# Assisted PD throughout Europe: advantages, inequities, and solution proposals

Anabela Malho Guedes · Sally Punzalan · Edwina A. Brown · Agneta Ekstrand · Maurizio Gallieni · Maite Rivera Gorrín, et al. [full author details at the end of the article]

Received: 1 May 2023 / Accepted: 13 August 2023 / Published online: 19 October 2023
© The Author(s) 2023

## Abstract

**Background** Peritoneal dialysis provides several benefits for patients and should be offered as first line kidney replacement therapy, particularly for fragile patients. Limitation to self-care drove assisted peritoneal dialysis to evolve from family-based care to institutional programs, with specialized care givers. Some European countries have mastered this, while others are still bound by the availability of a volunteer to become responsible for treatment.

**Methods** A group of leading nephrologists from 13 European countries integrated real-life application of such therapy, highlighting barriers, lessons learned and practical solutions. The objective of this work is to share and summarize several different approaches, with their intrinsic difficulties and solutions, which might helpperitoneal dialysis units to develop and offer assisted peritoneal dialysis.

**Results** Assisted peritoneal dialysis does not mean 4 continuous ambulatory peritoneal dialysis exchanges, 7 days/week, nor does it exclude cycler. Many different prescriptions might work for our patients. Tailoring PD prescription to residual kidney function, thereby maintaining small solute clearance, reduces dialysis burden and is associated with higher technique survival. Assisted peritoneal dialysis does not mean assistance will be needed permanently, it can be a transitional stage towards individual or caregiver autonomy. Private care agencies can be used to provide assistance; other options may involve implementing PD training programs for the staff of nursing homes or convalescence units. Social partners may be interested in participating in smaller initiatives or for limited time periods.

**Conclusion** Assisted peritoneal dialysis is a valid technique, which should be expanded. In countries without structural models of assisted peritoneal dialysis, active involvement by the nephrologist is needed in order for it to become a reality.
## Graphical abstract

# Assisted PD throughout Europe: Advantages, inequities, and solution proposals

Anabela Malho Guedes¹, Sally Punzalan², Edwina A. Brown², Agneta Ekstrand³, Maurizio Gallieni⁴,⁵, Maite Rivera Gorriola⁶, Helga Gudmundsdottir⁷, Marco Heidempergher⁸, Benno Kitsche⁸,⁹, Thierry Lobbedez¹⁰, Ulrika Hahn Lundström¹¹, Kate McCarthy¹², George J. Mellotte¹³, Olivier Moranne¹⁴, Dimitrios Petras¹⁵, Johan V. Povlsen¹⁶ and Martin Wiesholzer¹⁷

¹Servicio de Nefrología, Centro Hospitalar/Universitario do Algarve, Faro, Portugal, 2Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK, 3Abdomen Centre, Nephrology, Helsinki University Hospital, Helsinki, Finland, 4Department of Biomedical and Clinical Sciences, Università di Milano, Milan, Italy, 5Nephrology and Dialysis Unit, ASST Fatebenatratèl Sacco, Milano, Italy, 6Servicio de Nefrología, Hospital Ramón y Cajal, Madrid, Spain, 7Department of Nephrology, Oslo University Hospital, Ullevål, Oslo, Norway, 8Kuratorium for Dialysis and Nirentransplantation e.V., Cologne, Germany, 9NADia- Network assisterte Dialysen, Berlin, Germany, 10Nephrology, CHU CAEN, Normandy, France, 11Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden, 12Baster healthcare Ltd, Wallingford, Compton, Newbury, UK, 13Ninity Health Kidney Centre, Tallaght University Hospital, Tallaght, Dublin, Ireland, 14Department of Nephrology-Dialysis-Apheresis, CHU Carenneau Nimes, Nimes, France, 15IDESP Montgelior University, 15Department of Nephrology, General Hospital “Wigglestar”, Athens, Greece, 16Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark and 17Clinical Department for Internal Medicine, University Hospital St. Poulten, Karl Landsteiner University of Health Sciences, St. Poulten, Austria

### Background:

- PD should be offered as first kidney replacement therapy for frail patients.

- Limitations to self care can be an important obstacle, in the absence of global models of assisted PD (asPD).

### Methods:

- 13 European nephrologist integrated real-life application of such therapy, highlighting barriers, lessons learnt and practical solutions.

- The objective of this work is to share and summarize several different European approaches, with their intrinsic difficulties and solutions, which can help each PD unit to develop and offer asPD.

