity to cope with PD; 3) “overwhelming responsibility” reflected the patients’ perception that PD was a disruptive intrusion, onerous, and a burden on the family; 4) “control” described the patients’ ability to gain an understanding of how to adjust their PD regimen to manage symptoms, achieving self-efficacy, and to understand their disease and treatment; 5) “freedom” encompassed patients’ beliefs that PD offered flexibility and autonomy where they had the opportunity to individualize their own treatment schedules and therefore were better able to participate in social activities and travel; 6) “sick identity” characterized how patients felt PD could negatively impact their self-esteem and body image and their frustration about the perceived lack of empathy and understanding from others; and 7) “disablement” included patients’ experiences of physical incapacitation due to fatigue and sleep problems attributable to the PD machine, and their sense of social loss and devaluation in being dependent on others.

Personal resilience, confidence, and strong support structures underpinned positive adjustment, which in turn promoted a sense of control and freedom. In contrast, negative adjustment, based on lack of social support and perceptions that PD was an overwhelming responsibility, resulted in impaired self-esteem and an intensified sense of disablement.

eAJKD: You mention a limitation of your study was the lack of PD modality specification. Do you think that the results would vary drastically between patients on continuous ambulatory PD (CAPD) versus automated PD (APD)?

AT: Our study identified two main differences between CAPD and APD. Patients on APD reported sleep disturbances but believed APD offered more freedom to work compared with CAPD. We expect that there would be differences between CAPD and APD in terms of patient experiences and perspectives. In CAPD, three to five exchanges must be performed every day and this can lead to loss of patient motivation and more frequent peritonitis episodes. In terms of technical outcomes, APD does not have significant advantages over PD. However, APD is reported to confer more psychosocial benefits compared with CAPD related to the fewer exchanges required during the daytime. These advantages include reduced back pain and body image difficulties as the abdomen is free of fluid during the day, and more time for work, family and social activities. APD has been suggested to be a better PD option, particularly for patients who are employed, students, and those who act as family caregivers.

eAJKD: What elements from your article can practitioners (Nephrologists, Renal Nurse Practitioners, Nephrology Fellows) extract to present PD to a patient with chronic kidney disease nearing the need for renal replacement therapy?

AT: We believe our findings on the perspectives and beliefs of patients who have experienced PD can support informed shared decision making about dialysis modalities. Studies have shown that patients are influenced by the experiences of other patients. Providing information about the experiences of other patients can help prepare a patient for the psychosocial challenges they may face and to ensure support mechanisms are available to promote positive coping. Clinicians can discuss the positive aspects of PD including the ability to gain control, independence, self-efficacy, flexibility, and social freedom; as well as the potentially negative experiences of PD such as social isolation, impaired self-esteem, limited physical functioning, and the onerous nature of managing PD. Further, clinicians are encouraged to identify strategies to militate against inability to cope, poor psychosocial outcomes, and dissatisfaction with treatment.

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