Mortality Trends after Transfer from Peritoneal Dialysis to Hemodialysis

Staying home when peritoneal dialysis ends: the integrated home dialysis approach

PURPOSE OF REVIEW

Home dialysis has been promoted for several years for patients starting dialysis. Although incident use of peritoneal dialysis (PD) and home hemodialysis (HHD) is increasing in several regions, patients on home dialysis remain at high risk of transfer to facility-hemodialysis (HD). The integrated home dialysis model, where patient start dialysis on PD and eventually transition to HHD when PD cannot be optimally continued has gain interest from dialysis stakeholders.

RECENT FINDINGS

Transfers from PD to HHD are infrequently used among patients ending PD, representing between 2% and 6% of transfers to HD in registry studies. Nonetheless, this approach is associated with several clinical benefits as well as favorable cost-effectiveness.

SUMMARY

In this review, we will present data pertaining to home dialysis and the integrated home dialysis model, with broad discussion of the implementation challenges, including identifying patients who could most benefit from this approach, timely planning of the transitions and challenges relating to unexpected PD endings.

Establishing a peritoneal dialysis technique survival core outcome measure: A standardised outcomes in nephrology-peritoneal dialysis consensus workshop report

BACKGROUND

Technique survival, also reported with negative connotations as technique failure or transfer from peritoneal dialysis to haemodialysis, has been identified by patients, caregivers and health professionals as a critically important outcome to be reported in all trials. However, there is wide variation in how peritoneal dialysis technique survival is defined, measured and reported, leading to difficulty in comparing or consolidating results.

METHODS

We conducted an online international consensus workshop to establish a core outcome measure of technique survival. Discussions were analysed thematically.

RESULTS

Fifty-five participants including 14 patients and caregivers from 13 countries took part in facilitated breakout discussions using video-conferencing. The following themes were identified: capturing important aspects of the outcome (requiring a core event to define the outcome, distinguishing temporary from permanent events, recognising heterogeneous experiences of transfers), adopting appropriate neutral nomenclature (conveying with clarity, avoiding negative connotations), and ensuring feasibility and applicability (capturing data relevant to clinical and research settings, ease of adoption). The suggested definitions for the core outcome measure were 'the event of a transfer to haemodialysis', or 'discontinuation of peritoneal dialysis'. Applying the principles described within the workshop, defining the outcome measure as a 'transfer to haemodialysis' was preferable.

CONCLUSIONS

It is proposed that the core outcome of technique survival is redefined as 'transfer to haemodialysis' and that its components are standardised using simple, neutral terminology Components considered important by stakeholders included recording the reasons for transfer from peritoneal dialysis, and focussing on permanent events whilst ensuring the outcome remains easy to implement.

The Time-Dependent Effect of Assistance on Peritoneal Dialysis Duration: An Analysis of Data from the French Language Peritoneal Dialysis Registry

Key Points

It is unknown whether the benefit of assisted peritoneal dialysis (PD) programs appears immediately after PD initiation or rather after some time spent on PD. The protective effect of assisted PD on the risk of transfer to hemodialysis was not constant over time; it started after the first 6 months on PD. Assisted PD programs should be sustainable for at least 6 months to observe their benefits.

Background

Peritoneal dialysis (PD) patient compliance is crucial for the prevention of complications. Assistance is associated with a lower risk of transfer to hemodialysis. As the risk of noncompliance increases over time, the protective effect of assistance on the risk of transfer to hemodialysis may not be immediate after PD initiation, but rather may appear after some time on PD. We aimed to analyze the time-varying effect of assistance on the risk of PD cessation.

Methods

This retrospective study was conducted using data from the French Language PD Registry of incident PD patients between 2002 and 2018. Because of nonproportional hazards, with a change in the effect of the assistance modality on the different outcomes appearing at 6 months after PD initiation, the associations between the assistance modality and the different outcomes were explored using time-dependent coefficient Cox regression.

