Assisted PD throughout Europe: advantages, inequities, and solution proposals.

BACKGROUND: Peritoneal dialysis provides several benefits for patients and should be offered as first line kidney replacement therapy, particularly for fragile patients. Limitation to self-care drove assisted peritoneal dialysis to evolve from family-based care to institutional programs, with specialized care givers. Some European countries have mastered this, while others are still bound by the availability of a volunteer to become responsible for treatment. METHODS: A group of leading nephrologists from 13 European countries integrated real-life application of such therapy, highlighting barriers, lessons learned and practical solutions. The objective of this work is to share and summarize several different approaches, with their intrinsic difficulties and solutions, which might helpperitoneal dialysis units to develop and offer assisted peritoneal dialysis. RESULTS: Assisted peritoneal dialysis does not mean 4 continuous ambulatory peritoneal dialysis exchanges, 7 days/week, nor does it exclude cycler. Many different prescriptions might work for our patients. Tailoring PD prescription to residual kidney function, thereby maintaining small solute clearance, reduces dialysis burden and is associated with higher technique survival. Assisted peritoneal dialysis does not mean assistance will be needed permanently, it can be a transitional stage towards individual or caregiver autonomy. Private care agencies can be used to provide assistance; other options may involve implementing PD training programs for the staff of nursing homes or convalescence units. Social partners may be interested in participating in smaller initiatives or for limited time periods. CONCLUSION: Assisted peritoneal dialysis is a valid technique, which should be expanded. In countries without structural models of assisted peritoneal dialysis, active involvement by the nephrologist is needed in order for it to become a reality.

Availability of assisted peritoneal dialysis in Europe: call for increased and equal access.

BACKGROUND: Availability of assisted PD (asPD) increases access to dialysis at home, particularly for the increasing numbers of older and frail people with advanced kidney disease. Although asPD has been widely used in some European countries for many years, it remains unavailable or poorly utilized in others. A group of leading European nephrologists have therefore formed a group to drive increased availability of asPD in Europe and in their own countries. METHODS: Members of the group filled in a proforma with the following headings: personal experience, country experience, who are the assistants, funding of asPD, barriers to growth, what is needed to grow and their top three priorities. RESULTS: Only 5 of the 13 countries surveyed provided publicly funded reimbursement for asPD. The use of asPD depends on overall attitudes to PD, with all respondents mentioning the need for nephrology team education and/or patient education and involvement in dialysis modality decision making. CONCLUSIONS AND CALL TO ACTION: Many people with advanced kidney disease would prefer to have their dialysis at home, yet if the frail patient chooses PD most healthcare systems cannot provide their choice. AsPD should be available in all countries in Europe and in all renal centres. The top priorities to make this happen are education of renal healthcare teams about the advantages of PD, education of and discussion with patients and their families as they approach the need for dialysis, and engagement with policymakers and healthcare providers to develop and support assistance for PD.

Pilot Randomized Controlled Trial of a Standard Versus a Modified Low-Phosphorus Diet in Hemodialysis Patients.

INTRODUCTION: The standard low-phosphorus diet restricts pulses, nuts, and whole grains and other high phosphorus foods to control hyperphosphatemia. We conducted a randomized controlled trial to evaluate the effectiveness, safety, and tolerability of the modified diet, which introduced some pulses and nuts, increased the use of whole grains, increased focus on the avoidance of phosphate additives, and introduced the prescription of low-biological-value protein such as bread. METHODS: We conducted a multicenter, pragmatic, parallel-arm, open-label, randomized controlled trial of modified versus standard diet in 74 adults on hemodialysis with hyperphosphatemia over 1 month. Biochemistry was assessed using monthly laboratory tests. Dietary intake was assessed using a 2-day record of weighed intake of food, and tolerability was assessed using a patient questionnaire. RESULTS: There was no significant difference in the change in serum phosphate between the standard and modified diets. Although total dietary phosphorus intake was similar, phytate-bound phosphorus, found in pulses, nuts, and whole grains, was significantly higher in the modified diet (P < 0.001). Dietary fiber intake was also significantly higher (P < 0.003), as was the percentage of patients reporting an increase in bowel movements while following the modified diet (P = 0.008). There was no significant difference in the change in serum potassium or in reported protein intake between the 2 diets. Both diets were similarly well tolerated. CONCLUSION: The modified low phosphorus diet was well tolerated and was associated with similar phosphate and potassium control but with a wider food choice and greater fiber intake than the standard diet.

