1. Implementing NICE guidance
Peritoneal Dialysis
Implementing NICE guidance
ABOUT THIS PRESENTATION:
This presentation has been written to help you raise awareness of the NICE clinical guideline on ‘Kidney disease: peritoneal dialysis in the treatment of stage 5 chronic kidney disease’. This guideline has been written for healthcare professionals and other staff who support and care for people with stage 5 chronic kidney disease (CKD) who need dialysis (specifically peritoneal dialysis). The guideline aims to improve the care of people with stage 5 CKD who need and want to receive dialysis, by making evidence based recommendations on the role of peritoneal dialysis.
The guideline is available in a number of formats. See the end of the presentation for ordering details.
You can add your own organisation’s logo alongside the NICE logo.
We have included notes for presenters, broken down into ‘key points to raise’, which you can highlight in your presentation, and ‘additional information’ that you may want to draw on, such as a rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full.
DISCLAIMER
This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
PROMOTING EQUALITY
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
July 2011
NICE clinical guideline 125

2. Click here to go to NICE Pathways website
The NICE Peritoneal Dialysis pathway covers peritoneal dialysis in the treatment of stage 5 chronic kidney disease and recommendations on:
Information
Choice of dialysis
Peritoneal dialysis delivery
Switching treatment
NOTES FOR PRESENTERS:
NICE Pathways: guidance at your fingertips
Our new online tool provides quick and easy access, topic by topic, to the range of guidance from NICE, including quality standards, technology appraisals, clinical and public health guidance and NICE implementation tools. Simple to navigate, NICE Pathways allows you to explore in increasing detail NICE recommendations and advice, giving you confidence that you are up to date with everything we have recommended.
Click here to go to NICE Pathways website

3. NOTES FOR PRESENTERS:
The NICE pathway can be found at:

4. What this presentation covers
Background
Scope
Recommendations
Costs and savings
Discussion
Related guidance
Find out more
Chronic kidney disease quality standard
NOTES FOR PRESENTERS:
In this presentation we will start by providing some background to the guideline and why it is important.
We will then present the recommendations. The NICE guideline contains 16 recommendations.
The recommendations cover the following areas:
information and support
choosing dialysis
switching treatment modalities
Next, we will summarise the costs and savings that are likely to be incurred in implementing the guideline.
Then we will open the meeting up with a list of questions to help prompt a discussion on local issues for incorporating the guidance into practice.
Slide 20 provides information about other NICE guidance relevant to the management of patients with Chronic Kidney Disease.
Slide 21 provides details of further information about the support provided by NICE.
The final slides provide information on the Chronic kidney disease (CKD) NICE quality standard.

5. Background:1
There are two main types of dialysis available, haemodialysis and peritoneal dialysis
The factors that usually determine dialysis choice are lifestyle preferences and feasibility
Chronic kidney disease (CKD) is never ‘cured’, it is treated with different therapies. It is therefore imperative that the choices offered and made are in line with what the patient needs and wants.
NOTES FOR PRESENTERS:
Key points to raise:
Dialysis is needed to sustain life for patients with chronic kidney disease. If patients do not have a kidney transplant, dialysis is needed for the rest of the patient’s life.
For most people the choice of dialysis is not clinically driven but is related to individual characteristics and preferences and the impact on their own and their families’ lives.
The disease is never ‘cured’, it is merely treated with these different therapies. Choosing dialysis is difficult and people, and their families, need help to collate all relevant information and tailor it to their needs.

6. Background:2
Overall there are no significant differences between the two types of dialysis for critical outcomes which are:
health-related quality of life
patient involvement and satisfaction
mortality
preservation of renal function
technique failure or switch
resources use and costs including hospitalisation
Peritoneal dialysis may preserve residual renal function more effectively than haemodialysis.
NOTES FOR PRESENTERS:
Key points to raise:
Overall there is no evidence of significant differences between the modalities of dialysis for the critical outcomes which are:
-health-related quality of life
-patient involvement and satisfaction
-mortality (where reported, including deaths in the first 3 months of treatment)
-preservation of renal function
-technique failure or switch
-resource use and costs including hospitalisation
The general clinical view is that residual renal function may be preserved more effectively with peritoneal dialysis than with haemodialysis. The evidence base to support this is limited but the guideline development group highlighted that this is the general clinical view. Expert opinion suggests that good quality haemodialysis may preserve renal function; however, haemodialysis with hypotensive episodes in susceptible patients may adversely affect residual renal function.

