Managing Transition between dialysis modalities: a call for Integrated care In Dialysis Units

Abstract

Summary

Patients with chronic kidney disease have three main possible groups of dialysis techniques: in-center hemodialysis, peritoneal dialysis, and home hemodialysis. Home dialysis techniques have been associated with clinical outcomes that are equivalent and sometimes superior to those of in-center hemodialysis
Transitions between treatment modalities are crucial moments. Transition periods are known as periods of disruption in the patient’s life associated with major complications, greater vulnerability, greater mortality, and direct implications for quality of life. Currently, it is imperative to offer a personalized treatment adapted to the patient and adjusted over time.
An integrated treatment unit with all dialysis treatments and a multidisciplinary team can improve results by establishing a life plan, promoting health education, medical and psychosocial stabilization, and the reinforcement of health self-care. These units will result in gains for the patient’s journey and will encourage home treatments and better transitions.
Peritoneal dialysis as the initial treatment modality seems appropriate for many reasons and the limitations of the technique are largely overcome by the advantages (namely autonomy, preservation of veins, and preservation of residual renal function).
The transition after peritoneal dialysis can (and should) be carried out with the primacy of home treatments. Assisted dialysis must be considered and countries must organize themselves to provide an assisted dialysis program with paid caregivers.
The anticipation of the transition is essential to improve outcomes, although there are no predictive models that have high accuracy; this is particularly important in the transition to hemodialysis (at home or in-center) in order to plan autologous access that allows a smooth transition.

Introduction

Patients with chronic kidney disease have three main possible groups of dialysis techniques, each of which may have several specificities: in-center hemodialysis and home dialysis (peritoneal dialysis and home hemodialysis).

Home dialysis modalities have been associated with clinical outcomes that are equivalent and sometimes superior to those of in-center hemodialysis[1];[2];[3]. Home therapies allow for less disruption to patients’ routines, greater freedom, and better time management[4];[5].

Regardless of the first modality, the possibility of transferring the technique in the future should be highlighted early to the patient (even in the absence of identified risk factors) according to the patient’s «dialysis life plan». In fact, the decision to transfer between techniques must be understood as a continuous treatment process.

The transition: importance and scope

The concept of transition is broad and applied in the transition between chronic kidney disease and the beginning of chronic dialysis treatment, between the various dialysis techniques and, eventually, a transition to conservative treatment (Figure 1). This topic is important because the transition periods are known as periods of disruption in the patient’s life associated with major complications, greater vulnerability, greater mortality, and direct implications for quality of life[6];[7];[8].

The choice of dialysis modality for each patient is influenced by several factors: experience of the center and the nephrologist, health system, demographics and geographic situation, comorbidities, and frailty[6]. The most appropriate modality for each patient may not be unique and the patient may benefit from a combination of modalities over time. Younger patients with a lifetime of renal replacement will require several modality switches over the years, and there is some evidence that the use of more than one dialysis modality can confer benefits[9]. The nephrologist must clarify the goals and expectations of the patient and only in this way will provide a personalized treatment. The clinical team is responsible for the progressive follow-up of the patient, discussion about the technique to propose and the appropriate moment of transition.

We will discuss some aspects related to the transition between the techniques with primacy of home dialysis, whenever possible.

Preparing for dialysis: Achilles tendon or golden opportunity?

Several observational studies have shown that the first few months on dialysis are critical, especially the first 90-120 days, which are associated with an increased risk of mortality[10];[11]. Patient-related risk factors that are associated with these outcomes include age, cardiovascular disease, malnutrition, inflammation, anemia, and frailty[10];[11];[12]. Inadequate nephrological care and poor transitional management potentiate these results. The pre-dialysis and peri-dialysis period presents an opportunity to address several deficits in the management of end-stage renal disease, a window to implement new interventions, an opportunity for improving education and the best opportunity to introduce home and personalized treatments[6]. This concern is not new the first published example dates from 1981[13]and arose in response to the decreasing rate of home dialysis choice in the USA: the authors established a teaching program over six “units,” emphasizing modality, dietary and access education, patient rehabilitation, and the possibility of safe transitions to home dialysis, when applicable. It was a pioneering way to involve patients in their own treatment and increasing the number of home treatments.

The awareness of the need for personalized treatments and provision of multidisciplinary care led to the development of transition care units. These units are specialized in transition, preparing the patient for the start of dialysis with the aim of improving patient outcomes, offering a holistic approach and personalized treatment[14].

Referral to the transition clinic should be decided according to the risk of progression of chronic kidney disease[14]. The non-linear decline in glomerular filtration rate limits accurate projections about disease progression but the risk can be estimated by using the Kidney Failure Risk Equation, the most widely validated formula[15]. According to KDIGO, patients with an ESKD risk in the range of 10-20% within one year should be referred for planning dialysis[16].

Early referral has been associated with better outcomes (lower mortality, shorter hospitalizations, better access to transplantation, increased number of patients receiving home care, and better management of vascular and peritoneal access[14];[17];[18]; however, referral too early can lead to the inclusion of patients who may never benefit from such specialized care.

After inclusion in the transition program, investment in patient education is central and essential. The reduced information provided to patients with chronic kidney disease is associated to the reduced expression of home dialysis among incident patients and is related to some of the adverse outcomes at the beginning of dialysis[19]. Additionally, several studies still indicate that patients with CKD feel that their decision is not informed[20];[21].

Patients with chronic kidney disease have additional educational challenges due to the presence of identified barriers[22]:

-At the patient level: the low level of health literacy, low learning capacity, and comorbidities.

-At the clinical level: the time/resource constraints, disease complexity, low patient receptivity, and lack of consensus on the best appropriate moment.

-At the systematic level: the lack of multidisciplinary teams, poor communication between specialties, and lack of monetary incentives.

Investment in patient education is a central objective of pre-dialysis transition care; it allows the possibility of delineating

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