update on peritoneal dialysis: new positioning of an older ... · catheter type and exit-site •...
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Update on Peritoneal Dialysis: New Positioning of an Older TherapySteven Guest, MDDirector, Medical Consulting ServicesBaxter Healthcare CorporationDeerfield, Illinois, USA
49.4%
33.2%
15.8%
20.0%
17.1%
7.4%
0%
10%
20%
30%
40%
50%
60%
Jalisco (Mexico)New Zealand Netherlands Denmark Canada United States
% P
revale
nt
Pati
en
ts o
n P
DUnderutilization of Peritoneal Dialysis
2
U.S. Renal Data System. USRDS 2013 Annual Data Report.
Peritoneal Clearance
3Image courtesy of Steve Guest, MD
Incidence of ESRD
U.S. Renal Data System. USRDS 2013 Annual Data Report. 4
Incident ESRD patients.
Adj: gender/race; ref: 2010 ESRD patients.
Similar Outcomes- PD and HD
5
Mehrotra R, Chiu Y, Kalantar-Zadeh K, et al. Similar outcomes with hemodialysis and peritoneal dialysis in
patients with end-stage renal disease. Arch Intern Med 2011;171(2):110.
Perl J, Wald R, McFarlane P, et al. Hemodialysis vascular access modifies the associated between
dialysis modality and survival. J Am Soc Nephrol 2011;22:1113-1121.
6
Adapted from:
Perl J, Wald R, McFarlane P, et al. Hemodialysis vascular access
modifies the associated between dialysis modality and survival.
J Am Soc Nephrol 2011;22:1113-1121.
HD-CVC
HD-CVC
Unadjusted
Adjusted
PD, HD-
AVF, AVG
HD- AVF, AVG
PD
7
Catheter Use at First Outpatient HD
8
9
Medicare Spending Per Patient Year by Type of Renal Replacement Therapy
U.S. Renal Data System. USRDS 2013 Annual Data Report.
.
Costs of Caring for Patients with ESRD
10
U.S. Renal Data System. USRDS 2013 Annual Data Report.
Changes in Dialysis Reimbursement to Providers in the USA
11
Golper TA, Guest S, Glickman JD, Turk J, Pulliam JP. Home Dialysis in the New USA Bundled
Payment Plan: Implications and Impact. Perit Dia Int. 2011;31;12-16 .
The “Bundle”
12
49.4%
33.2%
15.8%
20.0%
17.1%
7.4%
0%
10%
20%
30%
40%
50%
60%
Jalisco (Mexico)New Zealand Netherlands Denmark Canada United States
% P
revale
nt
Pati
en
ts o
n P
DUnderutilization of Peritoneal Dialysis
13
U.S. Renal Data System. USRDS 2013 Annual Data Report.
Most Patients Are Medically Eligible for PD
1. Jager KJ, Korevaar JC, Dekker FW et al. The effect of contraindications and patient preference
on dialysis modality selection in ESRD patients in the Netherlands. Am J Kidney Dis. 2004;43:891-899.
2. Mehrotra R, Marsh D, Vonesh E, et al. Patient education and access of ESRD patients to renal replacement
therapies beyond in-center hemodialysis.. Kidney Int. 2005;68:378-390.
>1000 ESRD Patients Starting Dialysis
The prevalence of medical contraindications to PD
(23% to 24%) is similar to the 17% to 21% reported …
from other parts of the world.2
% Medically Eligible for PD
Netherlands1 83%
U.S.2 76%
Surveys of Nephrologists
1. Troidle L, Kliger A, Finkelstein F. Barriers to utilization of chronic peritoneal dialysis in network #1, New England. Perit Dial Int.
2006;26:452-457.
2. Mendelssohn DC, Mullaney SR, Jung B, et al. What do American nephrologists think about dialysis modality selection? Am J Kidney
Dis. 2001;37:22-29.
3. Jung B, Blake PG, Mehta RL, Mendelssohn DC. Attitudes of Canadian nephrologists toward dialylsis modality selection. Perit Dial
Int. 1999;19:263-268.
