Two Truths and a Lie: Peritoneal Dialysis
In January 2022, members of the Bean Pod, NSMC class of 2021, recorded a Two Truths and a Lie about peritoneal dialysis.
Cast:
Mythri Shankar
Carlo Trinidad
Brian Rifkin
References
Perl J, Fuller DS, Bieber BA, Boudville N, Kanjanabuch T, Ito Y,et al . Peritoneal Dialysis-Related Infection Rates and Outcomes: Results From the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS). Am J Kidney Dis. 2020 Jul;76(1):42-53. doi: 10.1053/j.ajkd.2019.09.016. Epub 2020 Jan 10. PMID: 31932094.
Miller LM, Clark E, Dipchand C, Hiremath S, Kappel J, Kiaii M,et al; Canadian Society of Nephrology Vascular Access Work Group. Hemodialysis Tunneled Catheter-Related Infections. Can J Kidney Health Dis. 2016 Sep 27;3:2054358116669129. doi: 10.1177/2054358116669129. PMID: 28270921; PMCID: PMC5332080.
Sun CY, Sung JM, Wang JD, Li CY, Kuo YT, Lee CC, Wu JL, Chang YT. A comparison of the risk of congestive heart failure-related hospitalizations in patients receiving hemodialysis and peritoneal dialysis - A retrospective propensity score-matched study. PLoS One. 2019 Oct 1;14(10):e0223336. doi: 10.1371/journal.pone.0223336. PMID: 31574134; PMCID: PMC6773217.
Zazzeroni L, Pasquinelli G, Nanni E, Cremonini V, Rubbi I. Comparison of Quality of Life in Patients Undergoing Hemodialysis and Peritoneal Dialysis: a Systematic Review and Meta-Analysis. Kidney Blood Press Res. 2017;42(4):717-727. doi: 10.1159/000484115. Epub 2017 Oct 19. PMID: 29049991.
Script
Contributors - Mythri Shankar, Carlo Trinidad, Brian Rifkin, Elliot Tannor, Paresh Jadav.
Hello and welcome to our second episode of 2 truths and a lie, an NSMC podcast.
Let’s go over the ground rules.
One at a time each member of our elite education panel will state two truths and one lie about Nephrology.
This episode will focus specifically on peritoneal dialysis.
The other panelist will then discuss which statement they think is The Lie.
Our presenter will then educate us all on which statement is incorrect and why.
So let’s warm up our lie detectors.
Let’s meet our three players for today.
I’m your host Dr.Mythri Shankar, Assistant Professor in Nephrology from Institute of Nephro-urology, Bengaluru, India.
And here is our second Panelist Dr.Carlo from the Philippines! Hi Dr.Carlo, can you please introduce yourself?
Our third Panelist is Dr.Brian Rifkin from the United states of America. Hello Dr.Brian, …..please introduce yourself?
Great, so let me start, I will give you 3 statements…
Number 1.Peritoneal Dialysis is a good option for patients with Diabetes mellitus. (True)
The concern for diabetic patients undergoing PD is over the absorption of dextrose from the PD fluid which would cause hyperglycemia. But studies comparing HD and PD in daibetic population has not shown that one is superior over the other. European Renal Best Practice Diabetes Guideline Development Group conducted a systematic review of 25 observational studies on the type of dialysis and mortality and found no mortality differences across the subpopulations. There were some limitations with respect to study designs. In the absence of clear evidence of superiority of one modality over the other, PD should not be denied to diabetic patients. The modality of dialysis should be according to patient preference. High dextrose solutions should be avoided as much as possible. Multidisciplinary team approach should be used for blood glucose management.
Number 2.The adequacy of Peritoneal dialysis (Kt/v) in obese patients is falsely low. (True)
Traditional exit sites cannot to used in obese patients which is a barrier for PD catheter insertion. In motivated obese patients, presternal exit site is a good option. There are no studies showing superiority of one catheter type over the other due to technical issues.
Also, it is thought that adequacy of dialysis is lesser in obese patients. This is because Kt/V can not be applied to obese patients. The watson equation assesses total body water using age, sex, height and weight which cannot be applied in obese patients.It give false high volume of distribution and hence, less kt/v. Alternatively, creatinine clearance can be calculated instead of kt/V.
