Evaluation of professional practices in the management of anemia and nutrition in peritoneal dialysis patients: About a single-center experience

Abstract

Since the French law of March 4, 2004, healthcare professionals in both the medical and paramedical fields have been participating in developing the evaluation of professional practices (EPP). This initiative forms part of a broader ongoing effort to enhance medical practices.
The EPP is an essential tool for improving the quality of care and guaranteeing patient safety. This assessment can be individual or collective. It aims to target one or more themes to correct any discrepancies between the care provided to patients and a set of standards for care and management.
We have consistently carried out EPPs since 2012, mainly on anemia and nutrition in peritoneal dialysis patients. Through this work, we wish to demonstrate our interest in conducting EPPs in the follow-up of peritoneal dialysis patients.

Introduction

The evaluation of professional practices (EPP) in medicine is an approach aimed at improving medical practices and implementing corrective and/or preventive actions, following an analysis of current practices and any deviations from the guidelines established by the Haute Autorité de Santé (HAS) [1]in France and/or learned societies. This is a global approach, as highlighted by a recently published general review [2].

Anemia and undernutrition are present in a large number of peritoneal dialysis patients, which is why personalized monitoring is necessary to adapt treatments to each patient according to indicators and clinical status.

At the heart of our nursing profession and in collaboration with other healthcare professionals, we are committed to improving patient care by carrying out various EPPs.

Our aim is to demonstrate the role of EPPs in the management of anemia and nutrition in peritoneal dialysis patients through our experience in the peritoneal dialysis unit of our hospital center.

Materials and Methods

I-Description of the population

In our hospital center, two full-time nurses are currently in charge of 38 peritoneal dialysis patients.

Our geographical area extends over a peripheral radius of more than 60 kilometers around our hospital center, with a catchment area of more than 260,000 inhabitants.

Our active file includes 12 women and 26 men, with an average age of 72.9 years. The oldest patient is 92 years old and the youngest is 49 years old, with an average technical survival of 50.55 months and an average patient survival of 39.5 months.

A total of 32 patients are treated by continuous ambulatory peritoneal dialysis (CAPD) and 6 patients by automated peritoneal dialysis (APD).

In our CAPD population, we have seven patients on pure cardiac peritoneal dialysis (with a single dialysate bag/day).

II-Assessment of professional practices

II-1- Definition

Decree No. 2005-346 of April 14, 2005, on the EPP and Art. D. 4133-0-1 in France [2]state the following: “The aim of the evaluation of professional practices re-ferred to in Article L. 4133-1-1 is the continuous improvement of the quality of care and service provided to patients by health-care professionals. It aims to promote the quality, safety, effectiveness, and efficiency of care and prevention and, more generally, public health, in compliance with ethical rules. It consists in analyzing professional practice with reference to recommendations and accord-ing to a method developed or validated by the French National Authority for Health (HAS) and includes the implementation and monitoring of actions to im-prove practices.”

EPP criteria are defined by the HAS [1]and include the following:

- Assessment of real-life professional practices

- Comparison of professional practice with expected practice (based on recommendations)

- Implementation of improvement actions designed to bring actual prac-tice into line with the expected reference practice.

The criteria can be based on the recommendations of professional societies or developed in line with the establishment’s own quality objectives.

II-2- In practice

The EPP is a tool for measuring professional practices, enabling the analysis of care after the fact to improve the quality of care and guarantee patient safety.

In particular, professionals come together around a common theme and analyze patient outcomes in relation to professional recommendations or references.

The nurse carries out daily care, evaluating and adapting it. He then communicates it to the doctor for adaptation and modification to each patient’s specific needs.

The ways in which the EPP can be implemented are diverse and evolving, depending on the objectives and expectations of the medical team and the resources of the facility.

In our case, during our EPP staff meetings, which began in 2012, in collaboration with the doctor, the peritoneal dialysis nurses, and the dietician, we share management and therapeutic decisions together, ensuring consistency in patient follow-up and increasing the cohesion of the health-care team by sharing the same objectives and using the same resources.

We also print out in advance a monitoring table of the most important parameters that we have filled in (Table I).

Table I.Monitoring table of most important parameters

Patient's name :		Age :
First name :		Date 1st session		Heart
Date of birth :		Diabetic pathology : Y/N	Y/N
Evaluator name :
Evaluation date :
Parameters	Targets	BS 1st quarter 2024	BS 2nd quarter 2024	BS 3rd quarter 2024	BS 4th quarter 2024
Pds
Hb	10 à 12
Ferritin	> 500
CSS	> 20
Alb	> 35
CRP	< 5
Npcr/6 months	> 1,1
Body fat
Lean mass
Handgrip
Treatment	Treatment 2023	1st quarter 2024	2nd quarter 2024	3rd quarter 2024	4th quarter 2024
Iron PER OS
Iron IV
EPO
Dietetic actions

This table is regularly filled in by the nurses when monitoring patients.

