Patient Recruitment

There is overwhelming evidence showing that when patients are given a choice through proper education before the start of dialysis, a large proportion elect home dialysis over center dialysis1-8.

Effect of pre-dialysis education on modality selection

Source Date n % choosing PD
Ahlmen et al.1 1993 60 62
Prichard2 1996 74 50
Levin et al.3 1997 171 63
Lameire et al.4 1997 N/A 70
Little et al.5 2001 254 45
FMC-NA6 2001 386 51
Stack7 2002 2435 **
Wuerth et al. 8 2002 40 83

The results are similar around the world, regardless of any other influences.  The patient should always be the decision-maker, along with his family and input from the medical team.  Unfortunately, this is not always the case.

Two factors are essential to empower the patient to make a judicious and well informed decision:  early and appropriate referral to a nephrologist and adequate education on therapy options.   For the latter, there are a number of excellent, well-established tools available to the nephrology team to help their patients understand and accept their illness.  In some ways we may consider education and planning more important than early referral to dialysis.  In a recent study, planned dialysis defined as selection of PD or creation of a vascular access at the time of initiation of dialysis, strongly correlated with pre-ESRD education (p=0.003), the creation of an AV fistula (p=0.001) and selection of PD (p=0.001)9.  Pre-ESRD education provides the foundation to help patients cope with the emotional stress of their illness and gives them some of the tools necessary to select the dialysis modality best suited to their medical needs and lifestyle.   Excellent pre-ESRD education programs focusing on therapy options specially designed for patients and their families are globally available through the Internet (www.kidneyoptions.com, www.kidney.org, www.homedialysiscentral.com).  How well a physician understands the therapies and how comfortable he or she feels prescribing it, critically impacts recruitment.  In the absence of significant medical contraindications and a lack of social support, a motivated patient should have access to home dialysis.

References:

  1. Ahlmen J, Carlsson L, Schonborg C:  Well-informed patients with end-stage renal disease prefer peritoneal dialysis to hemodialysis. Perit Dial Int 13:S196-S198, 1993
  2. Prichard S. Treatment modality selection in 150 consecutive patients starting ESRD therapy. Perit Dial Int 16:69-72, 1996
  3. Levin A, Lewis M, Mortiboy P, Faber S, Hare I, Porter EC, Mendelssohn DC. Multidisciplinary predialysis programs:  Quantification and limitations of their impact on patient outcomes in two Canadian settings. Am J Kidney Dis 29:533-540, 1997
  4. Lameire N, van Biesen W, Dombros N, Dratwa M, Faller B, Gahl GM, Gokal R, Krediet RT, La Greca G, Maiorca R, Matthys E, Ryckelynck JPH, Selgas R, Walls J. The referral pattern of patients with ESRD is a determinant in the choice of dialysis modality. Perit Dial Int 17(Suppl 2):S161-S166, 1997
  5. Little J, Irwin A, Marshall T, Rayner H, Smith S. Predicting a patient’s choice of dialysis modality: Experience in a United Kingdom renal department. Am J Kidney Dis 37:981-986, 2001
  6. Fresenius Medical Care-North America: Data on file
  7. Stack AG. Determinants of modality selection among incident US dialysis patients: Results from a national study. J Am Soc Nephrol 13:1279-1287, 2002
  8. Wuerth DA, Finkelstein SH, Schwetz O, Carey H, Kliger AS, Finkelstein FO. Patient’s descriptions of specific factors leading to selection of chronic peritoneal dialysis or hemodialysis.  Perit Dial Int 22:184-190, 2002
  9. Marron B, Ocana JCM, Salgueira M, Barril G, Lamas JM, Martin M, Sierra T, Rodriguez-Carmona A, Soldevilla A, Martinez F. Analysis of patient flow in dialysis:  Role of education in choice of dialysis modality. Perit Dial Int 25 (Suppl 3):S56-S59, 2005