Peritoneal Dialysis

Implementing NICE guidance

July 2011

NICE clinical guideline 125

NICE Pathway

The NICE Peritoneal Dialysis pathway covers peritoneal dialysis in the treatment of stage 5 chronic kidney disease and recommendations on:

• Information

• Choice of dialysis

• Peritoneal dialysis delivery

• Switching treatment

Click here to go to NICE Pathways

website

What this presentation covers

Background

Scope

Recommendations

Costs and savings

Discussion

Related guidance

Find out more

Chronic kidney disease quality standard

Background:1

• There are two main types of dialysis available, haemodialysis and peritoneal dialysis

• The factors that usually determine dialysis choice are lifestyle preferences and feasibility

• Chronic kidney disease (CKD) is never ‘cured’, it is treated with different therapies. It is therefore imperative that the choices offered and made are in line with what the patient needs and wants.

Background:2

• Overall there are no significant differences between the two types of dialysis for critical outcomes which are:

- health-related quality of life- patient involvement and satisfaction- mortality- preservation of renal function- technique failure or switch- resources use and costs including hospitalisation

• Peritoneal dialysis may preserve residual renal function more effectively than haemodialysis.

Epidemiology

• At any one time in the UK, 400-800 people per million of the population need dialysis and prevalence is highly age dependent

• 60-100% of the dialysis population use in-centre haemodialysis

• The NICE costing report for this guideline suggests that the current proportion of the eligible population using peritoneal dialysis in England is estimated to be approximately 15%

• 50% of patients given informed choice will opt for peritoneal dialysis (NHS Kidney Care, 2009)

ScopeThe NICE clinical guideline covers adults, children and infants with a diagnosis of CKD stage 5 who need/are having renal replacement therapy.

The guideline provides recommendations for secondary and tertiary healthcare and community settings on:

•factors that affect dialysis choice•the support needs of patients and carers when

peritoneal dialysis is started •when the type of renal replacement therapy

should be switched.

Definitions

• PD: Peritoneal dialysis

• APD: Automated peritoneal dialysis

• aAPD: Assisted automated peritoneal dialysis

• CAPD: Continuous ambulatory peritoneal dialysis

• CKD: Chronic kidney disease

• EPS: Encapsulating peritoneal sclerosis

• Conservative care: Full supportive treatment for those with advanced kidney failure who, in conjunction with carers and the clinical team, decide against starting dialysis

Offer patients with stage 5 CKD and their families and carers:

• information and support in line with ‘Chronic kidney disease’ (NICE clinical guideline 73, 2008).

• oral and written information about pre-emptive transplant, dialysis and conservative care, to allow them to make informed decisions about their treatment.

Providing information and support:1

To enable patients to make an informed decision, offer balanced and accurate information about dialysis options.

The information should include –

•a description of all dialysis options including:- efficacy and potential benefits, based on

prognosis- risks and potential side effects and their

severity- changing the modality and possible

consequences.

Providing information and support:2

Information should also involve a discussion about how treatment fits into peoples daily lives including:

- how the access point on the body may restrict physical activity

- ability to carry out and adjust treatment - impact on body image and

flexibility of regimen- home modifications- distance and time spent travelling- any additional support needed

Providing information and support:3

Image reproduced with kind permission of: University Hospital Coventry and Warwickshire NHS Trust (Dr David Bennett-Jones).

• Explain to patients and check they understand that CKD is a lifelong disease and that they may need to switch treatment modalities.

• When providing information, healthcare professionals should take into account information the patient has obtained from all other sources and its possible influence.

Providing information and support:4

• Make sure that healthcare professionals offering information have specialist knowledge about CKD, the skills to support decision making and are available to discuss information provided before and after the start of dialysis.

• Offer patients who have presented late or started treatment urgently the same information and choices as those presenting earlier.

Providing information and support:5

• Offer all patients a choice of PD or HD, but consider peritoneal dialysis as the first choice of treatment modality for:

- children 2 years old or younger- people with residual renal function - adults without significant associated comorbidities

• Before starting PD, offer all patients a choice, if appropriate, between CAPD and APD (or aAPD if necessary)

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

Choosing dialysis

• Do not routinely switch patients on peritoneal dialysis to a different treatment modality in anticipation of potential future complications

• Consider switching treatment modality if the patient, their family or carer asks

• When considering switching treatment modality, offer information which includes how any decision to switch may affect future treatment options

• Switching between treatment modalities should be planned if possible.

Switching treatment

Savings per 100,000 population

Recommendations with significant savingsPotential savings after 5 years (£ per year)

Consider peritoneal dialysis as the first choice of treatment modality for adults without significant associated comorbidities

7,979

Estimated saving of implementation 7,979

Recommendations with significant savingsSavings at optimal uptake (est. 20 yrs)(£ per year)

Consider peritoneal dialysis as the first choice of treatment modality for adults without significant associated comorbidities

38,233

Estimated saving of implementation 38,233

Discussion

• To what extent do our services meet these recommendations?

• What are the gaps and how can we address them?

• Which roles will lead developments in this area?

• What is the quality of information and education currently given to patients?

• What training in communication with patients do information givers need?

Related guidance

• Chronic kidney disease, NICE clinical guideline 73, http://guidance.nice.org.uk/CG73

• Anaemia management in people with chronic kidney disease, NICE Clinical Guideline 114, http://guidance.nice.org.uk/CG114

• Laparoscopic insertion of peritoneal dialysis catheter, NICE interventional procedure 208, http://guidance.nice.org.uk/IPG208

• Chronic Kidney Disease, NICE Quality Standard, http://www.nice.org.uk/media/9B7/B0/CKDQualityStandard.pdf

• Renal failure- home versus hospital dialysis, NICE technology appraisal 48,

http://guidance.nice.org.uk/TA48

Find out more

Visit www.nice.org.uk/guidance/CG125 for:

•the guideline •the quick reference guide•‘Understanding NICE guidance’•costing report and template•baseline assessment tool•clinical case scenarios•podcast 1: patients who present late•podcast 2: switching treatment modality

NICE Quality Standard

Chronic Kidney Disease

CKD quality standard

In 2011 NICE published a quality standard on the diagnosis, care and treatment of chronic kidney disease in adults.

Quality standards are a set of specific, concise statements that act as markers of high quality, cost-effective patient care across a pathway or clinical area.

The quality standard consists of 15 quality statements and can be found at:

http://www.nice.org.uk/media/9B7/B0/CKDQualityStandard.pdf

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References

Ansell D, Castledine C, Feehally J et al. (2010) UK Renal Registry twelfth annual report. Available from: http://www.renalreg.com/Reports/2010.html

NHS Kidney Care (2009): Specification for the Commissioning of Peritoneal Dialysis Pathway. Available from: http://www.kidneycare.nhs.uk/Library/Commissioning_of_PD_Pathway_Nov09_FINAL.pdf

NICE costing report for peritoneal dialysis guideline (2011). Available from: www.guidance.nice.org.uk/CG125/costingreport