Peritoneal dialysis in the nursing home

Advances in Human-Centered Care to Address Contemporary Unmet Needs in Chronic Dialysis

Advances in the treatment of kidney failure with chronic dialysis have stagnated over the past three decades, with over 50% of patients still managed by conventional in-hospital haemodialysis. In parallel, the demands of chronic dialysis medical care have changed and evolved due to a growing population that has higher frailty and multimorbidity. Thus, the gap between the needs of kidney failure patients and the healthcare capability to provide effective overall management has widened. To address this problem, healthcare policy has increasingly aligned towards a human-centred approach. The paradigm shift of human-centred approach places patients at the forefront of decision-making processes, ensuring that specific needs are understood and prioritised. Integration of human-centred approaches with patient care has been shown to improve satisfaction and quality of life. The aim of this narrative is to evaluate the current clinical challenges for managing kidney failure for dialysis providers; summarise current experiences and unmet needs of chronic dialysis patients; and finally emphasise how human-centred care has advanced chronic dialysis care. Specific incremental advances include implementation of renal supportive care; home-assisted dialysis; hybrid dialysis; refinements to dialysis methods; whereas emerging advances include portable and wearable dialysis devices and the potential for the integration of artificial intelligence in clinical practice.

Uremic encephalopathy in patients undergoing assisted peritoneal dialysis: a case series and literature review

We sometimes hesitate to switch renal replacement therapy from peritoneal dialysis (PD) particularly in elderly patients due to their physical tolerance levels and lifestyles. Here, we describe the cases of three patients treated with PD alone despite an anuric status who subsequently developed uremic encephalopathy, which was successfully treated with hemodialysis (HD). The first patient was a 75-year-old woman who developed uremic encephalopathy with an anuric status and inadequate PD after 7 months of treatment. HD immediately improved her condition; encephalopathy did not recur with combined therapy of PD and HD. The second patient was a 69-year-old woman who developed anuria and was treated with combined therapy. Her arteriovenous fistula was obstructed; therefore, she was treated with PD alone. Total weekly Kt/V was sufficiently high at 1.95; however, she developed uremic encephalopathy the following month, which was successfully treated with HD. The third patient was an 84-year-old woman who developed anuria, but was treated with PD alone with adequate total weekly Kt/V of 2.2. PD could not be performed for 2 days because of myocardial infarction intervention; subsequently, she developed uremic encephalopathy, which was successfully treated with HD. These cases are the first of their kinds, wherein patients undergoing PD, developed uremic encephalopathy without any obvious triggers, including drugs, and illustrate the necessity of initiating combined therapy for such patients considering the risk of developing severe uremia leading to uremic encephalopathy, in spite of it being less preferable for elderly patients due to their physical conditions and lifestyles.

Dialysis access: issues related to conversion from peritoneal dialysis to hemodialysis and vice versa

Hemodialysis (HD) and peritoneal dialysis (PD) represent two complementary modalities of renal replacement therapy (RRT) for end-stage renal disease patients. Conversion between the two modalities is frequent and more likely to happen from PD to HD. Every year, 10% of PD patients convert to HD, suggesting the need for recommendations on how to proceed with the creation of a vascular access in these patients. Criteria for selecting patients who would likely fail PD, and therefore take advantage of a backup access, are undefined. Creating backup fistulas at the time of PD treatment start to allow emergency access for HD has proved to be inefficient, but it may be considered in patients with progressive difficulty in achieving adequate depuration and/or peritoneal ultrafiltration. A big challenge is represented by patients switching from PD to HD for unexpected infectious complications. Those patients need to start HD with a central venous catheter (CVC), but an alternative approach might be using an early cannulation graft, provided that infection has been cleared by the circulation. An early cannulation graft might also be used to considerably shorten the time spent using a CVC. In patients who need a conversion from HD to PD, urgent-start PD is now an accepted and well-established approach.

