Rehabilitation of Patients with End-stage Renal Disease

1 3 Rehabilitation of Patients with End-stage Renal DiseaseK. F. CHAU, W. L. CHAK, M. K. WONG, K. S. CHOI, K. M. WONG,Y. H. CHAN, H. S. WONG, C. Y. CHEUNG, C. S. LIRenal Unit, Department of Medicine, Queen Elizabeth HospitalEnd-stage Renal Disease (ESRD) is the final commonpathway for a variety of Renal and urological replacement therapy (RRT) is employed to sustainlife when Renal function reaches End-stage . 5%normal. Renal transplantation is regarded as the bestRRT in terms of restoration of Renal function, survivalrate, Rehabilitation and quality of life. Howevertransplantation is limited by the scarce supply of results in an increasing size of dialysis populationworldwide.

2 Both peritoneal dialysis (PD) andhaemodialysis (HD) are effective modes of dialysistherapy. Since the invention of PD in 1976, there hasbeen a rapid growth in the utilization of PD. By the endof 1997 the chronic PD population worldwide was anestimated 115,000, representing 14% global dialysispatients. In Hong Kong, 80% of our prevalent ESRD Patients on dialysis are put on PD. This utilization rateranks second in the world, just next to Mexico. Majorityof Patients on PD are on continuous ambulatoryperitoneal dialysis (CAPD). The Patients have to perform3 to 4 bag exchanges at home every day. For patientson haemodialysis, the usual regime is 2 to 3 sessionsper week, 4 to 6 hours for each session, either in thehospital or satellite dialysis dialysis maintains life, Patients face life-longphysical, psychological and social problems related totheir illness and treatment.

3 Dialysis can only replace part,but not all, of the Renal functions. It cannot correct theco-morbid diseases and it itself incurs its owncomplications. Anxiety, depression, fear, emotionalfluctuation and various psychological stresses arecommon amongst ESRD Patients especially at the earlyphase of treatment. Dialysis treatment also causes asignificant change in daily living, disruption in workschedule and shift in social role which in turn imposesfinancial, housing, marital and employment adaptation and social adjustment areimportant challenges to Renal Patients on order to provide comprehensive and holistic care tothe ESRD Patients , a Renal Rehabilitation program wasestablished in Queen Elizabeth Hospital in July program was run by a multi-disciplinary teamcomprised of Renal physicians, Renal nurses, clinicalpsychologists, medical social workers and communitysocial workers from Patient Resources Centre,pharmacists, Renal dietitians.

4 Occupational therapists,physiotherapists and the patient support group. The aimis to achieve full physical and psychosocial rehabilitationwith good quality dialysis life. Apart from the day to dayservice, the program stresses on two major areas: pre-dialysis education and comprehensive care during theCAPD preparatory and training EducationSuccess of a comprehensive Renal replacement programdepends heavily on Patients ' acceptance of their Disease ,their positive motivation and active participation in thetreatment. This is related to Patients ' feeling of controlor lack thereof. Enhancement of patient's knowledgeabout their illness and treatment plan can improve theirsense of control, stress adaptation and psychologicaladjustment and in turn their compliance to or timely referral of pre-dialysis ESRD Patients tonephrologists allows early patient's education andpreparation as well as better pre-dialysis Renal care.

5 Onthe other hands, studies have confirmed that late referralis associated with increase need for emergent dialysisand temporary central venous catheterization and higherincidence of uremia-related complications, such assevere hypertension or fluid overload. This is associatedwith prolonged hospitalization at the start of dialysis andhas detrimental consequence on initial morbidity andmortality. Economic evaluations of Canadian and also suggested that early referral would result incost Queen Elizabeth Hospital, pre-dialysis educationclasses (PEC) are organized to provide patient educationand psychological guidance. The aim of PEC is toprovide basic knowledge to Renal Patients early in theircourses of diseases before RRT is anticipated.

6 Thisallows Patients to make an informed choice of their4 MEDICAL SECTIONA pril 2003preferred treatment modality. This also permits earlycreation of a permanent peripheral vascular access forhemodialysis or insertion of Tenckhoff catheter for PDin a timely fashion to ensure a smooth transition to with a creatinine of around 500 mol/L arerecruited into the class. Two integrated talks on2 consecutive Saturday afternoons are arranged. Theseclasses are held regularly every 4 months. During theclasses, the Renal physicians and Renal nurses discusson natural history and clinical features of ESRD,treatment plan and principles and options of from other paramedical departments emphasizeson the importance of exercise, diet and drug and community social workers introduce theavailable community resources to kidney diseasepatients.

7 ESRD Patients on dialysis or renaltransplantation are invited to share their experiences andgive their psychological Preparatory and Training PeriodFour weeks after insertion of Tenckhoff Catheter, thepatient will have the comprehensive CAPD trainingprogram by a designated Renal nurse. Home bloodpressure monitoring are taught. Exercise program isarranged by the physiotherapists. Device modification,home environment modification and enhancement ofactivity of daily living are provided by the occupationaltherapists. For Patients with employment problem,vocational counseling, job skills training and jobmatching services are provided in the integratedvocational Rehabilitation program.

8 Dietitian andpharmacist will counsel Patients according to theirindividual needs. Medical social worker will attend toissues related to financial assistance, community careservices and illness adjustment. There are small peergroup meeting with volunteers from patient supportgroup to provide in-depth experience sharing andpsychological support to Patients and cases are referred to the clinical psychologistfor further on Pre-dialysis Classes (PEC)Since the organization of PEC, we have two groups ofpatients, who did (Group A) and did not (Group B) attendthe PEC respectively. It would be interesting to note theimpact of PEC on the clinical outcome of the two groups,in terms of initial morbidity and mortality aftercommencement of total of 12 pre-dialysis education classes (PEC) wereorganized in Queen Elizabeth Hospital from November1996 to October 2000.

9 One hundred and ninety-fourpatients and their families have attended break-in period is defined as the time betweencatheter insertion and routine catheter use. Thetreatment strategy used during the break-in periodactually depends primarily on whether dialysis is neededfor the treatment and support of the Patients at the timeof catheter insertion. If the patient is asymptomatic withacceptable blood chemistry, patient is instructed to comeback to our dialysis unit weekly for flushing of the newlyinserted Tenckhoff catheter and blood testing for renalchemistry. This minimizes the manipulation of thecatheter and allows better wound healing as well asreduces the risk of future leakage.

10 The indications tostart dialysis in this phase include fluid overload,electrolytes imbalance and severe acid-basedecompensations. Patients were either maintained onintermittent HD by temporary dual-lumen catheter or lowvolume intermittent PD using the cycler machine. Hencethe number of intermittent HD and PD sessions reflectsthe need for emergent dialysis. Hospitalization rate inthe break-in period for the two groups was the commencement of PD, rate of peritonitis andexit site infection is measured to evaluate the effect ofPEC on morbidity of ESRD Patients at 3 and 6 Patients are encouraged to contact theirdesignated train-nurse or dialysis center in their earlydays on PD, the number of non-scheduled follow-up(NSFU) can also reflect their A comprised 107 Patients (44M and 63F) whilegroup B included 285 Patients (147M and 138F).