Renal Replacement Therapy (Haemodialysis, Peritoneal Dialysis) — Viva Defence

Opening statement (SASPOP, delivered aloud)

"Mrs Nguyen is a 67-year-old woman with CKD5 from hypertension and diabetes, an eGFR of 8 on a clear downward trajectory, and two facts that dominate every decision: ischaemic heart disease with a borderline ejection fraction — because cardiovascular disease is what kills dialysis patients and haemodialysis is itself a cardiac stress — and emerging frailty, which reshapes what any therapy can achieve. She is currently asymptomatic from her kidneys, so per the IDEAL evidence she does not need to start dialysis today; but her planning window is closing, and it has not yet been used. Her main problems are: advanced CKD needing a modality decision within months, not weeks; cardiovascular disease that both disqualifies her from transplant listing until assessed and makes intradialytic hypotension genuinely dangerous; frailty and dependence that must shape the modality and the goals conversation; and an unstarted access plan. My plan is to complete cardiac and frailty assessment, run the modality conversation honestly — assisted peritoneal dialysis at home versus supervised in-centre haemodialysis versus a structured conservative pathway — create access in time for the anticipated start, and integrate her stated priorities: time at home with her husband is the outcome she is actually buying." [1] [10] [7]

Structured problem list

1. CKD5, eGFR 8, asymptomatic — no start today per IDEAL, but triggers must be defined in writing and review made frequent, because her symptoms will arrive within months [1].
2. Ischaemic heart disease, EF 45% — the dominant mortality driver on dialysis, a relative barrier to transplantation, and a direct argument about modality: thrice-weekly ultrafiltration causes acute myocardial blood-flow reductions and stunning, which her ventricle tolerates poorly [10] [8].
3. Frailty and falls — predicts poor tolerance of centre-based schedules, transport burden, and shifts the balance toward home-based therapy or conservative care [5] [7].
4. No access, no transplant work-up — the planning gap; whatever modality is chosen, access needs months of lead time and a catheter must never become the default [9].
5. Stated priorities — she has already told us her goals: home, her husband, independence without the hospital chair. That is not colour; it is the decision criterion [7].
6. Husband's capacity and daughter nearby — the support structure that makes assisted home therapy feasible [6].

Integrated management plan

• Do not start dialysis today. She is asymptomatic with acceptable potassium and no overload — IDEAL supports monitored waiting with defined triggers (uraemic symptoms, refractory hyperkalaemia or acidosis, diuretic-resistant overload, pericarditis, encephalopathy), reviewed every 4–6 weeks so the start is planned, not crashed [1] [2].
• Assess the heart properly before any commitment. Echocardiogram updated, functional assessment, cardiology opinion — this answers two questions at once: whether transplant evaluation is realistic (at 67 with EF 45% and frailty, probably guarded, but the question must be asked rather than assumed, because a functioning graft remains the only therapy that outlives dialysis) and how much intradialytic stress her ventricle can bear [3] [10] [8].
• Run the modality conversation with her priorities in the chair. The evidence: survival is equivalent between HD and PD; in older patients, quality of life on PD is at least comparable to HD (BOLDE); and assisted PD — a trained nurse or family member performing exchanges — extends home therapy to patients whose frailty or dexterity would otherwise exclude it, endorsed by the ISPD as standard practice. For a woman who wants home and hates the chair, assisted APD overnight with days free is the modality that buys her stated outcome; the honest alternative is in-centre HD with a gentle prescription (longer sessions, cautious ultrafiltration, cooled dialysate) if her cardiac assessment says supervised intensity is safer; and the honest third option, given her frailty and comorbidity, is structured conservative kidney management, because in the very elderly and highly comorbid the survival advantage of dialysis attenuates while quality of life on a conservative pathway is preserved [4] [5] [6] [7].
• Create access with a clock on it. If she chooses PD: catheter insertion now with a healing window before training. If she leans HD: fistula referral now — 6–12 weeks to mature, failure-to-mature common, elderly vessels less forgiving — and a written rule that a catheter is a bridge, never a destination [9].
• Prescribe the start gently, whenever it comes. Whichever modality: incremental start if residual function allows, careful ultrafiltration targets, avoidance of intradialytic hypotension as an organ-protective act, and the holistic bundle — anaemia management, vaccination, dietetics, medication review for falls risk [8] [2].
• Goals-of-care defence. Advance care planning now, while she is well: what a good outcome looks like to her, under what circumstances dialysis would be stopped, and who speaks for her if she cannot. Document her words — "home, my husband, not the chair" — because that sentence will govern hard decisions later [7] [2].