Results

The study included 15,675 patients; 6717 deaths, 4973 transfers to hemodialysis, and 3065 kidney transplantations occurred. Both patients receiving nurse- and family-assisted PD had a lower risk of transfer to hemodialysis (mean cause-specific hazard ratio [cs-HR], 0.67; 95% confidence interval [CI], 0.62 to 0.72; and mean cs-HR, 0.75; 95% CI, 0.67 to 0.84). In the first 6 months after PD initiation, nurse-assisted PD patients had a greater risk of transfer to hemodialysis (<6 months cs-HR, 1.18; 95% CI, 1.03 to 1.36) but had a lower likelihood afterward (≥6 months cs-HR, 0.57; 95% CI, 0.53 to 0.62). Family-assisted PD was not associated with the risk of transfer to hemodialysis in the first 6 months after PD initiation, and those patients had a lower risk of transfer to hemodialysis afterward (≥6 months cs-HR, 0.72; 95% CI, 0.63 to 0.82).

Conclusions

When implementing a national nurse-assisted PD program, its positive impact on PD duration should not be expected immediately after PD initiation. Assisted PD programs should be sustainable for at least 6 months to observe their benefits.

Podcast

This article contains a podcast at https://www.asn-online.org/media/podcast/K360/2024_10_31_KID0000000577.mp3

Dialysis nurse demand in Europe: an estimated prediction based on modelling

Background

To estimate the projections of supply and demand for dialysis nurses (DNs) over 5 years in four European countries (France, Italy, Spain and the UK).

Methods

This study modelled the nursing labour workforce across each jurisdiction by estimating the current nursing labour force, number of nursing graduates and the attrition rate.

Results

France currently has the greatest demand for DNs (51 325 patients on dialysis), followed by Italy, the UK and Spain with 40 661, 30 301 and 28 007 patients on dialysis, respectively. The number of in-centre haemodialysis (HD) patients is expected to increase in the four countries, while the number of patients on home HD (HHD) or on peritoneal dialysis (PD) is expected to increase in the UK. Currently Italy has the greatest proportion of DNs (2.6%), followed by France (2.1%), Spain (1.7%) and the UK (1.5%). Estimation of the dialysis nursing staff growth rate over 5 years showed that the UK has the greatest estimated growth rate (6%), followed by Italy (2%), France (2%) and Spain (1%).

Conclusions

Dialysis demand will increase in the coming years, which may exacerbate the DN shortage. Additionally, competencies and training requirements of DNs should be precisely defined. Finally, implementing and facilitating PD and HHD strategies would be helpful for patients, healthcare professionals and healthcare systems and can even help ease the DN shortage.

Integrated home dialysis model: facilitating home-to-home transition

Peritoneal dialysis (PD) and home hemodialysis (HHD) are the two home dialysis modalities offered to patients. They promote patient autonomy, enhance independence, and are generally associated with better quality of life compared to facility hemodialysis. PD offers some advantages (enhanced flexibility, ability to travel, preservation of residual kidney function, and vascular access sites) but few patients remain on PD indefinitely due to peritonitis and other complications. By contrast, HHD incurs longer and more intensive training combined with increased upfront health costs compared to PD, but is easier to sustain in the long term. As a result, the integrated home dialysis model was proposed to combine the advantages of both home-based dialysis modalities. In this paradigm, patients are encouraged to initiate dialysis on PD and transfer to HHD after PD termination. Available evidence demonstrates the feasibility and safety of this approach and some observational studies have shown that patients who undergo the PD-to-HHD transition have clinical outcomes comparable to patients who initiate dialysis directly on HHD. Nevertheless, the prevalence of PD-to-HHD transfers remains low, reflecting the multiple barriers that prevent the full uptake of home-to-home transitions, notably a lack of awareness about the model, home-care "burnout," clinical inertia after a transfer to facility HD, suboptimal integration of PD and HHD centers, and insufficient funding for home dialysis programs. In this review, we will examine the conceptual advantages and disadvantages of integrated home dialysis, present the evidence that underlies it, identify challenges that prevent its success and finally, propose solutions to increase its adoption.

