SlideShare a Scribd company logo
1 of 21
AdvancingDialysis.org
Peritoneal Dialysis
Transitions to Hemodialysis
Summarized findings of outcomes after patients transition to
hemodialysis and interventional considerations
Kansal SK, Morfin JA, Weinhandl ED. Survival And Kidney Transplant Incidence On Home Versus In-
center Hemodialysis, Following Peritoneal Dialysis Technique Failure. Perit Dial Int. 2019 39:25-34.
AdvancingDialysis.org
Background
• Peritoneal dialysis utilization
has increased since Medicare
reimbursement changes in
2009
• Percentage of patients
initiating peritoneal dialysis
from 2009 – 2016 has grown
from 6.4% to 10%1
1USRDS 2018 Annual Data Report. Reference table D1: Percentages & counts of reported ESRD patients: by treatment
modality
85%
90%
95%
100%
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Incident Dialysis Patients by Modality
PD
HD
AdvancingDialysis.org
Number of Patients
Initiating Peritoneal Dialysis
6,939 6,771 6,525 6,602
7,141
7,755
8,345
9,601
10,733
11,264
11,864 12,095
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
OVER 12,000 PERITONEAL
DIALYSIS STARTS IN 2016
1USRDS 2018 Annual Data Report. Reference table D1: Percentages & counts of reported ESRD patients: by treatment
modality
AdvancingDialysis.org
High Peritoneal Dialysis Therapy
Attrition Rates Commonly Reported
1Guo A, Mujais S. Patient and technique survival on peritoneal dialysis in the United States: evaluation in large incident
cohorts. Kidney Int Suppl 2003; (88):S3–12.
2Afolalu B, Troidle L, Osayimwen O, Bhargava J, Kitsen J, Finkelstein FO. Technique failure and center size in a large cohort
of peritoneal dialysis patients in a defined geographic area. Perit Dial Int 2009; 29(3):292–6.
3Weinhandl ED, Collins AJ. Trend in peritoneal dialysis technique failure in incident dialysis patients. American Society of
Nephrology, San Diego, CA, 2018.
Therapy Attrition Studies Year Sample Size Findings
Guo and Mujais1 2003 >30,000 patients
First-year technique failure rates between 18.7% and 20.5%
from 1999 to 2001
Afolalu et al.2 2009 5,003 patients
15.6% and 11.9% among large and small centers,
respectively, in a regional cohort from 2001 to 2005
Weinhandl ED, Collins AJ3 2016 22,197 patients
19.5 and 20.8 events per 100 patient-years from 2005 to
2009
18.1 and 18.9 events per 100 patient-years from 2010 to
2012
AdvancingDialysis.org
7,016 7,320 7,250 7,274 7,589 7,894
8,493
9,307
10,109
10,675
11,949
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
1Analysis of United States Renal Data System Standard Analysis Files. PD technique failure defined by at least 30 days of HD
immediately following PD.
MORE ATTENTION NEEDED TO KEEP PATIENTS HOME
IN 2015 – NEARLY 12,000 PERITONEAL DIALYSIS PATIENTS TRANSITIONED TO HEMODIALYSIS1
AdvancingDialysis.org
• Peritonitis
• Catheter failure
• Ultrafiltration failure
• Inadequate solute clearance
• Psychosocial factors
• Abdominal complications
• Malnutrition
Common Complications Resulting in
Peritoneal Dialysis Technique Failure1,2
1Kolesnyk I, Dekker FW, Boeschoten EW, Krediet RT. Time-dependent reasons for peritoneal dialysis technique failure and mortality.
Perit Dial Int 2010; 30(2):170–7. 2Kansal SK, Morfin JA, Weinhandl ED. Survival And Kidney Transplant Incidence On Home Versus In-
center Hemodialysis, Following Peritoneal Dialysis Technique Failure. Perit Dial Int. 2019 39:25-34.
Home Dialysis Continuation
needing to transition to hemodialysis,
transitioned to home hemodialysis2
>4% of patients
AdvancingDialysis.org
Planned Transitions to
Hemodialysis may Improve Outcomes
• Fewer “crashes” into hemodialysis1
• Improvements in fistula placement2
• Less occurrence of fluid overload3
• Reduced hospitalizations and fewer hospitalization days1
• Improved survival and lower risk of death1
1Kansal SK, Morfin JM, Weinhandl ED. Survival and Kidney Transplant Incidence on Home versus In-Center Hemodialysis, Following
Peritoneal Dialysis Technique Failure. Perit Dial Int. January-February 2019 vol. 39 no. 1 25-34. 2Boissinot L, et al. Is transition
between peritoneal dialysis and hemodialysis really a gradual process? Perit Dial Int 2013; 33(4):391–7. 3Bakris GL, et al. Intensive
hemodialysis, blood pressure, and antihypertensive medication use. Am J Kidney Dis2016; 68(5s1):S15–23.
AdvancingDialysis.org
Reported Outcomes in Patients that
Transitioned from Peritoneal Dialysis to Hemodialysis1
1Kansal SK, Morfin JM, Weinhandl ED. Survival and Kidney Transplant Incidence on Home versus In-Center Hemodialysis,
Following Peritoneal Dialysis Technique Failure. Perit Dial Int. January-February 2019 vol. 39 no. 1 25-34
Transplantation Incidence
(4-year follow-up)
Survival
(4-year follow-up)
Hospitalization Days
Hemodialysis Setting
Study Population 33,452 peritoneal dialysis patients
transitioned to hemodialysis
521 patients
to Home HD (3.8%)
9.1 hospitalization days
during transition
70.1% survived
28.8% transplanted
32,931 patients
to In-center HD (96.2%)
18.5 hospitalization days
during transition
62.4% survived
22.4% transplanted
AdvancingDialysis.org
• 24% lower risk of death in transitions to
home hemodialysis vs. in-center
hemodialysis
• Risk of death varied significantly based on
Medicare coverage:
‒ 43% lower risk of death in non-
Medicare patients
‒ 8% lower risk of death in Medicare
patients
• ESRD duration at the time of PD therapy
attrition was 1.4 years greater in home
hemodialysis patients with vs. without Medicare
Lower Risk of Death in Transitions
to Home Hemodialysis1
Hazard ratios of death for home hemodialysis versus
matched in-center hemodialysis patients. HHD = home
hemodialysis; IHD = in-center hemodialysis.
Hazard ratio
0.76 (0.65–0.90)
1Kansal SK, Morfin JM, Weinhandl ED. Survival and Kidney Transplant Incidence on Home versus In-Center Hemodialysis,
Following Peritoneal Dialysis Technique Failure. Perit Dial Int. January-February 2019 vol. 39 no. 1 25-34
AdvancingDialysis.org
62.4%
70.1%
• 4-year survival differences between home
hemodialysis and in-center were 7.7%
overall
• Survival differences varied by Medicare
coverage:
‒ 12.5 point improvement 4-year
survival in non-Medicare patients
‒ 4.0 point improvement 4-year survival
in Medicare patients
• ESRD duration at the time of PD therapy
attrition was 1.4 years greater in home
hemodialysis patients with vs. without Medicare
Improved Survival in Transitions
to Home Hemodialysis1
Survival in non-Medicare peritoneal dialysis patients
transitioned to home hemodialysis and In-center
hemodialysis.
1Kansal SK, Morfin JM, Weinhandl ED. Survival and Kidney Transplant Incidence on Home versus In-Center Hemodialysis,
Following Peritoneal Dialysis Technique Failure. Perit Dial Int. January-February 2019 vol. 39 no. 1 25-34
AdvancingDialysis.org
• Transplantation incidence differences
between home hemodialysis and in-
center were 6.4% overall
• The likelihood of transplant was 36%
higher with home hemodialysis versus
in-center, and varied greatly by
Medicare coverage
‒ 86% higher likelihood of
transplantation in non-Medicare
patients
‒ No statistical difference in likelihood
in Medicare patients
Improved Transplantation Incidence in
Transitions to Home Hemodialysis1
Cumulative incidence of kidney transplant among home
hemodialysis and matched in-center hemodialysis
patients following peritoneal dialysis technique failure
1Kansal SK, Morfin JM, Weinhandl ED. Survival and Kidney Transplant Incidence on Home versus In-Center Hemodialysis,
Following Peritoneal Dialysis Technique Failure. Perit Dial Int. January-February 2019 vol. 39 no. 1 25-34
22.4%
28.8%
AdvancingDialysis.org
Planning for Transitions to Hemodialysis:
Proposed Clinical Indicators
When the Peritoneal Dialysis to Home Hemodialysis Therapy Transition Makes Sense. Multidisciplinary, Quality Improvement Team
Final Report on file. 2014.
Accelerate education and intervention
Waning Adequacy Hospitalizations
Physical
Appearance
Qualitative
Concerns
Medical
Complications
Vintage Malnutrition
AdvancingDialysis.org
Transition Planning Overview
When the Peritoneal Dialysis to Home Hemodialysis Therapy Transition Makes Sense. Multidisciplinary, Quality Improvement Team
Final Report. 2014.
Stage
1
Healthy PD
Adjustment
Prepare for the future even
as they begin home dialysis
Educate on modality options,
create Life Plan
Stage
2
PD @ Risk
Re-evaluation
Closely monitor
for signs of decline as the
journey continues
Re-assess if therapy is
meeting needs, re-educate
on modality options
Stage
3
PD Decline
Imminent Transition
Proactively plan to keep them
at home, if that’s what they
want
Establish access, train on
chosen modality
AdvancingDialysis.org
Recommended Indicators to Manage
Planned Patient Transitions to Hemodialysis
Stage 1: Healthy PD
Stage 2: PD @ Risk
Stage 3: PD Decline
Adjustment
• Peritonitis episode
• Albumin level < 3.5
• Life-changing events (family, change
in social support, depression)
• PD vintage > 5 years
• Transplant waiting list > 2 years
When the Peritoneal Dialysis to Home Hemodialysis Therapy Transition Makes Sense. Multidisciplinary, Quality Improvement Team
Final Report. 2014.
AdvancingDialysis.org
Recommended Indicators to Manage
Planned Patient Transitions to Hemodialysis
Stage 1: Healthy PD
Stage 2: PD @ Risk
Stage 3: PD Decline
Re-evaluation
• Declining or loss of Residual Renal Function
• Albumin level <3.0
‒ or decrease of .2 every 2 months
• 3 or more infections within a year
‒ Ex. peritonitis, ES, tunnel
‒ 1 very severe episode (fungal, sclerosing)
• <1 L/day of UF combined with residual and
therapy
• Increasing number of exchanges
• Use of Icodextrin
• Declining adequacy
‒ Kt/V<1.7 after Rx adjustments
• Decline in physical appearance and or abilities
When the Peritoneal Dialysis to Home Hemodialysis Therapy Transition Makes Sense. Multidisciplinary, Quality Improvement Team
Final Report. 2014.
AdvancingDialysis.org
Recommended Indicators to Manage
Planned Patient Transitions to Hemodialysis
Stage 1: Healthy PD
Stage 2: PD @ Risk
Stage 3: PD Decline
Imminent Transition
• 3 or more indicators, plus the following:
• Medical complications
• Ex. cardiovascular decline, fractures, hernias,
leaks
• >3 hospitalizations in 1 year (ICU)
When the Peritoneal Dialysis to Home Hemodialysis Therapy Transition Makes Sense. Multidisciplinary, Quality Improvement Team
Final Report. 2014.
AdvancingDialysis.org
Key Takeaways
FINDING1
• Keeping patients on a home
home modality offers better
outcomes
• PD patients transitioning to
hemodialysis already are
accustomed to managing
treatment at home
RECOMMENDATION1
• Planning modality transitions, with the
aim of keeping patients home, should
be a core strategy as the dialysis
patient population grows
• Leverage patient knowledge of chronic
disease, self-management at home
‒ Previously trained to manage
supplies, interface with a dialysis
cycler and aseptic techniques and
supplies
When the Peritoneal Dialysis to Home Hemodialysis Therapy Transition Makes Sense. Multidisciplinary, Quality Improvement Team
Final Report. 2014.
AdvancingDialysis.org
Broader context as summarized by Dr. José Morfín:
UC Davis School of Medicine
• Increased hemodialysis treatment frequency may be particularly important for peritoneal
patients, particularly after transitioning to hemodialysis
• Transiting to more frequent home hemodialysis may be especially helpful for patients with:
‒ Deteriorating cardiac status (due to volume expansion)
‒ Rising blood pressure
‒ Worsening left ventricular hypertrophy
• The most practical setting that conforms to increased treatment frequency is home
• Encouraging the transition from peritoneal dialysis to home hemodialysis is an evidence-based
approach and we have 12,000 (or more) chances each year to make this transition happen
Dr. José Morfín is an Associate Professor at UC Davis School of Medicine and is the Medical Director of Home Dialysis Services at
Satellite Wellbound in Sacramento, California. Dr. Morfín launched his first home program in 2009 and in 2017, launched Optimal
Transitions™—A first-of-its-kind program that provides dialysis patients and their families the time, support and resources needed to select
the right dialysis therapy for them.
Dr. Morfín is a member of NxStage Medical’s Scientific Advisory Board.
AdvancingDialysis.org
About this presentation
This presentation is one in an ongoing series focused on recent articles, clinical findings or
guidelines related to issues affecting dialysis patients.
AdvancingDialysis.org is dedicated to providing clinicians and patients with better access to and
more awareness of the reported clinical benefits and improved quality of life made possible with
home dialysis, including more frequent, solo, more intensive, and nocturnal therapy schedules.
For more information, visit AdvancingDialysis.org
AdvancingDialysis.org is a project of NxStage Medical, Inc.
AdvancingDialysis.org
Risk and Responsibility
All forms of hemodialysis, including treatments performed in-center and at home, involve
some risks. When vascular access is exposed to more frequent use, infection of the site,
and other access related complications may also be potential risks. In addition, there are
certain risks unique to treatment in the home environment. Patients differ and not everyone
will experience the reported benefits of more frequent hemodialysis.
Certain risks associated with hemodialysis treatment are increased when performing solo
home hemodialysis because no one is present to help the patient respond to health
emergencies.
Certain risks associated with hemodialysis treatment are increased when performing
nocturnal therapy due to the length of treatment time and because therapy is performed
while the patient and care partner are sleeping.
AdvancingDialysis.org
www.AdvancingDialysis.org
© 2019 NxStage Medical, Inc.

