Key Elements for a Excessive-High quality Peritoneal Dialysis Program — The Position of the PD Workforce and Steady High quality Enchancment

Results from the Dialysis Outcomes and Practice Patterns Study
May 6, 2021 0 Comments

Perit Dial Int. 2014 Jun; 34(Suppl 2): S35–S42.

Summary

The proportion of end-stage renal illness (ESRD) sufferers on peritoneal dialysis (PD) has elevated very quick in China over the past decade. Renji Hospital, affiliated with Shanghai Jiaotong College Faculty of Drugs, is a acknowledged high-quality PD unit with a excessive PD utilization price, wonderful affected person and approach survival (1-year and 5-year affected person survival price of 93% and 71%, and 1-year and 5-year approach survival of 96% and 82%, respectively), low peritonitis price and a well-documented good high quality of lifetime of the handled sufferers. We imagine {that a} devoted and skilled PD group, a structured affected person coaching program, steady affected person help, establishing and using standardized protocols, beginning PD with low dialysis dose, monitoring key efficiency indicators (KPIs), and steady high quality enchancment (CQI) are the important thing components underlying this profitable PD program.

Key phrases: Peritoneal dialysis, survival, peritonitis price, coaching, key efficiency indicators, steady high quality enchancment

The prevalence of end-stage renal illness (ESRD) continues to rise in China and worldwide. Peritoneal dialysis (PD) is a well-established modality of renal substitute remedy (RRT) for ESRD sufferers. Many research from various nations have constantly proven that PD has a survival benefit in contrast with hemodialysis (HD) sufferers within the first few years (1). Furthermore, the enhancements noticed in affected person and approach survival in PD over the past decade have exceeded these noticed in HD (2). PD additionally has many different benefits, together with price financial savings, preservation of residual renal perform, relative top quality of life, and larger capability to serve extra ESRD sufferers as a consequence of its decrease infrastructure necessities (3). Due to this fact, PD is the popular modality of RRT in lots of dialysis items in China as it may meet the good demand for dialysis remedy of the quickly growing ESRD inhabitants. In distinction with the regular decline in incident PD use in western nations (4-6), PD utilization is rising very quick in China (7). Nevertheless, affected person final result is markedly variable amongst totally different facilities. This text describes our experiences in growing a sustainable and profitable PD program.

PD Follow at Renji Hospital

Renji Hospital, affiliated with Shanghai Jiaotong College Faculty of Drugs, was one of many first hospitals to undertake PD in China and has run its PD program for 30 years. It’s a acknowledged high-quality PD unit with a excessive PD utilization price, wonderful affected person and approach survival, low peritonitis price and a well-documented good high quality of lifetime of the handled sufferers (8,9).

PD Utilization Fee

Though no nationwide renal registry is accessible in China, analyses of native registry knowledge assist to realize an understanding of the dialysis standing within the nation. A report from the Shanghai Renal Registry confirmed that, as of 31 December 2010, there have been 2,035 sufferers handled with PD in Shanghai, as in contrast with 459 sufferers in 1999, and 1,204 sufferers in 2006 (10,11). The utilization price of PD amongst all dialysis modalities was 24.2% in Shanghai in 2010 (10), and even larger in Renji Hospital, as mirrored by the truth that greater than 50% of latest ESRD sufferers go for PD as their most popular RRT modality, and 55% of all dialysis sufferers are handled with PD (unpublished knowledge, Renji Hospital). As proven in , the variety of PD sufferers at Renji Hospital has constantly elevated within the final 20 years.

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The variety of prevalent peritoneal dialysis (PD) sufferers at PD heart of Renji Hospital, 1985-2011.

Affected person and Approach Survival

Asian PD sufferers usually get pleasure from a superior survival when in comparison with western PD sufferers (12,13). Our earlier cohort research confirmed that the 1-year and 5-year actuarial affected person survival was 90% and 64% respectively (8), which in contrast favorably to that of knowledge from the US Renal Knowledge System (USRDS) and plenty of different reviews, particularly when it comes to long-term survival (14-17). In a more moderen cohort of 339 incident PD sufferers recruited between 1 January 2005 and 31 December 2009, we discovered an appropriate affected person and approach survival price, even after the inclusion of sufferers dying or failing PD inside 90 days (unpublished knowledge, Renji Hospital). Of those sufferers, 156 have been males, and the imply age of all sufferers was 55.4 ± 17.2 years. In 77 (23.3%) sufferers,

the renal failure was brought on by diabetes mellitus (DM), or DM was a comorbid situation. All sufferers have been dialyzed solely with conventional glucose-based PD options. Affected person and approach survival curves are proven in . In comparison with reviews from different items (), the PD final result in Renji seems best-in-class with 1-year and 5-year affected person survival charges of 93% and 71%, and 1-year and 5-year approach survival of 96% and 82%, respectively. Advancing age, low serum albumin degree and cardiovascular comorbidity have been unbiased predictors of mortality in our sufferers ().

