In-depth assessment key in identifying candidates for home dialysis, transplant
March 25, 2022
2 minute read
Disclosures: LaMantia and Pelletier do not report any relevant financial information.
PHOENIX — A successful transition from chronic kidney disease to home dialysis or transplantation requires a thorough assessment of the patient’s psychosocial and economic status, speakers said at the Southwest Nephrology Conference.
“The role of the social worker is vital for the stability of a patient on a home modality”, Lauren Pelletier, MSW, CCM, social worker for peritoneal dialysis patients at DaVita Inc. “Psychosocial status impacts a patient’s ability to adhere to treatment,” she said. “As social workers, we can help patients emotionally adjust to dialysis,” Pelletier said.
Choosing a home modality, whether PD or home hemodialysis, begins with the patient’s desire to take care of themselves, Pelletier said. She uses a decision-making tool called Method to Assess Treatment Choices for Home Dialysis, or Match D, offered by the Medical Education Institute, which helps patients navigate the demands of home dialysis.
Some of the reasons to consider home dialysis include being employed full-time, living away from a dialysis clinic, and being independent. “It’s valuable for the patient if they have a strong network of caregivers and home support,” Pelletier said.
Choice of transplant
As with the choice of home dialysis, patients considering a transplant should be vigilant and adhere to a care plan, Julia LaMantia, LCSW, CCTSW, a social worker at Banner University of Phoenix in the transplant division, told attendees.
“Patients will need to adapt to challenges as they arise,” LaMantia said. “This may include additional testing if necessary. Good communication is also important, as well as collaboration with the transplant team.
Home support after the transplant is helpful. She noted that 10% to 20% of surgery refusals made by the transplant team are due to the patient not having a good home support system. “It’s vital for the elderly, patients with complex medical histories, those with language barriers, and mental or medical disabilities,” LaMantia said.
A psychosocial assessment can also help the transplant team determine if a patient will be successful after the transplant. “Post-transplant non-adherence is very common and increases with time after transplantation,” LaMantia said. “It is estimated that non-adherence to medication is responsible for 15% of graft failures and 50% of late acute rejection.”
A transplant team must also assess a patient’s physical condition. For older patients who are interested in a transplant, frailty assessment includes testing a patient for walking speed, performing the stop and rest test, and a grip strength test of the hand is invaluable to the transplant team, Mantis said. “Obesity – with a BMI over 35 – is a contraindication to transplantation. These patients should be referred for dietary counseling or bariatric surgery,” she said.
Likewise, a history of substance abuse or signs of mental illness can often go unnoticed. “Marijuana is now legal in 30 states,” LaMantia said. “We want to be able to restrict the use of [such] drugs due to the risk of post-transplant interaction with immunosuppressive drugs.
“Social workers should look for cannabis use disorder, because of the higher risk of transplant failure, which often occurs within the first year of transplant,” LaMantia said. “Smokers also have a high risk of post-surgical respiratory complications.”
Finally, a patient’s ability to financially commit to the transplant is important. “Medicare covers transplant for eligible patients, but immunosuppressive drugs are only covered 80%, and currently that coverage only lasts 36 months,” LaMantia said. “That will change next January, when patients will get lifelong coverage for immunosuppressive drugs.”
Reference: LaMantia J, Pelletier L. What makes a good candidate for referral to transplant and home therapies? Presented at: Southwestern Nephrology Conference; March 17-18, 2022; Phoenix.