Choosing a Dialysis Therapy: Narrative Summary of a Panel Discussion

Choosing a Dialysis Therapy: Narrative Summary of a Panel Discussion A.J. Wing, MA, DM, FRCP, Chairperson

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HERE WAS general agreement that population characteristics such as age, diabetes mellitus, and cardiovascular disease influence mortality in patients on chronic dialysis therapies. Numerous reports suggest similar mortality rates for different dialysis therapies if comparable populations are studied. Other than the VA cooperative study, which randomized patients to hemodialysis or intermittent peritoneal dialysis, there have been no randomized prospective controlled comparisons of dialysis therapies. Therapies have complications common to all dialysis therapies and some unique complications. A standard index of morbidity is hard to define. Hospital days per year and various indices of rehabilitation are influenced by multiple factors other than the dialysis therapy per se. Dr Shapiro felt that certain patient groups will do better on one type of therapy than another and that cumulative future experiences will better define these group therapy relationships. Dr Nolph noted that patients tend to be influenced in their choice of therapy more by the impact of that decision on their lifestyle than by mortality and morbidity figures. The choice of therapy may depend on where patients live, whether they live alone, where they work, and what kind of family support they have. Dr DiazBuxo related the choice of dialysis therapy to a famous 19th century saying: "In the choice of a

Chairperson: Dr A.J. Wing, St Thomas' Hospital, London, England. Panel members: Dr K.D. Nolph, Professor of Medicine, Director, Division of Nephrology, University of Missouri, Columbia, Mo; Dr R. Fine, Professor of Pediatrics, UCLA School of Medicine, UCLA Center for the Health Sciences, Los Angeles; Dr C. Blagg, Northwest Kidney Center, Seattle; Dr R.M. Lindsay, Renal Unit, Victoria Hospital, London, Ontario, Canada; Dr 1. Diaz-Buxd, Director, Nalle Clinic Kidney Center, Charlotte, NC; Dr F.L. Shapiro, Hennepin County General Hospital, Department of Medicine, Minneapolis; and Dr R.i. Simmons, Department of Sociology, University of Minnesota, Minneapolis. Address reprint requests to Dr A.J. Wing, St Thomas' Hospital, London, SEI 7EH, United Kingdom. © 1984 by The National Kidney Foundation, Inc. 0272-6386/84/030256-04$01.00/0

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horse and a wife a man must please himself ignoring the opinion and advice of friends." Dr Blagg felt that physicians are influenced by past experiences with various therapies, financial circumstances, facility circumstances, and community conditions. In other words, economy and related issues are likely to influence decisions. Dr Blagg expressed his opinion that in younger patients with a willing living-related donor available, renal transplantation is best. Beyond that, Dr Blagg felt it was a question of what works best for each patient. Dr Simmons was intrigued that in the patient panel the patients described how "freedom" influenced their choice of therapy, yet each one chose a different therapy. She also emphasized that systems that are operative and successful in the United States need not be compatible with the best quality of life elsewhere. Also, Dr Simmons feels that doctors and nurses are influenced by their own sphere of activity. Nurses and doctors who deal more with dialysis see the transplant failures. Professionals more involved in kidney transplantation see patients who are glad to be off dialysis. With various forms of dialysis therapies, professionals develop prejudices based on their own perspective and assume that other therapies are inferior to theirs. Dr Lindsay believes that self-care dialysis and home dialysis provide far better therapy than center treatments. Promoting home and self-care may have had origins based on a shrinking economic environment, but Dr Lindsay holds that other benefits of more control over their own lives became obvious. Dr Lindsay pointed out that in Canada 50% or more of the dialysis population is in a home or self-care situation. He urged the United States to do this for patient benefit if not for taxpayer benefit. Dr Lindsay emphasized that age was no barrier to home hemodialysis. What about the small infant and the younger child? Dr Wing asked Dr Fine what advice he would give a colleague about placing an infant child on chronic dialysis. Dr Fine felt that th~ decision had to be made primarily by the parents once informed of the negative aspects of treatment, the

