Can peritoneal dialysis be a long-term therapy?
Editor’s Note: The use of peritoneal dialysis in the United States has risen substantially in the last few years, as providers find the therapy cost effective in the post-payment bundle era for patients with renal failure. Home dialysis still remains a very small portion of the overall patient population despite those economic incentives, however.
We asked Martin Schreiber, MD, vice president of Clinical Affairs for Home Modalities at DaVita Kidney Care, what he sees as the future for peritoneal dialysis. Schreiber was head of the division of nephrology and hypertension at the Cleveland Clinic before joining DaVita in 2014. In addition, this special focus on PD includes a perspective on nurse management from Patricia Herzog, RN, educator for Home Modalities at DaVita, and Jennifer Castillo, who offers her view on using PD at home.
NN&I: Do you see peritoneal dialysis as a short-term therapy only, leading to other modality options?
Martin Schreiber, MD: In order to achieve the longest quality survival for patients, it is critical for nephrologists to decide on the appropriate sequence of end-stage renal disease treatments that will provide effective renal replacement therapy, preserve future options once a transition point is reached, and achieve the highest quality of life for the patient.
In an optimal situation, the sequence of therapies looks like this ( from most desirable to least desirable, in descending order):
- peritoneal dialysis
- home hemodialysis
- in-center nocturnal dialysis
- in-center hemodialysis.
The sequence of therapies will be different depending on individual patient characteristics related to age, co-mor- bidity load, transplant status, residual renal function (RRF), and commitment to home therapies. PD plays an important role in slowing the rate of RRF deterioration, controlling both solute and water levels and preserving vascular access options for future use. PD does not necessarily need to be a short-term therapy, and it has longer-term potential if the patient avoids peritonitis, leverages lower hyperosmotic dialysate, and preserves residual renal function.
NN&I: When patients fail on PD, what are the usual reasons? Could they be addressed with better education?
Schreiber: Adequate education is important for a patient’s successful transition from chronic kidney disease to ESRD treatment. The frequency of outpatient PD visits and the consistency of those visits prior to starting dialysis, plus appropriate linkage with the primary care provider are important determinants of a patient’s outcomes for the year after starting ESRD treatment.
The main reasons for PD technique failure include psychosocial stressors, infection, catheter malfunction, inadequate dialysis, hypervolemia, and other medical conditions —e.g., uncontrolled diabetes, acute cardiovascular events, etc. Controlling reversible factors is critical to extending the time on therapy for PD patients.
NN&I: Why do you think that more patients who give up PD don’t transition to home hemodialysis?
Schreiber: When patients transition off PD, the health care community has not done a good job of enabling those patients on home therapies to remain at home and as such transition them to HHD. Why? Historically our mindset has automatically shifted them to in-center hemodialysis, mov- ing their care out of the home. This is the wrong approach in a significant number of cases. Many teams are not comfort- able or knowledgeable with HHD as a sequential therapy following PD.
The focus for patients and health care teams should be on enabling patients to treat their kidney disease at home as long as possible regardless of the modality. A patient’s home as a focal point for kidney disease care will be high- lighted more as we extend home dialysis programs into the patient’s actual home through remote monitoring and more holistic care of the patient by the provider. The technology is available and now we need to re-design the home unit and match it with a forward-thinking health management team equipped with a different skill set to match the expanded role of the future home unit.
Related: Why peritoneal dialysis works for me
The kidney care industry also needs to do a better job of advancing technology that pro- vides those capabilities essential to managing the health of patients at home and not just deliver dialysis treatments. Whether the treatment modality is HHD or PD, there needs to be a heightened effort to lower the patient burden before more individuals will be interested in taking on the responsibility of treating their kidney disease at home.
NN&I: Are there ways to stretch the life of a peritoneum to make PD a more long-lasting therapy?
Schreiber: As a living organ, the peritoneum is subject to those insults occurring in disease, e.g., vascular changes as the result of diabetes, atherosclerosis, and with certain aspects of treatment involving hyperosmotic glucose-based dialysate and peritonitis that damages the membrane over time. Peritoneal membrane function may be extended by avoiding significant hyperosmotic glucose and uncontrolled diabetes; avoiding peritonitis; considering diuretics to improve urine output when possible to avoid hyperosmotic glucose solutions; and leveraging angiotensin-converting enzymes, angiotensin II receptor blockers and/ or aldosterone inhibitors to preserve both kidney and membrane function.
NN&I: Are there any new technologies on the horizon that might improve PD adequacy?
