Dr Mohamed Alameen

PD: Patient selection Dr M Alamin

: Strong need for independence and control of own care.

to set up a safe area in their home for treatment

PD: Patient selection Dr M Alamin

: Ability to learn and apply theory, principles, and practical procedures

—employed or desire to travel

PD: Patient selection Dr M Alamin

especially if they have a motivated caregiver to assist

PD: Patient selection Dr M Alamin

: Any new ESRD patient with severe cardiovascular disease.

‡ Reduction in dialysis-associated symptoms

A patient whose blood pressure is not well controlled with medications.

PD: Patient selection Dr M Alamin

: Patients with hemodialysis access failure or fear of needles.

‡ No vascular access required

‡ Blood sugar can be well-controlled even though sugar is the base of PD solution

PD: Patient selection Dr M Alamin

Inclusion Criteria for PDChoose the modality.

Want “control.”

Prefer home for dialysis.

Have residual renal function.

CVD, CHF.

Geriatric.

Pediatric.

Social support system.

PD: Patient selection Dr M Alamin

PD: Patient selection Dr M Alamin

No/unreliable electricity

†Homeless

†Poor personal hygiene

†Dementia, poor short-term memory, brain injury without a helper

† Uncontrolled seizure disorder

PD: Patient selection Dr M Alamin

PD: Patient selection Dr M Alamin

Step 1: Promote Pre-Dialysis Care.

Step 2: Identify all patients who start dialysis without pre-dialysis care.

Step 3: Identify all patients who are eligible for PD.

Step 4: Overcome barriers to PD by offering support (Home Care).

Step 5: Educate patients about PD in the home and support them.

PD: Patient selection Dr M Alamin

PD: Patient selection Dr M Alamin

Continuous ambulatory peritoneal dialysis (CAPD) Continuous cycling peritoneal dialysis (CCPD) Conventional in-center HD (4 hoursX3 times/weekthree times

per week for three to four hours per treatment) Nocturnal in-center HD (6-8 hours X 3-4 times/week) Nocturnal HHD (three to six times per week for eight to 10 hours

per treatment) Short daily HHD ( five to seven times per week for two to three

hours per treatment) Transplant

PD: Patient selection Dr M Alamin

:

Assuages concerns and misconceptions.

Provides objective information.

Promotes self-care

Helps patients make an informed modality decision.

Dramatically increase patient choice of home dialysis.

PD: Patient selection Dr M Alamin

Who are the pre dialysis patients ?????? Proved CKD patient.

SCr > 250 umol/l or GFR < 30 ml/min.

How to reach to those patients ????

Informing the referring physicians about the importance of early referral: Family Physicians, ER Physicians, Specialists (General

Internal Medicine, Urology, Cardiology, Emergency; Hypertension specialists; Endocrine Clinics), Walk-In Clinics.

PD: Patient selection Dr M Alamin

Who will give predialysis care ???? Nephrologist

Nurses

Social workers

Dietitians

Social workers

Often include: a surgeon, a cardiologist, a psychologist, a psychiatrist, a physiotherapist etc.

PD: Patient selection Dr M Alamin

What is the predialysis care topics ????1. What is CKD?

2. Anemia of CKD.

3. Blood pressure.

4. CKD nutrition.

5. Conservative therapy

6. RRT: Transplantation, PD and HD

PD: Patient selection Dr M Alamin

Most patients with ESRD are anxious and unwell and

will be nervous about participating in their own

treatment

Getting them to do PD requires encouragement and

support and is best done in advance before they

become very uremic

PD: Patient selection Dr M Alamin

PD: Patient selection Dr M Alamin

PD: Patient selection Dr M Alamin

PD: Patient selection Dr M Alamin

All patients, including acute HD starts, should be offered the various options of RRT that they are suitable for.

Once patients are medically stable, they are to be rapidly assessed to determine what components of pre-dialysis care they have received.

Education about home dialysis to be completed prior to discharge.

PD: Patient selection Dr M Alamin

Absolute contraindications for PD1. Documented loss of peritoneal membrane function or

extensive abdominal adhesions that limit dialysateflow.

2. Uncorrectable mechanical defects that prevent effective PD or increase the risk of infection (eg, surgically irreparable hernia, omphalocele, gastroschisis, diaphragmatic hernia, and bladder extrophy)

PD: Patient selection Dr M Alamin

Absolute contraindicationsfor PD

PD: Patient selection Dr M Alamin

PD: Patient selection Dr M Alamin

Absolute contraindicationsfor PD

PD: Patient selection Dr M Alamin

Absolute contraindicationsfor PD

PD: Patient selection Dr M Alamin

Absolute contraindicationsfor PD

Relative contraindications for PD1. Fresh intra-abdominal foreign bodies (eg, 4-month wait

after abdominal vascular prostheses, recent ventricular-peritoneal shunt)

2. Body size limitations i.e. Morbid obesity (in short individuals)

3. Intolerance to PD volumes necessary to achieve adequate PD dose

PD: Patient selection Dr M Alamin

4. Inflammatory or ischemic bowel disease

5. Abdominal wall or skin infection

6. Severe malnutrition

7. Frequent episodes of diverticulitis.

PD: Patient selection Dr M Alamin

Relative contraindications for PD

Social Contraindications to PD

1. A patient lives in a residence that does not permit PD.

2. A patient requires rehabilitation in a centre that does not permit PD.

3. A patient’s residence has insufficient storage space for PD supplies and equipment.

4. A patient’s family is not supportive of PD in the home.

PD: Patient selection Dr M Alamin

Assess all patients starting chronic dialysis to determine if they are eligible for PD in the home (no contraindication).

Modality options for patients are determined by conducting multidisciplinary assessments in partnership with the patient and their families.

PD: Patient selection Dr M Alamin

Recommendations

Communication between pre-dialysis and home dialysis health care teams to be conducted on an ongoing basis to assist in the assessment process.

Involvement of home dialysis nurses in the pre-dialysis clinic to be part of the strategy.

PD: Patient selection Dr M Alamin

Recommendations

PD: Patient selection Dr M Alamin

The following conditions should not be considered as contraindications to PD

Physical or mental inability to perform PD

Older age

Poor adherence/non-compliance to therapy

Obesity

Congestive heart failure

Polycystic kidney disease

Diverticulosis

Abdominal hernias

Portal hypertension

Liver transplantation

PD: Patient selection Dr M Alamin

Theoretical: CKD

Acceptance of chronic disease

Conservative therapy

RRT options

Practical: Conducted by experienced PD nurse

Using educational materials

PD: Patient selection Dr M Alamin

Factors in Favour of PD Young child

Full time work

Desire for autonomy

Mother with young children

Good family support

Good motivation

Early transplant likely

PD: Patient selection Dr M Alamin

‘ PD FIRST ‘Advances of PD as Initial Modality

1. Preserves residual renal function better

2. May allow better blood pressure and volume control with cardiovascular benefits

3. May give better quality of life

4. Has less anemia and lower EPO doses

5. Lower risk of Hepatitis C

6. Equal or better survival in early years

7. Cost advantages - in many countries

Conclusion Several factors must be in place in order to maximize

patient compliance.

First, the health care professionals and treatment setting have to be positive and inspire hope and trust.

Patients should be seen as colleagues in the design and implementation of their treatment plan.

Treatment plans should be realistic based on what the patient should and will do.

PD: Patient selection Dr M Alamin

PD: Patient selection Dr M Alamin