Selecting Dialysis Modality for ESRD Patients: Clinical Advice from ERBP Advisory Board Reference: Covic A, Bammens B, Lobbedez T, et al. Educating end-stage renal disease patients on dialysis modality selection: Clinical advice from the European Renal Best Practice (ERBP) Advisory Board. Nephrol Dial Transplant. 2010;25:1757–1759.

Introduction: EBPG and KDIGO A single set of international guidelines under the guidance of Kidney Disease Improving Global Outcomes (KDIGO) was undertaken. This international effort is however not completely acknowledged by several nephrologists, who at times feel that differences in practice patterns make it diffi cult to apply guidelines developed outside Europe. Alternatively, the latest versions of the European Best Practice Guidelines (EBPG) may appear outdated in some respects, while not all aspects of nephrological practice are currently covered by KDIGO. A European guideline planning was discussed by a specially appointed ERA–EDTA Work Group that met in Paris in early January 2008 and agreed that the Association should continue producing and updating guidelines in collaboration with KDIGO. The decision that ERA–EDTA should issue suggestions for clinical practice in areas in which evidence is lacking or weak, which would be published as ‘clinical advice’ rather than ‘clinical guidelines’ was also agreed upon. The European Renal Best Practice (ERBP) Advisory Board recently decided not to create new or updated guidelines for peritoneal dialysis (PD), as there was not enough new evidence to produce a meaningful change in scope from the previous guidance documents published in 2005 by EBPG.

Introduction: EBPG and KDIGO In its place, the need for an advice on three important PD-related topics for everyday clinical use was called for—peritoneal membrane evaluation, modality selection and adequacy. Presently, the text on membrane evaluation is in press. The following publication that was issued by an ERBP Expert Group and approved by the ERBP Advisory Board comprises the clinical advice on renal replacement therapy (RRT) modality selection for end-stage renal disease (ESRD) patients. The following content is an executive summary of these recommendations, whereas the complete text, including the rationale of the statements, is published in the current issue of NDT Plus. Providing information and assisting in decision making is the focus of these statements, and is not intended to define a standard of care or to improve an exclusive course of diagnosis, prevention or treatment. However, variations in practice are inevitable when physicians take into account individual patient needs, available resources and limitations specifi c for a geographic area, country, institution or type of practice. Moreover, evidence may change over time with newer information, so that practice may be modified subsequently.

Choosing the Initial Dialysis Modality Clinical advice: Recommending hemodialysis (HD) over PD, or vice versa lacks concrete evidence. Hence, it is up to the well-informed patient to chiefly make the initial modality choice. Certain conditions should not be considered as contraindications to PD (see Table 1).

Choosing the Initial Dialysis Modality As a consequence, all available treatment options must be provided by all RRT centers, or in collaboration with other centers—PD (including CAPD and APD), HD (including home HD and nocturnal programs) and transplantation (including cadaveric and noncadaveric), to make sure that all patients can select the modality that is most suitable for them. As a consequence, well-balanced information about the different RRT modalities must be provided by means of a structured education program to all patients and their families. The same applies to late-referred patients and those starting dialysis in an emergency situation, whoshould receive the information once their conditions have stabilized.

Making the Choice between CAPD and APD Clinical advice: As long as the dwell time of the patient is matched to his/her peritoneal transport type, there is no basis to prefer CAPD or APD. Choice should be guided by patient preference as both modalities have reported equivalent outcomes.

Making the Exchange between Modalities Transition from HD to PD Clinical advice: Patients who are on HD and suffering from any of the following clinical conditions must be informed about the option of PD: I. Intradialytic hemodynamic intolerance and muscle cramps despite optimal adjustment of dry weight II. Problems to create a well-functioning native vascular access III. Intractable or recurrent ascites

Making the Exchange between Modalities Transition from PD to HD Clinical advice: Patients on PD and suffering from any of the following clinical conditions should be informed about the option of HD: I. Incapacity to maintain fl uid balance II. Relapsing or persistent peritonitis III. Incapacity to control uremic symptoms or to maintain a good nutritional state IV. Changes in lifestyle circumstances V. Declining residual renal function VI. Intra-abdominal surgery VII. Sclerosing peritonitis

Making the Exchange between Modalities Choice of Dialysis Modality for Patients with Failed Renal Transplantation Clinical advice: There is no proven difference in survival between HD and PD in patients with failed renal transplantation who return to dialysis. Hence, the choice of dialysis modality for these patients should be based on the same principles as those applying to the initial modality choice.

Assisted PD for Nonautonomous Patients Assisted PD is indicated for ESRD patients who choose PD as RRT modality or in whom HD is contraindicated, who have no contraindication to PD, but are incapable to perform PD exchanges by themselves, and whose family members’ quality of life could be affected by the burden of care giving. This modality can be performed at the patient’s home with the help of a healthcare technician, a community nurse, a family member or a partner; and may be proposed either to incident dialysis patients or to previously self-care PD patients who have lost their autonomy. Assisted PD is generally less expensive than incenter HD even with the additional cost of the assistance. The risk of peritonitis is however, similar in nurse-assisted and family-assisted CAPD patients.

Summary All RRT centers should be equipped with both PD and HD facilities and provide unbiased information to ESRD patients, thereby allowing them to freely choose between the two RRT modalities. The leading criterion for modality selection should be patient’s preference in both ‘de novo’ and failed renal transplantation cases. Alternatively, the availability of both modalities enables transition of patients from one modality to another, whenever particular clinical conditions occur. Assisted PD serves as the alternate option for non-autonomous patients to be treated with PD, to incenters HD. The clinical advice presented is believed by the ERBP Expert Group to be useful in expanding the use of PD in countries where it is currently underused. The availability of alternate options in RRT programs would allow patients to choose the dialysis modality they find most suitable for them. Besides, it serves to decrease the burden of HD units and lead to expenditure savings.

Comprehensive Basket in Anemia Management