The effect of urgent-start peritoneal dialysis and urgent-start hemodialysis on clinical outcomes in patients with chronic kidney disease: an updated systematic review and meta-analysis

OBJECTIVE

Recently, urgent-start peritoneal dialysis (PD) has been suggested in place of urgent-start hemodialysis (HD) in cases of chronic kidney disease (CKD). However, the comparative effectiveness of these methods is still unclear. This study compared the outcomes of urgent-start PD and urgent-start HD in CKD patients.

METHODS

Electronic searches were conducted in PubMed, EMbase, Google Scholar databases, and Cochrane Library, up to 30th July 2023 for studies reporting data on all-cause mortality. Secondary outcomes included dialysis-related infectious and mechanical complications. Risk ratios (RRs) with 95% confidence interval (CI) were calculated.

RESULTS

Nine eligible studies involving 941 PD and 779 HD patients were analyzed. Pooled analysis demonstrated elevated risk of all-cause mortality (RR: 1.06, 95% CI: 1.02 to 1.09), dialysis-related infectious complications (RR: 1.05, 95% CI: 1.02 to 1.07), and mechanical complications (RR: 1.08, 95% CI: 1.04 to 1.13) in patients undergoing urgent-start HD than in patients on urgent-start PD.

CONCLUSION

Our findings indicate that CKD patients that received urgent-start HD are at increased risk of all-cause mortality and infectious, and mechanical complications that are associated with the dialysis than patients that received urgent-start PD. These findings have to be considered when making treatment decisions for patients with acute kidney injury. Better understanding of the mechanism of these differences may help to create guidelines for more informed clinical practices.

Peritoneal dialysis versus haemodialysis for people commencing dialysis

BACKGROUND

Peritoneal dialysis (PD) and haemodialysis (HD) are two possible modalities for people with kidney failure commencing dialysis. Only a few randomised controlled trials (RCTs) have evaluated PD versus HD. The benefits and harms of the two modalities remain uncertain. This review includes both RCTs and non-randomised studies of interventions (NRSIs).

OBJECTIVES

To evaluate the benefits and harms of PD, compared to HD, in people with kidney failure initiating dialysis.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies from 2000 to June 2024 using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. MEDLINE and EMBASE were searched for NRSIs from 2000 until 28 March 2023.

SELECTION CRITERIA

RCTs and NRSIs evaluating PD compared to HD in people initiating dialysis were eligible.

DATA COLLECTION AND ANALYSIS

Two investigators independently assessed if the studies were eligible and then extracted data. Risk of bias was assessed using standard Cochrane methods, and relevant outcomes were extracted for each report. The primary outcome was residual kidney function (RKF). Secondary outcomes included all-cause, cardiovascular and infection-related death, infection, cardiovascular disease, hospitalisation, technique survival, life participation and fatigue.

MAIN RESULTS

A total of 153 reports of 84 studies (2 RCTs, 82 NRSIs) were included. Studies varied widely in design (small single-centre studies to international registry analyses) and in the included populations (broad inclusion criteria versus restricted to more specific participants). Additionally, treatment delivery (e.g. automated versus continuous ambulatory PD, HD with catheter versus arteriovenous fistula or graft, in-centre versus home HD) and duration of follow-up varied widely. The two included RCTs were deemed to be at high risk of bias in terms of blinding participants and personnel and blinding outcome assessment for outcomes pertaining to quality of life. However, most other criteria were assessed as low risk of bias for both studies. Although the risk of bias (Newcastle-Ottawa Scale) was generally low for most NRSIs, studies were at risk of selection bias and residual confounding due to the constraints of the observational study design. In children, there may be little or no difference between HD and PD on all-cause death (6 studies, 5752 participants: RR 0.81, 95% CI 0.62 to 1.07; I2 = 28%; low certainty) and cardiovascular death (3 studies, 7073 participants: RR 1.23, 95% CI 0.58 to 2.59; I2 = 29%; low certainty), and was unclear for infection-related death (4 studies, 7451 participants: RR 0.98, 95% CI 0.39 to 2.46; I2 = 56%; very low certainty). In adults, compared with HD, PD had an uncertain effect on RKF (mL/min/1.73 m2) at six months (2 studies, 146 participants: MD 0.90, 95% CI 0.23 to 3.60; I2 = 82%; very low certainty), 12 months (3 studies, 606 participants: MD 1.21, 95% CI -0.01 to 2.43; I2 = 81%; very low certainty) and 24 months (3 studies, 334 participants: MD 0.71, 95% CI -0.02 to 1.48; I2 = 72%; very low certainty). PD had uncertain effects on residual urine volume at 12 months (3 studies, 253 participants: MD 344.10 mL/day, 95% CI 168.70 to 519.49; I2 = 69%; very low certainty). PD may reduce the risk of RKF loss (3 studies, 2834 participants: RR 0.55, 95% CI 0.44 to 0.68; I2 = 17%; low certainty). Compared with HD, PD had uncertain effects on all-cause death (42 studies, 700,093 participants: RR 0.87, 95% CI 0.77 to 0.98; I2 = 99%; very low certainty). In an analysis restricted to RCTs, PD may reduce the risk of all-cause death (2 studies, 1120 participants: RR 0.53, 95% CI 0.32 to 0.86; I2 = 0%; moderate certainty). PD had uncertain effects on both cardiovascular (21 studies, 68,492 participants: RR 0.96, 95% CI 0.78 to 1.19; I2 = 92%) and infection-related death (17 studies, 116,333 participants: RR 0.90, 95% CI 0.57 to 1.42; I2 = 98%) (both very low certainty). Compared with HD, PD had uncertain effects on the number of patients experiencing bacteraemia/bloodstream infection (2 studies, 2582 participants: RR 0.34, 95% CI 0.10 to 1.18; I2 = 68%) and the number of patients experiencing infection episodes (3 studies, 277 participants: RR 1.23, 95% CI 0.93 to 1.62; I2 = 20%) (both very low certainty). PD may reduce the number of bacteraemia/bloodstream infection episodes (2 studies, 2637 participants: RR 0.44, 95% CI 0.27 to 0.71; I2 = 24%; low certainty). Compared with HD; It is uncertain whether PD reduces the risk of acute myocardial infarction (4 studies, 110,850 participants: RR 0.90, 95% CI 0.74 to 1.10; I2 = 55%), coronary artery disease (3 studies, 5826 participants: RR 0.95, 95% CI 0.46 to 1.97; I2 = 62%); ischaemic heart disease (2 studies, 58,374 participants: RR 0.86, 95% CI 0.57 to 1.28; I2 = 95%), congestive heart failure (3 studies, 49,511 participants: RR 1.10, 95% CI 0.54 to 2.21; I2 = 89%) and stroke (4 studies, 102,542 participants: RR 0.94, 95% CI 0.90 to 0.99; I2 = 0%) because of low to very low certainty evidence. Compared with HD, PD had uncertain effects on the number of patients experiencing hospitalisation (4 studies, 3282 participants: RR 0.90, 95% CI 0.62 to 1.30; I2 = 97%) and all-cause hospitalisation events (4 studies, 42,582 participants: RR 1.02, 95% CI 0.81 to 1.29; I2 = 91%) (very low certainty). None of the included studies reported specifically on life participation or fatigue. However, two studies evaluated employment. Compared with HD, PD had uncertain effects on employment at one year (2 studies, 593 participants: RR 0.83, 95% CI 0.20 to 3.43; I2 = 97%; very low certainty).

AUTHORS' CONCLUSIONS

The comparative effectiveness of PD and HD on the preservation of RKF, all-cause and cause-specific death risk, the incidence of bacteraemia, other vascular complications (e.g. stroke, cardiovascular events) and patient-reported outcomes (e.g. life participation and fatigue) are uncertain, based on data obtained mostly from NRSIs, as only two RCTs were included.

A comparison of urgent-start of hemodialysis vs urgent initiation of peritoneal dialysis: a meta-analysis study

OBJECTIVE

To investigate the effects of urgent-start HD(USHD) and urgent-start PD(USPD) on dialysis patients and provide references for relevant clinical practice.

METHODS

A literature search was conducted in Chinese and English databases (PubMed, Web of Science, Cochrane Library, CNKI, Wanfang, VIP) and the cutoff date for which was July 30, 2023. Studies comparing USHD and USPD were included and I2 statistics and Q tests were used to determine heterogeneity among them. Risk ratios (RR) with 95% confidence intervals (CI) were computed for count data.

RESULTS

Nine studies met the inclusion criteria. The all-cause mortality rate was 0.173 (0.070, 0.277) for USPD versus 0.214 (0.142, 0.286) for USHD, indicating that USPD had a protective effect against all-cause mortality compared to USHD (RR = 0.76, 95% CI 0.63-0.91). Patients receiving USPD had lower risks of infection-related mortality (RR = 0.19; 95% CI 0.05-0.76), bacteremia (RR = 0.38; 95% CI 0.18-0.80), and composite complications (RR = 0.54; 95% CI 0.41-0.71). However, no significant differences were found between USHD and USPD for cardiovascular mortality (RR = 0.68; 95% CI 0.28-1.68) or cancer mortality (RR = 0.44; 95% CI 0.15-1.29).

CONCLUSION

Compared to USHD, USPD has better protective effects against all-cause mortality, infection-related mortality, bacteremia, and composite complications. However, more high-quality research is still needed to further investigate the impacts of the two dialysis modalities on patients.

Survival, cumulative hospital days and infectious complications in urgent-start PD compared with urgent-start HD

BACKGROUND

Urgent-start peritoneal dialysis (PD) carries a similar efficacy and safety profile compared to urgent-start haemodialysis (HD) but is only sparsely applied due to resource issues and concerns of complication risks. Furthermore, few data exist on adverse outcomes associated with central venous catheter (CVC) insertions in urgent-start HD patients. Thus, we sought to compare patient and dialysis-related outcomes in patients undergoing urgent-start PD or HD.

METHODS

All patients initiating urgent-start PD in a tertiary research hospital in 2005-2018 were included in this retrospective, single-centre, comparative study and matched with urgent-start HD patients of similar age and chronic kidney disease aetiology. All urgent-start PDs were initiated within 72 h after catheter insertion, and urgent-start HDs were performed via a CVC. All analyses were performed at 3 months and at 1 year of follow-up, respectively.