### Main results:

<table><thead><tr><th></th><th>Question</th><th>Evaluate</th><th>Answer</th></tr></thead><tbody><tr><td>Choice</td><td>PD</td><td>No contraindications, eliminate barriers</td><td>PD should be seen as a first dialysis option</td></tr><tr><td>Choice</td><td>AsPD</td><td>Provide options</td><td>Provide initial assistance, re-evaluate capacity for performing self-care regularly</td></tr><tr><td>Patient</td><td>HD less favourable<br>Dialysis refusal</td><td>Cardiorespiratory and/or diabetic patients, adverse vascular access evaluation</td><td>Nephrologists' awareness of potential complications pursuing with HD option, informed decision of the patient</td></tr><tr><td>Patient</td><td>Status</td><td>Psychologic status, and verify correct information, is PD an option?</td><td>Refusal for self-care should lead to asPD, a period on asPD might destroy myths and barriers to dialysis, and reliefs the uremic milieu</td></tr><tr><td>Patient</td><td>Incremental asPD</td><td>Frailty, autonomy</td><td>AsPD improves clinical status of the frail and elderly patients, but those aren't the only ones to benefit from asPD</td></tr><tr><td>Prescription</td><td>asCAPD</td><td>Possibility of 2 home daily visits</td><td>One or two CAPD exchanges might be enough to start with</td></tr><tr><td>Prescription</td><td>asAPD</td><td>Possibility of 3 home daily visits</td><td>AsPD responsibility can be shared between parties, paid caregivers, asPD program providers and family, if 3 or 4 visits are prohibitive for asPD</td></tr><tr><td>Assistant</td><td>Family member<br>asPD program</td><td>Possibility of 2 home daily visits, with eventual reduction to once/daily</td><td>The level of assistance can change, normally reducing over time</td></tr><tr><td>Assistant</td><td>Paid caregiver</td><td>Availability and interest</td><td>Involve the family in the decision making, although the existence of close family doesn't mean availability for asPD</td></tr><tr><td>Assistant</td><td>Community Assistant</td><td>Eligibility of the patient</td><td>Still the best option: an organized system of assistance – not available in all countries</td></tr><tr><td>Cost</td><td>Personal</td><td>Prices and responsibility</td><td>Collaboration with Renal Units with regular communication and formation</td></tr><tr><td>Cost</td><td>Country</td><td>Social partners that are able to provide for asPD</td><td>Collaboration with Renal Units with regular communication and formation</td></tr><tr><td>Availability</td><td>Ethics</td><td>Contrast with HD transports (health care policy)</td><td>Non-health related professionals can execute PD, as long as trained in the Renal Unit</td></tr><tr><td>Availability</td><td>Ethics</td><td>Is there equity in dialysis offer?</td><td>Public care policy must change, economic studies are available, showing lower costs with asPD contrasting with in-centre HD</td></tr></tbody></table>

<figure><img src="image_1.png" /></figure>

Journal of NEPHROLOGY

<figure><img src="image_2.png" /></figure>

official journal of the Italian Society of Nephrology

### Conclusion:

AsPD is a valid technique, which should be expanded. In countries without structural models of asPD, it needs the nephrologist active consideration to become a reality

**Keywords** Assisted Peritoneal Dialysis · Community care · Frailty · Equity · Quality of life

## Introduction

Peritoneal dialysis (PD) provides several benefits for patients and should be offered as the first kidney replacement therapy when pre-emptive kidney transplant is not feasible, particularly for fragile patients [1]. Over the years, numerous barriers hindering PD initiation have been identified. As barriers have arisen, solutions appear in the same proportion of the imagination and resources of the nephrologist. Limitations to self-care drove assisted peritoneal dialysis (asPD) to evolve from family-based care to institutional programs, with specialized care givers. Since the first report of asPD was published in Europe [2], things have evolved, but important inequities in healthcare systems still persist. Although asPD has been available and widely used in some European countries for many years now, it remains unavailable or poorly utilized in many others [3]. Some European countries have overcome this, while others are still bound by the availability of volunteers to become responsible for treatment, otherwise, in-center hemodialysis (HD) becomes inevitable. A recent survey among European nephrologists revealed that around 40% of PD centers had no access to asPD [4]. In a recent paper requesting a call to action for increased and equal access to PD based on Assisted PD, a

group of leading nephrologists from several western European countries formed a group to drive increased availability of asPD in Europe and in their own countries [3]. From this collaboration, insights were provided into the main advantages and obstacles to PD for older, frail people; different global models of assisted PD delivery were compared, and the experience of asPD across 13 European countries was shared.