4. Jassal SV, Krishna G, Mallick NP, Mendelssohn DC. Attitudes of British Isles nephrologists toward dialysis modality selection: a
questionnaire study. Nephrol Dial Transplant. 2002;17:474-477.
Country Year% of ESRD patients
nephrologists feel should be
on PD N
USA1 2006 29% 59
USA2 2001 33% 240
Canada3 1999 37% 192
British
Isles4 2002 38% 108
Home based
Avoids needles
With cycler machines- exchanges done at night time
Travel, portability
Flexible scheduling, day to day to allow for dialysis to revolve
around the life schedule, not life revolving around HD
schedule
Challenges
• Storage of product
• Fear of doing medical procedure at home
Lifestyle Considerations of PD
16
Driving analogy
Patient Response - “I could never do that”
The Importance of Patient Education
Golper T. Patients education: can it maximize the success of therapy? Nephrol Dial
Transplant. 2001;16(suppl 7):20-24.
The National Pre-ESRD Education Initiative Survey
After Pre-ESRD Education, 45% Chose PD
and 33% Actually Started PD
PD
HD
N = 2400100
80
60
40
20
0
Choice of Modality Actual Modality Started US Incidence
Pe
rce
nta
ge
of P
atie
nts
Rioux J, Cheema H, Bargman JM, et al. Effect of an in-hospital chronic
kidney disease education program among patients with unplanned
urgent-start dialysis. Clin J Am Soc Nephrol 2011;6:799.
19
228 Acute Start Between 2005-2009228 Acute Start Between 2005-2009
Education program before dischargeEducation program before discharge
132In-center HD
132In-center HD
71Home 71
Home
49 PD49 PD 22 HHD22 HHD
25Died
(before discharge)
25Died
(before discharge)
Patients’ flow through the study
20
Adapted from:
Rioux J, Cheema H, Bargman JM, et al. Effect of an in-hospital chronic kidney disease education
program among patients with unplanned urgent-start dialysis. Clin J Am Soc Nephrol 2011;6:799.
Physician Preference For Modality
21
Merighi JR, Schatell DR, Bragg-Gresham JL, et al. Insights into nephrologist training, clinical
practice, and dialysis choice. Hemodial Int 2012;16:242-251.
N=629
Distribution of nephrologists’ modality choice for themselves
Adapted from: Merighi JR, Schatell DR, Bragg-Gresham JL, et al.
Insights into nephrologist training, clinical practice, and dialysis choice.
Hemodial Int 2012;16:242-251.
Select practice advances
Infectious complications
Surgical approaches
PD in the late-referred patient
Integrated care approach
What is current status of PD in USA?
23
Tenckhoff Modifications to Boen Technique
24
McBride P. Fred T.S. Boen, M.D. (1927……). Perit Dial Int 1982;2:50–53.
Boen’s Portable Cycler—U Washington
Home
Peritoneal
Dialysis
Baxter Museum, Largo Florida
Older Cyclers- PAX Extra
Current Cycler Machines
Rx Only. For Safe and proper use of these devices refer to respective operator’s manual.
Dialysis Completed at Night
28 Rx Only: For safe and proper use of these devices refer to respective operator’s manual
Univ. of Pittsburgh-Infection Rates Reduced In PDAs Innovations and Protocols Are Introduced
Bender FH, Bernardini J, Piraino B. Prevention of infectious complications in peritoneal dialysis:
best demonstrated practices. Kidney Int, 2006;70:S44-S54.29
ESI prophylaxis
Spike assist device
Double bag system introduced
Mupirocin Prophylaxis
30
Approaches to Reduce Exit-Site Infections
1
2
*Risk of exit-site infection, mupirocin : without mupirocin.
†P < 0.001 vs. placebo or no treatment.
