Preparing for Peritoneal Dialysis

C H A P T E R

71 Preparing for Peritoneal Dialysis Rajnish Mehrotraa, Beth Pirainob a

University of Washington, Seattle, WA, United States; bUniversity of Pittsburgh, Pittsburgh, PA, United States

INTRODUCTION

Abstract Preparation for home dialysis begins with a robust modality education program because patients cannot make a decision regarding the type of dialysis if they are not provided adequate information. This requires infrastructure that some programs do not have, as well as nephrologists who are welcoming and receptive to their patients’ choice of home dialysis. Unfortunately, many dialysis patients in the US do not recall receiving much information about peritoneal dialysis (PD), indicating that the process is often inadequate. This is one barrier to PD. Another is the nephrologist. The nephrologist is the most important influence regarding the decision for PD, so it is critically important that the nephrologist be trained in PD sufficiently to eliminate biases. The program must have the infrastructure to provide robust and comprehensive modality education to patients and their support persons. This includes a one-on-one session with an educator (often a nurse), videos, visits to a home program, peer-to-peer discussion with a PD patient, and follow-up with the nephrologist. Because many patients with advanced chronic kidney disease present urgently with signs and symptoms that require rapid dialysis implementation, an in-house education program is desirable but requires an investment in a nurse educator on site. Once the decision is made to start PD, arrangements are made for PD catheter placement. In most centers, scheduling this procedure can be delayed, so careful planning is necessary. Some innovative programs incorporate interventional nephrologists or radiologists in the program who can place PD catheters and thus ensure that rapid start PD is available. These approaches have been shown to greatly increase PD program size and allow a higher proportion of patients to choose PD at the outset. Use of the buried catheter technique is another approach that may facilitate timely PD start. The home dialysis program must be supported by the dialysis provider or hospital or institution, as appropriate. Adequate staffing is critical to the success of the program, allowing time for training (which is usually one on one), and for meeting the regulations in place for home programs. Space for the home program is also essential, with room for private training and for clinic visits.

Chronic Renal Disease, Second Edition https://doi.org/10.1016/B978-0-12-815876-0.00071-1

The choice of dialysis modality to manage advanced kidney disease is intensely personal. The initiation of dialysis has a tremendous impact on the person’s life.1 If done badly, a person who may have been functioning at a high level may abruptly become a “patient,” with disruption of work and other activities. Depression often ensues and is common in patients undergoing maintenance dialysis.2 Therefore, the process of dialysis preparation is essential for good outcomes. Unfortunately, many patients do not receive adequate modality education.3e5 Study after study of patients recently started on dialysis have shown that many treated with in-center hemodialysis (HD) do not recall receiving education about a choice of home dialysis.3e5 Even allowing for impaired recall, it is clear that modality education in many programs is woefully inadequate. There are many reasons for this, but leading are nephrologist bias against peritoneal dialysis (PD) due to lack of training in PD, as well as a failure of adequate infrastructure for the process.6e8 The need for urgent start dialysis is another reason given for inadequate or no modality education. Data suggest that survival is similar on in-center HD and PD.9e17 Early studies that showed an HD survival advantage were flawed by excluding many who were survivors, such as patients who were transplanted early in the course of dialysis.18,19 Patients treated with PD are more likely to be transplanted quickly than those on HD.10 This is one source of bias in such comparative studies. Another is selection bias. In The Choice study, done at Dialysis Clinic Inc units plus one unit in Connecticut, almost all the PD patients in the centers participating were included, whereas HD patients were a convenience sample, because the social workers recruited those that were available (that is those who

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© 2020 Elsevier Inc. All rights reserved.

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were not in the hospital on the recruitments days, and who had arrived for dialysis).20 Such an approach can impact the survival outcomes because some of the sicker patients on HD (as opposed to PD) were not included in the sample. More recent studies using large databases and controlling for all important variables show similar 5-year survival.9e17 Therefore, choice should be made by the patient after being fully informed of the options based on the patients’ preferences and the impact on lifestyle. Access plays an important role in subsequent survival on dialysis. Those with a HD catheter are more likely to die than those with a PD catheter or with an arteriovenous fistula (AVF) or graft.21 Therefore, proper and timely education of modality choice is very important to ensure that the right access is placed at the right time for each patient.

INDICATIONS AND CONTRAINDICATIONS FOR PD There are only a few contraindications for PD (Table 71.1). These include inability to do PD, or lack of a helper to perform the procedure for the patient. Most people can perform PD or may have a family member who is willing to assist. An attempt at a randomized controlled trial done in the Netherlands found that w65% of people had no contraindication to doing either PD or in-center HD.22 Once these patients were fully informed regarding PD and HD, to permit consent for randomization, almost everyone refused to be randomized after learning of the difference. Patients had a distinct preference for one dialysis method vs. another.22 45% chose PD. This study, although unsuccessful in its recruitment efforts, provides an important lesson, in that it clearly showed that given full information, patients want a choice of modality. TABLE 71.1

Contraindications to Peritoneal Dialysis (PD)

ABSOLUTE CONTRAINDICATIONS Nonfunctioning peritoneum (for example, history of abdominal radiation) Inability to perform PD combined with lack of a partner to perform PD Homeless state RELATIVE CONTRAINDICATIONS Ostomy (presternal catheter allows PD) Right-sided heart failure with ascites Ligation of thoracic duct and chylous ascites Active colitis