A retrospective clinical and economic analysis of an assisted automated peritoneal dialysis programme in Western Australia

BACKGROUND

Assisted peritoneal dialysis (aPD) represents an alternative kidney replacement therapy for dialysis-dependent patients whose only other options are prolonged hospitalisations or transfer to in-centre haemodialysis (HD). Most programmes have not examined the role of temporary aPD, and there is limited data surrounding the economic implications of temporary aPD programmes. The main aim of this study was to describe the cost-effectiveness of an assisted automated peritoneal dialysis (aAPD) programme, for patients whose only reason to stay in hospital was the temporary inability to independently perform PD at home.

METHODS

Retrospective, single-centre analysis of 45 referrals for aAPD from November 2015 to May 2021. Two groups of patients were enrolled in the study: respite patients already established on PD (to facilitate discharge or prevent admission) and new patients who were not yet trained (to facilitate discharge). To calculate the cost differential, patients were allocated to either staying in hospital or transferring to centre-based HD with comparison to costs on aAPD. Costs were calculated using a healthcare system perspective over the duration of aAPD assistance. Clinical outcomes including peritonitis rate, hospitalisation and mortality were also assessed.

RESULTS

Overall, 1349 episodes of aAPD care were delivered. One thousand forty-two episodes (77%) were for respite patients and 307 episodes (23%) were for new patients awaiting training. The mean duration of assistance was 18 days for pretraining patients and 37 days for respite patients. Overall, the mean length of stay on the programme was 30 days with a range of 1-263 days (SD 43) and 73% of patients graduated to self-care PD. The cost of the aAPD programme was $242 per visit, with an average cost $7260 per patient-episode. The aAPD programme was significantly cheaper than the alternatives, with average hospitalization costs $46,170 per episode, and in-centre HD costs of $9667. $1.497 million was saved over the course of the study. Eleven hospitalisations occurred and the peritonitis rate was 0.8 episodes per patient-year. Two patients died while on aAPD.

CONCLUSION

This study provides the first detailed description of an aAPD respite programme in Australia. We conclude that the implementation of a temporary aAPD programme could lead to a significant reduction in healthcare costs, however peritonitis rates were high.

The integrated care model: facilitating initiation of or transition to home dialysis

A proportion of end-stage kidney disease (ESKD) patients require kidney replacement therapy to maintain clinical stability. Home dialysis therapies offer convenience, autonomy and potential quality of life improvements, all of which were heightened during the COVID-19 pandemic. While the superiority of specific modalities remains uncertain, patient choice and informed decision-making remain crucial. Missed opportunities for home therapies arise from systemic, programmatic and patient-level barriers. This paper introduces the integrated care model which prioritizes the safe and effective uptake of home therapies while also emphasizing patient-centered care, informed decision-making, and comprehensive support. The integrated care framework addresses challenges in patient identification, assessment, eligibility determination, education and modality transitions. Special considerations for urgent dialysis starts are discussed, acknowledging the unique barriers faced by this population. Continuous quality improvement is emphasized, with the understanding that local challenges may require tailored solutions. Overall, the integrated care model aims to create a seamless and beneficial transition to home dialysis therapies, promoting flexibility and improved quality of life for ESKD patients globally.

Automated Peritoneal Dialysis With Remote Patient Monitoring: Clinical Effects and Economic Consequences for Poland

OBJECTIVES

Remote patient monitoring (RPM) of patients treated with automated peritoneal dialysis (APD) at home allows clinicians to supervise and adjust the dialysis process remotely. This study aimed to review recent scientific studies on the use of RPM in patients treated with APD and based on extracted relevant data assess possible clinical implications and potential economic value of introducing such a system into practice in Poland.

METHODS

A systematic literature review was performed in the MEDLINE, EMBASE, and Cochrane databases. The model of clinical effects and costs associated with APD was built as a cost-effectiveness analysis with a 10-year time horizon from the Polish National Health Fund perspective. Cost-effectiveness analysis compared 2 strategies: APD with RPM versus APD without RPM.

