Infection Control for Peritoneal Dialysis (PD) Patients After a Disaster

During hemodialysis, blood passes from the patient's body through a filter in the dialysis machine, called a "dialysis membrane." For this procedure, the patient has a specialized plastic tube placed between an artery and a vein in the arm or leg. Sometimes, a direct connection is made between an artery and a vein in the arm. This procedure is called a "Cimino fistula." Needles are then placed in the graft or fistula, and blood passes to the dialysis machine, through the filter, and back to the patient. In the dialysis machine, a solution on the other side of the filter receives the waste products from the patient.

Peritoneal dialysis uses the patients own body tissues inside of the belly (abdominal cavity) to act as the filter. The intestines lie in the abdominal cavity, the space between the abdominal wall and the spine. A plastic tube called a "dialysis catheter" is placed through the abdominal wall into the abdominal cavity. A special fluid is then flushed into the abdominal cavity and washes around the intestines. The intestinal walls act as a filter between this fluid and the blood stream. By using different types of solutions, waste products and excess water can be removed from the body through this process.

Peritoneal dialysis (PD) is a practical and widespread treatment for kidney failure. Because a soft tube (catheter) is present in the abdominal cavity for this treatment, special care must be taken by PD patients and their medical providers to prevent infection, especially following natural disasters when flooding may be present, access to medical supplies may be limited, or PD patients who may be living in temporary housing.kidneyhospitalabroad@hotmail.com

Some of the most common symptoms of peritonitis are:

• Abdominal pain
• Abdominal tenderness
• Abdominal distention
• Cloudy PD fluid
• Fever
• Nausea and vomiting

How One Doctor Helps Diabetes Patients Avoid Kidney Dialysis

Kidney failure is one of the most dreaded diseases. Even when one knows, it is coming, there is not much that one can do. Mainstream treatment normally means dialysis or transplant. Both are expensive and very taxing on the patient. Not to mention the difficulty of finding right donor in time. Economic cost of Dialysis in India would be about Rs 2-3 lakhs per year.

There are specific interventions, such as limiting salt in the diet, that can help prevent the progression of kidney disease in people who have the early signs.

Dr. de Boer often sees type 2 diabetes patients after signs of kidney trouble have surfaced. They may have very large amounts of protein in their urine (a marker of kidney disease), which is evidence of moderately impaired kidney function or difficult-to-control hypertension.

One particular patient, a man in his mid-50s, had all of the above. At 30 ml/min, his glomerular filtration rate, or GFR—a measure of kidney function—suggested he already had moderate to severe damage. He had a large amount of protein in his urine, poorly controlled hypertension, and poorly controlled blood sugar.

"His disease was clearly progressive by his recent history," Dr. de Boer explains. "When he learned that he was heading toward dialysis in the next year or less, that was a bit of a shock to him, and it actually motivated him to make a lot of changes."

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The Benefits of Transplant Versus Dialysis

Some patients may need to spend time on dialysis as they wait for a good match from a deceased donor kidney or search for a living donor kidney. Spending a long time on dialysis does not ruin your chances of having a kidney transplant. But research shows that getting a transplant sooner rather than later is generally the best approach because of the health problems dialysis can cause over time.

On the other hand, patients who receive a kidney transplant typically live longer than those who stay on dialysis. A living donor kidney functions, on average, 12 to 20 years, and a deceased donor kidney from 8 to 12 years.

Patients who get a kidney transplant before dialysis live an average of 10 to 15 years longer than if they stayed on dialysis. Younger adults benefit the most from a kidney transplant, but even adults as old as 75 gain an average of four more years after a transplant than if they had stayed on dialysis.

Moreover, spending a long time on dialysis before transplantation may also compromise the life of the new kidney graft once transplant occurs. Published medical data has shown that the kidney will work much longer in patients transplanted before they start dialysis. Patients who wait for a transplant on dialysis for two years are three times more likely to lose their transplanted kidney than those patients who wait less than six months on dialysis. Even the benefits of a live donor kidney transplant may fade away if you wait too long (more than two years) on dialysis. So given the choice, patients who find a donor match and opt for transplantation tend to do better than those who elect to live on dialysis.

Your transplant team is here to help you evaluate your health options early on, and make the treatment choice that is right for you. We can help you understand the risks and benefits of transplant surgery versus dialysis, and the advantages of having a live donor kidney compared to a deceased donor organ. We will carefully and clearly explain your options, offer advice and support, and help you and your loved ones make the best treatment choice.

