Identifying and Overcoming Barriers to Peritoneal Dialysis (PD)
Peritoneal dialysis (PD) is a treatment for kidney failure that can fit with patients’ lifestyles and goals. Most people who need dialysis can learn to do PD quickly, can do PD without a helper, and though some prefer manual PD exchanges during the day, most do PD while sleeping—leaving days free for work and other activities. Doing PD requires a clean (not sterile) space to do connections/disconnections and storage space for up to a month of supplies, but PD does not require home modifications. So far as clinical advantages, studies have shown that kidney function decline is slower and survival better in PD patients compared with those on hemodialysis (HD) for the first year or two.1,2,3,4
With all of these advantages, why don’t more patients do PD? The USRDS Quarterly Update for 2015-2016 reports that over 75% of new patients since Q2 2016 had seen a nephrologist before being diagnosed with kidney failure.5 With Medicare funding for physicians to provide kidney disease education to Stage IV patients6 and resources to help them educate patients about options such as those from Medical Education Institute like How to Have a Good Future with Kidney Disease and My Life, My Dialysis Choice, lack of education about treatment options should not be a barrier.
If not lack of education, could beliefs about who cannot do PD that have been passed down over time from healthcare professional to healthcare professional be the issue? Some of these beliefs can now be dispelled:
BELIEF: A patient who has had abdominal surgery can’t do PD.
FACT: A study by Crabtree7 found adhesions in only 22.7% of patients who had had one surgery and in 52% of patients who had had four or more surgeries and in 3.3% of those with no surgeries. Removing adhesions reduced catheter failures to 1.8%, while rescuing obstructed catheters reduced catheter loss to just 0.7%. Long-term catheter survival was comparable between those with or without prior surgeries. The Society of American Gastrointestinal and Endoscopic Surgeons guidelines published in 2014 state: "History of prior abdominal surgery, regardless of how many, is not a contraindication to laparoscopic PD catheter insertion. It is appropriate for surgeons with experience in advanced laparoscopy to attempt lysis of adhesions and catheter placement in these patients".8
BELIEF: Patients with an ostomy can’t do PD.
FACT: Although there are concerns about leaks and catheter or exit site infection from urine or feces contamination, one study found reasonable outcomes for PD in patients with ostomies.9 Presternal catheters can help to reduce the risk of infection in adults and children because the exit site is distant from the ostomy.10 That said, HD is a better option for someone with an ostomy for inflammatory bowel disease, due to a higher peritonitis risk.11 The 2000 Kidney Disease Outcomes Quality Initiative (KDOQI) guideline on peritoneal dialysis adequacy recognized the risk but recommended that the decision about whether to attempt PD should be individualized, since there had been published reports of successful PD in those patients.12
BELIEF: Obese patients can’t get adequate dialysis on PD.
FACT: One study found that patients weighing >90 kg (BMI >43 kg/m2) had earlier and more bouts of peritonitis. However, those patients also had fewer hernias and hospitalizations, and had similar survival to non-obese patients.13 Other studies have shown that obese patients had better survival than non-obese patients for at least the first 2 years of PD.14,15
BELIEF: Patients who have hernias are not candidates for PD, and patients on PD are more likely to get hernias.
FACT: Hernias are a potential complication of PD. In the 1980s, 10-15% of CAPD patients and 5% of cycler patients got one.16 According to one recent 10-year study of nearly 7,000 PD patients, improved catheter placement techniques have reduced the incidence of hernia in PD to just 0.04/patient/year.17 Some people do have a higher risk of developing a hernia, such as those with polycystic kidneys.18 Others may already have a hernia when they need to start dialysis. People with hernias or those at risk of having a hernia can still do PD. Patients They should do low volume dialysate exchanges if possible, and use the PD cycler in a supine position. Patients do not have to change to HD and can continue to do PD before and after hernia repair surgery. Although surgery to repair a hernia is usually recommended, PD patients can continue to do PD without having hernia surgery if surgery is risky or the patient chooses not to have surgery.19
BELIEF: Patients on PD should not do certain exercises or lift heavy things.
FACT: One study measured intra-abdominal pressure (IAP) in CAPD patients doing usual activities when they were carrying no fluid to three liters of fluid in three positions—lying down, sitting up and standing. The IAP increased as the weight lifted increased, up to 50 pounds, but was still lower than when coughing or straining. In fact, coughing and straining produced the highest—IAP no matter the position. Coughing or jumping with higher fluid levels produced more IAP. The lowest pressure measured was when biking.20 Activities that could increase IAP should be done when the peritoneal cavity has little or no fluid.
BELIEF: Patients on a mechanical ventilator cannot do PD.
FACT: A study of PD in patients with acute kidney injury (AKI) found that although intra-abdominal pressure increased, it didn’t rise to a critical level, and respiratory mechanics in AKI patients on high volume PD improved. The authors hypothesized that respiratory improvement might be due to fluid and/or uremic toxin removal.21
BELIEF: People on PD don’t live as long as those on HD.
