Episode 46: Improving CAPD Culture in the United States

Less than 10% of the PD population in the US is on Continuous Ambulatory Peritoneal Dialysis, or CAPD, with other parts of the world having much higher rates. We should ask ourselves if this is an appropriate utilization or if CAPD utilization should rise for best care and potential outcomes. What are the potential benefits of CAPD, and which patients are best treated with CAPD? Tune into this episode of Field Notes to listen to discussion on what we can do to improve CAPD Culture in the United States.

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Dr. Michael Kraus: Welcome, everyone, to this episode of Field Notes. I'm Dr. Michael Kraus, the Associate Chief Medical Officer at Fresenius Kidney Care, and your host for this discussion today. Here we interview the experts, physicians, and caregivers who bring experience, compassion, and insight into the work we do every day. 

I often say that we need to remove the hurdles from patients’ access to home therapies. We work hard at Fresenius Medical Care to promote and improve home therapies for our patients because we believe that dialysis treatment should fit in WITH your life. Your life shouldn't have to revolve around your therapy. And we know there are lots of benefits to home therapies. And today we're going to talk about one specific therapy that I think needs more attention: Continuous ambulatory peritoneal dialysis or CAPD. 

Peritoneal dialysis is a wonderful therapy for many patients in the home. There are two forms we will discuss today, CAPD (manual), and APD (machine assisted) peritoneal dialysis. Both have benefits and both have burdens. And both improve access to care.  We’ll spend most of today discussing CAPD and its potential benefits for many patients.  

And this isn’t because we prefer APD to CAPD, but because CAPD offers unique advantages that are underappreciated in the United States today. Individualization of care requires understanding the benefits of both therapies for each patient. 

CAPD is utilized less in the USA than the rest of the world. Less than 10% of the PD population in the U.S. is on CAPD, with other parts of the globe having much higher rates, such as 58% in Europe and even 92% in Asia. We should ask, is this an appropriate utilization and is the United States ahead of the curve or should CAPD utilization rise for best care and potentially outcomes?

We must understand what the potential benefits of CAPD are and which patients are best treated with CAPD. And we have to understand: are there perceived biases against CAPD which remain unfounded in literature and practice today? Ultimately, we know the outcomes globally are equivalent to the US. Why is our penetration so low when CAPD is a perfectly good therapy option for many patients? What can we do to improve our CAPD culture? 

I'm happy to have an expert with me today to discuss this matter with us. Michelle Carver, Senior Vice President of Nursing and Clinical Services at Fresenius Kidney Care. Michelle, welcome back to Field Notes.

Michelle Carver: Hello, Dr. Kraus, and thanks for inviting me.

Dr. Michael Kraus: It's always a pleasure to have you. Now, let's just start from the beginning. What is CAPD and how does it differ from automated PD, or APD?

Michelle Carver: In its simplest form, CAPD is continuous ambulatory peritoneal dialysis, and essentially that means that patients will be doing exchanges but manually with no equipment. APD, same functionality, except we use a cycler machine to do the exchanges for patients while they sleep at night.

Dr. Michael Kraus: One of the benefits of home therapies in general, and we'll get back to CAPD, has loosely been defined by many as patient choice, just patient choice being empowerment. It's been said that APD is driven by patient preference, but what is the real patient empowerment and how do we assist patients in this decision process?

Michelle Carver: Well, I think patient empowerment is extremely important. Ultimately, we want patients to choose the modality that's right for them and is going to be best suited for their lifestyle. Now, we provide a lot of education to patients around the different modality options so that we can understand what are their lifestyle goals and help them decide which modality is going to be suited for some of their goals.

One of the things we have to ensure is that we are evaluating every modality fairly and letting patients come to the conclusion of what might work best for them. So, when it comes to CAPD and APD, I think fundamentally we need to remember that all patients, no matter if they're going to be on a cycler and do APD or not need to be skilled in doing manual exchanges.