Dementia, if severe, may lead to problems with both in-center HD and PD. More attention is being given to conservative care approaches in older patients, those with considerable comorbidity and demented patients who will gain little benefit from starting dialysis.23 Patients who require nursing home care are often provided HD, and this is sometimes done on site. Nursing home PD programs are not common, but have been successful, and may lead to lower costs.24 One issue is ensuring that those doing the PD are adequately trained on the technique to prevent high peritonitis rates.24 Those patients with mental illness are problematic when treated with in-center HD. Paranoid patients have anxieties and fear increased by being attached to a machine and may lash out at healthcare providers and even prove dangerous. Such patients if able to perform PD and have a safe home environment may be offered PD and may do well. Nonadherence and anger expressed by those starting in-center HD may reflect in part lack of control and lack of autonomy. Having control over the dialysis such as is the case with self-care HD or PD may improve adherence and sense of control. Therefore, nonadherence should not be a reason to deny a patient full modality education. A nonfunctioning peritoneum is likely to be the case in someone with a prior ruptured viscus, or someone with prior history of radiation to the abdomen. Prior surgery is not a contraindication, as it is impossible to determine before the peritoneal catheter placement is attempted whether there will be too extensive adhesion formation to obtain a well-functioning catheter.25 In some cases, the adhesions may be lysed and PD successfully achieved.25 Experience of the operator placing the catheter is particularly important in such cases.25 Patients who have right-sided heart failure with extensive ascites, as seen with severe pulmonary hypertension or severe tricuspid regurgitation, do not do well on PD as fluid losses tend to be so great that there is profound hypovolemia. Similarly, ligation or damage to the thoracic lymphatic duct leads to chylous ascites; these patients tend to become malnourished and volume depleted on PD. Those with severe ascites from liver failure also are prone to development of hypotension and hypovolemia from excessive fluid removal. Such patients are not likely to do well on HD either. The prognosis is dictated by the underlying liver disease and not by the choice of dialysis modality. Some consider an ostomy to be a contraindication to PD. This issue can sometimes be managed with a sternal exit site for the PD catheter. Again the experience and comfort of the operator placing the PD catheter is key in these situations. There are few data on outcomes of PD patients with ostomies.

VIII. THERAPEUTIC CONSIDERATIONS

EDUCATION OF THE CKD PATIENT ABOUT DIALYSIS MODALITIES

Some patients do particularly well on PD, such as those that are younger with less comorbidity.26 However, PD is underutilized in the elderly, who sometimes prefer to stay at home for dialysis, and is underutilized in certain racial and ethnic groups.27 Asian Americans are somewhat more likely to do PD and African Americans are least likely.27e29 This is not based on outcome data, but is likely a consequence of inadequate preparation for dialysis based on bias, either implicit or overt, of the healthcare provider team. Implicit bias training of all healthcare providers might be an approach to ensure equity of care for our patients.

TABLE 71.2

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Approach to Education of the Patient on Modality Choice

Introduction of the topic by the nephrologist as CKD advances. Referral for education and decision support By physician or advanced care practitioner By nurse educator By social worker Videos Online information Visit to the home program Peer-to-peer education

EDUCATION OF THE CKD PATIENT ABOUT DIALYSIS MODALITIES PD is a good choice to manage end-stage renal disease for many.30 Studies have shown that approximately three-fourths to two-thirds of patients may be suitable for modality education.17,31 With full education, a substantial proportion chose PD.32e34 The most important reason for the low uptake of home dialysis in many developed countries, and particularly in the US, is inadequate dialysis modality education, not contraindications to PD. Surveys of nephrologists from different parts of the world suggest that ideally approximately half of patients starting dialysis would start with in-center HD, either due to contraindications to home dialysis or patient choice, with about 11% on home HD and 38% on PD.35,36 In countries with a PD first approach, such as Hong Kong and Thailand, as many as 80% start dialysis with continuous ambulatory PD (CAPD)37e41 mostly due to economics. In such situations, patient choice is confined by the government’s wish to save money with a high proportion of PD patients. PD is easy to learn and does not require a partner. Nighttime PD allows the patient to continue daytime activities including attendance at jobs and school. Perhaps, for this reason, children are often started on PD. CAPD, on the other hand, is a good choice for those who prefer not to be attached to a machine and for those who are restless sleepers and get up frequently at night. Cycler PD and CAPD, from the patient’s perspective, are quite different. Therefore, modality education needs to cover both options, outlining the differences and the advantages and disadvantages of each. CAPD is easier to learn than the cycler. Therefore, some older patients who wish to remain independent may chose CAPD, but not find cycler PD attractive. Although PD is usually performed by the patient independently, in some situations, there is a helper, who may be a spouse or an adult child, who performs the dialysis.

Follow-up visits with the nephrologist for decision support

Because incremental dialysis is possible in many who start dialysis with residual kidney function, CAPD does not have to be prescribed initially as four exchanges per day. For some patients, two or three exchanges per day may initially suffice.42 Similarly, cycler PD may only need to be done at nighttime with no day dwell or exchanges.42 This information can impact the decision made by the patient regarding modality. It has been shown time and time again that most patients treated with in-center HD have received inadequate education about the modality choice. There may be multiple reasons for this. The physician has been shown to be the person who most influences patient choice of modality, but most nephrologists and almost no internists have training or experience in supporting informed modality choice (decision support). Discussion of modality takes time and an adequate knowledge of the details of PD, including management of supplies, access, infection risk, different types of PD, training time, follow-up procedures, and support. Most nephrologists are familiar with in-center HD, but many have little training and are uncomfortable with home dialysis including PD.6,8 Many trainees make inappropriate assumptions about who might be “suitable” for PD or home HD. This is likely due to insufficient knowledge of the modalities by both the trainee and the faculty mentors. A comprehensive approach to modality education is shown in Table 71.2. Modality education is best done in a stepwise fashion.43 Patients when hearing about the upcoming need for dialysis are often frightened and in denial. Thus, many do not hear much of the initial information on this topic. The introduction of the topic of dialysis choice can begin with the patient once estimated glomerular filtration rate (eGFR) approaches around 20 mL/min/1.73 m2, although this must be tailored to rapidity of progression. This initial

