Dancing around Elephants

Most nephrologists are now accepting that there are similar general clinical outcomes between hemodialysis (HD) and peritoneal dialysis (PD) patients. Patient selection had played a role in the different earlier versus later outcomes, but these cofounders are understood and reconciled, and they helped us conclude that, for clinical outcomes, these modalities are similar. Thus, the choice of therapy should depend on other aspects of an individual’s life circumstances. Is that what happens? Prakash et al. (1), in this issue of CJASN, inform us that neighborhood socioeconomic status may influence specific barriers to PD choice but that, in general, PD eligibility and choice were not barriers. This well designed and thoughtfully executed study adjusted its insights as more knowledge was attained during the study’s course. Importantly, in the approach taken by the centers involved in this study, patients reported barriers to the use of PD, and those barriers were discussed internally to see if they could be addressed and overcome. Therefore, to the extent that patients verbalized barriers and that Ontario health insurance was available (>99%), the study seems solid, and the results seem valid. The health care providers described the following themes categorizing barriers to PD eligibility: medical condition, physical/social environment, medical procedures, functional limitations, cognitive/mental disorders, family/social support, self-management reasons, and others. Although I think that much of this Canadian study is probably broadly applicable, there may be important international differences to consider. The patients in the study were in a universal coverage health care system structured to emphasize education about dialysis, particularly through a uniform process. Prakash et al. (1) suggest that the US renal community adopt such processes. The absence of such processes in the United States has drawn criticism by me and my colleagues (2–4). Prakash et al. conclude that the “reasons for dialysis modality decisions are diverse and highly personalized based upon individual circumstances and preferences” (1). Furthermore, “health care providers should be aware of the complex sets of factors that patients consider in making dialysis modality decisions” (1). Many of these concepts were brilliantly articulated in the work by Morton et al. (5), which influenced the current work by Prakash et al. (1) and the earlier work by Golper and Schreiber (6). For 35 years, my nephrology practice and academic pursuits have focused on dialysis-related therapies. I strongly encourage preemptive transplantation. One half of my incident dialysis patients begin dialysis at home, and one third of my prevalent patients still dialyze at home. I enthusiastically support the quoted conclusions above by Prakash et al. (1). However, I emphasize a different philosophy in getting there. Health care providers can inadvertently reduce choice. I argue that the modality decision of home PD versus home HD is the fourth decision. The three preceding decisions are all important, which were first discussed in depth in the work by Golper and Schreiber (6). Decision 1 is to pursue kidney replacement therapy versus conservative therapy. If kidney replacement therapy is selected, decision 2 is transplant versus dialysis. If a preemptive transplant is not possible, then decision 3 is home dialysis versus in-center dialysis. There are limited in-center PD programs, and therefore, I will discount that option. Thus, if the third decision is for home dialysis, PD versus HD becomes the fourth decision. The maturation of understanding occurs as the patient goes through the decisions in this order. Bypassing any of the first three decisions has potential harm. Some of the barriers described in the work by Prakash et al. (1) and the works by Golper et al. (2,3) are the consequences. Using my approach and comparing it with the approaches of my contemporaries, I find that many more patients prefer home dialysis. When asked their preference if they were in need of dialysis, most of my support team generally respond that they would perform home dialysis. Thus, there is an emphasis on encouraging home dialysis when we perceive that it is feasible for that patient. The reason that I provided the modality status of my patients is that, in my experience, the major deciding factors of PD versus HD are the training time and dialysis partner availability. These features were included in the study by Prakash et al. (1) but did not seem to be as influential as they are in my practice. In our program, PD training takes about 1 week and is often done independently of a partner; in comparison, NxStage home HD (a unique simplified HD system requiring frequent dialysis) training takes 3 weeks, and more traditional home HD requires up to 8 weeks of training. For both forms of home HD, the availability of a partner is preferred but individualized. Medicare payments clearly incentivize home dialysis in the United States. Since the prospective payment system (Bundle) was implemented by the Centers for Medicare and Medicaid Services in 2011, home dialysis has grown in the United States (7). Systematic barriers exist for both PD and home HD (2,4), despite these financial incentives and publicized appeals for corrective actions. Prakash et al. (1) suggest targeting the identified barriers as a logical approach to increase the use of home dialysis (particularly PD). Frankly, I think that this approach is dancing around the elephants in the room. Editorials are opinions. In my opinion, there are two elephants in the room of barriers: one large elephant and one smaller child of the large elephant. The child is the lack of infrastructure to promote PD. There are too few surgeons committed and trained to address the unique surgical problems of PD. A parallel statement can be made for PD nurses. There is no specific course for training dialysis nurses in PD care. Hospital dialysis unit nurses and/or ward nurses are often inadequately trained or equipped to care for PD patients. At Vanderbilt University Medical Center, we observe hospital-acquired peritonitis far too frequently. Emergency departments are used as peritonitis management centers and often lack specific protocols. The same is true for the microbiology laboratories that process samples inappropriately. Organizing a PD catheter placement requires complex planning compared with the two telephone calls that it takes to organize in-center HD. One call goes to interventional radiology to place a central venous catheter, and the second call goes to the in-center HD charge nurse with a brief set of dialysis orders. PD is more complicated, and systems to streamline its planning and initiation are too often inadequate. However, the infrastructure deficiencies could and would be corrected by a larger group of PD-committed nephrologists. Nephrology certainly does not lack for energetic and creative problem-solvers. The infrastructure barriers comprise the small elephant, the child of the large elephant that is consuming the space in the room. This large elephant is the failure of US nephrology training programs to adequately prepare fellows for the practice of all forms of home dialysis. Ultimately, those fellows will become the committed nephrologists who tackle the infrastructure barriers by promoting surgical and nursing expertise. This deficiency has been well documented (8,9) and recently re-emphasized (2,3). Competency in PD is determined at the local level by the training program director. Several colleagues (John Burkart, Marty Schreiber, Joanne Bargman, Rajnish Mehrotra, Anjali Saxena, Isaac Teitelbaum, Steve Guest, and Fred Finkelstein) and I have collectively taught nearly 100 3-day courses in PD (originally called PD University; now called Home Dialysis University). We have observed a broad lack of training in US nephrology fellows, and therefore, our course is oversubscribed at all times. We are proud of the role of PD University, but to not question why it is needed is the ultimate dance around the elephant. If we want to address the barriers to PD, then the elephant cannot be ignored. US nephrology training has to set more clear and realistic standards to determine competency in PD. Until these standards are set, underuse of PD and home dialysis in general will persist. How to achieve this goal is the challenge. The American Society of Nephrology (ASN) Dialysis Advisory Group and a subgroup of training program directors are finishing a position paper on fellow training requirements in home dialysis that include competency criteria for certification. Even when the ASN finishes this paper, the task is not completed. The Residency Review Committee (RRC) of the Accreditation Council for Graduate Medical Education and the American Board of Internal Medicine (ABIM; through the nephrology certification board exam) must be involved if training in home dialysis is to be strong enough to produce a generation of nephrologists with enthusiasm and knowledge of home dialysis. The ASN seems to be tertiary to the RRC and ABIM as regulators. However, I believe it is up to the ASN to apply the pressure needed to see this process through, such that patient choice truly is the decider on kidney replacement modality. In other words, stop dancing around the elephants; eliminate them. Disclosures None. Acknowledgments Drs. Rajnish Mehrotra and John Burkart provided thoughtful comments and advice during the preparation of this editorial.

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