Urgent Start Peritoneal Dialysis: Time to Change Our Renal Replacement Algorithm

In the article Urgent Start Peritoneal Dialysis: A Chance for a New Beginning, the authors suggest a paradigm shift from our conventional algorithm of urgent renal replacement therapy.  They address the issue of urgent start peritoneal dialysis as a means by which we can improve the outcomes of the late referral chronic kidney disease patient or the patient in urgent need of renal replacement therapy. Corresponding author Dr. Rohini Arramreddy (RM) discusses this potential intervention with eAJKD Contributor Dr. Sean Kalloo (eAJKD).

eAJKD: Your article addresses the concept of urgent start peritoneal dialysis and the need for the nephrology community to break the “status quo”. What are the main barriers that need to be overcome in order to make this movement successful?

RM: Urgent-start PD is not a new concept, but it has received a lot of attention in the last decade as there is a concentrated effort to reduce the number of patients starting dialysis with a central venous catheter.  Despite successful urgent-start PD case reports published and presented at national meetings, the movement can only be successful with buy-in from all stakeholders (i.e., nephrologist, operator, hospital, dialysis center, and patient) involved in the program, and the establishment of a strong infrastructure to support it. This can be a challenge at times, but can definitely be overcome.

eAJKD: One might argue that the process of selecting a patient for a home dialysis modality is more labor intensive than selecting a patient for in-center hemodialysis. For example, in my peritoneal dialysis and home hemodialysis center, the patient and their partner/spouse meet with our entire team (home dialysis nurses, social workers, dietitians, and the physician). This meeting is used to educate the patient on all modalities and discuss what is required of a home modality. In addition, a home visit/inspection is conducted. Would such an evaluation process be possible in an urgent start situation?

RM: Urgent-start PD refers to dialysis needed within 2 weeks of PD catheter placement.  Therefore, the amount of time allocated towards education and evaluation varies. Ideally, the answer is yes. There are ways to optimize the education and patient selection process to make it as comprehensive as possible.  In the hospital setting, the nephrologist or dialysis team members can provide handouts and explanations detailing modality choices. In urgent situations, the patient may or may not have the cognitive capacity to understand the information so it is imperative that family and/or friends are involved in the discussions. Often times, engaging family and/or friends will provide great insight into the patient’s lifestyle and home situation. Also, the inpatient nephrology team can utilize pre-screening patient selection tools to help identify patients who may be appropriate for urgent-start PD.  When feasible, the consulting nephrologist can also engage the outpatient dialysis center in the process as well. A home nurse could visit the patient at bedside to continue the education process and make a home visit, if possible.

eAJKD: Figure one illustrates the “key elements” of a successful urgent-start peritoneal dialysis program. Can you discuss the importance of each element and the interplay between them?

RM: For an urgent-start PD program to be successful, there must be buy-in from all the stakeholders – the nephrologist, hospital, operator, dialysis center, and patient. However, the nephrologist is central to the process and should serve as the leader.  In the hospital setting, the nephrologist must engage and mobilize the other departments and disciplines. There must be transparency and communication about goals to ensure that everyone understands the importance and requirements of an urgent-start PD program.  For example, the nephrologist must coordinate with the operator and on-call staff to ensure timely PD catheter placement. Individuals allocating time in the operating suite need to identify PD catheter placement as a priority whenever possible. The nephrologist must ensure that there is dialysis staff available, and comfortable with the management of urgent-start PD. The nephrologist must also ensure that the hospital case managers and social workers are able to facilitate a smooth transition of care into the outpatient dialysis center.

In the outpatient setting, the nephrologist is the liaison between the dialysis center and the operator. The nephrologist is expected to make a timely referral to the dialysis center so that it can determine if it has adequate staff, supplies, and space to accommodate such a request.  The nephrologist must write or review urgent-start PD orders and protocols at the center. The nephrologist should have a relationship with a reliable and competent operator who can place a PD catheter in a timely fashion. There should also be an agreement on peri-operative care between the nephrologist and operator, as well as nephrologist and dialysis center to optimize patient outcomes.

The relationship between the nephrologist and patient is paramount. The nephrologist must help the patient make an appropriate modality choice by providing his/her best clinical judgment. Patients must trust their nephrologist and feel supported, particularly at a time when they are often overwhelmed and confused. However, the physician should also be the patient’s advocate, and guide modality selection if the patient does not have the cognitive capacity to make his/her own decisions.

eAJKD: What are the elements that you want a practitioner (nephrology fellow, nephrologist, nurse practitioner, etc) to take away from your article?  

RM: This is a very exciting time in nephrology as urgent-start PD poses a unique opportunity to change the current HD-centric model of ESRD care in the United States.  I encourage all nephrologists to explore the potential of urgent-start PD in their practice. With buy-in from all stakeholders and a strong infrastructure, urgent-start PD can be successful.

See a related post on this article. To view the article abstract or full-text (subscription required), please visit AJKD.org.


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