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Reducing Hospitalizations among Peritoneal Dialysis Patients

Peritoneal dialysis (PD) is often considered superior to in-center hemodialysis (HD) in terms of a number of clinical outcomes (e.g., preservation of residual renal function) and well-being for patients who are appropriate candidates for the therapy. Despite its potential benefits, many PD patients prematurely transition to HD. One of largest drivers of this transition is hospitalizations. In fact, 41 percent of PD patients transfer to HD within a year after hospitalization. To facilitate greater PD success, it is imperative to design strategies to maintain patients on PD after hospitalizations and, just as importantly, to implement efforts to decrease hospitalization risk in the first place.

Factors contributing to hospitalizations and avoidable transitions from PD to HD

As with dialysis patients on other treatment modalities, the causes of hospitalization are often related to factors such as comorbidities, infections, fluid overload and psychosocial concerns. Elements related to PD at home that may compound these factors and lead to an eventual transition to HD include the following:

Patient and caregiver burnout. Patients and/or caregivers may experience burnout from managing kidney disease at home. With a home modality, patients and caregivers are chiefly responsible for the day-in-and-day-out challenges of dialysis therapy, whereas in-center patients receive consistent in-person support from the care team through thrice-weekly visits to the center for HD. Some PD programs may not have the dedicated social worker time to recognize and treat early signs of burnout.

Provider inexperience with PD. Many physicians, due to lack of fellowship training or home experience, may not be especially familiar (and, thus, comfortable) with PD, so they may recommend the patient switch to in-center treatment after hospitalization or an inter-current illness rather than stay the course.

Comorbid issues. Most PD patients possess multiple comorbidities that, if uncontrolled, may lead to an increased risk for hospitalization and subsequent transition to another modality. Related scenarios can include uncontrolled hypertension, lack of diuretic use for patients with residual renal function, suboptimal PD prescription design, failure to initiate anti-depression treatment when justified clinically and by depression testing.

Tactics to help curb hospitalizations, readmissions and PD discontinuation

In order to address concerns that can lead to hospitalizations and a premature transition from PD to HD, care teams can adopt the following practices:

Training. Initial comprehensive training for patients on PD is extremely important as well as periodic retraining to refresh and enhance patient understanding and remind them of key practices, such as handwashing, appropriately selecting dialysate concentration and complying with PD treatment days.

Target weight monitoring. Because the ultrafiltration rate and level of residual renal function are constantly changing, frequent target weight monitoring is critical to avoid fluid volume overload. With timely monitoring, providers can modify the dialysate prescription as the body’s status changes. When this does not occur, the patient is at risk of volume overload, congestive heart failure or pneumonia, and, thus, a subsequent hospitalization.

Telemedicine. Home remote monitoring provides the ability to capture frequent biometric data, recognize new problems early on, adjust the dialysate prescription in a timely manner and change medications if needed. Starting new patients on home remote monitoring and ensuring this service is available to high-risk patients (e.g., those recently hospitalized or those with edema, uncontrolled blood sugar, hypertension or a reduction in residual renal function) can be game changing in helping preserve health and extending time on PD. Telemedicine may also help give patients a sense of more connectivity and less isolation, may help improve treatment adherence and help improve a sense of connection to the home program and care team.

Discharge evaluation. Contacting patients within three days of hospital discharge is critical to reducing readmission rates. When health care professionals on the team are provided information on the patient’s hospital course and associated tests, medications and consultations, they can better ensure the patient is on the right track with a cohesive continuation of care.

Mentorship. Burnout among PD patients can potentially lead to increased patient transitions off PD therapy. Therefore, care teams should engage in mentoring and supporting PD patients who take on the great responsibility of managing their kidney disease at home. It is common for care teammates to tell patients what they’re not doing well, but they also need to tell patients what they are doing well to reinforce that patients’ efforts can have a positive effect on their health.

With a mere 7 percent of the United States’ nearly 500,000 ESRD dialysis patients on PD, it is important to implement tactics such as the above to encourage patients to avoid hospitalizations and extend their time PD. It is estimated that increasing PD adoption from 7 percent to just 15 percent may save Medicare more than $1 billion over five years and may allow more patients to realize its many possible benefits: better preservation of residual kidney function, lower financial costs, lower mortality rates and a better quality of life. Many of the challenges of PD are addressable, and managing kidney disease in the home setting has proven to be in the best interest of many clinically appropriate patients; therefore, it is important that health care providers take those action steps to reduce hospitalizations among PD patients and improve the probability of PD longevity.

Martin Schreiber, MD

Martin Schreiber, MD

With nearly 40 years of experience in nephrology, Martin Schreiber, MD, serves as chief medical officer for DaVita Kidney Care's home modalities. Before this role, he worked primarily with Cleveland Clinic and held a number of key positions there, including member of the Board of Governors, chairman of the Department of Nephrology and Hypertension and director of home dialysis.