RESULTS

Thirty-three patients who commenced urgent-start PD and 58 matched urgent-start HD control patients were included. Altogether, 26 patients (29%; PD: 36%, HD 24%) died within the 1-year follow-up, and patient survival was similar at 3 months (hazard ratio (HR): 1.15, 95% confidence interval (CI): 0.35-3.81, p = 0.82) and at 1 year of follow-up (HR: 0.64, 95% CI: 0.30-1.39, p = 0.26) between the study groups. There were no differences in the total kidney replacement therapy (KRT)-related infection rate (p = 0.66) or cumulative first-year hospital care days (p = 0.43) between the treatment groups. Altogether, 139 CVCs were inserted during the 1-year follow-up. The number of CVCs per patient was associated with the emergence of blood culture-positive bacteraemia and increased cumulative first-year hospital care days.

CONCLUSIONS

Patient survival, cumulative first-year hospital care days and total KRT-related infection rate at 3 months and 1-year follow-up are similar between urgent-start PD and urgent-start HD patients. Furthermore, CVC insertion rate is associated with incident blood culture-positive bacteraemia and increased cumulative first-year hospital care days.

Urgent Implantation of Peritoneal Dialysis Catheter in Chronic Kidney Disease and Acute Kidney Injury-A Review

Acute kidney injury (AKI) and sudden exacerbation of chronic kidney disease (CKD) frequently necessitate urgent kidney replacement therapy (UKRT). Peritoneal dialysis (PD) is recognized as a viable modality for managing such patients. Urgent-start peritoneal dialysis (USPD) may be associated with an increased number of complications and is rarely utilized. This review examines recent literature investigating the clinical outcomes of USPD in CKD and AKI. Relevant research was identified through searches of the MEDLINE (PubMed), Scopus, Web of Science, and Google Scholar databases using MeSH terms and relevant keywords. Included studies focused on the emergency use of peritoneal dialysis in CKD or AKI and reported treatment outcomes. While no official recommendations exist for catheter implantation in USPD, the impact of the technique itself on outcomes was found to be less significant compared with the post-implantation factors. USPD represents a safe and effective treatment modality for AKI, although complications such as catheter malfunctions, leakage, and peritonitis were observed. Furthermore, USPD demonstrated efficacy in managing CKD, although it was associated with a higher incidence of complications compared to conventional-start peritoneal dialysis. Despite its cost-effectiveness, PD requires greater technical expertise from medical professionals. Close supervision and pre-planning for catheter insertion are essential for CKD patients. Whenever feasible, an urgent start should be avoided. Nevertheless, in emergency scenarios, USPD does remain a safe and efficient approach.

A novel edible colorant lake prepared with CaCO3 and Monascus pigments: Lake characterization and mechanism study

Monascus pigments (MPs) were adsorbed using calcium carbonate to produce CaCO₃-MPs lakes. The fundamental properties and formation mechanism of the lakes were investigated. Results indicated that CaCO₃ displayed a high enough affinity for the MPs to form colorant lakes, while the MPs tended to transform the CaCO₃ crystals from calcite to vaterite. The adsorption of MPs by CaCO₃ followed the Freundlich isothermal model with n value higher than 1, confirming it as physical adsorption. The ΔG⁰ (-29 to ∼-33 kJ/mol) and ΔH⁰(30-55 kJ/mol) indicated that lake formation was a spontaneous and endothermic process. UV/Vis spectroscopic analysis verified the complex formation between Ca²⁺ and MPs via physical bonding, suggesting a possible attraction between the Ca²⁺ and glutamate residues of the MPs. EDS showed that the MPs were trapped inside the particles. FTIR spectroscopy and XPS further confirmed that the physical bonding was the primary driving force behind the lake formation.

Impact of unplanned peritoneal dialysis start on patients' outcomes-A multicenter cohort study

Background

Patients with end-stage kidney disease (ESKD) who start unplanned dialysis therapy are more likely to be treated with hemodialysis (HD) using a central venous catheter, which has been associated with a greater risk of infections and other complications, as well as with a higher long-term risk of death. Urgent-start PD is an alternative that has been suggested as an option for starting dialysis in these cases, with potentially better patient outcomes. However, the definition of urgent-start PD is not homogeneous, and no study, to our knowledge, has compared clinical outcomes among urgent start, early start, and conventional start of PD. In this study, we aimed to compare these types of initiation of dialysis therapy in terms of a composite outcome of patient survival and technique failure.

Methods

This is a retrospective, multicenter, cohort study, involving data from 122 PD clinics in Brazil. We used the following: Urgent-start groups refer to patients who initiated PD within 72 h after the PD catheter insertion; early-start groups are those starting PD from 72 h to 2 weeks after the catheter insertion; and conventional-start groups are those who used the PD catheter after 2 weeks from its insertion. We analyzed the composite endpoint of all causes of patient's mortality and technique failure (within the initial 90 days of PD therapy) using the following three different statistical models: multivariate Cox, Fine and Gay competing risk, and a multilevel model.

Results

We included 509 patients with valid data across 68 PD clinics. There were 38 primary outcomes, comprising 25 deaths and 13 technique failures, with a total follow-up time of 1,393.3 months. Urgent-start PD had no association with the composite endpoint in all three models.

Conclusion

Unplanned PD seems to be a safe and feasible option for treatment for patients with non-dialysis ESKD in urgent need of dialysis.

Transitions in an integrated model of renal replacement therapy in a regional health system

INTRODUCTION AND OBJECTIVES

The choice of renal replacement therapy (RRT) is an important decision that determines the quality of life and survival. Most patients change from one RRT modality to another to adapt RRT to clinical and psychosocial needs. This has been called «integrated model of RRT» that implies new questions about the best sequence of techniques.

MATERIAL AND METHODS

The study describes the impact of transitions between RRT modalities on survival using the Madrid Registry of Renal Patients (2008-2018). This study used the proportional hazards models and competitive risk models to perform an intention-to-treat (ITT), according to their 1st RRT modality and as-treated (AT) analysis, that consider also their 1st transition.

RESULTS

A total of 8971 patients started RRT during this period in Madrid (6.6 Million population): 7207 (80.3%) on hemodialysis (HD), 1401 (15.6%) on peritoneal dialysis (PD) and 363 (4.2%) received a pre-emptive kidney transplantation (KT). Incident HD-patients were older (HD group 65.3 years (SD 15.3) vs PD group 58.1 years (SD 14.8) vs KTX group 52 years (SD 17.2); p < 0.001) and had more comorbidities. They presented higher mortality (HD group 40.9% vs PD group 22.8% vs KTX group 8.3%, p < 0.001) and less access to a transplant (HD group 30.4% vs PD group 51.6%; p < 0.001). Transitions between dialysis techniques define different groups of patients with different clinical outcomes. Those who change from HD to PD do it earlier (HD → PD: 0.7 years (SD 1.1) vs PD → HD: 1.5 years (SD 1.4) p < 0.001), are younger (HD → PD: 53.5 years (SD 16.7) vs PD → HD: 61.6 years (SD 14.6); p < 0.001), presented less mortality (HD → PD: 24.5% vs PD → HD: 32.0%; p < 0.001) and higher access to a transplant (HD → PD: 49.4% vs PD → HD: 31.7%; p < 0.001). Survival analysis by competitive risks is essential for integrated RRT models, especially in groups such as PD patients, where 51.6% of the patients were considered as lost follow-up (received a KTX after during the first 2.5 years on PD). In this analysis, survival of patients who change from one technique to another, is more similar to the destination modality than the origin one.

CONCLUSION

Our data suggest that transitions between RRT-techniques describes different patients, who associate different risks, and could be analyzed in an integrated manner to define improvement actions. This approach should be incorporated into the analysis and reports of renal registries.

Automated peritoneal dialysis as a cost-effective urgent-start dialysis option for ESRD patients: A prospective cohort study

BACKGROUND

Several studies have reported the feasibility of urgent-start peritoneal dialysis (PD) as an alternative to hemodialysis (HD) using a central venous catheter (CVC). However, the cost-effectiveness of automated peritoneal dialysis (APD) as an urgent-start dialysis modality has not been directly evaluated, especially in China.

METHODS

We prospectively enrolled patients with end-stage renal disease (ESRD) who required urgent-start dialysis at a single center from March 2019 to November 2020. Patients were grouped according to their urgent-start dialysis modality (APD and HD). Urgent-start dialysis conducted until 14 days after PD catheter insertion. Then, PD was maintained. Each patient was followed until July 2021 or death or loss to follow-up. The primary outcome was the incidence of short-term dialysis-related complications. The secondary outcome was the cost and duration of the initial hospitalization. Technique survival, peritonitis-free or bacteriamia-free survival and patient survival were also compared.

RESULTS

Sixty-eight patients were included in the study, of whom 36 (52.9%) patients were in APD group. Mean follow-up duration was 20.1 months. Compared with the HD group, the APD group had significantly fewer short-term dialysis-related complications. The cost of initial hospitalization was also significantly lower in APD patients. There was no significant difference between APD and HD patients with respect to duration of the initial hospitalization, technique survival rate, peritonitis-free or bacteriemia-free survival rate, and patient survival rate.

CONCLUSION

Among ESRD patients with an urgent need for dialysis, APD as urgent-start dialysis modality, compared with HD using a CVC, resulted in fewer short-term dialysis-related complications and lower cost.

Risk factors for mortality within 6 mo in patients with diabetes undergoing urgent-start peritoneal dialysis: A multicenter retrospective cohort study

BACKGROUND

The risk of early mortality of patients who start dialysis urgently is high; however, in patients with diabetes undergoing urgent-start peritoneal dialysis (USPD), the risk of, and risk factors for, early mortality are unknown.

AIM

To identify risk factors for mortality during high-risk periods in patients with diabetes undergoing USPD.

METHODS

This retrospective cohort study enrolled 568 patients with diabetes, aged ≥ 18 years, who underwent USPD at one of five Chinese centers between 2013 and 2019. We divided the follow-up period into two survival phases: The first 6 mo of USPD therapy and the months thereafter. We compared demographic and baseline clinical data of living and deceased patients during each period. Kaplan-Meier survival curves were generated for all-cause mortality according to the New York Heart Association (NYHA) classification. A multivariate Cox proportional hazard regression model was used to identify risk factors for mortality within the first 6 mo and after 6 mo of USPD.

