Time-Varying Effects of Nurse and Family-Assisted Peritoneal Dialysis

Peritoneal dialysis (PD) has clinical, quality-of-life, and economic benefits for both patients and the health care system. Clinically, PD prescriptions can be individualized to each patient's residual kidney function through incremental PD.1 PD also has benefits for patients with cardiorenal syndrome due to decreased ultrafiltration rates, leading to improved hemodynamic stability and less myocardial stunning compared with three times a week of intermittent hemodialysis.2 From a quality-of-life perspective, patients with PD have improved independence and treatment satisfaction.3 In addition, PD preserves health care resources because it is less costly to deliver than in-center hemodialysis in most countries and may reduce hospitalizations in patients with heart failure.2 Despite its benefits, there remain many barriers to the use of PD.4,5 One barrier is the inability of patients to perform self-care PD because of cognitive or physical barriers, which can affect up to 63% of patients who are eligible for PD.6 Barriers include vision loss, lack of dexterity, decreased strength for lifting dialysate bags, poor adherence to therapies, memory difficulties, and learning disabilities.6 Patients receiving family support may also experience challenges receiving PD because of caregiver burnout, which can occur in up to 60% of caregivers in PD.7 Assisted PD is an established solution to help patients and caregivers initiate or remain on PD as their modality of choice. Assisted PD programs in multiple countries, including France and Canada, have improved access to PD for vulnerable patients. Assisted PD in these countries has been shown to increase PD usage and provide equitable access to all dialysis modalities.8 There is great variability in how assisted PD is delivered between programs. The 2024 International Society of Peritoneal Dialysis position paper on assisted PD highlighted several different models in how assistance is provided.9 These models include paid and unpaid family members, friends, personal support workers, practical nurses, and registered nurses.9 Nursing assistance offers the additional benefit of clinical assessment, including BP, volume status, real-time troubleshooting of catheter inflow and outflow dysfunction, exit site care, and dressing changes. There is also heterogeneity in how programs use their assisted PD programs; some programs start all patients with nursing assistance at home and graduate patients to independence, whereas other programs introduce assistance on the basis of needs. Many assisted programs only offer assistance for a limited period of time after PD initiation. There remain many important questions of assisted PD, including whether the benefits of assisted PD change over time and whether assistance prevents specific causes of transfer from PD to hemodialysis, including issues related to compliance and how outcomes compare between nursing and family-assisted PD. The study by Boyer et al.10 in this issue of Kidney360 helps answer some of these questions. In this retrospective observational study using the French PD registry, the authors studied the effect of nurse-assisted or family-assisted PD on PD termination due to death or transfer to hemodialysis because of inadequate dialysis, peritonitis, catheter-related problems, and social-related issues. In this patient cohort, 44% of patients received nurse-assisted PD and 8% received family-assisted PD. Self-care PD was used as a control group. Similar to other studies, the assisted PD population had more comorbidities, was older, and was less frequently registered on the transplant waiting list.8 Patients who received family or nurse assistance were more likely to stop PD because of death—this is likely due to the increased age and comorbidities of the assisted PD group in comparison with the self-care PD group. Patients who received assistance had a lower risk of transfer to hemodialysis overall; however, this risk was higher in the first 6 months of starting PD and decreased over time. This suggests PD assistance is a marker of patient vulnerability, and patients who require assistance may be at higher risk compared with patients on self-care PD, particularly in the first 6 months. The highest risk of transfer to hemodialysis in the assisted group was in the first 6 months, but rapidly decreased to similar rates to self-care PD and then plateauing around 18 months. Patients in the nurse-assisted group were more likely to transfer to hemodialysis in the first 6 months because of inadequate dialysis and catheter-related problems. The increased risk was not observed in the family-assisted group. The authors hypothesize that this is multifactorial and includes burnout, treatment noncompliance, and increased pressure on nursing resources. Although the authors hypothesized assistance may reduce noncompliance over time, the study did not have any direct measurements of PD compliance. It is surprising that patients in the nurse-assisted group were more likely to transfer to hemodialysis in the first 6 months because of inadequate dialysis because most patients were expected to have residual urine renal function during this time. Catheter-related problems are the most common cause of early transfer to hemodialysis, and visiting nurses may be more likely to detect catheter-related issues. The total rate of peritonitis was not statistically significant between groups, with 0.36 per patient-year in the self-care group, 0.37 per patient-year in the family-assisted group, and 0.32 per patient-year in the nurse-assisted group. Overall, assistance was associated with decreased risk of peritonitis. In patients who receive family assistance, there is a decreased risk of transfer to hemodialysis due to infection in the first 6 months. One limitation of the study was it did not report whether periods of assistance varied over time. At the start of PD, patients and families may require initial assistance but eventually graduate to self-care or family-assisted PD once techniques are learned and confidence grows. Previous studies report graduation rates of 38% of patients starting on assisted PD graduate to self-care or family assistance.11 Patients may also experience changes in their health status that impede their independence, so providing assisted PD after a period of self-care may allow patients to remain at home during their dialysis modality of choice. Assisted PD also provides support to caregivers during periods of burnout. The percentage of self-care patients requiring assistance is not well described, but assisted PD programs often provide shorter periods of respite care.12 Boyer et al. did not examine how different periods of assistance influence patient outcomes on PD. Assisted PD is an established strategy to improve PD usage and help patients remain in the home modality of their choice. Access to assistance is varied across the globe, and more advocacy is required to ensure equitable access to dialysis modalities that improve clinical outcomes and, more importantly, patient quality of life. The study by Boyer et al. contributed key knowledge on the time-varying benefit of assisted PD and highlighted differences in models of assistance. Further work to examine the differences in nurse-assisted and family-assisted PD, as well as different periods of assistance, will provide valuable insight on designing the optimal assisted PD program.

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