Peritoneal Dialysis Utilization Research Articles

Patient Education and Care for Peritoneal Dialysis Catheter Placement: A Quality Improvement Study

Peritoneal dialysis catheter (PDC) complications are an important barrier to peritoneal dialysis (PD) utilization. Practice guidelines for PDC placement exist, but it is unknown if these recommendations are followed. We performed a quality improvement study to investigate this issue. ♢ A prospective observational study involving 46 new patients at a regional US PD center was performed in collaboration with a nephrology fellowship program. Patients completed a questionnaire derived from the International Society for Peritoneal Dialysis (ISPD) catheter guidelines and were followed for early complications. ♢ Approximately 30% of patients reported not being evaluated for hernias, not being asked to visualize their exit site, or not receiving catheter location marking before placement. After insertion, 20% of patients reported not being given instructions for follow-up care, and 46% reported not being taught the warning signs of PDC infection. Directions to manage constipation (57%), immobilize the PDC (68%), or leave the dressing undisturbed (61%) after insertion were not consistently reported. Nearly 40% of patients reported that their PDC education was inadequate. In 41% of patients, a complication developed, with 30% of patients experiencing a catheter or exit-site problem, 11% developing infection, 13% needing PDC revision, and 11% requiring unplanned transfer to hemodialysis because of catheter-related problems. ♢ There were numerous deviations from the ISPD guidelines for PDC placement in the community. Patient satisfaction with education was suboptimal, and complications were frequent. Improving patient education and care coordination for PDC placement were identified as specific quality improvement needs.

Impact of Modality Choice on Rates of Hospitalization in Patients Eligible for Both Peritoneal Dialysis and Hemodialysis

Hospitalization rates are a relevant consideration when choosing or recommending a dialysis modality. Previous comparisons of peritoneal dialysis (PD) and hemodialysis (HD) have not been restricted to individuals who were eligible for both therapies. ♢ We conducted a multicenter prospective cohort study of people 18 years of age and older who were eligible for both PD and HD, and who started outpatient dialysis between 2007 and 2010 in four Canadian dialysis programs. Zero-inflated negative binomial models, adjusted for baseline patient characteristics, were used to examine the association between modality choice and rates of hospitalization. ♢ The study enrolled 314 patients. A trend in the HD group toward higher rates of hospitalization, observed in the primary analysis, became significant when modality was treated as a time-varying exposure or when the population was restricted to elective outpatient starts in patients with at least 4 months of pre-dialysis care. Cardiovascular disease, infectious complications, and elective surgery were the most common reasons for hospital admission; only 23% of hospital stays were directly related to complications of dialysis or kidney disease. ♢ Efforts to promote PD utilization are unlikely to result in increased rates of hospitalization, and efforts to reduce hospital admissions should focus on potentially avoidable causes of cardiovascular disease and infectious complications.

Does Current Nephrology Fellowship Training Affect Uti-lization of Peritoneal Dialysis in the United States?

Background: The 2010 US Renal Data System annual report revealed that peritoneal dialysis is used by only 7% of end-stage renal disease patients on chronic dialysis vs. hemodialysis which is used by 93% of such patients, despite documented benefits of peritoneal dialysis over hemodialysis in these cases. Purpose: We examined whether education of nephrology fellows contributed to underutilization of peritoneal dialysis in the US. Methods: Self-report questionnaires were administered electronically to nephrology fellowship training program directors, October 2010-March 2011 (55% response). Results: Median number of training faculty and patients/fellow were significantly lower for peritoneal-dialysis vs. hemodialysis training. Hours of didactic teaching for fellows over their 2-year training period were significantly lower for peritoneal dialysis vs. hemodialysis. Peritoneal dialysis training was 20% of total training vs. 80% for hemodialysis. Most program directors (87%) believed lack of trained faculty in peritoneal dialysis and insufficient peritoneal dialysis patient population contributed to inadequate fellows’ peritoneal dialysis training. Conclusions: Findings suggest that current nephrology fellowship training in peritoneal dialysis is inadequate and contributes to its underutilization.