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introduction should be followed by a referral to an educator. The patient should be encouraged to visit the home program, as well as meeting with the home training nurse, viewing the equipment, and understanding the storage space needed, and, as appropriate, meeting other patients doing home dialysis. Subsequent follow-up with the nephrologist then can begin to pin down the choice with which the patient is most comfortable. This needs to be an iterative process, as many have such a fear of dialysis that the initial discussions are not fully absorbed.43 The partner or any significant support person should be present at some of these education sessions. Group sessions can be used to supplement the information, but alone are not adequate for education. One-on-one sessions allow the teacher to explore the level of understanding of the modalities. Because the physician is the most influential person in the patient’s final decision, the information process should not be entirely assigned to educators. The nephrologist should be the leader in the education process and ensure that sufficient steps are taken to guarantee understanding. Having the patient reflect back on information received is a helpful technique to ensure that misconceptions and biases have not crept into the process. Many patients have misconceptions about home dialysis that can be explored in conversations. Sometimes this misinformation comes from support persons who have not been part of the process. In other cases, misinformation can come from the primary care physician who may not be acquainted with PD. Fully informed patients have many reasons for their choices.1 One patient may elect to choose PD simply because of a fear of needles, another because it allows the patient to continue with a job or school or both. Yet another patient may like the independence and flexibility home dialysis brings vs. in-center HD.1 Patient autonomy is an important reason that patients choose home dialysis.1 It is important to understand that patients will not pick home dialysis without substantial and detailed education about this choice. Patients do not choose a modality they know little or nothing about. Many patients find the entire concept of dialysis frightening and intimidating. Therefore, a full understanding of the choices, and the impact this choice will have on lifestyle, requires considerable investment by the program. Most patients are capable of doing PD but have little confidence in their ability. Some develop depression on learning dialysis will be needed. This depression may paralyze decision making. Reassurance that patients can learn the technique if they chose to and a supportive approach are key parts of the process. Too often, the default is inadequate, cursory modality education and a default to in-center HD. This is one reason why the majority of patients in most western

countries are treated with in-center HD. A survey of nephrologists showed that a minority would pick in-center HD for themselves.44 Therefore, it is ironic that most patients in Canada and the US are maintained on incenter HD. In the US, with the implementation of the expanded prospective payment bundle for dialysis, PD became more economically advantageous for dialysis units.45,46 This is in part because PD patients require less erythropoietin and intravenous iron (drugs which are now included in the bundled rate) than HD patients. This incentive encouraged dialysis programs to enhance their modality education programs. One such program developed by Fresenius Medical Care, Treatment Options Program, was quite successful in increasing the uptake of patients on PD.47 However, many patients were not referred for the educational program. More recently, dialysis providers are employing nephrologists and thus have more control over the chronic kidney disease (CKD) clinics and the education process. Many patients once started on one modality are reluctant to make a switch.48 Therefore, education is best done before starting dialysis. This allows avoidance of placement of a HD catheter as a way of starting dialysis. However, late-referred patients should not be denied a choice, and all patients should receive iterative modality education with decision support.

PLANNED VERSUS NONPLANNED (URGENT) START PD Patient education on modality choice may take months to achieve. However, a large number of patients present with very advanced CKD, requiring urgent start dialysis due to uremia, hyperkalemia, volume overload, or other indications. The default approach is to place a HD catheter and start HD in the hospital. Discussion of modalities does not happen in most of these cases. However, several publications have shown that by implementing an in-house modality education program, the uptake of home dialysis, particularly PD, can be greatly increased.49,50 This requires that the program makes an educator available for late-referred patients and may involve visits to the home program and contact with a current PD patient for peer-to-peer education.51 The nephrologists in the program need to be supportive of this approach for it to be successful. Such an approach can be cost-effective.52,53 Numerous reports from around the world have shown that such an approach results in a significant proportion of late-referred patients starting with PD with good results.51,54e62 Infrastructure needed for a successful PD program, including one with an urgent start capability, is shown in Table 71.3.

VIII. THERAPEUTIC CONSIDERATIONS

TIMING AND PREPARATION FOR CATHETER PLACEMENT

TABLE 71.3

Infrastructure Needed for Peritoneal Dialysis (PD) Including Urgent Start

Ability to provide modality education and decision support on short notice Resources for rapid placement of PD catheter Ability to provide supine PD until patient can be trained Available nurse trainers, protected from in-center HD demands Adequate space for PD training and follow-up visits

ASSISTED HOME DIALYSIS There was a period of time in the US when assisted home HD was supported by the payors for dialysis, such that a nurse or dialysis technician would go to the home to do the HD. Because of costs, this quickly fell out of favor and is now rarely if ever an option. However, innovative programs in different parts of the world have implemented assisted PD.63e68 In such a situation, mostly involving elderly patients who prefer to do PD at home at night on a cycler, but do not feel capable of being completely independent, a visiting nurse travels to the home and sets up the cycler each day, sometimes also attaching the patient. Often the patient is able to disconnect from the cycler (which is an easy maneuver) in the morning. A proportion of these patients will eventually be able to perform dialysis at home independently.65 In France, there is a substantial home PD assisted program for elderly patients.64 This approach has not been implemented in the US, but given the economic advantage of PD over in-center HD for the dialysis provider, should be tested in the US on a trial basis. For now, patients in the US can benefit from assistance from their family members. In some states, publicly funded compensation is available for the provision of in-home support services.

