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.

Timing of kidney replacement therapy initiation for acute kidney injury

BACKGROUND

Acute kidney injury (AKI) is a common condition among patients in intensive care units (ICUs) and is associated with high numbers of deaths. Kidney replacement therapy (KRT) is a blood purification technique used to treat the most severe forms of AKI. The optimal time to initiate KRT so as to improve clinical outcomes remains uncertain. This is an update of a review first published in 2018. This review complements another Cochrane review by the same authors: Intensity of continuous renal replacement therapy for acute kidney injury.

OBJECTIVES

To assess the effects of different timing (early and standard) of KRT initiation on death and recovery of kidney function in critically ill patients with AKI.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant's Specialised Register to 4 August 2022 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, ClinicalTrials and LILACS to 1 August 2022.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs). We included all patients with AKI in the ICU regardless of age, comparing early versus standard KRT initiation. For safety and cost outcomes, we planned to include cohort studies and non-RCTs.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two authors. The random-effects model was used, and results were reported as risk ratios(RR) for dichotomous outcomes and mean difference(MD) for continuous outcomes, with 95% confidence intervals (CI).

MAIN RESULTS

We included 12 studies enrolling 4880 participants. Overall, most domains were assessed as being at low or unclear risk of bias. Compared to standard treatment, early KRT initiation may have little to no difference on the risk of death at day 30 (12 studies, 4826 participants: RR 0.97,95% CI 0.87 to 1.09; I²= 29%; low certainty evidence), and death after 30 days (7 studies, 4534 participants: RR 0.99, 95% CI 0.92 to 1.07; I² = 6%; moderate certainty evidence). Early KRT initiation may make little or no difference to the risk of death or non-recovery of kidney function at 90 days (6 studies, 4011 participants: RR 0.91, 95% CI 0.74 to 1.11; I² = 66%; low certainty evidence); CIs included both benefits and harms. Low certainty evidence showed early KRT initiation may make little or no difference to the number of patients who were free from KRT (10 studies, 4717 participants: RR 1.07, 95% CI 0.94 to1.22; I² = 55%) and recovery of kidney function among survivors who were free from KRT after day 30 (10 studies, 2510 participants: RR 1.02, 95% CI 0.97 to 1.07; I² = 69%) compared to standard treatment. High certainty evidence showed early KRT initiation increased the risk of hypophosphataemia (1 study, 2927 participants: RR 1.80, 95% CI 1.33 to 2.44), hypotension (5 studies, 3864 participants: RR 1.54, 95% CI 1.29 to 1.85; I² = 0%), cardiac-rhythm disorder (6 studies, 4483 participants: RR 1.35, 95% CI 1.04 to 1.75; I² = 16%), and infection (5 studies, 4252 participants: RR 1.33, 95% CI 1.00 to 1.77; I² = 0%); however, it is uncertain whether early KRT initiation increases or reduces the number of patients who experienced any adverse events (5 studies, 3983 participants: RR 1.23, 95% CI 0.90 to 1.68; I² = 91%; very low certainty evidence). Moderate certainty evidence showed early KRT initiation probably reduces the number of days in hospital (7 studies, 4589 participants: MD-2.45 days, 95% CI -4.75 to -0.14; I² = 10%) and length of stay in ICU (5 studies, 4240 participants: MD -1.01 days, 95% CI -1.60 to -0.42; I² = 0%).

AUTHORS' CONCLUSIONS

Based on mainly low to moderate certainty of the evidence, early KRT has no beneficial effect on death and may increase the recovery of kidney function. Earlier KRT probably reduces the length of ICU and hospital stay but increases the risk of adverse events. Further adequate-powered RCTs using robust and validated tools that complement clinical judgement are needed to define the optimal time of KRT in critical patients with AKI in order to improve their outcomes. The surgical AKI population should be considered in future research.

Use of Peritoneal Dialysis in Acute Kidney Injury: How Far Away?

Acute kidney injury (AKI) has become a worldwide public health problem, resulting in a high risk of mortality and progression to chronic kidney disease. Peritoneal dialysis (PD) can be an effective renal support for AKI, especially in regions where medical resources are limited, but actually underused. In this article, the current barriers and challenges of use of PD in AKI are discussed, including health strategy and medical resources, PD team organization, and technique-specific factors. Currently, we are just on the starting line of the campaign of acute PD. It is still a long way to the development of PD as a mature treatment in AKI.

