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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2008  |  Volume : 19  |  Issue : 4  |  Page : 574-582
Effectiveness of a Separate Training Center for Peritoneal Dialysis Patients


1 Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia
2 King Khaled University Hospital and Dalla Hospital, Riyadh, Saudi Arabia
3 Security Forces Hospital, Riyadh, Saudi Arabia
4 King Fahd Medical City, Riyadh, Saudi Arabia
5 Riyadh Medical Complex, Riyadh, Saudi Arabia
6 Baxter Renal Education Center, Riyadh, Saudi Arabia

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   Abstract 

The aim of this study is to analyze the patients' database of the Baxter's Training Peritoneal Dialysis Program (BTPDP) adopted at the Baxter Renal Education Center (BREC), Riyadh, Saudi Arabia in order to determine its effectiveness in the management, compliance, and outcome of the trained peritoneal dialysis (PD) patients. The study analyzes the database of the BTPDP, which includes the demographic data, duration of follow-up, complications, and outcome of the patients trained on PD between September 2003 and November 2007. Records of 376 patients with a mean age of 46.0 ± 22.6 years were available in the database for analysis. Of them, 187 (49.7%) were males, 312 (82.9%) were trained at the BREC, 315 (83.8%) were new PD patients, and 298 (79.3%) were trained on automated PD (APD). The dropouts during the study period included 172 patients (46%); 42 (24.4%) were transplanted, 45 (26.2%) switched to hemodialysis, 57 (33.1%) died and 28 (16.3%) were lost to follow-up. A comparison was made between the group trained at the BREC and the group trained at the hospital. There was an overwhelming adoption of BTPDP by the different hospitals during the study period (p < 0.00001). There were 264 (84.6%) patients trained on APD at the BREC vs. 34 (53.1%) at the hospital (p < 0.00001), and the patients trained at the BREC had significantly less dropouts than those trained at the hospital during the study period 135 (43.3%) vs. 38 (59.4%) respectively (p < 0.02). The mean period of follow-up was significantly different between the patients trained at the BREC and those trained at the referring hospital (390 ± 461 days vs. 679 ± 779 days respectively (p < 00000.8). Also, there was a trend for better technique survival after the second year, among the patients trained at the BREC. We conclude that the BREC model has increased the recruitment to PD, and helped in spreading this method of renal replacement therapy among patients. This model emphasizes the role of a designated training course by an expert team, and unifies the training standards. Furthermore, application of this model can be expanded nationwide and even to other countries.

Keywords: Chronic kidney disease, Peritoneal dialysis, Saudi Arabia, Ambulatory

How to cite this article:
Souqiyyeh MZ, Al-Wakeel J, Al-Harbi A, Al-Shaebi F, Al-Kanhal F, Mousa FM, Wahdan EY, Shaheen FA. Effectiveness of a Separate Training Center for Peritoneal Dialysis Patients. Saudi J Kidney Dis Transpl 2008;19:574-82

How to cite this URL:
Souqiyyeh MZ, Al-Wakeel J, Al-Harbi A, Al-Shaebi F, Al-Kanhal F, Mousa FM, Wahdan EY, Shaheen FA. Effectiveness of a Separate Training Center for Peritoneal Dialysis Patients. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2019 Nov 18];19:574-82. Available from: http://www.sjkdt.org/text.asp?2008/19/4/574/41317

   Introduction Top


Peritoneal dialysis (PD) has been established as a modality of renal replacement therapy (RRT) for patients with end-stage renal disease (ESRD) worldwide with great advantages for quality of life as well as outcome in this population. Organized training by dedicated teams is practiced in many bran­ches of medicine with gratifying results. [1],[2],[3] Training of PD patients requires a coordi­nated team and multidisciplinary approach, which have been emphasized in many earlier studies. [4],[5],[6],[7],[8],[9],[10],[11],[12],[13].

