Trends in assisted peritoneal dialysis over the last decade: a cohort study from the French Peritoneal Dialysis Registry

Description and outcomes of a staff-assisted peritoneal dialysis program in the United States

BACKGROUND

Staff-assisted peritoneal dialysis (PD) can help overcome barriers to self-care but is not yet available in the United States (US). We developed and implemented a staff-assisted PD program that fits within current regulatory and cost restraints in the US healthcare environment.

METHODS

Patient care technicians (PCTs) were trained on PD procedures and troubleshooting common problems. The program expanded from two centers in August 2020 to sixteen by October 2022. We described the logistic elements of program delivery, and patient and treatment outcomes for patients discharged by end of April 2023, with a cohort follow up until October 2023.

RESULTS

A total of 121 patients were referred to the program. The most common indications for referral were physical function limitations, cognitive impairment, and psychosocial challenges. Staff assistance was provided for 73 patients. Mean age was 72 (standard deviation 14) years. A total of 604 visits were delivered, with a median 5 (interquartile range [IQR] 3-10, range: 1-49) visits per patient. Median duration of assistance was 8 (IQR: 2-21, range: 1-84) days. Assistance was most frequently needed for PD treatment setup and for observing and directing the technique. No peritonitis events or exit-site infections were reported. Sixty-eight patients (93%) were discharged on PD without staff assistance. The 6- and 12-month survival of PD without assistance was 71% and 57%, respectively.

CONCLUSIONS

Staff-assisted PD for limited time periods is operationally feasible with PCTs in the US and can support transitioning and maintaining patients on PD.ClinicalTrials.gov Identifier: NCT04319185.

Evaluation and outcomes of a 5-year assisted peritoneal dialysis program

BACKGROUND

In 2016, Peritoneal Dialysis Assist (PDA) was implemented in British Columbia, Canada, as a pilot program to allow patients with physical, cognitive and social impairments to access an independent dialysis modality. This is a presentation of the usage and 5-year clinical outcomes of our provincial assisted peritoneal dialysis (PD) program.

METHODS

Patients who utilised long-term or respite PDA services in British Columbia, Canada, from 2016 to 2021 were included in this program evaluation. Incident and prevalent patient numbers were characterised annually as well as indications for PDA and patient demographics both annually and over time. Outcomes of interest included death, transfer to haemodialysis, transplantation and cessation of the PDA program but retention on PD.

RESULTS

Three hundred twenty-two total patients received services through the PDA program. The percentage of PD patients supported by long-term PDA service has grown to 11.2% in the most recent year. Patients spend a median of 13.6 (95% CI: 11.0, 16.1) months on long-term PDA, prolonging overall patient duration on PD by a little over a year. Of the patients who exited the long-term PDA program, 73 (37.4%) were able to utilise the service until they died.

CONCLUSION

PDA is an accessible, patient-centric service with clear and standardised referral criteria. Through the implementation of a local PDA program, patients have accessed PD and may have extended their PD life span, through avoidance of in-centre haemodialysis, by over 13 months during this 5-year study period. A significant proportion of patients on long-term PDA were able to use their preferred kidney replacement modality at home until they reached end of life.

Assisted peritoneal dialysis in Europe: a strategy to increase and maintain home dialysis

Peritoneal dialysis (PD) is a form of kidney replacement therapy with the major advantage that it can be performed at home. This has a positive impact on patients' autonomy and quality of life. However, the dialysis population is ageing and physical and/or cognitive impairments are common. These limitations often form a barrier to PD and contribute to the low incidence and prevalence of PD in Europe. Assisted PD can be a solution to this problem. Assisted PD refers to a patient being assisted by a person or device in performing all or part of their dialysis-related tasks, thereby making PD more accessible to elderly but also younger frail patients. In this way, offering an assisted PD program can help lower the threshold for initiating PD. In this review, we provide an overview of the epidemiology of assisted PD in Europe, we discuss the different categories and clinical outcomes of assisted PD, and we present how assisted PD can be implemented in clinical practice as a possible strategy to increase and maintain home dialysis in Europe.

Assisted PD throughout Europe: advantages, inequities, and solution proposals

BACKGROUND

Peritoneal dialysis provides several benefits for patients and should be offered as first line kidney replacement therapy, particularly for fragile patients. Limitation to self-care drove assisted peritoneal dialysis to evolve from family-based care to institutional programs, with specialized care givers. Some European countries have mastered this, while others are still bound by the availability of a volunteer to become responsible for treatment.

