CG125 Podcast with consultant in renal medicine, Dr David Bennett-Jones. How to approach switching treatment modalities
Consultant in renal medicine, Dr David Bennett-Jones, discusses how to approach switching treatment modalities and when a switch in treatment modalities should be considered.
This podcast was added on 27 Jul 2011
Interviewer: Hello and welcome to the NICE podcast about the NICE clinical guideline; Peritoneal Dialysis. This podcast will focus on how and when to consider switching treatment modalities for patients with stage 5 chronic kidney disease. I am Alexa Biesty, implementation lead for this guideline and with me is Consultant in Renal Medicine, Dr David Bennett-Jones from University Hospitals Coventry and Warwickshire NHS trust.
Q1 Interviewer: David could you please start by outlining the main treatment options which may be available to people with stage 5 chronic kidney disease?
DBJ: Yes Alexa, I would be very happy to do that. There are four main treatment options for advanced renal failure. There is transplantation, there is dialysis treatment, and then there are some patients who might choose not to have interventional treatment but to opt for more supportive approach. I think today we are probably going to be focusing on the dialysis options and these can be divided into two. Haemodialysis, which is predominantly a hospital based treatment and peritoneal dialysis, which we think of as a home based treatment. Those are the two main decision options which patients will be making in an early stage of their advanced kidney disease.
Q2 Interviewer: The guideline recommends that patients receiving peritoneal dialysis should not routinely be switched to another treatment modality in anticipation of future complications. Could you tell us why the guideline recommends this?
DBJ: The guideline emphasises the great importance of patient’s choice, very often in terms of lifestyle, in selecting their preferred dialysis modality. So unless there is a major change in their clinical circumstances or there is a particular reason why their personal choice may change, we do not suggest changing patients routinely from one dialysis modality to another. There is concern expressed about the risk of possible future complications, one of the more serious of these complications is encapsulating peritoneal sclerosis, sometimes called EPS for short. There is a view that the concern about this arising at some time in the future might be a reason for changing but we are discouraging that point of view. This is because EPS, although it is a very serious complication, remains very rare and probably is not sufficient to justify a switch.
Q3 Interviewer: So when should switching treatment modalities be considered?
DBJ: I think one needs to distinguish between the urgent need for a switch, and that is dictated by clinical circumstances, and the more elective reasons for considering a switch. The urgent reasons for switching might be a severe attack of peritonitis that is not responding to treatment, or a succession of recurrent attacks of peritonitis where the patient’s physical and medical wellbeing demands that a change from peritoneal dialysis to another treatment should be undertaken.
When you are considering the longer term, what we might call, elective switch, that is based on a gradual process for example of deteriorating peritoneal function or the social, psychological personal choice which we have talked about before.
If I could just mention one point about the deteriorating function. We are very much suggesting that patients should be checked both for the adequacy of their dialysis on peritoneal dialysis and also to check the ultra-filtration capacity of the peritoneal membrane, and if either of those changes or deteriorates then that is itself a medical reason for switching and might be an indicator for further problems down the line. So we would very much encourage a switch if either of those situations has arisen. But in the absence of those medical indications, we really do emphasise that it is based very much on patient choice. The patient needs to choose the dialysis option that suits them best and if their circumstances have changed and the reasons for choosing peritoneal dialysis in the first place has gone away, then a switch might well be indicated on purely psychosocial grounds.
Q4 Interviewer: And when considering switching treatment modality what approach should be adopted and what other factors should be taken into account?
DBJ: I think the first thing to do is to distinguish between the medical indications and the patient choice indications for switching. If there are medical indications, such as deteriorating peritoneal function, then first check that everything has been done to correct that. Ensure they are on the most appropriate dialysis regimen, try to maximise the amount of peritoneal dialysis they get from their dialysis regimen and also maintain their urine output as far as possible to supplement that.
If it comes down to patient choice, then I think we would suggest that the patient is invited and given the opportunity to revisit all the issues that first determined their original choice. Have they thought through the psychosocial implications of the dialysis modalities that are available? And if they now feel that maybe haemodialysis is preferable to peritoneal dialysis, then we have every reason to facilitate that change. But we do need to make sure that the patient fully understands the consequences of the decision. Because of course there is quite a lot of inconvenience in switching. There is another operation to have a fistula formed, there will be a small operation to have the Tenckhoff catheter removed, and nothing is entirely without risk, so one does need to make sure that the benefits of switching are greater than any of the possible disadvantages.
Q5 Interviewer: Is there anything else to take into account when considering switching treatment modalities?
DBJ: I think that all we need to do is ensure that the patient is aware of the different options available to them. There are a number of different options at each stage of dialysis treatment, and as long as the patient is aware of what those options are and what implications they have for their own lifestyle and their personal choices, then we can be satisfied that they are likely to make a good decision.
Interviewer: Thank you very much David. We hope that you will find the information in this podcast useful in helping you implement this NICE clinical guideline. For more information about the NICE clinical guidance on peritoneal dialysis, including the NICE implementation tools which can all be adapted for local use please visit our website www.nice.org.uk/cg125
This resource should be used alongside the published guidance. The information does not supersede or replace the guidance itself.
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This page was last updated: 19 September 2012