Predicting a patient's choice of dialysis modality:Experience in a United Kingdom renal department

doi:10.1016/S0272-6386(05)80014-9

American Journal of Kidney Diseases

Volume 37, Issue 5, May 2001, Pages 981-986

https://doi.org/10.1016/S0272-6386(05)80014-9 Get rights and content

Abstract

Education and counseling are important aspects of the management of patients starting dialysis. Free choice ofmodality may enhance patient well-being and, in the absence of clear survival benefits for either hemodialysis (HD) or continuous ambulatory peritoneal dialysis (CAPD), should have the major role in modality selection. This prospective study examines factors influencing this choice. Three hundred thirty-three new patients started renal replacement therapy at Birmingham Heartlands Hospital (Birmingham, UK) between August 1, 1992, and July 31, 1998. Data were incomplete for 14 patients, 11 patients were not counseled, and 54 patients had contraindications to a particular modality. The remaining 254 patients were offered a free choice. One hundred thirty-nine patients (55%) chose HD and 115 patients (45%) chose CAPD. Independent predictors for choosing CAPD rather than HD were being married (P = 0.004), being counseled before the start of dialysis (P = 0.019), and increased distance from the base unit (P < 0.001). Independent predictors for choosing HD were increasing age (P = 0.030) and male sex (P = 0.041). Use of these data should enhance planning of dialysis services and bring nearer the goal that all new patients with ESRD are able to have the dialysis modality of their choice.

