ResearchVI-Peritoneal dialysis: myths, barriers, and achieving optimum outcomes

Peritoneal dialysis: myths, barriers, and achieving optimum outcomes
by Judith Bernardini

Peritoneal dialysis provides an excellent alternative to in-center hemodialysis but the development of successful programs is often plagued by myths and misinformation. A review of recent literature can dispel some of the common myths and help understand the barriers to this modality. In addition, achieving optimum outcomes in peritoneal dialysis programs requires an active continuous quality improvement team.

When Continuous Ambulatory Peritoneal Dialysis (CAPD) was first introduced in 1975, it was a life sustaining procedure described as a "portable/wearable" dialysis (Popovich, Moncrief, Deckerd, Bomer, & Pyle, 1976). CAPD provided continuous and steady removal of solutes and fluid. The idea that a patient with renal failure could have a chronic renal replacement therapy that did not require a blood access, could be readily learned by the patient, and done independently at home was extremely innovative. The purpose of this article is to explore some of the myths and barriers that have developed about peritoneal dialysis (PD), to examine the evidence in the literature, and describe a process for optimum outcomes.

Myths

Dispelling myths allows for unbiased predialysis education from which patients can choose a modality that best fits their lifestyle and needs.

Lack of choice of modalities is a significant barrier to PD. Many Western countries have only 8 to 15% of patients on PD, however, where PD is equally available as HD, PD use rises to 30 to 40%. The United Kingdom and Australia report 50% on PD, while Mexico and Hong Kong report 90% use of PD. Four published studies have shown that patients who are provided predialysis education with an unbiased review of modality options will choose PD 45 to 54% of the time (Golper, 2000; Korevaar, 2003; Prichard, 1996; Stephenson & Villane, 1993). Educated patients have been shown to have improved quality of life, are more likely to be employed, and are more satisfied with their care (Latham, 1998). In addition, predialysis education has been found to be cost effective, with every dollar invested saving $3 to $4 on emergency room visits, admissions, and physician visits.

Paths to Optimal Outcomes

The technical aspects of CAPD in the early years from 1975 to 1987 included the initial use of glass bottles and then a modification to plastic bags, all with cumbersome connections from tubing to dialysis solutions. The resulting high incidence of peritonitis was not unexpected. This led to a common pun that CAPD actually stood for continuous ambulatory peritonitis. The joke was not lost on health care providers, dialysis manufacturers, or patients. The advantages of CAPD were often outweighed by its risks. The introduction of the y-set flush-before-fill, the double-bag, and the disconnect systems provided excellent protection from contamination of the system and reduced peritonitis due to Staphylococcus epidermidis. It also improved the quality of life for patients who could be free of dialysis bags between exchanges of solutions. Today's user friendly automated peritoneal dialysis (APD) machines provide an alternative to the "wearable" dialysis of CAPD with the convenience of dialyzing while sleeping each night

If a pattern of infections develops, the team may need to investigate the cause. For example, at our unit we noticed a sudden rise in Staphylococcus epidermidis peritonitis in the late 1990s. Analysis of the events revealed all had occurred in patients using the cycler which required manual spiking of dialysis bags. Spiking was recognized as a high risk procedure for patients. Patients on the double bag systems were not experiencing this problem. It was determined that APD patients should be re trained to use a spike assist device. Continuous tracking of peritonitis mad organisms indicated that within a few months, the incidence of touch contamination peritonitis was nearly eliminated.

Thus, the CQI team approach identified the problem, developed a solution, implemented the change, and evaluated the results. The CQI team needs to keep up with the literature and know what evidence-based research has identified as valid methods for preventing infections which is the key. The leader of the literature review may be a nephrologist or a nurse, but at least one person needs to be assigned this task. CQI identifies broader problems and directs research projects for research team. Results should have direct bearing on practice and outcomes. Using this team CQI approach at our dialysis unit, we have achieved quite low peritonitis rates, 1 episode every 75 months or 6.3 years, and excellent patient survival, which is far lower than USRDS rates (see Figure 2, Table 3). Some of the CQI initiatives are indicated on Figure 2.

[FIGURE 2 OMITTED]

Summary

Dialysis modality should be a choice for each patient based upon a clear presentation of information about PD and HD. Many patients will choose PD if they are given timely and complete predialysis education. It is important to address the myths and barriers surrounding PD in an unbiased way by examining evidence based medicine. Establishing a successful PD program begins with patient education and choice but must be maintained with a CQI program to assure retention of patients and optimal outcomes.