RESULTS

Forty-one patients died within the first 6 mo, accounting for the highest proportion of mortalities (26.62%) during the entire follow-up period. Cardiovascular disease was the leading cause of mortality within 6 mo (26.83%) and after 6 mo (31.86%). The risk of mortality not only within the first 6 mo but also after the first 6 mo was higher for patients with obvious baseline heart failure symptoms than for those with mild or no heart failure symptoms. Independent risk factors for mortality within the first 6 mo were advanced age [hazard ratio (HR: 1.908; 95%CI: 1.400-2.600; P < 0.001), lower baseline serum creatinine level (HR: 0.727; 95%CI: 0.614-0.860; P < 0.001), higher baseline serum phosphorus level (HR: 3.162; 95%CI: 1.848-5.409; P < 0.001), and baseline NYHA class III-IV (HR: 2.148; 95%CI: 1.063-4.340; P = 0.033). Independent risk factors for mortality after 6 mo were advanced age (HR: 1.246; 95%CI: 1.033-1.504; P = 0.022) and baseline NYHA class III-IV (HR: 2.015; 95%CI: 1.298-3.130; P = 0.002).

CONCLUSION

To reduce the risk of mortality within the first 6 mo of USPD in patients with diabetes, controlling the serum phosphorus level and improving cardiac function are recommended.

Feasibility of a break-in period of less than 24 hours for urgent start peritoneal dialysis: a multicenter study

Purpose

Urgent start peritoneal dialysis (USPD) is an effective therapeutic method for end-stage renal disease (ESRD). However, whether it is safe to initiate peritoneal dialysis (PD) within 24 h unclear. We examined the short-term outcomes of a break-in period (BI) of 24 h for patients undergoing USPD.

Methods

This real-world, multicenter, retrospective cohort study evaluated USPD patients from five centers from January 2013 to August 2020. Patients were divided into BI ≤ 24 h or BI > 24 h groups. The Primary outcomes included incidence of mechanical and infectious complications. The secondary outcome was technique failure. Moreover, we presented a subgroup analysis for patients who did not receive temporary hemodialysis (HD).

Results

A total of 871 USPD patients were included: 470 in the BI ≤ 24 h and 401 in the BI > 24 h groups. Mechanical and infectious complications did not differ between the two groups across the follow-up timepoints (2 weeks, 1 month, 3 months, and 6 months) (p > 0.05). Multiple logistic regression analysis revealed that BI ≤ 24 h was not an independent risk factor for mechanical complications, catheter migration, or infectious complications (p > 0.05). A BI ≤ 24 h was not an independent significant risk factor for technique failure by multivariate Cox regression analysis (p > 0.05). The subgroup analysis of patients who did not receive temporary HD returned the same results.

Conclusion

Initiating PD within 24 h of catheter insertion was not associated with increased mechanical complications, infectious complications, or technique failures.

Urgent-start peritoneal dialysis: Association with outcomes

The majority of end-stage kidney disease (ESKD) patients start dialysis without adequate pre-dialysis planning. Of these patients, the vast majority initiate in-centre haemodialysis using a central venous catheter (ICHD-CVC). A minority utilise urgent-start peritoneal dialysis (USPD), whereby a peritoneal dialysis catheter is placed and used for dialysis without the usual 2-4-week waiting period. In this multicentre, retrospective study of adult patients initiating dialysis during 2018, we compared outcomes among patients utilising these two dialysis initiation routes. Patients who initiated dialysis via ICHD-CVC were matched 1:1 to patients who utilised USPD on the basis of aetiology of ESKD, race, diabetes status and insurance type. Hospitalisation and mortality were evaluated from dialysis initiation through the first of death, transplant, loss to follow-up or study end (30 June 2019). Outcomes were compared using models adjusted for age and sex. A total of 717 USPD patients were matched to ICHD-CVC patients. During follow-up, USPD patients were hospitalised at a rate of 1.21 admissions/patient-year (pt-yr) versus 1.51 admissions/pt-yr for ICHD-CVC. This corresponded to a 24% lower rate of hospitalisation among USPD patients (adjusted incidence rate ratio 0.76, 95% confidence interval [CI] 0.65-0.88). Mortality rates were 0.08 and 0.11 deaths/pt-yr among USPD patients and ICHD-CVC patients, respectively (adjusted hazard ratio 0.84, 95% CI 0.62, 1.15). These findings suggest that more widespread adoption of USPD may be beneficial among patients with limited pre-dialysis planning.

Urgent Start Peritoneal Dialysis: A Population-Based Cohort Study,

Rationale & Objective

It is a common practice to start patients in urgent need of dialysis on hemodialysis via a central venous catheter. Because central venous catheter use is associated with increased risk of infections, hospitalizations, and mortality, urgent start peritoneal dialysis (PD) increasingly represents a viable alternative. This study aimed to examine clinical outcomes, complications, mortality, and modality retention in patients who initiated urgent start PD.

Study Design

Retrospective cohort study.

Setting and Participants

Eighty-four adult members of a large integrated health care system who initiated urgent start PD between January 1, 2011, and December 31, 2014.

Exposure

Urgent start PD.

Outcomes

Retention rates at 30, 90, and 365 days; time to the development of noninfectious and infectious complications, modality failure, and all-cause mortality.

Analytical Approach

Cumulative incidence of all-cause mortality was estimated using the Kaplan-Meier method. Retention rates for PD were computed using binomial proportions.

Results

Occurrence of major complications was less than 5%. Catheter malfunction occurred in 6% of cases; of those, catheter patency could be established in 80%. Infectious complications occurred in 20% of patients who initiated PD and included peritonitis and exit site infections. At 365 days after initiation, the cumulative incidence of all-cause mortality was 9.7% (95% CI, 4.7%-19.4%). PD retention rates were 98.8%, 91.3%, and 80.0% at 30 days, 90 days, and 1 year, respectively.

Limitations

Retrospective cohort design, a well-matched comparable group of urgent start hemodialysis patients could not be identified, small number of patients in a single integrated health care system, uncertain or limited generalizability of findings to other health care systems.

Conclusions

At 1 year after initiation, patients who initiated urgent start PD had high survival and modality retention rates. In unplanned initiation of dialysis, urgent start PD is a viable and sustainable option and should be considered in selected patients to optimize care.

Unplanned vs. planned peritoneal dialysis as initial therapy for dialysis patients in chronic kidney replacement therapy

AIM

To compare infectious and mechanical complications, technique failure and mortality of a planned PD vs. an unplanned PD program.

DESIGN

It was a prospective observational study that included chronic kidney disease (CKD) patients who started PD according to medical recommendation: group1-planned and group 2-unplanned PD.

METHODS

This study evaluated patients who started planned and unplanned PD programs in a teaching hospital from July 2014 to December 2017.

RESULTS

A total of 58 patients were included in the planned PD group and 113 in the unplanned PD group. There was difference between the two groups in leak and hospital admissions, that were more frequent in the unplanned PD group. Periods free from exite site infection, peritonitis and mechanical complications were longer in the planned group. Cox regression analysis identified age and the lowest albumin value as factors associated with mechanical complications; peritonitis indicated the presence of ESI and mechanical complications; the change to HD was associated with a younger age, mechanical complications, diabetes mellitus (DM) and peritonitis. The factors associated with death were age and lower values of albumin. After 48 months, the growth of the PD program was 252%.

CONCLUSION

The technique survival and patient mortality in unplanned PD was similar to planned PD, while the period marked by the absence of complications related to PD was longer in the planned PD group. In the Cox regression, unplanned PD was not identified as risk factor for death, transition to HD or complications related to therapy, while age and lower albumin values were predictors of negative outcomes.

IMPACT

Unplanned PD is not risk factor for death and complications related to PD and can be an option to unplanned HD.

Transitions in an integrated model of renal replacement therapy in a regional health system

INTRODUCTION AND OBJECTIVES

The choice of renal replacement therapy (RRT) is an important decision that determines the quality of life and survival. Most patients change from one RRT modality to another to adapt RRT to clinical and psychosocial needs. This has been called «integrated model of RRT» that implies new questions about the best sequence of techniques.

MATERIAL AND METHODS

The study describes the impact of transitions between RRT modalities on survival using the Madrid Registry of Renal Patients (2008-2018). This study used the proportional hazards models and competitive risk models to perform an intention-to-treat (ITT), according to their 1st RRT modality and as-treated (AT) analysis, that consider also their 1st transition.

RESULTS

A total of 8971 patients started RRT during this period in Madrid (6.6 Million population): 7207 (80.3%) on hemodialysis (HD), 1401 (15.6%) on peritoneal dialysis (PD) and 363 (4.2%) received a pre-emptive kidney transplantation (KTX). Incident HD-patients were older (HD group 65.3 years (SD 15.3) vs PD group 58.1 years (SD 14.8) vs KTX group 52 years (SD 17.2); p<0.001) and had more comorbidities. They presented higher mortality (HD group 40.9% vs PD group 22.8% vs 8.3% KTX group, p<0.001) and less access to a transplant (HD group 30.4% vs DP group 51.6%; p<0.001). Transitions between dialysis techniques define different groups of patients with different clinical outcomes. Those who change from HD to PD do it earlier (HD→PD: 0.7 years (SD 1.1) vs PD→HD: 1.5 years (SD 1.4) p<0.001), are younger (HD→PD: 53.5 years (SD 16.7) vs PD→HD: 61.6 years (SD 14.6); p<0.001), presented less mortality (HD→PD: 24.5% vs PD→HD: 32.0%; p<0.001) and higher access to a transplant (HD→PD: 49.4% vs PD→HD: 31.7%; p<0.001). Survival analysis by competitive risks is essential for integrated RRT models, especially in groups such as PD patients, where 51.6% of the patients were considered as lost follow-up (received a KTX after during the first 2.5 years on PD). In this analysis, survival of patients who change from one technique to another, is more similar to the destination modality than the origin one.

CONCLUSION

Our data suggest that transitions between RRT-techniques describes different patients, who associate different risks, and could be analyzed in an integrated manner to define improvement actions. This approach should be incorporated into the analysis and reports of renal registries.

