Chronic Kidney Disease

Tools For a Successful Urgent-Start Peritoneal Dialysis Program

In this podcast, James Matera, DO, speaks about the importance and benefits of urgent-start peritoneal dialysis (PD) in the management of patients with chronic kidney disease, the tools needed for a successful urgent-start PD program, and the pitfalls of urgent-start PD. 

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James Matera, DO, is a practicing nephrologist, Senior Vice President for Medical Affairs, and Chief Medical Officer at CentraState Medical Center (Freehold, New Jersey).


 

TRANSCRIPTION:

Jessica BardHello 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, a multidisciplinary medical information networkPatients in urgent need of dialysis often start on hemodialysis, however, urgent start peritoneal dialysis is becoming a more common first-line therapy option. Dr James Matera is here to speak with us today about what is needed for a successful urgent start PD program. Dr Matera is a practicing nephrologist, Senior Vice President for Medical Affairs, and Chief Medical Officer at CentraState Medical Center in Freehold, New Jersey, now an affiliate of Atlantic Health System. Thank you for joining us today, Dr Matera. What are the benefits of urgent start PD?

Dr James Matera: Yeah, I think when we look at this, two factors we need to take into account. One is peritoneal dialysis in general is not widely used in the United States when compared to other countries. And I think it's because of the ease at which people go on hemodialysis. And there's a lot of factors for that, but I do think when you look at it, peritoneal dialysis and/or move to home dialysis, whether it be home hemo or peritoneal, is so important going forward, not only on outcomes but on cost benefit ratios. We know that the president had put this in place of wanting to move more people to home and I think we just don't have enough information to keep PD in the forefront of our mind.

And I think part of the reason of that is selection of the patients, number one. I think that's a big factor. I think some Nephrologists are not comfortable with peritoneal dialysis, so they don't think about it as a first-line therapy. And certainly on the patient side they may want to "keep the therapy out of the house" and just go to a center to have it done. But there are also structural arrangements, so I think when we look at PD, if we have a good clinical-based shared decision-making process, we can increase the value of PD for our patients.

Jessica Bard: Let's talk about a wishlist for a successful program. What is needed to get a successful urgent-start PD program in place?

Dr James Matera: Yeah, that's a really good thing. And what you have to do is you have to have certain things in place in order to make this successful. First and foremost, you have to have a skilled staff who can put a peritoneal dialysis catheter in in a short period of time. Now, because peritoneal dialysis has been so low, a lot of surgeons aren't skilled in this. I've actually moved over to our interventional radiology department who is doing this, and I do most of this as an outpatient. Although certainly could be done as an inpatient, but my last three urgent-start patients, none of them saw the hospital except to have the catheter. Number two is there has to be education and it has to be focused and centered on the patient, shared decision making, and you have to have PD-specific nurses.

I think these things are best done in an outpatient at a transitional dialysis unit or a dialysis unit that has a home program. You certainly have to have the support of the administration, and it's nice that I'm part of the administration to support this as a service line. And most important, and probably the key factor, is the selection of that patient. I'll give you just a quick example. We had a patient recently who was a young patient and the nephrologist at the time was thinking along the lines of PD and thought it would be a great choice, however, factors such as the patient was not a United States citizen, didn't have access to any of these things, couldn't do the peritoneal dialysis. It was a really poor choice because it was set up to fail.

He basically then had to board at the hospital for a period of time until we could make arrangements for him to get peritoneal dialysis. Patient choice is the key turning point to whether or not this will be successful. And then also we have to have evidence-based protocols. This needs to be at the forefront of our minds so that we can decrease the variability of what we're doing, lessen our infections, which is another reason why a lot of people don't think about it, you worry about that peritoneal infection, and promote the success for an urgent-start program. That's my wishlist. I actually have that in place where I am and I've been moving towards this. I do have my wishlist.

Jessica Bard: And of course we always have to talk about the pitfalls as well. What are the pitfalls of urgent-start PD?

Dr James Matera: Yeah, I think while it's great, there are certain areas where urgent-start PD shouldn't be considered. If you have a patient who's really ill and has issues such as hyperkalemia, significant volume overload, or uremia, urgent-start PD would not be the way to go. Those patients I could tune up, if you will, with hemodialysis and then consider it, but if I'm looking for really urgent dialysis, this is not the way to go. We are used to, as a society of Nephrologists, putting a peritoneal dialysis catheter in and waiting anywhere from two to four weeks for it to heal. With this, we technically start within 24 to 48 hours, so there is a potential for the catheter to leak. I have not seen that, but we have to be very careful of that, and when we set up our protocols on how we do this, I think that alleviates that.

But if you look at overall in 2020 when they looked at 3000 patients that went on to conventional PD versus urgent-start PD, other than a slight increase in the leakage of the dialysate, there were no different outcomes. I think it affords you the same opportunity, if done correctly with protocols and all the things I had on my wishlist, to be a viable modality. And I also think that that takes us into the realm of using this more because we all know as nephrologists and as primary care physicians who have patients who go on dialysis, they come into the hospital where they're not ready for dialysis. They get a central venous catheter and that stays there, the risk of infection, and they transition to hemo with a central venous catheter. I think understanding some of these and having a good program price will alleviate some of that.

Jessica Bard: What would you say are the overall take-home messages from our conversation today?

Dr James Matera: I think the take-home message is we have to get better as nephrologists and primary care doctors to promote peritoneal dialysis. I think urgent-start allows us to do that because it gives you that option if a patient comes into the hospital or comes into your office late in their therapy and they haven't had the proper education. Number two, I think doing education ahead of time will shift the overall sentiment toward peritoneal dialysis. And number three, I think if you look at the outcomes, peritoneal is certainly as good as if not better than hemodialysis. It is a lower cost, and I think the patients ultimately do better. I think we need to really put that peritoneal program back at the forefront of our minds.

Jessica Bard: Well, thank you so much for joining us on the podcast today. We appreciate your time.

Dr James Matera: Thank you