GROWING A PERITONEAL DIALYSIS PROGRAM THROUGH NEPHROLOGIST/PRIMARY CARE PHYSICIANS COLLABORATION：A SINGLE CENTER EXPERIENCE

As of the end of 2023, a total number of 343,508 patients were receiving dialysis treatment in Japan, the average age of dialysis initiation is 71.59 years. In Center Hemodialysis (ICHD) accounted for about 97% of all dialysis modalities, while peritoneal dialysis (PD), accounted for the remaining 3%. Despite lower PD penetration, Japan PD is characterized by good clinical outcomes, availability of biocompatible solutions with low GDPs, equivalent reimbursement medical fees between PD and ICHD, and the availability of a regional medical collaborative care model, that potentially function as enablers to grow PD program.

Much of the focus has been on PCPs (Primary Care Physicians) and nephrologists’ collaboration in the early stages of CKD for improved diagnosis, timely referral but less is known about how collaborative care among PCPs, nephrologists and other members of a multidisciplinary care team for end stage of renal disease can enable growth of a PD program in Japan.

 The development and growth of a successful PD program requires that the organization and structure of the program be carefully planned, here we describe the critical steps taken to revamp the PD program at our facility, based on a medical cooperation system of collaboration between PCPs and our care team for PD patients, that includes nephrologists, nurses, pharmacists, dietician and social workers, with the aim of providing a strategy to build a successful collaborative PD program.

We report on our experience of growing a PD program from 2005 to 2024 at Kokura Memorial Hospital (KMH). Up to 2004, there were no PD patients, in 2005 the department of Nephrology initiated a new PD program for the treatment of end-stage kidney disease, and the following steps were taken to initiate and grow the program:

    1  .        CKD education: In Fukuoka Prefecture, the Kitakyushu City CKD Prevention Collaboration System began in 2010 for early detection, early diagnosis, timely referral to Nephrologist by PCP and early treatment of CKD with Nephrologist deciding on either reverse referral or co-management for each CKD patient with the PCP, as described in Figure 1.

In addition, at our level we hold regular CKD educational lectures and seminars catered toward patients, their families, PCPs, and general practitioners. We repeatedly held study sessions with community practitioners, explaining about CKD and the importance of early referrals, emphasizing that the patient will be reverse referred to the PCP along with advice on examinations and treatment policies as specialists. Thus, 2 to 3 years after the study sessions began, more early referrals began to be received by our hospital.

Figure 1: Kitakyushu City CKD Prevention Collaboration System

  2.     Increasing Enrollment of Patients to PD Program through Patient education and shared decision making: we have developed a robust pre-ESRD patient education program at KMH. At our center, all CKD patients are referred to pre-ESRD education classes regardless of their CKD stage. The educational team is comprised of nephrologists, nurses, dieticians, pharmacists, social workers, physical therapists, and psychologists. Using a teamwork approach, to allow patients and families to understand various treatment options and make judicious decisions, thereby allowing orderly planned initiation of the appropriate RRT (renal replacement therapy) modality.

 We also developed a PD initiating program for patients as early as CKD stage 4 with an eGFR<30, which englobes education about different RRT modalities and SDM consultations at different stage until RRT decision (Figure 2). At least 3 SDM consultations by doctors and nurses are planned before RRT decision. In case of frail patients selecting PD, multiple home visits by nurses are scheduled.

Figure 2: PD Initiating Program at KMH

  3.     Physicians and nurses training: a practicing nephrologist and nurse who did not have adequate PD training will be reluctant to offer this therapy. Moreover, ease with PD increases directly with experience, and the centers become more adept at selecting patients to receive PD and treating their complications. In our hospital they are exposed to all aspects of PD including therapy initiation, routine care, evaluation of PD prescription, and participation in multidisciplinary patient care plan meetings and education.

  4.     Successful PCPs/Nephrologists’ collaboration model in PD: in managing a rapidly growing PD program, we faced multiple challenges, which included labor constraints, and logistics. To address these workforce and other challenges, we developed a medical cooperation system that consists of a patient-centered care team of PCPs and a multidisciplinary care team consisting of nephrologists, nurses, pharmacists, dieticians and social workers.

This cooperation system includes PCPs education programs and seminars, study sessions and conferences, explanations of advantages of PD from an economic standpoint and PD reimbursement system.

Clear role segregation with the PCP role consisting of a bimonthly visit that includes a weight check, amount of fluid removed, salt and fluid intake status, infection prevention with exit site check and blood test prescription when needed, with the reassurance of hospital availability 24h/7day in case of emergency or when the PD prescription needs adjustment.

The patients still need to visit our facility once every three months for regular checkups, PET biannually, and for transfer set replacement. In addition, and during the patient visits we also review dialysis prescriptions, staff members re-educate patients regarding PD, their families and their support people, and examine cardiovascular diseases non-invasively. This also provides patients, their family, and the physicians with a sense of security (Figure 3)

Figure 3: PCP and Nephrologist collaboration model in PD

  5.     Continuous quality improvement (CQI) program: PD outcomes can be further improved by the implementation of a continuous quality improvement (CQI) program to track the root cause of peritonitis, exit-site infection, and technique failure, by careful data collection so that appropriate interventions can be implemented.

Moreover to keep the quality of our PD program, we hold twice a month a PD meeting for our PD team (doctor, nurse, social workers, dieticians, pharmacologists) as well as a quarterly to biannually PD meetings with our cooperating institutions that consists of home doctors (not nephrologist), nursing home staffs, to share information and discuss standard PD treatment and cardiovascular disease status of all PD patients under reverse referral.

In Kitakyushu City as a result of the CKD Prevention Collaboration System for early detection and early treatment of (CKD), and the recommended visit to the primary care physician and reverse referral or co-management for each CKD patient by a nephrologist, a shift of the peak of dialysis age introduction has occurred from the 60s to the 70s age range.

We were able to grow our PD program starting from 2005, from 0 to 320 PD patients making us one of the largest PD centers in Japan, with a 40% PD selection rate among incident dialysis patients(Figure　1a). We were also able to expand our medical collaboration system to 23 PCPs clinics, 13 home-visiting PCPs, 28 hospitals, 35 home visit nurse stations, more than 30 nursing care facilities, recovery, and convalescence hospitals. When the patient is in day care, a single bag change can reduce the burden on the family. Currently, five facilities in the Kokura northern and Southern district are capable of PD treatment through day care. Regarding peritonitis, incidence rates of peritonitis at our hospital remain stable at 0.22/episodes/year.

Figure 1a:Growth of KMH PD program from 2002-2025

The development of a successful peritoneal dialysis program requires that the organization and structure of the program be carefully planned, with key components including the development of a strong CKD education program, an adequate training for physicians and nurses, a full complement of supporting staff (including, PCPs, nurses, dietician, and social worker), adoption of remote patient monitoring technologies and a strong continuous quality improvement program. Fostering collaboration between primary care physicians and nephrologists to co-manage peritoneal dialysis patients by leveraging their respective expertise, may further enhance the growth of peritoneal dialysis in Japan.

Figure 2a: Multidisciplinary PD care model