Proceedings of the ISPD 2006 The 11th Congress of the ISPD August 25 29, 2006, Hong Kong Peritoneal

al Dialysis International, Vol. 27 (2007), Supplement 2

0896-8608/07 $3.00 + .00 Copyright 2007 International Society for Peritoneal Dialysis Printed in Canada. All rights reserved.

KEY SUCCESS FACTORS FOR A QUALITY PERITONEAL DIALYSIS PROGRAM

K.S. Nayak PD Center, Department of Nephrology, Global Hospitals, Hyderabad, Andhra Pradesh, India
The success of a peritoneal dialysis (PD) program depends on a multitude of factors that are interlinked and inseparable from one another. Each program needs to identify its special circumstances, deficiencies, and strong points, and then to strategize accordingly. Ultimately, teamwork is the mantra for a successful outcome, the patient being central to all endeavors. A belief and a passion for PD are the fountainhead and cornerstone on which to build a quality PD program.
Perit Dial Int 2007; 27(S2):S9S15 www.PDIConnect.com

for the modalitys further growth. A PD registry is lacking, as is a concerted effort at addressing, head-on, the problems related to PD. Implementing quality assurance program in PD units, together with objectively quantified key performance indicators and ways to achieve them, is mandatory in overcoming the problems.
DISCUSSION

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KEY WORDS: Quality PD program; mobile telephony in PD; connectology. eritoneal dialysis (PD) has come a long way since its introduction about three decades ago (1,2), becoming a viable means of renal replacement therapy the world over. As an end-stage renal disease (ESRD) treatment modality, PD was adopted in India in the 1990s (3). Some misgivings were initially expressed as to viability of this form of home dialysis therapy in a predominantly rural, underdeveloped, and geographically vast country with poor connectivity, poor access to health care, difficult sanitary conditions, and a tropical climate. Nevertheless, India has shown encouraging growth in PD over the last few years: by conservative estimate, about 250 nephrologists are prescribing PD, about 5000 patients total undergoing long-term PD, and penetrance has reached about 12%up from 6% less than a decade ago (Nayak KS. Overcoming CAPD cost barrier in Asian developing countries. Presented at the First Asian Chapter Meeting of the International Society for Peritoneal Dialysis, 1315 December 2002, Hong Kong; 4,5). However, technique survival remains poor, and a high dropout rate (for various reasons) remains the Achilles heel Correspondence to: K.S. Nayak, Department of Nephrology, Global Hospitals, Lakdi-ka-pool, Hyderabad, Andhra Pradesh 500 004 India. drksnayak@gmail.com

The various attributes of a quality PD program can all be addressed under a dozen key pointsall interlinked, each crucial for success, and incidentally, all starting with the letter P. I call them the Dozen Ps in a Pod (Table 1). However, the most important ingredient for the entire team in the PD unit is a Passion for PD. At my center, the entire staff believes that we have been reasonably successful in achieving our targets for most of the twelve key points. Though it may seem self laudatory, I would like to discuss each point in some detail, because I believe that such a discussion would be of benefit to PD units the world over who are working in difficult situations akin to ours. TABLE 1
A Dozen Ps in a Pod 1 2 3 4 5 6 7 8 9 10 11 12
a

Patient selection Personnel management Product selection Peritoneal dialysis prescription and pharmacotherapy Proteincalorie intake Para-clinical support and parallel services Patient-On-Line sof tware a , phone and Internet technology Peritonitis, exit-site infection, and other complication management Preservation of residual renal function Physiotherapy and rehabilitation Purse management of patients Postgraduate fellowships and academic activities