Underutilization of peritoneal dialysis: the role of the nephrologist's referral pattern

The incidence of end-stage renal disease is increasing, placing a tremendous burden on health care resources. Peritoneal dialysis (PD) is cheaper than hemodialysis and has many potential advantages and few contraindications as an initial modality selection. This study examined differences in patient PD attempt rates between nephrologists using technique survival and mortality as outcomes. We performed a retrospective review of the Manitoba Renal Program databases from January 2004 to January 2010. Analysis of 630 patients who commenced dialysis and had demographic data available was performed. A genetic matching algorithm was used to balance potential differences between patient characteristics. Each nephrologist was then compared against their peers to calculate a PD attempt rate. The highest attempt rate group was compared with the lowest. When comparing PD attempt rates between groups, all the results were significant. PD technique survival at >90 days showed no significant differences (P = 0.42). Patient mortality at >90 days was also not significant when comparing groups (P = 0.14). Our data suggest that when comparing the low- with high-attempt groups, the factors limiting PD utilization do not include on-site availability of PD, case mix, funding, patient location or reimbursement. Aggressive approaches of starting more patients on PD did not lead to lower technique survival or higher mortality rates. If the PD attempt rate was maximized, a significant amount of money and resources could be saved or directed toward helping a larger population without significant harm to patients.

Developed Countries Lag in Use of Cheaper and Easier Peritoneal Dialysis

PERITONEAL DIALYSIS IS LESS COSTLY than in-center hemodialysis and offers equal mortality risk and improved quality of life. Still, such therapy for patients with end-stage renal disease has not been widely embraced in the United States and other developed countries. Worldwide, an estimated 1.8 million patients receive some form of dialysis, withonlyabout11%undergoingperitonealdialysis. IntheUnitedStates,ofmore than 390 000 patients who received dialysis in2010,onlyabout7%weretreated withperitonealdialysis—downfrompeak usage in 1995, when 14.4% of US dialysis use was peritoneal. The low utilization rates of peritoneal dialysis prompted leaders in the field of kidney dialysis in the United States to meet at a National Summit on Home Dialysis Policy on March 29 in Washington, DC. This summit served as the impetus for the launching on April 25 of the Alliance for Home Dialysis to advance the recommendations identified at the summit to federal policy makers (http://tinyurl.com/82q95rp). The alliance said that stakeholders in the dialysis community should work with policy makers to ease accessibility to peritoneal dialysis, improve accountability of those delivering home dialysis services, and align incentives to expand access to home dialysis. Rajnish Mehrotra, MD, a professor of medicine at the University of California, Los Angeles, and a panelist at the summit, said the reasons for low US utilization of peritoneal dialysis are complex and interrelated. Because the United States has developed an infrastructure to support hemodialysis but not peritoneal dialysis, there have been fewer peritoneal dialysis patients in the clinics. “That means that physicians in training get little or no training in treating patients with peritoneal dialysis,” said Mehrotra. “And in part, because of this lack of training, most patients starting dialysis are not informed by their physicians of the possibility of doing peritoneal dialysis.” According to presenters at the summit, only about half of surveyed nephrologists following fellowship training felt “comfortable, well trained, and competent” in the use of peritoneal dialysis as a treatment modality. Another survey presented found that less than half of patients receiving hemodialysis were provided information about peritoneal dialysis; yet another survey found that 45% of patients who received education about both options before starting dialysis chose peritoneal dialysis. In contrast, another study presented suggested that among US nephrologists, more than 90% would choose home dialysis for themselves. Other developed nations also are having trouble boosting use of peritoneal dialysis, but its use relative to the use of hemodialysis has remained stable in the developing world. A recent study involving data from 130 countries found that over a 12-year period ending in 2008, the number of patients receiving peritoneal dialysis increased in developing countries by 24.9 patients per million population and in developed countries by 21.8 per million population. However, the proportion of all patients treated with peritoneal dialysis declined by 5.3% in developed countries but did not change in developing countries (Jain AK et al. J Am Soc Nephrol. 2012;23[3]:533-544). The study’s lead author, Arsh Jain, MD, an assistant professor at the University of Western Ontario in London, Canada, suggested that the number of hemodialysis units available for treating patients, as well as differing regulations, may explain why developing countries seem more likely to offer peritoneal dialysis. “In the United States, you have built hemodialysis centers, and there is an incentive to keep those units filled,” Jain said. “In developing countries, it is very different; some places have mandates where you have to be on peritoneal dialysis.” Christopher R. Blagg, MD, professor emeritus of medicine at the University of Washington in Seattle and editor in chief of Hemodialysis International, is optimistic that peritoneal dialysis use will continue to grow in the United States because the financial incentives by Medicare (which pays for

