Towards A Successful Peritoneal Dialysis Program
Kanoo Kidney Centre, Dammam Medical Complex, Dammam, Saudi Arabia.
Dr. Ayman Karkar, PhD, FRCP, FASN,
Department of Nephrology, Kanoo Kidney Centre, Dammam 31463, PO Box 11825, Kingdom of Saudi Arabia.
Tel : 00966 13 891 2710
Fax : 00966 13 891 2610
Received: September 14, 2016; Published: September 20, 2016
Citation: Karkar A (2016) Towards A Successful Peritoneal Dialysis Program. Int J Chronic Dis Ther. 2(1e), 1-4.
Copyright: Karkar A© 2016. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.
Keywords: Automated Peritoneal Dialysis; Hemodialysis; Renal Replacement Therapy; Chronic Kidney Disease; Education and Training.
Peritoneal dialysis (PD), hemodialysis (HD) and kidney transplantation constitute an integral renal replacement therapy program , where end-stage renal disease (ESRD) patients can be shifted to one or more of these treatment modalities according to their assessment and prescription and/or when one of these modalities fails to satisfy its needs . PD has been well established as a first choice renal replacement therapy (RRT) modality with higher survival rate, especially in the first few years of treating ESRD patients . PD, and in particular when there are no contraindications, can be an excellent initial choice and first treatment option (Table 1).
Multiple studies have shown that when compared to HD, PD is associated with equivalent or better survival especially among non-diabetic and younger diabetic patients, where PD has an equal or lower mortality rate during the first 1-2 years of therapy [3-6]. More recent studies have shown that PD and in center HD provide similar short and long term survival . PD has the benefits of preserving residual renal function , delaying the need for vascular access and helping patients with multiple vascular access failure, and constitutes a better option for older age groups especially those with cardiovascular disease [8, 10]. PD has been associated with lower risk of infection with hepatitis B and C [11, 12], better outcome after transplantation with lower incidence of acute kidney injury and delayed graft function, lower costs than HD, and in promoting self-care and helping patients who are in need of more freedom [reviewed in 1]. In fact, PD has become an attractive modality of renal replacement therapy following the recent availability of new PD solutions such as icodextrin and amino-acid-based [13, 14] and biocompatible PD fluids . The better understanding of the molecular mechanisms involved in solute and water transport across the peritoneum, the advances in PD technology, and in particular catheter placement , better connecting systems with significant reduction in peritonitis rate, and the improved technology of new generation of automated compact easy to use cyclers with many advantages (table 2) have enhanced PD utilization . Studies from the United Kingdom  and studies from Netherlands, Belgium and New Haven study [18-20] have documented that if patients are given informed choice of dialysis treatment, 40-60% will choose PD modality. In addition, when comparing patient satisfaction with modality of HD versus PD as in CHOICE study, patients on PD therapy were more satisfied . Furthermore, patients on PD modality from New Haven study were not only more satisfied with their care, but they also felt with less significant impact of PD on their lives .
The use of cyclers in North America has increased from 10% in 1990 to 54% in 2000  and in Australia increased from 4% in 1995 to 42% in 2004 . Furthermore, APD has grown steadily in different parts of the world and, for example, it accounts for 35% of the PD patients in Mexico . Globally, it has been estimated that approximately one-third of PD patients are being maintained on APD treatment . In contrast with continuous ambulatory peritoneal dialysis (CAPD), the efficacy of APD, especially in high and high-average peritoneal transport membranes , its higher  or similar [24, 28] patient and technique survival rates, reduced peritonitis rates [2, 25, 29, 30], similar extracellular fluid volume and blood pressure control and sodium removal  or enhanced ultrafiltration , avoidance of high intraperitoneal pressure and decreased mechanical complications , home therapy and improved quality of life with more freedom for patients to fulfill their employment and lifestyle , all of which enhanced the popularity of APD modality . These advantages have been shown in HD patients transferred to APD , and confirmed even for anuric patients as demonstrated in the European Automated Peritoneal Dialysis Outcome (EAPOS) Study .
However, despite these multiple benefits and advantages there hasn’t been much progress  but rather a decline in PD utilization in several countries. The penetration rate of PD worldwide is about 11% [35, 38]. PD modality has been declining in most developed countries[39, 40] but increasing in developing countries[35, 41]. In United States, the use of PD has increased appreciably in recent years (7.4% of patients with a known dialysis modality). This change is associated with the new bundled payment system, with its clear incentives for peritoneal dialysis . Likewise, allowing reimbursement of PD, but not HD, has permitted to increase the use of PD over HD in many Asian countries like Hong Kong, Vietnam, Taiwan, Thailand, as well as in New Zealand and Australia over recent years [42, 43]. The major reasons of under utilization of PD modality include (1) lack or inadequate pre-dialysis education  and patient’s awareness of RRT options [7, 44, 45], and in particular the suitability and advantages of PD modality, (2) insufficient or lack of focus on patients’ training and encouragement and support, especially for anxious and unwell patients who might be nervous about participating in their own treatment [46-48], (3) lack or inadequate training of nursing staff and nephrologists in PD therapy [45, 49], (4) insufficient encouragement and support of medical and nursing staff to guide patients to chose or implement PD modality as a possible first choice therapy [45, 50], (5) lack or insufficient appreciation of the concept of “integrated renal replacement therapy (RRT) program” , and (6) inadequate preparation or lack of a proper set up of an independent PD unit [51, 52].
The success and continuity of a PD program relies on different factors including (1) enthusiasm and commitment of the PD team [53, 54], (2) continuous training program for medical and nursing staff, (3) structured educational program for predialysis chronic kidney disease (CKD) patients,(4) application of continuously updated policies and procedures, (5) and continuous evaluation and assessment of the applied program (table 3). Actually, implementation of these major steps should not only lay the foundation for solid PD program, but also should help in providing and maintaining adequate and unified standard technical PD performance  and successful continuity of the program (table 4).This approach should be reflected on extended patient’s PD treatment years, as an initial option of RRT, preservation of residual renal function, better preparation of kidney transplantation, delaying or avoidance of HD with vascular access problems, enjoying social life and more freedom together with least technical, infectious and non-infectious complications.
In conclusion, peritoneal dialysis constitutes an essential partof the integrated renal replacement therapy care for patients with ESRD. Despite the multiple benefits and advantages and improved technology in PD sets, solutions and cyclers, there hasn’t been much progress in PD utilization in many countries. The achievement and maintenance of a successful performance of PD unit requires the understanding and implementation of an integrated PD program concept, and the availability of essential needs and requirements. A structured model of PD program should be based on adequate theoretical and practical training of medical and nursing staff, and provides education and practical training of pre-dialysis ESRD patients and those transferred to PD from failed HD treatment. The program should be supported by detailed written and applied PD policies and procedures, including protocols for training and treatment of infections. The establishment of a purpose built, or transformed PD unit, together with continuous evaluation and assessment of performance can ensure the success and continuity. These measures, and the availability of trained and dedicated PD team, and the effectiveness of a training center in unifying the training standards and technique survival in support of PD program, should result in a successful performance and continuity of a PD program.
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