NKF K/DOQI GUIDELINES 2000
GUIDELINES FOR PERITONEAL DIALYSIS ADEQUACY
VI. Strategies for Increasing the Likelihood of Achieving the Prescribed Dose of Peritoneal Dialysis
Identify and Correct Patient-Related Failure to Achieve Prescribed PD Dose (Opinion)
Potential patient-related causes of failure to achieve prescribed peritoneal dialysis dose should be investigated and corrected. These include:
Failure to comply with the prescription.
Lack of understanding of the importance of adherence to the full prescription.
Sampling and collection errors.
Rationale A detailed rationale is presented in Appendix H. The following is a summary.
Preliminary data from the USRDS DMMS Wave II project show that 487 CAPD patients self-report full compliance with 82.8% of their exchanges.3 One exchange/week is missed by 11.5% of patients and 2 to 3 exchanges/week are missed by 4.5% of patients, all self-reported. The American Association of Kidney Patients completed a patient self-reported survey about the impact of these DOQI guidelines and came up with a very similar number for frequency of missed exchanges.
Conditions causing noncompliance in PD patients have not been adequately analyzed. From studies on compliance with chronic drug regimens, it is known that patients are more compliant when they are convinced about the appropriateness and beneficial effects of the prescribed treatment and that frequent reinforcement of the importance of the treatment is associated with better compliance. Therefore, it is the opinion of the Work Group that, in addition to giving careful consideration to the selection of medically appropriate candidates for PD, as detailed in Section VIII: Suitable Patients for Peritoneal Dialysis, special emphasis should be placed on education of PD patients about the importance and technique of the PD prescription. Instructions should be repeated at least every 6 months, and patients should be monitored for signs of change in compliance. Monitoring the output of creatinine in the dialysate plus urine, as detailed in Guideline 7: PD Dose Troubleshooting, is recommended by the Work Group as a method for measuring compliance.
Identify and Correct Staff-Related Failure to Achieve Prescribed PD Dose (Opinion)
Potential staff-related causes of failure to achieve prescribed peritoneal dialysis dose should be investigated and corrected. These include:
Errors in prescription.
Inadequate monitoring of delivered dose.
Inadequate patient education.
Rationale To increase the likelihood of achieving a prescribed dose of PD, it is necessary to elucidate the staff-related causes of failure to achieve a prescribed dose of peritoneal dialysis. The Work Group found no reports addressing this issue in PD; the following discussion represents the opinion of the Work Group members.
Inadequate understanding of the physiology and kinetic principles of PD by the physicians and nursing staff may result in:
Errors in patient selection.
Errors in the prescription of the PD dose.
Errors in monitoring whether the prescribed dose is delivered.
Errors in PD dose modification to achieve the prescribed goal.
Inability to test for and recognize patient noncompliance.
Inadequate patient education.
The impact of patient education on patient compliance with the PD prescription was discussed in Guideline 19: Identify and Correct Patient-Related Failure to Achieve Prescribed PD Dose. The chance of inappropriate prescription of the PD dose is enhanced when the prescribing physician has a sketchy knowledge of the principles of clearance studies in PD. It has recently been recognized that nephrology fellowship curricula lack emphasis on training in dialysis.92 To prescribe and deliver the proper dose of PD, nephrologists must ensure adequate education and training in PD.
The use of computer modeling in PD may help achieve the prescribed dose by suggesting various options to alter the PD dose. This approach may assist in avoiding unrealistic PD dose schedules for certain patients (see Guideline 18: Use of Empiric and Computer Modeling of PD Dose).
The use of total creatinine appearance/output data in detecting noncompliance is important, as discussed in Section II: Measures of Peritoneal Dialysis Dose.
Inadequate education may be a key factor in the patient nonadherence to the prescribed dose of therapy resulting in the above-mentioned shortcuts. The American Association of Kidney Patients reports that PD patients are willing to increase the frequency and/or volumes of exchanges, if necessary, and that explanations (education) and participation in decision making are good incentives. Inadequate education may stem from both poor educator understanding of the principles of clearance and lack of proper teaching technique. Staff responsible for patient education should be trained and competent in both the principles of clearance and the technique of patient instruction.
RECOMMENDATIONS FOR RESEARCH
Validate methods of assessing compliance.
Evaluate the association between patient understanding of PD techniques and compliance. Specifically, what is the role of inadequate patient knowledge in noncompliance?
Evaluate effect of staffs knowledge of clearance principles and teaching techniques and repetition frequency of patient instruction on proper delivery of PD dose.
Is there a psychological profile which is predictive of noncompliance? If so, what is the best method to characterize this profile?
© 2001 National Kidney Foundation, Inc