Abstract
Introduction
Peritoneal dialysis (PD) is an alternative modality to hemodialysis (HD) for end-stage Kidney disease (ESKD) treatment. However, PD is underutilized, and patients’ knowledge about PD is crucial in making an informed decision about the dialysis modality. This study aims to evaluate the knowledge about PD among HD patients and explore the reasons for its underutilization.
Materials and methods
A cross-sectional study of 108 HD patients was conducted from August to November 2023, at Al-Jaber Dialysis Center in Al-Ahsa. They interviewed to assess the knowledge about PD and explore the reasons for its underutilization.
Results
The patients’ ages ranged from 20 to 80 years, with a mean age of 44.2 years. Regarding knowledge about PD, 81.5% of the ESKD patients had heard about other renal replacement modalities, with kidney transplant being the most commonly known option. Only 11.1% were aware of both kidney transplants and PD. 60.2% of patients reported that their nephrologists had discussed other treatment options with them. However, overall knowledge about PD among patients was relatively low, with 43.5% having good knowledge and 56.5% having poor knowledge. Lack of information, considering HD as a better method, and fear of complications were the primary reasons for not considering PD as the first treatment option.
Conclusion
This study highlights the inadequate knowledge about PD among HD patients and identifies factors contributing to the underutilization of PD. Lack of information, misconceptions about the effectiveness and safety of PD, and preference for HD were significant barriers. Enhancing patient education and addressing misconceptions are crucial in promoting PD as a viable treatment option for ESKD, thereby improving patients’ quality of life.
Keywords: Peritoneal dialysis; ESKD; hemodialysis; knowledge, underutilization
Introduction
Chronic kidney disease (CKD) is a clinical syndrome caused by a permanent change in the function and or structure of the kidney. It is marked by irreversibility and a slow and steady progression [1]. For many developing countries, the growing global epidemic of CKD and the resulting End-Stage Kidney Disease (ESKD) remains a serious challenge. ESKD reduces patients’ quality of life (QoL) by interfering with their social, financial, and psychological well-being. In addition to physical, functional, metabolic, social, and mental aspects, the disease can harm patients’ self-image and overall quality of life [2].
The global estimated prevalence of CKD is 13.4% (11.7–15.1%), and the number of patients with ESKD who require renal replacement therapy ranges between 4.902 and 7.083 million. CKD has a direct impact on the global burden of morbidity and mortality due to its effect on cardiovascular risk and ESKD [3].
The incidence and prevalence of ESKD have increased in the Kingdom of Saudi Arabia over the last three decades, owing to factors such as increased life expectancy and population growth [4]. Saudi Arabia has a higher age-standardized prevalence (9,892 per 100,000) of CKD (stages 1–2, stage 3, stage 4, and stage 5, excluding renal replacement therapy) than Western Europe (5,446 per 100,000) and North America (7,919 per 100,000) [5]. The Saudi Center for Organ Transplantation (SCOT) reported a total of 21,496 dialysis patients in 2020, with 19,715 patients receiving HD and the remaining 1,781 on PD (Figure 1). The prevalence rate of dialysis patients was 621 per million populations [6].
Figure 1.
Renal replacement therapy in KSA 1995–2020 [6].
According to the SCOT annual report of PD [6], 2020, the central region has the most patients (38%) followed by the western region (23%), eastern (21%), southern (11%), and northern (7%). The types of PD modalities were automated/continuous cyclic PD in 78% of patients, 13% were on continuous ambulating PD, and 9% were on intermittent peritoneal dialysis. The number of dialysis patients (HD and PD) in Al-Ahas was 3.89% of the total dialysis patients in Saudi Arabia, whereas PD patients represented 3% of all PD patients [6].
ESKD patients receiving maintenance dialysis have a significantly higher mortality rate than the general population (about 20% per year in the US and 10–15% in Europe), owing primarily to cardiovascular disease. HD patients typically visit dialysis centers two or three times per week for three or four hours each session, which can affect their professional and personal lives. PD, on the other hand, can be done at home, at work, or in any other clean place, either alone or with the assistance of a caregiver. PD can be done several times a day, every 4–5 h, with a longer pause at night (using the Continuous ambulatory peritoneal dialysis manual method), or continuously throughout the night, using a machine that performs exchanges for 8–10 h (with the Ambulatory PD automated method) [2].
PD has the following advantages over HD: there is no need for heparin therapy, no need for vascular access, the patient’s vascularity is preserved, blood filtration is gradual, hemodynamic and metabolic stability is maintained, blood pressure is better controlled, low complications from frequent blood transfusions such as viral hepatitis, and costs are lower [7–9].
