modalities also reassures the patient that the provid- ing centre has no hidden agenda in persuading him for one or the other therapy, and that a well-equipped.
Nephrol Dial Transplant (2001) 16 wSuppl 6x: 7–9
An integrated approach to end-stage renal disease W. Van Biesen1, S. Davies2 and N. Lameire3 1
Department of Internal Medicine, 3Renal Division, University Hospital Ghent, Belgium and 2Renal Division, Stoke-on-Trent, UK
Introduction The use of dialysis and transplantation as complementary therapies in the provision of renal replacement therapy (RRT) is well established. In contrast, peritoneal dialysis (PD) and haemodialysis (HD) are still commonly viewed as competitive therapies. There are many arguments to consider them as complementary, rather than competitive. These arguments do not only include medical, but also logistical, financial, and psycho-social aspects of RRT, as recently reviewed by Van Biesen et al. w1x. The need for RRT has an important impact on the life expectancy and the psycho-social life of the patient, and represents a substantial cost for the society in money and manpower. In addition, the increasing number of patients in need of RRT and the potential benefits of an earlier start of RRT should urge the nephrological community to consider new patient and treatment flow charts to optimize the treatment of RRT in a costeffective way. The ‘integrated care concept’ (IC-concept) advocates that RRT-providing centres should offer all three treatment modalities in an unbiased way to the patient w2x. In this approach, the advantages of HD, PD, and transplantation can be fully exploited, while many of the disadvantages can be avoided. In this way, every patient can be on the most optimal treatment at every particular stage of the disease, which finally should improve the patients’ outcome. Besides this integration of treatments, the ICconcept also emphasizes timely patient referral, adequate correction of co-morbid conditions and secondary complications, pre-end-stage renal disesase (ESRD) education and timely start of RRT.
Integrated care: the front stage of the concept There is now accumulating evidence that indeed the ‘PD first’ principle in patients motivated for PD can
Correspondence and offprint requests to: Wim Van Biesen, Renal Division, University Hospital Ghent, De Pintelaan 185, B-9000 Ghent, Belgium. #
have a beneficial impact on the outcome of these patients w3x. The advantages of ‘PD first’ have been well discussed elsewhere, and include (i) longer preservation of residual renal function, (ii) improved early graft function after renal transplantation, (iii) preservation of vascular access sites, (iv) avoidance of blood-borne infections, e.g. hepatitis C, (v) financial and logistical advantages, and (vi) improved quality of life and higher employment rates. There is also compiling evidence that mortality risk is lower on PD as compared with HD during the first 3–4 years of RRT w3x. The unbiased choice between the different RRT modalities is the first premiss of the integrated care approach. This implies education of patients and clinicians regarding the advantages and disadvantages of the different RRT modalities, the potential benefits of PD first, and the potential need to transfer between different modalities. Although it is hard to prove that educated ‘empowered’ patients have better outcomes, it is clear that patients will be more compliant with a therapy they have opted for themselves. Only a minority of patients has absolute contraindications for either HD or PD, and patients should not be persuaded to opt for one therapy on the basis that the other would be dangerous for them. This will lead to excessive anxiety when a therapy switch is the only option. The RRT-providing centre has to develop a wellstructured assessment and education policy, including dedicated staff members conducting interviews in the home environment, with patient, family members, and relatives. This should be backed up by unit visits and opportunities to meet with staff and other patients. The availability of both an established PD and HD programme increases the flexibility of the centre, as a PD programme can be expanded or reduced according to the needs, which is far more difficult to obtain for a HD programme. Eventual (short-term) emergency transfers, e.g. from PD to HD in case of severe peritonitis, or from HD to PD when vascular access fails, can also be managed more easily. It has also been proven that the centre experience enhances if a sufficient ‘critical mass’ is achieved to ensure expertise and quality of care. Analysis of PD services in the
2001 European Renal Association–European Dialysis and Transplant Association
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Netherlands (NECOSAD) has shown that small PD units have there is a higher technical failure rate. These data have been confirmed in an analysis of USRDS data, which also showed worse survival in centres with a limited patient number on a certain modality. The unbiased availability of the different RRT modalities also reassures the patient that the providing centre has no hidden agenda in persuading him for one or the other therapy, and that a well-equipped team is on standby to provide the ‘other’ RRT modality in case of transfer to the other treatment. Based on the analysis of the data of the Canadian registry and the Vonesh analysis of the USRDS data, it is attractive to conclude that survival on PD is superior to survival on HD w4,5x. Even when we make abstraction from theoretical (statistical) reasons why this is elusive, it is clear that this conclusion does not make sense if the rather high technique failure rate in PD after 4–5 years is considered. There are