Infrastructure Required for Urgent-Start Peritoneal Dialysis
In part 2 of this 2-part episode, James Matera, DO, FACOI, speaks about the infrastructure required for urgent-start peritoneal dialysis (PD) and the urgent-start PD clinical pathway from patient presentation to discharge home.
James Matera, DO, FACOI, is a practicing nephrologist, Senior Vice President for Medical Affairs, and Chief Medical Officer at CentraState Medical Center (Freehold, New Jersey).
Listen to part 1 of this episode here.
Jessica Bard: Hello, everyone, and welcome to another installment of Podcasts360, your go-to resource for medical news and clinical updates. I'm your moderator, Jessica Bard, with Consultant360 Specialty Network. Medicare-related spending for beneficiaries with end-stage kidney disease totaled nearly $50 billion in 2018, according to the National Institutes of Health. Dr James Matera is here to speak with us today about urgent-start peritoneal dialysis. Thank you for joining us today. What infrastructure is required for urgent-start PD?
Dr James Matera: The primary thing is the placement of the catheter. You have to have confidence in your interventional radiologist, or your surgeon, who can do this. At first, I was a little leery, but I started to look at our interventional radiologists. I knew they were doing it in another facility. I actually did my homework and followed up on some of the patients and physicians that were using them at another facility, and I became comfortable. And of course, I was there the first couple of times they did it. That's the number one priority.
The number 2 is being able to have a unit. In our hospital in particular, we tend to relegate peritoneal dialysis to one floor. They're where the peritoneal dialysis nurses are located, so they have a good working attitude towards us, and they're able to do this. However, this is a little different animal. This is a brand new catheter that hasn't had time to ingrain in. We're not using a cycler for the most part, as many nurses are used to, because we're going with low volumes. That's the key to keeping the catheter from leaking and other things. So we have to have reeducation into the whole process, and then of course, we have to have the facilities to do that. There have been some peritoneal dialysis shortages through the pandemic, so we have to make sure we have all the equipment available. And then, most importantly, is you have to be able to transition that patient from the acute care setting, where we don't want them to be, to the outpatient setting to finish their urgent-start training and to get back to home as quickly as possible.
Jessica Bard: What is the urgent-start PD clinical pathway from patient presentation to discharge home?
Dr James Matera: Yeah, so my goal with urgent-start PD, I tend to use that more in the inpatient setting, whereas when I have a patient who I know is going to start peritoneal dialysis, I usually have a little bit more control over that. But when patients do come in that haven't had enough time to think, or haven't made a decision on modality, but I know that they're going to be a good candidate, first and foremost is the education. You have to educate that patient. There are not a lot of contraindications to doing urgent-start PD. Certainly, I want to caution I would not use that in a really urgent situation. For instance, someone whose volume overloaded or has severe hyperkalemia or other issues. Then you know at least temporary hemodialysis is better, but once you make the decision, you can put that in place. So number one is education. You have to make sure that the patient's ready for that.
Number 2 is getting the catheter placed in a timeframe that's suitable, and then I like to get the patients out of here. I like to, if they're stable enough and I don't have to start the PD urgently, I transition them to an outpatient clinic where they'll go in and do the PD right in the clinic. That's my modality. I had one patient just recently who did not make his decision. He thought he was going to get a transplant. Long story short, it got down to the wire, the transplant was being put on hold due to some issues with his donor, and he was becoming very uremic. So I said, "We've got to do this." I put him in, we did the PD catheter that day. The next day, he started in our outpatient center with urgent-start PD, and has done phenomenally well for 6 weeks now, and I'm hoping his transplant will go in a couple of weeks. But I think that's the best part for this, is to get them out of the hospital as quick as possible and get them into a center where they can start the transition.
Jessica Bard: What would you say are the overall take-home messages from our conversation today?
Dr James Matera: I think the take-home messages are we have to put peritoneal dialysis back on our radar for modality choices. Of course, it takes a motivated patient, it takes an educated patient. We also have to take into account, Jessica, the socioeconomic things. We have to know those things in medicine these days. I teach my students that all the time, that it's not just your genetic code, but your ZIP code that may dictate where things are going. So if you have a patient who isn't capable of doing this for technical reasons, maybe they have food or home insecurities, they're not good peritoneal dialysis patients. You may know this, but I do go, or have gone prior to the COVID-19 pandemic, to Guatemala to do some work out there, and we actually have some people who live in huts who do peritoneal dialysis, but we have to take all those things into account. But I think if we move peritoneal dialysis up onto our forefront, that'll help us get to the home goals that we want to get to by 2024, 2025. I think that certainly helps.
Number 2 is I think the patients will like it better. I think their availability in their lifestyle is better on peritoneal dialysis, so I think that's a good take-home message for us to deal with our patients. Certainly shared decision-making is of utmost importance. You don't want to tell a patient what they can or cannot do, but you want to take it and say, "Okay, this modality will give you the following benefits, and the following benefits on your lifestyle, and long term, here's what we can expect." And we all know the outcomes data on peritoneal dialysis, while not overwhelming, tends to be a little bit more favorable than hemo.
Then I also think the key factor is avoiding infections. When you look at urgent-start versus conventional PD, there was not, in a cohort of studies that was published just about 2 years ago, they looked at it and they didn't see a higher incidence of infections for home patients versus conventional. But yet, when we put central venous catheters in patients for hemodialysis, that's one of our biggest fears and worries, is that they'll get an infection. So I think all those things wrapped up together make urgent-start PD a very good entryway into the home arena that we need to be focusing a little bit more on over the next few years.
Jessica Bard: Is there anything else that you'd like to add, that you think that I missed?
Dr James Matera: No. I think we look at that, and again, you have to have some really good studies. Actually, home or urgent-start PD started to get some traction about 10, 12 years ago, and there's a couple of algorithms that are out there from some of the studies, from some of the people who performed the studies, that show a good way for patient choice education and how you would do it. The prescription of the dialysis is also different, because again, we're starting with low volumes. Sometimes, a traditional patient on conventional dialysis will get up to two liters, sometimes even more, but with these patients, I start very low. It's 500 to 750 milliliters of fluid to start the process, to avoid leaking, to let the catheter kind of take its shape, because we don't have that 2-week window in urgent-start that we would normally do. And actually, there are no studies to really show that's a benefit of waiting the two weeks, so I think we can put that aside if done properly.
Dr James Matera: The other thing I would say is, and we didn't talk a lot about it today, but protocols. You have to have a protocol. I'm a big fan of algorithms and protocols, and we learned during COVID that was a very useful tool for us in order to get away from some of the things that we knew at the start of COVID to what we know now. I think you have to have a real good protocol in place of how you're going to do your peritoneal dialysis, and you have to have the buy-in from the administration at your facility, the nursing for sure, the dialysis unit and everybody, and even resources and materials management, to make sure that you have the supplies necessary to do this. I'm a big fan of developing protocols, and there are some out there. A friend of mine actually down in South Florida was among the first groups to look at this. I follow a lot from what they've taught us. So I think that's very important.
Jessica Bard: Well, thank you so much for your time today, Dr Matera. We really appreciate it.
Dr James Matera: Thank you. Have a good afternoon!