Unplanned Start on Peritoneal Dialysis Right after PD Catheter Implantation for Older People with End-Stage Renal Disease

Risk factors of different mortality periods in older patients with end-stage renal disease undergoing urgent-start peritoneal dialysis: a retrospective observational study

BACKGROUND

The first six months of therapy represents a high-risk period for peritoneal dialysis (PD) failure. The risk of death in the first six months is higher for older patients treated with urgent-start PD (USPD). However, there are still gaps in research on mortality and risk factors for death in this particular group of patients. We aimed to investigate mortality rates and risk factors for death in older patients with end-stage renal disease (ESRD) receiving USPD within and after six months of therapy.

METHODS

We retrospectively studied the clinical information of older adults aged ≥ 65 years with ESRD who received USPD between 2013 and 2019 in five Chinese hospitals. Patients were followed up to June 30, 2020. The mortality and risk factors for death in the first six months of USPD treatment and beyond were analyzed.

RESULTS

Of the 379 elderly patients in the study, 130 died over the study period. During the follow-up period, the highest number (45, 34.6%) of deaths occurred within the first six months. Cardiovascular disease was the most common cause of death. The baseline New York Heart Association (NYHA) class III-IV cardiac function [hazard ratio (HR) = 2.457, 95% confidence interval (CI): 1.200-5.030, p = 0.014] and higher white blood cell (WBC) count (HR = 1.082, 95% CI: 1.021-1.147, p = 0.008) increased the mortality risk within six months of USPD. The baseline NYHA class III-IV cardiac function (HR = 1.945, 95% CI: 1.149-3.294, p = 0.013), lower WBC count (HR = 0.917, 95% CI: 0.845-0.996, p = 0.040), lower potassium levels (HR = 0.584, 95% CI: 0.429-0.796, p = 0.001), and higher calcium levels (HR = 2.160, 95% CI: 1.025-4.554, p = 0.043) increased the mortality risk after six months of USPD.

CONCLUSION

Different risk factors correlated with mortality in older adults with ESRD within and after six months of undergoing USPD, including baseline NYHA class III-IV cardiac function, WBC count, potassium, and calcium levels.

Home dialysis: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Home dialysis modalities (home hemodialysis [HD] and peritoneal dialysis [PD]) are associated with greater patient autonomy and treatment satisfaction compared with in-center modalities, yet the level of home-dialysis use worldwide is low. Reasons for limited utilization are context-dependent, informed by local resources, dialysis costs, access to healthcare, health system policies, provider bias or preferences, cultural beliefs, individual lifestyle concerns, potential care-partner time, and financial burdens. In May 2021, KDIGO (Kidney Disease: Improving Global Outcomes) convened a controversies conference on home dialysis, focusing on how modality choice and distribution are determined and strategies to expand home-dialysis use. Participants recognized that expanding use of home dialysis within a given health system requires alignment of policy, fiscal resources, organizational structure, provider incentives, and accountability. Clinical outcomes across all dialysis modalities are largely similar, but for specific clinical measures, one modality may have advantages over another. Therefore, choice among available modalities is preference-sensitive, with consideration of quality of life, life goals, clinical characteristics, family or care-partner support, and living environment. Ideally, individuals, their care-partners, and their healthcare teams will employ shared decision-making in assessing initial and subsequent kidney failure treatment options. To meet this goal, iterative, high-quality education and support for healthcare professionals, patients, and care-partners are priorities. Everyone who faces dialysis should have access to home therapy. Facilitating universal access to home dialysis and expanding utilization requires alignment of policy considerations and resources at the dialysis-center level, with clear leadership from informed and motivated clinical teams.

Availability of assisted peritoneal dialysis in Europe: call for increased and equal access

INTRODUCTION

Availability of assisted PD (asPD) increases access to dialysis at home, particularly for the increasing numbers of older and frail people with advanced kidney disease. Although asPD has been widely used in some European countries for many years, it remains unavailable or poorly utilised in others. A group of leading European nephrologists have therefore formed a group to drive increased availability of asPD in Europe and in their own countries.