More Related Content

What's hot

Advancing dialysis - Improving Outcomes for Dialysis Patients
Advancing dialysis - Improving Outcomes for Dialysis PatientsAdvancing dialysis - Improving Outcomes for Dialysis Patients
Advancing dialysis - Improving Outcomes for Dialysis Patientsnxstage
 
Advancing Dialysis - Cardiovascular Disease
Advancing Dialysis - Cardiovascular DiseaseAdvancing Dialysis - Cardiovascular Disease
Advancing Dialysis - Cardiovascular DiseaseAdvancingDialysis.org
 
Early goal-directed therapy in severe sepsis and septic shock: ProCESS, ARISE...
Early goal-directed therapy in severe sepsis and septic shock: ProCESS, ARISE...Early goal-directed therapy in severe sepsis and septic shock: ProCESS, ARISE...
Early goal-directed therapy in severe sepsis and septic shock: ProCESS, ARISE...Moh'd sharshir
 
Advancing Dialysis - Symptoms During Dialysis
Advancing Dialysis - Symptoms During DialysisAdvancing Dialysis - Symptoms During Dialysis
Advancing Dialysis - Symptoms During DialysisAdvancingDialysis.org
 
Patient under dialysis with uncontrolled hypertension
Patient under dialysis with uncontrolled hypertension Patient under dialysis with uncontrolled hypertension
Patient under dialysis with uncontrolled hypertension Haytham Ghareeb
 
Hidratacion en ira
Hidratacion en iraHidratacion en ira
Hidratacion en iraHarold Marin
 
Prevention is easier than solving the problem
Prevention is easier than solving the problemPrevention is easier than solving the problem
Prevention is easier than solving the problemBuddhika Illeperuma
 
Steroid Sparing Regimens in Kidney Transplantation
Steroid Sparing Regimens in Kidney TransplantationSteroid Sparing Regimens in Kidney Transplantation
Steroid Sparing Regimens in Kidney TransplantationAbdullah Ansari
 