RRT Selection for AKI Patients With Critical Illness

Acute kidney injury (AKI) is a critical burden on intensive care units in Asia. Renal replacement therapy (RRT) acts as strong supportive care for severe AKI. However, various RRT modalities are used in Asia because of the diversity in ethics, climate, geographic features, and socioeconomic status. Extracorporeal blood purification is used commonly in Asian intensive care units; however, intermittent RRT is preferred in developing countries because of cost and infrastructure issues. Conversely, continuous RRT is preferred in developed countries, indicating the predominance of hospital-acquired AKI patients with complications of hemodynamic instability. Peritoneal dialysis is delivered less frequently, although several studies have suggested promising results for peritoneal dialysis in AKI treatment. Of note, not all RRT modalities are available as a standard procedure in some Asian regions, and it is absolutely necessary to develop a sustainable infrastructure that can deliver optimal care for all AKI patients.

Timing of renal replacement therapy initiation for acute kidney injury

BACKGROUND

Acute kidney injury (AKI) is a common condition among patients in intensive care units (ICUs), and is associated with high death. Renal replacement therapy (RRT) is a blood purification technique used to treat the most severe forms of AKI. The optimal time to initiate RRT so as to improve clinical outcomes remains uncertain.This review complements another Cochrane review by the same authors: Intensity of continuous renal replacement therapy for acute kidney injury.

OBJECTIVES

To assess the effects of different timing (early and standard) of RRT initiation on death and recovery of kidney function in critically ill patients with AKI.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant's Specialised Register to 23 August 2018 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. We also searched LILACS to 11 September 2017.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs). We included all patients with AKI in ICU regardless of age, comparing early versus standard RRT initiation. For safety and cost outcomes we planned to include cohort studies and non-RCTs.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two authors. The random-effects model was used and results were reported as risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI).

MAIN RESULTS

We included five studies enrolling 1084 participants. Overall, most domains were assessed as being at low or unclear risk of bias. Compared to standard treatment, early initiation may reduce the risk of death at day 30, although the 95% CI does not rule out an increased risk (5 studies, 1084 participants: RR 0.83, 95% CI 0.61 to 1.13; I2 = 52%; low certainty evidence); and probably reduces the death after 30 days post randomisation (4 studies, 1056 participants: RR 0.92, 95% CI 0.76 to 1.10; I2= 29%; moderate certainty evidence); however in both results the CIs included a reduction and an increase of death. Earlier start may reduce the risk of death or non-recovery kidney function (5 studies, 1076 participants: RR 0.83, 95% CI 0.66 to 1.05; I2= 54%; low certainty evidence). Early strategy may increase the number of patients who were free of RRT after RRT discontinuation (5 studies, 1084 participants: RR 1.13, 95% CI 0.91 to 1.40; I2= 58%; low certainty evidence) and probably slightly increases the recovery of kidney function among survivors who discontinued RRT after day 30 (5 studies, 572 participants: RR 1.03, 95% CI 1.00 to 1.06; I2= 0%; moderate certainty evidence) compared to standard; however the lower limit of CI includes the null effect. Early RRT initiation increased the number of patients who experienced adverse events (4 studies, 899 participants: RR 1.10, 95% CI 1.03 to 1.16; I2 = 0%; high certainty evidence). Compared to standard, earlier RRT start may reduce the number of days in ICU (4 studies, 1056 participants: MD -1.78 days, 95% CI -3.70 to 0.13; I2 = 90%; low certainty evidence), but the CI included benefit and harm.

AUTHORS' CONCLUSIONS

Based mainly on low quality of evidence identified, early RRT may reduce the risk of death and may improve the recovery of kidney function in critically patients with AKI, however the 95% CI indicates that early RRT might worsen these outcomes. There was an increased risk of adverse events with early RRT. Further adequate-powered RCTs using appropriate criteria to define the optimal time of RRT are needed to reduce the imprecision of the results.

Peritoneal dialysis for acute kidney injury

BACKGROUND

Peritoneal dialysis (PD) has been suggested as an effective and safe dialysis modality in patients with acute kidney injury (AKI). However, whether PD is superior to extracorporeal therapy (e.g. haemodialysis) in terms of improving survival, recovery of kidney function, metabolic and clinical outcomes is still inconclusive.

