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Controversies in Nephrology Nursing

Home Hemodialysis vs. Peritoneal Dialysis
Remedios Ash
Kimberly Davis

Home Hemodialysis Is an Alternative that Saves Patients And Nurses
There is nothing more profound than the words spoken by our patients. Home hemodialysis (HHD) is not easily accepted by many patients. However, if you speak to most patients on HHD, they will give you the long list of benefits to dialyzing in their own homes.

In my professional opinion, nephrology nurses and nephrologists are a controlling group of individuals. Many patients tell us stories of how they were discouraged by professionals when they expressed an interest in HHD. This glaring inconsistency should draw the attention of renal professionals. It is time to let go of the control issue!

From a professional prospective, I have seen the benefits of short daily hemodialysis from the first week of home training. After the patient’s second or third treatment, there is a dramatic difference in the appearance in these individuals. They no longer appear to be “sick” and will tell you the dramatic difference in how they feel.

One of our first patients came to us with many complaints regarding his dialysis center. He feared death. He feared being at the mercy of caregivers of whom he was scared. He told us, “If I don’t get out of there, they are going to kill me.” Upon further questioning, the patient expressed that he was at the mercy of inconsistent caregivers, infrequent visits from his physician, and resistance from staff when he made suggestions. HHD gave him the ability to make his own decisions regarding his care. Two years later, he still gives his telephone number to patients and has convinced his physician to refer patients to home therapy.

When you treat the patient, you treat the family. Another battle patients face prior to performing home therapy is being at the mercy of the schedule of the center, yet another personal loss of control. Often these patients do not have the convenience of a non-working family member who can provide transportation or assume the many responsibilities of running the household. Patients need the family member to be well to participate as much as possible in the day-to-day functions in the household. One of the greatest accomplishments is talking to patients during clinic visits and hearing about what is going on in their life, and not hearing how dialysis has taken away their life. They no longer reminisce about the life they had before; they are living everyday, as we all do.

Clinically, our patients on HHD are the most stable. This is not due to younger age because we have a large range of patient ages. One of our most stable patients is an aging baby boomer who was dialyzing in the center four times per week due to decreased cardiac function. As a unit manager, finding slots for these patients can be next to impossible. There are waiting lists for patients to dialyze at more convenient times. Who wants to go to dialysis at 5:00 p.m. and not return home until late at night? All nephrology nurses should ask themselves, “Would you like to be ‘scheduled’ versus receiving treatment on your time and a convenient schedule?”

Vascular access is not necessarily a limiting factor for HHD, as we have all kinds of accesses, including indwelling femoral catheters. Cannulation of a fistula or graft, as well as aseptic technique of accessing a central vein catheter, can be taught to patients and family members. It is the frequency of the treatment that is the real benefit. Weekly clearances for patients on HHD exceed the values of patients on in-center HD. Even if patients do not do daily therapy, the positive psychological effect on the patients is dramatic.

The hemoglobins of patients on HHD are more stable and more easily maintained with a decreased amount of erythropepsis stimulating agent (ESA) prescription. Most of our patients receive maintenance iron therapy only when they come for clinic visits. Their monthly chemistries are much improved over those from their time on in-center HD. They feel better, they eat better, and they live better.

As a nurse of a younger age than most of my colleagues, I realize that I am facing an uphill battle. A fair percentage of my colleagues will retire in the next 10 years (greater than 50%). The benefit to the clinic is that a home dialysis program can handle a higher patient load with fewer nephrology nurses. With quality teaching principles and good training resources, patients can even make nephrology nurses’ lives easier because of their increased independence. This is a win-win for patients and nurses. However, the reality is that there are decreasing numbers of nurses in the renal community. A serious question or dilemma is facing the nephrology community – “With more dialysis clinics opening, who will staff them?” A better idea or answer may be for the community to earnestly revisit an old paradigm and adopt a new slogan. Support HHD and save a nephrology nurse!

Alternatives to In-Center Hemodialysis: Peritoneal Dialysis Is an Excellent Choice
The number of patients with chronic kidney disease (CKD) requiring renal replacement therapy (RRT) is rising, and the shortage of nephrologists and nephrology staff is growing. The median age of patients commencing dialysis therapy is now about 65 years of age (Jacobs, Kjellstrand, Koch, & Winchester, 1996; U.S. Renal Date System, 2006). For most patients, the preferable treatment of choice is transplantation. However, some patients may not be suitable candidates for kidney transplantation, while others may have transplants that fail. Given that cadaveric donors are limited and many patients do not have potential living donors, the majority of patients resort to dialysis for survival.