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WHEN WILL DIALYSIS OR KIDNEY TRANSPLANTATION BE NEEDED

Nephrology Dialysis Transplantation (ndt) is the leading nephrology journal in Europe and renowned worldwide, devoted to original clinical and laboratory research in nephrology, dialysis and transplantation. ndt is an official journal of the ERA-EDTA (European Renal Association-European Dialysis and Transplant Association). Published monthly, the journal provides an essential resource for researchers and clinicians throughout the world. All research articles in this journal have undergone peer review.

As the kidneys lose their ability to function, fluid and waste products begin to build up in the blood. Dialysis should begin before kidney disease has advanced to the point where life-threatening complications occur. This usually takes many months or years after kidney disease is first discovered, although sometimes severe kidney failure is discovered for the first time in people who were not previously known to have kidney disease. (See "Patient information: Chronic kidney disease (Beyond the Basics)".)

It is best to begin dialysis treatments when you have advanced kidney disease, but while you still feel well and have no or only mild symptoms of kidney failure. Such symptoms include nausea, loss of appetite, loss of energy, vomiting, and others. You and your doctor will decide when to begin dialysis after considering a number of factors, including your kidney function (as measured by blood and urine tests), overall health, and personal preferences.

Some people with renal failure are not candidates for a kidney transplant. Older age and severe heart or vascular disease may mean that it is safer to remain on dialysis rather than undergo kidney transplantation. Other conditions that might prevent a person from being eligible for kidney transplantation include:

●Active or recently treated cancer
●A chronic illness that could lead to death within a few years
●Poorly controlled mental illness
●Severe obesity (a body mass index greater than 40) (calculator 1 and calculator 2)
●Inability to remember to take medications
●Current drug or alcohol abuse
●History of poor compliance with medications or dialysis treatments
Some people with HIV infection may be eligible for kidney transplantation if their disease is well-controlled.

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Dialysis Raises Hard Questions for Older Patients

Research suggests that older adults who are frail and unable to dress, toilet, bathe, eat on their own or get out of bed in the morning also tend not to live long on dialysis.

“If someone can’t perform multiple activities of daily living, you need to be introspective about whether dialysis adds to their longevity,” said Dr. Leslie Spry, medical director of The Dialysis Center of Lincoln, in Nebraska, and a spokesman for the National Kidney Foundation. “If they’re otherwise relatively healthy and getting around all right, that’s another matter altogether.”

One simple question that draws on the doctor’s clinical judgment — “Would you be surprised if Mr. Smith died within the next six months?” — turns out to be highly predictive of who will survive.

New research from the Mayo Clinic, presented last month at the annual meeting of the American Society of Nephrology, suggests other considerations. The study looked at 379 patients aged 75 and older at the Rochester, Minn., medical center between 2007 and 2011. Slightly more than three-quarters of them began dialysis in the hospital after an acute exacerbation of chronic kidney disease, a severe infection, or an acute kidney injury following surgery.

Those who started dialysis in the intensive care unit (60 percent of the hospital population) did especially poorly. Only 27 percent survived the next six months; 23 percent were alive at one year. Patients who started dialysis in the hospital but outside the I.C.U. had better results initially, but those worsened over time: 12 percent died in the first six months, but only 59 percent were alive after a year.

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How Long Does Someone Live Who is on Dialysis

The United States Renal Data System tracks dialysis mortality rates and issues the USRDS Annual Report there you'll find Section 6 Morbidity & Mortality (PDF link) this is where you'll find the relevant averages for your age and gender.

Remember when looking at statistics that averages are made of extremes. If five patients live two years and one patient lives twenty years, the average life span would be five years. This is called a bimodal distribution and really the average has little meaning to either group.

If you've just heard about dialysis go ahead and look at the statistics, but know there is a lot you can do to stay right of average. For the rest of the story checkout these nonprofit, independent, educational websites: Kidney School, Nocturnal Home Haemodialysis and Home Dialysis Central. You'll learn that with the proper dose, dialysis works well and you can live a life very similar to the one you were meant to live but for severe chronic kidney disease. This 12 part series of educational videos from IKAN Kidney does an excellant job addressing the most common questions people have when they learn they have kidney disease (follow link and press "Play All" at the top of the page to watch them in order, ~43 minutes).

More frequent and/or longer dialysis has a significant positive impact on mortality. Dialyzing every night, over night, as I do, improves your expected mortality to the point that it rivals having a kidney transplant from a deceased donor. Keep in mind too that these numbers are based on historic results; because of constant improvements in drugs and treatment, no one knows how long someone starting dialysis today can expect to live. No one knows how long you, a unique individual, will live.