7. Epidemiology
At any one time in the UK, people per million of the population need dialysis and prevalence is highly age dependent
60-100% of the dialysis population use in-centre haemodialysis
The NICE costing report for this guideline suggests that the current proportion of the eligible population using peritoneal dialysis in England is estimated to be approximately 15%
50% of patients given informed choice will opt for peritoneal dialysis (NHS Kidney Care, 2009)
NOTES FOR PRESENTERS:
Key points to raise:
At any one time in the UK, 400–800 people per million of the population need renal replacement in the form of dialysis. The prevalence of dialysis in the UK is highly age dependent – for adults aged 70–80 years it is between 1600 and 2000 people per million.
For about 40% of adults on dialysis a kidney transplant is the treatment of choice; this percentage is higher in children.
The proportion of people with chronic kidney disease requiring dialysis and using in-centre haemodialysis ranges from 60–100%. This variability is not fully understood, but it is likely that it represents variation in local practice, resources, and in particular the development of aAPD (assisted ambulatory peritoneal dialysis) and home haemodialysis programmes.
The NICE costing report for this guideline using data from the renal registry (2010) suggests that the current proportion of the eligible population using peritoneal dialysis in England is estimated to be approximately 15%. (The NICE costing report for this guideline can be found at: )
50% of dialysis patients given informed choice will opt for peritoneal dialysis (NHS kidney care, 2009).

8. Scope
The NICE clinical guideline covers adults, children and infants with a diagnosis of CKD stage 5 who need/are having renal replacement therapy.
The guideline provides recommendations for secondary and tertiary healthcare and community settings on:
factors that affect dialysis choice
the support needs of patients and carers when peritoneal dialysis is started
when the type of renal replacement therapy should be switched.
NOTES FOR PRESENTERS:
Key points to raise:
The NICE guideline covers adults, children and infants with a diagnosis of chronic kidney disease stage 5 who need or who are receiving renal replacement therapy.
It provides recommendations regarding factors that influence the choice of dialysis. These are based on factors identified as important to patients or healthcare professionals and includes:
clinical and cost effectiveness of peritoneal dialysis in the community compared with:
-haemodialysis in the hospital (or other similar settings, such as satellite units)
-haemodialysis in the community.
relative clinical and cost effectiveness of the different types of peritoneal dialysis:
-automated, including
-aAPD (assisted automated peritoneal dialysis)
-CAPD (continuous ambulatory peritoneal dialysis).
The guideline also covers the support needs of patients and carers when peritoneal dialysis is started and when the type of renal replacement therapy should be switched, either to or from peritoneal dialysis.
The guideline does not look at:
- diagnosis and assessment, and eligibility for renal replacement therapy or transplantation
management of chronic kidney disease stage 5, other than the interventions listed above
management of comorbidities
- haemodialysis (other than as a comparator for peritoneal dialysis)
- techniques of peritoneal dialysis (for example, the equipment, preparation for dialysis, ultra-filtration and fluid management, access and withdrawal)
- identification and management of complications arising from dialysis
management of acute presentation of CKD stage 5.
Before this guideline was published there was no national guidance in England and Wales on supporting people to make informed decisions about renal replacement therapy, specifically peritoneal dialysis.

9. Definitions PD: Peritoneal dialysis APD: Automated peritoneal dialysis
aAPD: Assisted automated peritoneal dialysis
CAPD: Continuous ambulatory peritoneal dialysis
CKD: Chronic kidney disease
EPS: Encapsulating peritoneal sclerosis
Conservative care: Full supportive treatment for those with advanced kidney failure who, in conjunction with carers and the clinical team, decide against starting dialysis

10. Providing information and support:1
Offer patients with stage 5 CKD and their families and carers:
information and support in line with ‘Chronic kidney disease’ (NICE clinical guideline 73, 2008).
oral and written information about pre-emptive transplant, dialysis and conservative care, to allow them to make informed decisions about their treatment.
NOTES FOR PRESENTERS:
Recommendations in full:
Offer patients with stage 5 chronic kidney disease (CKD) and their families and carers information and support in line with ‘Chronic kidney disease’ (NICE clinical guideline 73, 2008). [1.1.1]
Offer patients and their families and carers oral and written information about pre-emptive transplant, dialysis, and conservative care to allow them to make informed decisions about their treatment. [1.1.2]