Peritoneal dialysis has a more beneficial effect on the preservation of residual kidney function compared to hemodialysis, improving the survival of dialysis patients [10].
Another advantage of PD is the ability to perform dialysis at home without relying on a hospital, which results in increased self-confidence [7]. PD is recommended for diabetics and patients with chronic heart failure, and this dialysis modality lowers these patients’ mortality rates [11].
Despite its benefits, peritoneal dialysis confronts significant challenges and limitations that need to be considered. They include the need for rigorous sterility, the burden of duties related to home dialysis tasks, the lack of supportive home environments, the physical discomforts associated with home dialysis, negative psychosocial aspects of home-based treatment, insufficient confidence in one’s ability to manage therapy, decreased peer social interactions, logistical challenges imposed by geographic factors, and complications resulting from compromised health conditions [12].
Choosing which of these options is best for an individual patient, is dependent on his or her residual renal function and providing appropriate education to the patient about the various treatment options available [7]. The aim of this study, therefore, is to evaluate the knowledge about PD among ESKD patients on hemodialysis in the Al-Ahsa region and the reasons for its underutilization, which can influence their choice of dialysis modality as well as their quality of life.
Materials and methods
Study design, setting, and participants
A descriptive cross-sectional study was carried out at Al-Jaber Dialysis Center in Al-Ahsa, Saudi Arabia, during the period from August to November 2023. The aim of this study was to evaluate the reasons for underutilization of PD among ESRD patients. It targeted patients who were 18 years and above and undergoing HD treatment. Exclusion criteria included kidney transplanted patients; pediatric HD patients, and those with cognitive and vision impairment. The Ethics Committee of King Faisal University (KFU-REC-2023-JUN-ETHICS990) approved the study. The required sample size was 95 using the formula n = Z2 pq/E2, where the margin of error (E) equals 0.05. The confidence level (Za/2) was 95%, which equals 1.96. The expected proportion (p) of adults equals 0.5; the actual sample size was 108 randomly selected patients. A convenient sampling technique was employed to collect the data.
Questionnaire development and data collection
Data was collected through patients’ interviews during their HD sessions using a structured questionnaire. Prior to collecting data from the participants, verbal informed consent was obtained. The study utilized a questionnaire that was developed by the authors. Face and content validity techniques were used to create and validate the questionnaire. Face validity was achieved by administering the draft questionnaire to a few patients who met the inclusion criteria at Al-Jaber HD Center in order to determine whether the response appeared meaningful, well-designed, and/or a good measure of the construct to an innocent participant. With the help of the information acquired from this activity, the questionnaire was further refined and changed.
Five independent researchers from the field of nephrology evaluated the questionnaire’s appropriateness, clarity, coverage, and relevance to the study as part of the content validity process. The reliability of the questionnaire was calculated using Cronbach’s alpha test, and the result showed a Cronbach’s alpha value of 0.837, indicating that the questionnaire was highly reliable. Patients receiving hemodialysis participated in interviews to complete the questionnaire. The questionnaire consists of two sections. The first section focused on personal and demographic data which include age, gender, marital status, duration on HD, education level, and employment status. The second section assesses the knowledge about PD among ESKD patients on HD.
Statistical analysis
The data were collected, reviewed, and then fed to Statistical Package for Social Sciences version 21 (SPSS: An IBM Company). All statistical methods used were two-tailed with an alpha level of 0.05 considering significance if P ≤ 0.05. Regarding knowledge about PD, the correct answer was scored 1 point and others were scored zero point. The overall knowledge level regarding peritoneal dialysis was assessed by summing up discrete scores for different correct knowledge items. The overall knowledge score was categorized as a poor level if the participant’s score was <60% of the overall score and a good level of knowledge was considered if the participant’s score was 60% or more of the overall score [13–15]. Descriptive analysis was done by prescribing frequency distribution and percentage for study variables including patient’s personal data, medical history, and HD duration. Also, knowledge regarding peritoneal dialysis and their source of information were tabulated while overall knowledge was graphed. Cross tabulation for showing factors associated with study participants’ knowledge of peritoneal dialysis was carried out with Pearson chi-square test for significance and exact probability test if there were small frequency distributions.