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Affected person and death-censored approach survival of 339 incident peritoneal dialysis sufferers recruited at Renji Hospital between 1 January 2005 and 31 December 2009. PD = peritoneal dialysis.

TABLE 1

Affected person and Approach Survival in Peritoneal Dialysis at Renji Hospital In comparison with Different Studies

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TABLE 2

Predictors of Mortality on Multivariate Cox Evaluation

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Peritonitis Fee

With the advance in PD connectology and the now unique use of the twin-bag system, in addition to a robust deal with coaching and steady high quality enchancment (CQI), now we have achieved a really low peritonitis price. Within the Nineties when utilizing a disconnect system, the peritonitis price was round one episode each 24 patient-months. The speed step by step improved to 1 episode each 56 patient-months after the introduction of the twin-bag system (22). With additional deal with coaching and the applying of CQI, the peritonitis price improved to 1:60.6 patient-months in sufferers beginning PD throughout 2000-2004 (8), and 1:62.5 patient-months within the 2005-2009 cohort (unpublished knowledge, Renji Hospital).

High quality of Life

A lot of our sufferers are aged. Nevertheless, now we have proven that though bodily useful standing of older PD sufferers is inferior to that of youthful sufferers, their psychological useful standing is nearly as good as their youthful counterparts (9).

Why is PD so Profitable in Renji Hospital?

Varied inherent affected person components might have an effect on PD sufferers’ final result, together with genetic background, comorbidities, dietary habits, way of life, compliance with remedy, physique measurement, and presumably peritoneal transport traits (13). In the meantime, heart components additionally play a pivotal position. In our expertise, the important thing components for attaining wonderful PD outcomes embrace: a devoted and skilled PD group, a structured affected person coaching program and steady affected person help, establishing applicable protocols, beginning PD with a low dialysis dose, monitoring key efficiency indicators (KPIs), and establishing CQI packages.

A Devoted and Skilled PD Workforce

The first driver for the expansion of a PD program is the boldness and dedication of the PD group. Certainly, PD is a group effort the place every member is crucial for achievement. The PD group at Renji unit consists of 5 nephrologists and three devoted PD nurses. The nephrologists have 3-18 years of PD expertise, and all follow basic nephrology in parallel with PD care. The nurse to affected person ratio is 1:125 at our heart. The identical group of docs and nurses takes care of each outpatients and hospitalized PD sufferers. Consequently, we comply with our sufferers from pre-dialysis training, catheter insertion, coaching, and preliminary PD prescription to long-term follow-up and complication administration. The nephrologists in our heart are all engaged in scientific PD analysis, and play main roles in this system. They commit enough time for overseeing the planning, group and route of this system. Nephrologists additionally work along with the native hospital administration to make sure that each the necessity for satisfactory infrastructure for coaching and care of sufferers, in addition to satisfactory coaching of the employees is supplied. The devoted PD nurses contribute the core of the PD program, and act as a liaison with different members of the group to make sure steady care and coordination. Involvement of a surgeon who is aware of the distinctive wants of ESRD sufferers can be one of many contributors to the success of our PD program. The roles of the surgeon embrace session and administration of surgical problems reminiscent of hernia restore, laparoscopy catheter insertion for sophisticated sufferers, and so forth.

Heart-related components seemingly additionally contribute to attaining good outcomes. Huisman et al. reported that having lower than 20 PD sufferers in a middle, or having a small fraction of sufferers on PD, carries an elevated threat of approach failure (23). The Renji heart has a giant PD program, and the excessive affected person quantity is presumably related to the supply of particular medical experience and the intensive expertise in PD. In our heart, peritoneal catheter insertion and removing are largely carried out by appropriately skilled and skilled nephrologists in a devoted renal operation room with wonderful outcomes, which helps in lowering pointless surgical consultations and facilitates well timed interventions. Nephrologists are, certainly, reported to be ideally suited to carry out catheter insertion with wonderful catheter final result knowledge, due to their higher understanding of renal sufferers and the pathophysiology of the illness course of (24). The Renji heart has organized and hosted nationwide PD Persevering with Medical Training (CME) programs yearly since 1997 to share our expertise in PD. Furthermore, retraining of the Renji PD employees additionally happens to make sure our abilities and information are maintained and renewed. We’re inspired to replace ourselves by attending native steady training and regional and worldwide seminars at the very least twice yearly. The seminars additionally present a wonderful alternative for interplay between Renji employees and others within the renal discipline to share new concepts for higher administration of sufferers.