METHODS

A group of leading nephrologists from 13 European countries integrated real-life application of such therapy, highlighting barriers, lessons learned and practical solutions. The objective of this work is to share and summarize several different approaches, with their intrinsic difficulties and solutions, which might helpperitoneal dialysis units to develop and offer assisted peritoneal dialysis.

RESULTS

Assisted peritoneal dialysis does not mean 4 continuous ambulatory peritoneal dialysis exchanges, 7 days/week, nor does it exclude cycler. Many different prescriptions might work for our patients. Tailoring PD prescription to residual kidney function, thereby maintaining small solute clearance, reduces dialysis burden and is associated with higher technique survival. Assisted peritoneal dialysis does not mean assistance will be needed permanently, it can be a transitional stage towards individual or caregiver autonomy. Private care agencies can be used to provide assistance; other options may involve implementing PD training programs for the staff of nursing homes or convalescence units. Social partners may be interested in participating in smaller initiatives or for limited time periods.

CONCLUSION

Assisted peritoneal dialysis is a valid technique, which should be expanded. In countries without structural models of assisted peritoneal dialysis, active involvement by the nephrologist is needed in order for it to become a reality.

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.

Home dialysis: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Home dialysis modalities (home hemodialysis [HD] and peritoneal dialysis [PD]) are associated with greater patient autonomy and treatment satisfaction compared with in-center modalities, yet the level of home-dialysis use worldwide is low. Reasons for limited utilization are context-dependent, informed by local resources, dialysis costs, access to healthcare, health system policies, provider bias or preferences, cultural beliefs, individual lifestyle concerns, potential care-partner time, and financial burdens. In May 2021, KDIGO (Kidney Disease: Improving Global Outcomes) convened a controversies conference on home dialysis, focusing on how modality choice and distribution are determined and strategies to expand home-dialysis use. Participants recognized that expanding use of home dialysis within a given health system requires alignment of policy, fiscal resources, organizational structure, provider incentives, and accountability. Clinical outcomes across all dialysis modalities are largely similar, but for specific clinical measures, one modality may have advantages over another. Therefore, choice among available modalities is preference-sensitive, with consideration of quality of life, life goals, clinical characteristics, family or care-partner support, and living environment. Ideally, individuals, their care-partners, and their healthcare teams will employ shared decision-making in assessing initial and subsequent kidney failure treatment options. To meet this goal, iterative, high-quality education and support for healthcare professionals, patients, and care-partners are priorities. Everyone who faces dialysis should have access to home therapy. Facilitating universal access to home dialysis and expanding utilization requires alignment of policy considerations and resources at the dialysis-center level, with clear leadership from informed and motivated clinical teams.

Availability of assisted peritoneal dialysis in Europe: call for increased and equal access

INTRODUCTION

Availability of assisted PD (asPD) increases access to dialysis at home, particularly for the increasing numbers of older and frail people with advanced kidney disease. Although asPD has been widely used in some European countries for many years, it remains unavailable or poorly utilised in others. A group of leading European nephrologists have therefore formed a group to drive increased availability of asPD in Europe and in their own countries.

METHODS

Members of the group filled in a proforma with the following headings: personal experience, country experience, who are the assistants, funding of asPD, barriers to growth, what is needed to grow, and their top 3 priorities.

RESULTS

Only 5 of the 13 countries surveyed provided publicly funded reimbursement for asPD. The use of asPD depends on overall attitudes to PD with all respondents mentioning need for nephrology team education and/or patient education and involvement in dialysis modality decision making.

CONCLUSION AND CALL TO ACTION

Many people with advanced kidney disease would prefer to have their dialysis at home, yet if the frail patient chooses PD most healthcare systems cannot provide their choice. AsPD should be available in all countries in Europe and for all renal centres. The top priorities to make this happen are education of renal healthcare teams about the advantages of PD, education of and discussion with patients and their families as they approach the need for dialysis, and engagement with policy makers and healthcare providers to develop and support assistance for PD.

The availability of support and peritoneal dialysis survival: A cohort study

BACKGROUND

Providing support is important to maintain a patient on peritoneal dialysis (PD), though its impact on outcomes has not been investigated thoroughly. We examined the association between having support and risk of a transfer to hemodialysis.