Schreiber: Over the past decade, newer PD solutions have improved peritoneal ultrafiltration (icodextrin), reduced peritoneal glucose load (amino acid solution, icodextrin) and potentially provided protection of the peritoneal membrane (solutions with low concentration of glucose degradation products). Seemingly, newer devices focused on addressing the contamination risk associated with performing exchanges may reduce infection risk; one such example in early stage development is Fire Fly, which is a UV light device that could potentially lower infection rates in high risk patient groups. The peritoneal based automated portable or wearable artificial kidney (AWAK) remains an innovative technology, although it has been slow to move forward. The AWAK is a step in the right direction and could provide more continuous therapy, which decreases the number of dedicated exchanges a patient is required do in the home and thus lowering patient burden and driving acceptance.
NN&I: NxStage Medical is working on new PD technology. If you had a fresh sheet of paper, how would you design a PD system?
Schreiber: It is unclear whether newer PD cycler devices such as the one being developed by NxStage Medical will represent disruptive technologies and reshape how we deliver PD in the home. These new cyclers will be successful to the extent they lower patient burden; they’re designed for online solution generation; they were developed to be interactive and patient friendly; they achieve infection-free connections and they provide a level of connectivity to the physician prescriber that ensures adequacy and compliance. As the medical community learned from the current Baxter solution shortage, any new PD technology needs to address online fluid generation to avoid future solution shortages. At the same time newer technologies need to address creative approaches to assessing and control- ling hypervolemia in PD, a determinant of overall patient outcome.
NN&I: In your view, is there really an ideal candidate for PD—i.e., the candidate that will likely be the most successful long term?
Schreiber: I believe that the application of predictive analytics can help identify the ideal candidate for PD and predict the chances for success or likelihood of failure. Historically, the ideal candidates for PD are individuals wanting to treat their kidney disease in the home and who desire to play a key role in ensuring optimal care results. These patients may be younger, but they can be of any age as long as they are interested in a home modality; employed individuals who want to stay working; and patients with residual renal function and interested in pre- serving urine volume.
Many PD patients feel they can better control their health status while awaiting a kidney transplant by select- ing a home modality. Individuals may appreciate the benefits of preserving vascular access options for the future and therefore select PD.
Adequate education is essential to pointing out what patients should con-sider in selecting the best sequencing plan for achieving their individual life goals. Prior to education, patients may be unaware of what to think about in putting together a plan that best fits their goals. They need to learn about therapy differences; how decisions they make can affect their outcome; blood pressure control; preserving residual renal function and future vascular access options; diet; employment status; insurance coverage; the importance of avoiding long interdialytic treatment intervals; ultrafiltration removal limits, etc. It is important to think strategically about the therapy options, keeping in mind the critical nature of preserving options for the future with every decision they make.
NN&I: What would Marty Schreiber do if he were faced with kidney failure? Would he start on PD? HHD? In-center?
Schreiber: In strategizing for optimal survival—and if transplant were not an immediate option—I would preserve my vascular access and residual renal function and start on PD. If feasible I would initiate incremental continuous ambulatory PD, then transition to full-dose automated PD. Beyond PD, I would pursue nocturnal HHD. Modality notwithstanding, I would immediately get myself on the transplant list.
NN&I: How has the Baxter PD shortage impacted your ability to start more patients at home?
Schreiber: The Baxter solution shortage has been a real challenge to the entire health care community. The late decision to maintain a rationing of cycler solution beyond the first quarter timetable set by Baxter, and disconinuing the Irish importation of PD solution to help alleviate the shortage at U.S. facilities, despite the FDA view that a solution shortage still existed, caught physicians and patients off guard. The potential for future Baxter shortages for other components of PD has also raised concerns.
At this time we do not have a clear answer from Baxter as to when things will be back to supply levels which will support growth or whether Baxter will move to shrink their footprint in the U.S. in favor of overseas market expan- sion.
1. Singhal R, Hux JE, Alibhai SM, Oliver MJ. Inadequate predialysis care and mortality after initiation of renal replacement thera- py. Kidney Int. 2014 Aug;86(2):399-406. doi: 10.1038/ki.2014.16. Epub 2014 Feb 19. PMID:24552848
2. Mendu M, Schneider L, Aizer A, Singh K, Leaf D, Lee T, Sushrut S. Implementation of a CKD checklist for primary care providers. Waika Clin J Am Soc Nephrol 9: 1526–1535, 2014. doi: 10.2215/CJN.01660214