The expansion of use of PD in the King­dom of Saudi Arabia (KSA) has been rather sluggish over the past 20 years. [14] There are certain confounding factors that hinder PD services in KSA including lack of time and expertise among the caregivers, for training patients initiated on PD. [1]

Baxter Pharmaceuticals in KSA has pio­neered a program of training for patients starting on PD in KSA in September 2003. Ever since, this program has helped training new patients in several existing PD pro­grams, and achieved a large database for the follow-up of the progress of the patients in their management and outcome. The aim of this study is to analyze the patients' database of the Baxter's Training Peritoneal Dialysis Program (BTPDP) adopted at the Baxter Renal Education Center (BREC) in order to determine its effectiveness in the manage­ment, compliance, and outcome of the trained PD patients. In addition, we compared the complications and outcome of the trained PD patients by the Baxter's team with those trained by the PD teams in the respective hospitals.


   Methods and Patients Top


The study analyzes the database of the BTPDP in Riyadh area, Saudi Arabia, which includes the demographic data, duration of follow-up, complications, and outcome of the patients trained on PD from September 2003 to November 2007. The training program is performed at the BREC, which is located in Riyadh, Saudi Arabia. The BREC has a profe­ssional team of PD nurses and technicians who are dedicated for training patients with ESRD on home PD, either automated PD (APD) or chronic ambulatory peritoneal dialysis (CAPD).

The BTPDP is a flexible 5-day training course, with the duration of training increased or reduced, depending on the level of pre­vious training on PD. The training steps in­clude the following:

a). Day one of training: the admission form, which has all information related to the pa­tient's medical history, is filled. Next, the patient receives didactic information about renal failure including symptoms, signs and options of therapy for ESRD as well as diet management. Subsequently, the practical trai­ning is initiated, which could be either APD or CAPD.

b). Day two of training: the patient recites the instructions of the first day and applies the learned PD techniques under direct super­vision of the trainers, with focus on correc­tion of the flaws in the application of tech­nique. Information about the PD fluids and how to handle under and over-filtration of PD is provided to the patient.

c). Day three of training: further practical training on the PD technique is imparted. The patient is instructed about how to avoid peritonitis and exit-site infection with empha­sis on the care of the exit-site by the patient.

d). Days four and five of training: the patient practices PD under supervision. All the steps are reviewed with the trainer. Evaluation of the patient on this last day of training is performed to decide whether fur­ther training is necessary. Follow-up and online telephone support are offered to the patients to answer any queries at any time. Coordination with the referring physicians is continuous for assurance of services and to follow-up the outcome of patients.

Patients referred to the BREC, included in the database, were from King Khaled Uni­versity Hospital, Dalla Hospital, Security Forces Hospital, King Fahd Medical City, and Riyadh Medical Complex, all located in Riyadh city. Prior to referral, prospective PD patients should have already selected this method of RRT after discussion at the refe­rring dialysis center. In addition, the pa­tients should have PD catheters inserted by the referring team, and insertion site wounds should have healed completely (at least 15 days after insertion of catheters). Both patients already on PD, as well as patients with recent diagnosis of ESRD, were trained at the BREC. Some patients who were trained only at the referring hospitals allowed for comparison of results between the two groups of patients.

Statistical Methods

We first organized the data in Microsoft Excel spreadsheet and later analyzed with SPSS version 13. The chi-square test was used to compare the cross-tabulated categorical data, while for the quantitative data we used the independent samples "t" test. We per­formed survival analysis with the Kaplan­Meier procedure. The curves of technique­survival as well as patient-survival were cen­sored for transplantation, loss to follow-up, and change to HD. We only included in the survival curves the patients who met the criteria of modality start date to catheter insertion date (CID) date = 0, time from start prescription to modality start < 64 days and prescription start date 0 1/9/2003, which is the date of inception of the BREC. Statis­tical significance was set at p < 0.05.


   Results Top


Since the inception of the BREC, there has been a highly significant increase in the number of patients on PD in Riyadh city; the numbers even doubled in the hospitals that participated in the BTPDP [Figure 1],[Figure 2].

[Table 1] shows the summary of the data of the study patients. Records of 376 patients with a mean age of 46.0 ± 22.6 years were available in the database for analysis. Of them, 187 (49.7%) were males, 312 (82.9%) were trained at the BREC, 315 (83.8%) were new patients to PD, and 298 (79.3%) were trained on APD.

