KDIGO: The Choice of Dialysis Modality Must Consider Patient Individuality
The moment of initiating dialysis, as well as the period immediately before and after it, is crucial for good treatment outcomes. But what exactly can be considered a good outcome, and do the perspectives of doctors and patients align on this issue? Leading nephrologists worldwide discussed this at the KDIGO conference, which was specifically focused on controversies in dialysis treatment.
Personalization in the Context of Regional Differences
The number of patients requiring chronic dialysis treatment is continuously increasing worldwide. However, the approach to initiating dialysis and choosing its modality varies significantly between countries and regions, which, along with diverse healthcare availability, patient awareness, and other factors, significantly impacts treatment outcomes. At the international KDIGO conference (Kidney Disease: Improving Global Outcomes) held in January 2018, experts openly discussed the controversies prevailing in this area.
The overarching theme of most discussions and proposed solutions was the shift away from rigid recommendations, emphasizing a personalized approach and the importance of including the patient's perspective in decision-making processes. While conference participants acknowledged that the possibilities for changes and improvements within healthcare systems are limited, they published a general overview of the direction these efforts should take.
Dialysis Efficiency and Success Parameters
It is understandable that the treatment goals of clinicians and patients themselves may differ – doctors often focus on biochemical parameters or mortality, while for patients, quality of life and lifestyle are often more crucial. For example, a survey among home hemodialysis patients revealed that the ability to travel holds more value for them than extra months of life.
Currently, there is a shift away from clearance of small molecules as the sole parameter for dialysis efficacy. Experts further recommend that, in addition to other biochemical markers, patient clinical characteristics and personal goals should be consistently considered. Surprisingly important can be indirect treatment impacts, such as the patient's nutritional or psychological status. Treatment goals set by both clinician and patient should be continuously reevaluated.
Peritoneal Dialysis vs. Hemodialysis
When choosing a kidney replacement modality, it is time to move away from a generalized approach and more thoroughly consider individual patient clinical characteristics. In many countries, the standard approach is the initiation of in-center hemodialysis (HD); however, peritoneal dialysis (PD) from the start can be cost-effective, provided there is good availability of necessary supplies, education, and support for patients. This financial difference is currently most pronounced in developed countries. Patients undergoing in-center HD have higher early mortality, but this may also be because more severe cases are selected for this treatment.
Each modality has its absolute contraindications – for HD, it includes the inability to establish dialysis access or hemodynamic instability preventing HD; for PD, it involves an obliterated peritoneal cavity, non-functional peritoneal membrane, or inability to insert a catheter. All other potential contraindications are only relative, giving clinicians maneuvering space depending on the specific clinical situation. Contrary to some widespread beliefs, PD can also be initiated urgently, anuria is not a contraindication for starting PD, and there is no reliable evidence on which approach better preserves residual kidney function.
Up to Half of Patients Can Manage Home Treatment
Up to 50% of all patients requiring kidney function replacement could manage home dialysis with well-conducted education and support, which has the potential to significantly improve their quality of life and relationships. On the other hand, reasonable patient fears of not mastering the technique or lacking qualified assistance cannot be overlooked. Conference participants agreed that more patients should be directed towards home dialysis and that obstacles preventing its broader use must be removed. Patient education and support should not diminish at the moment of initiating dialysis but are often crucial precisely then.
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Source: Chan C. T., Blankestijn P. J., Dember L. M. et al. Dialysis initiation, modality choice, access, and prescription: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int. 2019 Jul; 96 (1): 37−47, doi: 10.1016/j.kint.2019.01.017.
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