Most patients starting hemodialysis in the U.S. choose in-center hemodialysis, or this choice is made for them. Conventional in-center hemodialysis requires the use of nursing and/or technical staff, transportation to and from a dialysis center at least three times per week, and patient confinement to a specific machine for several hours for each treatment. Furthermore, patients may have discomfort from needle cannulation, fear of care from inexperienced cannulators, prolonged bleeding, or hematoma leading to extended treatment time. Therefore, the underutilized alternative of peritoneal dialysis (PD) needs to be reconsidered.

PD is a form of dialysis free of needle cannulation, pain, and bleeding. PD is usually performed by the patient and or helper in the comfort of their homes after suitable training. The PD procedure is simple and can be easily learned within several days. Current technology of PD allows for either continuous ambulatory peritoneal dialysis (CAPD or manual) or continuous cycling peritoneal dialysis (CCPD or automated), or a combination of both, which can be done at home by the patient.

PD is associated with daily treatments. Patients experience fewer radical hemodynamic changes, and less fluid and diet restrictions. Since patients dialyze at home, there is less risk of blood-borne and nosocomial infections. Patients, particularly frail older adults, do not have to travel long distances or have prolonged waiting times in order to receive dialysis. Necessary follow-up visits are fewer with PD, which can be done virtually anywhere, allowing patients unlimited travel opportunities and social activities. Family members involved in the care of patients on PD may also experience greater independence in accomplishing other duties. These patients frequently enjoy the rapport with and clinical support of their dedicated and experienced nephrology nurses and the technical assistance of their manufacturer. Generally, patients on PD experience an improved quality of life (QOL) and greater convenience, as well as flexibility. PD is noted for lower treatment cost when compared to in-center HD in the U.S. (Lee et al., 2002), which may have economic impact on Medicare and other private providers.

Using PD as an initial treatment can preserve vascular access sites for future long-term HD when necessary. With an average waiting time of approximately 3 to 4 years for cadaveric renal transplant or possible future transplant failure, preservation of the vasculature for anticipated prolonged hemodialysis needs to be contemplated. With fewer acute hemodynamic changes, there is a tendency to maintain residual renal function (RRF) over a longer period of time with PD. Preservation of RRF is associated with improved survival (Wand & Lai, 2006). In addition, patients with significant volume overload, such as severe heart disease or cirrhosis, can benefit from this daily PD therapy to maintain better volume control and less hemodynamic instability with gentle, physiologically compatible ultrafiltration. PD can also be utilized for obese patients because larger volumes can be used with the cycler PD combined with daytime dwells to obtain dialysis efficiency (Shahab, Khanna, & Nolph, 2006). Patients with a history of past abdominal surgery can still be considered for PD because a healed surgical abdomen can still provide adequate residual peritoneal membrane function. PD therapy is found to be a reasonable alternative to hemodialysis in the management of chronic kidney failure in patients with spinal cord injuries (Vaziri, Lopez, Nikakhtar, Gordon, & Penera, 1984).

In conclusion, PD should be considered as the initial modality for all patients with end-stage renal disease (ESRD) initiating dialysis unless there is a major contraindication for this modality in a particular patient. PD provides flexibility and autonomy that can improve QOL for patients with ESRD. Therefore, it is imperative for health care providers to educate patients early regarding PD and its benefits. Incomplete presentation of the option for PD to potential ESRD patients can lead to underutilization of an excellent and safe treatment.

The Controversies in Nephrology Nursing department focuses on exploring ethical and clinical issues within the nephrology clinic practice in a point/counterpoint format. Address correspondence to: Christy Price Rabetoy, Department Editor, through the ANNA National Office; East Holly Avenue/Box 56; Pitman, NJ 08071-0056; (856) 256-2320; or by emailing her at christycpr@comcast.net. You may also log onto this column at www.nephrologynursingjournal.net (clink on Department link) and email your comments to the Editor (see Discussion Area). The opinions and assertions contained herein are the private views of the contributors and do not necessarily reflect the views of the American Nephrology Nurses' Association.