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NICE guidance

Peritoneal dialysis

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A NICE guideline gives recommendations on using peritoneal dialysis to treat people with stage 5 chronic kidney disease

Chronic kidney disease (CKD) is a progressive condition in which the kidneys do not function as well as they should. For those with stage 5 of the disease, the treatment options include dialysis, transplantation and conservative care.
Transplantation is not suitable for everyone. According to the 2009 annual report of the Renal Association (Ansell et al, 2009), the average age for starting dialysis in the UK is 65 years, but children and younger adults can also receive it.
There are two main types of dialysis:

  • Haemodialysis - when the blood is cleaned outside the body with a machine;
  • Peritoneal dialysis - when the blood is cleaned inside the body using a fluid introduced via a small tube into the abdomen.

Both procedures can be performed at home, but the majority of patients in the UK undergo haemodialysis in a hospital or clinic setting. Choosing the type of dialysis is based on many factors including lifestyle, work, flexibility, self-care ability, control and trust (Morton et al, 2010). Some health professionals may be discouraged from offering the peritoneal dialysis option, for example because of the perceived risk of complications or infection. However, this type of dialysis may be more appealing to some people as it can offer greater flexibility and freedom with their treatment.
The NICE clinical guideline aims to address concerns and offer informed choice to ensure decisions about dialysis treatment are more patient driven. The recommendations cover the care of both adults and children.

Recommendations

Informed choice

All patients, families and carers with stage 5 CKD should have access to information and support to enable them to make informed decisions about dialysis. Information and support should consist of written and oral information and be provided by specialist and trained staff. This may include training on how to use decision aids, or how to present information to children according to their developmental stage.
One aim of providing information is to ensure patients understand that CKD is a life-long condition and that they will probably need to switch between different dialysis modalities. Ideally, all patients with CKD will have time to go through this process and be part of a healthcare setting that allows it to take place.
Occasionally, patients may present at a late stage and so decisions may need to be made in urgent and stressful situations. It is important these patients have input from specialists so they can make informed decisions at an appropriate time and are offered the same information and options as those who present at an earlier stage in the disease.
The information patients need to ensure they can make informed decisions should include the different dialysis options, including the following types of peritoneal dialysis:

  • Assisted automated peritoneal dialysis (aAPD), for which assistance can be provided at home to set up the machine, as well as providing other support so patients receive treatment throughout the day;
  • Automated peritoneal dialysis (APD), which is carried out overnight, usually while the patient is asleep;
  • Continuous ambulatory peritoneal dialysis (CAPD), which is carried out during the day.

These can be delivered safely and effectively at home with the right training and support.
Options of home or in-centre dialysis should also be discussed for haemodialysis. Nurses should cover the efficacy of the dialysis options in their descriptions, as well as the risks, potential side-effects and the possible consequences or reasons for changing modality. It is also important to discuss how the treatment will fit into the patient’s lifestyle, including home circumstances, daily activities and time for travelling to and from treatment.

Choosing dialysis

NICE advises that all people with stage 5 CKD be offered a choice of peritoneal dialysis or haemodialysis, but to consider peritoneal dialysis as the preferred first treatment of choice for:

  • Children aged two years or younger;
  • People with residual renal function;
  • Adults without significant co-morbidities.

For children for whom peritoneal dialysis is appropriate, nurses should offer APD or aAPD in preference to CAPD if they are on a liquid diet.

Conclusion

The NICE guideline is a comprehensive approach to the decision-making process for individuals with stage 5 CKD. It is aimed at ensuring all individuals access accurate, unbiased information and support; this will enable them to make an informed decision about their choice of dialysis and prepare them for the management of their long-term condition.

The guideline is available for download here.

Helen Hurst is advanced nurse practitioner, Manchester Royal Infirmary, and member of the NICE guideline development group

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