KDOQI US Commentary on the 2020 ISPD Practice Recommendations for Prescribing High-Quality Goal-Directed Peritoneal Dialysis

The recently published 2020 International Society for Peritoneal Dialysis (ISPD) practice recommendations regarding prescription of high-quality goal-directed peritoneal dialysis differ fundamentally from previous guidelines that focused on “adequacy” dialysis. new ISPD publication emphasizes the need a person-centered approach with shared decision making between individual performing and clinical care team while taking broader view various issues faced by individual. Cognizant lack strong evidence made, they are labeled as “practice points” rather than being graded numerically. This commentary presents views work group convened National Kidney Foundation’s Disease Outcomes Quality Initiative (KDOQI) to assess these assist providers in United States interpreting implementing them. will require changes current paradigm, including greater resource allocation allow enhanced services provide more holistic assessment quality delivered. Because designed reflect responsible KDOQI Commentary reviewed approved NKF leadership, Commentaries not peer AJKD. article was prepared comprising authors co-chaired Dr Rajnish Mehrotra Isaac Teitelbaum. It Scientific Advisory Board Chair Vice Chairs. In States, Centers Medicare & Medicaid Services (CMS) has had long-stated goal incentivizing use home treating kidney failure. (PD) remains dominant modality because almost 85% people who perform long-term at PD.1Saran R. Robinson B. Abbott K.C. et al.US Renal Data System2019 Annual Report: epidemiology disease States. Am J Dis. 2020;75(1)(suppl 1):S1-S64. Institutes Health, Institute Diabetes Digestive Diseases, Bethesda, MD2019Google Scholar last decade, increase PD outpaced overall growth number persons treated failure.1Saran There 2 factors driving this large growth. First, there is now consistent around world provides similar short- survival failure in-center hemodialysis (HD).2Mehrotra Devuyst O. Davies S.J. Johnson D.W. state dialysis.J Soc Nephrol. 2016; 27: 3238-3252Crossref PubMed Scopus (130) Google Second, CMS financial incentives dialysis.3Hornberger J. Hirth R.A. Financial implications choice type revised payment system: an economic analysis.Am 2012; 60: 280-287Abstract Full Text PDF (29) As such, doubled since 2008 started, stayed on, switched after reform.1Saran Scholar,4Lin E. Cheng X.S. Chin K.K. al.Home prospective system era.J 2017; 28: 2993-3004Crossref (22) Scholar,5Sloan C.E. Coffman C.J. Sanders L.L. al.Trends reform.Clin 2019; 14: 1763-1772Crossref (9) expected get further boost planned rollout models delivery part Advancing American Health initiative.6Mehrotra Health: introduction.Clin 1788Crossref (7) Scholar,7Rivara M.B. Formica R.N. Health-new opportunities collaborative care.Am Med. 2020; 133: 335-337Abstract (0) With rapidly growing population individuals it pressing define what constitutes care. guideline adequacy issued 1997 first address how best PD, updated 2006.8Clinical adequacy.Am 2006; 48: S130-S158PubMed Scholar,9National FoundationNKF-DOQI 1997; 30: S67-S136Google Simultaneous update, targets solute fluid removal adult patients 2006.10Lo W.K. Bargman J.M. Burkart al.Guideline chronic dialysis.Perit Dial Int. 26: 520-522Crossref Both recommended management also recommending small-solute clearance measured total weekly Kt/Vurea emphasizing importance volume management. 2012, fulfill legislative mandate incorporate dose delivered Incentive Plan, included sole measure PD.11Sedor J.R. Watnick S. Patel U.D. al.ASN End-Stage Task Force: perspective payments renal facilities.J 2010; 21: 1235-1237Crossref Scholar,12Weiner D. ESRD Program-can we bridge chasm?.J 1697-1706Crossref 24-year period adequacy, become clear strength supporting based robust.13Boudville N. de Moraes T.P. 2005 Guidelines adults dialysis: 2019 update literature revision recommendations.Perit 40: 254-260Crossref For example, imprecise given difficulty accurately estimating “V,” assumed be total-body water.14Davies Finkelstein F.O. Accuracy estimation V when applying measuring 261-269Crossref (3) Furthermore, consensus entails much Kt/Vurea.15Teitelbaum I. Delivering really matters?.Clin 15: 1-3Crossref Finally, recognition “goal-directed” which person (and/or their caregivers) health establish individualized goals assessed broadly captured Kt/Vurea.16Finkelstein Foo M.W. Health-related life maintained 270-273Crossref (2) Scholar, 17Chan C.T. Blankestijn P.J. Dember L.M. al.Dialysis initiation, choice, access, prescription: conclusions Disease: Improving Global (KDIGO) Controversies Conference.Kidney 96: 37-47Abstract (28) 18Perl al.The multidimensional adequacy-moving beyond small kinetics.Clin 12: 839-847Crossref (24) Thus, guideline19Brown E.A. Blake P.G. Boudville al.International recommendations: prescribing 244-253Crossref (14) very timely welcome. Due statements, numerically.19Brown KDOQI-convened group. determining utility facilitate its implementation. chose comment statement 6 deals low- lower-middle-income countries. All statements copyright reproduced permission SAGE Publications. 1.PD should prescribed using decision-making doing team. aim realistic (1) maintain possible enabling them meet goals, minimize symptoms treatment burden ensuring provided. Person-centered critical during entire trajectory disease, time approaching end life.17Chan Scholar,20Morton R.L. Sellars M. From patient-centered diseases.Clin 623-625Crossref (8) involves educating condition prognosis so may determine care.21Muthalagappan Johansson L. Kong W.M. Brown or conservative frail older patients: ethics decision-making.Nephrol Transplant. 