METHODS

Members of the group filled in a proforma with the following headings: personal experience, country experience, who are the assistants, funding of asPD, barriers to growth, what is needed to grow, and their top 3 priorities.

RESULTS

Only 5 of the 13 countries surveyed provided publicly funded reimbursement for asPD. The use of asPD depends on overall attitudes to PD with all respondents mentioning need for nephrology team education and/or patient education and involvement in dialysis modality decision making.

CONCLUSION AND CALL TO ACTION

Many people with advanced kidney disease would prefer to have their dialysis at home, yet if the frail patient chooses PD most healthcare systems cannot provide their choice. AsPD should be available in all countries in Europe and for all renal centres. The top priorities to make this happen are education of renal healthcare teams about the advantages of PD, education of and discussion with patients and their families as they approach the need for dialysis, and engagement with policy makers and healthcare providers to develop and support assistance for PD.

A Quality Improvement Process to Increase and Sustain a Peritoneal Dialysis Programme in the United Kingdom

INTRODUCTION

Peritoneal dialysis (PD) remains underutilised in the West. The proportion of patients in the UK starting renal replacement therapy (RRT) with PD fell from 7.2% in 2011 to 6.0% in 2016. At our centre, 8.4% of dialysis patients received PD in April 2014. Evidence suggests that home dialysis improves patient clinical outcomes; therefore, a target was agreed to achieve 25% of dialysis patients receiving PD by 2018.

METHODS

A rapid improvement process was introduced, as a quality improvement tool, to increase and sustain the PD programme. With multidisciplinary team support for PD growth, a nephrologist was trained to insert PD catheters. Nurses were trained to provide patients with balanced pre-dialysis information and discuss alternative dialysis modalities with haemodialysis (HD) patients. The "Acceptance, Choice and Empowerment" project raised awareness of home therapy choices, using a peer educator model specifically for ethnic minority patients. Lean methodologies were used to ensure continuous quality improvement.

RESULTS

PD uptake increased from 37 to 84 patients, giving a PD penetration increase from 8.4% to 19.1% between April 2014 and March 2018. Catheter insertions increased from 94 at the end of QI Period 1 to 185 at the end of QI Period 2, representing a 97% increase, with the medical/surgical split remaining stable. Peritonitis rates remained stable, and PD drop off to HD reduced from 52% to 41% during the same period.

CONCLUSIONS

By implementing a rapid improvement process and embedding a quality improvement programme, the number of incidents and prevalent PD patients increased and was sustained.

Comparison of planned-start, early-start and deferred-start strategies for peritoneal dialysis initiation in end-stage kidney disease

INTRODUCTION

In patients with end-stage kidney disease (ESKD) suitable for peritoneal dialysis (PD), PD should ideally be planned and initiated electively (planned-start PD). If patients present late, some centres initiate PD immediately with an urgent-start PD strategy. However, as urgent-start PD is resource intensive, we evaluated another strategy where patients first undergo emergent haemodialysis (HD), followed by early PD catheter insertion, and switch to PD 48-72 hours after PD catheter insertion (early-start PD). Conventionally, late-presenting patients are often started on HD, followed by deferred PD catheter insertion before switching to PD≥14 days after catheter insertion (deferred start PD).

METHODS

This is a retrospective study of new ESKD patients, comparing the planned-start, early-start and deferred-start PD strategies. Outcomes within 1 year of dialysis initiation were studied.

RESULTS

Of 148 patients, 57 (38.5%) patients had planned-start, 23 (15.5%) early-start and 68 (45.9%) deferred-start PD. Baseline biochemical parameters were similar except for a lower serum urea with planned-start PD. No significant differences were seen in the primary outcomes of technique and patient survival across all 3 subgroups. Compared to planned-start PD, early-start PD had a shorter time to catheter migration (hazard ratio [HR] 14.13, 95% confidence interval [CI] 1.65-121.04, P=0.016) while deferred-start PD has a shorter time to first peritonitis (HR 2.49, 95% CI 1.03-6.01, P=0.043) and first hospital admission (HR 2.03, 95% CI 1.35-3.07, P=0.001).