TIMING AND PREPARATION FOR CATHETER PLACEMENT Once the patient has decided on PD, there is no need to put the access in until close to the timing of PD start. However, once the patient arrives at stage 5 CKD, follow-up should be performed with frequent laboratory checks to ensure that the timing of PD catheter placement is optimal. It is often prudent to send the patient to the person placing the PD catheter ahead of time to ensure there are no barriers. The PD catheter is most often placed by a surgeon. Although this is not a difficult surgery, it is important that each program finds surgeons who are interested

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in working as a team, will appreciate feedback, and who are good communicators. Some programs have had good success by having a nephrologist or radiologist train in PD catheter placement, which allows quick access to PD and PD training. This approach has led to dramatic increases in the size of already large PD programs.69 Because interventional nephrology as a subspecialty is gaining attention, PD catheter placement should be part of this training. Actual placement of the catheter should be timed so that there remain 10 days to two weeks for healing before training begins. There is no need to place the PD catheter earlier than this, although there are programs who prefer to use the buried catheter approach. With this approach, the tunneled portion of the catheter is completely within the subcutaneous tissue, with no external portion.70,71 The advantage of this approach is that when the patient is ready to start dialysis, the PD catheter can be brought to the exterior with the creation of an exit site, and because the cuffs are fully embedded, the catheter can be used immediately. Furthermore, during the waiting period to start dialysis, no care is needed for the catheter. Limited research indicates that catheter outcomes are no different with this approach, and there is no reduction in early PD-related infections as was posited. While offering the advantage of elective start of PD, in some patients the placement may be futile, as they may die before needing dialysis or start with HD, either because they may change their mind or may have had a change in health or social condition that may preclude home dialysis. In 10e15% of the cases, the catheter may have problems with drainage, which are generally readily resolved with vigorous flushing. Some programs routinely use this approach with good results.71e73 There is no preferred type of PD catheter. At one time, the literature suggested that a downward directed exit site would decrease the risk of exit site infection. However, there is little research to support this hypothesis and a laterally directed exit site may provide the same results.70 A skilled operator is the key to successful outcomes with a PD catheter. Generally, the catheter is placed when the eGFR is around 10 mL/min/1.73 m2. Placing a HD catheter in a patient who wants PD should be avoided as much as possible, as this leads to increased risk of infection and exposes the patient to HD which may decrease residual kidney function, lead to cardiac arrhythmias, and cause emotional distress to the patient and interfere with daily activities. PD catheter placement should be elective and done as an outpatient as much as possible, as a planned event. Once PD catheter placement is scheduled, the patient should be carefully instructed in the preparations for the placement. The skin should be clean and without

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infections. The patient should take a cathartic before the procedure to ensure that the colon is relatively empty. The patient should void before the procedure and if there is any suggestion of a neurogenic bladder, a bladder scan should be done to ensure that the bladder is empty. A single dose of preoperative intravenous antibiotics reduces the risk for early infection and should be the standard of care.74 After the catheter is placed, the patient will be generally discharged home, but should be instructed to keep the dressing dry and clean and to not change the dressing. Approximately one week later, the patient should visit the training center, where the nurse will do a dressing change, inspect the exit site, and, in some programs, flush the catheter to ensure proper function.70 Training can generally start 10 days to 2 weeks after catheter placement. Only when the exit site is well healed is the patient to resume showers and start performing daily exit site care.

BARRIERS TO PATIENT-DRIVEN MODALITY CHOICE Unfortunately, one of the major barriers to patient choice is the lack of training about home dialysis in many countries, including the US. Early in the growth of PD, in the 1980s, most PD patients were dialyzed at centers with a particular interest in PD, and at least one nephrologist who was a champion of PD. As HD centers became more and more common, there was pressure to fill HD seats, and less emphasis on providing modality education to patients. The proportion of patients starting dialysis with PD fell from a peak of about 15% to 6%.75 Training programs had small numbers of patients on PD, and some programs had no patients.6 This led to a cycle of newly graduated nephrologists being quite comfortable with in-center HD (although even training in this area sometimes was lacking) and with very little knowledge about home dialysis (either home HD or PD).8 Because the nephrologist is the main influencer on the patient’s decision about dialysis, this led to even fewer patients starting PD. Modality education takes time. If the program does not have a robust predialysis education program for patients, the burden falls almost entirely on the nephrologist. Modality education is best done with repetitive information sessions and multiple modalities, and nephrologists may not be able to schedule the necessary sessions. Economic barriers are greater with frequent home HD than with PD. With the implementation of the expanded prospective payment system in the US, PD became quite profitable for the dialysis providers who increased

efforts to educate patients about home modalities.45 This has led to about 10% of new patients starting dialysis with PD.75,76 However, with increased demands for training patients, which in US is done one on one with the PD nurse trainer and the patient with or without family member, staffing needs to be adequate to still run the clinics, answer phone calls, complete paper work, and do home visits. In addition, there needs to be adequate support by the social worker and the dietician. Data particularly hospitalization and infection rates, especially peritonitis and exit site infections, and outcomes of catheter placement must be tracked. In some programs, the home dialysis nurses are also part of the modality education program. Such personnel are ideal for assessing a patient’s ability to learn PD and are often better at this than the nephrologist (especially an inexperienced nephrologist). Support for the home program by the dialysis provider, hospital, or institution is critical for the success of the home program. This includes provision of adequate space for the home program and deployment of adequate personnel.

SUMMARY Preparation for PD involves a comprehensive education process for the patient and the patient’s support person(s). This takes infrastructure from the program, but the nephrologist needs to take the lead. Unfortunately, in the US, in particular, nephrologists are often inadequately trained in PD and many have significant biases against PD and biases about who can perform PD. Until these barriers can be overcome, despite the economic advantages of PD over in-center HD in the US, PD growth will be limited.

References 1. Morton RL, Tong A, Howard K, Snelling P, Webster AC. The views of patients and carers in treatment decision making for chronic kidney disease: systematic review and thematic synthesis of qualitative studies. BMJ 2010;340:c112. 2. Palmer S, Vecchio M, Craig JC, et al. Prevalence of depression in chronic kidney disease: systematic review and meta-analysis of observational studies. Kidney Int 2013;84(1):179e91. 3. Mehrotra R, Marsh D, Vonesh E, Peters V, Nissenson A. Patient education and access of ESRD patients to renal replacement therapies beyond in-center hemodialysis. Kidney Int 2005;68(1):378e90. 4. Finkelstein FO, Story K, Firanek C, et al. Perceived knowledge among patients cared for by nephrologists about chronic kidney disease and end-stage renal disease therapies. Kidney Int 2008; 74(9):1178e84. 5. Kutner NG, Zhang R, Huang Y, Wasse H. Patient awareness and initiation of peritoneal dialysis. Arch Intern Med 2011;171(2):119e24. 6. Mehrotra R, Blake P, Berman N, Nolph KD. An analysis of dialysis training in the United States and Canada. Am J Kidney Dis 2002; 40(1):152e60.