RESULTS

Thirteen publications assessing the clinical value of RPM among patients with APD were found. The statistical significance of APD with RPM compared with APD without RPM was identified for the main clinical outcomes: frequency and length of hospitalizations, APD technique failure, and death. An incremental cost-effectiveness ratio was equal to €27 387 per quality-adjusted life-year. The obtained incremental cost-effectiveness ratio is below the willingness-to-pay threshold for the use of medical technologies in Poland (€36 510 per quality-adjusted life-year), which means that APD with RPM was a cost-effective technology.

CONCLUSIONS

RPM in patients starting APD is a clinical option that is worth considering in Polish practice because it has the potential to decrease the frequency of APD technique failure and shorten the length of hospitalization.

The Burden of Home Dialysis: An Overlooked Challenge

Home dialysis offers several clinical and quality-of-life benefits for patients with kidney failure. However, it is important to recognize that home dialysis may place an increased burden on patients and their care partners. Sources of burden may include concerns about the ability to adequately and safely perform dialysis at home, physical symptoms, impairment of life participation, psychosocial challenges, and care partner burnout. Overlooking or failing to address these issues may lead to adverse events that negatively affect health and quality of life and reduce longevity of home dialysis. This study will explore aspects of home dialysis associated with burden, emphasize the need for increased awareness of potential challenges, and elaborate on strategies to overcome sources of burden. Future research should actively involve patients and care partners to better understand their motivation, experiences, and needs to better inform support strategies.

Clinical outcomes between elderly ESKD patients under peritoneal dialysis and hemodialysis: a national cohort study

With ageing populations, new elderly end-stage kidney disease (ESKD) cases rise. Unlike younger patients, elderly ESKD patients are less likely to undergo kidney transplant, and therefore the decision of receiving peritoneal dialysis (PD) and hemodialysis (HD) is more crucial. A total of 36,852 patients, aged more than 65, who were newly diagnosed with ESKD and initiated renal replacement therapy between 2013 and 2019 were identified. These patients were categorized into two groups: the PD group and the HD group according to their long-term renal replacement treatment. After propensity score matching, the PD group (n = 1628) displayed a lower incidence of major adverse cardiac and cerebrovascular events (MACCE) (10.09% vs. 13.03%, hazard ratio (HR): 0.74, 95% confidence interval (CI): 0.66-0.83), malignancy (1.23% vs. 2.14%, HR: 0.55, 95% CI: 0.40-0.76), and MACCE-associated mortality (1.35% vs. 2.25%, HR: 0.62, 95% CI: 0.46-0.84) compared to the HD group (n = 6512). However, the PD group demonstrated a higher rate of infection (34.09% vs. 24.14%, HR: 1.28, 95% CI: 1.20-1.37). The risks of all-cause mortality and infection-associated mortality were not different. This study may provide valuable clinical information to assist elderly ESKD patients to choose HD or PD as their renal replacement therapy.

An update on absolute and relative indications for dialysis treatment modalities

Background

Choosing a dialysis modality is an important decision for people to make as their kidney failure progresses. In doing so, their options should be informed by any absolute or relative indications that may favour one modality over another.

Methods

In creating this update, we reviewed literature using a framework that considered first, high-level outcomes (survival and modality transition) from large registry data and cohort studies when considering optimal patient pathways; second, factors at a dialysis provider level that might affect relative indications; and third, specific patient-level factors. Both main types of dialysis modality, peritoneal (PD) and haemodialysis (HD), and their subtypes were considered.

Results

For most people starting dialysis, survival is independent of modality, including those with diabetes. Better survival is seen in those with less comorbidity starting with PD or home HD, reflecting continued improvements over recent decades that have been greater than improvements seen for centre HD. There are provider-level differences in the perceived relative indications for home dialysis that appear to reflect variability in experience, prejudice, enthusiasm, and support for patients and carers. Absolute contraindications are uncommon and, in most cases, where modality prejudice exists, e.g. obesity, Adult Polycystic Kidney Disease, and social factors, this is not supported by reported outcomes.

Conclusion

Absolute contraindications to a particular dialysis modality are rare. Relative indications for or against particular modalities should be considered but are rarely more important than patient preferences.

