Session: Use of Peritoneal Dialysis in Non-Renal Organ End Stage (May 9, 2019)
Speaker: Kunal Chaudhary, MD, and Joanne Bargman, MD
Approximately 4-6% of patients with end-stage renal disease (ESRD) have cirrhosis at the time of initiation of renal replacement therapy. Patients with co-existing liver disease and renal failure pose significant management challenges for nephrologists.
In particular, hemodialysis (HD) can be problematic for a number of reasons including:
Coagulation and platelet disorders → risk of bleeding with cannulation of AV fistula or graft → high prevalence of dialysis catheters
Thrombosis of AV access due to hypotension → high prevalence of dialysis catheters
Risk of encephalopathy. Rapid electrolyte and osmolality shifts may result in cerebral edema and can precipitate encephalopathy.
Over-estimation of dialysis adequacy. Ascites is a large extracellular reservoir and consequently immediate post dialysis urea level may be falsely low resulting in over-estimation of urea reduction ratio.
Meanwhile, peritoneal dialysis (PD) offers several potential advantages over HD in patients with cirrhosis:
No risk of bleeding with dialysis (once PD catheter has been placed)
Less intra-dialytic hypotension
Regular drainage of ascitic fluid which removes the need for paracentesis
Increases caloric intake with dextrose solutions
However, nephrologists may hesitate to use PD in patients with concomitant liver disease due to concerns such as protein losses with dialysate, increased risk of peritonitis (due to risk of spontaneous bacterial peritonitis), herniation and fluid leaks (due to higher intra-abdominal pressure), and impaired dexterity and frailty of this patient population. While the evidence with regard to modality choice in patients with cirrhosis consists of mostly single-center case control and retrospective studies, the available data provide useful insights.
Survival in Patients with Liver Disease Treated With Peritoneal Dialysis
Survival of cirrhotic patients on PD with propensity matched patients on HD
Complications While on Peritoneal Dialysis
Peritonitis: Patients with cirrhosis are at risk of spontaneous bacterial peritonitis with the majority of cases being due to a gram-negative organisms. Studies have consistently shown that patients with cirrhosis receiving PD have similar rates of peritonitis as those without cirrhosis. Interestingly, there is no evidence of an increased rate of gram-negative peritonitis suggesting that spontaneous bacterial peritonitis is not a significant issue in PD. There may be a variety of reasons for this somewhat unexpected finding, including use of antibiotic prophylaxis in patients with cirrhosis, close attention to bowel care, as well as altered peritoneal immune function in PD.
Causative organism of PD peritonitis in patients with cirrhosis and controls
Protein loss: Malnutrition is common in patients with cirrhosis. This is of particular concern in patients with cirrhosis managed with PD who have been described to have substantially greater peritoneal protein losses in the months following initiation of PD than those without cirrhosis. The protein loss does reduce over time to levels comparable to those without cirrhosis which may be explained by counterpressure exerted on the peritoneal membrane by the dialysate with reduced ascites formation.
Hernias and Fluid Leaks: Studies have inconsistently reported on whether an increased rate of hernias occurs in patients with cirrhosis managed with PD. Fluid leak is a concern due to elevated intra-abdominal pressures at the time of PD initiation in this patient group but Dr Chaudhary reported good results were achieved at his center where the surgical team place a purse string suture in the posterior fascia/peritoneum to prevent leak.
Peritoneal dialysis in patients with a history of liver transplant
In the last presentation of the session, Dr Joanne Bargman gave specific advice on the management of patients with liver transplant who subsequently develop ESRD. In her published experience of patients who developed ESRD a mean of 9.7 years after liver transplant with the etiology due to calcineurin inhibitor toxicity in almost all cases, there appeared to be no specific concern related to patients with liver transplant undergoing PD. Peritonitis and mortality rates were no different from the general PD population and the liver graft was never threatened, even during peritonitis.