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REFERENCES

7. Golper TA, Saxena AB, Piraino B, et al. Systematic barriers to the effective delivery of home dialysis in the United States: a report from the public policy/advocacy committee of the North American chapter of the International Society for Peritoneal Dialysis. Am J Kidney Dis 2011;58(6):879e85. 8. Berns JS. A survey-based evaluation of self-perceived competency after nephrology fellowship training. Clin J Am Soc Nephrol 2010; 5(3):490e6. 9. Weinhandl ED, Foley RN, Gilbertson DT, Arneson TJ, Snyder JJ, Collins AJ. Propensity-matched mortality comparison of incident hemodialysis and peritoneal dialysis patients. J Am Soc Nephrol 2010;21(3):499e506. 10. Mehrotra R, Chiu YW, Kalantar-Zadeh K, Bargman J, Vonesh E. Similar outcomes with hemodialysis and peritoneal dialysis in patients with end-stage renal disease. Arch Intern Med 2011;171(2): 110e8. 11. Chang YK, Hsu CC, Hwang SJ, et al. A comparative assessment of survival between propensity score-matched patients with peritoneal dialysis and hemodialysis in Taiwan. Medicine (Baltim) 2012; 91(3):144e51. 12. Yeates K, Zhu N, Vonesh E, Trpeski L, Blake P, Fenton S. Hemodialysis and peritoneal dialysis are associated with similar outcomes for end-stage renal disease treatment in Canada. Nephrol Dial Transplant 2012;27(9):3568e75. 13. Heaf JG, Wehberg S. Relative survival of peritoneal dialysis and haemodialysis patients: effect of cohort and mode of dialysis initiation. PLoS One 2014;9(3):e90119. 14. Marshall MR, Polkinghorne KR, Kerr PG, Agar JW, Hawley CM, McDonald SP. Temporal changes in mortality risk by dialysis modality in the Australian and New Zealand dialysis population. Am J Kidney Dis 2015;66(3):489e98. 15. Ryu JH, Kim H, Kim KH, et al. Improving survival rate of Korean patients initiating dialysis. Yonsei Med J 2015;56(3):666e75. 16. van de Luijtgaarden MW, Jager KJ, Segelmark M, et al. Trends in dialysis modality choice and related patient survival in the ERAEDTA Registry over a 20-year period. Nephrol Dial Transplant 2016;31(1):120e8. 17. Wong B, Ravani P, Oliver MJ, et al. Comparison of patient survival between hemodialysis and peritoneal dialysis among patients eligible for both modalities. Am J Kidney Dis 2018;71(3):344e51. 18. Bloembergen WE, Port FK, Mauger EA, Wolfe RA. A comparison of mortality between patients treated with hemodialysis and peritoneal dialysis. J Am Soc Nephrol 1995;6(2):177e83. 19. Vonesh EF, Moran J. Mortality in end-stage renal disease: a reassessment of differences between patients treated with hemodialysis and peritoneal dialysis. J Am Soc Nephrol 1999;10(2):354e65. 20. Jaar BG, Coresh J, Plantinga LC, et al. Comparing the risk for death with peritoneal dialysis and hemodialysis in a national cohort of patients with chronic kidney disease. Ann Intern Med 2005;143(3): 174e83. 21. Perl J, Wald R, McFarlane P, et al. Hemodialysis vascular access modifies the association between dialysis modality and survival. J Am Soc Nephrol 2011;22(6):1113e21. 22. Korevaar JC, Feith GW, Dekker FW, et al. Effect of starting with hemodialysis compared with peritoneal dialysis in patients new on dialysis treatment: a randomized controlled trial. Kidney Int 2003; 64(6):2222e8. 23. Davis JL, Davison SN. Hard choices, better outcomes: a review of shared decision-making and patient decision aids around dialysis initiation and conservative kidney management. Curr Opin Nephrol Hypertens 2017;26(3):205e13. 24. Carey HB, Chorney W, Pherson K, Finkelstein FO, Kliger AS. Continuous peritoneal dialysis and the extended care facility. Am J Kidney Dis 2001;37(3):580e7. 25. Crabtree JH, Fishman A. A laparoscopic method for optimal peritoneal dialysis access. Am Surg 2005;71(2):135e43.