Peritoneal Dialysis Catheter Placement Techniques

The success of catheter placement is critically important for the ability to stay on peritoneal dialysis over the long-term. Nephrologists have used percutaneous placement with or without fluoroscopic guidance and placement using peritoneoscopic guidance to place these catheters. Complications can be divided into early, within 14 days, and late complications, those arising more that 14 days after the procedure. The main post-procedure complications are infection, leakage, and obstruction. Results of non-invasive placement have been comparable to surgical placements. The non- invasive technique is simple with minimal intra-operative morbidity, and a post-placement complication rate better than surgical placements. Comparing percutaneously placed catheters to laparoscopically and peritoneoscopically placed catheters shows that the laparoscopic technique has a better one year survival rate. In deciding which technique is best for the patient, it is important to identify advantages of percutaneous placement, such as use of local anesthesia, lower rates of complications, the fact that it is a bedside or office procedure, versus the limitations in that the percutaneous method is not suited for obese patients or those patients likely to have peritoneal adhesions. Peritoneal catheters can be placed in a timely manner without delays associated with surgical scheduling. This offers an added option, both to the neprhologist and the patient and may avoid starting dialysis using a central venous catheter. The placement of peritoneal dialysis catheters by nephrologists has been shown to increase utilization of peritoneal dialysis as a dialysis modality, and this is an important advantage of the procedure.

Peritoneal Dialysis and the Process of Modality Selection

The process of modality selection and how it works is a critical determinant of peritoneal dialysis (PD) utilization. This very complex process has not been well analyzed. Here, we break it down into 6 steps and point out how problems at each step can significantly reduce the proportion of endstage renal disease patients initiating PD. It is important that any program wishing it to grow its use of PD understand the steps and the points at which problems may be arising. Examples are presented.

Renal replacement therapy in Europe-a summary of the 2009 ERA-EDTA Registry Annual Report.

Introduction.This study provides a summary of the 2009 ERA-EDTA Registry Report, with a focus on the differences in the incidence and prevalence of haemodialysis (HD), peritoneal dialysis (PD) and renal transplantation between countries and over time.Methods.For this report, 56 data sets on renal replacement therapy (RRT) from national and regional registries in 30 countries in Europe and bordering the Mediterranean Sea were available. Data sets with individual patient data were received from 26 registries, whereas 19 registries contributed data in aggregated form. For both types of registries, we present incidence, prevalence and transplant rates. Survival analysis is based on individual patient records.Results.In 2009, the overall incidence rate of RRT for end-stage renal disease (ESRD) among all registries reporting to the ERA–EDTA Registry was 125 per million population (p.m.p.). Incidence rates varied from 259 p.m.p. in Turkey to 19 p.m.p. in Ukraine and the mean age of patients starting RRT in 2009 ranged from 47.6 years in Russia to 69.5 year in Dutch-speaking Belgium. When examining the relative change of the HD, PD and transplantation distribution (at Day 91 after the start of RRT) between 2005 and 2009, we found overall a 0.5% decrease in HD, 1.4% decrease in PD utilization and an 1.8% increase of the share of patients living on a functioning graft. The overall prevalence of RRT for ESRD as of 31 December 2009 was 730 p.m.p. The highest prevalence was reported by Portugal (1507 p.m.p.) and the lowest by Ukraine (101 p.m.p.). In Norway, 70% of the patients on RRT were living with a functioning graft (591 p.m.p.) at 31 December 2009. The number of transplants performed p.m.p. in 2009 was highest in Spain (Cantabria) (78 p.m.p.). For the cohort 2000–04, the adjusted 1-, 2- and 5-year survival of patients on RRT was 87.4% (95% confidence interval: 87.2–87.7), 78.5% (95% confidence interval: 78.2–78.8) and 56.3% (95% confidence interval: 55.9–56.7), respectively.