FACT: The United States Renal Data System shows that for incident HD patients starting HD in 2004, 5 and 10-year survival in 2014 was 41.6% (Table I.17 adj) and 19.1% (Table I.18 adj), respectively. For incident patients starting PD in 2004, the 5 and 10-year survival in 2014 was 51.5% (I.23 adj) and 27.2%, respectively (I.24 adj).22
Considering that a little research can dispel so many long-standing beliefs, if you help patients to make treatment decisions, monitor your biases and look for supporting or opposing evidence before you tell patients they cannot do PD if that’s the treatment option they want. Patients may be able to do PD for a long time.23
Rottembourg J, et al. Evolution of residual renal function in patients undergoing maintenance haemodialysis or continuous ambulatory peritoneal dialysis. Proc Eur Dial Transplant Assoc 1983;19:397–403.↩
Lysaght MJ, et al. The influence of dialysis treatment modality on the decline of remaining renal function. ASAIO Trans 1991;37:598–604.↩
Misra M, et al. Effect of cause and time of dropout on the residual GFR: a comparative analysis of the decline of GFR on dialysis. Kidney Int 2001;59:754–63.↩
Lang SM, et al. Preservation of residual renal function in dialysis patients: effects of dialysis-technique–related factors. Perit Dial Int 2001;21:52–7.↩
Kidney disease education, https://www.medicare.gov/coverage/kidney-disease-edu.html (Accessed August 27, 2017)↩
Crabtree JH, Burchette RJ. Effect of prior abdominal surgery, peritonitis, and adhesions on catheter function and long-term outcome on peritoneal dialysis. Am Surg 2009;75:140–147.↩
Haggerty SP, et al. Guidelines for laparoscopic peritoneal dialysis access surgery. 2014; Available from: http://www.sages.org/publications/guidelines/guidelines-laparoscopic-peritoneal-dialysis-access-surgery/. (Accessed August 27, 2017)↩
Korzets Z, et al. Peritoneal dialysis in the presence of a stoma. Perit Dial Int 1992;12:258–260.↩
Twardowski ZJ. Presternal peritoneal catheter. Adv Ren Replace Ther 2002;9:125–132.↩
Lee MB, Bargman JM. Myths in peritoneal dialysis. Curr Opin Nephrol Hypertens 2016;25:602-608.↩
II. NKF-K/DOQI Clinical Practice Guidelines for Peritoneal Dialysis Adequacy: update 2000. Am J Kidney Dis 2001; 37 (1 Suppl 1):S65–S136. http://www.ajkd.org/article/S0272-6386(01)70006-6/pdf (Accessed August 27, 2017)↩
Ananthakrishnan S, et al. Peritoneal dialysis outcomes in a modern cohort of overweight patients. Int Urol Nephrol 2014;46:183–189.↩
Snyder JJ, et al. Body size and outcomes on peritoneal dialysis in the United States. Kidney Int 2003;64:1838–1844.↩
Fernandes NM, et al. Body size and longitudinal body weight changes do not increase mortality in incident peritoneal dialysis patients of the Brazilian peritoneal dialysis multicenter study. Clinics (Sao Paulo) 2013;68:51–58.↩
Rocco M, Burkart JM. Abdominal hernias in continuous peritoneal dialysis. Up-to-Date. https://www.uptodate.com/contents/abdominal-hernias-in-continuous-peritoneal-dialysis (Accessed 8/31/2017)↩
Yang SF et al. The risk factors and the impact of hernia development on technique survival in peritoneal dialysis patients: a population-based cohort study. Perit Dial Int. 2015;35(3):351.↩
Hernias and Peritoneal Dialysis. http://www.homedialysis.org/life-at-home/articles/hernias-and-peritoneal-dialysis (Accessed August 31, 2017)↩
Bargman J. Hernias in peritoneal dialysis patients: limiting occurrence and recurrence. Perit Dial Int 2008;28:349-351↩
Twardowski ZJ et al. Intraabdominal pressures during natural activities in patients treated with continuous ambulatory peritoneal dialysis. Nephron 1986;44:129-35.↩
Almeida CP et al. Effect of peritoneal dialysis on respiratory mechanics in acute kidney injury patients. Perit Dialysis Int 2014;34:544–549.↩
United States Renal Data System. 2016 USRDS annual data report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2016. https://www.usrds.org/2016/ref/ESRD_Ref_I_Survival_2016.xlsx (Accessed August 27, 2017)↩
Islam MS, et al., More than 17 years of peritoneal dialysis: A case report. Adv Perit Dial. 1997;13:98-103. https://www.advancesinpd.com/adv97/pt2more19-97.html (Accessed August 27, 2017)↩