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26. Vonesh EF, Snyder JJ, Foley RN, Collins AJ. The differential impact of risk factors on mortality in hemodialysis and peritoneal dialysis. Kidney Int 2004;66(6):2389e401. 27. Mehrotra R, Soohoo M, Rivara MB, et al. Racial and ethnic disparities in use of and outcomes with home dialysis in the United States. J Am Soc Nephrol 2016;27(7):2123e34. 28. Wallace EL, Lea J, Chaudhary NS, et al. Home dialysis utilization among racial and ethnic minorities in the United States at the national, regional, and state level. Perit Dial Int 2017;37(1):21e9. 29. Turenne M, Baker R, Pearson J, Cogan C, Mukhopadhyay P, Cope E. Payment reform and health disparities: changes in dialysis modality under the new medicare dialysis payment system. Health Serv Res 2018;53(3):1430e57. 30. Mehrotra R, Devuyst O, Davies SJ, Johnson DW. The current state of peritoneal dialysis. J Am Soc Nephrol 2016;27(11):3238e52. 31. Mendelssohn DC, Mujais SK, Soroka SD, et al. A prospective evaluation of renal replacement therapy modality eligibility. Nephrol Dial Transplant 2009;24(2):555e61. 32. Devoe DJ, Wong B, James MT, et al. Patient education and peritoneal dialysis modality selection: a systematic review and metaanalysis. Am J Kidney Dis 2016;68(3):422e33. 33. Manns BJ, Taub K, Vanderstraeten C, et al. The impact of education on chronic kidney disease patients’ plans to initiate dialysis with self-care dialysis: a randomized trial. Kidney Int 2005;68(4): 1777e83. 34. Devins GM, Mendelssohn DC, Barre PE, Taub K, Binik YM. Predialysis psychoeducational intervention extends survival in CKD: a 20-year follow-up. Am J Kidney Dis 2005;46(6):1088e98. 35. Mendelssohn DC, Mullaney SR, Jung B, Blake PG, Mehta RL. What do American nephologists think about dialysis modality selection? Am J Kidney Dis 2001;37(1):22e9. 36. Jassal SV, Krishna G, Mallick NP, Mendelssohn DC. Attitudes of British Isles nephrologists towards dialysis modality selection: a questionnaire study. Nephrol Dial Transplant 2002;17(3): 474e7. 37. Liu FX, Gao X, Inglese G, Chuengsaman P, Pecoits-Filho R, Yu A. A global overview of the impact of peritoneal dialysis first or favored policies: an opinion. Perit Dial Int 2015;35(4):406e20. 38. Li PK, Chow KM. Peritoneal dialysis-first policy made successful: perspectives and actions. Am J Kidney Dis 2013;62(5):993e1005. 39. Chuengsaman P, Kasemsup V. PD first policy: Thailand’s response to the challenge of meeting the needs of patients with end-stage renal disease. Semin Nephrol 2017;37(3):287e95. 40. Li PK, Szeto CC. Success of the peritoneal dialysis programme in Hong Kong. Nephrol Dial Transplant 2008;23(5):1475e8. 41. Tantivess S, Werayingyong P, Chuengsaman P, Teerawattananon Y. Universal coverage of renal dialysis in Thailand: promise, progress, and prospects. BMJ 2013;346:f462. 42. Ankawi GA, Woodcock NI, Jain AK, Garg AX, Blake PG. The use of incremental peritoneal dialysis in a large contemporary peritoneal dialysis program. Can J Kidney Health Dis 2016;3. 2054358116679131. 43. Saggi SJ, Allon M, Bernardini J, et al. Considerations in the optimal preparation of patients for dialysis. Nat Rev Nephrol 2012;8(7): 381e9. 44. Merighi JR, Schatell DR, Bragg-Gresham JL, Witten B, Mehrotra R. Insights into nephrologist training, clinical practice, and dialysis choice. Hemodial Int 2012;16(2):242e51. 45. Hirth RA, Turenne MN, Wheeler JR, et al. The initial impact of Medicare’s new prospective payment system for kidney dialysis. Am J Kidney Dis 2013;62(4):662e9. 46. Golper TA. A view of the bundle from a home dialysis perspective: present at the creation. Clin J Am Soc Nephrol 2018;13(3):471e3. 47. Lacson Jr E, Wang W, DeVries C, et al. Effects of a nationwide predialysis educational program on modality choice, vascular access, and patient outcomes. Am J Kidney Dis 2011;58(2):235e42.

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48. Bass EB, Wills S, Fink NE, et al. How strong are patients’ preferences in choices between dialysis modalities and doses? Am J Kidney Dis 2004;44(4):695e705. 49. Rioux JP, Cheema H, Bargman JM, Watson D, Chan CT. Effect of an in-hospital chronic kidney disease education program among patients with unplanned urgent-start dialysis. Clin J Am Soc Nephrol 2011;6(4):799e804. 50. Hanko J, Jastrzebski J, Nieva C, White L, Li G, Zalunardo N. Dedication of a nurse to educating suboptimal haemodialysis starts improved transition to independent modalities of renal replacement therapy. Nephrol Dial Transplant 2011;26(7):2302e8. 51. Ghaffari A. Urgent-start peritoneal dialysis: a quality improvement report. Am J Kidney Dis 2012;59(3):400e8. 52. Liu FX, Ghaffari A, Dhatt H, et al. Economic evaluation of urgentstart peritoneal dialysis versus urgent-start hemodialysis in the United States. Medicine (Baltim) 2014;93(28):e293. 53. Piwko C, Vicente C, Marra L, et al. The STARRT trial: a cost comparison of optimal vs sub-optimal initiation of dialysis in Canada. J Med Econ 2012;15(1):96e104. 54. Song JH, Kim GA, Lee SW, Kim MJ. Clinical outcomes of immediate full-volume exchange one year after peritoneal catheter implantation for CAPD. Perit Dial Int 2000;20(2):194e9. 55. Banli O, Altun H, Oztemel A. Early start of CAPD with the Seldinger technique. Perit Dial Int 2005;25(6):556e9. 56. Povlsen JV, Ivarsen P. How to start the late referred ESRD patient urgently on chronic APD. Nephrol Dial Transplant 2006;21(Suppl. 2):ii56e59. 57. Jo YI, Shin SK, Lee JH, Song JO, Park JH. Immediate initiation of CAPD following percutaneous catheter placement without breakin procedure. Perit Dial Int 2007;27(2):179e83. 58. Lobbedez T, Lecouf A, Ficheux M, Henri P, Hurault de Ligny B, Ryckelynck JP. Is rapid initiation of peritoneal dialysis feasible in unplanned dialysis patients? A single-centre experience. Nephrol Dial Transplant 2008;23(10):3290e4. 59. Casaretto A, Rosario R, Kotzker WR, Pagan-Rosario Y, Groenhoff C, Guest S. Urgent-start peritoneal dialysis: report from a U.S. private nephrology practice. Adv Perit Dial Conf 2012; 28:102e5. 60. Koch M, Kohnle M, Trapp R, Haastert B, Rump LC, Aker S. Comparable outcome of acute unplanned peritoneal dialysis and haemodialysis. Nephrol Dial Transplant 2012;27(1):375e80. 61. Alkatheeri AM, Blake PG, Gray D, Jain AK. Success of urgent-start peritoneal dialysis in a large Canadian renal program. Perit Dial Int 2016;36(2):171e6. 62. Jin H, Ni Z, Mou S, et al. Feasibility of urgent-start peritoneal dialysis in older patients with end-stage renal disease: a single-center experience. Perit Dial Int 2018;38(2):125e30.

