Management of Peritoneal Dialysis within a Home Care Program for Hematological Malignancies: Concerns and Perspectives Illustrated by a Case Report.

The case of an 86-year-old man suffering from acute myeloid leukemia and end-stage renal disease, managed at home, with continuous peritoneal dialysis regimen, is described.

INTRODUCTION

Quality of life (QoL) is a particularly important issue for older patients with ESRD, particularly when the life expectancy is limited by an active malignancy and complicating multiple comorbidities.[1] The management of end-stage renal disease (ESRD) by hemodialysis (HD) may be a difficult task in the setting of old age and frailty because of several clinic and organizational problems. Continuous peritoneal dialysis (CPD) has been demonstrated to be a successful dialysis option for elderly patients.[23] The reliable application of CPD in at home can be of pivotal importance in patients not manageable by conservative measure alone and are unable to attend a hospital centre to receive HD, as recently observed in a case observed by us.

CASE REPORT

The patient was an 86-year-old man suffering from a long lasting myelodysplastic syndrome (MDS) transformed to an acute myeloid leukemia (AML). In order to avoid a useless hospital admission for a chronic and unrecoverable condition, he was followed up at his home, given the need of transfusion and his severe state of disability,[4] due to which he was unable to attend our day hospital unit. The patient was unsuitable for intensive chemotherapy and was treated with hydroxyurea, with a palliative intent. He suffered from multiple comorbidities, such as diabetes mellitus, hypertension, severe cognitive impairment due to progressive cerebrovascular illness, and chronic renal failure (CRF), which progressed to ESRD after one month of beginning of the home care program. Therefore, he was evaluated for HD; however, his clinical conditions and functional status precluded the possibility to attend a regular HD program as outpatient for which domiciliary CPD was offered. Therefore, the patient was admitted in the hospital for placement of peritoneal catheter. No complications were found in the postoperative period. During the recovery, given that he was unsuitable for learning or performing CPD, a patient's caregiver was trained in the catheter exit site medications, in the process and support system related to the technique to achieve the best practise for peritoneal dialysis state. Moreover, the caregiver was educated on the importance of infection control and an appropriate medical regimen to ensure adequate dialysis and improvment in the patient's general condition and well-being. The patient was discharged 10 days later, and caregiver training continued at the patient's home for another two weeks. The treatment plan were prescribed and supervised by our team, which included a skilled nephrologist, seven hematologists, 10 nurses, one psychologist and social worker, and several other care providers trained in hematology, palliative care, and rehabilitation medicine. A trained caregiver was present at home; moreover, written guidelines for the rapid admission of patients in case of clinical complications unmanageable at home were predisposed. Oral palliative chemotherapy with hydroxyurea, regular red blood cell transfusion and other medications were given as required. The CPD program was safely and effectively carried out for entire course of the domiciliary assistance without any complications. However, the patient died because of disease progression and pneumonia in his home, sustained during the end-life by the closeness and good feeling of his loved ones.

DISCUSSION AND CONCLUSIONS

The management of AML in older patients represents a challenge for which home care may be a suitable and effective option.[5] Moreover, in elderly ESRD patients, the management of QoL as well as the technical adequacy of dialytic method are important. Our experience demonstrated that this model of care is feasible, well tolerated, and effective in our older AML patient with a complex disease burden and ESRD, the management of which was feasible on a home care basis. This was done so as to avoid useless hospitalization and inappropriate removal from his domestic environment and loved ones. In conclusion, in our experience with domiciliary CPD represented an important added value to home care program. Working together, through the full integration between specialized nephrology facilities and a highly skilled hematological home care service, the best humanization of care was allowed for our patient.