Advancing Dialysis - Intensive Hemodialysis
Advancing Dialysis - Intensive HemodialysisAdvancing Dialysis - Intensive Hemodialysis
Advancing Dialysis - Intensive Hemodialysisnxstage
 
Joint Symposium of the Heart Failure Society of America and the American Coll...
Joint Symposium of the Heart Failure Society of America and the American Coll...Joint Symposium of the Heart Failure Society of America and the American Coll...
Joint Symposium of the Heart Failure Society of America and the American Coll...drucsamal
 
Early Goal-Directed Therapy in Septic Shock
Early Goal-Directed Therapy in Septic ShockEarly Goal-Directed Therapy in Septic Shock
Early Goal-Directed Therapy in Septic Shockshivabirdi
 
Contrast induced nephropathy-the truth and myth
Contrast induced nephropathy-the truth and mythContrast induced nephropathy-the truth and myth
Contrast induced nephropathy-the truth and mythTarek Samy
 
ICN VIctoria: John Botha on Critical Care Renal Failure
ICN VIctoria: John Botha on Critical Care Renal FailureICN VIctoria: John Botha on Critical Care Renal Failure
ICN VIctoria: John Botha on Critical Care Renal FailureGerard Fennessy
 
Marginal Donors/Expanded Criteria Donors Kidneys
Marginal Donors/Expanded Criteria Donors KidneysMarginal Donors/Expanded Criteria Donors Kidneys
Marginal Donors/Expanded Criteria Donors KidneysAbdullah Ansari
 
Management of gastrointestinal bleeding in patients anticoagulated with dabig...
Management of gastrointestinal bleeding in patients anticoagulated with dabig...Management of gastrointestinal bleeding in patients anticoagulated with dabig...
Management of gastrointestinal bleeding in patients anticoagulated with dabig...Cardiovascular Diagnosis and Therapy (CDT)
 
Sepsis and early goal directed therapy
Sepsis and early goal directed therapySepsis and early goal directed therapy
Sepsis and early goal directed therapyFaez Toushiro
 

What's hot (20)

Advancing dialysis - Improving Outcomes for Dialysis Patients
Advancing dialysis - Improving Outcomes for Dialysis PatientsAdvancing dialysis - Improving Outcomes for Dialysis Patients
Advancing dialysis - Improving Outcomes for Dialysis Patients
 
Renal Replacement therapy
Renal Replacement therapyRenal Replacement therapy
Renal Replacement therapy
 
Advancing Dialysis - Cardiovascular Disease
Advancing Dialysis - Cardiovascular DiseaseAdvancing Dialysis - Cardiovascular Disease
Advancing Dialysis - Cardiovascular Disease
 
Early goal-directed therapy in severe sepsis and septic shock: ProCESS, ARISE...
Early goal-directed therapy in severe sepsis and septic shock: ProCESS, ARISE...Early goal-directed therapy in severe sepsis and septic shock: ProCESS, ARISE...
Early goal-directed therapy in severe sepsis and septic shock: ProCESS, ARISE...
 
Advancing Dialysis - Symptoms During Dialysis
Advancing Dialysis - Symptoms During DialysisAdvancing Dialysis - Symptoms During Dialysis
Advancing Dialysis - Symptoms During Dialysis
 
Patient under dialysis with uncontrolled hypertension
Patient under dialysis with uncontrolled hypertension Patient under dialysis with uncontrolled hypertension
Patient under dialysis with uncontrolled hypertension
 
Hidratacion en ira
Hidratacion en iraHidratacion en ira
Hidratacion en ira
 
Prevention is easier than solving the problem
Prevention is easier than solving the problemPrevention is easier than solving the problem
Prevention is easier than solving the problem
 
Steroid Sparing Regimens in Kidney Transplantation
Steroid Sparing Regimens in Kidney TransplantationSteroid Sparing Regimens in Kidney Transplantation
Steroid Sparing Regimens in Kidney Transplantation
 
Advancing Dialysis - Intensive Hemodialysis
Advancing Dialysis - Intensive HemodialysisAdvancing Dialysis - Intensive Hemodialysis
Advancing Dialysis - Intensive Hemodialysis
 
Sprint 2015 nejm
Sprint 2015 nejmSprint 2015 nejm
Sprint 2015 nejm
 
Joint Symposium of the Heart Failure Society of America and the American Coll...
Joint Symposium of the Heart Failure Society of America and the American Coll...Joint Symposium of the Heart Failure Society of America and the American Coll...
Joint Symposium of the Heart Failure Society of America and the American Coll...
 
Early Goal-Directed Therapy in Septic Shock
Early Goal-Directed Therapy in Septic ShockEarly Goal-Directed Therapy in Septic Shock
Early Goal-Directed Therapy in Septic Shock
 
Incremental Dialysis
Incremental DialysisIncremental Dialysis
Incremental Dialysis
 
Contrast induced nephropathy-the truth and myth
Contrast induced nephropathy-the truth and mythContrast induced nephropathy-the truth and myth
Contrast induced nephropathy-the truth and myth
 
ICN VIctoria: John Botha on Critical Care Renal Failure
ICN VIctoria: John Botha on Critical Care Renal FailureICN VIctoria: John Botha on Critical Care Renal Failure
ICN VIctoria: John Botha on Critical Care Renal Failure
 
Marginal Donors/Expanded Criteria Donors Kidneys
Marginal Donors/Expanded Criteria Donors KidneysMarginal Donors/Expanded Criteria Donors Kidneys
Marginal Donors/Expanded Criteria Donors Kidneys
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitis
 
Management of gastrointestinal bleeding in patients anticoagulated with dabig...
Management of gastrointestinal bleeding in patients anticoagulated with dabig...Management of gastrointestinal bleeding in patients anticoagulated with dabig...
Management of gastrointestinal bleeding in patients anticoagulated with dabig...
 
Sepsis and early goal directed therapy
Sepsis and early goal directed therapySepsis and early goal directed therapy
Sepsis and early goal directed therapy
 

Similar to Advancing Dialysis Recent Findings: PD first ... what's next?

Perspectives in Peritoneal Dialysis
Perspectives in Peritoneal DialysisPerspectives in Peritoneal Dialysis
Perspectives in Peritoneal DialysisRichard McCrory
 
Indications of peritoneal dialysis
Indications of peritoneal dialysisIndications of peritoneal dialysis
Indications of peritoneal dialysisMuhammad Mohsin Riaz
 
Strict Glycemic Control in Critically ill patients: The Demise of another ver...
Strict Glycemic Control in Critically ill patients: The Demise of another ver...Strict Glycemic Control in Critically ill patients: The Demise of another ver...
Strict Glycemic Control in Critically ill patients: The Demise of another ver...Prof. Mridul Panditrao
 
Pd update nephro sudan 2017
Pd update nephro sudan  2017Pd update nephro sudan  2017
Pd update nephro sudan 2017FarragBahbah
 
AdvancingDialysis.org CMS ESRD Treatment Choices (ETC) Mandatory Payment Model
AdvancingDialysis.org CMS ESRD Treatment Choices (ETC) Mandatory Payment ModelAdvancingDialysis.org CMS ESRD Treatment Choices (ETC) Mandatory Payment Model
AdvancingDialysis.org CMS ESRD Treatment Choices (ETC) Mandatory Payment ModelAdvancingDialysis.org
 
EXACT PROJECT PRESENTATION DM.pgefuggsggegeggehgegptx
EXACT PROJECT PRESENTATION DM.pgefuggsggegeggehgegptxEXACT PROJECT PRESENTATION DM.pgefuggsggegeggehgegptx
EXACT PROJECT PRESENTATION DM.pgefuggsggegeggehgegptxBindu238662
 
Hemodialysis.com | Kidney Disease | ESRD | Dialysis
Hemodialysis.com | Kidney Disease | ESRD | DialysisHemodialysis.com | Kidney Disease | ESRD | Dialysis
Hemodialysis.com | Kidney Disease | ESRD | DialysisMarie Benz MD FAAD
 
Reducing Readmissions and Length of Stay | VITAS Healthcare
Reducing Readmissions and Length of Stay | VITAS HealthcareReducing Readmissions and Length of Stay | VITAS Healthcare
Reducing Readmissions and Length of Stay | VITAS HealthcareVITAS Healthcare
 