Tacconelli E, Carmeli Y, Aizer A, et al.Mupirocin prophylaxis to prevent Staphlococcus aureus infection
in patients udergoing dialysis: a meta-analysis. Clin Infect Dis. 2003;37:1629-1638.
Gentamicin Prophylaxis
*P < 0.01 vs. mupirocin
Bernardini J, Bender F, Florio T, et al. Randomized, double-blind trial of antibiotic exit site cream for
Prevention of exit site infection in peritoneal dialysis patients. J Am Soc Nephrol 16: 539-545, 2005.31
Rates of Exit-Site Infection (ESI) in PD
*
*
cream
Peritonitis Outcomes
Percent (%) of All Episodes (N = 666)
Adapted from:
Bunke CM, Brier ME, Golper TA. Outcomes of single organism peritonitis in peritoneal dialysis:
gram negatives versus gram positives in the Network 9 Peritonitis Study. Kidney Int. 1997;52:524-529.
CoagNS=coagulase-negative staphylococci; nP-GNR=non-pseudomonal gram negative
Resolved Hospital Catheter
Removed
Transfer Death0
10
20
30
40
50
60
70
80
90
Pe
rce
nt o
f A
ll E
pis
od
es
CoagNS S aureus nP-GNR
• Adequate training time
• Protocols (Hand washing, masks)
• Flush before fill
• Exit site topical antibiotics
• Exit site location
• Alcohol based hand washes or dilute bleach solutions
Reduce Infections
33
Probability of Remaining Free of Mechanical Flow Obstruction
At 24 Months Significantly Increased by Newer Techniques
P < 0.0001 vs. open or basic technique
Crabtree JH et al. Am Surg. 2005;71:135-143.34
Rectus sheath tunneling before entering the peritoneal cavity
Adjunctive Laparoscopic Procedures
35
Rectus Sheath Tunneling
Permission from John Crabtree, MD36
Permission from John Crabtree, MD37
Pelvis
Redundant
Omentum
Omental Wrap
Redundant Omentum
Courtesy of John Crabtree MD38
Omentopexy
Guest S. Handbook of Peritoneal Dialysis, 2011, pg 65.39
Minimally Invasive Surgery
Effective use of laparoscopy for long-term peritoneal dialysis access
Crabtree JH, Burchette RJ. Effective Use of Laparoscopy for Long-term
Peritoneal Dialysis Access. Am J Surg 2009;198,135-141.40
John H. Crabtree, M.D.a,*, Raoul J. Burchette, M.S.b
Laparoscopy Permits Diagnosis of Unsuspected Hernias
Courtesy of John Crabtree MD41
• Body habitus
• Occupations or responsibilities
that require bending at the
waist
• Factors affecting infection risk:
stoma, fecal incontinence
Exit Site Location to Suit Special Needs
42Crabtree JH. Kidney Int Suppl. 2006;70:S27-S37.
Crabtree JH. Kidney Int Suppl. 2006;70:S27-S37.
Chronic Infection - Poor Exit-Site Location
43 Courtesy of John Crabtree MD
A. Missouri catheter is
standard with kit
B. Presternal extension tube
C. Substituted Tenckhoff
catheter
D. Titanium connector
Extended Dialysis Catheter System
44 Courtesy of John Crabtree MD
Catheters cut to appropriate length
Courtesy of John Crabtree MD45
Joined with titanium connector and 2-0
polypropylene suture.
Obese Abdomen with Exit-Site Out of Sight and Under Belt Line
46
Preoperative Postoperative
Courtesy of John Crabtree MD
Presternal Exit-Site is Easily Visualized and Remote from Urostomy
47
Urostomy
Obesity
Presternal Exit-Site
Permission from John Crabtree, MD48
Advanced Planning
49
Courtesy of Steve Guest MD
Instructional DVD, 2nd Edition
51
John Crabtree MD
Kaiser Permanente Bellflower, CA
Funded and Distributed by Baxter Healthcare Corporation
Didactic Instruction:
• Introduction for surgeons to
concepts, issues and economics
of PD
• Preoperative assessment,
planning, and preparation
• Implantation techniques
• Salvage procedures for infectious
and mechanical complications
Surgical Laboratory:
• Preoperative mapping for
catheter type and exit-site
• Laparoscopic simulator for
rectus sheath tunneling
• Laparoscopic simulator for
omentopexy
• Simulator for extended
catheter placement
• Simulator for embedding
catheters
52
Peritoneal Dialysis University for Surgeons
www.pdusurgeons.com
Laparoscopic Simulator
Reusable
laparoscopic port
sites (to accept 5
mm ports).