PD is well-tolerated in ESRD patients with cirrhosis and ascites
Patients with cirrhosis on PD have similar or perhaps better survival than their HD counterparts (no RCTs exist, and further studies are needed)
The risk of bacterial peritonitis does not appear to be increased in patients with cirrhosis managed with PD
There may be a higher risk of hernias and leaks
Patients with a history of liver transplant at that subsequently develop ESRD should not be denied the option of PD
Peritoneal dialysis (PD) remains an important renal replacement option for patients with end-stage renal disease (ESRD). However, as compared to other countries, PD remains underutilized in the United States. According to the US Renal Data System (USRDS) 2017 Annual Data Report, while 9.6% of all incident patients with ESRD initiated PD in 2015, only 7% of all prevalent patients with ESRD were being treated with PD in the same year.
Several factors have been suggested for underutilization of PD in the US, including but not limited to: late referral of patients with CKD to nephrologists, inadequate patient education, financial disincentives, and inadequate PD education of trainees during fellowship.
Does the type of health insurance at the time of chronic dialysis initiation also play a role in PD utilization in the US?
A recent article by Perez et al published in AJKD examines the association between the type of health insurance and PD utilization. This retrospective study analyzed data of two socioeconomically similar patient groups that initiated dialysis between 2006 and 2012. The investigators compared patients aged 60-64 years with no health insurance (or having Medicaid only) to a Medicare- and Medicaid-eligible group of patients aged 66-70 years and determined the likelihood of PD utilization before the start of the fourth month of ESRD onset. Of note, patients in the younger (60-64 years) group were included only if they entered Medicare’s “90-day waiting period” at the time of ESRD onset. As all patients in this study became Medicare eligible after 3 months of ESRD onset, the likelihood of switching to PD after receiving Medicare was also assessed.
The results of this study should not surprise most practicing nephrologists in the US. By the fourth month of dialysis, 4.3 % of Medicare recipients utilized PD as compared to 2.7 % of patients who had no insurance or had Medicaid only (P < 0.001). While this P value may be impressive, what may stand out more is the overall low rate of PD utilization in both groups. Additional multivariable regression analysis also showed lower likelihood of PD utilization among patients with no health insurance (or Medicaid only), compared to patients with Medicare at ESRD onset. Interestingly, this association between the type of health insurance and PD utilization reversed when patients with no insurance/Medicaid only became Medicare-eligible. 3.7% of HD patients in this group switched to PD from months 4 to 12 of chronic dialysis initiation compared to 1.2 % of patients with Medicare at ESRD onset.
Additional analyses were also conducted by Perez et al including the impact of the ESRD Prospective Payment System (PPS) on early PD utilization. The ESRD PPS was enacted in 2011 in the US and this created new economic incentives for some PD providers. While this had led to a slight overall increase in PD utilization in the US, patients with no health insurance and Medicaid only in this study were 40% less likely to receive PD at the fourth dialysis month compared to Medicare recipients at ESRD onset. However the rate of switching to PD after the third month of dialysis did not change in these different insurance groups. Of note, this study only assessed the first 2 years following PPS enactment. It is likely that the result would have been more favorable if several more recent years of data were included.
Despite several limitations, this observational study does shed light on the fact that the type of health insurance that patients have during advanced stages of CKD may also play a role in initial dialysis modality. It is well known that patients with no health insurance in the US are more likely to initiate dialysis during a hospital stay and that hemodialysis (HD) would be the likely renal replacement option in this group. However, US patients who are eligible for Medicare as a result of ESRD diagnosis can receive coverage on the first day of the calendar month that they initiate PD or home HD treatment. In comparison, patients who start in-center HD treatment need to wait for 3 months to receive Medicare coverage. While this incentive may seem enticing for dialysis providers of uninsured patients, PD utilization at the time of ESRD onset would require patients to receive education and preparation for PD treatment, including PD catheter placement before initiation of PD. Logistics like these may be challenging/difficult to achieve in patients who have no health insurance.