Peritoneal dialysis in an ageing population: a 10-year experience.

BACKGROUND: Chronic kidney disease (CKD) is becoming increasingly prevalent and there are increasing numbers of older patients with advanced CKD. Peritoneal dialysis (PD) is a potential treatment. This study aims to compare PD outcomes in age-defined populations in the largest PD centre in the Republic of Ireland over 10 years. METHODS: We retrospectively identified all adult patients, over the age of 50 years, who commenced PD as their first modality of renal replacement therapy (RRT) between 1 January 1998 and 31 December 2008 at our institution. Primary outcome was patient survival; secondary outcomes were technique failure, peritonitis-free survival, transplantation and hospitalisations. RESULTS: One hundred and forty-eight patients with a mean age of 63 years were included. Twenty-two patients were on assisted PD, the majority of whom were aged 70 years or over (P = 0.001). There were no differences in patient survival or technique failure by age group, Charlson Co-Morbidity Index (CCI), modified-CCI or adjusted CCI. Renal transplantation occurred predominantly in younger patients (P = 0.001) with lower m-CCI (P = 0.001) and a-CCI (P = 0.002) who performed PD independently (P = 0.004). Older patients required longer hospital stays to initiate PD (P = 0.004). Assisted PD was not associated with an increase in early complications or technique failure but death rates were higher (P = 0.002). CONCLUSION: This study shows PD to be an acceptable modality of renal replacement therapy in elderly patients, with no observed differences in survival, technique survival or complication rates. Co-morbidities appear to play a stronger role in predicting survival than age alone. Assisted PD is a viable option in those unable to undergo PD independently.

Using the MDRD value as an outcome predictor in emergency medical admissions.

BACKGROUND: Both physiological- and laboratory-derived variables, alone or in combination, have been used to predict mortality among acute medical admissions. Using the Modification of Diet in Renal Disease (MDRD) not as an estimate of glomerular filtration rate but as an outcome predictor for hospital mortality, we examined the relationship between the MDRD value and in-hospital death during an emergency medical admission. METHODS: An analysis was performed on all emergency medical patients admitted between 1 January 2002 and 31 December 2008, using the hospital in-patient enquiry system, linked to the patient administration system and laboratory datasets. Hospital mortality (any in-patient death within 30 days) was obtained from a database of deaths occurring during the same period under physicians participating in the 'on-call' roster. Logistic regression was used to calculate unadjusted and adjusted odds ratios (OR) and 95% confidence intervals (CI) for MDRD value. RESULTS: Univariate analysis identified those with MDRD value of <60 as possessing increased mortality risk. Their 30-day mortality rate was 21.63 versus 4.35% for patients without an abnormal value (P < 0.0001) with an OR of 6.07 (95% CI's 5.49, 6.73: P < 0.001). After adjustment for 12 other outcome predictors including comorbidity, the OR was 4.63 (4.08, 5.25: P < 0.0001). Using the Kidney Disease Outcomes Quality Initiative (KDOQI) class, the respective mortality rates by 30 days increased with a lower MDRD value, from 2.8% in KDOQI Class 1 to 48.6% in KDOQI Class 5. Outcome prediction of in-hospital death, at 5 and 30 days with the MDRD, yielded areas under the receiver operator curves of 0.84 (0.83, 0.84) and 0.77 (0.77, 0.78). CONCLUSIONS: Many factors predict survival following an emergency medical admission. The MDRD value offers a novel readily available and reliable estimate of mortality risk.