How Clinician Preconceptions Affect Peritoneal Dialysis Utilization

Kidney replacement therapy (KRT) is essential to patients with kidney failure. Dialysis is the primary means of providing KRT, comprising 78% of KRT, but just 11% of KRT is performed using peritoneal dialysis (PD). Although PD is simple, effective, and fairly inexpensive, its utilization is limited in many countries. Despite strong support of home dialysis among clinicians and patients worldwide, hemodialysis remains the predominant method of KRT, including in the United States. 

Nikhil Shah, MBBS, DNB, and fellow researchers posited that a major barrier to PD utilization is clinicians’ perceptions of their patients’ suitability and capability to safely perform the treatment. In a study published in KI Reports, the researchers examined the prevalence of myths about PD use among kidney care physicians. They studied physician attitudes about PD initiation according to physical (eg, obesity), social (eg, pet ownership), and clinical (eg, previous surgery) characteristics. 

The researchers gathered an international team of nephrologists to develop a survey that used a Likert scale, allowing respondents to select whether they would “always,” “probably,” “probably not,” or “definitely” offer a patient PD in various situations. Elements of common misconceptions about PD eligibility were included, such as suitability of PD for patients with specific comorbidities (eg, obesity, cirrhosis, polycystic kidney disease, cognitive impairment, immunosuppression), previous abdominal surgeries, stomas, and those requiring urgent-start PD (PD within 2 weeks of catheter insertion). Questions also focused on the presence of pets, swimming, and planning for a future pregnancy. 

Respondents were recruited via several large nephrology and dialysis organizations, an international network of contacts supplied by the authors, and social media channels. Clinician information compiled included professional experience, years in practice, profession, size of PD unit, experience in an ambulatory PD unit, participation in specific home dialysis training, and demographic data such as age, gender, and country of practice. Each country was categorized as a low-income country (LIC), lower middle-income country (LMIC), upper middle-income country (UMIC), or high-income country (HIC). Answers were collected from September 2021 to January 2022. 

A total of 717 clinicians opened the survey, of whom 645 (522 nephrologists and 123 trainees; 56% male) from 54 countries (66% HICs, 22% UMICs, 12% LMICs, 1% LICs) answered at least one question; 574 respondents (89%) answered all the questions. Of those who responded to the survey, 84% worked in units that offered ambulatory or outpatient PD services and 22% had undergone specific home dialysis training. 

In most scenarios, respondents recommended PD, including in situations with repeated exposure to heavy lifting (but only 49% recommended in the case of professional weightlifting) and swimming (especially in a private pool [72%] or sea/ocean [50%]), among patients with cirrhosis or cognitive impairment with support available, in patients with obesity (59% for patients with a body mass index greater than 40 kg/m2), and in those living with a pet if the pet could be physically separated during PD. Some abdominal surgeries were deemed more acceptable with PD (hysterectomy, 90%) compared with others (hemicolectomy, 45%). Similarly, recommendations varied for different types of stomas (nephrostomies, 74%; suprapubic catheters, 53%; ileostomies, 27%). Across various scenarios, clinicians were more likely to recommend PD if they came from HICs or larger PD units, or if they had more clinical experience. 

The authors acknowledge a few limitations of the study. For instance, most respondents come from countries where PD is more prevalent, making meaningful comparisons among countries difficult. Also, there is potential positive bias toward PD from respondents who were sourced through large nephrology organizations. 

“In summary,” the authors wrote, “we found that most nephrologists and nephrology trainees will consider commencing dialysis in the presence of historically reported barriers. We found some variations that may be driven by experience, unit-level characteristics, and region of practice. Globally, evidence-informed education is warranted to rectify misconceptions to enable greater PD uptake.” 

Source: KI Reports