11. Providing information and support:2
To enable patients to make an informed decision, offer balanced and accurate information about dialysis options.
The information should include –
a description of all dialysis options including:
- efficacy and potential benefits, based on prognosis
- risks and potential side effects and their severity
- changing the modality and possible consequences.
NOTES FOR PRESENTERS:
Recommendation in full:
To enable patients to make an informed decision, offer balanced and accurate information about all dialysis options. The information should include:
a description of treatment modalities (assisted automated peritoneal dialysis [aAPD], automated peritoneal dialysis [APD], continuous ambulatory peritoneal dialysis [CAPD], and home or in-centre haemodialysis) including:
-efficacy
-risks
-potential benefits, based on the person’s prognosis
-potential side effects and their severity
-changing the modality of dialysis and the possible consequences (that is, the impact on the person’s life or how this may affect future treatment or outcomes)
a discussion about how treatment fits into people’s lives, including:
-the patient's and/or carer's ability to carry out and adjust the treatment themselves
-integration with daily activities such as work, school, hobbies, family commitments and travel for work or leisure
-opportunities to maintain social interaction
-the impact on body image
-how the dialysis access point on the body may restrict physical activity
-if their home will need to be modified to accommodate treatment
-distance and time spent travelling for treatment
-flexibility of treatment regimen
-any additional support or services that might be needed from others. [1.1.3]

12. Providing information and support:3
Information should also involve a discussion about how treatment fits into peoples daily lives including:
- how the access point on the body may restrict
physical activity
- ability to carry out and adjust treatment
- impact on body image and
flexibility of regimen
- home modifications
- distance and time spent travelling
- any additional support needed
NOTES FOR PRESENTERS:
Recommendation in full:
To enable patients to make an informed decision, offer balanced and accurate information about all dialysis options. The information should include:
a description of treatment modalities (assisted automated peritoneal dialysis [aAPD], automated peritoneal dialysis [APD], continuous ambulatory peritoneal dialysis [CAPD], and home or in-centre haemodialysis) including:
-efficacy
-risks
-potential benefits, based on the person’s prognosis
-potential side effects and their severity
-changing the modality of dialysis and the possible consequences (that is, the impact on the person’s life or how this may affect future treatment or outcomes)
a discussion about how treatment fits into people’s lives, including:
-the patient's and/or carer's ability to carry out and adjust the treatment themselves
-integration with daily activities such as work, school, hobbies, family commitments and travel for work or leisure
-opportunities to maintain social interaction
-the impact on body image
-how the dialysis access point on the body may restrict physical activity
-if their home will need to be modified to accommodate treatment
-distance and time spent travelling for treatment
-flexibility of treatment regimen
-any additional support or services that might be needed from others. [1.1.3]
Image reproduced with kind permission of: University Hospital Coventry and Warwickshire NHS Trust (Dr David Bennett-Jones).

13. Providing information and support:4
Explain to patients and check they understand that CKD is a lifelong disease and that they may need to switch treatment modalities.
When providing information, healthcare professionals should take into account information the patient has obtained from all other sources and its possible influence.
NOTES FOR PRESENTERS:
Recommendations in full :
Explain to patients and check they understand that CKD is a lifelong disease, and that during the course of renal replacement therapy they are likely to need to switch between treatment modalities depending on clinical or personal circumstances. [1.1.4]
When providing information about treatment options, healthcare professionals should discuss and take into account any information the patient has obtained from other patients, families and carers and all other sources, and how this information has influenced their decision. [1.1.5]

14. Providing information and support:5
Make sure that healthcare professionals offering information have specialist knowledge about CKD, the skills to support decision making and are available to discuss information provided before and after the start of dialysis.
Offer patients who have presented late or started treatment urgently the same information and choices as those presenting earlier.
NOTES FOR PRESENTERS:
Recommendations in full:
Make sure that healthcare professionals offering information have specialist knowledge about CKD and the necessary skills to support decision-making. This may include training in:
- using decision aids to help patients make decisions about their care and treatment .
- presenting information to children in a form suitable for their developmental stage, such as play therapies. [1.1.6]
Trained healthcare professionals (see recommendation 1.1.6) should be available to discuss the information provided both before and after the start of dialysis. [1.1.7]
Offer all patients who have presented late or started dialysis treatment urgently an enhanced programme of information, at an appropriate time, that offers the same information and choices as those who present at an earlier stage of chronic kidney disease. [1.1.8]
Further information:
The approach to providing information to support informed decision-making should be structured and timely, including for those patients who have presented late or started dialysis treatment urgently. This is consistent with other initiatives to support people with kidney disease, for example the use of kidney care plans. The NICE guidelines on chronic kidney disease ( also make recommendations on tailored education and information to be provided at appropriate times during the patient’s journey.