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PATIENT SELECTION

PERSONNEL MANAGEMENT

Ours is a tertiary care, corporate, non-university teaching hospital based in the city of Hyderabad in India. The PD center caters to patients from southern India, especially the state of Andhra Pradesh. We enroll 6 8 patients onto PD every month. All eligible patients with ESRD are offered PD either as a bridge to transplantation or as long-term maintenance therapy. We have an active cadaver and a live related-donor renal transplant program. Patients are encouraged to start PD while registering and awaiting a cadaveric kidney. In our opinion, this option is beneficial, because it avoids the possibility of contracting the hepatitis virus, with its potentially devastating complications, during the waiting period for renal transplant. Hepatitis C is now a major problem in most hemodialysis (HD) units in developing countries (6,7), especially India. In most HD units in India, it is not uncommon that more than half of the patients on maintenance HD are hepatitis Cpositive and that, because of an effective vaccination program, virtually no patients are positive for hepatitis B (8,9). The other advantage, once a cadaveric organ is available, is the ease of managing the pre-transplant care of the potential graft recipient on PD as compared with HD. Scheduling an urgent HD session becomes unnecessary, and the time thus saved allows for the selection of organ recipients from distances farther away from our hospital than would otherwise be possible. A major part of our clinical nephrology workload comes from the intensive care units. Apart from regular continuous renal replacement therapy (CRRT), we use automated PD (APD) in selected patients. A surgeon introduces a Tenckhoff catheter under local anesthesia, and exchanges are performed the same day using small volumes with a PD cycler and the patient in a recumbent position. In a subgroup of patients with suspected acute deterioration of chronic renal failure, we find better recovery of the acute component in patients put on PD than in those who receive HD (unpublished data). Those who have no recovery of renal function more readily accept PD as a long-term therapy option. One important aspect of patient selection in a country such as India is the ability to afford the expense over the long term. Dropout from PD for financial reasons is a common cause of technique failure. A significant percentage of patients are not covered by insurance or any other reimbursement modality (5), and they must cover the expenses on their own. We ensure that the patients and their families are properly counseled regarding the financial aspects before we start PD.
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The clinical coordinator (CC) is the key person taking care of the patient during the various stages of PD therapy. Beginning with the initial counseling of the patient and the family, and moving through pre and postcatheter insertion care, the break-in period, the subsequent training of the patient and at least two family members in PD, the care of the patient, and visiting in center and at home, the CC is directly responsible. The CC is basically a paramedical staff member who has graduated with a science background and subsequently been extensively trained at our center in all aspects of PD. A good CC adequately understands the special needs of the PD patient and of family members and strives to address those needs on a continuing basis. The CC is proficient in all the local languages, cultures, and local customs, which are crucial skills in a culturally diverse country such as India. Our PD center is recognized as a training center for nephrologists, nurses, and CCs by the International Society for Peritoneal Dialysis (ISPD) Asian Chapter fellowship program. A ratio of 1 CC to 20 PD patients is the minimum requirement that we maintain at our center. We use a software program called Patient On Line (POL: Fresenius Medical Care, Bad Homburg, Germany) to assign responsibilities to the CCs on a monthly basis. About 50% of our PD patients live in villages, and they have restricted access to medical facilities and laboratory services. The regular home visits by the CCs are an important part of follow-up care, because the family and the patient need to understand that continuing support is available (10). During a home visit, the CCs objective is to ensure that the exchange techniques are adhered to as recommended and that compliance is maintained. In addition, the CC strives to promote and support patients physical and social rehabilitation, to prevent morbidity, and to improve quality of life. In short, the CC becomes a close confidante of the patient and the family and is the crucial link between them and the PD center.
PRODUCT SELECTION

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Good connectology reduces spike-related peritonitis in patients on PD. We use the disc and pin device ANDYDisc (Fresenius Medical Care) double-bag disconnect system at our PD Serve center, with consistently good results and patient satisfaction as demonstrated elsewhere (11,12). The newer biocompatible solutions that are low in glucose degradation products or that use icodextrin are not yet available in India.

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PD PRESCRIPTION AND PHARMACOTHERAPY

The last word has not been said regarding adequacy and target Kt/V in PD patients (1316). In general, we prescribe anuric patients four exchanges of 2-L solution bags daily and three exchanges for patients with residual renal function (RRF). In selected patients of larger body weight, performing three exchanges with 2.5-L solution bags may prove cost-effective and achieve adequacy targets. A baseline peritoneal equilibration test and peritoneal function test (PFT)the latter being a user- and patient-friendly software program incorporated into POLis performed in every patient to guide the selection of the optimal PD prescription. The tests are repeated periodically and af ter ever y episode of peritonitis. Pharmacotherapy of comorbid factors includes anemia management, control of renal osteodystrophy, prevention and treatment of cardiovascular disease, control of hypertension and dyslipidemia, and management of diabetes mellitus and its complications. A detailed clinical management approach to these conditions can be found elsewhere, such as in the guidelines provided by the U.S. National Kidney Foundation Kidney Disease Quality Outcomes Initiative (K/DOQI) and the ISPD (1719). Proper management of these problems is a cornerstone in ensuring longevity of the patient on PD and directly affects quality of life and rehabilitation.
PROTEINCALORIE INTAKE

