NHS should offer more balanced advice about dialysis
Doctors and nurses are being encouraged to give balanced advice to their patients who have kidney failure, so that they can make informed decisions about their choice of dialysis treatment. NICE says that advice should consider the person's personal circumstances alongside their clinical requirements.
Dialysis is used to filter waste products and excess fluid from the blood if the kidneys are not working properly. There are two main types: haemodialysis (when the blood is cleaned outside the body using a machine) and peritoneal dialysis (when the blood is cleaned inside the body using a special fluid via a small tube into a small space inside the abdomen). Both are effective, so the choice is often down to the lifestyle and circumstances of the individual.
Peritoneal dialysis may be more appealing to some people as it can be performed at home, rather than in a hospital or local dialysis centre. It can give people more choice and flexibility with their treatment, as well as save the NHS money. However, just over 15% of those receiving dialysis in the UK currently receive it this way. Some healthcare professionals may be discouraged from offering the option, for example because of the perceived risk of infection or complications.
In its clinical guideline published today (27 July), the National Institute for Health and Care Excellence (NICE) advises doctors and nurses to offer everyone with kidney failure (stage 5 chronic kidney disease) balanced and accurate information about their dialysis options. This includes people who have presented late or have had to start dialysis treatment urgently.
Dr Fergus Macbeth, Director of the Centre for Clinical Practice at NICE said: “As dialysis is such a long term commitment, it's very important that people are able to make informed decisions about their choice of treatment and understand how it will affect their daily routines. If they don't receive a kidney transplant then they will need to remain on dialysis for the rest of their lives.
“We have published this guideline to encourage doctors and nurses to consider the individual circumstances of their patients alongside their clinical requirements. There may be people out there who could benefit from peritoneal dialysis but aren't currently receiving it.”
Dr Damien Longson, a consultant liaison psychiatrist and chair of the independent guideline development group said: “There are currently far more people receiving haemodialysis than there are who are on peritoneal dialysis. This is despite both forms working equally well and the possible benefits that peritoneal dialysis can offer, such as greater independence and fewer hospital visits. With the right training, peritoneal dialysis can be delivered safely and effectively at home or at another location of the patient's choice.
“Healthcare professionals advising on these treatments must have specialist knowledge of chronic kidney disease and the necessary skills to support their patients' decision-making. This may include training in how to use decision aids, or knowing how to present information to children according to their developmental stage.”
NICE is encouraging doctors and nurses to consider factors, such as the following, when discussing the options with their patients: the patient's or carer's ability to manage the treatment by themselves; how their choice of treatment would fit around their daily lives; which settings they would prefer to receive treatment in; how far they live from their nearest centre and whether they would prefer to have a dialysis connection in their arm or abdomen. Healthcare professionals should also fully explain the risks, benefits and requirements of the options and how their choice may affect future treatments or outcomes.
Dr Lindsey Barker, a kidney specialist and guideline developer said: “The guideline recognises that peritoneal dialysis isn't clinically appropriate for all patients who have renal failure. For example it isn't usually suitable for people who have had several major abdominal operations
“Equally, there will be some people who may benefit more from peritoneal dialysis as their first choice of treatment. The guideline highlights children aged two years or younger, adults who don't have any other serious medical concerns and people with some remaining renal function, as possible groups for healthcare professionals to consider.
“When discussing the choice of dialysis, healthcare professionals should remember that their patients' priorities are not necessarily the same as their own. Different treatments will suit different people.”
Notes to Editors
About the clinical guideline
1. For further information about NICE clinical guideline 125 on “Peritoneal dialysis in the treatment of stage 5 chronic kidney disease” visit: www.nice.org.ukCG125. This includes a version of the guideline specifically written for patients, which details the care that they should receive and questions that they may wish to ask their doctor or nurse.Contact the press office for embargoed copies.
2. Peritoneal dialysis involves using a thin membrane that lines the inside of the abdomen (called the peritoneum) as a filter to remove excess waste and water. A small flexible catheter is inserted into the abdomen during an operation. During dialysis, a special fluid is pumped into this cavity. As blood moves through the peritoneum, waste products and excess fluid are moved out of the blood and into the dialysis fluid. The dialysis fluid is then drained out of the cavity after a few hours.
3. Peritoneal dialysis can be delivered safely and effectively at home or at another location of the patient's choice. Patients administer it themselves, although children and some adults might need help from their families or carers. Patients must have a clean and hygienic place to exchange dialysis fluid and/or set up dialysis delivery services, either to have dialysis throughout the day (automated peritoneal dialysis) or overnight while they are asleep (automated peritoneal dialysis and assisted automated peritoneal dialysis). The NICE guideline encourages healthcare professionals to explain these different options to their patients.
4. There are around 40,515 people on dialysis treatment in England, 15.1% of these receive it via their peritoneum. Peritoneal dialysis is not going to be clinically suitable or preferred for everyone - based on NHS Kidney Care and expert clinical opinion it has been estimated that the optimal level of uptake could be as high as 39%.
5. Being on dialysis has a substantial effect on the lives of patients. If it is suitable, peritoneal dialysis gives patients more choice and flexibility. There could also be significant savings for the NHS if peritoneal dialysis is considered as the first choice of treatment modality for children aged 2 years or younger, people with residual renal function and adults without significant associated comorbidities. NICE has estimated that over £7.6 million could be saved each year from the NHS budget after 5 years, based on a conservative increase in the number of people on peritoneal dialysis of 1% each year. This figure could rise to over £36.8 million annually if the optimal level (39%) is achieved (this is estimated to take approximately 20 years).
1. The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing national guidance and standards on the promotion of good health and the prevention and treatment of ill health
2. NICE produces guidance in three areas of health:
- public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
- health technologies - guidance on the use of new and existing medicines, treatments, medical technologies (including devices and diagnostics) and procedures within the NHS
- clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS
3. NICE produces standards for patient care:
- quality standards - these reflect the very best in high quality patient care, to help healthcare practitioners and commissioners of care deliver excellent services
- Quality and Outcomes Framework - NICE develops the clinical and health improvement indicators in the QOF, the Department of Health scheme which rewards GPs for how well they care for patients
4. NICE provides advice and support on putting NICE guidance and standards into practice through its implementation programme, and it collates and accredits high quality health guidance, research and information to help health professionals deliver the best patient care through NHS Evidence.
This page was last updated: 27 July 2011