different reasons why the initial benefits of PD disappear over time. Both the progressive decrease of residual renal function (RRF), and the deterioration of the peritoneal membrane function lead to an impaired clearance and ultrafiltration in long-term PD patients. In a cohort of patients maintained on PD for more than 7 years, Faller et al. demonstrated that the decrease in adequacy was nearly totally attributable to a decline and finally disappearance of RRF w6x. While there was an initial improvement of blood pressure control after the start of PD in these patients, this beneficial evolution totally inversed after disappearance of RRF. For a long time, it has been neglected that residual renal function is important even in patients on RRT. The most important observation from the CANUSA study was the relation between RRF and outcome w7x. Studies like that of Moist et al. demonstrate that measures to preserve RRF also apply to patients already on RRT w8x. Davies et al. observed a steady decrease of ultrafiltration capacity in a cohort of patients with longterm PD w9x. This decrease of ultrafiltration was associated with an increase of MTAC for small solutes. This tendency became more expressed after 3–4 years of PD. The same observation was made by Selgas et al. w10x. It is striking that in both studies, this creeping deterioration of peritoneal membrane function is only present in a certain subgroup of patients, while other patients have a stable peritoneal membrane function even after years of PD treatment. The deterioration of peritoneal membrane function is probably related to the continuous exposure of the peritoneal membrane to bio-incompatible dialysis fluids. It can be hoped that by the application of newer, less bio-incompatible solutions, possibly without glucose, this deterioration can be avoided or at least diminished. The inter-patient variability in the evolution of RRF and peritoneal membrane function urge the clinician to test both on a regular basis. Methods to evaluate RRF and peritoneal membrane function are reviewed by Lameire et al. w11x and by Davies et al. w12x, respectively.
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The progressive decline of RRF and the peritoneal membrane function, urge the patient to use progressively more fluids, in a progressively more complex exchange regimen. This ultimately leads to a decreased quality of life, patient burn out and finally technique failure. Several studies have observed an increased mortality in the months after (urgent, not planned) transfer between modalities w13x. This excess mortality is probably a result of a protracted and creeping deterioration of the general status of the patient as a result of inefficient dialysis. Once again, this should urge the clinician to closely observe the patient, and prepare him for timely transfer to the other modalities, without waiting for frank complications. Based on the regular evaluation of the RRF and peritoneal membrane characteristics, the transfer to HD should be planned, and a vascular access should be created, so that the patient can start HD in the most optimal conditions.
. . . and the back stage Integrated care also includes adequate pre-ESRD care, including timely patient referral, control of secondary complications and of co-morbid conditions. It has been well established that late referral has detrimental effects on the outcome of ESRD patients regarding survival, morbidity and financial cost w14x. Dialysis centres should have programmes to educate primary care physicians, and those involved with specialized care of high-risk patients, like diabetologists and cardiologists, on the benefits of early referral. The centres should also offer established and welldefined pre-ESRD management programmes, including hepatitis vaccination, preservation of vascular access, management of anaemia, cardiovascular risk factors, calciumuphosphor disturbances, and malnutrition. There is evidence that this policy can lead to improved outcomes and can reduce costs w15x. The IC-concept also includes a ‘timely’ start of dialysis. Although it is clear that a ‘late’ start of RRT has detrimental effects, the exact definition of ‘timely’ start is far from established. According to DOQI guidelines, RRT should be started when the weekly KtuV falls below 2, unless the nutritional status of the patient is stable, or there is a complete absence of symptoms. Registry data show that in most centres, RRT is only started at a level far below these recommended guidelines. In a recent European survey, less than 15% of patients were started according to DOQI guidelines w14x. The concept of healthy start is relatively new, and only limited data are available to evaluate its potential benefits and drawbacks. Two recent papers report positive effects of healthy start. In both papers, RRT was started with one single exchange of PD, and dose was incrementally adapted to maintain total weekly KtuV above 2. Burkart et al. w16x found a better control
An integrated approach to ESRD
of blood pressure, a stabilization of dietary protein intake and albumin, and a general improvement in patient well being. De Vecchi et al. w17x reported that 95% of patients were very happy with this ‘healthy start-incremental dialysis’ approach. In our centre, we recently analysed the data of 18 patients started at a weekly KtuV of 2 anduor a creatinine clearance between 10 and 15 mlumin. Preliminary results show that the slope of decline of residual renal function improves after start of PD, an effect that, in some patients, is maintained for more than 2 years (Van Biesen et al., unpublished results). Comparable results have been found by other centres (Paul Williams, oral communication).