OBJECTIVES

The aim of this review was to evaluate the benefits and harms of PD for patients with AKI compared with extracorporeal therapy or different PD modalities.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies to 29 May 2017 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. We also searched the China Biological Medicine Database.

SELECTION CRITERIA

We included patients with AKI who were randomised to receive PD, extracorporeal therapy, or different PD modalities regardless of their age, sex, primary disease and clinical course.

DATA COLLECTION AND ANALYSIS

Screening, selection, data extraction and quality assessments for each retrieved article were carried out by two authors using standardised forms. Authors contacted when published data were incomplete. Statistical analyses were performed using the random effects model and results expressed as risk ratio (RR) with 95% confidence intervals (CI). Heterogeneity among studies was explored using the Cochran Q statistic and the I² test. Outcomes of interest included all-cause mortality, recovery of kidney function, weekly delivered Kt/V, correction of acidosis, fluid removal, duration of dialysis, and infectious complications. Confidence in the evidence was assessing using GRADE.

MAIN RESULTS

Six studies (484 participants) met our inclusion criteria. Five studies compared high volume PD with daily haemodialysis, extended daily haemodialysis, or continuous renal replacement therapy. One study focused on the intensity of PD. The overall risk of bias was low to unclear. Compared to extracorporeal therapy, PD probably made little or no difference to all-cause mortality (4 studies, 383 participants: RR 1.12, 95% CI 0.81 to 1.55; I² = 69%; moderate certainty evidence), or kidney function recovery (3 studies, 333 participants: RR 0.95, 95% CI 0.68 to 1.35; I² = 0%; moderate certainty evidence). PD probably slightly reduces the amount of fluid removal compared to extracorporeal therapy (3 studies, 313 participants: MD -0.59 L/d, 95% CI -1.19 to 0.01; I² = 89%; low certainty evidence), and probably made little or no difference to infectious complications (2 studies, 263 participants: RR 1.03, 95% CI 0.60 to 1.78; I² = 0%; low certainty evidence). It is uncertain whether PD compared to extracorporeal therapy has any effects on weekly delivered Kt/V (2 studies, 263 participants: MD -2.47, 95% CI -5.17 to 0.22; I² = 99%; very low certainty evidence), correction of acidosis (2 studies, 89 participants: RR 1.32, 95% CI 0.13 to 13.60; I² = 96%; very low certainty evidence), or duration of dialysis (2 studies, 170 participants: MD -1.01 hours, 95% CI -91.49 to 89.47; I² = 98%; very low certainty evidence). Heterogeneity was high and this may be due to the different extracorporeal therapies used.One study (61 participants) reported little or no difference to all-cause mortality, kidney function recovery, or infection between low and high and intensity PD. Weekly delivered Kt/V and fluid removal was lower with low compared to high intensity PD.

AUTHORS' CONCLUSIONS

Based on moderate (mortality, recovery of kidney function), low (infectious complications), or very low certainty evidence (correction of acidosis) there is probably little or no difference between PD and extracorporeal therapy for treating AKI. Fluid removal (low certainty) and weekly delivered Kt/V (very low certainty) may be higher with extracorporeal therapy.

Acute Peritoneal Dialysis in Patients with Acute Kidney Injury

Background

The purpose of this study was to evaluate the efficacy, complications, and mortality rate associated with acute peritoneal dialysis (PD) in patients with acute kidney injury (AKI).

Methods

A total of 75 patients who were treated at Samsung Changwon Hospital between February 2005 and March 2016 were included in the study sample. The outcomes included in-hospital survival, renal recovery, metabolic and fluid control rates, and technical success rates.

Results

Refractory heart failure was the most frequent cause of acute PD (49.3%), followed by hepatic failure (20.0%), septic shock (14.7%), acute pancreatitis (9.3%), and unknown causes (6.7%). The hospital survival of patients in the acute PD was 48.0%. Etiologies of acute kidney injury (AKI) (refractory heart failure, acute pancreatitis compared with hepatic failure, septic shock or miscellaneous causes), use of inotropes, use of a ventilator, and simplified acute physiology score (SAPS) II were associated with survival differences. Maintenance dialysis required after survival was high (80.1% [29/36]) due to AKI etiologies (heart or hepatic failures). Metabolic and fluid control rates were 77.3%. The technical success rate for acute PD was 93.3%.