2013; 2717-2722Crossref Scholar,22Saggi Allon Bernardini al.Considerations optimal preparation dialysis.Nat Rev 8: 381-389Crossref They educated about provided prescriptions therapy can tailored goals; includes initiate discontinue dialysis.22Saggi patient-reported outcomes experiences used improve effectiveness Importantly, essential principles practicing medicine own right, do levels evidence. words “rights” receiving medical “essentially extension informed consent.”23Corbett R.W. Goodlet G. MacLaren done 349-352Crossref agrees spirit guideline, shifts focus meets specific needs, preferences, values PD. Many face high comorbidity, short expectancy, low life, socioeconomic deprivation, rates anxiety depression.24Nesrallah G.E. Dixon S.N. MacKinnon palliative service utilization among Ontario residents dying dialysis.Can 2018; 52054358118783761Crossref (4) Therefore, effective, engagement, education, empowerment all crucial. achieved care.25Hibbard J.H. Stockard Mahoney E.R. Tusler Development Patient Activation Measure (PAM): conceptualizing activation consumers.Health Serv Res. 2004; 39: 1005-1026Crossref Scholar,26Greene Hibbard Sacks Overton V. Parrotta C.D. When patient change, costs too.Health Aff (Millwood). 2015; 34: 431-437Crossref (202) well engaged. lifelong condition. likely follow regimen she/he feels respected involved process.27Barry M.J. Edgman-Levitan Shared making--pinnacle care.N Engl 366: 780-781Crossref have understanding prognosis, expect. might help coping acceptance.28Gorrin M.R. Teruel-Briones J.L. Vion V.B. Rexach Quereda C. Palliative implementation programme terminal (PD).Nefrologia. 35: 146-149Crossref outlines conversations guide care, such consideration manual versus automated (APD), incremental PD.29Bieber S.D. Golper T.A. Teitelbaum Comparative continuous ambulatory narrative review.Am 2014; 63: 1027-1037Abstract 30Blake Dong Incremental 320-326Crossref (5) 31Grubbs Moss A.H. Cohen al.A care: transition life.Clin 9: 2203-2209Crossref challenges making, acknowledges. represents shift culture nephrology; some uncomfortable others training deliver confidently effectively.32Amro O.W. Ramasamy Strom J.A. Weiner D.E. Jaber B.L. Nephrologist-facilitated advance planning improvement project.Am 68: 103-109Abstract addition, less engage process if limited literacy, cognitive impairment, depression, perceive cultural barriers allowed make decision.33Dahlerus Quinn Messersmith al.Patient perspectives modality: results Empowering Patients Choices Replacement Therapy (EPOCH-RRT) Study.Am 901-910Abstract (41) structural within system, increasing productivity, continuity transitions offers potential solutions overcome challenges. communication skills, competence, activation. Ideally, universally no cost existing systems; otherwise, difficult educate practitioners resources seek additional training. One pharmacists teams caregivers self-manage medications pain, erectile dysfunction, pruritus. Although challenging pharmacists, Care models, wherein nephrologists metrics activation, depression screening remission. different members could leverage telehealth frequency engagement support home.34Rosner M.H. Lew S.Q. Conway P. al.Perspectives advancing technologies remote monitoring self-care RRT.Clin 1900-1909Crossref (20) Promoting experience use. Presently, validated instrument undergoing hence data—which routinely collected those HD In-Center Consumer Assessment Healthcare Providers Systems (ICH-CAHPS) survey—are PD.12Weiner many US themselves PD; better education nephrology community flexibility options necessary before turn relaxation congressionally mandated measures Kt/Vurea. summary, but acknowledge scale structure particularly incentives, align principles. 2.The take into account local country resources, wishes lifestyle considerations needing treatment, families/caregivers’, especially providing assistance acknowledges select value privacy, flexibility, freedom.20Morton imperative ensure fits person’s asking fit prescription.35Teitelbaum Crafting starting dialysis.Clin 13: 483-485Crossref important mindful trade-offs willing achieve Collectively, goal-concordant optimize burden, satisfaction possibly reduce burnout, perhaps risk transfer HD. However, benefits personalizing been formally evaluated remain speculative. ungraded. endorses believes operationalizing maximize modality. possibility wide range leveraged prescriptions. At most fundamental level, selecting (CAPD) APD, each offering fill volumes selection dialysate (different tonicity dextrose icodextrin-based solutions).29Bieber even increased 100-mL increments, exchanges overnight (generally 3-5) day 0-2), combinations dextrose-based removal. Further include urgent-start significant residual function, assisted requiring support, nearing life.30Blake Scholar,31Grubbs Scholar,36Blake Jain A.K. Urgent start defining why matters.Clin 1278-1279Crossref (12) Scholar,37Oliver Salenger Making reality States: Canadian viewpoint.Clin 566-568Crossref Given multiplicity options, utility. Adopting articulated re-orienting nephrologists, facilities, providers. An often-cited barrier metric dialysis, Kt/Vurea.12Weiner adopting often unrelated, adoption full limits icodextrin provider organization. development programs hampered referred late, placement catheters notice, ability facilities train notice.38Mehrotra Expanding access incident patients.Am 59: 330-332Abstract performed paid workers presently supported payers generally reimbursed hospice secondary failure.37Oliver Notwithstanding long-standing list challenges, individualization available ready 3.A assessments care.3a.Patient reported outcome – experiencing his/her feeling well-being. symptoms, impact mental social circumstances. 2006 emphasis symptom health-related adjusting (PROMs), along concordant priorities nationally internationally nephrology.17Chan Scholar,18Perl Sch