Growing a peritoneal dialysis program: A single‐center experience

Growing a peritoneal dialysis program: A single‐center experience

Longitudinal Analysis of Market Factors Associated With Provision of Peritoneal Dialysis Services

Despite the appeal of peritoneal dialysis (PD) among patients, payers, and providers, its use in the United States has been limited and declining. Prior research has found that patient factors explain little variation in PD utilization, and little is known about the contribution of dialysis facility factors. The authors examined market factors associated with the provision of PD services in dialysis facilities between 1995 and 2003. Less than half of dialysis facilities offered PD. PD provision was not explained by disease trends or patient characteristics commonly associated with PD use. Facilities were more likely to offer PD in less competitive and less spatially concentrated markets. PD services may not be available to all patients who would benefit from it and there may be insufficient demand, economics of scale, or incentives for facilities to provide PD. These findings warrant further investigation on dialysis facilities' provision of a preferred, potentially beneficial, and cost-effective therapy.

Trends in Renal Replacement Therapy and Changes in Peritoneal Dialysis Utilization in the United Kingdom

Correspondence to: C. Castledine, UK Renal Registry, Southmead Hospital, Southmead Road, Bristol BS10 5NB United Kingdom. clarecas@yahoo.co.uk Received 21 September 2009; accepted 8 July 2010. The past 30 years have seen the dissemination of renal replacement therapy (RRT) throughout the United Kingdom. Trends in the numbers of patients treated with RRT and the modalities they use have evolved and continue to change today.

In Peritoneal Dialysis, Is There Sufficient Evidence to Make “PD First” Therapy?

Since its introduction more than 3 decades ago, the use of peritoneal dialysis (PD) has increased greatly due to its simplicity, convenience, and low cost. Advances in technique, antibiotic prophylaxis, and the introduction of newer solutions have improved survival, quality of life, and reduced rate of complications with PD. In Hong Kong, approximately 80% end-stage renal disease (ESRD) patients perform PD; in others, that is, Canada, Australia, and New Zealand, 20%–30% patients use PD. However, in the United States, the annual rate of prevalent patients receiving PD has reduced to 8% from its peak of 15% in mid-1980s. PD as the initial modality is being offered to far less patients than hemodialysis (HD), resulting in the current annual incidence rate of less than 10% in USA. There are many reasons preventing the PD first initiative including the increased numbers of in-center hemodialysis units, physician comfort with the modality, perceived superiority of HD, risk of peritonitis, achieving adequate clearances, and reimbursement incentives to providers. Patient fatigue, membrane failure, and catheter problems are other reasons which discourage PD utilization. In this paper, we discuss the available evidence and provide rationale to support PD as the initial renal replacement modality for ESRD patients.