Conclusion

Acute PD remains a suitable treatment modality for patients with AKI in the era of continuous renal replacement therapy (CRRT). Nearly all patients who require dialysis can be dialyzed with acute PD without mechanical difficulties. This is particularly true in patients with refractory heart failure and acute pancreatitis who had a weak requirement for inotropes.

A Study of Continuous Renal Replacement Therapy and Acute Peritoneal Dialysis in Hemodynamic Unstable Patients

Objective:

The objective of the following study was to assess the outcome of continuous renal replacement therapy (CRRT) and acute peritoneal dialysis (PD) in dialysis-requiring renal failure in patients with hemodynamic instability.

Materials and Methods:

A retrospective analysis of all the patients who received CRRT and acute PD over a period of 1 year at our institute, a tertiary care center, was done for diagnosis, type of renal replacement therapy (RRT), and survival outcome. The indications for administering either of the therapy were usual indications of doing hemodialysis with the presence of hemodynamic instability (systolic blood pressure <90 mm of Hg even with inotropes).

Results:

Forty patients, 22 in CRRT and 18 in acute PD group were studied. All these patients required inotropes to maintain desired blood pressure. Twenty-five (62.5%) patients had acute kidney injury (AKI), and 15 (37.5%) had chronic kidney disease (CKD) superimposed over other primary diagnosis. A total of 8 (20%) patients (4 in CRRT, 4 in acute PD) survived at the time of discharge from hospital. The mean age of survivors was approximately a decade less than nonsurvivors (P = 0.15). Overall, there were no survivors in CKD group and all the patients who survived at the time of discharge from hospital had underlying AKI (P = 0.016).

Conclusion:

This study showing comparable survival outcome in acute PD and CRRT gives evidence that either of the modalities can be adopted in hemodynamically unstable patients requiring RRT depending on the resources available.

Peritoneal dialysis for the management of pediatric patients with acute kidney injury

Renal replacement therapy (RRT) is the most important supportive measure used in the management of acute kidney injury (AKI). Peritoneal dialysis (PD) is a safe, simple and inexpensive procedure and has been used in pediatric AKI patients, ranging from neonates to adolescents. It is the modality of choice for RRT in developing countries with cost constraints and limited resources. However, its use has declined with the availability of newer types of extracorporeal modalities for RRT in the developed world. Much controversy exists regarding the dosing and adequacy of PD in the management of AKI. Data in infants and children have shown that PD can provide adequate clearance, ultrafiltration and correction of metabolic abnormalities even in those who are critically ill. Although there are no prospective studies in children, data from retrospective studies reveal no differences in mortality rates between different modalities of RRT. In this review, we discuss the advantages and limitations of PD, indications for acute PD, strategies to improve the efficiency of acute PD and outcomes of PD in children with AKI.

Renal Replacement Therapy in Acute Kidney Injury: Controversies and Consensus

Acute kidney injury (AKI) is a common complication among critically ill patents, and 5% of intensive care unit (ICU) patients require initiation of renal replacement therapy (RRT). In recent years, clinical trials have provided evidence-based guidance for some important aspects of RRT management in patients with AKI, such as dialysis dosing and approaches to anticoagulation in patients undergoing continuous RRT. However, there remain many areas of uncertainty, and delivery of RRT in the ICU requires clinical judgment, flexibility, and an understanding of dialysis principles. This article reviews the components of RRT prescription and provides an update on best practices.

Peritoneal dialysis treatment for severe lupus nephritis patients complicated with essential organ dysfunction