Urgent start peritoneal dialysis: Is there room for more?

BACKGROUND

Despite the increasing prevalence of end-stage renal disease, peritoneal dialysis (PD) is still offered to a minor subset of patients. One way to increment the utilization rates of this technique is the early start of PD after catheter placement, but there are several concerns related to this approach.

METHODS

Retrospective analysis in a single-center; 52 patients, 34.6% of the patients started in the first 14 days after catheter placement (Urgent start Group - Group 1) and percentage started PD in a conventional mode (Non-urgent start Group - Group 2). Baseline data, short-term (90-day) clinical outcomes, mechanical complications and infectious episodes were compared among Groups.

RESULTS

At baseline, Group 1 had an higher Charlson Comobidity Index (CCI). Exchange volumes were significantly lower in Group 1, as expected. Short-term outcomes were equal except for iPTH and albumin, both lower in urgent-start Group (p<0.05). Episodes of leak, catheter dysfunction and rate of infections were similar among Groups (p>0.05). In Urgent-start Group we didn't observed a higher risk for the first peritonitis episode (HR 0.68; 95% CI 0.24-1.99; p>0.05), higher dropout rate or risk to quit the technique (long rank test, p>0.05; HR 0.57; 95% CI 0.29-1.13; p>0.05).

CONCLUSION

According to our observations, urgent-start PD seems to be a valid and safe alternative to urgent hemodialysis with central venous catheter and should be offered to patients without major contraindications.

Comparison of mortality and complications between urgent-start peritoneal dialysis and urgent-start hemodialysis: A systematic review and meta-analysis

The advantages of urgent-start peritoneal dialysis (PD) vis-à-vis urgent-start hemodialysis (HD) are not clear. We performed a systematic review and meta-analysis of studies comparing the two modalities. Databases of PubMed, Embase, Ovoid, and Google Scholar were searched up to November 1, 2020. The primary outcome was mortality, and secondary outcomes were dialysis-related infectious complications and mechanical complications. Risk ratios (RRs) were calculated for all outcomes. Seven studies were included. The pooled analysis revealed a statistically significant reduced risk of all-cause mortality in patients undergoing urgent-start PD as compared to urgent-start HD (RR: 0.61, 95% confidence interval [CI] [0.40, 0.94], I²  = 56.34%). A meta-analysis of dialysis-related infectious complications indicated no statistically significant difference between the two modalities (RR: 0.66, 95% CI [0.29, 1.50], I²  = 69.62%). Our analysis revealed a statistically significant reduced risk of mechanical complications in patients undergoing urgent-start PD (RR: 0.54, 95% CI [0.40, 0.73], I²  = 0%). To conclude, unadjusted data from observational studies are indicative of lower mortality and lower risk of mechanical complications with urgent-start PD versus urgent-start HD. The risk of infectious complications was not different between the two groups. Further studies with a larger sample size using propensity-matched cohorts are needed to strengthen current evidence.

Commentary on the NICE guideline on renal replacement therapy and conservative management

NICE Guideline NG107, “Renal replacement therapy and conservative management” (Renal replacement therapy and conservative management (NG107); 2018:1–33) was published in October 2018 and replaced the existing NICE guideline CG125, “Chronic Kidney Disease (Stage 5): peritoneal dialysis” (Chronic kidney disease (stage 5): peritoneal dialysis | Guidance | NICE; 2011) and NICE Technology Appraisal TA48, “Guidance on home compared with hospital haemodialysis for patients with end-stage renal failure”(Guidance on home compared with hospital haemodialysis for patients with end-stage renal failure (Technology appraisal guideline TA48); 2002) The aim of the NICE guideline (NG107) was to provide guidance on renal replacement therapy (RRT), including dialysis, transplant and conservative care, for adults and children with CKD Stages 4 and 5. The guideline is extremely welcomed by the Renal Association and it offers huge value to patients, clinicians, commissioners and key stakeholders. It overlaps and enhances current guidance published by the Renal Association including “Haemodialysis” (Clinical practice guideline: Haemodialysis; 2019) which was updated in 2019 after the publication of the NICE guideline, “Peritoneal Dialysis in Adults and Children” (Clinical practice guideline: peritoneal Dialysis in adults and children; 2017) and “Planning, Initiation & withdrawal of Renal Replacement Therapy” (Clinical practice guideline: planning, initiation and withdrawal of renal replacement therapy; 2014) (at present there are no plans to update this guideline).

There are several strengths to NICE guideline NG107 and we agree with and support the vast majority of recommendation statements in the guideline. This summary from the Renal Association discusses some of the key highlights, controversies, gaps in knowledge and challenges in implementation. Where there is disagreement with a NICE guideline statement, we have highlighted this and a new suggested statement has been written.

Urgent start peritoneal dialysis: Is there room for more?

BACKGROUND

Despite the increasing prevalence of end-stage renal disease, peritoneal dialysis (PD) is still offered to a minor subset of patients. One way to increment the utilization rates of this technique is the early start of PD after catheter placement, but there are several concerns related to this approach.

METHODS

Retrospective analysis in a single-center; 52 patients, 34.6% of the patients started in the first 14 days after catheter placement (Urgent start Group - Group 1) and percentage started PD in a conventional mode (Non-urgent start Group - Group 2). Baseline data, short-term (90-day) clinical outcomes, mechanical complications and infectious episodes were compared among Groups.

RESULTS

At baseline, Group 1 had an higher Charlson Comobidity Index (CCI). Exchange volumes were significantly lower in Group 1, as expected. Short-term outcomes were equal except for iPTH and albumin, both lower in urgent-start Group (p<0.05). Episodes of leak, catheter dysfunction and rate of infections were similar among Groups (p>0.05). In Urgent-start Group we didn't observed a higher risk for the first peritonitis episode (HR 0.68; 95% CI 0.24-1.99; p>0.05), higher dropout rate or risk to quit the technique (long rank test, p>0.05; HR 0.57; 95% CI 0.29-1.13; p>0.05).

CONCLUSION

According to our observations, urgent-start PD seems to be a valid and safe alternative to urgent hemodialysis with central venous catheter and should be offered to patients without major contraindications.

Overview on urinary tract infection, bacterial agents, and antibiotic resistance pattern in renal transplant recipients

Background:

Urinary tract infection (UTI) is a mainly common infection in kidney transplant recipients. This study decided to investigate UTI, bacterial agents, and antibiotic resistance pattern in kidney transplant recipients from Iran.

Materials and Methods:

Search process was conducted for UTI, bacterial agents, and antibiotic resistance pattern in kidney transplant recipients from Iran via electronic databases (Scopus, PubMed, Web of Science, etc.,) with Mesh terms in either Persian and English languages without limited time to May 31, 2020. Data were analyzed by comprehensive meta-analysis software.

Results:

The combined prevalence of UTI in renal transplant recipients was reported by 31.1%. The combined prevalence of Gram-negative bacteria was 69%. The most common pathogens among Gram negatives were E. coli followed by Klebsiella pneumoniae with frequency 43.4% and 13%, respectively. Subgroup analysis for Gram-positive bacteria showed the combined prevalence of 31%. The most common microorganism among Gram positives belonged to coagulase-negative Staphylococci and Enterococci with a prevalence of 10.2% and 9%, respectively. Subgroup meta-analysis of antibiotic resistance for Gram-negative showed the most resistance to cephalexin followed by carbenicillin with a prevalence of 89.1% and 87.3%, respectively.

Conclusion:

Our review showed a noticeable rate of UTI (31.1%) among renal transplant recipients in Iran and a high prevalence of Gram-negative (69%) and Gram-positive (13%) microorganisms. A high resistance rate was seen against almost all antibiotics used for the treatment of UTI. Therefore, empirical prescription of antibiotics should be avoided, and it should be based on data obtained from antibiogram tests.

Urgent-start peritoneal dialysis versus haemodialysis for people with chronic kidney disease

BACKGROUND

Patients with chronic kidney disease (CKD) who require urgent initiation of dialysis but without having a permanent dialysis access have traditionally commenced haemodialysis (HD) using a central venous catheter (CVC). However, several studies have reported that urgent initiation of peritoneal dialysis (PD) is a viable alternative option for such patients.

OBJECTIVES

This review aimed to examine the benefits and harms of urgent-start PD compared to HD initiated using a CVC in adults and children with CKD requiring long-term kidney replacement therapy.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 25 May 2020 for randomised controlled trials through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. For non-randomised controlled trials, MEDLINE (OVID) (1946 to 11 February 2020) and EMBASE (OVID) (1980 to 11 February 2020) were searched.

SELECTION CRITERIA

All randomised controlled trials (RCTs), quasi-RCTs and non-RCTs comparing urgent-start PD to HD initiated using a CVC.

DATA COLLECTION AND ANALYSIS

Two authors extracted data and assessed the quality of studies independently. Additional information was obtained from the primary investigators. The estimates of effect were analysed using random-effects model and results were presented as risk ratios (RR) with 95% confidence intervals (CI). The GRADE framework was used to make judgments regarding certainty of the evidence for each outcome.

MAIN RESULTS

Overall, seven observational studies (991 participants) were included: three prospective cohort studies and four retrospective cohort studies. All the outcomes except one (bacteraemia) were graded as very low certainty of evidence given that all included studies were observational studies and few events resulting in imprecision, and inconsistent findings. Urgent-start PD may reduce the incidence of catheter-related bacteraemia compared with HD initiated with a CVC (2 studies, 301 participants: RR 0.13, 95% CI 0.04 to 0.41; I² = 0%; low certainty evidence), which translated into 131 fewer bacteraemia episodes per 1000 (95% CI 89 to 145 fewer). Urgent-start PD has uncertain effects on peritonitis risk (2 studies, 301 participants: RR 1.78, 95% CI 0.23 to 13.62; I² = 0%; very low certainty evidence), exit-site/tunnel infection (1 study, 419 participants: RR 3.99, 95% CI 1.2 to 12.05; very low certainty evidence), exit-site bleeding (1 study, 178 participants: RR 0.12, 95% CI 0.01 to 2.33; very low certainty evidence), catheter malfunction (2 studies; 597 participants: RR 0.26, 95% CI: 0.07 to 0.91; I² = 66%; very low certainty evidence), catheter re-adjustment (2 studies, 225 participants: RR: 0.13; 95% CI 0.00 to 18.61; I² = 92%; very low certainty evidence), technique survival (1 study, 123 participants: RR: 1.18, 95% CI 0.87 to 1.61; very low certainty evidence), or patient survival (5 studies, 820 participants; RR 0.68, 95% CI 0.44 to 1.07; I² = 0%; very low certainty evidence) compared with HD initiated using a CVC. Two studies using different methods of measurements for hospitalisation reported that hospitalisation was similar although one study reported higher hospitalisation rates in HD initiated using a catheter compared with urgent-start PD.