Peritoneal dialysis: an underutilized modality

There have been differential changes in outcomes of patients treated with in-center hemodialysis and peritoneal dialysis. In light of these changes, providers and practices should reevaluate the utilization of peritoneal dialysis. Accumulating evidence confirms that the present distribution of dialysis modality in the United States does not reflect patient choice. Furthermore, in most recent cohorts, the 5-year adjusted survival of patients treated with hemodialysis and peritoneal dialysis is remarkably similar (35 and 33% respectively). Similar results have been reported from Canada, Australia, and New Zealand. Moreover, health-related quality of life of peritoneal dialysis patients are no different from that reported by those treated with nocturnal hemodialysis. Finally, an expansion of use of peritoneal dialysis for the treatment of end-stage renal disease makes economic sense for the taxpayers - the payors for dialysis services. The improvement in outcomes of peritoneal dialysis patients makes a compelling argument for the expansion of the use of the therapy for the treatment of end-stage renal disease in the United States. We think that 20-40% of patients can be treated with peritoneal dialysis. However, any expansion in use should be done gradually and should include training healthcare providers while continuously monitoring patient outcomes.

Peritoneal dialysis in the elderly--is its underutilization justified?

Peritoneal dialysis (PD) is underused as a dialysis modality in the elderly population. This is partly due to insufficient information about whether PD confers similar outcomes and quality of life as other modalities. In the BOLDE cross-sectional study, the authors compared different aspects of quality of life (cognitive function, index of deprivation and illness intrusiveness) in matched patients older than 65years of age treated by PD or haemodialysis. Quality of life was similar (and possibly somewhat better) in patients on PD. These data justify efforts to increase the utilization of PD in older subjects.

Impact of contraindications, barriers to self-care and support on incident peritoneal dialysis utilization

Targets for peritoneal dialysis (PD) utilization may be difficult to achieve because many older patients have contraindications to PD or barriers to self-care. The objectives of this study were to determine the impact that contraindications and barriers to self-care have on incident PD use, and to determine whether family support increased PD utilization when home care support is available. Consecutive incident dialysis patients were assessed for PD eligibility, offered PD if eligible and followed up for PD use. All patients lived in regions where home care assistance was available. The average patient age was 66 years. One hundred and ten (22%) of the 497 patients had absolute medical or social contraindications to PD. Of the remaining 387 patients who were potentially eligible for PD, 245 (63%) had at least one physical or cognitive barrier to self-care PD. Patients with barriers were older, weighed less and were more likely to be female, start dialysis as an inpatient and have a history of vascular disease, cardiac disease and cancer. Family support was associated with an increase in PD eligibility from 63% to 80% (P = 0.003) and PD choice from 40% to 57% (P = 0.03) in patients with barriers to self-care. Family support increased incidence PD utilization from 23% to 39% among patients with barriers to self-care (P = 0.009). When family support was available, 34% received family-assisted PD, 47% received home care-assisted PD, 12% received both family- and home care-assisted PD, and 7% performed only self-care PD. Incident PD use in an incident end-stage renal disease (ESRD) population was 30% (147 of the 497 patients). Contraindications, barriers to self-care and the availability of family support are important drivers of PD utilization in the incident ESRD population even when home assistance is available. These factors should be considered when setting targets for PD.

The Future of Peritoneal Dialysis in the United States

Peritoneal dialysis (PD) has been used to treat patients with stage V chronic kidney disease since 1976. However, despite this long history, as of 2008 <8% of prevalent ESRD patients in the United States are treated with PD, a modality mix that is significantly different from what is seen in other developed countries. Data are reviewed that suggest that the reasons for this seem to be caused by non-medical-related issues such as subtle differences in practice patterns and unintended financial considerations. Medical outcome date would seem to favor more utilization of PD. For instance, data from the USRDS suggested that the relative risk of death for PD versus center hemodialysis has been improving, tending to favor those on PD for longer and longer periods of time. Infectious complications have also been markedly reduced. It is anticipated that changes in government reimbursement, such as the bundling of dialysis-related services, will stimulate a renewed interest in home therapies. Currently most home dialysis units are small, and some have minimal clinical experience with PD. If trends in reimbursement do favor a renewed interest in PD, for patient outcomes on PD to continue to improve, there will likely need to be further educational activities focused on PD, and perhaps, consolidation of PD programs may needed.

