Organization and Structure of a Successful Peritoneal Dialysis Program

One important reason for the limited use of peritoneal dialysis in the United States involves problems with the organization of peritoneal dialysis facilities. The basic structure and function of peritoneal dialysis facilities needs to be quite different from that of in-center hemodialysis facilities. Four key elements need to be addressed in organizing a peritoneal dialysis facility: Adequate chronic kidney disease (CKD) education program, adequate size and structure of peritoneal dialysis centers, development of appropriate support systems/team approach, development of appropriate continuous quality improvement (CQI) programs to monitor a variety of domains.

CKD education

The importance of developing and implementing adequate CKD education programs cannot be overemphasized. The vast majority of CKD patients do not have contraindications to receiving peritoneal dialysis. The majority of patients approaching ESRD have surprisingly little knowledge about treatment options. This occurs even if patients have been referred to nephrologists, indicating that the process of providing education for CKD patients needs to be reexamined. Funds should be allocated to support education programs and train educators and to incorporate CKD education into the routine fabric of care.

Center size

Several studies have documented the impact of center size on the outcome in patients receiving peritoneal dialysis. In terms of peritonitis rates, technique failure, and mortality rates, smaller units tend to have worse outcomes. The reasons likely relate to the experience of nurses and physicians, the ability to develop a support team, and the development of effective CQI programs. It has been suggested that the growth of peritoneal dialysis programs in the United States has been limited by the attempts to grow small peritoneal dialysis programs rather than the consolidation of small peritoneal dialysis programs into larger centers. Certainly, the experience in the Far East suggests that large programs may be extremely successful. Many programs in China, Taiwan, and Hong Kong care for more than 300 peritoneal dialysis patients and report excellent results of this therapy, with low rates of peritonitis and technique failure.

Appropriate support systems: a team approach

The peritoneal dialysis unit needs to use a team approach to treating the patient. Nurses are the backbone of the program. Nurses who are dedicated to the peritoneal dialysis program, have sufficient experience, and are readily available to patients 24 hours a day are critically important to program success. Social work and dietary input are also crucial ingredients for a successful program. Psychosocial assessments and interventions are particularly important for patients receiving maintenance therapy at home because various psychosocial factors can have an adverse impact on outcomes, including depression and anxiety in patients and stress in caregivers. Attention to dietary input is also essential. The importance of sodium restriction in terms of controlling blood pressure and limiting the dextrose exposure required to maintain fluid balance with peritoneal dialysis needs to be emphasized. Limitations of phosphate clearance with peritoneal dialysis require that careful attention be paid to restriction of dietary phosphate and compliance with the administration of phosphorus binders.

CQI programs

CQI programs are critical to the success of a peritoneal dialysis program, as has been discussed in the KDOQI guidelines. A modification of the domains suggested in the KDOQI guidelines for CQI is summarized in Table 1. Successful peritoneal dialysis programs need to track their outcomes and address the important areas that affect the outcomes in peritoneal dialysis patients. Difficulties in managing a peritoneal dialysis unit vary from facility to facility, and each facility must identify and deal with the problem areas that are unique to its program.

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Notes

[1] Fredric O. Finkelstein, MD, is affiliated with the Hospital of St. Raphael, Yale University, New Haven, CT.

August 2012 (Vol. 4, Number 8)