63. Povlsen JV, Ivarsen P. Assisted automated peritoneal dialysis (AAPD) for the functionally dependent and elderly patient. Perit Dial Int 2005;25(Suppl. 3):S60e63. 64. Verger C, Duman M, Durand PY, Veniez G, Fabre E, Ryckelynck JP. Influence of autonomy and type of home assistance on the prevention of peritonitis in assisted automated peritoneal dialysis patients. An analysis of data from the French Language Peritoneal Dialysis Registry. Nephrol Dial Transplant 2007;22(4):1218e23. 65. Oliver MJ, Quinn RR, Richardson EP, Kiss AJ, Lamping DL, Manns BJ. Home care assistance and the utilization of peritoneal dialysis. Kidney Int 2007;71(7):673e8. 66. Lobbedez T, Verger C, Ryckelynck JP, Fabre E, Evans D. Is assisted peritoneal dialysis associated with technique survival when competing events are considered? Clin J Am Soc Nephrol 2012; 7(4):612e8. 67. Franco MR, Fernandes N, Ribeiro CA, Qureshi AR, DivinoFilho JC, da Gloria Lima M. A Brazilian experience in assisted automated peritoneal dialysis: a reliable and effective home care approach. Perit Dial Int 2013;33(3):252e8. 68. Brown EA, Wilkie M. Assisted peritoneal dialysis as an alternative to in-center hemodialysis. Clin J Am Soc Nephrol 2016;11(9):1522e4. 69. Asif A, Pflederer TA, Vieira CF, Diego J, Roth D, Agarwal A. Does catheter insertion by nephrologists improve peritoneal dialysis utilization? A multicenter analysis. Semin Dial 2005;18(2):157e60. 70. Crabtree JH. Selected best demonstrated practices in peritoneal dialysis access. Kidney Int Suppl 2006;(103):S27e37. 71. McCormick BB, Brown PA, Knoll G, et al. Use of the embedded peritoneal dialysis catheter: experience and results from a North American Center. Kidney Int Suppl 2006;(103):S38e43. 72. Prischl FC, Wallner M, Kalchmair H, Povacz F, Kramar R. Initial subcutaneous embedding of the peritoneal dialysis catheter–a critical appraisal of this new implantation technique. Nephrol Dial Transplant 1997;12(8):1661e7. 73. Crabtree JH, Burchette RJ, Siddiqi RA. Embedded catheters: minimizing excessive embedment time and futile placement while maintaining procedure benefits. Perit Dial Int 2015;35(5):545e51. 74. Gadallah MF, Ramdeen G, Mignone J, Patel D, Mitchell L, Tatro S. Role of preoperative antibiotic prophylaxis in preventing postoperative peritonitis in newly placed peritoneal dialysis catheters. Am J Kidney Dis 2000;36(5):1014e9. 75. Rivara MB, Mehrotra R. The changing landscape of home dialysis in the United States. Curr Opin Nephrol Hypertens 2014;23(6): 586e91. 76. Lin E, Cheng XS, Chin KK, et al. Home dialysis in the prospective payment system era. J Am Soc Nephrol 2017;28(10):2993e3004.

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QUESTIONS AND ANSWERS

QUESTIONS AND ANSWERS Question 1 You are seeing a 65-year-old woman with diabetes mellitus who has advancing CKD, now with eGFR of 11 mL/min/1.73 m2. She is asymptomatic at this time and has trace edema and clear lungs on examination. Her BMI is 32 kg/m2. She lives alone and is fiercely independent. Her diabetes is reasonably well controlled. You explain to her that her kidney disease is quite advanced and she needs to consider her options. What options do you discuss with her? A. In-center HD is the best choice given she lives alone and is a diabetic B. Kidney transplantation should be the focus as perhaps she can receive a kidney without going on dialysis C. In-center HD and PD are both reasonable choices and referral for education about these is appropriate D. Refer her for placement of a central venous catheter to start dialysis as soon as possible as her kidney disease is so advanced E. PD is the best choice given that she is fiercely independent Answer: C Both in-center HD and home PD are choices for this woman. She may well prefer one over the other. Until the choice is made based on full information, no access should be placed. Although renal transplantation is certainly an option, the referral, workup, and wait time make the timing not very feasible for preemptive kidney transplantation unless she has a living donor. While her kidney disease is advanced, she is asymptomatic and there is no need to initiate dialysis urgently.

Question 2 A 24-year-old single woman who still lives with her parents is followed for chronic glomerulonephritis, which despite immunosuppression is progressing. She has a full-time desk job working from 8 a.m. to 5 p.m. She has been reluctant to receive much information about dialysis. The family’s plan is to have the father donate a kidney to her. Once the evaluation is done, the father is found to have unrecognized coronary artery disease, and the transplant team refuses to consider him further as a donor. The mother is not a suitable donor. The sister is 21 years old, and the parents ask you about her as a candidate. Now the patient’s creatinine is 13 mg/dL, and even though she is still asymptomatic and the rest of the laboratory not worrisome, you are concerned about the very advanced state of her renal function (eGFR 4 mL/min/1.73 m2).