As mentioned in the introduction, additional factors play a role for underutilization of PD in the US. In addition to health insurance, several patient (preference, life-style or work-related needs, lack or limited home/family support, etc.) and physician factors play an important role in the choice for dialysis modality in the US. It is important not only to recognize these factors but also to take several measures to enhance PD utilization in the US.
Enhanced exposure and training of fellows in PD during fellowship may be one such measure. Fellowship program directors and the training community need to ensure that all trainees receive adequate training in PD during fellowship and that they feel comfortable in offering this option to patients. Implementation of urgent-start PD programs would be another measure that may result in increased utilization of PD in the US, although this is not available at all training programs/hospitals. In addition, fellowship training should cover education and discussion on health insurance policies, including Medicare’s coverage of patients with ESRD (see the work that NBLU has done here).
Finally, another important measure would be to enhance patient education and understanding of the various dialysis modalities. Augmented nurse care management in CKD stages 4 and 5 has been shown to improve patient education and preparation for various ESRD treatment options (AJKDBlog interview here). In a randomized trial, PD was the initial ESRD treatment in 7 of 30 (23%) participants receiving augmented nurse care management versus only 1 of 29 (3%) receiving usual nephrology care.
When you look at the global landscape of PD, the US is falling behind. Even in developed countries, the US rate of 7% demonstrates underutilization of an option that offers distinct advantages to traditional hemodialysis. Insurance coverage (or lack thereof) is another limiting factor that providers need to be aware of when having conversations about dialysis therapy.
In this study, conducted approximately 1 year after Hurricane Katrina made landfall, almost 1 in 4 hemodialysis patients had PTSD. Many subpopulations, including blacks and patients more recently initiating treatment for ESRD, were more likely to have PTSD symptoms. Additionally, hemodialysis patient evacuation experiences were associated with having PTSD. This finding indicates the need for improved preparation and emergency plans for hemodialysis patients. Staff at dialysis facilities need to be aware of the high PTSD symptom burden and coordinate interventions for patients who have PTSD after future disasters.
Kelman et al used claims data from the Centers for Medicare & Medicaid Services (CMS) Datalink Project to characterize patterns of care and mortality of patients with ESRD who live and receive dialysis in the areas that were most affected by Sandy. Understanding how patients with ESRD receive care during disasters is critical to informing preparedness actions and mitigating adverse outcomes for this vulnerable population.
Blog Commentary: Providing Dialysis Care During Natural Disasters
Navdeep Tangri interviews corresponding author Nicole Lurie to discuss the impact of Hurricane Sandy on the lives of patients on dialysis residing in some of the hurricane’s worst affected areas
This study confirms that early dialysis ahead of Hurricane Sandy’s landfall decreased the likelihood of ED visits, hospitalizations, and 30-day mortality for dialysis patients in the areas most affected. Such evidence affirms the importance of preparedness practices on the part of dialysis facilities to provide early dialysis, as well as the need for dialysis patients to receive early dialysis when access to routine dialysis may be threatened.
Katrina exposed numerous gaps in emergency preparedness for dialysis patients, facilities, and providers. Patients receiving dialysis did not know how to adequately prepare for the storm, many hospitals and dialysis centers had insufficient disaster plans, and public health and emergency management agencies did not know how many people in their community were dialysis dependent and likely to need assistance in the wake of the storm. In the 10 years since Katrina, the United States has made significant progress in emergency preparedness for dialysis patients. In this editorial, Dent et al review key elements of progress and discuss what can be done to address the remaining gaps.
In this In A Few Words essay, Dr Ullian relates the story of a patient who set up peritoneal dialysis in his RV instead of his home. One of the reasons? Since Charleston is susceptible to hurricanes, evacuation with his life-sustaining PD supplies and equipment would be much easier if they were already in the RV.
Emergency Access Initiative (EAI)
The Emergency Access Initiative (EAI) provides temporary free access to full text articles from major health and medicine journals, including AJKD, to healthcare professionals, librarians, and the public affected by Hurricanes Irma, Harvey, and Maria, as well as the earthquakes in Mexico, until November 10, 2017.