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3.
4.
5. 6. 7. 8.
Conclusion The concept of integrated care tries to put forward a treatment strategy for management of patients with ESRD. Although the exact boundaries of how, for whom, and when the different stages of the flow-chart should be applied are still unclear, there is rising awareness amongst nephrologists that RRT can not longer be seen as a separate entity of HD or PD or transplantation. On the contrary, all aspects of the patient and his progressive disease should be assessed and tackled, in order to improve outcomes. As there is, until now, no definite cure for ESRD, it is evident that all possible treatment modalities should be applied to their maximum capacity to improve the outcome of these patients at an affordable level.
9. 10.
11. 12. 13. 14.
15.
References 16. 1. Van Biesen W, Vanholder R, Lameire N. The role of peritoneal dialysis as the first-line renal replacement modality. Perit Dial Int 2000; 20: 375–383 2. Thodis E, Passadakis P, Vargemezis V, Oreopoulos DG. Peritoneal dialysis: better than, equal to, or worse than
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hemodialysis? Data worth knowing before choosing a dialysis modality. Perit Dial Int 2001; 21: 25–35 Van Biesen W, Vanholder RC, Veys N, Dhondt A, Lameire NH. An evaluation of an integrative care approach for end-stage renal disease patients. J Am Soc Nephrol 2000; 11: 116–125 Vonesh EF, Moran J. Mortality in end-stage renal disease: a reassessment of differences between patients treated with hemodialysis and peritoneal dialysis. J Am Soc Nephrol 1999; 10: 354–365 Fenton S, Schaubel D, Desmeules M et al. Hemodialysis versus peritoneal dialysis: a comparison of adjusted mortality rates. Am J Kidney Dis 1997; 30: 334–342 Faller B, Lameire N. Evolution of clinical parameters and peritoneal function in a cohort of CAPD patients followed over 7 years. Nephrol Dial Transplant 1994; 9: 280–286 Churchill DN. Implications of the Canada-USA (CANUSA) study of the adequacy of dialysis on peritoneal dialysis schedule. Nephrol Dial Transplant 1998; 13 (Suppl 6): 158–163 Moist LM, Port FK, Orzol SM et al. Predictors of loss of residual renal function among new dialysis patients. J Am Soc Nephrol 2000; 11: 556–564 Davies SJ, Bryan J, Phillips L, Russell GI. Longitudinal changes in peritoneal kinetics: the effects of peritoneal dialysis and peritonitis. Nephrol Dial Transplant 1996; 11: 498–506 Selgas R, Munoz J, Cigarran S et al. Peritoneal functional parameters after five years on continuous ambulatory peritoneal dialysis (CAPD): the effect of late peritonitis. Perit Dial Int 1989; 9: 329–332 Lameire N, Van Biesen W. The impact of residual renal function on the adequacy of peritoneal dialysis. Perit Dial Int 1997; 17 (Suppl 2): S102–S110 Davies SJ. Monitoring of long-term peritoneal membrane function. Perit Dial Int 2001; 21: 225–230 Davies SJ, Phillips L, Griffiths AM et al. What really happens to people on long-term peritoneal dialysis. Kidney Int 1998; 54: 2207–2217 Van Biesen W, De Vecchi A, Dombros N et al. The referral pattern of end-stage renal disease patients and the initiation of dialysis: a European perspective. Perit Dial Int 1999; 19 (Suppl 2): S273–S275 Obrador G, Arora P, Kausz A, Pereira B. Pre-end stage renal disease care in the United States: a state of disrepair. J Am Soc Nephrol 1998; 9: S44–S54 Burkart JM, Satko SG. Incremental initiation of dialysis: one center’s experience over a two-year period. Perit Dial Int 2000; 20: 418–422 De Vecchi AF, Scalamogna A, Finazzi S, Colucci P, Ponticelli C. Preliminary evaluation of incremental peritoneal dialysis in 25 patients. Perit Dial Int 2000; 20: 412–417