Two reusable holes
through this port site
for laparoscope or
omentopexy needle
(one hole to accept
5 mm port and 2nd to
accept omentopexy
needle.
Reusable rectus
sheath tunneling
port site (to
accept 7-8 mm
port).
Umbilicus
53
Probability of Remaining Free of Mechanical Flow Obstruction
At 24 Months Significantly Increased by Newer Techniques
P < 0.0001 vs. open or basic technique
Crabtree JH et al. Am Surg. 2005;71:135-143.54
Ultrasound / Fluoroscopic Placement
Ivan Maya MD55
Peel-away Sheath In Place
Courtesy of Ivan Maya MD56
Tunnel Creation
57 Courtesy of Ivan Maya MD
Final View
Courtesy of Ivan Maya MD58
Urgent Start PD Program
59
BUN 120
Cr 14
Femoral Catheter
IJ temporary or tunneled catheter
Urgent HD
Urgent Start PD
60
BUN 120
Cr 14
Femoral Catheter
IJ temporary or tunneled catheter
Urgent HD
Urgent PD catheter placement
Urgent-Start PD
61Ghaffari A. Am J Kidney Dis 2012;59:400-408.
62
“…at our center, the interventional radiology group is the main
group placing urgent tunneled HD catheters and therefore was
the ideal service for placing urgent PD catheters, essentially
substituting one procedure for another…”
Ghaffari A. Urgent-Start Peritoneal Dialysis: A Quality
Improvement Report. Am J Kidney Disease 2012;59: 402.
Urgent Start PD Program
63
BUN 120
Cr 14
Femoral Catheter
IJ temporary or tunneled catheter
Urgent HD
Urgent interventional
or surgical PD catheter
?
Urgent Start PD
64
BUN 120
Cr 14
Femoral Catheter
IJ temporary or tunneled catheter
Urgent HD
Urgent interventional
or surgical PD catheter
Hospitalized- low volume, recumbent PD
Outpatient- low volume, recumbent PD
Urgent Start PD Program
65
BUN 120
Cr 14
Femoral Catheter
IJ temporary or tunneled catheter
Urgent HD
Urgent interventional
or surgical PD catheter
Hospitalized- low volume, recumbent PD
Outpatient- low volume, recumbent PD
Chronic IPD M-W-F for 2 weeks
Then
Train for Home
The Influence of Dialysis Treatment Modality on Remaining RRF
Adapted from:
Lysaght MJ, Vonesh EF, Gotch F, et al. The influence of dialysis treatment modality on the decline of
remaining renal function. Trans Am Soc Artif Intern Organs. 1991;37:598-604.66
N = 57
N = 58
The difference persists after adjustment for age,
sex, hypertensive status and the use of ACEI
• Fluid removal
• Sodium removal
• Phosphate removal
• Middle molecule clearance
• Vitamin D production
• Erythropoietin production
• Reduced Left ventricular hypertrophy
• Survival benefit
Benefits of Residual Kidney Function
67
5 L/wk per 1.73 m2 GFR
• 12% decrease in relative risk (RR) of death
250 mL increment in urine volume
• 36% decrease in the RR of death
RRF & Survival Re-analysis of CANUSA
Bargman JM, Thorpe KE, Churchill DN. Relative contribution of residual renal function and peritoneal
clearance to adequacy of dialysis: a reanalysis of the CANUSA study. J Am Soc Nephrol 2001;12:2158-
2162.