Patient perspectives on peritoneal dialysis (PD) and the PD catheter: Strategies and Solutions

INTRODUCTION

Peritoneal dialysis (PD) catheter complications reduce quality of life and increase risks for hospitalizations, for unplanned transitions to haemodialysis and for death. Patient PD catheter management is crucial for safe, sustained PD. Patient perspectives on strategies for living with PD and using a PD catheter may inform efforts to reduce PD catheter complications, increase individual patient PD modality persistence, and thus increase overall home dialysis prevalence.

METHODS

We interviewed 32 adult PD patients in Nashville, Tennessee. Qualitative analyses included (1) isolation of themes, (2) development of a coding system and (3) creation of a conceptual framework using an inductive-deductive approach.

RESULTS

Challenges identified by patients as important included drain pain, difficulty eating and sleeping, and fear of peritonitis. Coping strategies included repositioning while draining, adjusting eating patterns, and development of PD patient and helper knowledge and confidence, especially at home after initial training. Patients described a trial-and-error iterative process of trying multiple strategies with input from multiple sources, which led to individualised solutions.

CONCLUSIONS

The trial-and-error process may be crucial for maintaining PD. Individual patient success with PD may be promoted by creating expectations during training that a solution may require multiple attempts, and by a reimbursement policy that supports robust nursing support for safe progression through the trial-and-error process, particularly in the first few months for incident patients. Interventions to support patient motivation and optimal coping behaviour may also support an increase in PD modality duration for individual patients, and thus increase overall PD prevalence.

Patients and nursing-related factors associated with switching from peritoneal dialysis to hemodialysis: A cross-sectional survey

The study aimed at analyzing patients and nursing-related factors associated with switching from peritoneal dialysis to hemodialysis. A telephone survey with 574 patients receiving care at six peritoneal dialysis centers of the Mexican Institute of Social Security was conducted: 64.3% were on peritoneal dialysis, and 35.7% had transitioned from peritoneal dialysis to hemodialysis. Data were collected on participants' sociodemographic and clinical characteristics, peritoneal dialysis center size, and nursing workload. Descriptive, bivariate, and multiple Poisson regression analyses were performed. Factors associated with an increased probability of switching from peritoneal dialysis to hemodialysis were a history of catheter dysfunction, peritonitis, and being treated in a large peritoneal dialysis center with a low (<50 patients per nurse per month) or high nursing workload (>70 patients per nurse per month) located in the State of Mexico, compared to a medium-size peritoneal dialysis center with a moderate workload (50-70 patients per nurse per month). To decrease the odds of switching from peritoneal dialysis to hemodialysis, improvement programs should aim to limit nurses' workload to 50-70 patients per nurse per month and implement evidence-based nursing interventions to prevent, detect, and manage peritonitis and peritoneal catheter dysfunction.

Transitions between dialysis modalities

Thanks to the progress of dialysis, survival of patients with end-stage renal disease is increasing. For those patients who cannot benefit from a kidney transplantation, several dialysis alternatives exist, but the transition between dialysis techniques may be difficult. Home dialysis offers many advantages but requires personal commitment from the patients and the caregivers. How can we ensure smooth transitioning to the best dialysis technique at the right time for the right person? One of the main caveats of peritoneal dialysis is its limited technique survival, however, it combines the advantages of preserving residual kidney function, avoiding the need for a vascular access, or preserving it, when present, while providing good cost-effectiveness. On the other hand, home hemodialysis has excellent long-term technique survival. The home integrated model of peritoneal dialysis followed by home hemodialysis has been described as the ideal pathway of care. Eventually, in-center hemodialysis can be provided according to several schedules to adapt to the needs of the patients. The issue of technique survival and the possible need to switch to another technique should be part of the initial discussion, when the patient needs to choose the first dialysis modality. Unplanned transfers are associated with poor outcomes and unwanted shifts to in-center hemodialysis. Therefore, transfers from home-based techniques should be anticipated as much as possible in order to establish a shared decision modality process and to choose the desired new modality. Dialysis units dedicated to "transition care" should answer the needs of patients and smooth the transition process between dialysis modalities.