The major indication for starting the patients on PD was referral of newly diagnosed ESRD patients, seen in 234 patients (62.2%). There were 172 dropouts (46%) during the study period; 42 (24.4%) were transplanted, 45 (26.2%) switched to hemodialysis, 57 (33.1%) died with the cause of death not related to PD, and 28 (16.3%) were lost to follow-up.

[Table 2] shows the comparison between the groups trained at the BREC and the hospital. There was an overwhelming adoption of BTPDP by the different hospitals during the study period (p < 0.00001). There were 264 patients (84.6%) trained on APD at the BREC vs. 34 (53.1%) at the hospital (p< 0.00001). Also, the patients trained at the BREC had significantly less dropouts than those trained at the hospital during the study period [135 (43.3%) vs. 38 (59.4%) respectively, p< 0.02], and the mean period of follow-up was significantly different between the patients trained at the BREC and those trained at the referring hospital (390 ± 461 days vs. 679 ± 779 days respectively, p < 00000.8).

[Figure 3] shows the comparison of cumu­lative PD technique-survival in the patients trained at the Hospital and those trained at the BREC. [Figure 4] shows the patient survi­val in the two groups. Only 170 cases who fulfilled the following criteria were used for comparison: start date minus catheter insertion date < 15 days, prescription start date minus modality start date < 64 days, and pres­cription start date after September 2003. There was a trend for better technique survi­val in the patients trained at the BREC after the second year.

[Table 3] shows the comparison of the adult and pediatric patients trained on PD. The pediatric group formed 15.1% of all the study patients. The salient features of this group included: more number of males, more children were trained on APD, higher number of new PD cases, lesser number of dropouts, lesser duration of follow-up, higher number of renal transplants and lower mortality.

[Table 4] shows comparison between the APD and CAPD modalities among trained patients. Overall, there were more adult patients on APD than CAPD. APD was more frequently used among patients trained at the BREC, among newly trained patients and among new CKD patients. Also, there were more dropouts in the APD group than the CAPD group.

[Table 5] shows the comparison of the active patients and the droupouts. The mean age of the dropout patients was higher and there were significantly more dropouts in the adult group. There was a lesser number of dropouts in the group trained at the BREC's, more dropouts than active patients in the APD group, more dropouts than active patients among the new CKD patients, and more dropouts than active patients in the group that switched from other systems.

Finally, there were no significant differ­rences found between the males and females trained on PD in our study.


   Discussion Top


The results of our study support the notion that a free standing training center for PD such as the BREC is a successful model that can support PD programs. Moreover, this study includes a large database that proves the escalation of the number of PD patients in the Riyadh area, Saudi Arabia since the inauguration of the Baxter's PD training pro­gram for CKD patients; the numbers have doubled ever since.

The Baxter's program overcomes the obs­tacle of not training patients by the busy or inexperienced hospital staff in many hos­pitals, since the dedicated team at the BREC delivers the initial training to the pa­tients who are followed-up later in the dia­lysis centers at the hospitals. The BREC trains patients of all ages, which range from less than one year to 90 years. In the extreme ages, the training is usually direc­ted to a family member who plays the role of caretaker.

Furthermore, the BREC trained both males and females with predominance of females in all age-groups. The pediatric group bene­fited more from the training with fewer drop­outs than the adult group. The dropouts were more in the hospital-trained patients than those trained at the BREC.

Most of the patients at the BREC were trained more on APD than CAPD; this re­flects the increasing popularity of APD due to automaticity and application during slee­ping hours than CAPD. The BREC was more attractive to the new patients than the old patients. The number of patients trained by the hospital staff was significantly less than that trained at the BREC, which was appea­ling to the patients and the referring phy­sicians alike.

The patients with initial training on PD at the BREC showed a trend towards better technique-survival than patients who were trained in the hospital. Despite the multiple factors that affect the course of the PD patients after the initial training, the training at the BREC retained its beneficial effect.

The mortality rate was comparable bet­ween the patients trained at the hospital and the BREC, despite the multifactorial causes of death. Finally, there was a large varia­bility among the different hospitals in the study that reflects a center effect on the follow-up of the patients.