METHODS

In this retrospective observational cohort study, we used data captured in the Dialysis Measurement Analysis and Reporting system about patients who started PD in Alberta, Canada, between 1 January 2013 and 30 September 2018. Support was defined as the availability of a support person in the home who was able, willing and available to provide support for PD in the patient's residence. The outcome of interest was a transfer to hemodialysis for at least 90 days. We estimated the cumulative incidence of a transfer over time accounting for competing risks and hazard ratios to summarise the association between support and a transfer. We split follow-up time as hazard ratios varied over time.

RESULTS

Six hundred and eighty-three incident PD patients, median age 58 years (IQR: 47-68) and 35% female, were followed for a median of 15 months. The cumulative incidence of a transfer to hemodialysis at 24 months was 26%. Having support was associated with a reduced risk of a transfer between 3 and 12 months after the start of dialysis (HR_3-12mo: 0.44; 95% CI: 0.25-0.78), but not earlier (hazard ratio (HR)_<3mo: 0.96; 95% confidence interval (CI): 0.55-1.69) or later (HR_>12mo: 1.19; 95% CI: 0.65-2.17).

CONCLUSIONS

A transfer to hemodialysis is common. Having a support person at home is associated with a short-term protective effect after the initiation of PD.

Comparison of frailty, sarcopenia and protein energy wasting in a contemporary peritoneal dialysis cohort

BACKGROUND

More elderly frail patients are now treated by peritoneal dialysis (PD). Frailty, sarcopenia and protein energy wasting (PEW) are all associated with increased mortality. Simple screening tools are required to identify patients to allow for interventions. As such, we wished to review the prevalence of frailty and compare frailty with sarcopenia and PEW in a contemporary PD population.

PATIENTS AND METHODS

We used the Clinical Frailty Score (CFS) to determine frailty, bio-impedance body composition and hand grip strength (HGS) to determine sarcopenia and combining laboratory, body composition and protein nitrogen appearance rate (PNA) to assess PEW.

RESULTS

Records of 368 PD patients, 61% male, mean age 60.9 ± 16.1 years, body mass index (BMI) 26.2 ± 5.1 kg/m² were reviewed, with 71 classified as frail (19.3%; CFS > 4), and frailty associated with age (odds ratio (OR) 1.047, 95% confidence interval (CL) 1.01-1.085, p = 0.012), Stoke-Davies co-morbidity (OR 1.808, 95%CL 1.129-2.895, p = 0.014) and negatively with HGS (OR 0.906, 95% CL 0.897-0.992, p = 0.033); 17.7% met muscle loss and HGS criteria for sarcopenia, with fair agreement with frailty (kappa 0.24 (CL 0.09-0.38)). Only two patients (0.5%) met all four criteria for PEW, 26.1% met the reduced BMI criteria, 4.6% the serum albumin, 32.9% the PNA and 39.4% the reduced muscle mass. HGS correlated with lean muscle mass (r ² = 0.42, p < 0.001).

CONCLUSION

Using the CFS, 19.3% of patients were classified as frail, compared to 17.7% with sarcopenia and <1% with PEW. The CFS requires no special equipment or laboratory tests and was associated with age, co-morbidity and HGS weakness.

Dialysis-network variability in home dialysis use not explained by patient characteristics: a national registry-based cohort study in France

Background

Although associated with better quality of life and potential economic advantages, home dialysis use varies greatly internationally and appears to be underused in many countries. This study aimed to estimate the dialysis-network variability in home dialysis use and identify factors associated with 1) the uptake in home dialysis, 2) the proportion of time spent on home dialysis and 3) home dialysis survival (patient and technique).

Methods

All adults ≥ 18 years old who had dialysis treatment during 2017-2019 in mainland France were included. Mixed-effects regression models were built to explore factors including patient or residence characteristics and dialysis network associated with variation in home dialysis use.

Results

During 2017-2019, 7 728/78 757 (9.8%) patients underwent dialysis at least once at home for a total of 120 594/ 1 508 000 (8%) months. The heterogeneity at the dialysis-network level and to a lesser extent the regional level regarding home dialysis uptake or total time spent was marginally explained by patient characteristics or residence and dialysis-network factors. Between-network heterogeneity was less for patient and technique survival. These results were similar when the analysis was restricted to home peritoneal dialysis or home hemodialysis.

