NATIONAL HARBOR, MD—A mismatch between the percentage of patients that nephrologists think should be on peritoneal dialysis (PD) and the proportion actually using the modality is clear. But while this discrepancy may be easy to spot, figuring out what to do about it is much more complicated.
According to a survey published in Peritoneal Dialysis International in 2001, North American nephrologists estimated that 32% to 45% of dialysis patients should be on peritoneal dialysis to optimize survival, wellness, and quality of life (21:335–337). Currently, though, the rate of PD utilization sits at around 7%.
This divide set the stage for a debate here at the National Kidney Foundation 2012 Spring Clinical Meetings on overcoming barriers to home dialysis, including PD and home hemodialysis.
Thomas Golper, MD, Professor of Nephrology at Vanderbilt University Medical Center and Medical Director of the Medical Specialties Patient Care Center in Nashville, TN, took the position that nephrologists are to blame, and Alfred Cheung, MD, Professor of Medicine, Executive Director of Dialysis, and Chief of the Division of Nephrology at University of Utah School of Medicine, argued the opposing viewpoint.
While the two sides did reach middle ground with the agreement that less blame should be thrown around and more action should be taken to garner increased use of home dialysis, they differed on what the nephrologist's role should be in supporting the option, beginning with patient education.
There is no denying that many patients with chronic kidney disease (CKD) are unaware of their options for end-stage renal disease (ESRD) therapy.
Dr. Cheung and Dr. Golper both cited a study led by Fredric O. Finkelstein, MD, and published in Kidney International demonstrating that 35% of 676 Stage 3–5 CKD patients had no perceived knowledge of dialysis modalities (2008;74:1178–1184).
Dr. Cheung placed some of the responsibility on patients to ask for information on dialysis therapies and questioned when such details become necessary—for example, he asked, does a Stage 3 CKD patient with a glomerular filtration rate of 59 mL/min have to know about dialysis?
Dr. Golper agreed that patients need to take some of the burden but added that nephrologists indeed should be the ones to initiate patient education.
“We want knowledgeable people to do the education, and there are data demonstrating benefits among patients,” he said.
Nephrology could learn a lesson about dialysis education from efforts to expand diabetes education, noted session cochair Rajnish Mehrotra, MD, Professor of Medicine at the University of Washington and Section Head of the Division of Nephrology at Harborview Medical Center.
“Diabetes education is a structured class that is reimbursable by Medicare,” he said in an interview after the meeting. “It has been demonstrated as being effective in treating outcomes associated with diabetes, and this is a model that CKD education needs to follow.”
This education should come from the perspective of a care continuum.
“It doesn't need to be a one-time encounter in which options are presented and the patients are forced to make a point,” Dr. Mehrotra said.
“It needs to be an iterative process, not necessarily stressing that this is dialysis and here is what you need to do, but rather this is CKD and you need renal replacement therapy; dialysis is one way of treating it, and transplant is another. Here is a dialysis unit; here are some patients who are doing dialysis. This is what you need to do with your diet and insurance. It needs to be a comprehensive process that engages the patient and family.”
When multifaceted education is successfully provided, there is evidence that patients go on to dialyze at home, Dr. Mehrotra noted.
In Dr. Cheung's presentation, he created mock complaints to represent responses of patients who do not opt for home treatment. They included: “I am too sick to take care of myself.” “My house is too cluttered.” “I don't like putting needles into my body.” “Medical care is the job of doctors and nurses.”
But Dr. Mehrotra thinks the patient is more scared than anything, he said.
“I think the goal of the education program is beyond informing the patients; it's helping patients overcome the fear. Many patients feel, ‘I'm not smart enough to do this; what if something goes wrong? I'd like to stay home, but will I be safe?’”
Role of Dialysis Providers
Dr. Cheung shifted the blame for low rates of home therapy to dialysis organizations, arguing that home dialysis is rarely an available option. According to a survey of the crowd prompted by Dr. Cheung, one-third of dialysis organizations do not offer home hemodialysis, and 9% do not offer PD.
Dr. Golper argued that dialysis organizations' perspectives on home modalities can easily be addressed through financial incentives and regulations, physician activism, and pressure from the customer.
Large dialysis organizations are starting to see home dialysis as a more cost-effective option because of the bundled End-Stage Renal Disease Prospective Payment System, according to Dr. Mehrotra.
“I think there was not enough attention to PD within facilities, which had a huge impact on lack of investment in infrastructure, lack of education of physicians, and poor outcomes,” Dr. Mehrotra said.
“That fed the notion that PD is not as good, and that cycle has been broken with the introduction of the bundle, which makes PD a more financially viable and attractive therapy. There has been an interest on a scale I've never seen before.”
Guiding the Patient
By the end of the debate, it had become clear that the question had shifted from whom to blame to how the benefits of home dialysis could best be spread throughout nephrology.
Ultimately, whether or not the nephrologist is at fault, it comes down to the nephrologist to guide the patient, according to Dr. Golper.
“Have the chutzpah to be a leader and not just follow the path of least resistance,” he said. “The physician must take them through the baby steps to have the confidence to tell a patient that it will take time, but we will help you. Physicians are the captain of the ship.”
Dr. Mehrotra thinks that the financial benefits of home dialysis will positively influence its uptake, he said.
“I believe PD is growing very fast. I wouldn't be surprised if in five years we are back to a PD use of 15 to 18 percent like it was in the mid-1980s.”
As for who won the debate, Dr. Mehrotra said, “It's a combination. The nephrologist has to accept responsibility. We can not pass the buck.”