Earlier reports have suggested a beneficial role for patients receiving their training outside the hospital campus. [6] The BREC is a similar model that has proved its efficacy in encouraging growth of the PD programs with similar outcomes to those trained at the hospital.

We believe the existence of the free­standing reinforces the training of the new patients, at least from their prospective, being the center of attention by dedicated staff. However, the standards of the such centers should be under careful scrutiny by critical and longitudinal review of their per­formance and database in relation to the follow-up and outcome of patients.

We conclude that the BREC model has escalated the recruitment to PD, and helped spreading center this method of renal re­placement therapy among patients. This model emphasizes the role of a designated training course by an expert team, and unifies the training standards. Furthermore, application of this model can be expanded nationwide and even to other countries.


   Acknowledgment Top


We would like to thank the hospitals participating with the BREC for the data provided of their patients for this study. In addition, we extend our appreciation to Dr. Peter Rutherford from Baxter Healthcare for his advice and help in this study.[15]

 
   References Top

1.Feste C, Anderson RM. Empowerment: From philosophy to practice. Patient Educ Couns 1995;26(1-3):139-44.  Back to cited text no. 1    
2.Solomon-Dimmitt R. Focus on rehabilitation:Teamwork that works. Adv Ren Replace Ther 1999;6(3):278-81.  Back to cited text no. 2    
3.Funnell MM. Patient empowerment. Crit Care Nurs Q 2004;27(2):201-4.  Back to cited text no. 3    
4.Tsay SL, Hung LO. Empowerment of patients with end-stage renal disease: A randomized controlled trial.Int J Nurs Stud 2004;41(1):59-65.  Back to cited text no. 4    
5.Golper TA. Quality control in a peritoneal dialysis program. Adv Ren Replace Ther 1995;2(2):143-7.  Back to cited text no. 5    
6.Zuccherato N, Bordin G, Evangelista F, Oliva S, Susin E. Campus and education: An experience with PD patients. EDTNA ERCA J 2003;29(2):89-92.  Back to cited text no. 6    
7.Neville A, Jenkins J, Williams JD, Craig KJ. Peritoneal dialysis training: A multisensory approach. Perit Dial Int 2005;25(Suppl 3):S149-51.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Wang L, Dong J, Gan HB, Wang T. Empowerment of patients in the process of rehabilitation. Perit Dial Int 2007;27(Suppl 2):S32-4.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Diaz-Buxo JA, Crawford-Bonadio TL, St Pierre D, Ingram KM. Establishing a successful home dialysis program. Blood Purif 2006;24(1):22-7.  Back to cited text no. 9    
10.Chow KM, Szeto CC, Leung CB, Law MC, Kwan BC, Li PK. Adherence to peritoneal dialysis training schedule. Nephrol Dial Transplant 2007;22(2):545-51.  Back to cited text no. 10    
11.Bernardini J, Price V, Figueiredo A. Peritoneal dialysis patient training, 2006. Perit Dial Int 2006;26(6):625-32.  Back to cited text no. 11    
12.Prowant BF. Determining if characteristics of peritoneal dialysis home training programs affect clinical outcomes: Not an easy task. Perit Dial Int 2006;26(6):643-4.  Back to cited text no. 12    
13.Russo R, Manili L, Tiraboschi G, et al. Patient re-training in peritoneal dialysis: Why and when it is needed. Kidney Int Suppl 2006;103:S127-32.  Back to cited text no. 13  [PUBMED]  
14.Saudi Center for Organ Transplantation data. Saudi J Kidney Dis Transplant 2007; (3):457-458.  Back to cited text no. 14    
15.Souqiyyeh MZ, Shaheen FA. Study of attitude of physicians toward establishing and maintaining peritoneal dialysis programs in Saudi Arabia. Saudi J Kidney Dis Transplant 2006;17(3):348-53.  Back to cited text no. 15    

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Correspondence Address:
Muhammad Ziad Souqiyyeh
Saudi Center for Organ Transplantation, P.O. Box 27049, Riyadh 11417
Saudi Arabia
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PMID: 18580016

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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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    Abstract
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