Designing dialysis prescriptions.

Our objective was to determine the adequacy of dialysis in our patients currently on home peritoneal dialysis and develop a program of surveillance aimed at maintaining tKt/V (Kt/V calculated from peritoneal clearance and residual renal function) greater than 2.0 as recommended by the CANUSA study. Eighty-nine patients were entered into our study between September, 1993 and September, 1995. Initial dialysate volumes used during the training period were determined by using a patient-specific protocol. Two weeks after discharge a standard peritoneal equilibration test was performed to determine total Kt/V using a computer program, and dialysis prescriptions were changed to achieve a tKt/V > 2.0 in those patients who had tKt/V < 2.0, and those with tKt/V > 2.0 were followed without further intervention. Of the patients who had initial assessments, 33.7% had tKt/V of 1.65 and 66.3% had tKt/V of 2.46, and the difference was mainly due to residual renal function. Forty-four patients were started on continuous ambulatory peritoneal dialysis (CAPD), of whom 34% had tKt/V < 2.0 and 66% had tKt/V > 2.0, and of the 36 patients on continuous cycling peritoneal dialysis (CCPD), 30.5% had tKt/V < 2.0 and 69.5% had tKt/V > 2.0. The cost of changing dialysis prescriptions is less with CCPD than with CAPD, and a 0.8-1.0 L increase in dialysate volume will increase peritoneal Kt/V (dKt/V) by 0.1 on average. Patients weighing less than 53 kg can achieve a dKt/V > 2.0 even in the absence of residual renal function, but as body weight increases there is greater dependence on residual renal function to achieve adequate dialysis. We have been able to maintain patients on adequate dialysis (tKt/V > 2.0) by checking peritoneal clearance and residual renal function initially and on a regular basis. Whether a tKt/V > 2.0 will be sufficient to maintain health and well-being of our patients will require a longer period of observation.

The use of community nurses for home peritoneal dialysis: is it cost-effective?

In the late 1970s, continuous ambulatory peritoneal dialysis was first introduced as a mode of treatment for patients with end-stage renal disease. Since that time many patients, themselves or with the help of family members, have routinely performed the therapy at home. There are now 2935 home peritoneal dialysis patients in Canada (36% of the total dialysis population). Today, however, the average patient on dialysis is likely to be older and have other complicating illnesses; moreover, patients may live alone, or have family members who are working. Over the past three years, through the use of innovative assistive devices and strong educational links with community nursing agencies, we have been able to manage peritoneal dialysis patients with complex needs in the home. We performed a retrospective analysis of 18 patients, with severe comorbid conditions, who were managed in the home with the help of community nurses. We will show that this is an economic, efficient, and effective method of caring for home dialysis patients with severe disabilities. Home care agencies need our support so that they can continue to help us manage the complex peritoneal dialysis patient in the 1990s.