In this context, the same panel of specialists amalgamated real-life application of such therapy, highlighting barriers, lessons learned and practical solutions. Each experience is unique, but each one of them is focused in providing the best care to a non-autonomous patient for PD technique. The objective of this work is to share and summarize several different European approaches, with their intrinsic difficulties and solutions, which might help each PD unit to develop and offer asPD on a regular basis.

## Methods

Against this background, some of the leading nephrologists from several western European countries formed a group to drive increased availability of asPD in Europe and in their
<table><caption>**Table 1** European Case Studies</caption><thead><tr><th>Country</th><th>Problem</th><th>Action</th><th>Impact</th><th>Points of learning</th></tr></thead><tbody><tr><td>Case study 1 Austria</td><td>71 years, on PD since 2011<br>Pleuroperitoneal leak in 2014+psychiatric issues<br>Relapse of leak after 8 weeks on HD<br>Successful surgical repair<br>Patient wants to stay on PD–no family support, lost ability for self-care<br>Transition for HD was a major concern due to his psychiatric condition</td><td>Home based 24-h-care was needed for multiple issues<br>APD regime, with 2 home visits by nurses of the Renal Unit<br>Patient improved and learnt how to disconnect–asPD with 1 daily visit (for cycler set-up)</td><td>The patient maintained a home-base therapy, which enabled him to visit his sister, who was trained for APD, to ensure his short visits<br>The patient gained social and health status, and acquired partial responsibility for his treatment</td><td>Interaction with his family (sister), his family doctor and the home based 24 h-care-assistants enabled the recovery of this patient<br>In 2014 only specialized nurses in Nephrology were allowed to perform PD, resources were limited, 2–visit/day was the initial compromise</td></tr><tr><td>Case study 2 Finland</td><td>88 years, CKD<br>Prevalent patient in APD<br>Dementia ensued 5 years after PD initiation</td><td>Switched to CAPD 3times per day, PD staff educated the home care staff (that she was able to afford)</td><td>Quality of life maintained, avoiding travelling to a HD unit</td><td>Collaboration of Renal Units with private carers is a feasible option, when the patient has economic ability to pay, in the absence of a public care policy for asPD</td></tr><tr><td>Case study 3 France</td><td>85 years, CKD<br>The patient chose PD, but unable to perform the technique due to cognitive dysfunction and dexterity<br>His wife refused to assist him on the dialysis</td><td>Nurse-assisted CAPD, 3 exchanges per day was initiated</td><td>Improved quality of life, as he opted for asAPD and after 3 months he is able to connect and disconnect his PD catheter, assistance is maintained for cycler set-up</td><td>The existence of a close family member doesn't mean availability for asPD<br>The best option is an organized system of assistance<br>The level of assistance can change, normally reducing over time</td></tr><tr><td>Case study 4 Italy</td><td>85 years, CKD stage 5<br>No family support, autonomous, but assisted by a caregiver in daily house routines<br>The patient refused HD, refused self-care, opted initially for conservative treatment</td><td>AsPD was offered, and the patient agreed<br>Caregiver was trained on PD<br>The patient was started on incremental CAPD</td><td>The patient didn't feel limited in his daily life, for 3 years, which was the main motif for refusal of dialysis in first place<br>He travelled for summer vacation with his caregiver<br>Dialysis was discontinued due to dementia</td><td>HD refusal must drive the team to offer PD, refusal for self-care led to asPD<br>PD can be executed by non-health related professionals, as family members, or another caregiver</td></tr><tr><td>Case study 5 Ireland</td><td>80 years, frail, unable to perform PD, developing recurrent infections</td><td>Engaged a private healthcare nursing service</td><td>Remains on asPD, at home</td><td>Public care policy must change to support asPD similar to the support offered to pay two-way travel to HD facilities and higher HD costs, 3 times per week</td></tr><tr><td>Case study 6 Greece</td><td>80 years, frail, unable to perform PD, developing recurrent infections<br>78 years, cardiorenal syndrome, reduced vision<br>No family support, 50 km from Renal Unit<br>Patient refused HD</td><td>Limited family support<br>Transferred to in-centre HD<br>A caregiver (paid by the patient) was trained on PD<br>Incremental asCAPD was initiated</td><td>In-centre HD, 3 times per week, with paid transportation<br>The patient quality of life improved, hospital readmissions due to fluid overload ceased</td><td>No AsPD available, if no family member involved<br>This was the only case of asPD (excluding supported by family member) in the last 25 years</td></tr><tr><td>Case study 7 Portugal</td><td>77 years, prevalent PD patient, well adapted to APD<br>Suffers an ischemic cerebellar stroke—requires functional capacitation at a Physical Rehabilitation Unit<br>Refusal of transition to HD, due to very low BP and bedridden state</td><td>Daughter offers to perform asAPD at home and to pay for rehabilitation sessions, as the Physical Rehabilitation Unit doesn't provide PD support</td><td>The patient had both treatments at home–asPD and rehabilitation<br>Maintained preserved communication and cognitive status, previous functional state was not recovered</td><td>Equity in dialysis offer must be a priority to preserve our patients' freedom of choice in Health Units (HD would be guaranteed during the Physical Rehabilitation Unit, relying on the transfer of a bedridden frail patient 3x/week, but asPD not considered)</td></tr></tbody></table>

