Dear ASPN Members,
In light of the recent flooding and subsequent closure of Baxter’s North Cove manufacturing facility, we are anticipating shortages in peritoneal dialysis (PD) solutions. The ASPN Clinical Affairs and Practice Management Committees, along with other members and leadership of ASPN, are closely monitoring the situation and collaborating with key organizations to develop strategies that will ensure our patients continue to receive safe and effective care.
It is critical to emphasize that reducing the number of PD solution bags used per day is the primary goal. Simply reducing the total volume of fluid without reducing the number of bags used will not be sufficient in addressing the current supply challenges.
To this end, please consider the following strategies:
- Adjust PD Prescriptions to Reduce Bag Use:
Review patient prescriptions carefully to determine if adjustments can be made to decrease the number of bags used per day. For instance, a patient with a fill volume of 2800 mL x 7 cycles (19,600 mL total) uses four 6L bags. Reducing the fill volume to 2500 mL or dropping one cycle would lower the total volume to 17,500 mL or 16,800 mL respectively, allowing for the use of only 3 bags. Such a change may not have a large impact on Kt/V. Reviewing PET results can inform potential changes (i.e. when choosing between decreasing fill volume vs dropping a cycle and lengthening dwells).
- Minimizing Waste from Mixing Bags:
Pediatric patients requiring volumes less than 6L may mix two 6L bags of different dextrose concentration, leading to significant waste. To minimize bag use, consider alternating between different dextrose concentrations (e.g., 1.5% one night and 2.5% the next), rather than mixing. Individualized fluid intake adjustments may be needed based on the choice made: higher fluid intake if the higher dextrose concentration is chosen, and lower fluid intake if the lower dextrose concentration is chosen.
- Conserve by Reducing Bag Count, Not Just Volume:
As noted above, changes should focus on reducing the total number of bags used, not just the volume of solution. For example, a patient using only two bags with total volume of 11,000 mL may not be able to safely reduce their total volume to less than 6L, but could potentially skip a night of dialysis each week if their residual kidney function allows. When making prescription adjustments, keep in mind that a priming volume of 500 mL is needed for standard cassette, and 300 mL for low-fill cassette.
- Monitor Patients Closely After Prescription Adjustments:
After making any significant changes to prescriptions, increased monitoring is necessary. Increased lab frequency should be considered. Ensure that patients track daily weights and blood pressures closely. We recommend frequent phone check-ins to monitor for any potential adverse effects of prescription changes.
- Assess and Manage PD Bag Inventories:
Encourage patients to take stock of their current PD bag supplies, as some may have recently received shipments while others may be running low. Many recent orders were canceled due to supply disruptions. If this is the case, patients should be prompted to reorder immediately, and clinics should assist in ensuring orders are placed as needed.
- Planning for Potential Emergency Measures:
Should the supply shortage worsen or persist for an extended period, more drastic measures may be required. This could include moving to emergency PD protocols, changing modality to hemodialysis, or implementing emergency diets. For now, we recommend focusing on smaller, controlled changes that lead to fewer bags being used per day. Dialysis teams should continue to carefully monitor the situation and make changes as indicated based on further information about PD solution supply.
- Inpatient PD:
While the information above is focused on the outpatient PD population, when deemed possible, similar strategies should be considered for the inpatient PD population as well.
We appreciate your ongoing efforts to adapt and care for your patients during this challenging period. Please continue to monitor your patients closely and consider the above adjustments where appropriate. We will provide further updates as more information becomes available.
Sincerely,
ASPN Clinical Affairs and Practice Management Committee
