SP685DIALYSIS MODALITY SELECTION: FROM THE PRE-DIALYSIS EDUCATION CLINIC TO THE FINAL DECISION

Abstract

INTRODUCTION: Pre-dialysis education clinic aims to elucidate and clarify patients about the different options of treatment of advanced chronic kidney disease, helping them make an informed choice of modality. In this single-moment appointment, patient expresses a preferential dialysis modality, which is not always the one that initiates. METHODS: This work intends to make a comparative analysis between the initially preferred dialysis modality and the modality that the patient started, identifying factors that may be associated with this change. RESULTS: In the period between 1st January 2014 and 31th December 2017, 284 patients were observed in the pre-dialysis education clinic. 65% male (n=184), median age of 66.0 years, a follow-up time in the nephrology clinic of 51 months and a mean eGFR value of 12.2mL/min. 89% were autonomous (n=252) and 22% were professionally active (n=63). 47% had type 2 diabetes mellitus, 96% arterial hypertension, 60% dyslipidemia and 38% heart disease. 90% had no contraindication to any dialysis technique (n=255) and 32% were potencial kidney transplant candidates (n=91). At the end of the follow-up, 56% initiated dialysis technique (n=147), 33% remained in the pre-dialysis period (n=102), 10% died (n=31) and 1% were lost (n=4). Among patients who started dialysis, at the moment of pre-dialysis education clinic, 54% showed preference for hemodialysis (HD) (n=80) and 40% for peritoneal dialysis (PD) (n=58). At the end, 76% started HD (n=111) and a significant lower number than the initial one (p<0.001) started PD (25%, n=36). Only 2 patients changed their initial preference from HD to PD. Among patients whose initial preference was PD, at the end of the study, 25 started HD (43%). Of these, 20% (n=5) started with a dialysis central venous catheter and the remainder with an arteriovenous fistula. We found that those patients who changed their option to HD were statistically significantly older (70 versus 51.5 years, p<0.001), were less professionally active (52% versus 24%, p=0.031), had more hypervolemia (28% versus 9%, p=0.013), rate of hospitalization (28% versus 2%, p=0.009) and lower eGFR values (6.8 versus 7.7mL/min, p=0.024). However, we didn't found differences neither in other studied variables neither in the degree of autonomy during follow-up. CONCLUSIONS: This study showed that 43% of patients who have had initial preference for PD, changed their choice for HD, and this does not seem to be related to higher prevalence of comorbidities or to the degree of autonomy. Higher age and lower professional activity may be a cause of less motivation of nephrologists, patients and relatives for the beginning of PD, which has a lower financial burden and at least has a comparable survival to HD. In addition, some studies have shown that PD may be better in the elderly, without a higher incidence of infectious and non-infectious complications. We believe that increasing the frequency of pre-dialysis education clinic, which is currently a single moment, or developing a low clearance clinic may change this reality.