etable sources such as tofu from soya beans, boiled peanuts with low-potassium garnishes, and low-sugar and low-potassium milk-based dessertshelp to a certain extent in ensuring a reasonably adequate diet. The renal dietitian prepares a diet plan that is individualized to the patients special nutritional needs, dietary preferences, and familial cultural background. A cookbook with simple-to-prepare dishes has been created for the benefit of our patients. Multi-frequency bioelectric impedance assessment is helpful in nutritional assessment in PD (21,22). In addition, we have found that keto-analog supplementation improves the nutritional status of patients on PD (23).
PARA-CLINICAL SUPPORT AND PARALLEL SERVICES

Ensuring adequate protein intake in the diet of patients in India is a formidable challenge. Some of our pure vegetarians even avoid food sourced from below the earthfor example, onion, garlic, and so on. Other vegetarians are lacto-vegetarians (they consume milk and milk products) and ovo-lacto vegetarians (they eat eggs as well). The non-vegetarians also come in a variety of types, such as those who eat only fish, those who eat meat once in a week or a fortnight, and aggressive non-vegetarians who eat meat for breakfast, lunch, and dinner. In addition, we have some non-vegetarians who avoid beef, and others who absolutely avoid pork. Some evidence shows that Indian vegetarian PD patients have statistically significantly lower serum albumin levels than do Indian patients on a non-vegetarian diet (20). Adequate protein and calorie intake in those patients needs innovative culinary expertise and indepth knowledge of dietetics, a combination that is possible only in a dedicated renal nutritionist. Innovative recipesespecially curries using protein from veg-

Microbiologic Techniques: With continual effort, we have improved our culture-positive peritonitis rate to 64% in 2006 from 54% in 2005 and 43% in 2004. Being able to identify specific micro-organisms has helped us in the proper management of peritonitis. Gram-negative rods (GNRs) accounted for 52% of culture-positive peritonitis infections. Gram-positive cocci caused another 39%, and Candida infections caused the remaining episodes. Escherichia coli were the leading cause of GNR peritonitis (37%), followed by Klebsiella (31%), and Pseudomonas species (31%). Among the gram-positive infections, Staphylococcus aureus caused 50% of the episodes, followed by coagulase-negative staphylococcus or Staphylococcus epidermidis (34%) and enterococci (16%). No infections were attributable to mycobacterium species. In addition to following the ISPD guidelines for microbiologic practices to obtain a good yield from PD effluent (24), we have incorporated these procedures: Effluent is inoculated (5 mL each) for aerobic, anaerobic, and fungal culture into Bactec blood culture vials (Becton Dickinson, Franklin Lakes, NJ). Effluent (100 mL) is centrifuged, and the sediment is inoculated into blood agar, chocolate agar, MacConkey agar, brain heart infusion agar, Sabouraud dextrose agar, and LJ medium (if mycobacterium is suspected on ZeihlNeelsen smears). Nonionic surface-acting techniques using agents such Tween 80, Triton X, and Water Lysis are used to lyse the neutrophils and extrude the ingested bacilli in them. Surgical Support: Insertion and repositioning of the PD catheter and correction of mechanical complications is done mostly laparoscopically by a dedicated surgeon.
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Catheters are inserted under local anesthesia in selected patients who may not be fit for general anesthesia. Backup Hemodialysis Services:As a matter of policy, we have an arteriovenous fistula created for each PD patient, which is helpful when treating infectious and mechanical complications of PD or when discontinuation of PD becomes necessary for some period of time. Having a prepared fistula available avoids hospitalization and the need for a temporary HD access. It also saves money for the patient.
POL, PHONE, AND INTERNET TECHNOLOGY

