Video: Promoting the Right Dialysis Therapy at the Right Time

Posted August 23, 2018 in Clinical Care, Podcasts by Mark H. Shapiro, MD.

It is important to recognize that patients with end stage renal disease are individuals, and that they are choosing the dialysis modality that best suits their needs. Watch this video, in which Martin Schreiber, MD, interviews Mark Shapiro, MD, on how clinically appropriate patients can often benefit from initiating on peritoneal dialysis first, rather than the default treatment (often hemodialysis) and what efforts can help increase the number of patients receiving the right therapy at the right time.

If you prefer only audio, listen to the podcast below.

Comments

August 23, 2018 at 11:18 am

Brian Michel

I think I speak for many nephrologists when I say that one of the biggest barriers to promoting PD is the experience we have when someone has to convert to HD. Almost uniformly there is a reluctance, sometimes outright refusal to comply with the switch, sometimes even when only a temporary switch is required as in peritonitis treatment failure. How can we better prepare the PD patient for the possible eventuality of switching to HD? Offering home hemo is often the reply but this is often impractical, especially in the case of a temporary switch. Having the patient obtain a fistula concurrent with starting PD is a good option but not nearly as common as it should be, in my opinion.

September 5, 2018 at 4:42 pm

Mark H. Shapiro, MD

I don’t think I would consider a patient refusing to stop PD a barrier, but it can sometimes create unsafe situations for the patient. It is uncommon, but sometimes there are reasons why patients must permanently stop PD against their will (encapsulating peritoneal sclerosis, severe debilitation that requires permanent nursing home, uncorrectable adhesions). More commonly, the nephrologist or surgeon is reluctant to put the patient back on PD due to non-compliance or recurrent peritonitis.

It can be difficult if a physician rightfully believes that a patient would be better off clinically by switching from PD to HD. However, we never force patients to switch from HD to PD due to access problems or recurrent bacteremia, so this can sometimes be a double standard.

It is rare that a patient would refuse to allow removal of a PD catheter when the consequences of leaving it in could be life threatening, but I did have one patient die when I could not compel him to get the catheter out. Not sure that I have any great advise here.

Regarding simultaneous AVF placement- we rarely do it and most studies suggest a low likelihood of ever using the AVF. We do, however, try to place an AVF in any patient for whom we think it likely that a transfer to HD within the next 8 months will occur.

I hope that is helpful.

Reply

September 6, 2018 at 11:47 am

Martin Schreiber, MD

When patients start RRT I typically discuss the fact that there is no one therapy for the life of the ESRD patient. Most patients transition to an alternate therapy at a point where the current therapy is not having the desired effect whether risk factor control, functional status change or new medical problem obviating the ability to stay on the current therapy. If a patient has decreased functional status, uncontrolled risk factors or change in home or partner status a transition may be in order. Timing of a transition should be discussed with the patient and nurse team. When patients come into clinic I talk with them about how they are doing on paper and ask how they see themselves . The possibility for a potential transition needs to be discussed with patients and families at the start of RRT. I do not place a simultaneous fistula in patients I have accepted onto PD.

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