AUTHORS' CONCLUSIONS

Compared with HD initiated using a CVC, urgent-start PD may reduce the risk of bacteraemia and had uncertain effects on other complications of dialysis and technique and patient survival. In summary, there are very few studies directly comparing the outcomes of urgent-start PD and HD initiated using a CVC for patients with CKD who need to commence dialysis urgently. This evidence gap needs to be addressed in future studies.

Urgent-start peritoneal dialysis versus conventional-start peritoneal dialysis for people with chronic kidney disease

BACKGROUND

Urgent-start peritoneal dialysis (PD), defined as initiation of PD within two weeks of catheter insertion, has been emerging as an alternative mode of dialysis initiation for patients with chronic kidney disease (CKD) requiring urgent dialysis without established permanent dialysis access. Recently, several small studies have reported comparable patient outcomes between urgent-start and conventional-start PD.

OBJECTIVES

To examine the benefits and harms of urgent-start PD compared with conventional-start PD in adults and children with CKD requiring long-term kidney replacement therapy.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 25 May 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. For non-randomised controlled trials, MEDLINE (OVID) (1946 to 27 June 2019), EMBASE (OVID) (1980 to 27 June 2019), Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov (up to 27 June 2019) were searched.

SELECTION CRITERIA

All randomised controlled trials (RCTs) and non-RCTs comparing the outcomes of urgent-start PD (within 2 weeks of catheter insertion) and conventional-start PD ( ≥ 2 weeks of catheter insertion) treatment in children and adults CKD patients requiring long-term dialysis were included. Studies without a control group were excluded.

DATA COLLECTION AND ANALYSIS

Data were extracted and quality of studies were examined by two independent authors. The authors contacted investigators for additional information. Summary estimates of effect were examined using random-effects model and results were presented as risk ratios (RR) with 95% confidence intervals (CI) as appropriate for the data. The certainty of evidence for individual outcome was assessed using the GRADE approach.

MAIN RESULTS

A total of 16 studies (2953 participants) were included in this review, which included one multicentre RCT (122 participants) and 15 non-RCTs (2831 participants): 13 cohort studies (2671 participants) and 2 case-control studies (160 participants). The review included unadjusted data for analyses due to paucity of studies reporting adjusted data. In low certainty evidence, urgent-start PD may increase dialysate leak (1 RCT, 122 participants: RR 3.90, 95% CI 1.56 to 9.78) compared with conventional-start PD which translated into an absolute number of 210 more leaks per 1000 (95% CI 40 to 635). In very low certainty evidence, it is uncertain whether urgent-start PD increases catheter blockage (4 cohort studies, 1214 participants: RR 1.33, 95% CI 0.40 to 4.43; 2 case-control studies, 160 participants: RR 1.89, 95% CI 0.58 to 6.13), catheter malposition (6 cohort studies, 1353 participants: RR 1.63, 95% CI 0.80 to 3.32; 1 case-control study, 104 participants: RR 3.00, 95% CI 0.64 to 13.96), and PD dialysate flow problems (3 cohort studies, 937 participants: RR 1.44, 95% CI 0.34 to 6.14) compared to conventional-start PD. In very low certainty evidence, it is uncertain whether urgent-start PD increases exit-site infection (2 cohort studies, 337 participants: RR 1.43, 95% CI 0.24 to 8.61; 1 case-control study, 104 participants RR 1.20, 95% CI 0.41 to 3.50), exit-site bleeding (1 RCT, 122 participants: RR 0.70, 95% CI 0.03 to 16.81; 1 cohort study, 27 participants: RR 1.58, 95% CI 0.07 to 35.32), peritonitis (7 cohort studies, 1497 participants: RR 1.00, 95% CI 0.68 to 1.46; 2 case-control studies, participants: RR 1.09, 95% CI 0.12 to 9.51), catheter readjustment (2 cohort studies, 739 participants: RR 1.27, 95% CI 0.40 to 4.02), or reduces technique survival (1 RCT, 122 participants: RR 1.09, 95% CI 1.00 to 1.20; 8 cohort studies, 1668 participants: RR 0.90, 95% CI 0.76 to 1.07; 2 case-control studies, 160 participants: RR 0.92, 95% CI 0.79 to 1.06). In very low certainty evidence, it is uncertain whether urgent-start PD compared with conventional-start PD increased death (any cause) (1 RCT, 122 participants: RR 1.49, 95% CI 0.87 to 2.53; 7 cohort studies, 1509 participants: RR 1.89, 95% CI 1.07 to 3.3; 1 case-control study, 104 participants: RR 0.90, 95% CI 0.27 to 3.02; very low certainty evidence). None of the included studies reported on tunnel tract infection.

AUTHORS' CONCLUSIONS

In patients with CKD who require dialysis urgently without ready-to-use dialysis access in place, urgent-start PD may increase the risk of dialysate leak and has uncertain effects on catheter blockage, malposition or readjustment, PD dialysate flow problems, infectious complications, exit-site bleeding, technique survival, and patient survival compared with conventional-start PD.

Early-start and conventional-start peritoneal dialysis: a Chinese cohort study on outcome

Background

Early-start peritoneal dialysis (PD) is an effective option for patients need unplanned dialysis. However, there are few studies on the long-term prognosis of early-start PD patients.

Methods

In this retrospective study, 635 eligible patients from 1 March 1996 to 30 September 2016 were included, and divided into three groups according to the duration of break-in period: 3 days or less, 4–13 days and more than 14 days. Patients started PD within 2 weeks and after 2 weeks were defined as early-start and conventional-start, respectively. The primary outcome was all-cause mortality, and the secondary outcome measures were peritonitis free survival and technical survival. Mechanical and infectious complications in the first 180 days were also analyzed.

Results

Early-start PD patients were more likely to have higher serum total carbon dioxide and creatinine levels and lower serum albumin, Kt/v, creatinine clearance (Ccr) and residual glomerular filtration rate (rGFR) levels at the start of PD. The median follow-up period was 30 months (interquartile range, 13-53 months). A worse survival was observed in the early-start group than that in the conventional-start group (p < 0.001), even adjustment for the covariates (HR 1.549, 95%CI 1.104–2.173, p = 0.011). In the subgroup analysis, in patients commencing PD after 2006 early-start and conventional-start PD patients had comparable survival. No differences were observed in the rate of infectious and mechanical complications, peritonitis-free survival and technique survival between early-start and conventional-start PD patients.

Conclusions

Early-start PD could be a safe and effective strategy for patients needing unplanned dialysis initiation with the progress of technology on PD.

Percutaneous peritoneal dialysis catheter implantation with no break-in period: A viable option for patients requiring unplanned urgent-start peritoneal dialysis

Background

Urgent-start peritoneal dialysis (PD) is applied to patients who need PD within two weeks but are able to wait for more than 48 hours before starting PD. To evaluate the usefulness of percutaneous PD catheter insertion in urgent-start PD, we reviewed the clinical outcomes of percutaneous catheter insertion with immediate start PD and surgical insertion with longer break-in time in Pusan National University Hospital.

Methods

This study included 177 patients who underwent urgent-start PD. Based on the PD catheter insertion techniques, the patients with urgent-start PD were divided into percutaneous (n = 103) and surgical (n = 74) groups. For the percutaneous group, a modified Seldinger percutaneous catheter insertion with immediate initiation of continuous ambulatory PD was performed by nephrologists.

Results

The percutaneous group showed higher serum urea nitrogen, creatinine, and lower serum albumin compared with the surgical group (P < 0.05). Ninety-day infectious and mechanical complications showed no significant differences between the two groups. Ninety-day peritonitis in the percutaneous group was 9.7% compared to 5.4% in the surgical group (P = not significant [NS]). Major leakage was 3.9% in the percutaneous group compared to 1.4% in the surgical group (P = NS). Overall infectious and mechanical complication-free survival was not significantly different between the two groups. The percutaneous group and surgical group showed no statistical difference with respect to catheter survival over the entire observation period (P = NS).

Conclusion

This study suggests that urgent-start PD can be applied safely with percutaneous catheter insertion by nephrologists with no break-in period.

Comparison of outcomes of urgent-start and conventional-start peritoneal dialysis: a single-centre experience

BACKGROUND

There has been a growing interest in urgent-start peritoneal dialysis (PD) in patients with end-stage kidney disease to avoid central venous catheter use and its complications. This study aimed to compare clinical outcomes between urgent-start PD (defined as PD commencement within 2 weeks of PD catheter insertion) and conventional-start PD.

METHODS

This was a single-centre retrospective cohort study of all incident PD patients at Singapore General Hospital between January 2017 and February 2018. The primary outcome was dialysate leak. Secondary outcomes included catheter malfunction, catheter readjustment, exit-site infection, peritonitis, technique and patient survival.

RESULTS

A total of 187 incident PD patients were included. Of these, 66 (35%) initiated urgent-start PD. Dialysate leak was significantly higher in urgent-start PD compared with conventional-start PD groups (7.6% versus 0.8%; p = 0.02) whilst catheter malfunction (4.5% vs. 3.3%; p  = 0.70) and catheter readjustment (1.5% vs. 2.5%; p  = 1.00) were comparable between the two groups. Exit-site infection was comparable (IRR: 0.66 95% CI 0.25-1.74) whilst peritonitis was significantly higher in urgent-start PD compared with conventional-start PD (incidence risk ratio (IRR) 3.10, 95% confidence interval (CI) 1.29-7.44). Time to first episode of peritonitis, particularly Gram-positive peritonitis was significantly shorter with urgent-start PD. Technique survival (hazards ratio (HR) 1.95, 95% CI 0.89-4.31) and patient survival (HR 1.46, 95% CI 0.44-4.87) were comparable between the two groups.