The aim of the present study was to evaluate the clinical efficacy of peritoneal dialysis (PD) in patients with severe lupus nephritis (LN) complicated with organ dysfunction. In total, 13 severe LN patients complicated with multiple-organ dysfunction, who underwent PD treatment between November 2003 and September 2010, were enrolled in the study. Six patients received methylprednisolone pulse therapy due to lupus activity and progressive renal failure. These patients were complicated with severe edema, cardiac insufficiency and severe hypoalbuminemia. PD was applied to the patients, followed by the administration of immunosuppressants. Patients were followed-up to review the parameters of renal function, the immunological indexes and the systemic lupus erythematosus disease activity index. The results indicated that the general state of health was markedly improved following PD treatment, with edema abatement and improvement of heart function and physical strength. Serum creatinine levels significantly decreased from 6.3±1.6 to 2.6±1.0 mg/dl. A total of 10 cases ceased PD treatment during the follow-up, while three cases continued PD to the end of the follow-up period. The levels of albumin and hemoglobin exhibited a marked increase from 29.7±5.7 to 35.2±5.5 g/l and 8.7±1.8 to 9.8±1.8 g/l, respectively. There was one case of peritonitis, one case of peritoneal leakage and two cases of pneumonia. Therefore, PD may be a successful treatment method for severe LN patients complicated with essential organ dysfunction. PD not only improved the symptoms of edema and heart failure, but also played an important role in preserving residual renal function and improving the nutritional state of the patients. Thus, PD can be considered as a treatment option for patients with severe LN associated with acute kidney injury, however, selecting a suitable immunosuppressant during PD treatment is essential.

Renal replacement therapy in adult and pediatric intensive care : Recommendations by an expert panel from the French Intensive Care Society (SRLF) with the French Society of Anesthesia Intensive Care (SFAR) French Group for Pediatric Intensive Care Emergencies (GFRUP) the French Dialysis Society (SFD)

Acute renal failure (ARF) in critically ill patients is currently very frequent and requires renal replacement therapy (RRT) in many patients. During the last 15 years, several studies have considered important issues regarding the use of RRT in ARF, like the time to initiate the therapy, the dialysis dose, the types of catheter, the choice of technique, and anticoagulation. However, despite an abundant literature, conflicting results do not provide evidence on RRT implementation. We present herein recommendations for the use of RRT in adult and pediatric intensive care developed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system by an expert group of French Intensive Care Society (SRLF), with the participation of the French Society of Anesthesia and Intensive Care (SFAR), the French Group for Pediatric Intensive Care and Emergencies (GFRUP), and the French Dialysis Society (SFD). The recommendations cover 4 fields: criteria for RRT initiation, technical aspects (access routes, membranes, anticoagulation, reverse osmosis water), practical aspects (choice of the method, peritoneal dialysis, dialysis dose, adjustments), and safety (procedures and training, dialysis catheter management, extracorporeal circuit set-up). These recommendations have been designed on a practical point of view to provide guidance for intensivists in their daily practice.

Injury-induced inflammation and inadequate HSP expression in mesothelial cells upon repeat exposure to dual-chamber bag peritoneal dialysis fluids

PURPOSE

Peritoneal dialysis fluids (PDFs) may induce inadequate heat-shock protein (HSP) expression and injury-related inflammation in exposed mesothelial cells. The aim of this study was to relate cellular injury to these cellular responses in mesothelial cells following repeated exposure to 3 commercial PDFs with different biocompatibility profiles.

METHODS

Primary cultures of human peritoneal mesothelial cells (HPMC) were exposed to a 1:2 mixture of cell culture medium and CAPD2 (single-chamber bag PDF; Fresenius, Bad Homburg, Germany), Physioneal (dual-chamber bag PDF; Baxter, Deerfield, IL, USA) or Balance (dual-chamber bag PDF, Fresenius) for up to 10 days exposure time (4 dwells). Supernatant was analyzed for LDH, IL-6, and IL-8, cells for HSP-72 expression, and protein content.

RESULTS

PDF exposure resulted in a biphasic pattern of cell damage switching from an earlier phase with increased injury by single-chamber PDF to a delayed phase with increased susceptibility to dual-chamber PDF. Sterile inflammation was related to LDH release over time and could be reproduced by exposure to necrotic cellular material. PDF exposure resulted in low HSP-72 expression in all tested PDFs.

CONCLUSIONS

Exposure to single-chamber as well as to dual-chamber bag PDFs induce increased vulnerability of mesothelial cells to repeated exposure of the same solution. These effects were delayed with dual-chamber PDFs. Injury-induced inflammation and impaired HSP expression upon PDF exposure might initiate a vicious cycle with progredient mesothelial cell damage upon repeated PDF exposure. Certainly, interventional studies and translation of these results into the in vivo system is needed.