Predictors of Change in Adherence Status from 1 Year to the Next Among Patien...
Predictors of Change in Adherence Status from 1 Year to the Next Among Patien...Predictors of Change in Adherence Status from 1 Year to the Next Among Patien...
Predictors of Change in Adherence Status from 1 Year to the Next Among Patien...Vishal Saundankar MS, PGDMM, BS (PHARMACY)
 
Concept of a ‘CKD Clinic’
Concept of a ‘CKD Clinic’Concept of a ‘CKD Clinic’
Concept of a ‘CKD Clinic’drsanjaymaitra
 
Reducing Readmissions and Lengths of Stay
Reducing Readmissions and Lengths of StayReducing Readmissions and Lengths of Stay
Reducing Readmissions and Lengths of StayVITAS Healthcare
 
Reducing Readmissions and Length of Stay
Reducing Readmissions and Length of StayReducing Readmissions and Length of Stay
Reducing Readmissions and Length of StayVITAS Healthcare
 
Reducing Readmissions and Length of Stay
Reducing Readmissions and Length of StayReducing Readmissions and Length of Stay
Reducing Readmissions and Length of StayVITAS Healthcare
 
Embargo version rx15_tt_wed_300_zibbell
Embargo version rx15_tt_wed_300_zibbellEmbargo version rx15_tt_wed_300_zibbell
Embargo version rx15_tt_wed_300_zibbellOPUNITE
 
Benjamin Bearnot - New treatments for the infectious complications of substan...
Benjamin Bearnot - New treatments for the infectious complications of substan...Benjamin Bearnot - New treatments for the infectious complications of substan...
Benjamin Bearnot - New treatments for the infectious complications of substan...Benjamin Bearnot, MD
 
Introduction of the NZ Health IT Plan enables better gout management
Introduction of the NZ Health IT Plan enables better gout managementIntroduction of the NZ Health IT Plan enables better gout management
Introduction of the NZ Health IT Plan enables better gout managementHealth Informatics New Zealand
 
Managing ACO Populations across the Continuum Financially and Clinically - Do...
Managing ACO Populations across the Continuum Financially and Clinically - Do...Managing ACO Populations across the Continuum Financially and Clinically - Do...
Managing ACO Populations across the Continuum Financially and Clinically - Do...Healthcare Network marcus evans
 
DFCM Top 5 research studies that will impact clinical practice
DFCM Top 5 research studies that will impact clinical practiceDFCM Top 5 research studies that will impact clinical practice
DFCM Top 5 research studies that will impact clinical practiceHealth Quality Ontario (HQO)
 
16. #ifad219 report of fluid day spain (colomina)
16. #ifad219 report of fluid day spain (colomina)16. #ifad219 report of fluid day spain (colomina)
16. #ifad219 report of fluid day spain (colomina)International Fluid Academy
 

Similar to Advancing Dialysis Recent Findings: PD first ... what's next? (20)

Perspectives in Peritoneal Dialysis
Perspectives in Peritoneal DialysisPerspectives in Peritoneal Dialysis
Perspectives in Peritoneal Dialysis
 
Indications of peritoneal dialysis
Indications of peritoneal dialysisIndications of peritoneal dialysis
Indications of peritoneal dialysis
 
Strict Glycemic Control in Critically ill patients: The Demise of another ver...
Strict Glycemic Control in Critically ill patients: The Demise of another ver...Strict Glycemic Control in Critically ill patients: The Demise of another ver...
Strict Glycemic Control in Critically ill patients: The Demise of another ver...
 
Pd update nephro sudan 2017
Pd update nephro sudan  2017Pd update nephro sudan  2017
Pd update nephro sudan 2017
 
AdvancingDialysis.org CMS ESRD Treatment Choices (ETC) Mandatory Payment Model
AdvancingDialysis.org CMS ESRD Treatment Choices (ETC) Mandatory Payment ModelAdvancingDialysis.org CMS ESRD Treatment Choices (ETC) Mandatory Payment Model
AdvancingDialysis.org CMS ESRD Treatment Choices (ETC) Mandatory Payment Model
 
EXACT PROJECT PRESENTATION DM.pgefuggsggegeggehgegptx
EXACT PROJECT PRESENTATION DM.pgefuggsggegeggehgegptxEXACT PROJECT PRESENTATION DM.pgefuggsggegeggehgegptx
EXACT PROJECT PRESENTATION DM.pgefuggsggegeggehgegptx
 
Hemodialysis.com | Kidney Disease | ESRD | Dialysis
Hemodialysis.com | Kidney Disease | ESRD | DialysisHemodialysis.com | Kidney Disease | ESRD | Dialysis
Hemodialysis.com | Kidney Disease | ESRD | Dialysis
 
Reducing Readmissions and Length of Stay | VITAS Healthcare
Reducing Readmissions and Length of Stay | VITAS HealthcareReducing Readmissions and Length of Stay | VITAS Healthcare
Reducing Readmissions and Length of Stay | VITAS Healthcare
 
Predictors of Change in Adherence Status from 1 Year to the Next Among Patien...
Predictors of Change in Adherence Status from 1 Year to the Next Among Patien...Predictors of Change in Adherence Status from 1 Year to the Next Among Patien...
Predictors of Change in Adherence Status from 1 Year to the Next Among Patien...
 
Concept of a ‘CKD Clinic’
Concept of a ‘CKD Clinic’Concept of a ‘CKD Clinic’
Concept of a ‘CKD Clinic’
 
Reducing Readmissions and Lengths of Stay
Reducing Readmissions and Lengths of StayReducing Readmissions and Lengths of Stay
Reducing Readmissions and Lengths of Stay
 
Reducing Readmissions and Length of Stay
Reducing Readmissions and Length of StayReducing Readmissions and Length of Stay
Reducing Readmissions and Length of Stay
 
Reducing Readmissions and Length of Stay
Reducing Readmissions and Length of StayReducing Readmissions and Length of Stay
Reducing Readmissions and Length of Stay
 
Embargo version rx15_tt_wed_300_zibbell
Embargo version rx15_tt_wed_300_zibbellEmbargo version rx15_tt_wed_300_zibbell
Embargo version rx15_tt_wed_300_zibbell
 
Benjamin Bearnot - New treatments for the infectious complications of substan...
Benjamin Bearnot - New treatments for the infectious complications of substan...Benjamin Bearnot - New treatments for the infectious complications of substan...
Benjamin Bearnot - New treatments for the infectious complications of substan...
 
Introduction of the NZ Health IT Plan enables better gout management
Introduction of the NZ Health IT Plan enables better gout managementIntroduction of the NZ Health IT Plan enables better gout management
Introduction of the NZ Health IT Plan enables better gout management
 
Blood Product Transfusion in Emergency Departments: a Case-Control Study of P...
Blood Product Transfusion in Emergency Departments: a Case-Control Study of P...Blood Product Transfusion in Emergency Departments: a Case-Control Study of P...
Blood Product Transfusion in Emergency Departments: a Case-Control Study of P...
 
Managing ACO Populations across the Continuum Financially and Clinically - Do...
Managing ACO Populations across the Continuum Financially and Clinically - Do...Managing ACO Populations across the Continuum Financially and Clinically - Do...
Managing ACO Populations across the Continuum Financially and Clinically - Do...
 
