Retention for patients on PD requires multidisciplinary approach
Editor’s Note: The number of patients on PD in the United States has historically outnumbered those patients choosing home hemodialysis. In Nephrology News & Issues’ 2019 dialysis provider survey, for example, growth in the PD population among the 10 largest providers was quadruple that of home hemodialysis, representing 28% of new patients who started dialysis among these providers from 2018 to 2019 (click here for the complete survey results).
Directing patients to start PD is a home dialysis success story, but what are the challenges that the nephrologist and the kidney care team face in retaining patients on the therapy?
Nephrology News & Issues interviewed Jaime Uribarri, MD, professor of medicine, Icahn School of Medicine at Mount Sinai Hospital, New York, and director of the Home Dialysis Program there, along with Mt. Sinai Home Dialysis Program social workers Yvette Braunstein, LCSW, and Baptiste Nicolas, LCSW, on how they work together to help the 85 patients in Mt. Sinai’s PD program thrive and have good outcomes.
Nephrology News & Issues: How would you define retention? Is it the goal for patients to be on PD for as long as adequacy requirements can be met?
Jaime Uribarri, MD: Retention is about maintaining a patient in our PD program for as long as they want to continue the therapy and are showing good clinical results with the dialysis prescription. From my perspective, if the patient feels well, objectively is doing well and most biochemical parameters are within reason, one should assume dialysis is adequate. In the United States, however, CMS requires a weekly urea Kt/V equal or greater than 1.7 to define adequacy and this is not always reasonable from the clinical viewpoint. That makes it difficult at times to retain patients on PD.
Nephrology News & Issues: How much influence does patient selection bear on retention? Is there an accepted set of criteria that define a good candidate for PD?
Uribarri: Patient selection has a tremendous influence. The ideal candidate should be able to stay on PD for a long period; we have several patients on PD for close to 10 years in our program. The reality is the ideal patient seldom exists; over the years we have been accepting more patients who we would have rejected in the past when we had a set of strict criteria for admission to the program.
I believe one of the most important factors in growing and retaining PD patients is the existence of a dedicated and enthusiastic PD care team that not only includes the nephrologist, but nurses, social workers and dietitians.
Nephrology News & Issues: What is the influence of program size on retention? Are there data that show smaller programs are not as successful?
Uribarri: Program size has been shown repeatedly to influence technique survival and therefore retention. In Piper and colleagues a metanalysis showed a lower mortality for PD patients in high-volume centers. Schreiber also discussed the concerns about low-volume centers, suggesting small programs might benefit from shifting patient training to magnet training centers and providers could develop a hub-and-spoke care model where small programs can be managed by larger experienced centers.
Nephrology News & Issues: What are common complaints from patients who decide not to continue PD?
Yvette Braunstein, LCSW: We have found that at times, we underestimate the burden on family in making home dialysis successful. Some common complaints include disrupted sleep due to the machine’s alarms; some spouses choose to sleep in a different room as a result. Family members often take on extra responsibilities at home while the patient dialyzes. Adult children who are performing the treatments for an impaired parent say they feel burned out as they also strive to balance their own responsibilities with their families.
Baptiste Nicolas, LCSW: We also hear some spouses say they feel their home has become a medical facility, and this negatively affects the relationship. The change in lifestyle (having to be home in time to connect to the machine) also affects the family. Others complain about becoming a caregiver when their spouse can’t or won’t manage the PD regimen independently.
Nephrology News & Issues: Is there a checklist of things, you use to help the patients stay on PD successfully?
Uribarri: We do not have a specific checklist, but all the disciplines (nephrologist, nurses, dietitians and social workers) review in detail the patient’s status during their monthly PD clinics and are involved in the yearly Comprehensive Interdisciplinary Patient Assessment.
Nephrology News & Issues: What is the role of technology in patient retention?
Uribarri: We use Sharesource from Baxter Renal Care. It allows us to identify problems as soon as they occur and therefore act on them earlier and potentially more successfully. The degree of monitoring that the system permits is useful to visualize patterns of ultrafiltration, alarms that may suggest problems with catheter draining, etc. Moreover, the system facilitates ongoing monitoring of compliance with therapy.
I know our patients are happy with this technology and they realize the system permits the staff to provide faster advice when problems ensue. It is still a new system, not widely used, and therefore a final nephrologists’ opinion may not be there yet.
Nephrology News & Issues: Is a more automated system the key to helping patients stay on PD?
Uribarri: The more automation we introduce, the easier the dialysis therapy will be for patients; ultimately, the less the patient must do, the better. – by Mark E. Neumann
- Piper D et al. BMJ. 2019;doi.org/10.1186/s13104-015-1785-5.
- Schreiber M. Neph News Issues. 2018;32(8):23-27.
Disclosures: Uribarri, Braunstein and Nicolas report no relevant financial disclosures.