<figure><img src="image_3.png" /></figure>
<figure><img src="image_4.png" /></figure>

<table><caption>**Table 1 (continued)**</caption><thead><tr><th>Country</th><th>Problem</th><th>Action</th><th>Impact</th><th>Points of learning</th></tr></thead><tbody><tr><td>Case study 8 Spain</td><td>62 years, cardiorenal syndrome, hypo-tensive, CKD<br>PD proposed by his Cardiologist, as an ultrafiltration method</td><td>The spouse was trained on PD<br>A nocturnal exchange was prescribed<br>As the patient improved, he was autonom-mous for PD and most daily activities</td><td>Increased survival, this patient was on PD for 6 years<br>Increased his quality of life, allowing him to drive again, and travel</td><td>Initial need of assistance, doesn't mean the patient won't become capable of performing self-care</td></tr><tr><td>Case study 9 Spain</td><td>78 years, blind, CKD<br>Started HD, due to her blindness<br>Multiple vascular access failures (5 AVF, 4 tunnelled CVC, 5 provisory catheters, from 2001 to 2004), neph-rologist preference for HD could have been a barrier to earlier transferal to PD</td><td>The spouse was trained on PD<br>The patient was on asPD for 31 months<br>Died due to pneumonia</td><td>PD decreased her and her husband anx-iety towards vascular access interven-tions<br>PD decreased associated costs</td><td>Vascular access planification could have predicted such difficulties and asPD could have been the first dialysis option<br>PD should be seen as a first dialysis option, if absence of self-care possibil-ity, assisted PD must be addressed by health care teams</td></tr><tr><td>Case study 10 Spain</td><td>19 years, cerebral palsy, CKD<br>The parents opted for PD</td><td>The parents were trained on PD<br>APD with dry day was prescribed</td><td>PD allowed her to stay home with her parents, avoiding 3x/week travel to HD centre</td><td>Not only frail and elderly patients benefit from asPD</td></tr><tr><td>Case study 11 Sweden</td><td>73 years, diabetic, high BP, CKD, amputation of the right lower leg, bedridden in the post-op of lower left leg amputation</td><td>Advanced health care team offered to provide asPD<br>The patient refused APD, due to noise and alarms<br>CAPD-2exchanges per day was initi-ated</td><td>No need for recurrent HD department visits in her frail state</td><td>Two CAPD exchanges seem to be enough to resolve her uremic symptoms</td></tr><tr><td>Case study 12 UK</td><td>68 years, CKD, bipolar disorder, Parkin-son's disease<br>Transplant failed in 2019 and PD was started<br>Loss of autonomy, but sustained PD option</td><td>CAPD increased to 3 exchanges per day, for volume control, 2 exchanges were provided by asPD team, 1 by the private carer<br>Intensified to 4 CAPD exchanges-2 by asPD and 2 by private carers (trained by PD nurse in community)</td><td>HD was not an option for the patient, APD option was excluded due to the night wandering habit of the patient<br>Successful dialysis was possible with asPD</td><td>AsPD responsibility can be shared between parties, paid caregivers, asPD program providers and family, in a col-laborative strategy for the best interest of the patient</td></tr><tr><td>Case study 13 UK</td><td>Prevalent CAPD patient, with repeated hospital admissions due fluid overload in the setting of heart failure with hypotension and loss of residual kidney function</td><td>Conversion to asAPD,<br>The patient was trained to connect and disconnect, an extra daytime exchange and cycler setup was performed by the Renal Technician</td><td>Hospital admissions ceased with regular communication by the Renal Techni-cian and warranted advice<br>The patient feels safe at home, now</td><td>Regular follow-up of unstable situations, whether with a community team with regular reports to the Nephrologist, as in this case, or with frequent Renal Unit visits</td></tr></tbody></table>
<table><caption>**Table 2** Assisted Peritoneal Dialysis Profiles</caption><thead><tr><th>Country</th><th>Age</th><th>Previous dialysis</th><th>assisted PD details</th><th>Nr of assisted procedures</th><th>Assistant</th></tr></thead><tbody><tr><td>Austria</td><td>71</td><td>CAPD, transition to HD</td><td>APD</td><td>1</td><td>Nurses (Renal Unit)*</td></tr><tr><td>Finland</td><td>88</td><td>APD</td><td>CAPD</td><td>3</td><td><strong>Paid</strong> Caregiver</td></tr><tr><td>France</td><td>85</td><td>–</td><td>CAPD followed by APD</td><td>1</td><td>Nurses (asPD program)*</td></tr><tr><td>Italy</td><td>85</td><td>–</td><td>Incremental CAPD</td><td>3</td><td><strong>Paid</strong> Caregiver</td></tr><tr><td>Ireland</td><td>80</td><td>APD</td><td>APD</td><td>2</td><td><strong>Paid</strong> Nursing System</td></tr><tr><td>Greece</td><td>78</td><td>–</td><td>CAPD</td><td>3</td><td><strong>Paid</strong> Caregiver</td></tr><tr><td>Portugal</td><td>77</td><td>APD</td><td>APD</td><td>2</td><td>Family member</td></tr><tr><td>Spain</td><td>62</td><td>–</td><td>Nocturnal CAPD</td><td>2</td><td>Family member</td></tr><tr><td>Spain</td><td>78</td><td>HD</td><td>APD</td><td>2</td><td>Family member</td></tr><tr><td>Spain</td><td>19</td><td>–</td><td>APD</td><td>2</td><td>Family member</td></tr><tr><td>Sweden</td><td>73</td><td>–</td><td>CAPD</td><td>2</td><td>Advanced health care team*</td></tr><tr><td>UK</td><td>68</td><td>Transplant/CAPD</td><td>CAPD</td><td>3</td><td><strong>Paid</strong> Caregiver &amp; Community nurse*</td></tr><tr><td>UK</td><td>–</td><td>CAPD</td><td>APD</td><td>1</td><td>Self &amp; Community assistance*</td></tr></tbody></table>

