• ? Hospital-based treatment.
  • ? Suitable for dependent patients.
  • ? Provides social structure for frail elderly patients.
  • ? Requires transport time.
  • ? Interferes with work.
  • ? Increased hospitalization for vascular access problems.
  • ? Difficult to travel for holiday or work.

Peritoneal dialysis

  • ? Home-based treatment.
  • ? Patient independence.
  • ? Fits in with work.
  • ? Can be done by carer at home.
  • ? Fewer visits to hospital.
  • ? Easier to travel and go on holiday.

16 per cent starting HD.10 There is some evidence that automated PD with a cycling machine at night while asleep may allow patients more time for work and leisure activities.11

Work and dialysis

The well-being of someone on dialysis depends on many factors, both physical and psychological. The physical symptoms that some continue to experience will depend on adequacy of dialysis and compliance with treatment. Depression, anxiety, and denial of illness can contribute to poor compliance and interfere with treatment. Family and social support is important.

Half of those commencing dialysis are under the age of 65 but studies show very high rates of unemployment (>70 per cent) compared to the general population.12 In non-diabetic renal disease, choosing PD, employer support, and EPO treatment all increase the likelihood of maintaining employment.

Some of the complexities faced in helping an individual remain at work are illustrated by the following case.

Mr C is a 50-year-old man from Hong Kong who had a successful career as an accountant in a large firm. At age 45 he developed angina, required coronary bypass surgery, and was found to be diabetic with renal impairment. He found it hard to discuss things with his family. As his renal function declined, he found his job increasingly stressful and therefore left his firm and took on short-term contracts. He denied he had symptoms of renal failure but was eventually persuaded to start dialysis when his plasma creatinine was 950 gmol/L. He chose automated PD as this left him free during the day. He initially managed to work full-time. However, after a year he announced that he had given up work and now spent all his time at home. At a meeting with him, his wife, and members of the healthcare team, it became apparent that compliance was poor—he often failed to put himself on dialysis at night and missed EPO injections; he had lost self-esteem and felt a burden on his family. He accepted counselling, compliance improved, he felt better and was able to return to part-time work.

Many individuals do continue to work in all sorts of professions. They can be enabled to do so with the aid of the occupational health team at the place of work, or if the employer has some understanding of the flexibility required in the working day. It is important for the dialysis team caring for the patient to adapt the treatment round the needs of the patient, by, for example, arranging HD in the evening if the patient works during the day, and being flexible over the times of clinic appointments. It is often easier to fit RRT round work if treatment is carried out at home, whether HD or PD. Box 19.3 lists some of the specific work problems patients encounter on dialysis.

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