So, it's really, for me, not one or the other. It's all patients need to be able to do CAPD very well, even if they're going to choose APD and be on a cycler at night. But I also think we have opportunity to evaluate what patients might be better suited for CAPD as opposed to APD.

Dr. Michael Kraus: So, empowerment is more than just asking me on that first day, what would you like to do? It really does take education and making sure that we don't have biases as we discuss this with our patients. Is that true?

Michelle Carver: That is true. And I think we need to recognize we all come with bias. It's human nature. We just have to be much more conscious about not putting those biases on patients when we're educating them about their options, because what we may do may be completely different than what a patient should be doing or wants to do. And we need to always keep that in mind.

Dr. Michael Kraus: Then looking in, as we said in the U.S., where we are predominantly an APD country with less than 10% on CAPD, what do you think has gone into driving that APD world?

Michelle Carver: I think going back to bias, I think we as health care professionals assume that having a machine or technology do something for us is inherently easier. And while that may be true in some cases, I don't always think we evaluate all the other things that come along with using technology. 

So, I think we have, in some regard, guided patients to doing APD because we say you can hook up and go to sleep and the equipment will do the exchanges for you. And then when you wake up, you can disconnect and go about your day. So, we kind of guide the patient into thinking this is going to be simple and easy. And when you hear that, it is a very compelling story. I believe though, CAPD offers a lot of those same simplicity factors for patients. I don't think APD is always the best solution for all patients. I think in some cases CAPD would be much easier and simpler for patients, in many situations.

Dr. Michael Kraus: The burdens of CAPD are what drives a lot of our nurses and physicians to push people towards APD. Do you think they overemphasize those burdens or is CAPD actually a burden?

Michelle Carver: I don't believe CAPD is a burden, and I also think that some people assume that doing an exchange three or four times a day is somehow very time consuming. But I think if we really step back and break it down, and we look at how patients can fit this into their daily lifestyle, doing an exchange manually is pretty simple and you can do it while you're doing other activities.

So sometimes I think it's just stepping back and recognizing that the time it takes to wash your hands and prepare to do an exchange actually connects. And then while they're draining and filling, they could be doing something else in their home or at work. I think it affords a lot of flexibility that we don't always think about.

Dr. Michael Kraus: I think we tell patients that dwell time, drain time, is a burden when in actuality I can have my morning cup of coffee, read the paper, talk to the dog, talk to my wife, whatever, and we can make it fit part of our life rather than be a burden to our lives. 

As we think about that going forward, let's talk about the benefits of CAPD, why clinically it may be better in some patients with APD. Let's start with the most important toxin to our patients: volume, or salt and water. Which therapy drives salt and water change and how do we make it work better for our patients?

Michelle Carver: When we look at PD, just by the nature of how you do exchanges, because most often with CAPD, patients are going to do an exchange. If they're doing it four times per day, they're going to do an exchange when they wake up around lunchtime, around dinner time, and at bedtime. That just inherently provides long dwell time, which is very suitable for ultra filtration. We know in the US, we often have short dwell times, and some of that is associated with utilizing the cycler where we have to fit a certain number of exchanges into the time period that the patient is sleeping. When you do CAPD, because of how you spread out the exchanges, they’re getting very nice dwell times that offer great ultra filtration.

Dr. Michael Kraus: How much time does it take to maximize sodium water removal with the PD exchange?

Michelle Carver: Depending on the patient's membrane characteristics, most patients, at a minimum, should have at least a two hour dwell, but we see the best benefits when we keep that solution longer. You know, something like three hour dwell times or even longer.

Dr. Michael Kraus: Maximizing even at four, five, or six and as we move from salt and water, let's move to urea, where even it takes an additional hour to maximize. So, we're getting that greater efficiency with CAPD, we're using our fluid more efficiently. How much more fluid does it take to get equivalent clearances between APD and CAPD in general?

Michelle Carver: CAPD, you generally use less fluid, and that's because we're capitalizing on the dwell time, and we're maximizing clearance and ultra filtration. So, on average, patients use anywhere from 6 to 8 liters. Most patients are around a two liter fill volume. Now, obviously, for our larger patients, those fill volumes can go up a bit. But in general, 6 to 8 liters is a pretty minimal total volume for the day.