CONCLUSION

Planned-start PD is the best PD initiation strategy. However, if this is not possible, early-start PD is a viable alternative. Catheter migration may be more frequent with early-start PD but does not appear to impact technique survival.

Urgent vs. planned peritoneal dialysis initiation: complications and outcomes in the first year of therapy

INTRODUCTION

Urgent-start peritoneal dialysis (US-PD) has been proposed as a safe modality of renal replacement therapy (RRT) for end-stage renal disease (ESRD) patients with an indication for emergency dialysis initiation. We aimed to compare the characteristics, 30-day complications, and clinical outcomes of US-PD and planned peritoneal dialysis (Plan-PD) patients over the first year of therapy.

METHODS

This was a single-center retrospective study that included incident adult patients followed for up to one year. US-PD was considered when incident patients started therapy within 7 days after Tenckhoff catheter implantation. Plan-PD group consisted of patients who started therapy after the breaking period (15 days). Mechanical and infectious complications were compared 30 days from PD initiation. Hospitalization and technique failure during the first 12 months on PD were assessed by Kaplan-Meier curves and the determinants were calculated by Cox regression models.

RESULTS

All patients starting PD between October/2016 and November/2019 who fulfilled the inclusion criteria were analyzed. We evaluated 137 patients (70 in the US-PD x 67 Plan-PD). The main complications in the first 30 days were catheter tip migration (7.5% Plan-PD x 4.3% US-PD - p= 0.49) and leakage (4.5% Plan-PD x 5.7% US-PD - p=0.74). Most catheters were placed using the Seldinger technique. The main cause of dropout was death in US-PD patients (15.7%) and transfer to HD in Plan-PD patients (13.4%). The occurrence of complications in the first 30 days was the only risk factor for dropout (OR = 2.9; 95% CI 1.1-7.5, p = 0.03). Hospitalization rates and technique survival were similar in both groups.

CONCLUSION

The lack of significant differences in patients' outcomes between groups reinforces that PD is a safe and applicable dialysis method in patients who need immediate dialysis.

Assisted peritoneal dialysis across Europe: Practice variation and factors associated with availability

BACKGROUND

In Europe, the number of elderly end-stage kidney disease patients is increasing. Few of those patients receive peritoneal dialysis (PD), as many cannot perform PD autonomously. Assisted PD programmes are available in most European countries, but the percentage of patients receiving assisted PD varies considerably. Hence, we assessed which factors are associated with the availability of an assisted PD programme at a centre level and whether the availability of this programme is associated with proportion of home dialysis patients.

METHODS

An online survey was sent to healthcare professionals of European nephrology units. After selecting one respondent per centre, the associations were explored by χ ² tests and (ordinal) logistic regression.

RESULTS

In total, 609 respondents completed the survey. Subsequently, 288 respondents from individual centres were identified; 58% worked in a centre with an assisted PD programme. Factors associated with availability of an assisted PD programme were Western European and Scandinavian countries (OR: 5.73; 95% CI: 3.07-10.68), non-academic centres (OR: 2.01; 95% CI: 1.09-3.72) and centres with a dedicated team for education (OR: 2.87; 95% CI: 1.35-6.11). Most Eastern & Central European respondents reported that the proportion of incident and prevalent home dialysis patients was <10% (72% and 63%), while 27% of Scandinavian respondents reported a proportion of >30% for both incident and prevalent home dialysis patients. Availability of an assisted PD programme was associated with a higher incidence (cumulative OR: 1.91; 95% CI: 1.21-3.01) and prevalence (cumulative OR: 2.81; 95% CI: 1.76-4.47) of patients on home dialysis.

CONCLUSIONS

Assisted PD was more commonly offered among non-academic centres with a dedicated team for education across Europe, especially among Western European and Scandinavian countries where higher incidence and prevalence of home dialysis patients was reported.

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.

Choice of dialysis modality among patients initiating dialysis: results of the Peridialysis study

Background

In patients with end-stage kidney disease (ESKD), home dialysis offers socio-economic and health benefits compared with in-centre dialysis but is generally underutilized. We hypothesized that the pre-dialysis course and institutional factors affect the choice of dialysis modality after dialysis initiation (DI).