*Despite these examples, there is national healthcare system fund assistance in Austria, Denmark, France, Norway, Sweden and UK; and an experimental regional healthcare system fund assistance in Italy.

own countries. This panel included one or two nephrologists/ country, from 13 different countries. The meetings started in 2021 in response to the need to increase access to asPD across Europe. These meetings were virtual, timetabled and sponsored by Baxter Healthcare (Europe). As part of this initiative, each member of the group provided information about the use of asPD in their own center and country, barriers to further developments and priorities to enable expansion of access to asPD. Each panel member was asked to contribute with a case report to illustrate barriers, advantages, lessons learned and practical solutions, etc. These illustrative examples were compiled based on the different strategies that might augment asPD availability.

## Results

We describe 13 representative cases (Table 1) and profiles (Table 2) for assisted PD in some countries in Western Europe. Even though healthcare systems are different and there are different social and cultural approaches, we can define some shared aspects that allow us to determine similar causes, circumstances and possible solutions for patients with end-stage kidney disease (ESKD).

## Patients

Starting kidney replacement therapy for ESKD patients represents an important patient biographical breakdown that will determine their quality and span of life. In this environment and taking into consideration that ESKD is

a life-threatening condition, peritoneal dialysis is in many cases the best possible treatment available and in many others the only possible treatment [5, 6].

Assisted PD has been strongly associated with older age, and although it is an important related factor, asPD is not only advocated in such condition, but actually encouraged in a broader range of non-autonomous candidates for PD. An increasing number of ESKD patients suffer from a physical or mental disability preventing adequate PD treatment implementation or performance. Frailty encompasses other dimensions that have been operationally defined by Fried et al. as meeting three out of five phenotypic criteria indicating compromised energetics: low grip strength, low energy levels, slowed walking speed, low physical activity, and/or unintentional weight loss [7].