DFCM Top 5 research studies that will impact clinical practice
DFCM Top 5 research studies that will impact clinical practiceDFCM Top 5 research studies that will impact clinical practice
DFCM Top 5 research studies that will impact clinical practice
 
16. #ifad219 report of fluid day spain (colomina)
16. #ifad219 report of fluid day spain (colomina)16. #ifad219 report of fluid day spain (colomina)
16. #ifad219 report of fluid day spain (colomina)
 

More from AdvancingDialysis.org

AdvancingDialysis.org CMS Kidney Care Choices (KCC) Voluntary Payment Model
AdvancingDialysis.org CMS Kidney Care Choices (KCC) Voluntary Payment ModelAdvancingDialysis.org CMS Kidney Care Choices (KCC) Voluntary Payment Model
AdvancingDialysis.org CMS Kidney Care Choices (KCC) Voluntary Payment ModelAdvancingDialysis.org
 
Advancing Dialysis - Quality of Life
Advancing Dialysis - Quality of LifeAdvancing Dialysis - Quality of Life
Advancing Dialysis - Quality of LifeAdvancingDialysis.org
 
Advancing Dialysis - Potential Risks
Advancing Dialysis - Potential RisksAdvancing Dialysis - Potential Risks
Advancing Dialysis - Potential RisksAdvancingDialysis.org
 
Advancing Dialysis - Mineral and Bone Disease
Advancing Dialysis - Mineral and Bone DiseaseAdvancing Dialysis - Mineral and Bone Disease
Advancing Dialysis - Mineral and Bone DiseaseAdvancingDialysis.org
 
Intensive Hemodialysis, Left Ventricular Hypertrophy and Cardiovascular Disease
Intensive Hemodialysis, Left Ventricular Hypertrophy and Cardiovascular DiseaseIntensive Hemodialysis, Left Ventricular Hypertrophy and Cardiovascular Disease
Intensive Hemodialysis, Left Ventricular Hypertrophy and Cardiovascular DiseaseAdvancingDialysis.org
 

More from AdvancingDialysis.org (6)

AdvancingDialysis.org CMS Kidney Care Choices (KCC) Voluntary Payment Model
AdvancingDialysis.org CMS Kidney Care Choices (KCC) Voluntary Payment ModelAdvancingDialysis.org CMS Kidney Care Choices (KCC) Voluntary Payment Model
AdvancingDialysis.org CMS Kidney Care Choices (KCC) Voluntary Payment Model
 
Advancing Dialysis - Quality of Life
Advancing Dialysis - Quality of LifeAdvancing Dialysis - Quality of Life
Advancing Dialysis - Quality of Life
 
Advancing Dialysis - Potential Risks
Advancing Dialysis - Potential RisksAdvancing Dialysis - Potential Risks
Advancing Dialysis - Potential Risks
 
Advancing Dialysis - Mineral and Bone Disease
Advancing Dialysis - Mineral and Bone DiseaseAdvancing Dialysis - Mineral and Bone Disease
Advancing Dialysis - Mineral and Bone Disease
 
Advancing Dialysis - Hypertension
Advancing Dialysis - HypertensionAdvancing Dialysis - Hypertension
Advancing Dialysis - Hypertension
 
Intensive Hemodialysis, Left Ventricular Hypertrophy and Cardiovascular Disease
Intensive Hemodialysis, Left Ventricular Hypertrophy and Cardiovascular DiseaseIntensive Hemodialysis, Left Ventricular Hypertrophy and Cardiovascular Disease
Intensive Hemodialysis, Left Ventricular Hypertrophy and Cardiovascular Disease
 

Recently uploaded

Emerging Markets Documentation for Drug Regulatory Affairs
Emerging Markets Documentation for Drug Regulatory AffairsEmerging Markets Documentation for Drug Regulatory Affairs
Emerging Markets Documentation for Drug Regulatory AffairsDimple Marathe
 
Top 10 Most Beautiful Chinese Pornstars List 2024
Top 10 Most Beautiful Chinese Pornstars List 2024Top 10 Most Beautiful Chinese Pornstars List 2024
Top 10 Most Beautiful Chinese Pornstars List 2024locantocallgirl01
 
MOTION MANAGEMANT IN LUNG SBRT BY DR KANHU CHARAN PATRO
MOTION MANAGEMANT IN LUNG SBRT BY DR KANHU CHARAN PATROMOTION MANAGEMANT IN LUNG SBRT BY DR KANHU CHARAN PATRO
MOTION MANAGEMANT IN LUNG SBRT BY DR KANHU CHARAN PATROKanhu Charan
 
Drug development life cycle indepth overview.pptx
Drug development life cycle indepth overview.pptxDrug development life cycle indepth overview.pptx
Drug development life cycle indepth overview.pptxMohammadAbuzar19
 
Failure to thrive in neonates and infants + pediatric case.pptx
Failure to thrive in neonates and infants  + pediatric case.pptxFailure to thrive in neonates and infants  + pediatric case.pptx
Failure to thrive in neonates and infants + pediatric case.pptxclaviclebrown44
 
Lachesis Mutus- a Homoeopathic medicinel.pptx
Lachesis Mutus- a Homoeopathic medicinel.pptxLachesis Mutus- a Homoeopathic medicinel.pptx
Lachesis Mutus- a Homoeopathic medicinel.pptxMUHAMMADZAHID314
 
Hombegowda Nagar | ℂall Girl in Bangalore - Phone 6378878445 Esℂorts Serviℂe ...
Hombegowda Nagar | ℂall Girl in Bangalore - Phone 6378878445 Esℂorts Serviℂe ...Hombegowda Nagar | ℂall Girl in Bangalore - Phone 6378878445 Esℂorts Serviℂe ...
Hombegowda Nagar | ℂall Girl in Bangalore - Phone 6378878445 Esℂorts Serviℂe ...darmandersingh4580
 
Top 10 Most Beautiful Russian Pornstars List 2024
Top 10 Most Beautiful Russian Pornstars List 2024Top 10 Most Beautiful Russian Pornstars List 2024
Top 10 Most Beautiful Russian Pornstars List 2024locantocallgirl01
 
VIP ℂall Girls Kaggadasapura {{ Bangalore }} 6378878445 WhatsApp: Me 24/7 Hou...
VIP ℂall Girls Kaggadasapura {{ Bangalore }} 6378878445 WhatsApp: Me 24/7 Hou...VIP ℂall Girls Kaggadasapura {{ Bangalore }} 6378878445 WhatsApp: Me 24/7 Hou...
VIP ℂall Girls Kaggadasapura {{ Bangalore }} 6378878445 WhatsApp: Me 24/7 Hou...deepakkumar115120
 
💚Gorgeous Mumbai Escorts Service 💯Call Us 🔝 9920874524 🔝💃Top Class Call Girl ...
💚Gorgeous Mumbai Escorts Service 💯Call Us 🔝 9920874524 🔝💃Top Class Call Girl ...💚Gorgeous Mumbai Escorts Service 💯Call Us 🔝 9920874524 🔝💃Top Class Call Girl ...
💚Gorgeous Mumbai Escorts Service 💯Call Us 🔝 9920874524 🔝💃Top Class Call Girl ...golu varma
 
💚Mature Women / Aunty Call Girl Chennai Escorts Service 💯Call Us 🔝 6367492432...
💚Mature Women / Aunty Call Girl Chennai Escorts Service 💯Call Us 🔝 6367492432...💚Mature Women / Aunty Call Girl Chennai Escorts Service 💯Call Us 🔝 6367492432...
💚Mature Women / Aunty Call Girl Chennai Escorts Service 💯Call Us 🔝 6367492432...chaddanishu186
 
Creeping Stroke - Venous thrombosis presenting with pc-stroke.pptx
Creeping Stroke - Venous thrombosis presenting with pc-stroke.pptxCreeping Stroke - Venous thrombosis presenting with pc-stroke.pptx
Creeping Stroke - Venous thrombosis presenting with pc-stroke.pptxYasser Alzainy
 
Gross Anatomy and Histology of Tongue by Dr. Rabia Inam Gandapore.pptx
Gross Anatomy and Histology of Tongue by Dr. Rabia Inam Gandapore.pptxGross Anatomy and Histology of Tongue by Dr. Rabia Inam Gandapore.pptx
Gross Anatomy and Histology of Tongue by Dr. Rabia Inam Gandapore.pptxDr. Rabia Inam Gandapore
 
VIP ℂall Girls Budhwar Peth Pune 8005736733 WhatsApp: Me All Time Serviℂe Ava...
VIP ℂall Girls Budhwar Peth Pune 8005736733 WhatsApp: Me All Time Serviℂe Ava...VIP ℂall Girls Budhwar Peth Pune 8005736733 WhatsApp: Me All Time Serviℂe Ava...
VIP ℂall Girls Budhwar Peth Pune 8005736733 WhatsApp: Me All Time Serviℂe Ava...patanjali9823#S07
 