Results
This study included 108 HD patients. Patients’ ages ranged from 20 to 80 years with a mean age of 44.2 ± 14.1 years old. Exact of 59 (54.6%) patients were males, 49 (45.4%) were females and 75 (69.4%) were married. As for educational level, 55 (50.9%) had below the secondary level of education, 44 (40.7%) had a secondary level of education and 9 (8.3%) had a university level of education or above. 66 (61.1%) patients were unemployed, 25 (23.1%) were employed and 17 (15.7%) were retired. As for the duration of HD, it ranged from months to 39 years with an average duration of 4 years (Table 1).
Table 1.
Demographic characteristics of study CKD patients on hemodialysis.
| Demographic data | No | % |
|---|---|---|
| Age in years | ||
| <40 | 42 | 38.9% |
| 40–49 | 32 | 29.6% |
| 50+ | 34 | 31.5% |
| Mean ± SD | 44.2 ± 14.1 | |
| Gender | ||
| Male | 59 | 54.6% |
| Female | 49 | 45.4% |
| Marital status | ||
| Single | 33 | 30.6% |
| Married | 75 | 69.4% |
| Educational level | ||
| Below secondary | 55 | 50.9% |
| Secondary/diploma | 44 | 40.7% |
| University/above | 9 | 8.3% |
| Employment | ||
| Unemployed | 66 | 61.1% |
| Employed | 25 | 23.1% |
| Retired | 17 | 15.7% |
| Duration of hemodialysis in years | ||
| <5 years | 65 | 60.2% |
| 5–10 years | 21 | 19.4% |
| >10 years | 22 | 20.4% |
| Mean ± SD | 6.2 ± 7.2 | |
| Median (range) | 4.0 (2 months – 39 years) | |
Table 2 shows Knowledge about PD among HD patients. 88 of them (81.5%) heard about other renal replacement modalities (other than HD), where 76 (70.4%) heard about kidney transplants and only 12 (11.1%) heard about kidney transplants and PD. 65 of HD patients (60.2%) reported that their treating physician (nephrologist) discussed with them the other options (other than HD). Generally, 58 of the patients (53.7%) think that they have very limited knowledge about PD, but 26 (24%) think they have great to extensive knowledge about PD. Only 24 of HD patients (22.2%) reported correctly that PD can be done outside the healthcare setting independently, and 16 patients (14.8%) think that PD is safe. More than half of the patients (55.6%) correctly reported that compared to HD, PD requires more frequent dialysis sessions, and 43 patients (39.8%) think that compared to HD, PD is more stressful physically and psychologically. Regarding sources of information about PD, the most reported were physicians (63.9%), family and friends (9.3%), social media, and other healthcare staff (3.7% for each).
Table 2.
Knowledge about peritoneal dialysis among CKD patients on hemodialysis.
| Knowledge | No | % |
|---|---|---|
| Have you ever heard about other renal replacement modalities (other than HD)? | ||
| Yes | 88 | 81.5% |
| No | 20 | 18.5% |
| Which of the following renal replacement modalities are you familiar with? | ||
| Renal transplant | 76 | 70.4% |
| Renal transplant and PD | 12 | 11.1% |
| None of them | 20 | 18.5% |
| Did your treating physician (nephrologist) discuss with you the other options (other than HD)? | ||
| Yes | 65 | 60.2% |
| No | 43 | 39.8% |
| In general, how would you rate your knowledge about the other replacement modalities? | ||
| Very limited knowledge | 58 | 53.7% |
| Limited knowledge | 10 | 9.3% |
| Some knowledge | 14 | 13.0% |
| Great knowledge | 17 | 15.7% |
| Extensive knowledge | 9 | 8.3% |
| Do you think that PD can be done outside the healthcare setting independently? | ||
| Yes | 41 | 38.0% |
| No | 24 | 22.2% |
| I don’t know | 43 | 39.8% |
| Do you think that PD is a safe procedure? | ||
| Yes | 16 | 14.8% |
| No | 37 | 34.3% |
| I don’t know | 55 | 50.9% |
| Compared to HD, do you think that PD requires more frequent dialysis sessions? | ||
| Less frequent | 1 | .9% |
| Same frequency | 3 | 2.8% |
| More frequent | 60 | 55.6% |
| I don’t know | 44 | 40.7% |
| Compared to HD, do you think that PD is more stressful physically and psychologically? | ||
| Yes | 43 | 39.8% |
| No | 11 | 10.2% |
| I don’t know | 54 | 50.0% |
| Source of information | ||
| Physicians | 69 | 63.9% |
| Social media | 4 | 3.7% |
| Family or friends | 10 | 9.3% |
| Other healthcare providers | 4 | 3.7% |
| I did not hear about these modalities | 21 | 19.4% |
Figure 2 shows the overall knowledge level about peritoneal dialysis among HD patients. 47 of them (43.5%) had an overall good knowledge of PD, while 61 patients (56.5%) had a poor knowledge level. Figure 3 shows ESRD Patients’ reasons for not considering peritoneal dialysis as the first treatment option. The most reported reasons included lack of information (36.1%), thinking HD is a better method (32.4%), fear of complications (32.4%), lack of social support (13.9%) and medical reasons (4.6%).