Conclusions

Variability between networks in the use of home dialysis was not fully explained by non-modifiable patient and residence characteristics. Our results suggest that to increase home dialysis use in France, one should focus on home dialysis uptake rather than survival. Financial incentives and a quality improvement program should be implemented at the dialysis-network level to increase home dialysis use.

Self-assessment sheet submission rate predicts technique survival in patients initiating peritoneal dialysis

AIM

Patients play a crucial role in preventing peritoneal dialysis (PD)-related events, including peritonitis and fluid overload, as PD procedures are mainly carried out at home. We asked patients to submit a PD self-assessment sheet at each outpatient visit in our daily clinical practice and evaluated its usefulness for outcomes in patients initiating PD.

METHODS

This retrospective cohort study included patients who underwent PD catheter insertion between January 2008 and October 2018. The submission rate of a PD self-assessment sheet was calculated from medical records until PD cessation or study completion (October 2020). The association between the submission rate and technique survival was analysed.

RESULTS

Among the 105 recruited patients (78 men, 60.4 ± 12.2 years), 44 discontinued PD and transferred to haemodialysis during the study period. The follow-up was 52.3 (28.7-79.3) months, and the median submission rate was 78%. The log-rank test showed that technique survival was significantly better in patients with a submission rate ≥ 78% than those with a submission rate < 78% (P = 0.006). The submission rate remained significantly associated with less technique failure (hazard ratio 0.88 per 10%, P = 0.002) by the Cox regression analysis adjusted for age, sex, Charlson comorbidity index, estimated glomerular filtration rate and geriatric nutritional risk index.

CONCLUSION

The submission rate of a PD self-assessment sheet is useful as a predictor of technique survival in patients initiating PD. Instruction that increases submission may improve technique survival in PD patients. This article is protected by copyright. All rights reserved.

Home dialysis in french speaking countries in 2020 (RDPLF database)

The RDPLF collects the main peritoneal dialysis data from centers in French-speaking countires and, since 2012, home hemodialysis (HHD) data. This article presents a summary of the main results in the RDPLF in 2020. It highlights important differences in the practices and patient profiles between French-speaking countries. Mortality in patients with clinical symptoms of COVID-19 varied from 15 to 63% depending on the country. A slight drop in the incidence rate for peritoneal dialysis in 2020 was observed when the Covid-19 pandemic should have favored a dialysis treatment at home. In patients with HHD, daily hemodialysis five days a week, at a low flow rate of dialysate, is predominant in the new centers and sometimes begins to appear as a mode of transition which allows to maintain at home patients who cannot anymore be treated by PD. In HHD, the use of a central catheter is frequent in Belgium while this is exceptional in France. Likewise, in France, puncture of an arteriovenous fistula remains classic, while in Belgium the Buttonhole technique is widely preferred. We did not observe COVID-19 mortality in HHD in 2020 but only 47% of HDD patients are included in the RDPLF while 98% of PD patients are included.

Health Outcomes and Cost Considerations of Assisted Peritoneal Dialysis: A Narrative Review

BACKGROUND

Peritoneal dialysis (PD) is underutilized in many parts of the world despite pro-PD health policies. The physical and cognitive demands of PD means that over half of eligible patients require some form of assistance. As such, many countries now offer assisted PD (aPD) programs to help patients start or stay on PD as opposed to in-center hemodialysis (HD). In order to evaluate the potential scope of aPD, it is important to review the outcomes and cost considerations of aPD.

SUMMARY

We reviewed available data from different countries and regions for health outcomes between aPD and in-center HD, with a focus on quality of life (QoL), mortality, hospitalization, and technique survival. We also evaluated studies discussing the overall costs of delivering aPD, including training, operating costs, and indirect costs and compared these to in-center HD costs for the same regions. Key Messages: aPD patients are older and more frail than either self-care PD patients and many in-center HD patients. We found no evidence for any difference in QoL, mortality, or hospitalization between aPD and in-center HD after adjustment for these differences. There is some evidence for an association between nurse assistance and improved technique survival as compared to family assistance or self-care PD. Despite increased cost of providing assistance in PD, it is still significantly less expensive than in-center HD in Western Europe and Canada.