Relatively inexpensive camera phones are now available, and the cost of using a mobile phone and Internet services is inexpensive. It is not unusual for us to manage a patients PD-related problems from a distance of as much as 1500 km. We are in the process of developing this technology further using a dedicated Web site that the patient can log onto and to which the patient can upload information and images using a mobile phone or the Internet, any time of the day or night, for a response from the PD center.
PERITONITIS, ESI, AND OTHER COMPLICATION MANAGEMENT

The POL software includes all the continuous ambulatory PD and APD tools needed to assist dialysis physicians in making the best decisions when individualizing patient prescriptions and maintaining patient clinical and demographic details. The PFT, which is part of POL, provides adequate information about peritoneal membrane transport, total peritoneal solute clearance, and the time required to achieve 50% of full solute equilibration (Pt50 creatinine, Pt50 urea, and Pt50 sugar all help in deciding dwell times). In addition, information regarding RRF, net ultrafiltration, and the nutritional status and energy metabolism of the patient (estimated resting energy expenditure) is available. Data on protein loss in effluent and daily glucose absorption help in deciding the final proteincalorie needs of the patient. We have used the Internet and mobile telephony to aid in treating PD complications, especially peritonitis, exit-site infection (ESI), and others. Although much progress has been made in the field of telemedicine and PD, the focus has been more on blood-pressure control and related problems (25), and not on infectious complications. India being a land of distances, we have, to a large extent, been able to monitor the infectious complications of peritonitis and ESIs by using a camera phone to transmit images via a multimedia messaging service to another telephone kept in the PD center. Alternatively, images can be captured by a digital camera and sent by e-mail. The images may be those of the solution bag photographed at the patients home with a standardized font in the background to confirm the transparency of the solution bag. Similarly, ESI can be diagnosed and followed, minimizing the patients need to visit the center. Advice is given to the patient by a short-message service over a mobile phone or by e-mail. India has made great strides in telephone and Internet facilities in recent years. Internet cafs have sprung up in nooks and corners of every town, and the entire country is now covered by the mobile telephone network.
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Through a concerted effort, we have achieved consistently low peritonitis rates in our PD patients (Nayak KS. Overcoming CAPD cost barrier in Asian developing countries. Presented at the First Asian Chapter Meeting of the International Society for Peritoneal Dialysis, 1315 December 2002, Hong Kong; 11). Our peritonitis rate of 1 episode every 63.2 patientmonths has surpassed the earlier good results reported by P.K.T. Li and his colleagues (12) using a similar system called the StaySafe double-bag disconnect system (Fresenius Medical Care). Under these circumstances, it is surprising that a recent Malaysian multicentric study did not have a similar experience (26). Inherent flaws in the design of the study may explain this discrepancy (27,28).
PROBLEMS WITH THE EXIT SITE RELATED TO INDIAN SKIN

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The typical skin color of Indian patients makes diagnosis of infections difficult. The typical flipcharts designed to guide clinicians and CCs picture either Caucasian or black skin. Indian patients also tend toward keloid formation. Furthermore, additional caution is necessary in exit-site care because of excessive sweating in Indias tropical climate. Nevertheless, our Indian PD practitioners have been feeling that we tend to see fewer ESIs than do our Western counterparts. The typical Indian style of bathing standing erectprobably aids in draining off exit-site secretions. This avoidance of tub baths, plus a lesser use of swimming pools, and the wearing of typical Indian attire that eschews a trouser belt, may be reducing ESIs; however, this speculation is not currently validated by study evidence.
PRESERVATION OF RRF

Extensive literature is available to suggest that PD is superior to HD in preserving RRF (29). Our own unpublished data has confirmed that finding. Prevention and

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early detection of peritonitis and good microbiologic support and follow-up are essential in reducing morbidity and in complete RRF recovery. We have observed better recovery of RRF if, in the intensive care unit, a patient with suspected acute deterioration of chronic renal failure is put on APD as their CRRT instead of an extracorporeal CRRT therapy. Evidence regarding therapy with aminoglycosides and its deleterious effect on RRF is equivocal (30,31). A quick recovery from peritonitiswith or without aminoglycosidesseems to be the bottom line. A diligent effort needs to be made to avoid nonsteroidal anti-inflammatory agents and other possibly nephrotoxic drugs. A continuous effort in maintaining good blood pressure control, optimum hydration and nutritional status, and proper management of comorbid conditions, especially cardiovascular complications, may aid in the prolongation of RRF.
PHYSIOTHERAPY AND REHABILITATION

changes of 2.5-L solution bags, meaning that they get 7.5 L of PD solution for the cost of 6 L (that is, 2 L 3 exchanges). In patients with RRF and in slow transporters, we have successfully used daytime ambulatory peritoneal dialysis with a dry night.
POSTGRADUATE FELLOWSHIPS AND ACADEMICS