When asPD is not available, older age and comorbid conditions can be considered contraindications for PD [8]. To respect the patient's shared decision-making, after adequate information and presentation of available solutions, the patient might be compelled to decide for palliative treatment, as long as they do not have to spend most of the day, three days a week in a hemodialysis center often complicated by transportation issues due to disability. This is another reason to raise awareness to asPD availability, as it should be possible to offer it to these patients.

## Social environment

One of the most important and different factors between countries, and also between patient cases, is the social structure, the family structure, and relationships. Some patients
have an adequate and structured social environment that, at least at the beginning, or in specific situations such as intercurrent illnesses, allows them to structure an asPD plan without any external support. Others can afford (and pay for) a professional caregiver to support the asPD therapy. Many patients, eventually, are candidates for external support for their PD treatment and the asPD should be a structured program available through the healthcare system.

## Healthcare systems

We analyzed different healthcare system models, public, private, and combined, and most of them are unable to offer adequate support to these patients. Although asPD has been available and widely used for many years in some European countries, including France, it remains unavailable or poorly utilized in many countries due to an evident lack of support from healthcare systems. In fact, AsPD is not available in many European countries because there is no funding for assistants in the community.

France has the longest and largest experience of asPD [9, 10] using private community nurses funded by the healthcare system to support patients predominantly on manual continuous ambulatory peritoneal dialysis (CAPD) 3–4 exchanges/day. Patient care is maintained by groups of 3–4 nurses with PD experience as they need to visit each patient for each exchange. They are responsible for every connection and disconnection, with the exception of APD patients who are trained to disconnect in the morning.

In many countries, though, the availability of resources for asPD patients depends more on the will and determination of healthcare professionals than on the healthcare system model. In some, even that model prevents any type of home-based assistance.

## PD therapy

Peritoneal dialysis is a self-administrated home therapy. Patients stay at home, adapting the therapy to their lifestyle, and maintaining the best possible quality of life while at the same time benefiting from the best morbidity/mortality results. These patients can lose all these benefits due to a temporary or permanent socio-sanitary situation. Peritoneal dialysis therapy is usually prescribed 7 days a week in a manual CAPD regimen, with different exchanges during the daytime or in an automatic regimen (APD) with exchanges during sleep.

Discussion made the panel of experts aware that asPD patients can benefit from a flexible and individualized prescription whereby patients, following current guidelines [11], can maintain an adequate balance between quality of

life and clinical results. Incremental PD prescription allows for slower decline in residual kidney function. This feature will enable days off PD, so PD, and therefore the assistance, may only be required 5–6 days a week.

New technologies are emerging, with remote monitoring of PD treatments on APD, allowing quicker communication of treatment data with the health care team, thus improving quality of assistance, and virtual reality being used to train assistants. In Germany, some PD training teams are already using virtual reality to train PD patients. This way, the training of the trainers can be done in a resource-saving way and can be repeated as often as needed. It offers a standardized learning protocol in which individual steps can be taught separately and then put in the right order [18–20]. In Italy, the possibility to teach PD patients remotely by video training has proven to be as effective as home training, while significantly reducing the number of home visits, and can be a powerful tool as an alternative type of assistance in PD [21–23].

## Assisted peritoneal dialysis

Assisted PD is defined as PD performed at the patients’ home with the assistance of a health care technician, a community nurse, a family member, or a partner [12]. There are some well-known characteristics of asPD patients compared to patients undergoing self-care PD, such as lower risk of transfer to hemodialysis, a higher risk of death, and a lower probability of transplantation [13].

Furthermore, we have found that asPD is an adequate therapy for (1) offering PD benefits to patients previously classified as “no candidates to PD” (2) allowing kidney replacement therapy when PD is the only indicated or available therapy (3) maintaining patients on PD therapy and thus avoiding unwanted therapy discontinuation (4) providing an adequate temporary solution for ensuing patient problems.