Peritoneal dialysis practice in Australia and New Zealand: A call to sustain the action

This paper updates a previous 'Call to Action' paper (Nephrology 2011; 16: 19-29) that reviewed key outcome data for Australian and New Zealand peritoneal dialysis patients and made recommendations to improve care. Since its publication, peritonitis rates have improved significantly, although they have plateaued more recently. Peritoneal dialysis patient and technique survival in Australian and New Zealand have also improved, with a reduction in the proportion of technique failures attributed to 'social reasons'. Despite these improvements, technique survival rates overall remain lower than in many other parts of the world. This update includes additional practical recommendations based on published evidence and emerging initiatives to further improve outcomes.

Peritoneal Dialysis-Related Infection in the Older Population

With appropriate training and adequate support, it is possible to keep the peritonitis rate of elderly peritoneal dialysis (PD) patients at a highly respectable level. In general, the latest recommendations for the treatment and prevention of PD-related infections by the International Society for Peritoneal Dialysis (ISPD) are applicable to older patients. However, there are minor differences in the spectrum of causative organisms amongst elderly patients, with coagulase-negative staphylococcal species (CNSS) and Enterobacteriaceae species being more common in elderly patients. Elderly PD patients who develop peritonitis have an excessive short-term mortality, and, amongst elderly patients, a high burden of comorbid load increases the risk of relapsing episodes. In addition, technical problems, social difficulties, and concomitant comorbid diseases often have profound effects on the risk of peritonitis as well as its management.

Peritoneal dialysis in centenarian patients: no age limitation?

BACKGROUND

The majority of dialysis patients are elderly, and the trend towards even more elderly people with end-stage renal disease (ESRD) will further determine the dialysis field in the future.

METHOD

If these elderly ESRD patients do not opt for conservative ESRD care, they may still qualify for peritoneal dialysis (PD), which may be assisted or unassisted.

RESULTS

Although they may be more frail and have a greater co-morbidity burden compared to their younger counterparts, elderly patients with ESRD may still be able to maintain a good functionality level with adequate quality of life by performing PD, which may be assisted (treatment performed or supported e.g. by partner or nurse) or unassisted (without support). PD may indeed further contribute to maintaining autonomy, and enhance quality of life compared to in-center conventional hemodialysis. In order to illustrate this strategy, we hereby describe a centenarian patient with ESRD who received assisted PD successfully.

CONCLUSIONS

With appropriate management and infrastructure, (very) high age is not a contra-indication for PD.

End-stage renal disease in nursing homes: a systematic review

OBJECTIVES/INTRODUCTION

Demand for nursing home (NH) care by patients with end-stage renal disease (ESRD) is likely to increase with growing numbers of older adults initiating chronic dialysis. We completed a systematic review to summarize the literature on NH residents with ESRD.

METHODS

MEDLINE, CINAHL, EMBASE, and relevant conference proceedings were searched to identify articles using the following MESH terms or related key words in the title or abstract: "residential facilities", "renal dialysis", "renal replacement therapy", and "chronic kidney failure". We selected case control, cohort studies, and clinical trials that included older adults with ESRD (defined as those receiving chronic dialysis or those with stage 5 chronic kidney disease) living in residential care facilities. We abstracted information on study design, quality, and results.

RESULTS

Of 198 unique citations identified by the search strategy, 14 articles met eligibility criteria. Most articles were multicenter studies that were conducted in the 1990 s. One study focused on patients with stage 5 chronic kidney disease, and the remaining 13 studies focused on patients receiving chronic dialysis, of which eight studies included only those receiving peritoneal dialysis, four studies included patients receiving both peritoneal dialysis and hemodialysis, and one study included only patients receiving hemodialysis. All studies were observational, no clinical trials were identified, and study design limitations and heterogeneity within study populations were common. Summarizing results across these studies suggests that NH residents with ESRD have limited survival, particularly early after dialysis initiation. Functional impairment is highly prevalent in this population and independently associated with poor outcomes.