Peritoneal dialysis for children with acute kidney injury in Lagos, Nigeria: experience with adaptations

♦

INTRODUCTION

International professional groups are supporting the training of physicians in developing countries in nephrology, including peritoneal dialysis (PD). This report documents the impact of such efforts in the provision of manual PD for children with acute kidney injury (AKI) in a public hospital in Lagos, Nigeria. ♦

METHODS

Medical records of all children with AKI managed with PD between July 2010 and March 2013 were reviewed. ♦

RESULTS

Seventeen children with a mean (SEM) age of 3.8 (0.8) years received PD for 0 - 18 days; about half were infants. PD was provided manually, frequently with intercostal drains as catheters. Blockage of catheters and peritonitis occurred in 4 (23.5%) and 2 (11.8%) children, respectively. Eight (47.1%) of the 17 children had resolution of AKI and were discharged from hospital. In 4 (57.1%) of the 7 children who died, PD was performed for ≤ 2 days. ♦

CONCLUSION

PD for childhood AKI is feasible in resource-constrained regions with fairly good outcome. Blockage of catheter was the most common complication encountered.

Raising awareness of acute kidney injury: a global perspective of a silent killer

Worldwide, acute kidney injury (AKI) is associated with poor patient outcomes. Over the last few years, collaborative efforts, enabled by a common definition of AKI, have provided a description of the epidemiology, natural history, and outcomes of this disease and improved our understanding of the pathophysiology. There is increased recognition that AKI is encountered in multiple settings and in all age groups, and that its course and outcomes are influenced by the severity and duration of the event. The effect of AKI on an individual patient and the resulting societal burden that ensues from the long-term effects of the disease, including development of chronic kidney disease (CKD) and end-stage renal disease (ESRD), is attracting increasing scrutiny. There is evidence of marked variation in the management of AKI, which is, to a large extent, due to a lack of awareness and an absence of standards for prevention, early recognition, and intervention. These emerging data point to an urgent need for a global effort to highlight that AKI is preventable, its course is modifiable, and its treatment can improve outcomes. In this article, we provide a framework of reference and propose specific strategies to raise awareness of AKI globally, with the goal to ultimately improve outcomes from this devastating disease.

Use of peritoneal dialysis in AKI: a systematic review

BACKGROUND AND OBJECTIVES

The role of peritoneal dialysis in the management of AKI is not well defined, although it remains frequently used, especially in low-resource settings. A systematic review was performed to describe outcomes in AKI treated with peritoneal dialysis and compare peritoneal dialysis with extracorporeal blood purification, such as continuous or intermittent hemodialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

MEDLINE, CINAHL, and Central Register of Controlled Trials were searched in July of 2012. Eligible studies selected were observational cohort or randomized adult population studies on peritoneal dialysis in the setting of AKI. The primary outcome of interest was all-cause mortality. Summary estimates of odds ratio were obtained using a random effects model.

RESULTS

Of 982 citations, 24 studies (n=1556 patients) were identified. The overall methodological quality was low. Thirteen studies described patients (n=597) treated with peritoneal dialysis only; pooled mortality was 39.3%. In 11 studies (7 cohort studies and 4 randomized trials), patients received peritoneal dialysis (n=392, pooled mortality=58.0%) or extracorporeal blood purification (n=567, pooled mortality=56.1%). In the cohort studies, there was no difference in mortality between peritoneal dialysis and extracorporeal blood purification (odds ratio, 0.96; 95% confidence interval, 0.53 to 1.71). In four randomized trials, there was also no difference in mortality (odds ratio, 1.50; 95% confidence interval, 0.46 to 4.86); however, heterogeneity was significant (I(2)=73%, P=0.03).

CONCLUSIONS

There is currently no evidence to suggest significant differences in mortality between peritoneal dialysis and extracorporeal blood purification in AKI. There is a need for good-quality evidence in this important area.

Renal replacement therapy in acute kidney injury

Although the use of renal replacement therapy (RRT) to support critically ill patients with acute kidney injury (AKI) has become routine, many of the fundamental questions regarding optimal management of RRT remain. This review summarizes current evidence regarding the timing of initiation of RRT, the selection of the specific modality of RRT, and prescription of the intensity of therapy. Although absolute indications for initiating RRT-such as hyperkalemia and overt uremic symptoms-are well recognized, the optimal timing of therapy in patients without these indications continues to be a subject of debate. There does not appear to be a difference in either mortality or recovery of kidney function associated with the various modalities of RRT. Finally, providing higher doses of RRT is not associated with improved clinical outcomes.