## Discussion

The advantages of using home PD as compared to in-center HD [3] have been identified, and include preservation of residual kidney function and more cost-efficient dialysis modality, to name a few. In relatively fit older patients who can manage PD themselves, illness intrusiveness is lower on PD compared to matched patients on in-center HD [14]. Nonetheless, the inability to perform self-care is often a barrier to PD at home. Assistance is therefore needed and can be provided by a family member or paid healthcare worker; it is available in many countries worldwide and is mostly reimbursed by the healthcare system.
<table><caption>**Table 3** asPD take home messages</caption><thead><tr><th>Question</th><th></th><th>Evaluate</th><th>Answer</th></tr></thead><tbody><tr><td rowspan="3">Choice</td><td>PD</td><td>No contraindications, eliminate barriers</td><td>PD should be seen as a first dialysis option</td></tr><tr><td>AsPD</td><td>Provide options</td><td>Provide initial assistance, re-evaluate capacity for performing self-care regularly</td></tr><tr><td>HD less favourable</td><td>Cardiorenal and/or diabetic patients, adverse vascular access evaluation</td><td>Nephrologists' awareness of potential complications pursuing with HD option, informed decision of the patient</td></tr><tr><td rowspan="2">Patient</td><td>Dialysis refusal</td><td>Psychologic status, and verify correct information, is PD an option?</td><td>Refusal for self-care should lead to asPD, a period on asPD might destroy myths and barriers to dialysis, and reliefs the uremic milieu</td></tr><tr><td>Status</td><td>Frailty, autonomy</td><td>AsPD improves clinical status of the frail and elderly patients, but those aren't the only ones to benefit from asPD</td></tr><tr><td rowspan="3">Prescription</td><td>Incremental asPD</td><td>Possibility of 2 home daily visits</td><td>One or two CAPD exchanges might be enough to start with</td></tr><tr><td>asCAPD</td><td>Possibility of 3 home daily visits</td><td>AsPD responsibility can be shared between parties, paid caregivers, asPD program providers and family, if 3 or 4 visits are prohibitive for asPD</td></tr><tr><td>asAPD</td><td>Possibility of 2 home daily visits, with eventual reduction to once/daily</td><td>The level of assistance can change, normally reducing over time</td></tr><tr><td rowspan="4">Assistant</td><td>Family member</td><td>Availability and interest</td><td>Involve the family in the decision making, although the existence of close family doesn't mean availability for asPD,</td></tr><tr><td>asPD program</td><td>Eligibility of the patient</td><td>Still the best option: an organized system of assistance—not available in all countries</td></tr><tr><td>Paid caregiver</td><td>Prices and responsibility</td><td>Collaboration with Renal Units with regular communication and formation</td></tr><tr><td>Community Assistant</td><td>Social partners that are able to provide for asPD</td><td>Collaboration with Renal Units with regular communication and formation</td></tr><tr><td rowspan="2">Cost</td><td>Personal</td><td>Private paid caregiver</td><td>Non-health related professionals can execute PD, as long as trained in the Renal Unit</td></tr><tr><td>Country</td><td>Contrast with HD transports (health care policy)</td><td>Public care policy must change, economic studies are available, showing lower costs with asPD contrasting with in-centre HD</td></tr><tr><td>Availability</td><td>Ethics</td><td>Is there equity in dialysis offer?</td><td>Preserve and respect our patients' informed option</td></tr></tbody></table>

In 2021, this group of European nephrologists identified major barriers to the use and growth of asPD, namely overall attitudes towards PD, referring to the need for nephrology team education and/or patient education and involvement in dialysis modality decision making [3]. Secondly, the need for involvement with healthcare policymakers regarding recognition and financial support of community care is of particular importance in countries where no reimbursement for assistance exists [3]. Finally, the need for collaboration among PD units so that expertise with asPD can be shared, led to this work exposing some myths, detecting some challenges and sharing solutions found by others.

Assisted PD does not mean 4 CAPD exchanges, 7 days a week, nor does it exclude cycler, and many different prescriptions might work for our patients. For instance, supportive two-exchange asCAPD for older frail individuals can improve symptoms and can be an acceptable dialysis

modality [15]. Indeed, this was adopted in case eleven (Table 1) as a feasible alternative allowing this patient to avoid in-center HD. Tailoring the PD prescription to residual kidney function and maintaining recommended levels of small solute clearance reduces dialysis burden and is associated with higher technique survival [16].

Assisted PD does not mean assistance will be needed permanently. It can be seen as a transitory event towards individual or family caregiver autonomy, full or partial, as in the eighth case (Table 1). Initiation of home-based therapy might be made more difficult by several factors, such as the initial lack of concentration during PD training in uremic patients, the emotional fear of therapy responsibility or even the existence of a transitory physical condition. Guaranteeing initial home support could in several cases be the answer to PD choice. For example, many of our patients rely on a partner to help at first, and then feel assured that they are capable of such task. These fears are
higher if the patient lives alone. Home-support can also be needed for prevalent patients, often on a temporary basis, e.g., after an acute event, partner illness, caregiver holiday [17]. Also, for some patients, assistance can be reduced to one visit a day in APD patients, in most cases only for cycler set-up, thereby reducing AsPD-related costs.

