Authors (including presenting author) :
Lee S.H, Tang H.L., Cheuk A., Wong W. Y. S., Chan Y.M., Hui K. C., Kiang Y. C., Ho L. F., Fung Samuel K.S., Tang M. K. C.
Affiliation :
Renal Unit, Department of Medicine and Geriatric, Princess Margaret Hospital, HKSAR
Introduction :
Biocompatible solutions for peritoneal dialysis (PD) have been introduced to Hong Kong to improve patient and dialysis outcomes in end-stage renal disease patients. In comparison with standard conventional dialysis solutions, biocompatible solutions are characterized by a neutral pH and low in potentially nephrotoxic glucose degradation products (GDP). Evidences showed that trends of less ultrafiltration and more fluid accumulation were observed after switching from conventional to low GDP PD solutions, that leading to a higher risk of fluid overload incidents and emergency hospital admissions1,2. An organized structure program is needed to prevent patients from suffering of the foresaid known risks. When the double-chamber bag Stay-Safe Balance Fresenius system became available in May 2018 at Princess Margaret Hospital, patients on conventional glucose containing solutions of Stay-Safe Fresenius system were offered to switch to biocompatible Stay-Safe Balance solutions. A “SAFE” (Safe, Active, Follow-up, Evaluate) Transition program was implemented to overcome challenges and monitoring for the patients. Safe in stages for transition; Active and proactive education; Follow-up progress and compliance; Evaluate and audit on the outcome.
Objectives :
A “SAFE” (Safe, Active, Follow-up, Evaluate) Transition program was implemented to overcome challenges and monitoring for the patients. Safe in stages for transition; Active and proactive education; Follow-up progress and compliance; Evaluate and audit on the outcome.The program aims to safely manage patients who are planned to switch from conventional Stay-Safe Fresenius system to the new Stay-Safe Balance Fresenius system.
Methodology :
A protocol is designed to ensure a safe and smooth transition to the new system. Continuous Ambulatory Peritoneal Dialysis (CAPD) patients currently on Stay-Safe Fresenius system and consented to the program, are invited to attend a half-day educational & practical training session to learn the new technical skills for mixing of PD solutions in a double-chamber bag, and the schedule for system conversion stages involves progressive weekly stages conversion in new solutions starting from one bag change per week with the complete changeover to 4 bags per day (1 patient on 5 bags/d) in 5 weeks. After the first week schedule, patients are followed up by phone weekly for 1 month to monitor the progress: clinical data including body weight (BW), blood pressure, presence of edema, and compliance to dialysis exchange are collected by direct questioning, subsequently if stable monthly for up to 6 months in additional to clinic follow ups by nephrologists 4-8 weekly. In addition, body fluid composition is assessed on the training day, after conversion at one month and at 4-month. Bioimpedance spectroscopy (Body Composition Monitor, Fresenius Medical Care, Germany) is being used3. Through education emphatically, Patient is empowered to manage his/her over-hydration state on self-monitoring and measures to tackle fluid overload.
Result & Outcome :
Ten CAPD patients on Stay-Safe Fresenius system agreed to switch to new Stay-Safe Balance Fresenius system and attended any of the 3 training sessions scheduled on 16 May, 17 May and 10 July 2018 respectively. They were 4 males and 6 females, with mean age 57.1 ranged from 35 to 66. Eight patients (80%) was noted to have over- hydration (OH) state by the bioimpedance spectroscopy before switching to new solutions, ranged from 1.9 to 3.7 L (3.1% to 6.8% of BW). After switching to new solutions at 4th week, the BW changes varied from -1.0kg to +0.7kg, and 8 patients (80%) showed improved OH status with an average reduction of 0.6 L (range from 0.1 L to 2.3 L) in body fluid. However, at 4th month, 7 patients (70%) were found to have a rebound increase in OH of an average 2.8 L (range from 1.5L to 3.3L), in which 5 patients (50%) required increase in PD fluid concentration to tackle their gradual over-hydration states. However, there was no emergency hospital admission due to fluid overload for these patients during the study period. Conclusion The period during conversion to biocompatible solutions may pose higher risk of fluid overload for CAPD patients. A well-structured program with a staged plan conversion protocol to guide the change and empowering patients to monitor and manage early over-hydration condition is effective to prevent patient from potential fluid overload complications and emergency hospital admissions. Reference 1. Szeto C C, Kwan B C H, Chow K M, Cheng P M S, Kwong V W K, Choy A S M, Law M C, Leung C B, Li P K T. (2015). The Effect of Neutral Peritoneal Dialysis Solution with Low Glucose-Degradation- Product on the Fluid Status and Body Composition – A Randomized Control Trial. Oct. 28 2015. PLoS ONE 10(10: e0141425. Doi:10.1371/journal 2. Lichodziejewska-Niemierko M., Chmielewski M., Dudziak M., Ryta A., Rutkowski B. (2015). Hydration Status of Patients Dialyzed with Biocompatible Peritoneal Dialysis Fluids. Peritoneal Dialysis International, Vol. 36, pp. 257-261. 3. Cader RA1, Gafor HA, Mohd R, Kong NC, Ibrahim S, Wan Hassan WH, Abdul Rahman WK. (2013). Assessment of fluid status in CAPD patients using the body composition monitor. Journal of Clinical Nursing. 2013 Mar;22(5-6):741-8. doi: 10.1111/j.1365-2702.2012.04298.x. Epub 2012 Oct 8.
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