Probing questions with model answers

"Why not just start her on haemodialysis now, eGFR 8, before she gets sick?" — "Because that is the hypothesis IDEAL tested and rejected. Planned early start at eGFR 10–14 gave no survival benefit over starting at 5–7 for symptoms or complications — early start only added dialysis-days, access interventions and hospital time, which is the exact currency she told me she does not want to spend. What I will not do is waste the waiting: the monitoring interval is for cardiac assessment, access creation and the goals conversation, so that when symptoms trigger the start it is one planned day, not an emergency admission through a temporary catheter." [1] [9]

"Her EF is 45%. Can she even tolerate haemodialysis?" — "That is the right question, and it has a mechanism behind it. Haemodialysis acutely reduces global and segmental myocardial blood flow — McIntyre's work showed transient regional wall-motion abnormalities, stunning, occurring during routine sessions, recurring three times a week and consolidating into ventricular damage. On a ventricle of 45% with ischaemic disease, that is not a theoretical concern. It does not rule HD out, but it changes the prescription — longer sessions, slower ultrafiltration, cooled dialysate, dry-weight caution — and it strengthens the case for the gentler continuous physiology of peritoneal dialysis, which avoids the peak ultrafiltration stress entirely. Her cardiac assessment is therefore not a formality; it is the pivot of the modality decision." [8] [10]

"She is frail and her husband is 70. Is peritoneal dialysis realistic, or are you romanticising it?" — "The fair challenge, and the answer is that I am not proposing she does PD — I am proposing PD is done for her, at home. Assisted PD, with a trained nurse or trained family member performing the cycler setup, is ISPD-endorsed standard practice precisely for patients whose frailty, dexterity or cognition would otherwise exclude home therapy; between her husband and her daughter, with nursing support, the workforce exists. And the evidence in older patients is reassuring: BOLDE found quality of life on PD at least comparable to HD, with the advantage of avoiding thrice-weekly transport — which for a woman with falls and a stick is not comfort, it is safety. If the support proves insufficient, that finding itself moves her toward supervised HD or conservative care — the assessment answers it." [6] [5]

"Are you offering her conservative care? Isn't that giving up?" — "I am offering it as information, not as a recommendation — and it is not giving up, it is a different active treatment. Structured conservative kidney management is symptom control, anaemia and volume management, dietetics, and palliative involvement with explicit goals — care, differently aimed. The data matter here: in patients over 75 with stage 5 CKD, the survival advantage of dialysis attenuates as comorbidity rises, and quality of life on the conservative pathway is preserved; at 67 with ischaemic heart disease and frailty she sits near, not yet inside, that phenotype — which is why I present it as one honest option among three and let her priorities, not my discomfort, decide. Naming the option is respect; hiding it is paternalism." [7] [2]

"Should she be transplanted?" — "The question must be asked because the evidence is absolute: transplantation outlives every form of dialysis, and the benefit is greatest where life-years are at stake. But at 67 with an ejection fraction of 45%, active frailty and falls, her pre-transplant cardiac work-up would need to clear her for a major operation and immunosuppression — I suspect it will not, and registry reality agrees that few like her are listed. So my honest sequence is: complete the cardiac assessment, make the listing decision on evidence rather than assumption, and plan her modality as if dialysis will be her therapy — with the transplant conversation reopened if her cardiac status ever improves." [3] [10]

"She deteriorates next month — uraemic nausea, eGFR 6, no access yet. What do you do?" — "Then the planning failure is mine, and I manage it without compounding it. She needs dialysis within days: I would favour urgent-start PD if the centre offers it and she has chosen that modality — catheter in, low-volume supine exchanges, a validated path — or a tunneled catheter with gentle haemodialysis if not. Either way, permanent access is created the same week, and the catheter — venous or peritoneal, if she later transitions — is documented as a bridge with a named exit plan, because catheter-days are a countable harm: bacteraemia, central vein stenosis, and mortality that accumulates with every week the bridge becomes the road." [9]

Communication points

• Reflect her own words back as the decision criterion: "You told me home and your husband matter more than the chair — so let us build the plan that buys you that, and be honest about what each choice costs." [7]
• Present the three options without steering: "There is no wrong door here — there is only the door that fits your life, and my job is to make sure you walk through it with the numbers in front of you." [4] [5]
• Normalise the goals conversation as routine, not ominous: "We make this plan now, while you are well, so that every decision later is yours and not a crisis meeting's." [7] [2]
• Include the husband explicitly — his capacity is part of the prescription, and his questions deserve the same evidence as hers. [6]