In countries without global models of asPD, family support is not the only feasible option for assistance. As in the second case (Table 1), if the patient has sufficient financial means, private care agencies can be used to provide assistance. Other options may include implementing PD training programs for the staff of nursing homes or convalescence units. Social partners may be interested in participating in smaller initiatives or for limited time periods.

Assisted PD, however, in countries without global models of asPD, will never be a reality if the nephrologist does not take it into consideration. It must be in the nephrologist's portfolio to offer and to be talked about; then families, patients' associations, society and government can take responsibility for assuring care. Several valuable lessons and points of learning come about through normal patients, who challenge our ability to offer them the best solution (Table 1). Table 2 clearly shows the lack of coordinated asPD programs, with family or paid private caregivers taking on the care of these patients. However, the difference in the ease of providing transport and in-center HD compared to all the efforts needed to maintain and respect the initial choice of dialysis therapy of our patients is truly amazing (Table 3).

**Funding** Baxter Healthcare (Europe) funded and arranged the virtual meetings of the authors has funded free open access.

**Data availability** Not applicable.

**Declarations**

**Conflict of interest** AMG.: Baxter Healthcare – speaker fees. EAB.: Baxter Healthcare—advisory board and speaker fees; LiberDi, AWAK—advisory boards; Vifor—speaker fees. GJM Baxter Healthcare—speaker fees. MW Baxter Healthcare—advisory board and speaker fees; Fresenius Medical Care—speaker fees. BK speaker fees: Baxter and Fresenius Medical Care. UHL speaker and consultancy engagements for Baxter Healthcare. AE Advisory Board Boehringer Ingelheim, AstraZeneca. The results presented in this paper have not been published previously in whole or in part.

**Ethical approval** This work was conducted in compliance with the ethical principles of the Helsinki Declaration.

**Informed consent** Informed consent obtained (oral or written), according to each unit policy of data management.

**Open Access** This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source,

provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

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## Authors and Affiliations

Anabela Malho Guedes¹, ∗ · Sally Punzalan² · Edwina A. Brown² · Agneta Ekstrand³ · Maurizio Gallieni⁴,⁵ ·

Maite Rivera Gorrín⁶ · Helga Gudmundsdottir⁷ · Marco Heidempergher⁵ · Benno Kitsche⁸,⁹ · Thierry Lobbedez¹⁰ ·

Ulrika Hahn Lundström¹¹ · Kate McCarthy¹² · George J. Mellotte¹³ · Olivier Moranne¹⁴ · Dimitrios Petras¹⁵ ·

Johan V. Povlsen¹⁶ · Martin Wiesholzer¹⁷

<figure><img src="image_5.png" /></figure>

Anabela Malho Guedes
anabelamalho@hotmail.com

1. Serviço de Nefrologia, Centro Hospitalar Universitário Do Algarve, Faro, Portugal

2. Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK

3. Abdomen Centre, Nephrology Helsinki University Hospital, Helsinki, Finland

4. Department of Biomedical and Clinical Sciences, Università Di Milano, Milan, Italy

5. Nephrology and Dialysis Unit, ASST Fatebenefratelli Sacco, Milan, Italy

6. Servicio de Nefrología, Hospital Ramón Y Cajal, Madrid, Spain

7. Department of Nephrology, Oslo University Hospital, Ulleval, Oslo, Norway

8. Kuratorium Für Dialyse Und Nierentransplantation E.V, Cologne, Germany

9. NADia—Netzwerk assistierte Dialyse, Berlin, Germany

10. Néphrologie, CHU CAEN, Normandy, France

11. Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden

12. Baxter Healthcare Ltd, Wallingford, Compton, Newbury, UK

13. Trinity Health Kidney Centre, Tallaght University Hospital, Tallaght, Dublin, Ireland

14. Department of Nephrology-Dialysis-Apheresis, CHU Caremeau Nimes, IDESP Montpellier University, Nimes, France

15. Department of Nephrology, General Hospital ‘Hippokration’, Athens, Greece

16. Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark

17. Clinical Department for Internal Medicine, University Hospital St Poelten, Karl Landsteiner University of Health Sciences, St Poelten, Austria