Barriers to Peritoneal Dialysis in Aboriginal Patients

Abstract

Background:Aboriginal people in Canada have an unduly high burden of end-stage kidney disease (ESKD) and many live in rural settings. Peritoneal dialysis (PD) is a home-based dialysis modality that may provide a valuable alternative to in-center hemodialysis which is relatively underutilized by the Aboriginal population.Objective:We aim to assess the barriers to PD utilization in Aboriginal patients with ESKD.Design:This article is a prospective observational cohort study.Setting:The setting involves 3 predialysis clinics in Winnipeg, Kingston, and Moose Factory.Patients:The patients were 99 individuals (67 non-Aboriginal and 32 Aboriginal) who were at least 18 years of age with an estimated glomerular filtration rate of less than 30 mL/min/1.73m2, and were enrolled in one of the 3 study sites from April 2011 to October 2013.Measurements:Patient demographics and comorbidities were documented. Barriers to PD, PD as modality choice, and Aboriginal status were assessed via patient survey upon study enrollment. PD use as the initial dialysis modality was assessed via monthly patient follow-up for 1 year after enrollment in the study.Methods:The patient survey was created based on literature review of known barriers to PD, repaired based on direct patient feedback, and tested for reliability via the test-retest method. Differences in PD choice, barriers to PD, and PD use between Aboriginal and non-Aboriginal patients were determined by chi-square test and logistic regression.Results:All patients enrolled in the study completed the survey. Mean age was 65.5 versus 54.6 years for non-Aboriginals and Aboriginals, respectively. Barriers to PD significantly associated with Aboriginal status were lack of money (odds ratio [OR]: 21.3; 95% confidence interval [CI]: 5.3-86.4; P < .0001) and anxiety (OR: 2.8; 95% CI: 1.1-7.1; P = .03). There was no difference in PD choice between non-Aboriginals and Aboriginals (66.7% vs 68.8%, respectively; P = .83). One of 67 non-Aboriginals (1.5%) and 5 of 32 Aboriginals (15.6%) died prior to initiating dialysis (P = .013). No significant difference was observed between non-Aboriginals (33%) and Aboriginals (28%) in use of PD (P = .81).Limitations:Small sample size was a limitation of this study.Conclusions:Aboriginal people in Canada have a disproportionately large burden of ESKD, and PD could provide an alternative to in-center hemodialysis for those living in rural areas. Our study identified anxiety and lack of money as barriers to PD significantly associated with Aboriginal status. When choosing dialysis modality, shared decision making between physicians and patient is of key importance to weigh all potential benefits and risks and emphasize the Aboriginal patient’s values and preferences. These results can be used to guide future research and to help devise interventions targeting barriers to PD in Aboriginals.

Community-Based Dialysis in Saskatchewan First Nations: A Grassroots Approach to Gaining Insight and Perspective From First Nations Patients With Chronic Kidney Disease

“…A prospective cohort study by Mathew et al utilized self-reported patient surveys in patients with end-stage renal disease and found that Aboriginals reported lack of money and anxiety as significant barriers to the use of home-based peritoneal dialysis when compared with non-Aboriginal patients. 16 In contrast to the self-reported surveys from Aboriginal patients, our methodology was quite different and may be the reason the barriers our research identified were different. Logistics such as housing, clean water, and reliable electricity may be similar in what Mathew et al reported as “lack of money” when trying to prepare a home for dialysis treatments.…”

“…Previous literature has identified that Aboriginal patients have diabetes-caused end-stage kidney disease 84% of the time versus 37.3% of the time. 16 It is plausible that the physical limitations caused by diabetes such as blindness or severe neuropathy are physical barriers to implementing home-based peritoneal dialysis more so than other conditions that require patients to go on dialysis.…”

A Retrospective Study of Chronic Kidney Disease Burden in Saskatchewan’s First Nations People

“…In Ontario and Manitoba, financial concerns and anxiety were the main barriers to utilization of peritoneal dialysis. 20 Therefore, more work needs to be done to identify the barriers to providing equitable home services within First Nations communities compared with their non-First Nations counterparts.…”

Kidney disease and care among First Nations people with diabetes in Ontario: a population-based cohort study

“…However, a previous study identified anxiety and financial reasons as barriers to peritoneal dialysis among First Nations people. 25 A large qualitative study among Indigenous people with end-stage kidney disease in Australia showed that, although the majority of patients had favourable opinions about kidney transplantation, many felt ill-informed about the process. 26 Similar research has been conducted in Alberta and Saskatchewan.…”