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Peritoneal Dialysis –
A Model for Partnering with Patients in Self-Management
by ANNA President Lesley C. Dinwiddie
All
nephrology nurses should welcome this monograph on peritoneal dialysis
as a very special educational resource! Even though the majority of us
work predominantly with hemodialysis (HD) patients, it is
incumbent upon us all as nephrology nurses to be current and conversant
with chronic kidney disease (CKD) management and all modalities of
renal replacement therapy (RRT). Why? Because, even though it is life-
saving, RRT, by its very nature, is iatrogenic. Hemodialyisis requires
vascular access to establish the necessary extracorporeal circuit. The
surgical alteration to create that access frequently leads to damage
and loss of major veins. Transplantation not only requires surgery to
place the graft but introduces foreign tissue against which normal
immune responses must be suppressed. Chronic immune rejection is the
most common cause of graft loss.
Peritoneal dialysis necessitates the placement of a “permanent”
catheter through the abdominal wall and into the peritoneal space for
the infusion and drainage of large quantities of dialysis solution with
the potential long-term complication of peritoneal scarring. The good
news is that most patients should be able to avail themselves of all
three types of RRT over the course of their life as end stage renal
disease (ESRD) patients in order to obtain the maximum quality and
quantity of life possible. A Logical Order for RRT?
The question then becomes, is there a logical order for RRT? In a
perfect world, CKD patients would be identified around stage 3 (less
than 60 mL/min eGFR), giving the nephrology team time to both slow
progression and to evaluate and educate the patient about his/her
suitability for different modes of RRT. The patient and family who are
capable of a self- management therapy such as PD could be encouraged in
that mode initially because the residual renal function protection that
PD provides is thought to be superior to that of HD. In addition,
dialysis programs that make some degree of self-management an
expectation benefit the patient who might otherwise become passive and
dependent. It is well recognized that long-term survivors of ESRD are
frequently the ones who maintain control over their health management
(Curtin & Mapes, 2001). Having PD as the first RRT should make
these patients excellent candidates for the self-management required
after transplantation and/or the opportunity to do home hemodialysis if
PD is no longer an option. Until that time, chronic PD patients and
their partners/families can perform the dialysis at home because of the
one-on-one education from PD nursing staff and with their ongoing
guidance and support. This is what partnering with patients in self-
management is all about!
Do we practice in a perfect world? Well, no – but recently introduced
legislation, the ESRD Modernization Act of 2004, will provide funding
for the all-important education of CKD patients in the RRT modalities.
Bernardini, (2004) shows in her article (see pp. 494-498) that this
education can lead to the choice of PD in 45%-54% of incident ESRD
patients, making the introduction of this legislation and the
publication of this PD monograph coincidentally very timely.
Congratulations to PD SIG!
The ANNA Peritoneal Dialysis (PD) Special Interest Group, under the
leadership of Maria Luongo, is to be congratulated for the enthusiastic
promotion of an under- appreciated, under-utilized modality. With the
PD Resource Guide of October 2003, the PD continuing education sessions
at ANNA symposia, and this comprehensive monograph, all nephrology
nurses can become more knowledgeable about partnering with patients who
choose peritoneal dialysis.
References
Bernardini, J. (2004). Peritoneal dialysis: Myths, barriers, and
achieving optimum outcomes. Nephrology Nursing Journal, 31(5), 494-497.
Curtin, R., & Mapes, D. (2001). Health care management strategies
of long-term dialysis survivors. Nephrology Nursing Journal, 28(4),
385-394.
Lesley C. Dinwiddie, MSN, RN, FNP, CNN
ANNA President
Cardinal Chapter
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