A Structured Affected person Coaching Program and Steady Affected person Help

Efficiently sustaining sufferers on PD requires disciplined and ongoing affected person training and help. We’ve established a well-designed affected person coaching program incorporating real-life problem-solving strategies, and carried out coaching practices based mostly upon adult-learning rules, which have been proven to cut back exit-site infections, enhance fluid steadiness, compliance and reduce dropout (25). In our heart, the devoted PD nurse is the coach and, if relevant, each the affected person and his/her household or caregivers are learners. In round 10% of sufferers, PD is carried out by their members of the family at house. The opposite benefit of coaching sufferers’ households is that within the case of sufferers being unwell, their members of the family can do PD exchanges for them. It has been proven that the presence of devoted coaching nurses can scale back the danger of peritonitis (26). All sufferers in our heart are admitted for coaching, and the coaching period usually is 4 to 5 days. We use standardized easy-to-read supplies written in easy language and quick sentences in an uncluttered format, with a font giant sufficient for simple studying, and with easy photos. Arms-on-training aids, reminiscent of a model or coaching apron with a PD catheter are used for coaching and follow. For automated peritoneal dialysis sufferers, we prepare each automated peritoneal dialysis and steady ambulatory peritoneal dialysis (CAPD) strategies. Earlier than sufferers are despatched house, a post-training check for the affected person will likely be accomplished to rigorously decide if the coaching aims have been met. In our heart, retraining is carried out after each episode of peritonitis, catheter an infection, extended hospitalization, some other interruption in PD, or periodically in line with Worldwide Society for Peritoneal Dialysis suggestions (27). Retraining contains re-education of connection procedures, an infection management, contamination dangers, and medicine compliance. Primarily based on a survey, it has been proven that peritonitis charges are considerably decrease in facilities performing retraining in comparison with facilities that don’t (28).

Throughout follow-up, we conduct steady monitoring and supply help to our sufferers by: 1) Month-to-month PD clinic visits, together with bodily and blood examination, and prescription adjustment when wanted; 2) Biweekly PD group conferences and case dialogue; 3) A nurse-led and checklist-based phone follow-up specializing in complication prevention in chosen sufferers reminiscent of sufferers who couldn’t come to the clinic; 4) 24-hour on-call service by the nurses to assist sufferers take care of emergent conditions; 5) Dwelling go to for problematic sufferers reminiscent of a affected person having skilled a number of peritonitis; 6) Retraining.

Establishing Acceptable Protocols

Establishing applicable protocols is crucial for standardizing PD follow. Accordingly, now we have developed center-specific protocols for catheter insertion, affected person coaching, an infection management, peritonitis remedy, and so forth. in our heart, all based mostly on obtainable home and worldwide pointers. For instance, the protocol for catheter insertion contains: 1) Administration of prophylactic antibiotic on the time of catheter insertion. The Worldwide Society for Peritoneal Dialysis pointers suggest a single intravenous dose of antibiotic on the time of catheter insertion (29,30); cephalosporin or vancomycin is utilized in our heart; 2) Inserting the catheter in a downward route with the superficial cuff 2-3 cm from the exit website, as this has been proven to cut back the danger of exit-site/tunnel infections (31); 3) Catheter perform is examined by filling and draining PD fluid earlier than tunneling the catheter; 4) Bowel preparation to keep away from constipation earlier than and after surgical procedure, as constipation is related to catheter malfunction and Gram-negative peritonitis (32); 5) Acceptable catheter care after insertion, together with anchoring the catheter to immobilize the exit website and decrease entry of micro organism into the tunnel monitor. In our heart, all catheter implantations adhere strictly to a standardized protocol. In a latest evaluation (33), we confirmed that, throughout 2001-2010, a complete of 657 catheters have been inserted. Amongst them, 37 (5.6%) sufferers developed catheter-related problems, solely 8 (1.2%) wanted surgical intervention, and 10 (1.5%) needed to be transferred to HD as a consequence of catheter dysfunction; others recovered with conservative remedy. In our opinion, establishing normal protocols and strict adherence to them is crucial for an optimum final result of catheter insertion, in addition to a excessive approach survival.