CONCLUSION

Urgent-start PD was associated with higher risks of dialysate leak and peritonitis but comparable technique and patient survival compared to conventional-start PD.

How To Build a Successful Urgent-Start Peritoneal Dialysis Program

In-center hemodialysis (HD) remains the predominant dialysis therapy in patients with ESKD. Many patients with ESKD present in late stage, requiring urgent dialysis initiation, and the majority start HD with central venous catheters (CVCs), which are associated with poor outcomes and high cost of care. Peritoneal dialysis (PD) catheters can be safely placed in such patients with late-presenting ESKD, obviating the need for CVCs. PD can begin almost immediately in the recumbent position, using low fill volumes. Such PD initiations, commencing within 2 weeks of the catheter placement, are termed urgent-start PD (USPD). Most patients with an intact peritoneal cavity and stable home situation are eligible for USPD. Although there is a small risk of PD catheter–related mechanical complications, most can be managed conservatively. Moreover, overall outcomes of USPD are comparable to those with planned PD initiations, in contrast to the high rate of catheter-related infections and bacteremia associated with urgent-start HD. The ongoing coronavirus disease 2019 pandemic has further exposed the vulnerability of patients with ESKD getting in-center HD. PD can mitigate the risk of infection by reducing environmental exposure to the virus. Thus, USPD is a safe and cost-effective option for unplanned dialysis initiation in patients with late-presenting ESKD. To develop a successful USPD program, a strong infrastructure with clear pathways is essential. Coordination of care between nephrologists, surgeons or interventionalists, and hospital and PD center staff is imperative so that patient education, home visits, PD catheter placements, and urgent PD initiations are accomplished expeditiously. Implementation of urgent-start PD will help to increase PD use, reduce cost, and improve patient outcomes, and will be a step forward in fostering the goal set by the Advancing American Kidney Health initiative.

Evaluating Factors Contributing to Dropout in a Large Peritoneal Dialysis Program

BACKGROUND

The low prevalence of peritoneal dialysis (PD) (9%) vs. hemodialysis (HD) (88.2%) is partly due to patient dropout from therapy.

METHODS

This retrospective study identified patients who withdrew from PD between 2016 and 2018 in our program. We evaluated all other factors as controllable losses. Analysis included time on therapy at dropout (very early, early or late) and method of initiation (HD to PD conversion, unplanned PD, or planned start).

RESULTS

Eighty-three patients enrolled into our PD program. 27 dropped out; 24 were due to controllable factors, 3 due to death, with a median age at dropout of 52 years old. We determined psychosocial factors (PF) to be the largest controllable factor influencing dropout; contributing a 63% rate among all controllable factors. When considering time until dropout, 100% of very early dropout patients and 50% of late dropout patients did so due to PF. Among early dropout patients 67% dropped out due to other medical reasons. The mean time to dropout for PF, other, and infection (INF) were 13, 26, and 33 months, respectively. When considering type of initiation, we found PF to be the largest attributable factor with 50% of unplanned, 100% of planned, and 50% of conversions stopping therapy.

CONCLUSIONS

Our study indicates that the primary reason for controllable loss from therapy was secondary to PF regardless of the time on therapy or the method of initiation to therapy.

Association between initial dialytic modalities and the risks of mortality, infection death, and cardiovascular events: A nationwide population-based cohort study

To date, few studies have been conducted to pairwise compare the prognosis of peritoneal dialysis (PD), unplanned PD, and unplanned hemodialysis (HD). We analyzed longitudinal data from Taiwan’s National Health Insurance Research Database. We included 45,165 patients whose initial dialytic modality was PD or unplanned HD between January 1, 2001 and December 31, 2013. We divided the patients into three groups according to their initial dialytic modalities. The primary outcomes were all-cause mortality and death from infection during 1-year follow up. The risks of all-cause mortality and infection death were higher in the unplanned PD group than in the planned PD group (hazard ratio [HR] 1.43, 95% confidence interval [CI] 1.28–1.60; HR 1.54, 95% CI 1.32–1.80). Likewise, the risks of all-cause mortality and infection death were higher in the unplanned HD group (HR 1.64, 95% CI 1.48–1.82; HR 1.85, 95% CI 1.61–2.13). Furthermore, the risks of all-cause mortality and infection death were also higher in the unplanned HD group than in the unplanned PD group (HR 1.15, 95% CI 1.07–1.23; HR 1.20, 95% CI 1.09–1.32). In conclusion, our study demonstrates that patients whose initial modality was planned PD or unplanned PD may have better clinical outcomes than those whose initial modality was unplanned HD.

Urgent-start peritoneal dialysis: is it ready for prime time?

PURPOSE OF REVIEW

This review aims to provide an up-to-date summary of the definition, current practice and evidence regarding the role of urgent-start peritoneal dialysis (USPD) in patients with end-stage kidney disease who present with unplanned dialysis requirement without functional access.

RECENT FINDINGS

USPD can be broadly defined as peritoneal dialysis initiation within the first 2 weeks after catheter insertion. Published practice patterns, in terms of catheter insertion approach, peritoneal dialysis initiation time or initial fill volume, are highly variable. Most evidence comes from small, retrospective, single-center observational studies and only one randomized controlled trial. Compared with conventional-start peritoneal dialysis, USPD appears to moderately increase the risk of mechanical complications, such as dialysate leak (relative risk 3.21, 95% confidence interval 1.73-5.95), but does not appear to adversely affect technique or patient survival. USPD may also reduce the risk of bacteremia compared with urgent-start hemodialysis delivered by central venous catheter (CVC).

SUMMARY

USPD represents an important opportunity to establish patients with urgent, unplanned dialysis requirements on a cost-effective, home-based dialysis modality with lower serious infection risks than the alternative option of hemodialysis via CVC. Robust, well executed trials are required to better inform optimal practice and safeguard patient-centered and patient-reported outcomes.

Urgent-start peritoneal dialysis in chronic kidney disease patients: A systematic review and meta-analysis compared with planned peritoneal dialysis and with urgent-start hemodialysis

An increasing number of studies have focused on whether peritoneal dialysis (PD) can be used for the urgent initiation of dialysis in patients with chronic kidney disease (CKD). We performed this systematic review and meta-analysis to evaluate the feasibility and safety of urgent-start PD compared with those of planned PD and urgent-start hemodialysis (HD) in this population. PubMed, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), clinicaltrials.gov, and China National Knowledge Infrastructure (CNKI) were searched for relevant studies. Conference abstracts were also searched in relevant websites. The meta-analysis was performed using RevMan 5.3 software. A total of 15 trials involving 2426 participants were identified. The quality of the included studies was fair, but the quality of evidence was very low. Unadjusted meta-analysis showed that urgent-start PD had significantly higher mortality than planned PD, while adjusted meta-analysis did not show a significant difference. Higher incident of leakage and catheter mechanical dysfunction were observed in urgent-start PD. However, peritonitis, exit-site infection, or PD technique survival were comparable between urgent-start and planned PD. The all-cause mortality was comparable in urgent-start PD and urgent-start HD. Bacteremia was significantly lower in the urgent-start PD group than with urgent-start HD. Based on limited evidences, PD may be a viable alternative to HD for CKD patients requiring urgent-start dialysis. Because of the inconsistent results and the low quality of evidence, a definitive conclusion could not be drawn for whether urgent-start PD was comparable with planned PD. Therefore, high-quality and large-scale studies are needed in the future.

Urgent-start peritoneal dialysis results in fewer procedures than hemodialysis

BACKGROUND

Peritoneal dialysis (PD) is an underutilized modality for hospitalized patients with an urgent need to start renal replacement therapy in the USA. Most patients begin hemodialysis (HD) with a tunneled central venous catheter (CVC).

METHODS

We examined the long-term burden of dialysis modality-related access procedures with urgent-start PD and urgent-start HD in a retrospective cohort of 73 adults. The number of access-related (mechanical and infection-related) procedures for each modality was compared in the first 30 days and cumulatively through the duration of follow-up.

RESULTS

Fifty patients underwent CVC placement for HD and 23 patients underwent PD catheter placement for urgent-start dialysis. Patients were followed on average >1 year. The PD group was significantly younger, with less diabetes, with a higher pre-dialysis serum creatinine and more likely to have a planned dialysis access. The mean number of access-related procedures per patient in the two groups was not different at 30 days; however, when compared over the duration of follow-up, the number of access-related procedures was significantly higher in the HD group compared with the PD group (4.6 ± 3.9 versus 0.61 ± 0.84, P < 0.0001). This difference persisted when standardized to procedures per patient-month (0.37 ± 0.57 versus 0.081 ± 0.18, P = 0.019). Infection-related procedures were similar between groups. Findings were the same even after case-matching was performed for age and diabetes mellitus with 18 patients in each group.

CONCLUSIONS

Urgent-start PD results in fewer invasive access procedures compared with urgent-start HD long term, and should be considered for urgent-start dialysis.

Urgent-start dialysis: Comparison of complications and outcomes between peritoneal dialysis and haemodialysis

BACKGROUND

Few studies have evaluated the viability and outcomes between peritoneal dialysis (PD) and haemodialysis (HD) in urgent-start renal replacement therapy (RRT). This study aimed to compare infectious and mechanical complications related to urgent-start PD and HD. Secondary outcomes were to identify risk factors for complications and mortality related to urgent-start dialysis.

METHODS

A quasi-experimental study with incident patients receiving PD and HD in a Brazilian university hospital, between July 2014 and December 2017. Subjects included individuals with final-stage chronic kidney disease who required immediate RRT, that is, HD through central venous catheter or PD in which the catheter was implanted by a nephrologist and utilized for 72 h, without previous training. Patients with PD were subjected, initially, to high-volume PD for metabolic compensation. After hospital discharge, they remained in intermittent PD in the dialysis unit until training was completed. Mechanical and infectious complications were compared, as well as the recovery of renal function and survival.