In APD, we see higher volumes because we, again, are trying to do a number of exchanges in a short amount of time. And so those exchanges and fill volumes tend to get either more frequent or larger in volume to provide enough clearance for patients. So, we see sometimes ten liters or greater in our APD patients.

Dr. Michael Kraus: And when we stick to APD and you think about that prescription, as you already said, you want dwell times to be at least 2 hours. Frequently, we see dry days. And so, we're not even making use of the daytime exchange, and we're getting much shorter than those two-hour dwell times. So APD, when you have a dry day, is probably 40, 50% more fluid to get equal clearance just because you're inefficient. It's an impressive difference. What about phosphorus? Which therapy is best or how is that moved?

Michelle Carver: We know that phosphorus takes longer to clear, and so any time we extend the dwell times in patients, we have better phosphorus clearance. So CAPD, again, just by the nature of how patients conduct their exchanges, affords them improved phosphorus clearance because we're giving them extended dwell times.

Dr. Michael Kraus: Phosphorus acts like a big molecule, but actually small but charts. So, it does take that long dwell time to drain. And CAPD offers a huge benefit in phosphorus clearance because of that. That's very interesting. 

So, some of us have always thought about CAPD first and moving to APD fairly quickly, but recently you've talked about saving people that were coming off therapy or maybe improving the struggling patient on APD. I've heard you mentioned that a couple of times. Can you speak to that?

Michelle Carver: So, we know that we have a population of patients on APD that struggle with drain complications because most people are laying down when they sleep at night and just by the position of their body, sometimes the catheter doesn't work as if they were sitting upright. So, with drain complications becomes alarms and sleep disruptions. And oftentimes what we see is we see a patient having frequent alarms and issues with draining at night. And then we have them--we check placement, and we do all the evaluation. And actually, the patient drains and fills just fine when they're upright, but then we send them back home because we didn't identify a problem. So, we send them back home and they have the same problems when they lay down and they get frustrated because they're not getting any sleep and they're getting all these alarms associated with their treatment.

I believe we need to, in those patients, evaluate whether or not CAPD would be a better option for them because we remove the sleep disruption because they're going to be doing their exchanges while they're awake during the day and they likely won't have the same drain complications as they did when they were laying down. So, I do think it affords us an opportunity to retain patients and try them on a different modality. Sometimes I believe we wait too long, and we let a patient get very frustrated and then they just want to stop because we all know if you're not sleeping, that's never a good ending for any of us. And it's very difficult to stick with this if we're not giving patients good sleep and we're giving them a lot of alarms to have to try to troubleshoot. So, I think we should be using it as a tool to retain our patients and extend their time on therapy.

Dr. Michael Kraus: It is about time. So, you're hooked to a machine, not 6 hours, nine or 10 hours if we prescribe well. And the average dialysis patient sleeps only seven. And for interrupting sleep, that's bad. You know what I just heard recently of an elderly gentleman who is on PD and his wife has dementia, but he was on the cycler, so he'd be attached to the machine for nine, ten hours at night and she'd get up and it was making him go crazy. He just couldn't handle the whole ability to take care of her and himself at the same time; switched him to CAPD and his life turned around. He slept better. He was able to take care of his wife better. And so, it's looking for that right patient. So, while we're on that, how do we improve the CAPD culture and educate our patients about CAPD differently?

Michelle Carver: I think it starts first with us again, educating patients and removing bias and really giving them an understanding of the benefits of CAPD, of APD, and letting them come to a determination of what's going to work best for them. And you provided a great example of a story. And here's an example I just heard the other day as we had a young mother who has little kids that needs to go on PD, and she's chosen PD, and everyone was pushing her to do the cycler because they're like then your days will be free to manage your kids.But what happens with young kids at night? You often are getting up with them. And now she's tethered to a machine that complicates her ability to get up with her young children at night. And so, in this circumstance, she actually wants to do CAPD because she can do our exchanges and while she's dwelling, be free to do whatever she needs to support her family.

