Transcript Selecting Dialysis Modality for ESRD Patients: Clinical

Selecting Dialysis Modality for ESRD
Patients: Clinical Advice from ERBP
Advisory Board
Reference: Covic A, Bammens B, Lobbedez T, et al.
Educating end-stage renal disease patients on dialysis
modality selection:
Clinical advice from the European Renal Best Practice
(ERBP) Advisory Board. Nephrol Dial Transplant.
2010;25:1757–1759.
Introduction: EBPG and KDIGO
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A single set of international guidelines under the guidance of Kidney Disease
Improving Global Outcomes (KDIGO) was undertaken. This international effort is
however not completely acknowledged by several nephrologists, who at times feel
that differences in practice patterns make it diffi cult to apply guidelines developed
outside Europe.
Alternatively, the latest versions of the European Best Practice Guidelines (EBPG)
may appear outdated in some respects, while not all aspects of nephrological
practice are currently covered by KDIGO.
A European guideline planning was discussed by a specially appointed ERA–EDTA
Work Group that met in Paris in early January 2008 and agreed that the
Association should continue producing and updating guidelines in collaboration
with KDIGO. The decision that ERA–EDTA should issue suggestions for clinical
practice in areas in which evidence is lacking or weak, which would be published
as ‘clinical advice’ rather than ‘clinical guidelines’ was also agreed upon.
The European Renal Best Practice (ERBP) Advisory Board recently decided not to
create new or updated guidelines for peritoneal dialysis (PD), as there was not
enough new evidence to produce a meaningful change in scope from the previous
guidance documents published in 2005 by EBPG.
Introduction: EBPG and KDIGO
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In its place, the need for an advice on three important PD-related topics for
everyday clinical use was called for—peritoneal membrane evaluation, modality
selection and adequacy.
Presently, the text on membrane evaluation is in press.
The following publication that was issued by an ERBP Expert Group and approved
by the ERBP Advisory Board comprises the clinical advice on renal replacement
therapy (RRT) modality selection for end-stage renal disease (ESRD) patients.
The following content is an executive summary of these recommendations,
whereas the complete text, including the rationale of the statements, is published
in the current issue of NDT Plus.
Providing information and assisting in decision making is the focus of these
statements, and is not intended to define a standard of care or to improve an
exclusive course of diagnosis, prevention or treatment.
However, variations in practice are inevitable when physicians take into account
individual patient needs, available resources and limitations specifi c for a
geographic area, country, institution or type of practice.
Moreover, evidence may change over time with newer information, so that
practice may be modified subsequently.
Choosing the Initial Dialysis Modality
Clinical advice:
• Recommending hemodialysis (HD) over PD, or vice versa lacks concrete
evidence.
• Hence, it is up to the well-informed patient to chiefly make the initial
modality choice.
• Certain conditions should not be considered as contraindications to PD
(see Table 1).
Choosing the Initial Dialysis Modality
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As a consequence, all available treatment options must
be provided by all RRT centers, or in collaboration with
other centers—PD (including CAPD and APD), HD
(including home HD and nocturnal programs) and
transplantation (including cadaveric and noncadaveric), to
make sure that all patients can select the modality that is
most suitable for them.
As a consequence, well-balanced information about the
different RRT modalities must be provided by means of a
structured education program to all patients and their
families. The same applies to late-referred patients and
those starting dialysis in an emergency situation,
whoshould receive the information once their conditions
have stabilized.
Making the Choice between CAPD
and APD
Clinical advice:
• As long as the dwell time of the patient is
matched to his/her peritoneal transport type,
there is no basis to prefer CAPD or APD.
• Choice should be guided by patient preference
as both modalities have reported equivalent
outcomes.
Making the Exchange between Modalities
Transition from HD to PD
Clinical advice:
• Patients who are on HD and suffering from any of the
following clinical conditions must be informed about
the option of PD:
I. Intradialytic hemodynamic intolerance and muscle
cramps despite optimal adjustment of dry weight
II. Problems to create a well-functioning native vascular
access
III. Intractable or recurrent ascites
Making the Exchange between Modalities
Transition from PD to HD
Clinical advice: Patients on PD and suffering from any of the
following clinical conditions should be informed about the
option of HD:
I. Incapacity to maintain fl uid balance
II. Relapsing or persistent peritonitis
III. Incapacity to control uremic symptoms or to maintain a
good nutritional state
IV. Changes in lifestyle circumstances
V. Declining residual renal function
VI. Intra-abdominal surgery
VII. Sclerosing peritonitis
Making the Exchange between Modalities
Choice of Dialysis Modality for Patients with Failed
Renal Transplantation
Clinical advice:
• There is no proven difference in survival between
HD and PD in patients with failed renal
transplantation who return to dialysis.
• Hence, the choice of dialysis modality for these
patients should be based on the same principles
as those applying to the initial modality choice.
Assisted PD for Nonautonomous Patients
• Assisted PD is indicated for ESRD patients who choose PD as RRT
modality or in whom HD is contraindicated, who have no
contraindication to PD, but are incapable to perform PD exchanges
by themselves, and whose family members’ quality of life could be
affected by the burden of care giving.
• This modality can be performed at the patient’s home with the help
of a healthcare technician, a community nurse, a family member or
a partner; and may be proposed either to incident dialysis patients
or to previously self-care PD patients who have lost their autonomy.
• Assisted PD is generally less expensive than incenter HD even with
the additional cost of the assistance.
• The risk of peritonitis is however, similar in nurse-assisted and
family-assisted CAPD patients.
Summary
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All RRT centers should be equipped with both PD and HD facilities and provide
unbiased information to ESRD patients, thereby allowing them to freely
choose between the two RRT modalities.
The leading criterion for modality selection should be patient’s preference in
both ‘de novo’ and failed renal transplantation cases.
Alternatively, the availability of both modalities enables transition of patients
from one modality to another, whenever particular clinical conditions occur.
Assisted PD serves as the alternate option for non-autonomous patients to be
treated with PD, to incenters HD.
The clinical advice presented is believed by the ERBP Expert Group to be
useful in expanding the use of PD in countries where it is currently underused.
The availability of alternate options in RRT programs would allow patients to
choose the dialysis modality they find most suitable for them.
Besides, it serves to decrease the burden of HD units and lead to expenditure
savings.
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