Another retrospective study, showed that obese pts had longer survival on PD compared to low BMI pts even after adjustment for transplant and modality failure.
Number 3. Infectious complications are very frequent in Peritoneal Dialysis patients (False)
Peritonitis, the most common infection among PD patients, is actually quite rare. A large multicenter study by Perl et al published in the year 2020 demonstrated that among 7000 patients across 209 facilities in 7 countries, there were 2272 peritonitis episodes during 7876 follow-up years. This translates to a crude rate of only 0.28 episodes per patient year . In comparison, catheter related bloodstream infections associated with hemodialysis tunneled catheters were much more common at 1.1 to 5.5 episodes per 1000 catheter days (Miller et al. 2016).
The risk of peritonitis can be reduced with proper training and handwashing techniques.
OK, that was fun. Moving on to Dr.Carlo, can you give us your 2 truths and a lie.
Dr.Carlo:
A. Patients on PD have a lower risk of developing heart failure compared to their HD counterparts (True)
In a large retrospective cohort study involving 4754 matched pairs of HD and PD patients, PD patients had a significantly lower incidence of CHF (19.71 per 1000 patient years versus 25.98 per 1000 patient years) (Sun et al. 2019). PD provides gentle ultrafiltration, resulting in lesser hemodynamic fluctuations, neurohormonal activation and myocardial ischemia. Unlike in HD, PD is not associated with myocardial stunning (Selby and McIntyre, 2011), an important process in the progression of heart failure.
B. PD is a better dialysis modality than haemodialysis (false)
There are numerous studies comparing PD to HD in terms of mortality and quality of life Zazzeroni L et al, 2017. Quality of life has been shown to be a useful outcome measure in patients with kidney failure Tannor et al, 2018. There is no difference between PD and HD with respect to survival and quality of life Gokal et al, 1999. PD and HD have been shown to be rather complementary and should be chosen based on availability and patient preference and be worked up for kidney transplantation which has rather been shown to be better than PD and HD in terms of cost, quality of life and survival Kawanishi H et al, 2008.
C. Peritoneal dialysis is more expensive than Haemodialysis in low and lower-middle income countries. (True)
Peritoneal dialysis has been suggested as less expensive than Haemodialysis in most developed countries as it is assumed to be operational without expensive machines. But there is evidence to suggest that this may not be the case in low and low-middle income countries as the cost is comparable to that of HD or even more expensive as there is no local production of PD fluid and the import duties on PD fluid and equipment are expensive. Karopadi AN, 2013
OK, that was fun. Moving on to Dr.Brian, can you give us your 2 truths and a lie.
Dr. Brian Rifkin:
Doing Peritoneal Dialysis exchanges are time consuming (FALSE)
PD may allow you more time to spend with family and friends, at work, or to simply do what you love most because you can perform dialysis outside of a dialysis center. Additionally, if you choose continuous cycling peritoneal dialysis (CCPD), you will dialyze while you sleep and spend an average of three hours per week setting up and cleaning equipment.
Peritoneal dialysis is not complicated and can be done by very elderly people and people with disabilities. (TRUE)
Although PD may be more challenging for people with certain disabilities (blindness, deafness, amputation, etc.), this treatment may still be an option. With the help of a care partner and/or special equipment it can often be done. Training and safety programs are available to educate patients on how to perform safe and effective treatments.
There are no age limits for this treatment option. Elderly people as well as children may be able to perform PD with assistance. Care partners can make it easier to perform treatments, which may help patients feel more confident and comfortable dialyzing at home.
Peritoneal dialysis patients can own pets (TRUE)
Pets cannot be in the room while you are performing PD, but you can still have them. Be sure to keep your home and designated treatment area clean. Also catheters are not toys. Women with a cat ended up with pasterella infection when cat bit the catheter.
Conclusion by Dr.Mythri:
Well, that was really helpful and informative. I would like to thank our panelists for participating today. Be sure to tune in next time for more FOAMed nephrology education.