So I think one is removing bias. I also think, and this is where I want to ask you a question from a physician prescribing perspective: which therapy do you feel like is the easiest to prescribe, CAPD or APD? And why do you believe that most physicians gravitate toward APD prescriptions?

Dr. Michael Kraus: CAPD is clearly easier to prescribe. Let's be honest, because it's going to be when your full dose three or four exchanges a day. And we'll get back to that because I think I want to cover that with you in the algorithm. It's easy to learn. It's less anxiety to the patient. You take somebody just adapting to renal failure, the anxiety of throwing a machine at them and learning even more is unnecessary. If we start with CAPD and they get used to it, it's a very simple procedure. If they have residual renal function, like we said, we can go to three exchange a day, which is very simple. So, I think by far it's the easiest. 

I think why from a physician's point of view, sometimes we got enamored by the ability to, for lack of a better term, sell therapy by saying you're going to be attached to a machine for 8 hours a night. It's wonderful and you won't have anything during the day. It's unfortunately untrue but sounds good. So, I think as we go forward and change the culture of what we have to ask our nurses or doctors and everybody else involved is let's be brutally honest. Let's talk about the burdens, what it takes and, and how we're going. I think CAPD described well and honestly has great benefits and less burden. You know, if I was choosing for myself, frankly I’d pick CAPD over APD.

Michelle Carver: Thank you.

Dr. Michael Kraus: I was always taught when I was a young man, which was way too long ago, that PD was a four exchange a day thing. So, everybody was too two liters, four exchanges. But we've learned that's not how the rest of the world looks at it. In fact, you go to Hong Kong, everybody starts on three exchanges today. Can you talk about where the algorithm fits in and what your thoughts are on three exchanges a day as well?

Michelle Carver: Sure. We have an algorithm for initiating patients on peritoneal dialysis and one of the first pieces of the algorithm is initiating all patients on CAPD. And if patients have enough residual renal function, they actually can do quite well on just three exchanges a day. And when you think about the burden factor and the simplicity, doing three exchanges where you're probably doing one when you wake up in the morning, one around dinnertime and one at bedtime, that's a really low burden prescription for many patients.

Dr. Michael Kraus: That sounds like a plan with low burden. It will remain incumbent on the dialysis units to monitor residual renal function closely to know when the PD does may need to be increased.

Michelle Carver: And we're also affording them extended dwell times that improve ultrafiltration and improve clearance. So, I think in many of our patients, that prescription will be very well suited for their lifestyle. I also think, and as part of the algorithm, we need to get back to kind of our old ways of initiating patients on peritoneal dialysis. And for those of us that are older PD nurses, I like to call us more mature nurses. We used to always start our patients on CAPD no matter what, so we would train them on CAPD first and they would go home for a period of time, often several weeks to months before we brought them back and train them on a cycler if that was their choice. We've gotten away from that and in a lot of cases we're training patients how to do CAPD or manual exchanges and then putting them on the cycler right away.

And I think two things we should consider: One, we need to give our patients practice in muscle memory to remember how to do a manual exchange. So, I think they need more time than just a couple of days to become proficient. And we always need CAPD because we know we have power outages, we have natural disasters, so we never know when a patient, even on a cycler, is going to need to do a manual exchange. I also think some patients go home on manuals and it fits really well into their lifestyle and they don't want to transition to a cycler. But we never give patients the opportunity to experience how CAPD could fit into their lifestyle, and so they just automatically assume a cycler is better for them.

Dr. Michael Kraus: Because we say, “we'll put you on CAPD for two, three, or four weeks and then we'll switch you” saying that the cyclers best choice. So that's where we want you. What we should be saying is let's start at CAPD, let's see how you do and see if fits your lifestyle and if you need the differences, then we can bring in the cycler if that fits you better.