Acute kidney injury: controversies revisited

This paper addresses the epidemiology of AKI specifically in relation to recent changes in AKI classification and revisits the controversies regarding the timing of initiation of dialysis and the use of peritoneal dialysis as a renal replacement therapy for AKI. In summary, the new RIFLE/AKIN classifications of AKI have facilitated more uniform diagnosis of AKI and clinically significant risk stratification. Regardless, the issue of timing of dialysis initiation still remains unanswered and warrants further examination. Furthermore, peritoneal dialysis as a treatment modality for AKI remains underutilised in spite of potential beneficial effects. Future research should be directed at identifying early reliable biomarkers of AKI, which in conjunction with RIFLE/AKIN classifications of AKI could facilitate well-designed large randomised controlled trials of early versus late initiation of dialysis in AKI. In addition, further studies of peritoneal dialysis in AKI addressing dialysis dose and associated complications are required for this therapy to be accepted more widely by clinicians.

Management of acute kidney injury in neurotrauma

Fortunately, the incidence of acute kidney injury (AKI) in neurotrauma is low and decreasing. Whereas the majority of AKI occurs in older patients with pre-existing chronic kidney disease, neurotrauma typically occurs in children and young adults with normal renal function. The development of outreach trauma teams has improved initial resuscitation, reducing both volume responsive and volume unresponsive cases of AKI. Most cases occur in the setting of multiple organ trauma with muscle injury, or patients who subsequently develop multiple organ failure. Once AKI has developed and renal replacement therapy is required, continuous modalities of renal replacement therapy offer an advantage to the patient with compromised cerebral perfusion and intracranial hypertension, by reducing the rate of change in serum urea, compared with standard intermittent therapies of hemodialysis and hemofiltration, thus minimizing abrupt changes in serum osmolality. Continuous hemodialysis and hemofiltration are better suited to maintain a normal or high serum sodium and thermal losses through the extracorporeal circuit, than peritoneal dialysis. Dialyzers should preferably be minimally bioincompatible and of a small surface area. In patients at risk of intracranial hemorrhage and those with invasive intracranial monitoring, systemic anticoagulants should either be avoided or regional anticoagulants should be used.

Comparing continuous venovenous hemodiafiltration and peritoneal dialysis in critically ill patients with acute kidney injury: a pilot study

BACKGROUND

There are few reports on the role of peritoneal dialysis in critically ill patients requiring continuous renal replacement therapies.

METHODS

Patients with acute kidney injury and multi-organ involvement were randomly allotted to continuous venovenous hemodiafiltration(CVVHDF, group A) or to continuous peritoneal dialysis (CPD, group B). Cause and severity of renal failure were assessed at the time of initiating dialysis. Primary outcome was the composite correction of uremia, acidosis, fluid overload, and hyperkalemia. Secondary outcomes were improvement of sensorium and hemodynamic instability, survival, and cost.

RESULTS

Groups A and B comprised 25 patients each with mean ages of 45.32 ± 17.53 and 48.44 ± 17.64 respectively. They received 21.68 ± 13.46 hours and 66.02 ± 69.77 hours of dialysis respectively (p = 0.01). Composite correction was achieved in 12 patients of group A (48%) and in 14 patients of group B (56%). Urea and creatinine clearances were significantly higher in group A (21.72 ± 10.41 mL/min and 9.36 ± 4.93 mL/min respectively vs. 22.13 ± 9.61 mL/min and 10.5 ± 6.07 mL/min, p < 0.001). Acidosis was present in 21 patients of group A (84%) and in 16 of group B (64%); correction was better in group B (p < 0.001). Correction of fluid overload was faster and the amount of ultrafiltrate was significantly higher in group A (20.31 ± 21.86 L vs. 5.31 ± 5.75 L, p<0.001). No significant differences were seen in correction of hyperkalemia, altered sensorium, or hemodynamic disturbance. Mortality was 84% in group A and 72% in group B. Factors that influenced outcome were the APACHE (Acute Physiology and Chronic Health Evaluation) II score (p=0.02) and need for ventilatory support (p < 0.01). Cost of disposables was higher in group A than in group B [INR 7184 ± 1436 vs. INR 3009 ± 1643, p < 0.001 (US$1=INR 47)].

CONCLUSIONS

Based on this pilot study, CPD may be a cost-conscious alternative to CVVHDF; differences in metabolic and clinical outcomes are minimal.