A Patient’s Journey: Treatment for Kidney Failure and the Decision on Peritoneal Dialysis

By: Marcus Clem, MD News Greater Kansas; Dennis L. Ross, MD, FACP, FASN; Gina Novak, BSN, RN, Renal Care Coordinator; Teresa Robben, RN, Home Dialysis Manager; and Shirley Irvin, BSN, RN, CDN, Home Therapy Director of Operations
Thursday, April 7, 2016

Peritoneal dialysis (PD) is a wonder of modern medicine. PD is a form of treatment for kidney disease in which waste products and excess fluid buildup are removed from the body. Using the peritoneal membrane already in a patient’s body, it acts as a filter — functioning similarly to a “third kidney.”

Dennis Ross, MD; patient Cesar Godinez; and Jason Taylor, MD

Cesar Godinez knew through his own medical training the hurdles of long-term treatment for chronic kidney disease (CKD) before he developed it.

When doctors advised him he had no choice but to begin dialysis, he realized a challenge awaited him.

Cesar, like most patients, felt discouraged by the need for treatment. However, Kansas Nephrology Physicians (KNP), with Fresenius Medical Care (FMC), helped him along the way. He attended a Treatment Options Program (TOPs) class to learn about his options.

“I was just scared as hell of surgery,” says Cesar, who worked as a pharmacist in the Wichita area before his condition forced him to retire.

Cesar eventually received a kidney transplant, but only after several phases of dialysis through FMC.

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Cesar Godinez is thankful to the team of experts that helped him through his dialysis journey.
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Dennis L. Ross, MD, FACP, FASN, (right) and Jason Taylor, MD, explain the benefits of peritoneal dialysis to Cesar Godinez and his wife, Karen.

In-center Nocturnal Hemodialysis

Nocturnal dialysis is effective in taking care of a patient’s needs while he or she sleeps. Treatment begins with a program designed to take advantage of the average person’s six to eight hours of nonproductive time sleeping in order to perform clinically administered hemodialysis.

“Nocturnal therapy is a slow, gentle therapy that avoids many adverse effects that occur with short, fast treatments,” says Dennis L. Ross, MD, FACP, FASN.

Cesar hoped to continue working as a pharmacist during the day and dialyze at night, assuaging some of his financial and professional concerns.

However, he struggled to sleep and concluded that nocturnal therapy wasn’t the best fit for him.

In-center Daytime Hemodialysis

To address Cesar’s sleep difficulties, his physicians switched him to an in-center daytime hemodialysis plan.

“It worked for part of the time,” Cesar says, “but the problems just started adding up.”

His physicians found his dialysis access required additional surgery in order to improve the hemodialytic process and give him a more comfortable experience.

These circumstances prompted a look at a newer and less invasive method of dialysis: peritoneal therapy. This approach allowed Cesar the flexibility he desired.

“Peritoneal dialysis is a gentler dialysis that preserves our own kidney function longer,” Dr. Ross explains.

Higher Efficiency through CAPD, CCPD

With instructional care, Cesar transitioned to a self-applied dialysis regimen, starting with continuous ambulatory peritoneal dialysis (CAPD).

Rather than interface directly with the bloodstream, CAPD relies on a fluid called dialysate. The dialysate is filtered into the peritoneum, the lining on the inside of the abdomen — in this case accessed via PD catheter.

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Dennis L. Ross, MD, FACP, FASN

From the beginning, PD is easier on the body, as it involves no needles. It is the patient’s responsibility to make sure the PD catheter and exit site remain clean.

“This is a therapy that can be done alone,” Dr. Ross notes.

CAPD is performed four times a day to keep up with the body’s processes and can be a little more time-consuming, though it has a gentler impact minute by minute.

“I just hated the process before, and PD took less planning,” Cesar says of his experience with CAPD. “It was psychological relief.”

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Jason Taylor, MD, encourages Cesar to give continuous cycling peritoneal dialysis a try.

For the first time in his treatment procedure, Cesar was able to think about how to make his life better and manage a difficult process.

He reported 30–40 percent improvement in day-to-day function within the first month of starting peritoneal therapy, and it continued to go up from there. It then came time to address the time requirement.

He decided, with some reluctance, to return to a form of nighttime treatment that relied on his ability to sleep through the process: continuous cycling peritoneal dialysis (CCPD).

The new process, Cesar says, was not without challenges, but it left his days before he received his transplant more or less completely open to do other things.

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Cesar Godinez encourages potential dialysis patients to consider peritoneal dialysis as their initial dialysis treatment.

Cesar says he has faith in the system as it is designed and believes it should be an early option for any patients in a similar situation.

In the wake of his experience, he says he hopes to be able to encourage other kidney failure patients.

“I’ve had this talk with three or four people,” he says. “You have to show people how quickly this dialysis can make them feel better. You gotta remember, it’s not the way they have it set up, it’s not the system, it’s not your ability to follow it that is the issue. You have to have belief in yourself.”

Compass 250Advantages of PD

Here are some advantages of peritoneal dialysis (PD):

  • Patients can keep their remaining kidney function longer.
  • Patients can fit continuous ambulatory peritoneal dialysis or continuous cycling peritoneal dialysis treatment schedules around work or school.
  • Performing their own PD can make travel easier for patients.
  • There are no needles.
  • Patients may have more freedom in choosing their diet.
  • No home partner or home caregiver is needed.
  • PD is a gentle treatment. It acts as a “third kidney” as compared with a hemodialysis machine.

Peritoneal Dialysis

Many patients who choose peritoneal dialysis (PD) as their treatment option for kidney failure begin therapy with a small amount of kidney function remaining. This is known as residual renal function, or residual kidney function. Data suggest that PD supports the retention of residual renal function. It is suggested that diuretics can have continued clinical benefits in dialysis patients to assist with the management of extracellular fluid volume and hypertension, and to reduce the tendency of hyperkalemia. The importance of residual kidney function is supported by the CANUSA PD study, which showed that for each additional 250mL of urine excreted per day, the relative risk for death declined by 36 percent.

The peritoneal membrane surrounds the organs of the abdominal cavity. This membrane has the ability to filter waste products and ultrafiltrate fluids from the body with the use of a dialysate solution in a manner that is similar to the way the kidneys function. The peritoneal membrane is sometimes referred to as the “third kidney.” The peritoneal membrane of PD patients changes over time. While the cause of these changes is not fully understood, the activation of the renin-angiotensin-aldosterone system (RAAS) may have an important role. The use of ACE inhibitors and ARBs is suggested as potential strategies to protect the peritoneal membrane from damage by preserving membrane integrity.