American Journal of Kidney Diseases, Vol IV, No 3, November 1984

CHOOSING A DIALYSIS THERAPY

potential complications, and the limitations of treatment with regard to long-term results. Dr Fine pointed out that the great majority of parents, despite receiving negative information, base their decision on the fact that the child will die if nothing is done and may live if something is done, and for them everything else is irrelevant. If parents wish the treatment, Dr Fine feels nephrologists do not have the right to say no. Dr Wing asked whether parents must be given all the facts. Dr Fine felt it was not fair to parents to present anything other than a realistic portrait of what the therapy would offer. A specific example. Dr Wing asked the panel what they would choose as the ideal mode of therapy for a very active, athletic young man of 25 without any social attachments. Dr Nolph stated that, in his program, the patient would have a major role in making the decision. Transplantation would be encouraged. Meantime, a chronic dialysis therapy would be chosen. If the patient lived a great distance from the center, as so many Missouri patients do, center dialysis would probably not be the patients choice. Continuous cyclic peritoneal dialysis (CCPD), continuous ambulatory peritoneal dialysis (CAPD), satellite hemodialysis, and home hemodialysis would all be options. If the patient disliked machines or longer training periods, he might choose CAPD. Dr Simmons said she would certainly think of transplantation first. Assuming that dialysis is necessary for at least some time, she suspected that in many programs the chances of discussing all of the alternate dialysis therapies described would be unlikely. Dr Lindsay felt that such a patient needed to go on minimal care hemodialysis until such a time that he or she is transplanted. Dr Blagg suggested the possibility of finding a helper among the patient's friends to help him do hemodialysis. Dr Nolph interpreted Dr Lindsay's and Dr Blagg's comments as implying that hemodialysis was more compatible with atheletics and travel. Dr Nolph stressed that in his experience the catheter and fluid in the peritoneal cavity did not interfere with participation in sports such as baseball, jogging, swimming, and tennis. Hemodialysis disequilibrium may even discourage activities. Travel arrangements were just as easy or easier with CAPD. Dr Lindsay suggested that unwanted weight gain would be likely with CAPD.

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A specific example. Dr Wing asked the panel to recommend therapy for a low-income, female patient living in an inner city. Dr Lindsay would attempt to determine if she could manage CAPD in her own home, provided the conditions were suitable. However, he felt she would probably end up on center hemodialysis. Dr Simmons stressed that such a patient may be poor but, on the other hand, may have a fairly active social support system. She felt it would be necessary to determine whether the home environment could be made conducive to one of the forms of home dialysis. Dr Wing described the domiciliary services provided in the United Kingdom. Workers visit homes and try to improve the hygiene and the potential to perform home dialysis. Dr Blagg wanted to look at some form of selfcare of CAPD in this situation. A specific example. Dr Wing asked the panel to recommend therapy for a type 1 diabetic with gastroparesis, cachectic, weighing 781b, and demonstrating a minimal nutritional intake of 30 to 40 g of protein per day. The patient expresses a wish for CAPD. Dr Nolph felt that CAPD could be considered in this patient if protein intake could be improved. In some diabetics metoclopramide has helped to overcome the effects of gastroparesis. Thbe feedings may improve nutritional status, which in turn may lead to improved eating habits. Some experiences suggest that if the vomiting cycle can be broken the patients may do better. Dr Blagg would first try hemodialysis rather than peritoneal dialysis. He would strongly consider parenteral nutrition. Chronic peritoneal dialysis or other forms of long-term therapy could be considered if nutritional status improved. He emphasized that integration of therapies is important. One therapy may provide support but lead to the preferred therapy when the problem of nutrition is corrected. Dr Lindsay echoed the feelings of Dr Blagg. He stated that he had used a combination of both hemodialysis and peritoneal dialysis on an intermittrent basis in such patients. Long-term plans were decided after nutritional status was under control. Dr Lindsay challenged the popular impression that diabetic patients would do better on CAPD. He would like to see proof. The role of aggressive dietary management predialysis. Dr Wing asked the panel to comment on

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whether aggressive dietary management could extend the predialysis period. In his experience such an extension has often been at the cost of malnutrition. Dr Nolph mentioned that anecdotal reports suggest that protein restriction early in renal failure may slow the progression of renal disease and delay the need for dialysis. Large-scale controlled studies may soon be undertaken. Dr Blagg felt that unrestricted protein intake may accelerate renal disease. Studies of protein restriction of a modest degree early in renal failure will be important. However, Dr Blagg indicated that in far-advanced renal disease, unless there were some specific circumstances for delaying dialysis for a patient, he would prefer to initiate dialysis early. Dr Blagg was also skeptical as to whether dietary therapy could work in a community setting as well as in controlled circumstances. Dr Fine cautioned the panel about the adverse effects of restricting dietary protein on growth in children. Dr Lindsay felt that protein restriction to slow the progression of renal disease might be important when the nephron mass remains above 25 % to 30%. A patient with 5 % to 10% of functioning normal nephron mass is probably hyperfiltering no matter what the protein intake. The time to start dialysis. Dr Lindsay asked Dr Blagg whether he had proof of an advantage of early dialysis. Dr Blagg replied that the Seattle approach is to start dialysis when the patient begins to have some symptoms that could interfere with usual activities. He has not started dialysis based on a specific residual renal creatinine clearance, even in diabeti.cs. Dr Lindsay described exeriences in the United Kingdom where dialysis was delayed until serum creatinines exceeded 15 mg/ dL. In Canada an average-sized dialysis patient is started on dialysis by the time serum creatinine is 10 mg/dL, or earlier if there are symptoms. Dr Lindsay felt there was no doubt that patients started earlier had fewer complications in the early months and years of treatment. Dr Blagg quoted Dr Scribner as saying that he had never seen a patient who was dialyzed too early but he had seen plenty of the reverse. Dr Fine felt that there may be some virtue in initiating early dialysis in children. He pointed out that if children started CAPD with a low serum