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A. You call her once you receive this laboratory result and tell her to go to the emergency department to get admitted to start HD via a HD catheter B. You tell her that the nurse is going to schedule outpatient placement of a tunneled HD catheter, following which she will start in-center HD C. You again explain the choice of in-center HD vs. PD to her and encourage her to consider nighttime PD so she can continue with her job D. You tell her that home HD is the best choice given that her parents can do this with her E. You encourage her to ask her sister to be a living donor to avoid dialysis Answer: C Because she is asymptomatic, there is no need to admit her to the hospital. However, dialysis needs to be implemented very soon, within a few weeks. If she agrees with PD, a PD catheter would need to be placed promptly and then urgent start PD can be implemented, with training starting simultaneously. There is insufficient time to get a transplant from the sister even if the sister is willing. If she does not want PD, then a tunneled HD catheter can be placed as an outpatient and she can be started on in-center HD at a center convenient, but this should be a choice, not mandated by the nephrology team.

Question 3 All of the following are absolute or relative contraindications to PD except? A. A 68-year-old woman who has received radiation to her abdomen for metastatic ovarian cancer B. A 50-year-old man with pulmonary hypertension and severe right heart failure with large ascites C. A 72-year-old woman with mild dementia who lives with her devoted husband and adult son D. A 48-year-old woman with diabetes mellitus who has a BMI of 42 who wants to undergo bariatric surgery to become eligible for a kidney transplant E. A 70-year-old man who lives alone, who has marked impaired vision due to macular degeneration Answer: C Radiation to the abdomen makes PD not very feasible as the peritoneum is likely somewhat damaged. Those with severe right-sided heart failure and large ascites, tend to lose too much fluid with PD, leading to profound hypotension, difficult to manage. PD in a person with a BMI of 42 and wants to undergo bariatric surgery is challenging. The patient with impaired vision who lives alone and is therefore unlikely to have a helper is at high risk for peritonitis, unless an assisted PD program is available. The woman with dementia who lives with

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supportive family may well decide with her family that home dialysis is best, because the son and/or the husband could do the PD for her. Therefore, Answer C is the correct answer.

Question 4 You follow a 55-year-old man who works as an electrician, BMI 35, who is approaching the need to start dialysis. He is interested in kidney transplantation and has been accepted on the transplant list but has no donors. After appropriate education about modalities, he has chosen cycler nocturnal PD, because he wants to keep his job and hates needles. His eGFR is now 10 mL/min/1.73 m2. He has mild symptoms of fatigue and has lost 5 pounds in the last month. S[K] is 5 mEq/L and Hb is 10 g/dL. Which of the following is your course of action at this time? A. Refer to the surgeon for placement of PD catheter, then start PD training 1e2 weeks later B. Admit him to the hospital, place HD catheter, and place on HD, with a plan to start PD later C. Tell him that as he has few symptoms that it is fine to wait longer before starting dialysis D. Have the PD catheter placed and then have the nurse train him on CAPD before allowing him to train on the cycler. He can miss work while on CAPD because he says it is not feasible to do an exchange while working E. Explain to him that both a PD catheter and an AVF will be placed by the surgeon because HD backup access is necessary Answer: A Because the eGFR is now 10 mL/min/1.73 m2, it is better to plan on PD catheter placement and starting because sometimes it takes a bit of time to arrange the PD catheter placement. In addition, the patient needs to be alert to train on PD. There is no need to place him on HD first, and this places the patient at risk of infection from the HD catheter, and possibly some harm to residual kidney function. Backup AVF is not needed at this time, as he may get a kidney transplant and never need HD. Choice D is somewhat controversial and depends on the programdsome train directly on the cycler and others place the patient on CAPD first. Nevertheless, even such programs will likely make an exception for the patient to accommodate the limitations on his schedule imposed by work.

Question 5 You are the medical director of a dialysis program that has 70 patients treated with in-center HD and 5 patients in the PD program and no home HD patients. The

nurse assigned to PD is also expected to work on the incenter HD side if there are shortfalls in staffing. The space for the home program consists of one room that is a combined storage space and home nurse office and one clinic room. Five physicians send their patients to the clinic and all seem eager to expand the home program. The modality education program is done at a separate location by a nurse educator who is eager to do a good job but is not being referred many patients. Which of the following might be the most effective approach by the director to increase the home program census? A. Focus on the current HD patients and ask the home nurse to talk to them about home dialysis B. Meet with the five physicians and the nurse educator and develop an approach to referring all patients anticipated to transition to dialysis for iterative modality education C. Arrange a group modality education program to which you invite the current in-center HD patients and all CKD stage 4 patients D. Talk to the HD staff about promoting PD to the incenter HD patients E. Put posters about the advantages of home dialysis in the in-center waiting room Answer: B The physicians need to be behind the effort to educate the patents on modality choice as the physician has the most influence in this process, not only by the referral but by speaking positively about home dialysis. Although A, C, D, and E can be easily implemented, these approaches will be much less effective than B.

Question 6 You provide care to a 35-year-old man with IgA nephropathy with progressive decline in kidney function and now with advanced CKD. His last eGFR was 12 mL/min/1.73 m2. He has undergone iterative modality education and has decided to be treated with PD when he needs dialysis. He has no potential living donor. He has recently been placed on a deceased donor transplant list (wait time, 5e7 years). You recommend the placement of an embedded PD catheter and he wants to understand the potential risks with such an approach. Which of the following are the risks associated with placement of embedded PD catheters? A. Problems with catheter drainage on exteriorization from fibrin thrombi B. Higher risk of peritonitis in the 3-month period following exteriorization

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QUESTIONS AND ANSWERS

C. A higher likelihood of internal leaks on initiation of PD D. More frequent occurrence of hernias E. Greater need to replace the PD catheter because of primary nonfunction Answer: A Placement of an embedded PD catheter allows for an elective start of PD while precluding the need for caring for an externalized PD catheter for long before

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patients need dialysis. The catheter can be exteriorized in the office setting and can be used for full-dose PD from day 1. Up to 15% of patients have problems with drainage on exteriorization, but these are often readily resolved with vigorous flushing. The rate of primary nonfunction is <5% and it is rare to need to replace the PD catheter. There is no difference in rates of peritonitis or herniae, and there is a lower likelihood of leak.

VIII. THERAPEUTIC CONSIDERATIONS