腹透优先pd-first

PeritonealDialysisFirstACaseForThoseWhoChooseIt!Objectives•ReviewchoicesavailableforESRDPatients•Discussmedicalandnon-medicalfactorsthatinfluenceFirstModalitySelectiontoday•DiscusshowPDastheFirstModalitySelectioncanpositivelyimpactdialysispatients’continuumofcarethroughouttheirlifetime•DiscussstrategiesforchangingtheperceptionofPDTransplantation“BestforQualityofLife”RenalReplacementTherapy(RRT)HemodialysisPeritonealDialysisVanBiesenW,etal,PeritDialInt.,2000;20.Pp375-383.ModalityOptionsforESRDMedicalandNon-medicalFactorsThatImpactESRDModalitySelection•ExpectedpatientsurvivalisamajormedicalfactorthatimpactESRDmodalityselection–QuestionofwhethersurvivalonPDvs.HDiscomparablestillremainsadebate–Modalityselectionshouldbebasedontotalsurvivalratherthanthesurvivalononesinglemodality•ThereasonforthedebateisduetoconflictingstudiescomparingHDversusPD–Resultsofstudiesareconflictingdueto:•Differenceincasemix•Singleversusmulti-centerdesign•VariableexperiencewithPDoftheparticipatingcenters•Numberofpatientsincluded•Differenceintypeofstatisticalanalysis•InclusionofincidentandprevalentpatientsNissensonAR,KidneyInt,1993;43(Suppl.40):S120-S127VanBiesenW,etal,PeritDialInt.,2000;20.Pp375-383.MedicalandNon-medicalFactorsThatImpactESRDModalitySelectionNissensonAR,KidneyInt,1993;43(Suppl.0):S120-S127•Financial/reimbursement•Physicianexperiencewithboththerapies•Patientandfamilyunderstandingofmodalityoptions•Resourceavailability•Socialfactors•CulturalhabitsMedicalandNon-medicalFactorsThatImpactESRDModalitySelection•Lackofpre-ESRDeducation•Latereferrals•MisconceptionsaboutPDtreatment•Physicianbiases•Time-wornstoriesof“someonewhoknewsomeone”whodidhomedialysiswithnegativeconsequencesDehaan,B,Dialysis&Transplantation,Vol.32,Number3,March2003MODALITYCHOICEShouldinvolve:•Patienteducation•Discussionofoptionswithpatient/family•Considerpatientqualityoflifeissues•Listentopatientinput•Reviewbenefits/risksoftherapiesPatientChoice:ModalitySelection•150consecutivepatientsstartingESRDtherapyattheRoyalVictoriaHospitalinMontrealwereassessedretrospectively.Overall,–55%wenttoHD–45%wenttoPD•Studyconcludedthatamonginformedpatients,ifgivenachoiceoftreatmentmodality,themajoritywillchooseself-caredialysisincludingCAPDorselfcareHD.Prichard,S:PeritDialInt16:69-72,1996SlowProgressionofRenalDiseaseManageCo-morbidConditions–CardiovascularDisease–Diabetes–AnemiaPreserveVascularAccessSiteMaintainProperNutritionPre-dialysisEducationforPatientPre-ESRDESRDPreserveResidualRenalFunctionManageCo-morbidConditions–CardiovascularDisease–Diabetes–AnemiaPreserve/MaintainVascularAccessSiteMaintainProperNutritionPatientSocialandEmploymentRehabilitationBloodPurificationFluidBalanceElectrolyteandAcidBaseEquilibriumGoalsBeforeandFollowingInitiationofDialysisInitiationofDialysisVanBiesenW,etal,PeritDialInt.,2000;20.Pp375-383.•RatherthanlookatsurvivalratesofPDvsHDatonepointintime,thegoalofthefirstmodalityselectedshouldbetoattainthebestqualityoflifeforthepatientthroughoutthecontinuumoftheircareto:•optimizetheuseofeachtreatmentmodality•maximizetheadvantagesofeachmodality•avoidorminimizethedisadvantagesGoalofFirstRRTModalityVanBiesenW,etal,PeritDialInt.,2000;20.Pp375-383.SelectionofFirstRRTModality•Shouldbebasedon:–Theimpactofthatmodalityonoutcomesofasubsequentmodality;i.e.,renaltransplantation–Theimpactontheevolutionofco-morbidconditions–FinancialandlogisticalaspectswithinmedicallyethicalacceptablelimitsHemodialysisvsPeritonealDialysis•SincebothPDandHDhaveadvantagesanddisadvantages,theyaremorecomplementaryratherthancompetitive.VanBiesenW,etal,PeritDialInt.,2000;20.Pp375-383.IntegratedESRDCare–APlannedApproachToPre-Dialysis•Timelyreferral•Timelypreparation•TimelyinitiationHemodialysisCreatinineClearance(ml/min)20151050TimeonDialysisInitiationofDialysisPeritonealDialysisTransplantPDMendelssohnDC,PierratosA.PDI2002;22.,Vol.22,NO.1•OutcomePostTransplant•PlanningforandPreservationofAccess•ResidualRenalFunction•ManagementofComorbidities•Hepatitis•CongestiveHeartFailure(CHF)•AnemiaManagementClinicalConsiderationsIntegratedFirstModalitySelectionVanBiesenW,etal,PeritDialInt.,2000;20.Pp375-383.OutcomesAfterTransplantation•PDcomparedtoHDhasabeneficialeffectontheimmediaterecoveryofrenalfunctionaftercadaverickidneytransplantation•PatientstreatedwithPDpre-transplantationhave:–LowerAcuteRenalFailure–Lessdelayedgraftfunctioning•MorelikelytohavedelayedgraftfunctioniftransplantedfromHD.50.4%vs23.1%onPD•possibilitythatthepresenceofdelayedgraftfunctionandARFmayjeopardizethelongtermfunctionofthegraft–Reducedneedforpost-transplantationdialysisVanBiesenW,etal,PeritDialInt.,2000;20.Pp375-383.VanholderRetal.AJKD33:934-940,1999DialysisModalityandDelayedGraftFunctionGroupPDHDPvaluePercentageofpatientswhodidnotproduceurineinthefirst24hposttransplant8.311.90.001Percentageofpatientsrequiringdialysisinthefirstweekaftertransplant20.028.60.001Percentageofpatientstreatedforrejectionduringinitialhospitalization12.012.90.20BleyerAJ,BurkartJM,etal,JASN,1999;10:154-159Datasource:UnitedNetworkforOrganSharing(UNOS)n=9,350