15. Choosing dialysis
Offer all patients a choice of PD or HD, but consider peritoneal dialysis as the first choice of treatment modality for:
- children 2 years old or younger
- people with residual renal function
- adults without significant associated comorbidities
Before starting PD, offer all patients a choice, if appropriate, between CAPD and APD (or aAPD if necessary)
For children for whom peritoneal dialysis is appropriate, offer APD in preference to CAPD if they are on a liquid diet.
NOTES FOR PRESENTERS:
Recommendations in full:
Offer all people with stage 5 CKD a choice of peritoneal dialysis or haemodialysis, if appropriate, but consider peritoneal dialysis as the first choice of treatment modality for:
-children 2 years old or younger
-people with residual renal function
-adults without significant associated comorbidities . [1.1.9]
When discussing choice of treatment modalities, healthcare professionals should take into account that people’s priorities are not necessarily the same as their own clinical priorities. [1.1.10]
Before starting peritoneal dialysis, offer all patients a choice, if appropriate, between CAPD and APD (or aAPD if necessary). [1.1.11]
For children for whom peritoneal dialysis is appropriate, offer APD in preference to CAPD if they are on a liquid diet, especially if they have low residual renal function. [1.1.12]

16. Switching treatment
Do not routinely switch patients on peritoneal dialysis to a different treatment modality in anticipation of potential future complications
Consider switching treatment modality if the patient, their family or carer asks
When considering switching treatment modality, offer information which includes how any decision to switch may affect future treatment options
Switching between treatment modalities should be planned if possible.
NOTES FOR PRESENTERS:
Recommendations in full:
Do not routinely switch patients on peritoneal dialysis to a different treatment modality in anticipation of potential future complications such as encapsulating peritoneal sclerosis. However, healthcare professionals should monitor risk factors such as loss of ultrafiltration and discuss with patients regularly the efficacy of all aspects of their treatment. [1.1.13]
Consider switching treatment modality if the patient, their family or carer asks. [1.1.14]
When considering switching treatment modality, offer information on treatment options described in recommendations 1.1.1–1.1.8). This should also include how any decision to switch may affect future treatment options. [1.1.15]
Switching between treatment modalities should be planned if possible. [1.1.16]
Further information:
The duration of peritoneal dialysis is often used as a reason to switch treatment in anticipation of rare but significant adverse events, such as encapsulating peritoneal sclerosis (EPS). Although the duration of peritoneal dialysis is associated with the development of EPS, there is no evidence that people should be switched to prevent such adverse events.

17. Savings per 100,000 population
Recommendations with significant savings
Potential savings after 5 years
(£ per year)
Consider peritoneal dialysis as the first choice of treatment modality for adults without significant associated comorbidities
7,979
Estimated saving of implementation
Savings at optimal uptake (est. 20 yrs)
38,233
ADAPTING THIS SLIDE FOR LOCAL USE:
We are aware that local factors such as incidence and baseline can vary considerably when compared with the national average. NICE has provided a costing template for you to calculate the financial impact this guideline will have locally. We encourage you to calculate the local impact of this guideline by amending the local variations in the template such as incidence, baseline and uptake. You can then remove the national figures from the table and replace them with your local figures to present to your colleagues.
NOTES FOR PRESENTERS:
NICE has worked closely with people within and outside the NHS to look at the major savings related to implementing this guideline.
NICE has produced a costing report that provides detailed estimates of the national savings associated with implementing this guideline. NICE has also developed a costing template to calculate the local savings associated with implementing this guideline. The saving per 100,000 population are summarised in the table.
It has been estimated that the recurrent annual saving after uptake of peritoneal dialysis has reached the optimal level, that is, when the population on dialysis consists entirely of people who have been offered peritoneal dialysis as a first choice where appropriate, is £38,233 per 100,000 population. It is estimated that it could take approximately 20 years to reach optimal uptake. As NHS organisations budget for the next 3–5 years, we have also estimated that annual savings of £7,979 per 100,000 population could be realised after 5 years, with a conservative increase in the number of people on peritoneal dialysis of 1% each year.
For further information please refer to the costing template and costing report for this guideline on the NICE website.