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Nocturnal hemodialysis is a form of intensive hemodialysis, which may be done in center or at home. Despite the documented clinical and economic benefits of ncturnal hemodialysis, uptake of this modality has been relatively low. In this review, we aim to address the potential barriers and possible mitigation strategies. Among the patient-related barriers, lack of knowledge and awareness remains the most common barrier, while administrative inertia to change from conventional in-center hemodialysis continues to be a challenge. Current global effort to grow home dialysis will re-focus the need for better patient education, innovate home dialysis technology, and evolve new models of care. New patient-focused policy will allow changes in reimbursement and develop appropriate momentum toward an integrated “home first model” to kidney replacement therapy.
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International Variations in Peritoneal Dialysis Utilization and Implications for Practice
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In many countries, the use of peritoneal dialysis (PD) remains low despite arguments that support its greater use, including dialysis treatment away from hospital settings, avoidance of central venous catheters, and potential health economic advantages. Training patients to manage aspects of their own care has the potential to enhance health literacy and increase patient involvement, independence, quality of life, and cost-effectiveness of care. Complex reasons underlie the variable use of PD across the world, acting at the level of the patient, the health care team that is responsible for them, and the health care system that they find themselves in. Important among these is the availability of competitively priced dialysis fluid. A number of key interventions can affect the uptake of PD. These include high-quality patient education around dialysis modality choice, timely and successful catheter placement, satisfactory patient training, and continued support that is tailored for specific needs, for example, when people present late requiring dialysis. Several health system changes have been shown to increase PD use, such as targeted funding, PD First initiatives, or physician-inserted PD catheters. This review explores the factors that explain the considerable international variation in the use of PD and presents interventions that can potentially affect them.
From care management decision to set-up of home dialysis: what are the challenges for the nephrologist in assisting the patient?
2018, Nephrologie et Therapeutique
Depuis quelques années, un nouveau paradigme de soins se met en place, dans lequel le patient joue un rôle de plus en plus important dans le choix de sa prise en charge. Renseigner le malade dans un contexte où la relation médecin-patient s’en trouve pleinement modifiée et où l’information évolue constamment représente un défi pour le néphrologue. Pour le patient qui décide d’être traité à domicile, les questionnements sont nombreux et jalonnent chaque étape du parcours décisionnel. Comment aborder les alternatives qui s’offrent à lui ? Que disent les données récentes sur les différentes méthodes possibles ? Parce que confort, qualité de vie et niveau d’autonomie déterminent fréquemment le choix de la prise en charge, la dialyse à domicile peut être plus largement privilégiée grâce à un accompagnement approprié du néphrologue et de l’équipe soignante.
Since a couple of years, a new paradigm of care has taken place where the patient plays a major role in the choice of his treatment. Patient information in a context where the doctor-patient relationship has drastically changed and where knowledge is continuously growing, is a challenge for the nephrologist. For the patient who decides to undergo home dialysis, numerous questions arise during the decision-making process. How should treatment alternatives be discussed with the patient? What are the current data available on the different methods? As comfort, quality of life and level of autonomy often drive the choice of care management, home dialysis can be promoted more with appropriate assistance from both the nephrologist and the healthcare team.
Cet article fait partie du numéro supplément Innovations en Néphrologie réalisé avec le soutien institutionnel de Vifor Fresenius Medical Care Renal Pharma.
Impact of Obesity on Modality Longevity, Residual Kidney Function, Peritonitis, and Survival Among Incident Peritoneal Dialysis Patients
2018, American Journal of Kidney Diseases
The prevalence of severe obesity, often considered a contraindication to peritoneal dialysis (PD), has increased over time. However, mortality has decreased more rapidly in the PD population than the hemodialysis (HD) population in the United States. The association between obesity and clinical outcomes among patients with end-stage kidney disease remains unclear in the current era.
Historical cohort study.
15,573 incident PD patients from a large US dialysis organization (2007-2011).
Body mass index (BMI).
Modality longevity, residual renal creatinine clearance, peritonitis, and survival.
Higher BMI was significantly associated with shorter time to transfer to HD therapy (P for trend < 0.001), longer time to kidney transplantation (P for trend < 0.001), and, with borderline significance, more frequent peritonitis-related hospitalization (P for trend = 0.05). Compared with lean patients, obese patients had faster declines in residual kidney function (P for trend < 0.001) and consistently achieved lower total Kt/V over time (P for trend < 0.001) despite greater increases in dialysis Kt/V (P for trend < 0.001). There was a U-shaped association between BMI and mortality, with the greatest survival associated with the BMI range of 30 to < 35 kg/m² in the case-mix adjusted model. Compared with matched HD patients, PD patients had lower mortality in the BMI categories of < 25 and 25 to < 35 kg/m² and had equivalent survival in the BMI category ≥ 35 kg/m² (P for interaction = 0.001 [vs < 25 kg/m²]). This attenuation in survival difference among patients with severe obesity was observed only in patients with diabetes, but not those without diabetes.
Inability to evaluate causal associations. Potential indication bias.
Whereas obese PD patients had higher risk for complications than nonobese PD patients, their survival was no worse than matched HD patients.
Comparison of Patient Survival Between Hemodialysis and Peritoneal Dialysis Among Patients Eligible for Both Modalities
2018, American Journal of Kidney Diseases
Citation Excerpt :
Patients who did not undergo modality assessment and those deemed ineligible for PD made up 36% of the total dialysis population, were older, and had a higher burden of comorbid conditions. Prior estimates6,17-20 of PD eligibility have ranged from 64% to 83% among incident dialysis patients. As a consequence, PD eligibility may have been an important contributor to the underlying case-mix differences between HD and PD patients in many of the previous comparisons.
Although peritoneal dialysis (PD) costs less to the health care system compared to in-center hemodialysis (HD), it is an underused therapy. Neither modality has been consistently shown to confer a clear benefit to patient survival. A key limitation of prior research is that study patients were not restricted to those eligible for both therapies.
Retrospective cohort study.
All adult patients developing end-stage renal disease from January 2004 to December 2013 at any of 7 regional dialysis centers in Ontario, Canada, who had received at least 1 outpatient dialysis treatment and had completed a multidisciplinary modality assessment.
HD or PD.
Mortality from any cause.
Among all incident patients with end-stage renal disease (1,579 HD and 453 PD), PD was associated with lower risk for death among patients younger than 65 years. However, after excluding approximately one-third of all incident patients deemed to be ineligible for PD, the modalities were associated with similar survival regardless of age. This finding was also observed in analyses that were restricted to patients initiating dialysis therapy electively as outpatients. The impact of modality on survival did not vary over time.
The determination of PD eligibility was based on the judgment of the multidisciplinary team at each dialysis center.
HD and PD are associated with similar mortality among incident dialysis patients who are eligible for both modalities. The effect of modality on survival does not appear to change over time. Future comparisons of dialysis modality should be restricted to individuals who are deemed eligible for both modalities to reflect the outcomes of patients who have the opportunity to choose between HD and PD in clinical practice.

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Original investigationPredicting a patient's choice of dialysis modality:Experience in a United Kingdom renal department

Abstract

Am J Kidney Dis

Lancet

Am J Kidney Dis

Am J Kidney Dis

Am J Kidney Dis

Selection and preparation of patients for dialysis

Choice of treatment improves quality of life. A study on patients undergoing dialysis

Arch Intern Med

Original investigation
Predicting a patient's choice of dialysis modality:Experience in a United Kingdom renal department