I read a journal article about the combined hemo/PD in Advances in Peritoneal Dialysis, Vol. 18, 2002 entitled “Five Years Experience of Combination Therapy: Peritoneal Dialysis with Hemodialysis.” I believe the study was done in Japan. It is mostly PD with a day or two of HD as I recall.
Don’t know if you have read anything about the “un-physiology” theory that was popular in the 70s and has come back into its own. It basically says that doing HD 3x weekly is not good for one’s body since the fluid levels and electrolytes are never truly at a normal level. I will have to look for the article and send you the link. It really makes sense.
Yes, combination therapy is possible–the trick is how to get it paid for. And the “combination” can go in various directions, like:
– 3x/week in-center HD + a PD exchange/day
– Manual or cycler PD + 1-2 HD treatments/week
PD does some things HD can’t, like removing protein-bound solutes. Adding a bit of HD can make PD possible for folks who just aren’t getting quite enough blood cleaning with PD alone.
“CONCLUSION: Hemodialysis and PD are not mutually exclusive. They can be used in combination to achieve targeted solute clearances, to improve certain clinical conditions, and to control volume and blood pressure in a subset of patients. Further evaluation is needed to better establish the long-term outcomes of using combined modality. Total solute clearance goals and methods for determining total solute clearance need to be standardized.”
AND THIS:
"The combined therapy was well tolerated, and symptoms related to uremia improved in all six cases. Additionally, improvements in quality of life (QOL) were documented in all patients who were managed with the combined therapy. "
“We postulated that, for CAPD patients who are unable to achieve adequate solute clearance or volume control following optimization of their PD prescription, adding one hemodialysis session in conjunction with PD therapy (PD+HD therapy) would improve QOL.”
The reason I was interested is - IF my wife had to go back on Hemo Dialysis full time - it reduces quality of life. If however one could augment the PD with one session of Hemo to get more consistent dialysis - then … how bad!
In the thread on Aranesp, I quoted Section 50.6.1 from the Medicare Claims Processing Manual, Chapter 8 that states that Medicare will pay for both HD and PD if it is medically justified at least temporarily. However, Medicare would eventually expect selection of one type of treatment.
[QUOTE=Beth Witten MSW ACSW;16215]In the thread on Aranesp, I quoted Section 50.6.1 from the Medicare Claims Processing Manual, Chapter 8 that states that Medicare will pay for both HD and PD if it is medically justified at least temporarily. However, Medicare would eventually expect selection of one type of treatment. http://www.cms.hhs.gov/manuals/downloads/clm104c08.pdf[/QUOTE]
[QUOTE=Beth Witten MSW ACSW;16215]In the thread on Aranesp, I quoted Section 50.6.1 from the Medicare Claims Processing Manual, Chapter 8 that states that Medicare will pay for both HD and PD if it is medically justified at least temporarily. However, Medicare would eventually expect selection of one type of treatment. http://www.cms.hhs.gov/manuals/downloads/clm104c08.pdf[/QUOTE]
Beth/Dori,
Yesterday, I emailed the information from the Medicare Claims Manual to my dad’s dr.; have not heard back from him yet, but yesterday was an interesting day.
At 6:30AM my dad called me to let me know that the center to his catheter–a blue piece that activates the iodine prior to his PD treatments–was missing. He had no idea how but felt as though it came out and did not want to do dialysis without it for fear of peritonitis (again).
I attempted to reach the dr. on call who never called either my dad or me back; called back to try to reach him again; left a message on my dad’s dr’s phone; called the answering service back again and finally (after an hour and a half) spoke with a dr. who gave us 2 options after saying that neither the HD or PD clinics would be open and staffed until today–first option was to come to the hospital ER and have a nurse “check the catheter” but that they wouldn’t have any “extra parts to fix it” OR he could just not do dialysis at all yesterday and call his nurse this morning. I could not believe it!! I explained to him that my dad could not just suspend dialysis for a day; that it would not be healthy to do so with his fluid retention issues.
My dad left a msg on his doctor’s phone and decided to do his treatment anyway and hope for the best. Finally, at 12:20PM, his doctor saw my email and called my dad; he prescribed an antibiotic to hopefully prevent peritonitis and told my dad to start treatments 6 times daily using 2.25% dialysate each time (rather than two 2.5% and two 4.25%) until he loses 4-5 lbs. While I understand that the lower the concentrate, the easier it is on the peritoneal membrane, when calculating the net total projected fluid taken off he will still be coming out the same (about 1200 mL daily). Each treatment should be easier on the membrane but I wonder if at the end of the day the total treatments will have any different affect?
All that to say that his catheter extension was defective so he went without that idodine protection through one treatment and he is not happy about being tied to the house with 6 treatments daily for however long it takes to lose the weight. I am hoping that the dr. is just doing what he thinks will help to remove the excess fluid and not trying to force my dad into HD before he makes the decision to do so.
I can understand the urge to speak to a doctor when something seems to be wrong, but it is often the nurses who handle the nuts and bolts of PD and who know what needs to be done when something seems to be going wrong. It might be worth it to speak to your dad’s nurse about this. Is he doing manual exchanges? Has he been evaluated for a cycler? Six CAPD exchanges in a day is certainly burdensome. Doing some or all of those with a cycler at night would free up his days for other activities.
Unfortunately, my dad’s nurse is not very helpful; she is not very easy to talk with or compassionate and makes my dad feel incapable of doing anything properly. He works with her, though, and tries to keep the relationship on an even keel, but she has been in dialysis (hemo dept. first, now peritoneal) for 24 years and can be quite intimidating. The dr. and I have a good relationship and he has encouraged me to email him or call anytime. We have absolutely no way of contacting the nurses (there are only two of them in PD) after hours and only a slightly better chance of getting in touch with a dr.
My dad is doing manual exchanges and his dr. said that a cycler would not work for him due to the many issues he has with fluid buildup, etc. I understand this 6x a day procedure to be an experimental thing (to get the excess weight off) and then possibly go to HD for a couple of months with the possibility of returning to PD. It’s just a lot for someone who is 82 years old.
Thank you for getting back to me!! Have a good day.
You might want to read our article about the peritoneal equilibrium test (PET), which is used to decide whether someone is or is not a candidate for a cycler. (http://www.homedialysis.org/resources/tom/200801/). It shouldn’t just be about how much fluid there is to remove–nearly everyone on dialysis has fluid to remove–but how the peritoneum itself works.
I’m not sure which thread – this one or the Aranesp one – you posted that your dad’s drain is 1300ml daily. Is this the amount he drains out plus the 2000ml x 4 that he has been using for his fill each day OR is this the total amount he drains out each day?
I talked with an experienced PD nurse I know who I often turn to when people are having problems with PD, including problems removing enough fluid. She said if your father isn’t draining well, he may have a catheter that’s not positioned correctly. An x-ray should show whether the catheter is in the correct place. She also said he may have a leak in his peritoneum that is allowing fluid to pass from his peritoneal cavity into his tissues. This fluid could build up around his lungs causing a pleural effusionl which would appear as a spot on a scan. I forgot to ask how to tell if there is a leak in the peritoneum. Pleural effusions make it harder for the lungs to work like they should and can cause a cough. Here’s a description of pleural effusion that doesn’t mention CAPD. An article I read said that 90% of pleural effusions in CAPD patients occur on the right side. Was that where the spot showed up?
It might be worth asking the doctor or nurse if either of these might be possibilities, how to rule them out, and what to do if either is found to be present.