The CC, a crucial link to the patient and the family, is instrumental in ensuring the physical and emotional wellbeing of the patient. A recent Indian study showed a very high incidence of depression in the PD population (32). Constant psychological support by CCs during home visits, identification and rectification of problems at an early stage, social gatherings during special occasions (for example, World Kidney Day), patient support groups with activities such as picnics, and so on, help to build patient morale, aid in rehabilitation, and improve quality of life.
PURSE MANAGEMENT

Making PD affordable, without compromising patient care, is a constant endeavor on the part of every member of the PD center. However, patients and doctors appear to have the misconception (probably perpetuated by certain misinformation) that PD in India is more expensive than HD (33). The hidden costs in HD, such the greater need for erythropoietin, the more frequent blood tests, the loss of time on the part of the patient and an accompanying attendant for in-center HD, the costs of treating hepatitis B and C and their complications, the travel costs to and from the HD center, and the poorer rehabilitation and quality of life, are greater. Most of our PD patients are better rehabilitated and are able to resume work and earn a living, so as to offset the cost of treatment. This experience of reduced expenses has been borne out by others (34). In addition, in selected larger patients, we encourage the use of 3 ex-

An ongoing fellowship program is learning process for everyone. A regular teaching program incorporating postgraduate fellows helps everyone to keep abreast of the latest developments in the field and also helps in patient care. Such a program also acts as an impetus to publish in journals and to present papers at conferences. Our unit is a training centre for ISPD Asian Chapter fellows. We have developed a regular ongoing curriculum covering all aspects of PD therapy for CCs training in PD. Our program ensures that we have a highly trained staff to take best care of our patients. A renal-center twinning project with San Bortolo Hospital, Vicenza, Italy, has been established under the aegis of International Society of Nephrology. This twinning is expected to provide our postgraduate fellows with well-rounded international exposure and to help them practice PD using the latest developments in the field. Our PD Serve center has recruited 127 patients on chronic PD since its initiation in July 2003. Of those 127 patients, 74 continue on PD. Of the 53 dropouts, 31 died [mainly from cardiovascular causes (68%)]. Cerebrovascular accidents and peritonitis-related complications accounted for most of the remaining mortality. Catheter-related problems and poor ultrafiltration resulted in 11 patients being shifted to HD. Of those 11 patients, 8 underwent renal transplantation, and 3 discontinued PD because of RRF recovery. Our longest surviving patient on PD was initiated in 1994 and, incidentally, is also Indias longest surviving PD patient. Our peritonitis rates are, as stated earlier, 1 episode in every 63.2 patientmonths. CONCLUSIONS A high-quality PD program is central to achieving good technique survival in PD patients. Well-trained CCs with a passion for PD under direct supervision of clinicians are the mainstay of a PD program. Support from all paraclinical and parallel services is essential, because the success of a PD program ultimately depends on teamwork. Newer communication technologies such as mobile telephony and the Internet have to be used to keep in close touch with the patients clinical condition at all times.
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aminoglycosides for peritonitis do not affect residual renal function. Am J Kidney Dis 2003; 41:6705. 32. Mahajan S, Tiwari SC. Analysis of depression and its effects on outcome in adult Indian peritoneal dialysis patients. Perit Dial Int 2006; 26(Suppl 2):S97. 33. Li PK, Chow KM. The cost barrier to peritoneal dialysis in

the developing worldan Asian perspective. Perit Dial Int 2001; 21(Suppl 3):S30713. 34. Hooi LS, Lim TO, Goh A, Wong HS, Tan CC, Ahmad G, et al. Economic evaluation of centre haemodialysis and continuous ambulatory peritoneal dialysis in Ministry of Health hospitals, Malaysia. Nephrology 2005; 10:2532.

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