PD in the Elderly—Wouldn’t SLOW and LOW Make More Sense?

This blog post was made by Dori Schatell, MS, Executive Director, Medical Education Institute on October 16th, 2014.
PD in the Elderly—Wouldn’t SLOW and LOW Make More Sense?

Sometimes worlds collide. For example, one of my friends from my Civil War reenacting group ended up with kidney failure and did PD (she had a simultaneous kidney-pancreas transplant a few years ago). And, a few months ago, I learned that a neighbor’s dad had kidneys that were teetering on the brink after an X-ray dye test. He was in his 80s and active, and liked to travel. “Have I ever told you what I do for a living?” I asked her. I hadn’t, so lots of conversations with her and her mom, and a copy of Help, I Need Dialysis! later, they decided to do PD.

It all went great for them for the first 4 months. His PD catheter placement went without a snag, and it worked well. It took them some time to get used to having all of those boxes of fluid in their otherwise neat as a pin home, but they adapted to the manual exchanges and looked forward to learning how to use the cycler.

Only, the cycler training didn’t come in time. The nurse was too busy, and the clinic didn’t hire another one (maybe they couldn’t find one).

After a busy week of golfing, mowing the lawn, and washing his car (all with 4 lbs. or so of extra fluid in his belly), his peritoneum sprung a leak into his testicles. A CT scan ruled out a hernia, but since he could not have general anesthesia, the surgeon couldn’t look for the leak to try to fix it.

You can imagine the rest—the central venous catheter placement, removal of his PD catheter, the urgent search for a clinic with a slot (and the research into the clinic—is it a good one?), the blaming the patient for being “too active” when he was never warned not to be (and was, in fact, told to keep doing his normal activities).

It’s going to be a lot more challenging for this elderly couple to travel now, and their lives will need to shift to the rhythms of the clinic. And, it’s hard to get past the notion that this didn’t have to happen.

When someone starts PD, they tend to have a reasonable amount of residual kidney function . So, why do we start them out with four exchanges a day? In 1996, I staffed the DOQI Anemia Work Group and still recall sitting next to Tom Golper, MD at a dinner event and having him point out that it might make more sense to start people on PD incrementally—one exchange, then two, then three, and ramping up to four as their residual function dropped and it became necessary. I always thought his idea was brilliant, but as far as I know, it hasn’t happened. SLOW PD = fewer exchanges.

“Ambulatory” PD might be fine for younger people with resilient, flexible peritoneal tissue. But, as we age and lose collagen, it makes sense that the peritoneum loses integrity as well. Low-volume, recumbent-only PD (LVRO PD), a technique used to allow PD to continue after surgery, may make more sense for new, elderly PD starts while they are doing manual exchanges. If people are lying down, they are putting less stress on their peritoneums—reducing the risk of tears and hernias. LVRO PD is most often done using a cycler, but it doesn’t have to be. LOW PD = Staying Recumbent.

I am not a nurse or a PD expert, but starting with SLOW and LOW PD in the elderly seems to be common sense. And, if a little common sense had been applied, my neighbor’s dad might still be planning his usual winter trip out of the snow zone.

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Comments

  • Theodôr

    Oct 27, 3:08 AM

    I support the viewpoint of Bettie; APD/ CCPD works well in our group of elderly patients. Assisted PD is often a good alternative. We attune to the needs of the individual patients including volume prescription. But starting with one exchange I was told by our MD gives you quite little effciency and the risk Bettie mentioned on the overhydration/ pulonological and cardiac risks. So you have to look per patient if the stress of the PD treatment gives enough benefit, compared with the burden that the patient experiences.

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  • Maria Pia

    Oct 20, 11:46 AM

    I'm sorry about your father. In the Italian will not start ever with 4 exchanges when we have a residual diuresis. We do the dialysis incrementally starting with one and then two exchanges per day. Then, before moving on to 4 exchanges proposes the machine. It depends on the clinic, the residual diuresis, to respond to a treatment effective. An elderly person will have no need of such treatment as a young person. Dialysis should be personalized is not standard. Sorry for my bad English.

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    • Dori

      Oct 21, 12:55 PM

      Thank you, Maria! And, your English is fine. :-) I am glad to hear that all patients from Italy do not get the same treatment when they start PD. It makes sense to prescribe different treatment for an active young person than for an active older person with weak tissues.

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  • Bettie Hoekstra

    Oct 20, 1:21 AM

    Hi Dori, I am a nurse practioner, working in PD in the Netherlands. I agree with you that in the elderly we should be careful in building up a PD-schedule. We choose to start with automatic PD in low volumes. There for we can use caretakeers in the surroundig of the patient, daily homecare and our own mobile PD team. The most important thing is to give the patient a guideline for ajusting to the treatment and possible complications and make them as comfortable as we can.
    Ofcourse when there is enough residual kidney function the choice can be of low amount of exchanges, but medically there can be the problem of peritoneum function and overhydration with cardial and pulmonal problems.

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    • Dori

      Oct 21, 12:57 PM

      Thank you so much for your comment, Bettie. I don't know why they did not start this gentleman on a cycler right away. With fewer connections to make, this is easier and safer! It sounds from both you and Maria that other countries do not do the "one-size-fits-all" PD that we seem to be giving people in the US.

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  • Gale Schulke

    Oct 16, 2:43 PM

    In my practice, the last fill for these elderly people is never more than 1000ml. We can make up the need with more exchanges on the cycler. CAPD starts off at 4 exchanges at 1500cc. I prefer to do more exchanges at lower fills. We have the Baxter pt sleep in ICO with a larger fill. ICO really is my saver for CAPD as they can sleep with higher volumes.
    As nurses, we tend to forget that we need to caution our pts about strenuous work, particularly men with fluid in the belly.

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    • Dori

      Oct 17, 9:01 AM

      Why start with 4 exchanges a day in someone in their '80s, though? Isn't this perhaps more tradition than anything clinically indicated for someone with significant residual kidney function?

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