COMMENTARY

Offering Options for Dialysis: 'We Need to Do a Better Job'

Jeffrey S. Berns, MD

Disclosures

July 10, 2014

Editorial Collaboration

Medscape &

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Hello. I am Jeffrey Berns, Editor-in-Chief of Medscape Nephrology. I gave a talk recently at the National Kidney Foundation Spring Clinical Meeting on dialysis modality education and selection. I tried to make the case that no single dialysis modality is right for all patients, and that everyone should have a reasonable opportunity to learn about all of the different dialysis modalities to make an informed choice as to which is the best modality for them individually.

We know that more than 90% of dialysis patients in the United States are on in-center hemodialysis.[1] That percentage may be changing a bit now because of recent incentives to encourage peritoneal dialysis and home hemodialysis. I believe that we should examine how we communicate with patients and influence their decisions about dialysis modalities. There are many influences, including nephrologists, dialysis nurses, hospital nurses, perhaps house staff, family members, and friends, all of whom have some input and influence patients' decisions about dialysis modality.

It is worth noting that virtually everyone who starts with any given dialysis modality stays on that modality forever; it is about 99%.[1] Therefore, if you think you will start a patient on hemodialysis and then subsequently switch them to peritoneal dialysis, that is not likely to happen in practice. Evidence from Fred Finkelstein and colleagues,[2] published in Kidney International in 2008, indicates that a lot of people who need dialysis do not know about different dialysis modalities. Even if they know about them, they do not understand them. This is even more the case with peritoneal dialysis than with hemodialysis.

The lack of training in peritoneal dialysis for nephrologists further complicates the low number of patients receiving peritoneal dialysis as their initial form of dialysis. In 2010, I surveyed 133 recently graduated nephrology trainees and found that fewer than 10% of them felt really well trained and completely confident in managing patients on chronic peritoneal dialysis.[3] I cannot imagine that this is not going to influence the ways they encourage patients who are choosing one dialysis modality over another.

The Disconnect Between Nephrologists' Choice and Nephrologists' Advice

Another recent study,[4] published in Hemodialysis International in 2012, surveyed nephrologists with this simple question: "If you had to start dialysis, what modality would you use?" Roughly 90% or so of the surveyed nephrologists would choose peritoneal dialysis, daily home hemodialysis, or nocturnal home hemodialysis, and only 6% would choose in-center, 3-times-a-week, conventional hemodialysis. I queried the audience at the talk I gave at the Spring Clinical Meeting, and absolutely no one indicated that they would be willing to do 3-times-weekly, in-center hemodialysis as their own initial dialysis modality.

There is clearly a tremendous disconnect between what we as nephrologists would opt to do if we needed renal replacement therapy and what our patients end up doing. This is troubling and disconcerting. We ought to think long and hard about how we can change this so that we offer our patients and encourage them to do what we ourselves would do for dialysis. We need better training for ourselves as nephrologists and nephrology trainees, and better education for our patients, our nursing staff, and everyone who interacts with patients as they select a dialysis modality.

We need to begin encouraging more and more people to use home peritoneal dialysis. Personally, I believe that it is a better modality for many patients, giving them more freedom and more control over their medical therapy. In addition, this does not tie them to an in-center dialysis unit. The absence of evidence to suggest that there is a significant morbidity or survival advantage with in-center hemodialysis compared with peritoneal dialysis, even for diabetics, supports the use of these other modalities.

Collectively, we need to do a better job of encouraging our patients to find the best therapy for themselves, be it peritoneal dialysis, home hemodialysis, nocturnal hemodialysis, or traditional in-center, 3-times-weekly hemodialysis. We need to get away from the notion that 3-times-per-week, in-center hemodialysis is the default dialysis option, and we need to stop pushing everyone towards that when they need renal replacement therapy. Hopefully we will see more of a push towards home therapies. I believe we need to do a better job of encouraging our patients to choose home therapies.

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