Figure 2.
Overall knowledge level about peritoneal dialysis among CKD patients on hemodialysis.
Figure 3.
CKD patients’ reasons for not considering peritoneal dialysis as the first treatment option.
Factors associated with HD patients’ knowledge about PD are shown in Table 3. Patients under 40 years old had good knowledge of PD, compared to patients 50 years of age or older (p = 0.022). The gender of the patients had no effect on their overall knowledge level (p = 0.792). Overall single patients had strong knowledge, compared to married patients (p = 0.048). In comparison to individuals with a higher education level, those with a secondary level of education had better knowledge of PD (p = 0.020). Patients on HD for 5–10 years demonstrated better knowledge of PD than those on HD for <5 years (p = 0.011). Those who got their information from a physician had a higher level of knowledge than those who got it via social media (p = 0.001).
Table 3.
Factors associated with CKD patients’ knowledge about peritoneal dialysis.
| Overall knowledge level | |||||
|---|---|---|---|---|---|
| Poor | Good |
||||
| Factors | No | % | No | % | p-value |
| Age in years | |||||
| <40 | 17 | 40.5% | 25 | 59.5% | 0.022* |
| 40–49 | 20 | 62.5% | 12 | 37.5% | |
| 50+ | 24 | 70.6% | 10 | 29.4% | |
| Gender | 0.792 | ||||
| Male | 34 | 57.6% | 25 | 42.4% | |
| Female | 27 | 55.1% | 22 | 44.9% | |
| Marital status | |||||
| Single | 14 | 42.4% | 19 | 57.6% | 0.048* |
| Married | 47 | 62.7% | 28 | 37.3% | |
| Educational level | |||||
| Below secondary | 36 | 65.5% | 19 | 34.5% | 0.020* |
| Secondary/diploma | 18 | 40.9% | 26 | 59.1% | |
| University/above | 7 | 77.8% | 2 | 22.2% | |
| Employment | |||||
| Unemployed | 32 | 48.5% | 34 | 51.5% | 0.080 |
| Employed | 16 | 64.0% | 9 | 36.0% | |
| Retired | 13 | 76.5% | 4 | 23.5% | |
| Duration of hemodialysis in years | |||||
| <5 years | 44 | 67.7% | 21 | 32.3% | 0.011* |
| 5–10 years | 7 | 33.3% | 14 | 66.7% | |
| >10 years | 10 | 45.5% | 12 | 54.5% | |
| Source of information about the other modalities | |||||
| Physicians | 28 | 40.6% | 41 | 59.4% | |
| Social media | 4 | 100.0% | 0 | 0.0% | 0.001*^ |
| Family or friends | 6 | 60.0% | 4 | 40.0% | |
| Other healthcare providers | 2 | 50.0% | 2 | 50.0% | |
| I did not hear about these modalities | 21 | 100.0% | 0 | 0.0% | |
P: Pearson X2 test; ^: Exact probability test.
*p < 0.05 (significant).
Discussion
CKD patients are a rapidly increasing group of individuals [16]. Living with CKD for a long period of time is a challenge that requires proper education for treatment adherence [17], and patient empowerment [18–20]. Having the right knowledge about the disease, its multidimensional aspects, and its management are crucial for patients to feel empowered and in control of their own health [21–23]. However, despite the strategic focus on supporting the empowerment of long-term passion, there is limited evidence of the adequacy of knowledge among these patients [24,25].
The current study aimed to assess knowledge about PD among HD patients. The study results showed that most patients had a low level of education and were not working due to their chronic health problems as most of them also were recent cases (on HD for <5 years). As for their knowledge level, less than half of the study patients on HD had good knowledge about PD and about one-third of them think they are knowledgeable about PD (moderate to extensively knowledgeable).