68
Probability of Anuria
Adapted from:
Li PK, Chow KM, Wong TY, et al. Effects of an angiotensin-converting enzyme inhibitor on residual renal
function in patients receiving peritoneal dialysis. A randomized, controlled study.
Ann Intern Med. 2003;39:105-112.69
ARBs Preserve RRF
Suzuki H, Kanno Y, Sugahara S, et al. Effects of an angiotensin II receptor blocker, valsartan, on residual
renal function in patients on CAPD. Am J Kidney Dis. 2004;43:1056-1064. 70
Diuretics in Peritoneal Dialysis Patients
Medcalf JF, Harris KPG, Walls J. Role of diuretics in the preservation of residual kidney function in
patients on continuous ambulatory peritoneal dialysis. Kidney Int. 2001;59:1128-1133.
71
Possible Membrane PreservationMesothelial RAS System
72
Effect of Valsartan Versus Lisinopril on Peritoneal Sclerosis in RatsS. Duman, S. Sen, C. Duman, D.G. Oreopoulos
73
A. Normal
B. PD Solution
C. Valsartan
D. Lisinopril
Duman S, et al. Int J Artif Organs. 2005;28:156-163. 74
RAS System and the Peritoneum
75
Nessim SJ, Perl J, Bargman JM. The renin-angiotensin-aldosterone system in peritoneal dialysis: what
is good for the kidney also good for the peritoneam? Kidney Int 2010;78:23-28.
Integrated Care Concept
Davies SJ, Van Biesen W, Nicholas J, Lamiere N. Integrated care.
Perit Dial Int 2001;21:[Suppl 3]:S269-S274.
ESRD Life Plan
CKD
Nurse Educator
ESRD: Initial
Renal DietitianSocial Worker
PeritonealDialysis
Hemodialysis
Transplant
“Transition Points”
Death/Treatment Withdrawal
Late
Monthly VisitAcute Visits
Post HospitalizationAcute Transition Points
Continuing Care
Home HD
MD
Design a SEQUENCE
To Maximize Survival
ESRD Life Plan
CKD
Nurse Educator
ESRD: Initial
Renal DietitianSocial Worker
PeritonealDialysis
Death/Treatment Withdrawal
Late
Monthly VisitAcute Visits
Post HospitalizationAcute Transition Points
Continuing Care
Home based
Initial survival advantage
Preserve RRF
Preserve arms
MD
PD Is Not Just a Viable RRT Option
CKD
Nurse Educator
ESRD: Initial
Renal DietitianSocial Worker
PeritonealDialysis
Death/Treatment Withdrawal
Late
Monthly VisitAcute Visits
Post HospitalizationAcute Transition Points
Continuing Care
Home HDHome based
Initial survival adv.
Preserve RRF
Preserve arms
MD
PD Is Not Just a Viable RRT Option
CKD
Nurse Educator
ESRD: Initial
Renal DietitianSocial Worker
PeritonealDialysis
Transplant
Death/Treatment Withdrawal
Late
Monthly VisitAcute Visits
Post HospitalizationAcute Transition Points
Continuing Care
Home HDHome based
Initial survival adv.
Preserve RRF
Preserve arms
MD
ESRD Life Plan
CKD
Nurse Educator
ESRD: Initial
Renal DietitianSocial Worker
PeritonealDialysis
In CenterHemodialysis
Transplant
Death/Treatment Withdrawal
Late
Monthly VisitAcute Visits
Post HospitalizationAcute Transition Points
Continuing Care
Home HDHome based
Initial survival adv.
Preserve RRF
Preserve arms
MD
• The ESRD population continues to rise
• Financial constraints dictate that we consider cost effective
therapies
• Patient education on the home option is critical
• Survival studies indicate similar long term survival HD vs PD
• Peritonitis rates have decreased
• Novel surgical approaches have improved long-term catheter
function
• PD offers many lifestyle benefits for the appropriate patient
population
• “Life Plan” approach for integrated care
Conclusion
82
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