Michelle Carver: I think that's an excellent point that we don't think about. Is that no matter what we're talking about, when we talk about home modalities, they are fluid. Patients can go between modalities. Just because I say I wanted CAPD today and or APD today doesn't mean I can't transition to something that's more suited for what I need at the time. So, I do believe we need to be much more flexible in how we educate our patients and not force them into one therapy over another. I do think patients experiencing both has a great value, and we don't afford them much experience with CAPD today.

Dr. Michael Kraus: And you mentioned transport status before, the ability to move poisons across my peritoneal membrane. Are there transporters that you think are better served by one therapy or another?

Michelle Carver: So, the majority of membrane types would do well on either CAPD or APD, with the exception of two. Low, low patients, so low equilibrators, obviously need long dwell time so they're better suited for a CAPD prescription entirely. And then we have our high equilibrators where they move solutes very quickly, and we have to be more thoughtful about dwell times and number of exchanges in those patients. But those are not the largest population of our patients either. So, we have to also keep that in mind. The majority of patients can do CAPD quite well.

Dr. Michael Kraus: That being said, we know the benefits to patients. Can you speak just real briefly how CAPD might benefit my nurses as well as my programs?

Michelle Carver: Well, you mentioned it earlier, and that is teaching someone how to do a manual exchange is simpler. We've removed the technology, which sometimes is scary. I think any time you introduce equipment, people have anxiety around all of that. So, there's no technology to speak of when it comes to CAPD. So, it's a simple therapy to teach.

I also think that it has great benefit for our nurses in emergency situations and when we need the ability to support our patients with manual exchanges. I also think it affords itself to patients who want to go back to work, who want to travel, being able to take just minimal equipment and be able to do their peritoneal dialysis exchanges wherever they go is much easier to support.

So, I think from a nurse’s perspective, I do think it has a lot of benefits. We also remove a lot of the troubleshooting education we have to teach because you know there's not too many things you need to verify and check when you're doing a manual exchange. As opposed to equipment that can give you numerous alarms. And there's tons of different ways to troubleshoot that alarm sequence. So, I think it's very simple and easy to teach.

Dr. Michael Kraus: So, we can train more efficiently, I think, because you're focusing on what the patient's medical needs are more than a machine, which I think is really beautiful. And one other thing I found out because not being a nurse, I wouldn’t have known. Turns out APD patients call their nurses when they have problems with their machine, CAPD patients sleep all night long. So, if you're a nurse that wants to sleep, you want your patients to sleep. So, there's an added benefit there. 

This has been great, and I am sure we can go on longer, but is there anything you want to close off? Another story or anything else you want to share about CAPD?

Michelle Carver: I just would encourage those of you who are listening to really evaluate your current patient population. And even if you have existing patients that might be struggling on the cycler, consider maybe educating them about a CAPD option. Like I said, you can try it, see how it works for them. Doesn’t mean they have to completely switch out of the gate. So, I encourage people to really think about both new patients and existing patients to see if this therapy can improve time on therapy for our patients.

Dr. Michael Kraus: It's important that we work to provide as many modalities of care as we can to our patients and when we see something like CAPD being underutilized, it's especially important for us to analyze why and discuss whether we think we can do something better to better promote therapy. It’s better for patients and patient outcomes when used correctly, having APD and CAPD available improves patient care and prescription. Thanks again for all your insight on this topic, Michelle. 

Michelle Carver: Thank you. I appreciate it.

Dr. Michael Kraus: And to our audience, thank you for joining us today. If you are a health care professional, it's time to think about the benefits of CAPD for your patients and discuss how that may improve their quality of care. If you have any further questions, please reach out to us at Medical.Office@freseniusmedicalcare.com. That’s Medical.Office@freseniusmedicalcare.com.

If you're new to the Field Notes podcast, you can download past episodes on the Apple Store, Google Play, or wherever you download your favorite podcasts. Please remember to subscribe so you can receive the very latest updates as they occur. Until next time. I'm Dr. Michael Kraus and you've been listening to Field Notes by Fresenius Medical Care. Take care, everyone, and let's begin a better tomorrow.