RESULTS

In total, 93 patients were included in PD and 91 in HD. PD and HD groups were similar regarding age (58 ± 17 vs. 60 ± 15 years; p = 0.49), frequency of diabetes mellitus (37.6% vs. 50.5%; p = 0.10), other comorbidities (74.1% vs. 71.4%; p = 0.67) and biochemical parameters at the beginning of RRT, that is, creatinine (9.1 ± 4.1 vs. 8.0 ± 2.8; p = 0.09), serum albumin (3.1 ± 0.6 vs. 3.3 ± 0.6; p = 0.06) and haemoglobin (9.5 ± 1.8 vs. 9.8 ± 2.0; p = 0.44). After a minimum follow-up period of 180 days and a maximum follow-up period of 2 years, there was no difference regarding mechanical complications (24.7% vs. 37.4%; p = 0.06) or bacteraemia (15.0% vs. 24.0%; p = 0.11); however, there was a difference regarding infection of the exit site (25.8% vs. 39.5%; p = 0.04) and diuresis maintenance [700 (0-1500) vs. 0 (0-500); p < 0.001], with better results in the PD group. There was better phosphorus control at 180 days in the PD group (62.4% vs. 41.8%; p = 0.008), with a lower requirement for phosphate binder usage (28% vs. 55%; p < 0.001), erythropoietin (18.3% vs. 49.5%; p < 0.001) and anti-hypertensives (11.8% vs. 30.8%; p = 0.003). Time to death was similar between groups. In the multivariate analysis, PD was a predictor of renal function recovery [odds ratio: 3.95 (1.01-15.4)].

CONCLUSION

PD is a viable and safe alternative to HD in a scenario of urgent-start RRT with complication rates and outcomes similar to those of HD, highlighting the results regarding renal function recovery.

Complications and outcomes of urgent-start peritoneal dialysis in elderly patients with end-stage renal disease in China: a retrospective cohort study

OBJECTIVES

To investigate the complications and survival of elderly patients with end-stage renal disease (ESRD) who received urgent-start peritoneal dialysis (USPD) or urgent-start haemodialysis (USHD), and to explore the value of peritoneal dialysis (PD) as the emergent dialysis method for elderly patients with ESRD.

DESIGN

Retrospective cohort study.

SETTING

Two tertiary care hospitals in Shanghai, China.

PARTICIPANTS

Chinese patients (n=542) >65 years of age with estimated glomerular filtration rate ≤15 mL/min/m2 who received urgent-start dialysis between 1 January 2005 and 31 December 2015, and with at least 3 months of treatment. Patients who converted to other dialysis methods, regardless of the initial dialysis method, were excluded, as well as those with comorbidities that could significantly affect their dialysis outcomes.

PRIMARY AND SECONDARY OUTCOME MEASURES

Dialysis-related complications and survival were compared. Patients were followed until death, stopped PD, transfer to other dialysis centres, loss to follow-up or 31 December 2016.

RESULTS

There were 309 patients in the USPD group and 233 in the USHD group. The rate of dialysis-related complications within 30 days after catheter implantation was significantly lower in the USPD group compared with the USHD group (4.5% vs 10.7%, p=0.031). The 6-month and 1, 2 and 3-year survival rates were 95.3%, 91.4%, 86.6% and 64.8% in the USPD group, and 92.2%, 85.7%, 70.2% and 57.8% in the USHD group, respectively (p=0.023). The multivariable Cox regression analysis showed that USHD (HR=2.220, 95% CI 1.298 to 3.790; p=0.004), age (HR=1.025, 95% CI 1.013 to 1.043, p<0.001) and hypokalaemia (HR=0.678, 95% CI 0.487 to 0.970; p=0.032) were independently associated with death.

CONCLUSIONS

USPD was associated with slightly better survival compared with USHD. USPD was associated with fewer complications and better survival than USHD in elderly patients with ESRD.

Early and Late Patient Outcomes in Urgent-Start Peritoneal Dialysis

Background

Significant interest in the practice of urgent-start peritoneal dialysis (PD) is mounting internationally, with several observational studies supporting the safety, efficacy, and feasibility of this approach. However, little is known about the early complication rates and long-term technique and peritonitis-free survival for patients who start PD urgently (i.e. within 2 weeks of catheter insertion), compared to those with a conventional start.

Methods

This single-center, matched case-control study evaluated patients commencing PD between 2010 and 2015. Urgent-start PD patients were matched 1:3 with conventional-start PD controls based on diabetic status and age. The primary outcomes were early complications, both following catheter insertion and PD commencement (within 4 weeks). Secondary outcomes included technique and peritonitis-free survival.

Results

A total of 104 patients (26 urgent-start, 78 conventional-start) were included. Urgent-start patients were more likely to be referred late, initiate PD in hospital, and be prescribed lower initial exchange volumes ( p < 0.01). They experienced more frequent leaks post-catheter insertion (12% vs 1%, p = 0.047) and more frequent catheter migration following commencement of PD (12% vs 1%, p = 0.047). There were no significant differences in the rates of overall or infectious complications. Kaplan-Meier estimates of technique survival and time to first episode of peritonitis were comparable between the groups.

Conclusion

Compared with conventional-start PD, urgent-start PD has acceptably low early complication rates and similar long-term technique survival. Urgent-start PD appears to be a safe way to initiate urgent renal replacement therapy in patients without established dialysis access.

Double purse-string around the inner cuff of the peritoneal catheter: A novel technique for an immediate initiation of continuous peritoneal dialysis

International guidelines recommended a delayed start of peritoneal dialysis at least 2 weeks between catheter insertion and continuous peritoneal dialysis therapy initiation (break-in period). Up to now, the optimal duration of the break-in period is still unclear. The aim of our study was to evaluate in patients, with immediate initiation of continuous peritoneal dialysis, the efficacy of a double purse-string around the inner cuff in preventing mechanical and infectious complications either in semi-surgical or surgical catheter implantation. From January 2011 to December 2018, 135 peritoneal dialysis catheter insertions in 125 patients (90 men and 35 women, mean age 62.02 ± 16.7) were performed. Seventy-seven straight double-cuffed Tenckhoff catheters were implanted semi-surgically on midline under the umbilicus by a trocar, and 58 were surgically implanted through the rectus muscle. In all patients, continuous peritoneal dialysis was started immediately after catheter placement. Mechanical and infectious catheter-related complications during the first 3 months after initiation of continuous peritoneal dialysis were recorded. The overall incidence of leakages, catheter dislocations, peritonitis, and exit-site infections was 4/135 (2.96%), 2/135 (1.48%), 14/135 (10.3%), and 4/135 (2.96%), respectively. Regarding the incidence of catheter-related complications, no bleeding events, bowel perforations, or hernia formations were observed with either the semi-surgical or surgical technique. Double purse-string technique around the inner cuff allows an immediate start of continuous peritoneal dialysis both with semi-surgical and surgical catheter implantation. This technique is a safe and feasible approach in patients needing an urgent peritoneal dialysis.

The Potential Burden of Home Dialysis on Patients and Caregivers: A Narrative Review

Purpose of review:

Home dialysis modalities offer several benefits for patients with end-stage kidney disease when compared with facility-based thrice-weekly hemodialysis. To increase uptake of home dialysis, many centers are encouraging a “home-first” approach. However, it is important to appreciate that “one size may not fit all” and that dialysis modality selection is a complex decision that needs to be individualized. The purpose of this review was to explore aspects associated with home dialysis that may be associated with burden for patients and their caregivers and to discuss strategies to alleviate these concerns.

Sources of information:

Original research articles were identified from PubMed using search terms “peritoneal dialysis,” “home hemodialysis,” “home dialysis,” “barriers,” “quality of life” and “burden.”

Methods:

We performed a focused narrative review examining potential sources of burden with home dialysis therapies after conducting a critical appraisal of the literature and identifying the major recurring themes.

Key findings:

Home dialysis is associated with burden for certain patients. Indeed, some patients may experience ongoing concerns regarding the risks of adverse events and of inadequately performing dialysis on their own. Psychosocial issues affecting quality of life may also arise and include fear of social isolation, sleep disturbances, perceived financial burden, anxiety, and fatigue. Patients who depend on a caregiver may worry about creating a stressful home environment for their close ones. Furthermore, the demands associated with being a caregiver may lead to psychosocial distress in the caregivers themselves. All these factors may lead to burnout and consequently, therapy discontinuation necessitating an unplanned transition to in-center hemodialysis leading to adverse outcomes. However, certain strategies may help alleviate burden especially if concerns are identified early on.

Limitations:

As we did not apply any formal tool to assess the quality of the studies included, selection bias may have occurred. Nonetheless, we have attempted to provide a comprehensive review on the topic using numerous diverse studies and extensive review of the literature.

Implications:

Future studies should focus on better identifying patient priorities and strategies to facilitate dialysis modality selection and improve quality of life.

Implementation of Urgent Start Peritoneal Dialysis Reduces Hemodialysis Catheter Use and Hospital Stay in Patients with Unplanned Dialysis Start

Background: Unplanned start of renal replacement therapy is common in patients with end-stage renal disease and often accomplished by hemodialysis (HD) using a central venous catheter (CVC). Urgent start using peritoneal dialysis (PD) could be an alternative for some of the patients; however, this requires a hospital-based PD center that offers a structured urgent start PD (usPD) program. Methods: In this prospective study, we describe the implementation of an usPD program at our university hospital by structuring the process from presentation to PD catheter implantation and start of PD within a few days. For clinical validation, we compared the patient flow before (2013–2015) and after (2016–2018) availability of usPD. Results: In the 3 years before the availability of usPD, 14% (n = 12) of incident PD patients (n = 87) presented in an unplanned situation and were initially treated with HD using a CVC. In the 3 years after implementation of the usPD program, 18% (n = 18) of all incident PD patients (n = 103) presented in an unplanned situation of whom n = 12 (12%) were treated with usPD and n = 6 (6%) with initial HD. usPD significantly reduced the use of HD by 57% (p = 0.0005). Hospital stay was similar in patients treated with usPD (median 9 days) compared to those with elective PD (8 days), and significantly lower than in patients with initial HD (26 days, p = 0.0056). Conclusions: Implementation of an usPD program reduces HD catheter use and hospital stay in the unplanned situation.

Urgent-start peritoneal dialysis for patients with end stage renal disease: a 10-year retrospective study

Background

Urgent-start peritoneal dialysis (PD) can help patients with end-stage renal diseases (ESRD) that are referred late to dialysis. However, catheter patency and related complications of urgent-start PD have not been thoroughly clarified. We investigated the clinical outcomes of urgent-start PD in a Chinese cohort.