WING ET AL

albumin, it was likely to remain low. In those who started CAPD with a higher albumin, it tended to remain at that level. Are mortalities the same with different dialysis therapies? Dr Wing asked the panel to comment on relative mortalities with different therapies. Dr Nolph mentioned that survival on CAPD for Registry patients less than 60 years of age and not diabetic was 91 % at 18 months. He felt this was similar to survivals with hemodialysis therapies for similar patients. Dr Shapiro felt that future applications of the Cox multiple hazard model will allow us to better focus on this question. He predicted that we will find a segment of the popUlation with certain characteristics that will do better on CAPD than on hemodialysis. Likewise, he predicted that certain patients will do better on hemodialysis than on CAPD. He suggested that dialysis results in young patients are now so good that a mandate to push for cadaveric kidney transplantation could be questioned. What are the approximate costs of dialysis therapies? The panel had no precise cost figures but estimated that costs for maintenance therapy (not including costs of hospitalization for complications) range from $25,000 to $30,000 per year for center hemodialysis; $12,000 to $15,000 per year for home dialysis; $17,000 to $18,000 per year for CAPD; and $18,000 to $19,000 per year for CCPD. Costs may run higher in children. CCPD is slightly more costly than CAPD because of the purchase of a cycler and the use of special tUbing. Kidney transplantation costs are variable and difficult to determine. Dr Wing made the point that the least expensive of all treatments is that which avoids dialysis and transplantation. Sadly enough this has been a necessity in some areas of the world. Dr Wing made an interesting comparison of the costs of ESRD therapy with the costs of keeping a villain in custody. A low-risk villain costs about the same as hospital hemodialysis, but a villain requiring a high-security jail costs more than any method of renal replacement therapy. Dr Shapiro felt that real costs of center dialysis in a hospital are probably inflated because of the spin-off of services to other hospital programs. Lower costs of freestanding facilities demonstrate this. Dr Lindsay pointed out that hospital days per

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year may be a misleading index of additional costs for complications. Short frequent admissions may be more costly than fewer prolonged admissions. The first day in the hospital is frequently the most expensive one. Dr Diaz-Buxo felt that home hemodialysis was the cheapest of dialysis therapies. In his experience, actual total costs for CAPD and center programs were similar (including complication and hospitalization costs). Patients on home hemodialysis and CCPD had costs between the low costs of home hemodialysis and the higher costs. He noted that this may relate to the patient selection for the different therapies in his program and hospitalization requirements related to patient characteristics. Dr Simmons mentioned that policy issues related to disability insurance are very real. A successful transplant may not rehabilitate a patient if it is unrewarding financially to return to work. Dr Simmons knew of a patient that would lose $335.00 a month in benefits for the acceptance of a job paying $300.00 a month. The group felt there were many physical and psychologic benefits of returning to work. Means of circumventing counter incentives should be considered. Dr Blagg stressed the differences between costs and charges. He felt that some dialysis therapies cost the government more than actual costs to the facility. Failure to distinguish costs from charges causes confusion. Dr Shapiro pointed out that with current reimbursement policies there must be a mixture of home- and facility-based patients to break even. Dr Wing expressed interest among nephrologists in the United Kingdom in how United States reimbursement policies may modify clinical practice. Peritonitis. Regarding the question of whether the hospitalization rate for CAPD would be lower if the outpatient treatment of peritonitis was funded, Dr Nolph responded that it is difficult to find money for antibiotics for some patients and this indeed may influence the decision as to whether to hospitalize the patient. Are peritonitis rates with CCPD below those with CAPD? Dr Diaz-Buxo pointed out that rates

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of peritonitis with CCPD vary. Some programs report one episode every 72 to 75 patient-months while others report one episode every 5 patientmonths. He suggested that results were mainly a matter of patient selection and program experience. Centers reporting to the Registry have very few patients on CCPD and are offering mainly CAPD. This may explain similar rates for CCPD and CAPD in the Registry. Dr Nolph emphasized the importance of common definitions of peritonitis before comparing peritonitis rates. Does CCPD allow greater tolerance to increased peritoneal volumes? Dr Diaz-Buxo described the relationship between intraabdominal volume and pressure and noted the fact that intra-abdominal pressure is lower for the same volume in a supine position. However, some data suggest that cardiovascular and pulmonary function may be compromised more in the supine position at any given pressure. Dr Diaz-Buxo urged caution in suggesting that higher volumes could be tolerated at night in CCPD patients. The majority of his patients have tolerated up to 2.5 L of instillation in the supine position. Is the impact of a therapy on body image important? Dr Simmons described studies indicating that body image influences emotional adjustment. Patients adjust less well to diseases with visible defects. Does CAPD arrest the progression of diabetic retinopathy better than hemodialysis? Dr Shapiro felt that hemodialysis was not associated with progression of diabetic retinopathy at a rate different than transplantation. He also felt that recent data on CAPD and diabetic retinopathy show progression rates similar to those with transplantation and hemodialysis. It was his impression that control of BP and the use of aspirin or other platelet inhibitors helped to stabilize progression of retinopathy on any of the treatment modalities. He felt there was a need for regular ophthalmologic review and treatment with laser. It was his opinion that treatment modalities no longer make a difference in the preservation of the eye provided good eye and medical care are rendered.