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Dialysis Modality Selection

Among patients over the age of 65 with ESRD in the United States, in-center HD is the initial modality for 93–98% of patients, peritoneal dialysis (PD) is the initial modality for 2–5% of patients, preemptive kidney transplant for 0–2% of patients, and home HD for <1% (Figure 2). Our discussion of modality selection focuses on comparisons of in-center HD vs. PD, as outcomes data for home HD, particularly in the elderly, are limited. For the same reasons, we also consider various PD modalities together.

To assess the relative importance of these events in patients with different life expectancies, we estimated the NNT with PD vs. HD with a CVC to prevent one sepsis hospitalization. We first calculated the remaining lifetime risk of sepsis hospitalization for each modality. We then estimated the absolute risk reduction associated with PD, allowing us to calculate the NNT. Next, we compared this to the NNT after incorporating the age-specific modality transfer rates (Supplementary Information online), assuming that patients who switch from PD to HD do so with a CVC.

Recent observational studies suggest that survival of incident PD patients in the US has improved over time, and is now comparable to survival of incident HD patients. A notable exception is the subgroup of diabetic patients ≥65 years of age with comorbidity. In this subgroup survival with PD has improved over time but remains lower than for HD. Paradoxically the improvement in PD survival for most patient subgroups has occurred as PD utilization has declined, perhaps pointing to unmeasured selection bias.

If survival is comparable or nearly comparable with PD and HD, what other modality-related outcomes matter? A variety of outcomes have been considered in the literature, including modality transfer, peritonitis, sepsis, access procedures, quality of life and satisfaction with care. Modality transfer occurs more commonly with PD vs. HD, and is most often attributable to medical causes—recurrent peritonitis, ultrafiltration failure, and catheter malfunction. Modality transfer is associated with greater treatment burden, higher costs of care and possibly greater morbidity; thus it may be an outcome that clinicians and patients would like to avoid. Although in some countries older patients have similar or lower rates of transfer from PD to HD as compared with younger patients, in the US older patients are more likely to transfer from PD to HD, and less likely to transfer from HD to PD as compared with younger patients (Supplementary Information online). In contrast to modality transfers, serious infection related morbidity occurs more commonly among HD patients, particularly those dialyzed through central venous catheters (CVCs). Serious infection rates for both modalities decline slightly between the ages of 65–85, and then increase over the age of 85 for patients on HD. The competing effects of infectious morbidity and modality transfer may explain the observation that early mortality is lower for PD vs. HD, whereas late mortality is higher. That is, PD confers an early benefit from avoiding infectious morbidity associated with a CVC, but a higher late risk due to the high rate of modality failure and transfer to HD with a CVC.

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Life Expectancy With and Without Dialysis

Patients both with CKD and with end-stage renal disease (ESRD) experience symptoms, although there are dialysis-specific symptoms related to the treatment itself. Recent studies have evaluated symptom burden in conservatively managed patients. Common symptoms including fatigue, itch, drowsiness, dyspnea, edema, pain, loss of appetite, dry mouth, and poor concentration at stage 5 CKD occur in 50–85% of conservatively managed patients. Psychosocial issues are usually not a prominent feature till close to end of life. There are a number of validated tools which can help in the assessment of symptoms including the second edition of the textbook 'Supportive Care for the Renal Patient'.

Health-related quality of life (HRQOL) has become an important clinical and research outcome for patients with advanced kidney disease. A number of dialysis-specific mediators have been identified as contributing to decrements in HRQOL, including rigors of dialysis treatment, psychosocial and vocational adjustments, loss of independence and functional status, and metabolic derangements as a result of kidney disease. Given the impact of dialysis on HRQOL, studies have examined whether patients not opting for dialysis experience similar derangements in quality of life.

De Biase et al. found that the quality of life in conservatively managed patients was comparable to that of patients on hemodialysis. In particular, though conservatively managed patients had worse unadjusted physical health (SF36), there was no difference in mental health scores between those receiving conservative management versus hemodialysis. In the UK, Da Silva-Gane et al. measured the quality of life [Short-Form, Hospital Anxiety and Depression Scale and Satisfaction with Life Scale (SWLS)] in elderly patients with advanced kidney disease who had opted either for dialysis or for conservative kidney management. Patients were followed every 3 months for up to 3 years. Baseline patients opting for conservative management were older, more dependent, and had higher comorbidities than those who opted for dialysis. Conservative patients had poorer physical health and higher levels of anxiety; however, mental health, depression symptoms, and global satisfaction with life were similar between groups. Importantly, patients who initiated dialysis experienced a significant decrease in global satisfaction with life score which did not subsequently recover (Fig. 3). For elderly patients with geriatric syndromes and poor functional status, it remains unclear whether dialysis initiation impacts life satisfaction.

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