Koramangala $ ℂall Girls in Bangalore - Book 6378878445 ℂall Girls Available ...
Koramangala $ ℂall Girls in Bangalore - Book 6378878445 ℂall Girls Available ...Koramangala $ ℂall Girls in Bangalore - Book 6378878445 ℂall Girls Available ...
Koramangala $ ℂall Girls in Bangalore - Book 6378878445 ℂall Girls Available ...darmandersingh4580
 
💚Independent In Mumbai Escorts Service 💯Call Us 🔝 9920874524 🔝💃Top Class Call...
💚Independent In Mumbai Escorts Service 💯Call Us 🔝 9920874524 🔝💃Top Class Call...💚Independent In Mumbai Escorts Service 💯Call Us 🔝 9920874524 🔝💃Top Class Call...
💚Independent In Mumbai Escorts Service 💯Call Us 🔝 9920874524 🔝💃Top Class Call...golu varma
 
TEST BANK For Porth's Essentials of Pathophysiology, 5th Edition by Tommie L ...
TEST BANK For Porth's Essentials of Pathophysiology, 5th Edition by Tommie L ...TEST BANK For Porth's Essentials of Pathophysiology, 5th Edition by Tommie L ...
TEST BANK For Porth's Essentials of Pathophysiology, 5th Edition by Tommie L ...rightmanforbloodline
 
Vesu * HiFi ℂall Girls Surat Phone No 8849756361 Elite ℂall Serviℂe Available...
Vesu * HiFi ℂall Girls Surat Phone No 8849756361 Elite ℂall Serviℂe Available...Vesu * HiFi ℂall Girls Surat Phone No 8849756361 Elite ℂall Serviℂe Available...
Vesu * HiFi ℂall Girls Surat Phone No 8849756361 Elite ℂall Serviℂe Available...Dharvi Mehra$I11
 
Report Back from SGO: What’s the Latest in Ovarian Cancer?
Report Back from SGO: What’s the Latest in Ovarian Cancer?Report Back from SGO: What’s the Latest in Ovarian Cancer?
Report Back from SGO: What’s the Latest in Ovarian Cancer?bkling
 
Part I - Anticipatory Grief: Experiencing grief before the loss has happened
Part I - Anticipatory Grief: Experiencing grief before the loss has happenedPart I - Anticipatory Grief: Experiencing grief before the loss has happened
Part I - Anticipatory Grief: Experiencing grief before the loss has happenedbkling
 

Recently uploaded (20)

Emerging Markets Documentation for Drug Regulatory Affairs
Emerging Markets Documentation for Drug Regulatory AffairsEmerging Markets Documentation for Drug Regulatory Affairs
Emerging Markets Documentation for Drug Regulatory Affairs
 
Top 10 Most Beautiful Chinese Pornstars List 2024
Top 10 Most Beautiful Chinese Pornstars List 2024Top 10 Most Beautiful Chinese Pornstars List 2024
Top 10 Most Beautiful Chinese Pornstars List 2024
 
MOTION MANAGEMANT IN LUNG SBRT BY DR KANHU CHARAN PATRO
MOTION MANAGEMANT IN LUNG SBRT BY DR KANHU CHARAN PATROMOTION MANAGEMANT IN LUNG SBRT BY DR KANHU CHARAN PATRO
MOTION MANAGEMANT IN LUNG SBRT BY DR KANHU CHARAN PATRO
 
Drug development life cycle indepth overview.pptx
Drug development life cycle indepth overview.pptxDrug development life cycle indepth overview.pptx
Drug development life cycle indepth overview.pptx
 
Failure to thrive in neonates and infants + pediatric case.pptx
Failure to thrive in neonates and infants  + pediatric case.pptxFailure to thrive in neonates and infants  + pediatric case.pptx
Failure to thrive in neonates and infants + pediatric case.pptx
 
Lachesis Mutus- a Homoeopathic medicinel.pptx
Lachesis Mutus- a Homoeopathic medicinel.pptxLachesis Mutus- a Homoeopathic medicinel.pptx
Lachesis Mutus- a Homoeopathic medicinel.pptx
 
Hombegowda Nagar | ℂall Girl in Bangalore - Phone 6378878445 Esℂorts Serviℂe ...
Hombegowda Nagar | ℂall Girl in Bangalore - Phone 6378878445 Esℂorts Serviℂe ...Hombegowda Nagar | ℂall Girl in Bangalore - Phone 6378878445 Esℂorts Serviℂe ...
Hombegowda Nagar | ℂall Girl in Bangalore - Phone 6378878445 Esℂorts Serviℂe ...
 
Top 10 Most Beautiful Russian Pornstars List 2024
Top 10 Most Beautiful Russian Pornstars List 2024Top 10 Most Beautiful Russian Pornstars List 2024
Top 10 Most Beautiful Russian Pornstars List 2024
 
VIP ℂall Girls Kaggadasapura {{ Bangalore }} 6378878445 WhatsApp: Me 24/7 Hou...
VIP ℂall Girls Kaggadasapura {{ Bangalore }} 6378878445 WhatsApp: Me 24/7 Hou...VIP ℂall Girls Kaggadasapura {{ Bangalore }} 6378878445 WhatsApp: Me 24/7 Hou...
VIP ℂall Girls Kaggadasapura {{ Bangalore }} 6378878445 WhatsApp: Me 24/7 Hou...
 
💚Gorgeous Mumbai Escorts Service 💯Call Us 🔝 9920874524 🔝💃Top Class Call Girl ...
💚Gorgeous Mumbai Escorts Service 💯Call Us 🔝 9920874524 🔝💃Top Class Call Girl ...💚Gorgeous Mumbai Escorts Service 💯Call Us 🔝 9920874524 🔝💃Top Class Call Girl ...
💚Gorgeous Mumbai Escorts Service 💯Call Us 🔝 9920874524 🔝💃Top Class Call Girl ...
 
💚Mature Women / Aunty Call Girl Chennai Escorts Service 💯Call Us 🔝 6367492432...
💚Mature Women / Aunty Call Girl Chennai Escorts Service 💯Call Us 🔝 6367492432...💚Mature Women / Aunty Call Girl Chennai Escorts Service 💯Call Us 🔝 6367492432...
💚Mature Women / Aunty Call Girl Chennai Escorts Service 💯Call Us 🔝 6367492432...
 
Creeping Stroke - Venous thrombosis presenting with pc-stroke.pptx
Creeping Stroke - Venous thrombosis presenting with pc-stroke.pptxCreeping Stroke - Venous thrombosis presenting with pc-stroke.pptx
Creeping Stroke - Venous thrombosis presenting with pc-stroke.pptx
 
Gross Anatomy and Histology of Tongue by Dr. Rabia Inam Gandapore.pptx
Gross Anatomy and Histology of Tongue by Dr. Rabia Inam Gandapore.pptxGross Anatomy and Histology of Tongue by Dr. Rabia Inam Gandapore.pptx
Gross Anatomy and Histology of Tongue by Dr. Rabia Inam Gandapore.pptx
 
VIP ℂall Girls Budhwar Peth Pune 8005736733 WhatsApp: Me All Time Serviℂe Ava...
VIP ℂall Girls Budhwar Peth Pune 8005736733 WhatsApp: Me All Time Serviℂe Ava...VIP ℂall Girls Budhwar Peth Pune 8005736733 WhatsApp: Me All Time Serviℂe Ava...
VIP ℂall Girls Budhwar Peth Pune 8005736733 WhatsApp: Me All Time Serviℂe Ava...
 
Koramangala $ ℂall Girls in Bangalore - Book 6378878445 ℂall Girls Available ...
Koramangala $ ℂall Girls in Bangalore - Book 6378878445 ℂall Girls Available ...Koramangala $ ℂall Girls in Bangalore - Book 6378878445 ℂall Girls Available ...
Koramangala $ ℂall Girls in Bangalore - Book 6378878445 ℂall Girls Available ...
 
💚Independent In Mumbai Escorts Service 💯Call Us 🔝 9920874524 🔝💃Top Class Call...
💚Independent In Mumbai Escorts Service 💯Call Us 🔝 9920874524 🔝💃Top Class Call...💚Independent In Mumbai Escorts Service 💯Call Us 🔝 9920874524 🔝💃Top Class Call...
💚Independent In Mumbai Escorts Service 💯Call Us 🔝 9920874524 🔝💃Top Class Call...
 
