#4909 THE HEALTHCARE ACTIVITY BURDEN OF A HOME-BASED TREATMENT: A SUMMARY OF THE FIRST 365 DAYS OF PERITONEAL DIALYSIS
Authors: Crowe Kirsty , Murray Eleanor , Macleod Joan , Thomson Peter 
Published: June 2023

Abstract

Background and Aims
Peritoneal dialysis (PD) is the incident kidney replacement therapy (KRT) for 16% of patients in Scotland. Conveying the healthcare-related burden associated with KRT is essential for informed patient choice but has not been characterised as comprehensively in PD as in haemodialysis (HD) or kidney transplantation. Knowledge of the patient journey and the cumulative impact of renal service interactions is key to practising patient-centred realistic medicine, and considering service configuration, resource deployment, and the targeting of carbon emission reductions necessary for addressing the climate emergency. This study therefore aimed to capture the nature and extent of kidney-related healthcare activity in the first year of PD therapy.

Method
This retrospective observational study included all incident adult patients on PD between 1st January 2015–31st December 2019 from two Scottish health boards servicing a population of 1.6 million people. Analysis was undertaken of prospectively recorded healthcare-related activity from the electronic patient record. Data pertaining to hospital admissions, scheduled and unscheduled outpatient clinic, and home visit activity was captured up to the first 365 days post commencement of PD, and censored by death or switch in KRT modality. Data concerning dialysis access activity, radiological activity and relevant infection episodes was also analysed. Carbon mapping of healthcare activity was estimated using patient postcode data and previously published carbon footprint estimations.

Results
PD was initiated in 122 patients over the study period. Four patients died and 63 patients (52%) transitioned to another KRT within 365 days of commencing PD (10 live donor kidney transplantation, 19 cadaveric kidney transplantation, 34 HD) and one patient recovered native function. The median duration from insertion of PD catheter to utilisation was 26 days (IQR 34). Mean distance travelled to renal unit was 23.7 miles. Over the first year, patients had a mean 36.4 days (SD 22.7) of face-to-face contact days with renal services. This included a mean of 1.5 (SD 1.6) hospital admissions, with a median 5 (IQR 10.8) in-patient days. Additionally, a mean of 2.5 (SD 2.5) unscheduled ambulatory assessments per patient; 4.7 (SD 6.2) telephone consultations; 14.9 (SD 8.96) face-to-face clinics with a PD nurse and 7 (SD 3.9) with a nephrologist, and 2.5 (SD 3.4) home visits occurred. Within these contact episodes there were on average 4.4 (SD 4.1) radiological investigations per patient (3.1 x-rays, 0.4 CTs, 0.4 ultrasounds, 0.1 MRIs); and 1.4 (SD 0.3) infection events (0.02 bloodstream infections, 0.2 urinary tract infections, 0.7 PD catheter site infections, and 0.5 PD peritonitis episodes). The estimated carbon footprint from patient contact with renal services was 803.6kg CO2e/patient; this included 402.6kg CO2e/patient for inpatient days, 54.6kg CO2e/patient for unscheduled ambulatory assessment, 0.24kg CO2e/patient for telephone consultations, 293.8kg CO2e/patient for outpatient clinic activity and 17.6kg CO2e/patient for home visits, and 34.8kg CO2e/patient for radiological investigation and treatment of infection episodes.

Conclusion
Although PD is a home-based therapy patients should be aware of the frequency of attendance and admission days in the first year. KRT transition appeared common in this cohort, with similar proportions of transplantation and conversion to HD which prompts consideration of early vein mapping for arteriovenous haemodialysis in patients without prospect of early transplantation. Sixty-eight percent of the cohort experienced at least one infection episode necessitating anti-microbials, with implications for patient experience and anti-microbial stewardship. The length of time PD catheters remained in situ but not used was heterogeneous and merits further examination given the frequency of infection episodes and KRT transition. Estimates of carbon footprint relating to routine and unscheduled care indicate that carbon hotspots include patient travel and hospital admissions, and episodes of peritonitis; a full life cycle analysis is merited.