Nephrology News & Issues
Tracking outcomes in the increasing use of urgent peritoneal dialysis
Mark E. Neumann
Mr. Neumann has been executive editor of Nephrology News & Issues since 1989.
Individuals who end up in the hospital emergency room after months, maybe years, of ignoring the signs of kidney failure usually have a fairly standard course of treatment: dialysis delivered via a temporary hemodialysis catheter.
At that point, says Arshia Ghaffari, DO, MA, MBA, there is a strong likelihood that the individual will stay on that therapy. "Once they are on in-center hemodialysis, it is rare that a patient moves to peritoneal dialysis," Ghaffari said at the 45th annual symposium of the American Nephrology Nurses Association held in Anaheim, Calif. in April. Ghaffari, who started the urgent start for PD a few years ago, says there are now over 1,000 successful cases in the U.S. Also, data presented in early March shows that this approach to emergent dialysis is not only improving outcomes but technique survival is now over two years with few complications (Kumar et al., Southwest Kidney Institute Inc., abstract presentation, Annual Dialysis Conference, Atlanta, Ga.)
Pre-dialysis education not always the solution
Even with pre-dialysis care and counseling up to one year with a nephrologist, 85% of all patients start with a temporary hemodialysis catheter, Ghaffari said. That's not always the fault of the nephrologist––patients can be in denial about the seriousness of their kidney disease and will cancel appointments set up by nephrologists for a permanent access because of the fear of the surgery. "Even if we do our best to get these patients prepared, there is a certain percentage that will crash" and end up in the ER needed dialysis immediately, Ghaffari said. That usually means a temporary hemodialysis catheter, and studies show that increases the patient's risk for infection and death.
One solution that may reverse this tide, which is partly responsible for close to 90% of patients being on in-center dialysis, is urgent peritoneal dialysis. The idea that such patients, who have ignored their deteriorating kidney condition and are forced to seek help in an emergency room, would be ideal candidates for self-care seems odd. But after becoming medical director at his Los Angeles-based clinic, Ghaffari began looking into why his percentage of PD patients was not growing. "Most referrals were coming from my county hospital—patients who were underinsured, had little or no experience with primary care—and coming in late in the disease process." But Ghaffari told nurses that if patients are presented with PD as the best therapy at the onset, they take on the responsibility. "We need to give these patients the option to do self-care," he told his staff.
Urgent PD is placing the patient on peritoneal dialysis right from the start of therapy. Patients may get a temporary hemodialysis catheter and have several hemodialysis sessions to reduce fluid overload and help stabilize the patients' condition if they are highly uremic, but the HD catheter is removed before the patient leaves the hospital.
Some of the benefits of choosing urgent PD over traditional in-center hemodialysis include preservation of the vasculature, preserving residual renal function, a lower cost, greater patient satisfaction, and better outcomes for PD patients who go on to a kidney transplant vs. HD patients.