TEST BANK For Porth's Essentials of Pathophysiology, 5th Edition by Tommie L ...
TEST BANK For Porth's Essentials of Pathophysiology, 5th Edition by Tommie L ...TEST BANK For Porth's Essentials of Pathophysiology, 5th Edition by Tommie L ...
TEST BANK For Porth's Essentials of Pathophysiology, 5th Edition by Tommie L ...
 
Vesu * HiFi ℂall Girls Surat Phone No 8849756361 Elite ℂall Serviℂe Available...
Vesu * HiFi ℂall Girls Surat Phone No 8849756361 Elite ℂall Serviℂe Available...Vesu * HiFi ℂall Girls Surat Phone No 8849756361 Elite ℂall Serviℂe Available...
Vesu * HiFi ℂall Girls Surat Phone No 8849756361 Elite ℂall Serviℂe Available...
 
Report Back from SGO: What’s the Latest in Ovarian Cancer?
Report Back from SGO: What’s the Latest in Ovarian Cancer?Report Back from SGO: What’s the Latest in Ovarian Cancer?
Report Back from SGO: What’s the Latest in Ovarian Cancer?
 
Part I - Anticipatory Grief: Experiencing grief before the loss has happened
Part I - Anticipatory Grief: Experiencing grief before the loss has happenedPart I - Anticipatory Grief: Experiencing grief before the loss has happened
Part I - Anticipatory Grief: Experiencing grief before the loss has happened
 

Advancing Dialysis Recent Findings: PD first ... what's next?