CONCLUSIONS

NH residents with ESRD appear to be a particularly vulnerable population, but current information on their prevalence, characteristics, and outcomes is limited. Further research is needed to provide a better understanding of modifiable predictors of survival and functional decline in this population.

Intensive hemodialysis in the (nursing) home: the bright side of geriatric ESRD care?

Elderly ESRD patients often lose functionality when they start dialysis, which may be due to a variety of clinical problems. We recently postulated that intensive (longer and/or more frequent) hemodialysis (HD) may be the ideal strategy to try to prevent these ESRD- and dialysis-related complications, including dialysis-induced hypotension, cardiac and cerebral events, malnutrition, infections, sleep problems, and psychological issues. The feasibility of home dialysis therapies has been demonstrated in observational studies. As self-care dialysis is often a challenge in the elderly patient, assisted intensive home HD may facilitate the long-term continuation of this modality. Intensive nursing home HD seems to be an attractive goal for the future because many elderly ESRD patients reside in an extended care facility. Combination with rehabilitation and support by social worker and psychologist remains crucial in the holistic approach toward the elderly ESRD patient. Further studies are required to test the potential protective effects of intensive HD on functionality and quality of life in elderly ESRD patients, and to elucidate the mechanisms underlying frailty and other geriatric syndromes in this highly vulnerable patient population.

Dialysis options for end-stage renal disease in older people

The numbers of older patients requiring dialysis therapy is rising, reflecting the ageing of the general population. Older dialysis patients have a tendency to present later for dialysis, have a higher number of comorbid conditions, are at higher risk of cognitive dysfunction and have increased levels of frailty. These are all barriers to home dialysis therapy so hospital haemodialysis (HD) is the predominant dialysis modality for older patients. Evidence suggests, however, that home treatment with peritoneal dialysis (PD) intrudes less into the life of older patients than hospital HD. Assisted PD is available in some countries and this enables more older patients to be treated in their own homes. Adjustments to patient education also need to be made to accommodate the barriers to learning and decision-making that often exist in older people.

Comparison and causes of transfer from one dialysis modality to another

AIM

To evaluate the patients transferred from one dialysis modality to another and to compare the patient characteristics on both renal replacement modalities.

PATIENTS AND METHOD

The data of dialysis patients, who were followed up between January 2000 and December 2009 in our nephrology department, was evaluated retrospectively. Fifty-seven patients were transferred from HD to PD (Group 1) and 94 patients were transferred from PD to HD (Group 2) were included in this study. We recorded patients' demographic, clinical, and laboratory findings, and the cause of transfer from HD to PD or from PD to HD.

RESULTS

The mean age of the patients was 52.1 ± 14.1 years. Eighty-four of the 151 patients were men and 67 were women. The etiology of end-stage renal failure was diabetes mellitus and hypertension in most of the patients. The causes of transfer from HD to PD were vascular access problems in 37 (64.9%), patient preference in 8 (14.0%), cardiovascular problems in 7 (12.3%), inadequate dialysis in 4 (7.0%) patients, and unknown in 1 (1.8%) patient. On the other hand, the causes of transfer from PD to HD were refractory peritonitis in 61 (64.9%), catheter-related problems in 14 (14.9%), inadequate dialysis in 8 (8.5%), increased intraabdominal pressure-related problems in 7 (7.4%), patient preference in 2 (2.1%), and ultrafiltration failure in 2 (2.1%) patients. Alkaline phosphatase and calcium × phosphorus products were significantly higher in Group 1 compared to Group 2. The presence of diabetes mellitus, Kt/V(urea), and 24-h residual urine volume were significantly higher in Group 2 than in Group 1. There was no significant difference in terms of other parameters.

CONCLUSION

Vascular access problems were the most frequent cause of transfer from HD to PD. On the other hand, the most frequent cause of transfer from PD to HD was refractory peritonitis. Preservation of residual urine volume was better in PD patients compared to HD patients.