18. Discussion To what extent do our services meet these recommendations?
What are the gaps and how can we address them?
Which roles will lead developments in this area?
What is the quality of information and education currently given to patients?
What training in communication with patients do information givers need?
NOTES FOR PRESENTERS:
These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation.
Additional questions:
Who else needs to be involved?

19. Related guidance
Chronic kidney disease, NICE clinical guideline 73,
Anaemia management in people with chronic kidney disease, NICE Clinical Guideline 114,
Laparoscopic insertion of peritoneal dialysis catheter, NICE interventional procedure 208,
Chronic Kidney Disease, NICE Quality Standard,
Renal failure- home versus hospital dialysis, NICE technology appraisal 48,

20. Find out more Visit www.nice.org.uk/guidance/CG125 for: the guideline
the quick reference guide
‘Understanding NICE guidance’
costing report and template
baseline assessment tool
clinical case scenarios
podcast 1: patients who present late
podcast 2: switching treatment modality
NOTES FOR PRESENTERS:
You can download the guidance documents from the NICE website.
The full guideline – all the recommendations, details of how they were developed, and reviews of the evidence they were based on.
A quick reference guide – a summary of the recommendations for healthcare professionals.
‘Understanding NICE guidance’ – information for patients and carers.
For printed copies of the quick reference guide or ‘Understanding NICE guidance’, phone NICE publications on or and quote reference numbers N2600 (quick reference guide) and/or N2601 (‘Understanding NICE guidance’).
NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website.
Costing tools– a costing report looks at resource impact to implementing the guideline.
A baseline assessment tool - to help organisations to monitor their current performance against the recommendations so that interventions can be put into place to implement the guideline.
Two implementation podcasts have been developed for this guideline discussing two specific areas of the guideline: switching treatment modalities; and providing patients who present late with information support and choices.
Clinical case scenarios- an educational resource that can be used in individual or group learning situations.
NICE published a quality standard for Chronic Kidney Disease in March 2011 and this should be referred to alongside the guideline.
Full details available at:

21. Chronic Kidney Disease
NICE Quality Standard
Chronic Kidney Disease

22. CKD quality standard
In 2011 NICE published a quality standard on the diagnosis, care and treatment of chronic kidney disease in adults. Quality standards are a set of specific, concise statements that act as markers of high quality, cost-effective patient care across a pathway or clinical area. The quality standard consists of 15 quality statements and can be found at:
NOTES FOR PRESENTERS:
Key points to raise:
Quality standards are developed by an independent topic expert group (TEG) and define markers of high quality care.
They are developed using the best available evidence and produced collaboratively with the NHS and social care organisations, along with their partners and service users.
Quality standards are based on evidence that includes NICE guidance and other evidence sources accredited by NHS Evidence.
Each quality statement has accompanying quality measures. Accompanying the quality standard is:
Information for adults who use NHS services for chronic kidney disease.
NICE cost impact and commissioning assessment. Additional information:
Quality standard topics are referred to NICE by ministers on the advice of the National Quality Board, a group of representatives from health and social care, committed to improving quality in the NHS and overseeing the reforms aimed at improving care. Further information on the National Quality Board can be found at:

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NOTES FOR PRESENTERS:
Additional information:
The final slide is not intended to be part of the presentation, it asks for feedback on whether this implementation tool meets your requirements and whether it will help you to put this NICE guidance into practice - your opinion would be appreciated.
To open the links in this slide set right click over the link and choose ‘open link’
To open the links in this slide set right click over the link and choose ‘open link’

24. References
Ansell D, Castledine C, Feehally J et al. (2010) UK Renal Registry twelfth annual report. Available from: NHS Kidney Care (2009): Specification for the Commissioning of Peritoneal Dialysis Pathway. Available from: _PD_Pathway_Nov09_FINAL.pdf NICE costing report for peritoneal dialysis guideline (2011). Available from: