Lack of motivation: a new modifiable risk factor for peritonitis in patients undergoing peritoneal dialysis?

AIM: Can we identify modifiable risk factors for peritonitis in patients undergoing peritoneal dialysis (PD)? We aimed to determine whether housing standard, PD exchange technique or patient motivation might be modifiable risks for peritonitis. We also explored the relationship between lack of motivation and depression. METHODS: Nurse home visits assessed PD exchange technique, environment and patient motivation. Motivation scores were correlated separately with an Apathy Evaluation Score and a depression score using PHQ-9 questionnaires. RESULTS: Home hygiene, exchange technique and motivation were above average in 53%, 56% and 60%, respectively in 104 patients undergoing PD. After 15 months, 25.9% patients developed peritonitis but nurses' ratings of homes and exchange techniques were not predictive. Low patient motivation was predictive. Patients rated to have above or below median motivation had significantly different Apathy Scores (p = 0.0002). Unmotivated depressed patients were significantly more likely to develop peritonitis compared to motivated depressed patients. CONCLUSION: Lack of motivation predicted peritonitis particularly if associated with depression. Further studies are required focusing on specific motivation scoring schemes and the psychosocial support that might lead to better outcomes.

Comparing automated peritoneal dialysis with continuous ambulatory peritoneal dialysis: survival and quality of life differences?

BACKGROUND: There is a wide disparity in the use of automated peritoneal dialysis (APD) or continuous ambulatory peritoneal dialysis (CAPD) in the UK. This may be due to a perceived quality of life and technique survival advantage with APD, although evidence is lacking. METHODS: We conducted a single-centre retrospective study of incident end-stage renal disease initiating APD and CAPD with data collected prospectively over 5 years. PD modality was based on patient preference. Health status was assessed using SF-36 questionnaires at initial and 1-year follow-up appointments. RESULTS: Three hundred and seventy-two patients were included: 194 patients chose APD, and 178 patients chose CAPD. CAPD patients were generally older and more dependent than APD patients. Univariate analysis for technique survival was inferior for CAPD (relative risk for failure 1.46, 95% CI 1.08-1.97). But on multivariate analysis when comorbidity was added into the model, PD modality was no longer a significant predictor of technique survival. There was no difference in decline in residual renal function. Baseline CAPD patients had worse health status (HS); mean (SEM) physical and social composite scores were 32.3 (0.9) vs 36.5 (0.9) and 33.3 (1.2) vs 40.3 (1.2). After 1 year, HS scores for CAPD and APD patients were similar, but the improvement in HS scores correlated with baseline scores (PD modality was not an independent predictor of the change in HS). CONCLUSIONS: This study did not show any advantages of APD over CAPD in terms of technique survival or HS. There is no evidence to support physician bias towards one PD modality, and both should be available to allow patient choice.

Quality of life of caregivers and patients on peritoneal dialysis.

Peritoneal dialysis is the archetypal home-based therapy and is often favoured by patients. However, as patients with end-stage renal failure become more elderly, with more co-morbidity, their dependence on carers to provide physical, emotional and logistical support increases. The effect of this chronic burden has not been systematically studied. We have prospectively studied patients with end-stage renal failure starting peritoneal dialysis and their carers over a 1-year period. We selected a cohort of caregivers that are actively involved with the care of their partners' dialysis. Quality of Life (QoL) assessed by SF-36 questionnaires showed the patients and carers had impairment of QoL at the start of dialysis. As expected, the baseline QoL Physical Component Scores highly correlated with co-morbidity and assessment of functional capacity. Scores of all QoL domains improved after 1 year and this reached statistical significance for social functioning for both patients and carers. When we compared carers of highly dependent patients (required to perform daily dialysis) with carers of less dependent patients, we noted that the former had a statistically significant worsening of their mental health but other parameters were not different. We have shown that despite increasing the burden for caregivers, with careful selection, education and support, we did not adversely impact on the QoL of carers whilst there was some evidence of improvement, especially in social functioning. This gives reassurance that establishing dependent patients on PD is compatible with a holistic approach to the patients and their families.