Tailored peritoneal dialysis training program cuts infection, dropout rates

A Singapore hospital has pioneered a tailored peritoneal dialysis (PD) training program that has yielded a significant reduction in PD-related infections and dropouts among patients with end-stage kidney disease (ESKD).

The 4-day PD training program aligns with the International Society for Peritoneal Dialysis (ISPD) recommendations. Trainers tailor their approach to individual needs by using diverse learning methods such as printed manuals and mannequins. The aim was to help patients and/or their caregivers safely perform PD procedures using an aseptic technique, recognize contamination and take appropriate follow-up action, identify changes in fluid balance and its relationship to hypertension/hypotension, and detect, report, and manage potential dialysis complications using available resources.

In a retrospective study, the percentage of patients who dropped out of PD declined over time following the implementation of the tailored training program in 2018. From 40 percent in 2019, the number decreased to 17 percent in 2020, 10 percent in 2021 and 2022, and 7 percent in 2023. [Cureus 2024;16:e67997]

The decrease in dropout rate was statistically significant, with the training program being associated with 55-percent lower odds of patients dropping out of PD (odds ratio, 0.45, 95 percent confidence interval, 0.49–0.84; p=0.010).

Furthermore, the frequency of PD-related infections was maintained within the ISPD guidelines. Exit site infection rates ranged from 0.18 to 0.29 episodes per year, while PD peritonitis rates fluctuated between 0.2 and 0.26 episodes per patient-year.

“The ISPD recommends that overall exit site infection rates should not exceed 0.40 episodes per year at risk, and peritonitis rates should be less than 0.4 episodes per patient-year at risk. These metrics are crucial for assessing the quality of PD care, as they directly impact patient outcomes and treatment sustainability,” the investigators noted. [Nephrol Dial Transplant 2015;30:137-142; Int Urol Nephrol 2017;49:2177-2184]

“High peritonitis and dropout rates often indicate inadequate training, support, or clinical practices, necessitating continuous monitoring and improvement… [And the improvements in dropout rates in the present cohort] likely reflect enhanced patient education, better support systems, and more effective management of comorbid conditions,” they added. [Perit Dial Int 2011;31:614-630; BMC Nephrol 2020;21:205; Am J Kidney Dis 2020;76:42-53]

The investigators underscored the need for further optimization of the one-to-one training model, given its resource-intensive nature and potential for exceeding recommended hours. Gathering feedback from patients and nurses could provide valuable insights for future improvements, they said.

The analysis included 99 ESKD patients (mean age 58.63 years, 55.6 percent male, 59.6 percent had diabetes, 92.9 percent had hypertension) who completed their PD training program at the hospital. The primary causes of ESKD were diabetic nephropathy (56.6 percent), glomerulonephritis (24.2 percent), and hypertension (14.1 percent). The mean baseline eGFR was 7.05 mL/min/1.73m², and the mean albumin level was 35.92 g/L.

“Overall, our experience highlights the importance of targeted training programs and support systems in managing PD effectively. By maintaining low infection rates and reducing dropout rates, we have demonstrated that with the right resources and strategies, it is possible to achieve high standards of care in PD,” the investigators said.

“Our findings contribute to the broader discourse on PD management, offering valuable insights into best practices that can be adopted by other institutions aiming to improve their PD programs,” they added.