Methods

We enrolled ESRD patients who received urgent-start PD (starting PD within 14 days after catheter insertion) in our center from January 1, 2006 to December 31, 2014, and followed them up for 10 years. The primary outcome was catheter failure. Secondary outcomes included short-term and long-term complications related to urgent-start PD.

Results

Totally 2059 patients (58.9% male, mean age 47.6 ± 15.9 years) were enrolled. Few perioperative complications were observed, including significant hemorrhage (n = 3, 0.1%) and bowel perforation (n = 0). Early peritonitis occurred in 24 (1.2%) patients (0.28 episodes per patient-year). Within the first month after catheter insertion, functional catheter malfunction occurred in 85 (4.1%) patients, and abdominal wall complications (including hernia, hydrothorax, hydrocele, and leakage) in 36 (1.7%) patients. During a median 36.5 (17.7–61.4) months of follow-up, 75 (3.6%) patients experienced catheter failure, and 291 (14.1%) had death-censoring technique failure. At the end of 1-month, 1 -year, 3-year, and 5-year, catheter patency rate was 97.6, 96.4, 96.2, 96.2%; and technique survival rate was 99.5, 97.0, 90.3, 82.7%, respectively. After adjusting for confounders, every 5-year increase in age was associated with 19% decrease of risk for catheter failure (hazard ratio [HR]: 0.81, 95% confidence interval [CI]: 0.73–0.89). Male sex (HR: 1.43, 95% CI: 1.00–2.04), diabetic nephropathy (HR: 1.56, 95% CI: 1.08–2.25) and low hemoglobin levels (HR: 0.89, 95% CI: 0.81–0.98) were independent risk factors for abdominal wall complications.

Conclusions

Urgent-start PD is a safe and efficacious option for unplanned ESRD patients. A well-trained PD team, a standardized catheter insertion procedure by experienced nephrologists, and a carefully designed initial PD prescription as well as comprehensive follow-up care, might be essential for the successful urgent-start PD program.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1408-9) contains supplementary material, which is available to authorized users.

Outpatient Dialysis for Acute Kidney Injury: Progress and Pitfalls

Dialysis-requiring acute kidney injury (AKI) has increased markedly in the United States. At the same time, mortality rates have recently improved. As such, increasing numbers of patients with AKI are surviving to hospital discharge, including up to 30% who will continue to require outpatient dialysis. In recent years, policy changes have significantly affected the care of this high-risk population. Beginning in 2017, new legislation reversed a previous Centers for Medicare & Medicaid Services policy that prohibited dialysis for AKI at end-stage renal disease (ESRD) facilities. This has improved dialysis options for patients, but the impact on patient outcomes remains uncertain. Unfortunately, there is currently a lack of evidence basis to guide management of this vulnerable patient population. Moving forward, additional data reporting and analyses will be required, analogous to how the US Renal Data System has helped inform ESRD care. As the dialysis setting for patients with AKI shifts to the ESRD setting, it is incumbent on the nephrology community to identify best practices to promote kidney recovery, recognizing that these practices will differ from standard ESRD protocols.

Urgent start peritoneal dialysis

PURPOSE OF REVIEW

Although historically peritoneal dialysis was widely used in nephrology, it has been underutilized in recent years. In this review, we present several key opportunities and strategies for revitalization of urgent start peritoneal dialysis use, and discuss the recent literature on clinical experience with peritoneal dialysis use in the acute and unplanned setting.

RECENT FINDINGS

Interest in using urgent start peritoneal dialysis to manage acute kidney injury (AKI) and unplanned chronic kidney disease (CKD) stage 5 patients has been increasing. To overcome some of the classic limitations of peritoneal dialysis use in AKI, such as a high chance of infectious and mechanical complications, and no control of urea, the use of cycles, flexible catheters, and a high volume of dialysis fluid has been proposed. This knowledge can be used in the case of an unplanned start on chronic peritoneal dialysis, and may be a tool to increase the peritoneal dialysis penetration rate among incident patients starting chronic dialysis therapy.

SUMMARY

Peritoneal dialysis should be offered in an unbiased way to all patients starting unplanned dialysis, and without contraindications to peritoneal dialysis. It may be a feasible, well tolerated, and complementary alternative to hemodialysis, not only in the chronic setting, but also in the acute.

The modality of choice, manual or automated, for urgent start peritoneal dialysis

Over the last decade, urgent start peritoneal dialysis (USPD), defined as initiation of peritoneal dialysis (PD) before the traditionally recommended break-in period of 2-4 weeks, has increasingly been seen as a viable option for late-presenting end-stage renal disease patients, obviating the need for haemodialysis via central venous catheter. Different prescriptions and protocols involving both manual and automated exchanges have been published, but there is no head-to-head comparison of the two modalities and no consensus on the most suitable modality exists. Evaluation of the available evidence suggests that PD can be initiated urgently using either or both options without much difference in the outcome. The two most critical aspects dictating the success of a USPD programme are using low dwell volumes and keeping patients in a strict supine position during the dialysis exchanges in the first couple of weeks of the therapy. These measures are crucial in keeping the intraperitoneal pressure to a minimum and reduce the risk of mechanical complications, including catheter leaks and malpositioning.

Is surgical PD catheter insertion safe for urgent-start peritoneal dialysis?

Urgent-start peritoneal dialysis (USPD) is increasingly seen as a viable alternative to hemodialysis through a central venous catheter for late-presenting end-stage renal disease patients. However, concerns remain about starting dialysis early following the surgical implantation of the peritoneal dialysis (PD) catheter; urgent PD is often thought to be a safe option only after minimally invasive percutaneous catheter insertions. Analysis of the cumulative data from published literature presented in this review appears to negate this general perception and shows that compared to the percutaneous catheter insertions, starting PD urgently following surgically placed catheter is not associated with more catheter leaks, dysfunctions, or other complications. The outcome of USPD is independent of the mode of catheter insertion. Instead, measures to minimize intra-peritoneal pressure including using the low initial dwell volume based on patient's weight and body habitus and keeping patients in strict supine posture during exchanges in the first 2 weeks of treatment are the two most important factors ensuring a minimization of the risk of catheter-related complications.

Urgent-Start Peritoneal Dialysis as a Bridge to Definitive Chronic Renal Replacement Therapy: Short- and Long-Term Outcomes

Background: The peritoneal dialysis (PD) urgent-start pathway, without typical 2-week break-in period, was meant for late-referral patients able and prone to join PD-first program, with its main advantages such as: keeping the vascular system intact, preserving their residual renal function and retaining life-style flexibility. We compared the short- and long-term outcomes of consecutive 35 patients after urgent- and 94 patients after the planned start of PD as the first choice.

Methods: The study included all incident end-stage renal disease patients starting PD program between January 2005 and December 2015, classified into two groups: those with urgent (unplanned) and those with elective (planned) start. Urgent PD was initiated as an overnight automatic procedure (APD) with dwell volume gradually increased, and after 2–3 weeks, target PD method was established.

Results: The mean time between catheter implantation and PD start was 3.5 ± 2.3 in urgent and 16.2 ± 1.7 days in planned-start groups (p < 0.00001). 51% of the patients in the urgent-start group required PD during first 48 h after catheter insertion. Mean follow-up of 17.6 ± 11.09 months (median: 19.0) was in the urgent-start group and 28.6 ± 26.6 months (median: 19.5) in the planned-start group. The early mechanical complications were observed more often in the urgent-start group (29 vs. 4%, p = 0.00005). The only significant predictors of early mechanical complications were serum albumin (p = 0.02) and time between the catheter insertion and PD start. The first year patient survival and technique survival censored for death and kidney transplantation were not significantly different between groups. In Cox proportional analysis the independent risk factors for patient survival as well as for method and patient survival appeared Charlson Comorbidity Index CCI (HR 1.4; p = 0.01 and 1.24; p = 0.02) and time from catheter implantation to PD start with HR 5.11; p = 0.03 and 4.29; p = 0.04 for <2 days, while time >14 days lost its predictive value (p = 0.07).

Conclusion: Peritoneal dialysis may be a feasible and safe alternative to HD in patients who need to start dialysis urgently without established dialysis access, with an acceptable complications rates, as well as patient and technique survival.

Risk of death after first-time blood stream infection in incident dialysis patients with specific consideration on vascular access and comorbidity

Background

The mortality following blood stream infection (BSI) and risk of subsequent BSI in relation to dialysis modality, vascular access, and other potential risk factors has received relatively little attention. Consequently, we assessed these matters in a retrospective cohort study, by use of the Danish nation-wide registries.

Methods

Patients more than 17 years of age, who initiated dialysis between 1.1.2010 and 1.1.2014, were grouped according to their dialysis modality and vascular access. Survival was modeled in time-dependent Cox proportional hazard analyses. Potential risk factors confined by a modified Charlson comorbidity index (MCCI), were subsequently assessed in stepwise selection models.

Results

At baseline, 764 patients received peritoneal dialysis (PD), and 434, 479, and 782 hemodialysis (HD) patients were dialyzed by use of arteriovenous fistulas (AVFs), tunneled catheters (TCs), and non-tunneled catheters (NTCs), respectively. We identified 1069 BSIs with an overall incidence rate of 17.7 episodes per 100 person years, and 216 BSIs occurred more than one time in the same patient. HRs of post BSI mortality relative to PD were 3.20 (95% CI 1.86–5.50; p < 0.001) with NTCs; whereas no associations were found for AVF and TC. The risk of subsequent BSIs was higher with NTCs [HR 2.29 (95% CI 1.09–4.82), p = 0.030], and no significant difference was found for AVF and TC, in relation to PD. There was an increased risk of both outcomes with TC relative to AVF [death: 1.57 (95% CI 1.07–2.29, P < 0.021); BSI: 1.78 (95% CI 1.13–2.83, P < 0.014], and risk of death was reduced in patients who changed to AVF after first-time BSI. The MCCI was significantly associated with the risk of subsequent BSI and post BSI death; however, only some of the variables contained in the index were found to be significant risk predictors when analyzed in the fitted model.

Conclusions

While NTC was the most predominant risk factor for subsequent BSI and post BSI mortality, AVF appeared protective.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3594-7) contains supplementary material, which is available to authorized users.