The Role, Benefits, and Challenges of Urgent-Start Peritoneal Dialysis
In part 1 of this 2-part episode, James Matera, DO, FACOI, speaks about the role, benefits, and challenges of urgent-start peritoneal dialysis in adults and children with chronic kidney disease requiring long-term kidney replacement therapy.
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 2 of this episode here.
Jessica Bard: Hello everyone. And welcome to know their installment of Podcast 360, your go-to resource for medical news and clinical updates. I'm your moderator, Jessica Bard with Consultant360 Specialty Network. Nearly 786,000 people in the United States are living with end-stage kidney disease. 71% of those people are on dialysis, 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, Dr Matera. What is the role of urgent start PD in patients with CKD requiring long-term kidney replacement therapy?
Dr James Matera: Yeah, I think one of the things that we've learned, especially in the COVID-19 pandemic, and one of the things that I can relate to as a personal anecdote, is when I first started training the training program that I had at Robert Wood Johnson in New Brunswick, we were the largest peritoneal dialysis program in the country at that time. And we didn't have a lot of hemodialysis, so everybody was geared to doing peritoneal dialysis. So for me, it was inherent in my training, where I know a lot of other nephrologists didn't get a lot of peritoneal dialysis training. When I started practice, coming to Central State for the first time back in the early 1990s, we also didn't have any capability of doing hemodialysis. So at that point, not even knowing what it was, I was essentially doing urgent start peritoneal dialysis. Because all the patients here, unless we transferred them out, had to get a peritoneal dialysis catheter and start peritoneal dialysis.
And I didn't think too much about that until, again, the COVID-19 pandemic hit us, and I realized that our resources were very limited. And that we had so many patients, either previous dialysis patients who were getting sick or people with COVID that started to develop problems with end-stage or acute kidney injury requiring therapy, and our limitation on resources as far as hemodialysis was dwindling. So that brought it back again, a little bit of the idea of using peritoneal dialysis more acutely. I think nephrologists primarily think of peritoneal dialysis as a planned modality that you get your patient ready for, and then you get them all ready, they're educated, they're motivated. And then they get their peritoneal dialysis catheter. And yet when patients come into the hospital and they haven't had any planning, we immediately jumped to hemodialysis. And I think we need to rethink that.
Certainly, when President Trump was in place and he put together some of his criteria that he wanted to see towards, coming up to 2025, it was an increase in peritoneal dialysis, number one or home therapies, including home hemodialysis. But also he really wanted to increase transplantation. Over the last couple years, since that came out, we really haven't made a lot of strides in increasing peritoneal dialysis. And I think, again, it has to do with comfort level of the nephrologist, but I do think urgent start PD has a place for us to start thinking. A lot of things have to be in place for it to happen. We'll talk about that as we go along. But I think it's a modality that should be considered a lot more frequently so that we can cut down on many things. I think the advantages are there as well, over conventional in-center dialysis. And I think it's a great way to increase our use of peritoneal dialysis long term.
Jessica Bard: What are the benefits of urgent start peritoneal dialysis compared with conventional start peritoneal dialysis in adults and children with CKD requiring long-term kidney replacement therapy?
Dr James Matera: Good. I think that's a great question because is I do feel that we need to increase our use of peritoneal dialysis across the board, adults and children. And I think, as I stated, we don't think about it so much. And once a patient comes in, especially patients who haven't had any planning for modalities, they come into the hospital, it's almost as if peritoneal dialysis leaves our mind all together and we jump right to in center or emergent hemodialysis. I think if we put peritoneal dialysis more towards the forefront, given the known benefits that it does have and the need, not only benefits in the patient and their outcomes, but benefits in cost. We know that dialysis is the costliest thing that the government pays for now, with our patients consuming about 7% of the total Medicare spend every year.
Dr James Matera: And we do know that home therapies, particularly peritoneal dialysis, are a little less. So I think urgent start PD is that way to start thinking, "Hey, I have a program here. I don't have to immediately morph into hemodialysis. I can get what I want with peritoneal dialysis in a motivated patient and get them moving in that direction." So I do think the fact that we know that sometimes these patients do have some better outcomes. This is certainly a way to go along with it. I know that a lot of groups are starting to consider this also as a modality. And I think that is clear that we know that outcomes can be better. Again, you have to have a motivated patient. I don't discount that whatsoever, but I do think that if you have a program that's in place, it'll really substantiate the move towards home therapies.
Jessica Bard: Let's talk about the challenges and limitations now. What are the challenges and limitations of urgent start peritoneal dialysis compared to conventional start?
Dr James Matera: Yeah. Conventional start is a little bit more tucked in. You get your patient. You know they're going to go to peritoneal dialysis. When the time comes, you have the catheter placed. Generally, we want to watch it for two weeks and get the flushes. And then they start on an outpatient training program. This is a different animal. This is something that's going to be driven and you have to have a dedicated team in place for that to happen. So I think that you have to have a perfect outcome. I think the step that really decides whether this program is possible or not, is the availability to place a catheter. So in a real good urgent start PD program, you have to have usually 24 to 48 hours to get a catheter placed. And traditionally that hasn't been the case because surgeons may not be available, and the surgeons would go in and put these catheters in.
Dr James Matera: Now we see a lot more interventional nephrologists and interventional radiologists performing this. So their services are a lot easier to come by and you can schedule them acutely. I know in my particular practice, when I'm doing urgent start PD, I basically set it up with interventional radiology. The patient only spends that morning in the hospital. They go home and I start them in what we call a transitional care clinic to start their PD as an outpatient. So they're really not seeing the hospital, which I think is fantastic. Also, you have to have the education of the staff. If the patient's in the hospital, in particular, and you're dealing with a brand new catheter, you have to ensure that your people are comfortable with that. When I transition to the outpatient centers that I use, they're, of course, very comfortable because they're the same people that are doing the long-term and conventional PD.
Dr James Matera: So I think you have to have that in place. And you certainly have to have the administrative backup in a hospital to be able to do this. It's a new program for many people. So you have to have resources. You have to have that availability to put the catheter in. You have to have nurses and other personnel who can guide that patient through. But when you think about that and you weigh it against the potential benefits for this, number one, considering peritoneal dialysis as a modality in patients you might normally not do that to. Number two is without putting in a central venous catheter for hemodialysis, we cut down on infection rates. And number three, this will get us to our goal of being able to utilize peritoneal dialysis a lot more in the future than we have in the past.
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!