Peritoneal Dialysis Catheter Insertion by Interventional Nephrologists

Peritoneal dialysis (PD) catheter placement is performed by surgeons, interventional radiologists, and interventional nephrologists. Catheter insertion is accomplished through various methods including open surgical technique and laparoscopic, peritoneoscopic, and fluoroscopic guidance. Complication rates and catheter survival can vary based on the insertion technique used. Recently, nephrologists have made significant advances in the area of peritoneal dialysis catheter design and placement. Current data suggest that nephrologists are increasingly placing PD catheters using peritoneoscopic and fluoroscopic technique. This review focuses on peritoneoscopic and fluoroscopic insertion and highlights the advantages of catheter insertion by nephrologists.

Peritoneal dialysis in elderly patients: report from the French Peritoneal Dialysis Registry (RDPLF)

The number of elderly patients starting dialysis is increasing in developed countries. Older age is frequently associated with contraindication of peritoneal dialysis (PD). The aim of this study was to report the outcome of elderly patients on PD in a country where assisted PD is available. This was a retrospective study based on the data of the French Language Peritoneal Dialysis Registry (RDPLF). We retrospectively analysed 1613 patients older than 75 years who started PD between January 2000 and December 2005. The end of the observation period was 31 December 2007. The mean age at dialysis initiation was 81.9 years; 545 patients had a Charlson comorbidity index (CCI) >9. Of these 1613 patients, 1435 were treated by continuous ambulatory peritoneal dialysis (CAPD) and 1232 were on assisted PD. The median patient survival was 27.1 months. In the multivariate analysis, patient survival was associated with sex, age, modified CCI, method of assistance and underlying nephropathy. The median pure technique survival was 21.4 months. In the Cox model, technique survival was associated with the modified CCI, but the association did not remain significant after adjustment for the centre size. The median survival free of peritonitis was 32.1 months. Neither the modality of assistance nor the centre size was associated with peritonitis risk. PD is a suitable method for elderly patients. In order to increase the rate of PD utilization in elderly patients, the need for the funding of assisted peritoneal dialysis has to be taken into account.

Peritoneal Dialysis in the Far East—an Astonishing Situation in 2008

The dialysis treatment rate varies tremendously in the Far East Asian countries, influenced by the economic status of those countries. The peritoneal dialysis (PD) utilization rate also varies greatly, ranging from 80% in Hong Kong to 3.5% in Japan. In certain low-economy countries, PD is rarely practiced. In recent years, PD utilization has been growing very fast in several countries, particularly China and Vietnam. New policies to encourage a shift from hemodialysis to PD have been undertaken recently in several countries such as Taiwan and Thailand, with a resultant rapid increase in patients on PD. The background and reasons for those changes are discussed.

Policies and Health Care Financing Issues for Dialysis in Latin America: Extracts from the Roundtable Discussion on the Economics of Dialysis and Chronic Kidney Disease

During the 2008 Congress of the International Society for Peritoneal Dialysis, academic nephrologists, nephrology societies, and government officials from Colombia, Brazil, Argentina, Chile, Central America, Ecuador, and Mexico participated in a roundtable discussion on the Economics of Dialysis and Chronic Kidney Disease in Latin America. The main focus was policy and health care financing. The roundtable promoted open discussion between policymakers and clinicians on how to find viable solutions to contain spending on treatment for end-stage renal disease into the future. A number of options were proposed, including early medical intervention (disease management programs) to slow the progression of chronic kidney disease in high-risk patients, promotion of pre-emptive renal transplantation, and use of the most cost-effective dialysis therapy that can be offered to a patient without compromising outcome. It was concluded that the burden of treating more patients in the future could be alleviated by wider utilization of peritoneal dialysis (PD). However, important changes in health care reimbursement systems and realignment of incentives in the region are required to support wider PD penetration.