In more detail, the vast majority of the study patients heard about other renal replacement modalities mainly from health care staff as about two-thirds were discussed about PD by their treating physician. Also, very few percent of them knew about PD as renal transplant was the dominant modality they knew other than HD. About one-third of the patients don’t think about the safety of PD and more than half of them know that more frequent sessions are needed with PD than HD. Also, more than one-third of them think that PD is more stressful physically and psychologically compared to HD. A similar finding was reported by Sayed et al. [26] as the median achieved knowledge score was 11.5 of 35 points (32.8%). Also, Ghafari et al. [7] documented that 75% of his study patients had little information; 19% had moderate information and 6% of patients were well informed. In Kenya, Ngaruiya et al. [27] documented that participants who had been taught how to perform PD and those who had the knowledge that PD is an effective treatment modality were associated with the level of practice of PD. In a study by Gómez et al. [28] the patient education program using a standard information package significantly improved knowledge and understanding of ESRD and treatment options. Kutner et al. [29] found that among CKD participants who stated that they had discussed PD before dialysis, 108 (10.9%) chose to begin treatment using PD. In contrast, only 10 out of the 631 CDS participants who had not discussed PD opted for this treatment (1.6%).
Regarding factors associated with patients’ knowledge about PD, the current study showed that higher knowledge was reported among young age patients, long duration of HD, and among those who had their information from healthcare staff. The surprising finding was that low education was associated with a higher knowledge level which may be explained by that most low-educated patients are those who had the disease for a long time period (the disease affected their learning ability) so they are more experienced about all treatment modalities including PD.
Regarding patients’ perception of PD, the most reported reasons for not putting PD as the first management option were lack of information, thinking HD is a better method, fear of complications, lack of social support, and medical reasons. On the other hand, Schellartz et al. [30] documented that Participants who generally want to keep control of their lives and take responsibility for their dialysis treatment tended to choose PD. Other studies assessed PD patients often stressed aspects of autonomy and control that were causal for their decision [31,32], while HD patients reported a loss of control due to their feeling of inability to manage their life any longer [33].
A multifaceted strategy involving education, training, and support is needed to increase the awareness of PD among physicians and patients. The following are some approaches and strategies that can be used to improve PD knowledge. First, comprehensive educational modules (e.g. printed materials, online modules, videos) that address the basics of PD and should be tailored for both physicians and patients. Second, interdisciplinary training programs that involve physicians, nurses, and other healthcare professionals. Including nurses in these programs is crucial because they play a significant role in PD patient education, monitoring, and support. Third, patient education and empowerment will be provided through support groups, online forums, and peer support networks. Fourth, home visit programs will enable healthcare providers to assess patients’ techniques, address any concerns or challenges, and provide personalized education and support in the comfort of the patient’s home environment. Fifth, telehealth and remote monitoring will allow healthcare providers to assess patients’ progress, address concerns, and provide timely interventions without the need for in-person visits. Lastly, raise awareness of PD and its benefits through community outreach initiatives, public health campaigns, and educational activities. Work in collaboration with patient advocacy groups, community organizations, and local media to spread correct information, dispel myths, and promote early detection and treatment of kidney disease.
It is important to consider these results in the context of their limitations. First, the relatively small sample size might decrease statistical power. The second, single-center study will restrict the results’ generalizability to the broader population. Larger multi-center studies are required to contextualize our findings and better understand frequently overlooked barriers to the adoption of PD. Third, there was limited exploration of socioeconomic factors. Fourth, Self-reported data may be subject to recall errors or memory bias. Lastly, it cannot establish causality between variables.
Conclusion
The study found that a significant number of participants had limited knowledge about PD, and there was a lack of information provided by healthcare providers, particularly nephrologists. Misconceptions and concerns about complications were identified as barriers to considering PD as a treatment option. The study emphasized the importance of patient education, healthcare provider involvement, and accurate information dissemination to promote informed decision-making and increase the utilization of PD. By addressing these issues, it is possible to enhance patient outcomes and quality of life in ESKD patients.
Funding Statement
This study was funded by the Deanship of Scientific Research, King Faisal University, KSA (Project number GrantA079).
Author contributions
Conceptualization: K.Z. and B.M.A.; Methodology: M.A.A; Software: M.Y.A.; Validation: M.A., H.A. and A.A.; Formal Analysis: K.Z.; Investigation: H.H.K; Writing – Original Draft Preparation: B.M.A., H.H.K, M.A, M.Y.A; Writing – Review and Editing: K.Z, E.A and M.A.; Visualization: H.A.; Supervision: A.A, E.A. All authors agree to be accountable for all aspects of the work.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Data availability statement
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.