Eligibility and patient barriers to peritoneal dialysis in patients with advanced chronic kidney disease

Patient screening and assessment for home dialysis therapies: A scoping review

BACKGROUND

Home dialysis therapies have limited uptake in most regions despite recognized benefits such as increasing patients' independence, and several domains of quality of life with cost savings in some systems.

OBJECTIVE

To perform a scoping review of published literature to identify tools and guides used in systematically screening and assessing patient suitability for home dialysis. A secondary objective was to explore barriers and enablers associated with the home dialysis assessment process. It is important to identify gaps in current research to pose pertinent questions for future work in the field.

DESIGN

Online databases Embase, Medline (Ovid), and CINAHL were used to identify articles published between January 2007 to May 2023. A total of 23 peer-reviewed primary and secondary studies that investigated screening or selection for patients > 18 years old with kidney failure for home dialysis met the study inclusion criteria.

RESULTS

The studies consisted of secondary studies (n = 10), observational studies (n = 8), and survey-based studies (n = 5). The major themes identified that influence patient screening and assessment for home dialysis candidacy included: screening tools and guidelines (n = 8), relative contraindications (n = 4), patient or program education (n = 9), and socioeconomic factors (n = 2).

LIMITATIONS

Consistent with the scoping review methodology, the methodological quality of included studies was not assessed. The possible omission of evidence in languages other than English is a limitation.

CONCLUSION

This scoping review identified tools and factors that potentially guide the assessment process for home dialysis candidacy. Patient screening and assessment for home dialysis requires a comprehensive evaluation of clinical, psychosocial, and logistical factors. Further research is required to validate and refine existing tools to establish standardized patient screening criteria and evaluation processes. Up-to-date training and education for healthcare providers and patients are needed to improve the utilization of home dialysis and ensure optimal outcomes.

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.

Urgent Implantation of Peritoneal Dialysis Catheter in Chronic Kidney Disease and Acute Kidney Injury-A Review

Acute kidney injury (AKI) and sudden exacerbation of chronic kidney disease (CKD) frequently necessitate urgent kidney replacement therapy (UKRT). Peritoneal dialysis (PD) is recognized as a viable modality for managing such patients. Urgent-start peritoneal dialysis (USPD) may be associated with an increased number of complications and is rarely utilized. This review examines recent literature investigating the clinical outcomes of USPD in CKD and AKI. Relevant research was identified through searches of the MEDLINE (PubMed), Scopus, Web of Science, and Google Scholar databases using MeSH terms and relevant keywords. Included studies focused on the emergency use of peritoneal dialysis in CKD or AKI and reported treatment outcomes. While no official recommendations exist for catheter implantation in USPD, the impact of the technique itself on outcomes was found to be less significant compared with the post-implantation factors. USPD represents a safe and effective treatment modality for AKI, although complications such as catheter malfunctions, leakage, and peritonitis were observed. Furthermore, USPD demonstrated efficacy in managing CKD, although it was associated with a higher incidence of complications compared to conventional-start peritoneal dialysis. Despite its cost-effectiveness, PD requires greater technical expertise from medical professionals. Close supervision and pre-planning for catheter insertion are essential for CKD patients. Whenever feasible, an urgent start should be avoided. Nevertheless, in emergency scenarios, USPD does remain a safe and efficient approach.

The case for Increased Peritoneal Dialysis Utilization in Low- and Lower-Middle-Income Countries

Peritoneal dialysis (PD) has several advantages compared to hemodialysis (HD), but there is evidence showing underutilization globally, especially in low-income and lower-middle-income countries (LLMICs) where kidney replacement therapies (KRT) are often unavailable, inaccessible, and unaffordable. Only 11% of all dialysis patients worldwide use PD, more than 50% of whom live in China, the United States of America, Mexico, or Thailand. Various barriers to increased PD utilization have been reported worldwide including patient preference, low levels of education, and lower provider reimbursement. However, unique but surmountable barriers are applicable to LLMICs including the excessively high cost of providing PD (related to PD fluids in particular), excessive cost of treatment borne by patients (relative to HD), lack of adequate PD training opportunities for doctors and nurses, low workforce availability for kidney care, and challenges related to some PD outcomes (catheter-related infections, hospitalizations, mortality, etc.). This review discusses some known barriers to PD use in LLMICs and leverages data that show a global trend in reducing rates of PD-related infections, reducing rates of modality switches from HD, and improving patient survival in PD to discuss how PD use can be increased in LLMICs. We therefore, challenge the idea that low PD use in LLMICs is unavoidable due to these barriers and instead present opportunities to improve PD utilization in LLMICs.