Managing patients on dialysis in the community

In an average GP practice there will be one or two patients currently on renal replacement therapy (RRT) and a larger number with progressive chronic kidney disease who will reach end stage renal disease (ESRD). The options for RRT are kidney transplantation, haemodialysis (HD) or peritoneal dialysis (PD). For many patients with ESRD, treatment at home allows greater flexibility and independence than can be facilitated by inpatient HD. PD can be broadly categorised into two types: continuous ambulatory peritoneal dialysis and automated peritoneal dialysis. Each PD patient has a personalised prescription depending on their body mass, residual renal function and the physical properties of their peritoneal membrane. On average patients can have four years of successful PD before needing to switch to an altemative mode of RRT. In home haemodialysis (HHD), the entire process is initiated and managed by the patient at home. HHD is an option for any motivated patient who can learn the necessary skills to manage their own HD and deal with the potential complications. The strongest clinical argument for choosing HHD is the ability to provide longer and more regular HD sessions. Daily HD results in an improvement in BP control, solute clearance and anaemia management, and thus confers a significant survival benefit to patients.