The criteria and targets have been defined beforehand by the physician in charge of peritoneal dialysis patients, with reference to the recommendations established for this type of population.

We review each patient’s results with the doctor. An analysis of the patient’s biological results and clinical situation is then carried out, enabling corrective action to be taken or existing therapies to be adjusted. Our peritoneal dialysis patients undergo a blood test every three months for medical consultation and a day of hospitalization every six months (including a dietetic consultation).

A posteriori, we inform patients of the various changes made to their treatment, and if necessary call them in for a day of hospitalization. Changes are recorded in the patient’s file, together with a report of the meeting held. These are signed by the doctor and forwarded to our center’s quality department and the association in charge of patients at home.

II-3- Staff EPP Anemia/Nutrition

II-3a EPP Anemia

Renal failure leads to a failure of the kidney’s endocrine function. This results in a failure to synthesize the erythropoietin (EPO) responsible for the anemia. Once another cause of the patient’s anemia has been ruled out (martial deficiency, inflammatory syndrome, etc.), the appropriate treatment is put in place. Accord-ing to the HAS, the prescription of EPO in patients with chronic renal failure is subject to three conditions:

- Hemoglobin <10 g/dl

- Anemia responsible for troublesome symptoms (asthenia, dyspnea, angina)

- Anemia exclusively secondary to CKD (EPO production deficiency)

Our EPP meetings for the evaluation of anemia include the following criteria:

- Patient’s age and weight

- Presence of heart failure and/or diabetes

- RFP start date

More specifically, anemia criteria include the following: hemoglobin level, ferritin and transferrin saturation coefficient, taking CRP into account, and current or past treatments (per os, IV or EPO).

A prescription or adjustment of the EPO prescription is made during this EPP, with the correction of any martial deficiency by an injection of IV iron.

Every three months, we also complete the anemia module of the French-language Peritoneal Dialysis Registry (RDPLF). This is a tool for monitoring the anemia management of patients on peritoneal dialysis or home hemodialysis, and it indicates the degree of compliance with recommendations; this module also flags patients whose results are in line with recommendations [4].

II-3b EPP Nutrition

Protein-energy undernutrition is a frequent complication of peritoneal dialysis and is induced by an unavoidable loss of protein and amino acids (around 6–10 g/day) in the dialysate, which must be compensated for by the patient’s dietary intake.

Protein intake for peritoneal dialysis patients should be 1–1.2 g/kg/day to prevent undernutrition. This will be increased in the event of peritonitis.

The main symptoms of undernutrition are loss of appetite, weight loss, asthenia, and reduced physical and functional capacity.

Assessing undernutrition requires a combination of several criteria. There are various types of treatment, including dietary supplements and enteral feeding.

Our peritoneal dialysis patients mainly benefit from oral nutritional supplements (ONS) in a variety of types and forms: high-protein milky or fruity drinks, creams, amino acid solutions, etc.

The dietician intervenes as soon as peritoneal dialysis is started, with an interview designed to ascertain the patient’s eating habits and tastes, so as to estimate and optimize his or her nutritional intake. The patient is then seen for a dietary interview every six months during his six-month follow-up, at which time a dietary survey is once again carried out.

When assessing nutrition within the staff EPP framework, we take into account the following criteria in particular:

- Patient’s age and weight

- Presence of heart failure and/or diabetes

- Start date of peritoneal dialysis

More specifically, the criteria for undernutrition are as follows: blood albumin level, presence of an inflammatory syndrome by measuring CRP, nPCR (normalized protein catabolism rate), body fat and lean mass (obtained by impedancemetry), and handgrip test (measurement of muscle strength, more specifically grip strength, which we carry out every six months).

An assessment of ONS intake is carried out at the same time. It is also possible to track the criteria for adequate dialysis and nutrition in the “Nutrition and Ade-quate Dialysis” module of the RDPLF, which calculates PCR, KT/V, and weekly creatinine clearance (indicating the portion related to residual renal function and dialysis) [5].

Results

Of our 38 patients, 6 currently have hemoglobin <10 g/dl, and 24 have albumin <35 g/L (Figure 1. andFigure 2.).

Figure 1.Hemoglobin monitoring in PD patients

Figure 2.Monitoring albumin levels in PD patients

a) Anemia

Treatments to correct anemia include the following:

- Oral folic acid

- IV iron

- Subcutaneous EPO

The distribution of folic acid treatments and the types of erythropoiesis activators are summarized in Figure 3. and Figure 4..