  • 1. AdvancingDialysis.org Peritoneal Dialysis Transitions to Hemodialysis Summarized findings of outcomes after patients transition to hemodialysis and interventional considerations Kansal SK, Morfin JA, Weinhandl ED. Survival And Kidney Transplant Incidence On Home Versus In- center Hemodialysis, Following Peritoneal Dialysis Technique Failure. Perit Dial Int. 2019 39:25-34.
  • 2. AdvancingDialysis.org Background • Peritoneal dialysis utilization has increased since Medicare reimbursement changes in 2009 • Percentage of patients initiating peritoneal dialysis from 2009 – 2016 has grown from 6.4% to 10%1 1USRDS 2018 Annual Data Report. Reference table D1: Percentages & counts of reported ESRD patients: by treatment modality 85% 90% 95% 100% 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Incident Dialysis Patients by Modality PD HD
  • 3. AdvancingDialysis.org Number of Patients Initiating Peritoneal Dialysis 6,939 6,771 6,525 6,602 7,141 7,755 8,345 9,601 10,733 11,264 11,864 12,095 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 OVER 12,000 PERITONEAL DIALYSIS STARTS IN 2016 1USRDS 2018 Annual Data Report. Reference table D1: Percentages & counts of reported ESRD patients: by treatment modality
  • 4. AdvancingDialysis.org High Peritoneal Dialysis Therapy Attrition Rates Commonly Reported 1Guo A, Mujais S. Patient and technique survival on peritoneal dialysis in the United States: evaluation in large incident cohorts. Kidney Int Suppl 2003; (88):S3–12. 2Afolalu B, Troidle L, Osayimwen O, Bhargava J, Kitsen J, Finkelstein FO. Technique failure and center size in a large cohort of peritoneal dialysis patients in a defined geographic area. Perit Dial Int 2009; 29(3):292–6. 3Weinhandl ED, Collins AJ. Trend in peritoneal dialysis technique failure in incident dialysis patients. American Society of Nephrology, San Diego, CA, 2018. Therapy Attrition Studies Year Sample Size Findings Guo and Mujais1 2003 >30,000 patients First-year technique failure rates between 18.7% and 20.5% from 1999 to 2001 Afolalu et al.2 2009 5,003 patients 15.6% and 11.9% among large and small centers, respectively, in a regional cohort from 2001 to 2005 Weinhandl ED, Collins AJ3 2016 22,197 patients 19.5 and 20.8 events per 100 patient-years from 2005 to 2009 18.1 and 18.9 events per 100 patient-years from 2010 to 2012
  • 5. AdvancingDialysis.org 7,016 7,320 7,250 7,274 7,589 7,894 8,493 9,307 10,109 10,675 11,949 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 1Analysis of United States Renal Data System Standard Analysis Files. PD technique failure defined by at least 30 days of HD immediately following PD. MORE ATTENTION NEEDED TO KEEP PATIENTS HOME IN 2015 – NEARLY 12,000 PERITONEAL DIALYSIS PATIENTS TRANSITIONED TO HEMODIALYSIS1
  • 6. AdvancingDialysis.org • Peritonitis • Catheter failure • Ultrafiltration failure • Inadequate solute clearance • Psychosocial factors • Abdominal complications • Malnutrition Common Complications Resulting in Peritoneal Dialysis Technique Failure1,2 1Kolesnyk I, Dekker FW, Boeschoten EW, Krediet RT. Time-dependent reasons for peritoneal dialysis technique failure and mortality. Perit Dial Int 2010; 30(2):170–7. 2Kansal SK, Morfin JA, Weinhandl ED. Survival And Kidney Transplant Incidence On Home Versus In- center Hemodialysis, Following Peritoneal Dialysis Technique Failure. Perit Dial Int. 2019 39:25-34. Home Dialysis Continuation needing to transition to hemodialysis, transitioned to home hemodialysis2 >4% of patients
  • 7. AdvancingDialysis.org Planned Transitions to Hemodialysis may Improve Outcomes • Fewer “crashes” into hemodialysis1 • Improvements in fistula placement2 • Less occurrence of fluid overload3 • Reduced hospitalizations and fewer hospitalization days1 • Improved survival and lower risk of death1 1Kansal SK, Morfin JM, Weinhandl ED. Survival and Kidney Transplant Incidence on Home versus In-Center Hemodialysis, Following Peritoneal Dialysis Technique Failure. Perit Dial Int. January-February 2019 vol. 39 no. 1 25-34. 2Boissinot L, et al. Is transition between peritoneal dialysis and hemodialysis really a gradual process? Perit Dial Int 2013; 33(4):391–7. 3Bakris GL, et al. Intensive hemodialysis, blood pressure, and antihypertensive medication use. Am J Kidney Dis2016; 68(5s1):S15–23.
  • 8. AdvancingDialysis.org Reported Outcomes in Patients that Transitioned from Peritoneal Dialysis to Hemodialysis1 1Kansal SK, Morfin JM, Weinhandl ED. Survival and Kidney Transplant Incidence on Home versus In-Center Hemodialysis, Following Peritoneal Dialysis Technique Failure. Perit Dial Int. January-February 2019 vol. 39 no. 1 25-34 Transplantation Incidence (4-year follow-up) Survival (4-year follow-up) Hospitalization Days Hemodialysis Setting Study Population 33,452 peritoneal dialysis patients transitioned to hemodialysis 521 patients to Home HD (3.8%) 9.1 hospitalization days during transition 70.1% survived 28.8% transplanted 32,931 patients to In-center HD (96.2%) 18.5 hospitalization days during transition 62.4% survived 22.4% transplanted
  • 9. AdvancingDialysis.org • 24% lower risk of death in transitions to home hemodialysis vs. in-center hemodialysis • Risk of death varied significantly based on Medicare coverage: ‒ 43% lower risk of death in non- Medicare patients ‒ 8% lower risk of death in Medicare patients • ESRD duration at the time of PD therapy attrition was 1.4 years greater in home hemodialysis patients with vs. without Medicare Lower Risk of Death in Transitions to Home Hemodialysis1 Hazard ratios of death for home hemodialysis versus matched in-center hemodialysis patients. HHD = home hemodialysis; IHD = in-center hemodialysis. Hazard ratio 0.76 (0.65–0.90) 1Kansal SK, Morfin JM, Weinhandl ED. Survival and Kidney Transplant Incidence on Home versus In-Center Hemodialysis, Following Peritoneal Dialysis Technique Failure. Perit Dial Int. January-February 2019 vol. 39 no. 1 25-34
  • 10. AdvancingDialysis.org 62.4% 70.1% • 4-year survival differences between home hemodialysis and in-center were 7.7% overall • Survival differences varied by Medicare coverage: ‒ 12.5 point improvement 4-year survival in non-Medicare patients ‒ 4.0 point improvement 4-year survival in Medicare patients • ESRD duration at the time of PD therapy attrition was 1.4 years greater in home hemodialysis patients with vs. without Medicare Improved Survival in Transitions to Home Hemodialysis1 Survival in non-Medicare peritoneal dialysis patients transitioned to home hemodialysis and In-center hemodialysis. 1Kansal SK, Morfin JM, Weinhandl ED. Survival and Kidney Transplant Incidence on Home versus In-Center Hemodialysis, Following Peritoneal Dialysis Technique Failure. Perit Dial Int. January-February 2019 vol. 39 no. 1 25-34
  • 11. AdvancingDialysis.org • Transplantation incidence differences between home hemodialysis and in- center were 6.4% overall • The likelihood of transplant was 36% higher with home hemodialysis versus in-center, and varied greatly by Medicare coverage ‒ 86% higher likelihood of transplantation in non-Medicare patients ‒ No statistical difference in likelihood in Medicare patients Improved Transplantation Incidence in Transitions to Home Hemodialysis1 Cumulative incidence of kidney transplant among home hemodialysis and matched in-center hemodialysis patients following peritoneal dialysis technique failure 1Kansal SK, Morfin JM, Weinhandl ED. Survival and Kidney Transplant Incidence on Home versus In-Center Hemodialysis, Following Peritoneal Dialysis Technique Failure. Perit Dial Int. January-February 2019 vol. 39 no. 1 25-34 22.4% 28.8%
  • 12. AdvancingDialysis.org Planning for Transitions to Hemodialysis: Proposed Clinical Indicators When the Peritoneal Dialysis to Home Hemodialysis Therapy Transition Makes Sense. Multidisciplinary, Quality Improvement Team Final Report on file. 2014. Accelerate education and intervention Waning Adequacy Hospitalizations Physical Appearance Qualitative Concerns Medical Complications Vintage Malnutrition
  • 13. AdvancingDialysis.org Transition Planning Overview When the Peritoneal Dialysis to Home Hemodialysis Therapy Transition Makes Sense. Multidisciplinary, Quality Improvement Team Final Report. 2014. Stage 1 Healthy PD Adjustment Prepare for the future even as they begin home dialysis Educate on modality options, create Life Plan Stage 2 PD @ Risk Re-evaluation Closely monitor for signs of decline as the journey continues Re-assess if therapy is meeting needs, re-educate on modality options Stage 3 PD Decline Imminent Transition Proactively plan to keep them at home, if that’s what they want Establish access, train on chosen modality
  • 14. AdvancingDialysis.org Recommended Indicators to Manage Planned Patient Transitions to Hemodialysis Stage 1: Healthy PD Stage 2: PD @ Risk Stage 3: PD Decline Adjustment • Peritonitis episode • Albumin level < 3.5 • Life-changing events (family, change in social support, depression) • PD vintage > 5 years • Transplant waiting list > 2 years When the Peritoneal Dialysis to Home Hemodialysis Therapy Transition Makes Sense. Multidisciplinary, Quality Improvement Team Final Report. 2014.
  • 15. AdvancingDialysis.org Recommended Indicators to Manage Planned Patient Transitions to Hemodialysis Stage 1: Healthy PD Stage 2: PD @ Risk Stage 3: PD Decline Re-evaluation • Declining or loss of Residual Renal Function • Albumin level <3.0 ‒ or decrease of .2 every 2 months • 3 or more infections within a year ‒ Ex. peritonitis, ES, tunnel ‒ 1 very severe episode (fungal, sclerosing) • <1 L/day of UF combined with residual and therapy • Increasing number of exchanges • Use of Icodextrin • Declining adequacy ‒ Kt/V<1.7 after Rx adjustments • Decline in physical appearance and or abilities When the Peritoneal Dialysis to Home Hemodialysis Therapy Transition Makes Sense. Multidisciplinary, Quality Improvement Team Final Report. 2014.
  • 16. AdvancingDialysis.org Recommended Indicators to Manage Planned Patient Transitions to Hemodialysis Stage 1: Healthy PD Stage 2: PD @ Risk Stage 3: PD Decline Imminent Transition • 3 or more indicators, plus the following: • Medical complications • Ex. cardiovascular decline, fractures, hernias, leaks • >3 hospitalizations in 1 year (ICU) When the Peritoneal Dialysis to Home Hemodialysis Therapy Transition Makes Sense. Multidisciplinary, Quality Improvement Team Final Report. 2014.
  • 17. AdvancingDialysis.org Key Takeaways FINDING1 • Keeping patients on a home home modality offers better outcomes • PD patients transitioning to hemodialysis already are accustomed to managing treatment at home RECOMMENDATION1 • Planning modality transitions, with the aim of keeping patients home, should be a core strategy as the dialysis patient population grows • Leverage patient knowledge of chronic disease, self-management at home ‒ Previously trained to manage supplies, interface with a dialysis cycler and aseptic techniques and supplies When the Peritoneal Dialysis to Home Hemodialysis Therapy Transition Makes Sense. Multidisciplinary, Quality Improvement Team Final Report. 2014.
  • 18. AdvancingDialysis.org Broader context as summarized by Dr. José Morfín: UC Davis School of Medicine • Increased hemodialysis treatment frequency may be particularly important for peritoneal patients, particularly after transitioning to hemodialysis • Transiting to more frequent home hemodialysis may be especially helpful for patients with: ‒ Deteriorating cardiac status (due to volume expansion) ‒ Rising blood pressure ‒ Worsening left ventricular hypertrophy • The most practical setting that conforms to increased treatment frequency is home • Encouraging the transition from peritoneal dialysis to home hemodialysis is an evidence-based approach and we have 12,000 (or more) chances each year to make this transition happen Dr. José Morfín is an Associate Professor at UC Davis School of Medicine and is the Medical Director of Home Dialysis Services at Satellite Wellbound in Sacramento, California. Dr. Morfín launched his first home program in 2009 and in 2017, launched Optimal Transitions™—A first-of-its-kind program that provides dialysis patients and their families the time, support and resources needed to select the right dialysis therapy for them. Dr. Morfín is a member of NxStage Medical’s Scientific Advisory Board.
  • 19. AdvancingDialysis.org About this presentation This presentation is one in an ongoing series focused on recent articles, clinical findings or guidelines related to issues affecting dialysis patients. AdvancingDialysis.org is dedicated to providing clinicians and patients with better access to and more awareness of the reported clinical benefits and improved quality of life made possible with home dialysis, including more frequent, solo, more intensive, and nocturnal therapy schedules. For more information, visit AdvancingDialysis.org AdvancingDialysis.org is a project of NxStage Medical, Inc.
  • 20. AdvancingDialysis.org Risk and Responsibility All forms of hemodialysis, including treatments performed in-center and at home, involve some risks. When vascular access is exposed to more frequent use, infection of the site, and other access related complications may also be potential risks. In addition, there are certain risks unique to treatment in the home environment. Patients differ and not everyone will experience the reported benefits of more frequent hemodialysis. Certain risks associated with hemodialysis treatment are increased when performing solo home hemodialysis because no one is present to help the patient respond to health emergencies. Certain risks associated with hemodialysis treatment are increased when performing nocturnal therapy due to the length of treatment time and because therapy is performed while the patient and care partner are sleeping.

Editor's Notes

  1. New
  2. Michelle - Could be a large patient pool to try something different.
  3. Still updating
  4. Why not use these indicators as triggers to accelerate patients on their education and intervention path? In this way, they’ll be prepared, well before the time when transition is necessary and imminent. And that can lead to greater patient comfort when it comes to making decisions and making their modality transition.
  5. The longer a patient is on PD, the harder it is to manage their care. As time progresses, they may experience more drain pain, have more infections, and suffer from other signs of decline. By stage 3, transition to a new modality is imminent. This is where proactive planning, and education throughout stages 1 and 2, really pays off. With a plan in place to keep them home, if that’s what they want, you can now focus on establishing access and training on the chosen modality.
  6. Reformat stage 1,2&3 like this
  7. Reformat stage 1,2&3 like this
  8. Reformat stage 1,2&3 like this