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By Robert Provenzano, M.D., F.A.C.P.
How often are nephrology healthcare professionals, nephrologists, dietitians, nurses or technicians asked the question, “If you had kidney failure, which dialysis treatment would you choose?” More often than we may realize. Chronic kidney disease (CKD) patients who need dialysis frequently reach out to their health care team, grasping for the “right choices.” What do I tell the patient? Some doctors may not have thought about what therapy they would want if they required dialysis. And other health care professionals may wonder if they have the right to share their thoughts with patients. Many questions are out there, so I will share with you my perspective when asked this question.
There are several dialysis modalities available to patients with chronic kidney disease or end stage renal disease (ESRD).
So what do you choose? How do you choose? In my conversations with my patients I often focus not on the modality, but on the person’s lifestyle. Decisions about dialysis treatment selection must be based on keeping the patient feeling as independent as possible and in control of their therapy. That judgment can only be made with an intimate knowledge of the patient, their family structure and family support systems. Knowledge of their transportation needs and social situation is also important. I ask questions such as:
All of these questions must be considered when assisting the patient in the decision-making process.
There are pros and cons of each therapy. Some reasons that come up are whether or not a patient is living with comorbidities, has transportation or if a certain treatment even fits into their social life.
The majority of patients select traditional in-center hemodialysis. This therapy is often best for patients who are relatively dependent. All the patient needs do is get to dialysis (and for those with transportation needs, the social worker can work with those patients to secure help arriving to and from their treatments). The nurses will place the needles, do the person’s treatment and discharge the patient. This type of treatment can fit into many patients’ lifestyle.
The dialysis center is a structured environment where patients know precisely how much time and on what days they will receive therapy. On non-dialysis days, patients’ only responsibility is taking their medicines and adhering to their fluid restrictions. This treatment choice is viewed as advantageous for those patients who require a structured environment or have compliance trouble. The down side is there are strict dietary and fluid restrictions patients have to stick to.
The advantage of nocturnal in-center hemodialysis is this treatment almost doubles the amount of therapy than traditional day-time hemodialysis. The patients have their days free and have a more liberal diet and less fluid restriction. The disadvantage is that the patient must agree to 7 to 8 hours of treatment 3 times a week, spend time away from home and have to be comfortable sleeping in a new environment.
Peritoneal dialysis (PD) is a home therapy that requires dedication and active participation by the patient. Patients who choose PD tend to have “take charge” personalities. Most patients choose to do place themselves on an automatic peritoneal dialysis (APD) machine, also called a cycler, each night. This therapy is usually performed while the patient sleeps, but it is a daily therapy rather than just three times per week. Additionally, the patient should understand PD works if the patient works with the healthcare team and is able to follow the team’s advice and treatment program. A person who chooses PD needs to pay attention to things and communicate any problems or changes to the doctor or nurse. One advantage of PD is the patient does not have to travel back and forth to a dialysis center, except to visit his or her kidney care team once a month. Also, patients have a more liberal diet with less fluid restriction. Because the patient is not obligated to a center’s schedule, they are generally much freer to travel. And if a patient has some residual kidney function, PD may be the best treatment to help preserve kidney function – this is important for overall health.
The other home therapy is home hemodialysis (HHD). The advantages of home hemodialysis are similar to peritoneal dialysis, such as more liberal fluid and diet compared to traditional in-center hemodialysis, control over their treatments and when they perform them. The patient does have to go through an extensive training process and is required to have a care partner with them when performing HHD. One important aspect is a patient must be comfortable placing their own needles.
How a health care team professional answers, “Which dialysis therapy would you choose if you required dialysis?” has to depend on his or her lifestyle and circumstances. So let me answer the question for myself. Because of my busy and changing schedule, I would choose home hemodialysis. My down time, when I am at home reading and relaxing, could be spent dialyzing 2-1/2 to 3 hours, 5 or 6 times each week. I would have no restriction on my fluids, I would remain independent and because of technology and the miniaturization of dialysis equipment, my home would not look like a hospital room.
I would encourage my fellow dialysis health care teammates to go through the above exercise, know which dialysis modality you would want and once you are comfortable you can share your thoughts when a patient asks you, “If you had kidney failure, which dialysis treatment would you choose?”
Robert Provenzano, M.D., F.A.C.P., is Vice President of Medical Affairs at DaVita Inc. and Chief of Nephrology at St. John Hospital and Medical Center in Detroit.
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