Beginning PD with Low Dialysis Dose

Beginning PD with low dialysis dose has been our follow for a few years, i.e., most sufferers begin PD with a 3 × 2 L/24 h routine, even when our sufferers provoke dialysis comparatively late with a mean residual renal perform (RRF) of three.5 mL/min/1.73 m2 physique floor space (BSA) (8). With this routine, sufferers can obtain a imply complete Kt/Vurea of two.2 (8). We beforehand in contrast the PD follow sample and outcomes between our heart and a Canadian heart. In that research, in the course of the first 4 years on PD, nearly all of sufferers in our heart have been dialyzed with three 2-liter CAPD whereas the Canadian sufferers have been dialyzed with a a lot larger dose. Nevertheless, the affected person survival was equivalent between the 2 cohorts. Moreover, our sufferers loved a considerably larger approach survival in addition to a decrease peritonitis price (8). Comparable outcomes have been reported from Hong Kong, the place, regardless of a major decrease complete small solute clearance, the affected person survival price of sufferers present process three exchanges of CAPD was corresponding to that of sufferers receiving 4 exchanges of CAPD (34,35). Along with saving prices and time, the decrease dose may theoretically indicate a decreased threat of dialysis-related problems together with hyperglycemia, weight problems, peritonitis, and even encapsulating peritoneal sclerosis (36). As well as, compliance with remedy could also be enhanced, because it has been reported that there have been vital variations in compliance with totally different CAPD regimens, with regimens above 4 exchanges per day discovered to be an unbiased predictor for non-compliance (37). We not too long ago investigated the impression of the dose of PD on RRF in incident CAPD sufferers in a randomized managed trial. On this research we discovered that urine output declined slower within the first six months on PD in sufferers dialyzed with 3 × 2L than with a 4 × 2L routine, and certainly, it has been argued that the decrease glucose uptake from the dialysate throughout this era is perhaps useful for the preservation of RRF (38). Thus, beginning PD with a small dose, adopted by an incremental improve when wanted, is perhaps one of many contributors to the constructive final result of our program.

Monitoring Key Efficiency Indicators (KPIs), and Establishing Steady High quality Enchancment (CQI) Applications in PD Follow

A KPI is a time period for a kind of measure of efficiency. KPIs are generally used to guage the success of a specific exercise, offering a benchmark to be met or exceeded. KPIs ought to be achievable and permit for interand intra-unit comparisons. Measuring KPIs is a vital part of PD follow and is important for benchmarking, efficiency enchancment and higher scientific outcomes. For instance, making use of CQI rules to scientific follow has been proven to considerably scale back PD-related an infection charges (39,40). CQI packages ought to be established, together with common reporting of outcomes, and turn out to be a pure a part of on a regular basis work to an extent that it turns into ingrained inside the tradition of a PD unit. In 2005, we began common CQI conferences to guage root causes of issues and subsequent plans for intervention. Dedicated and passionate group members in addition to energetic involvement of all the group are essential to a profitable CQI program. In our heart, the lead PD nephrologist decides which side requires enchancment. To find out the impact of CQI, we in contrast affected person traits and outcomes of sufferers initiating PD in two consecutive intervals. All ESRD sufferers who began PD between 1 January 2000 and 31 December 2009 have been included within the evaluation. Throughout this era, a complete of 598 sufferers have been enrolled, 259 began PD in 2000-2004, and 339 in 2005-2009. The affected person survival charges have been: 90%, 79%, 72% and 64% for the 2000-2004 cohort (8) and 93%, 88%, 82% and 71% for the 2005-2009 cohort after 1, 2, 3 and 5 years, respectively (unpublished knowledge, Renji Hospital). Approach survival charges have been 96%, 94%, 92% and 82% after 1, 2, 3 and 5 years respectively for the sufferers who initiated PD in 2005-2009. In comparison with the earlier cohort, affected person survival of the sufferers from the 2005-2009 cohort improved considerably (Log

rank 5.547, p = 0.019) and approach survival remained wonderful (). Price noting is that the prevalence of diabetes was considerably larger within the latter cohort (23.3% vs 15.8%, p = 0.028) ().

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(A) Comparability of affected person survival charges in incident peritoneal dialysis sufferers between 2000-2004 (n=259) and 2005-2009 cohort (n=339) in Renji Hospital (p=0.019). (B) — Comparability of approach survival charges in incident peritoneal dialysis sufferers between 2000-2004 (n=259) and 2005-2009 cohort (n=339) in Renji Hospital (p>0.05).

TABLE 3

Comparability of Baseline Affected person Traits Between 2000-2004 Cohort and 2005-2009 Cohort

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Conclusion

In abstract, the Renji PD unit is a high-quality PD heart with wonderful affected person outcomes. We imagine {that a} devoted and skilled PD group, a structured affected person coaching program, steady affected person help, establishing and using standardized protocols, beginning PD with low dialysis dose, monitoring KPIs, and CQI represent the principle components underlying this profitable PD program. With the supply of latest know-how and extra biocompatible options reminiscent of icodextrin, a fair higher final result in PD sufferers is prone to be achieved sooner or later.

Disclosure

The authors haven’t any conflicts of curiosity to declare.

Acknowledgments

We want to sincerely thank Dr. Anders Tranaeus for his constructive feedback and assist in revising the manuscript.

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