Figure 3.Patients treated with folic acid, IV iron and EPO

Figure 4.Different types of EPO used

b) Nutrition

In our center, 24 patients benefit from oral nutritional supplements ( Figure 5..).

Figure 5.Number of patients taking oral nutritional supplements

Discussion

According to HAS recommendations, hemoglobinemia is within the target range (>10 g/dl) for the majority of our peritoneal dialysis patients ( Figure 1..).

Furthermore, as assessed by plasma albumin levels, severe undernutrition was noted in eight patients, with albumin levels below 30 g/L—a minority of patients ( Figure 2..).

More specifically, mean albumin levels were 33.77 g/dl (33.07 g/dl in men and 35.28 g/dl in women).

a) Anemia

Around 29% of patients received folic acid, while 58% of patients received an IV iron infusion and 68% were treated with subcutaneous injections of EPO ( Figure 3..).

The different types of EPO used are as follows:

- Darbepoetin alfa (long half-life EPO)

- Epoetin alfa (short half-life EPO)

- Epoetin beta (short half-life EPO)

The majority of patients are treated with darbepoetin alfa, an EPO with a long half-life, enabling injections to be spaced out when the patient’s hemoglobin has stabilized ( Figure 4..).

b) Nutrition

In our center, 24 patients benefit from oral food supplements ( Figure 5..).

The main oral food supplements we use are as follows:

- RENORAL® (Théradial) (Renoral® is an oral nutritional supplement containing amino acids, specifically formulated for the nutritional needs of adult patients suffering from end-stage chronic renal failure without carbohydrate or lipid calories.)

- DELICAL® (Lactalis nutrition santé)/CLINUTREN® (Nestlé Health Science) (These are ternary mixes with a complete nutritional profile, rich in protein and/or calories. They can be administered orally in the form of desserts, drinks, jellies, etc.)

We note that the majority of patients receive DELICAL® or CLINUTREN® nutritional supplements, with a minority on RENORAL®. However, nine patients receive both types of supplements.

These oral supplements aim to help meet the nutritional needs of the malnourished patient as well as to compensate for the protein losses induced by peritoneal dialysis, thereby maintaining a satisfactory nutritional status. Muscle mass is a noteworthy indicator for nutritional assessment. We monitor the evolution of the patient’s lean body mass index(LTI) and fat mass index (FTI) every six months using impedancemetry. The results are analyzed at each staff EPP. FTI averaged 15.85 kg, while LTI averaged 11.34 kg.

Handgrip tests are performed every six months. They assess muscle function and can be used as a phenotypic criterion for diagnosing undernutrition in adults (N = >26 kg in men and >16 kg in women, according to HAS [6]). In our center, the average HGS is 28.92 kg in men and 16 kg in women.

We did not find any studies similar to ours in the literature, allowing us to compare results. Nevertheless, it is well accepted that the implementation of good practice indicators in peritoneal dialysis patients helps to improve their quality of life and prognosis [7].

The regular monitoring of various health indicators is essential to ensure the long-term success of dialysis management without neglecting the need to educate patients and encourage them to stick to their medication recommendations over time, thereby limiting the risk of treatment fatigue [8].

Conclusion

The EPP is part of a drive to improve the quality and safety of care. It is vital to make this initiative a permanent fixture so as to maintain consistency in therapeutic management among doctors, nurses, and other healthcare professionals. Multidisciplinary staff meetings enable the sharing of knowledge and expertise. It is also a time for exchange among different healthcare professionals for the primary benefit of dialysis patients.

Declaraton of interest

The author declares no conflict of interest.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

References

1. Publisher Full Text
2. Doleman G., Twigg D.. Development, implementation and evaluation of a Professional Practice Model: A scoping review. Journal of nursing management. 2022; 30(7):3519-3534. DOI
3. Publisher Full Text
4. Issad B., Griuncelli M., Verger C., Rostoker G.. Que nous apprend le ‘’Module Anémie’’ du Registre de dialyse Péritonéale de langue Française (RDPLF) ? Intérêt et Résultats.DOI
5. Azar R., Coevoet V.. Statut acido -basique des patients prévalents en dialyse pé-ritonéale: Données du RDPLF.DOI
6. Diagnostic de dénutrition : les nouveaux critères de la Haute Autorité de Santé [Internet.
7. Dratwa M., Verger C.. Recommandations de pratique de la Société internatio-nale de dialyse péritonéale: prescrire une dialyse péritonéale de haute qualité dirigée par un objectif : Traduction des recommandations de l’ISPD Janvier 2020.DOI
8. PLOS ONE. 2021. DOI