Transitional Dialysis Care (TDC)

Joanna Lee Neumann, RN, CNN

It is well researched and known that patients who are informed about the need to start dialysis often go through the process of grieving. New dialysis patients may be frightened, confused, anxious and lost. In particular, those “crashing in” needing emergent start. Transitional Dialysis Care (TDC) is a humanizing approach to gently ease a patient into dialysis. While the patient is receiving the crucial dialysis treatment, their emotional needs are also addressed. Education about end stage kidney disease (ESKD), treatment options, dialysis procedures, nutrition, and financial aspects of ESKD are provided to empower the patients to make the most informed decision of their treatment choice. These educations are provided to both the patient and the care partner by the interdisciplinary team. They also have the opportunity to learn about different home dialysis equipment, both hemodialysis and peritoneal dialysis.

A typical transitional dialysis care program is four weeks. By the end of the program, the patient should be hemodynamically stabilized and has a good understanding of ESKD and the pros and cons for all treatment choices. There are different ways to provide TDC depending on how the services are set up. Some programs have designated staff to provide focused chairside education while the patient is receiving treatment. It can also be a separate dialysis units providing broad support services. A common goal is that these units provide a supportive and safe environment to all the patients who will receive and learn about dialysis treatment. It is an opportunity for them to feel what home therapy is like. They are usually prescribed more frequent treatments, preferably without 2-day treatment gap.

The following are examples of candidates who are appropriate to participate in the TDC program:

New ESKD patients who have little to no modality education
In-center hemodialysis (ICHD) patients who are interested in home dialysis modality and want to experience the therapy in a safe environment
Peritoneal Dialysis (PD) patients who are experiencing problem with the therapy due to inadequate dialysis or ultrafiltration failure and want to try another home dialysis modality
Transplant rejection patients who need dialysis

The following are examples of candidates who will be challenging to participate in the TDC program:

Permanent patients of long-term care facilities
Patient in hospice care
Patients with severe cognitive impairment and without care partner
Patients with unstable living arrangements

In conclusion, Transitional Dialysis Care is a way to ease patients initially into dialysis. More frequent dialysis is proven to reduce the mortality and hospitalization risk during the first 90 days post initiation of dialysis as a result of acute coronary events, arrhythmia, heart failure/cardiomyopathy or fluid overload/pulmonary edema. Comprehensive and strategic ESKD education enable new patients to make the best choice of treatment.

References:

Michael Kraus and Dinesh Chatoth, “Benefits of Home Hemodialysis,” Fresenius Medical Care North America, published July 12, 2019, https://fmcna.com/insights/articles/benefits-home-hemodialysis/.
Clin J Am Soc Nephrol. “Transitional Care Units: Greater Than the Sum of Their Parts” 2019 May 7; 14(5): 765–767.
2. United States Renal Data System: 2017 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States, Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2017