Methods

The Peridialysis study is a multinational, multicentre prospective observational study assessing the causes and timing of DI and consequences of suboptimal DI. Clinical and biochemical data, details of the pre-dialytic course, reasons for DI and causes of the choice of dialysis modality were registered.

Results

Among 1587 included patients, 516 (32.5%) were judged unsuitable for home dialysis due to contraindications [384 ( 24.2%)] or no assessment [106 (6.7%); mainly due to late referral and/or suboptimal DI] or death [26 (1.6%)]. Older age, comorbidity, late referral, suboptimal DI, acute illness and rapid loss of renal function associated with unsuitability. Of the remaining 1071 patients, 700 (65.4%) chose peritoneal dialysis (61.7%) or home haemodialysis (HD; 3.6%), while 371 (34.6%) chose in-centre HD. Somatic differences between patients choosing home dialysis and in-centre dialysis were minor; factors linked to the choice of in-centre dialysis were late referral, suboptimal DI, acute illness and absence of a ‘home dialysis first’ institutional policy.

Conclusions

Given a personal choice with shared decision making, 65.4% of ESKD patients choose home dialysis. Our data indicate that the incidence of home dialysis potentially could be further increased to reduce the incidence of late referral and unplanned DI and, in acutely ill patients, by implementing an educational programme after improvement of their clinical condition.

Prevalence, associated factors and cardiocerebral vascular prognosis of anaemia among patients on chronic haemodialysis in South Guangdong, China

OBJECTIVE

To assess the prevalence, associated factors and cardiocerebral vascular prognosis of anaemia in patients undergoing haemodialysis.

METHODS

This multicentre, retrospective, observational cohort study included patients on maintenance haemodialysis in South Guangdong, China. Anaemia in haemodialysis was defined as haemoglobin (Hb) <90 g/l. A proportion of patients were enrolled in a follow-up of the cardiocerebral vascular prognosis.

RESULTS

A total of 1161 patients were enrolled and 938 were followed-up for cardiocerebral vascular events. Of 1161 patients, 250 (21.5%) had anaemia and 524 (45.1%) had an Hb level of 100-120 g/l. Adjusted multivariate logistic regression analysis demonstrated that frequency of dialysis ≤ twice weekly, hypoalbuminaemia and use of unfractionated heparin were independent factors associated with anaemia. Kaplan-Meier survival curve analysis for no myocardial infarction was 100%, 100%, 100% and 100% after 3, 6, 9 and 12 months, respectively, in patients with Hb < 90 g/l; compared with 97%, 95%, 93% and 93%, respectively, in patients with Hb ≥ 130 g/l. Adjusted Cox proportional hazards regression demonstrated that Hb ≥ 130 g/l was an independent risk factor for myocardial infarction.

CONCLUSION

Anaemia is highly prevalent among patients undergoing haemodialysis in South Guangdong and requires careful management.

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.

COVID-19 Extrapulmonary illness - The Impact of COVID-19 on Nephrology care

Coronavirus disease-2019 (COVID-19) has caused a pandemic that has affected millions of people worldwide. COVID-19 is caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and is spread by close contact and by respiratory droplets. It has also impacted different aspects of caring for people with kidney disease, including those with acute kidney injury (AKI), chronic kidney disease (CKD), those requiring kidney replacement therapy (KRT), and those with a kidney transplant. All of these patients are considered high risk. The lessons learned from the COVID-19 pandemic will hopefully serve to protect patients with kidney disease in a similar situation in the future.

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.

Setting Up and Expanding a Home Dialysis Program: Is There a Recipe for Success?

Home dialysis modalities remain significantly underused in the United States despite similar overall survival in the modalities, and recent incentives to expand these modalities. Although the absolute number of patients using home modalities has grown, the proportion compared to in-center hemodialysis (ICHD) continues to remain quite low. Well known barriers to home dialysis utilization exist, and an organized and team-based approach is required to overcome these barriers. Herein, we describe our efforts at growing our home dialysis program at a large academic medical center, with the proportion of home dialysis patients growing from 12% to 21% over the past 9 years. We prioritized individualized education for patients and better training for physicians, with the help of existing resources, aimed at better utilization of home modalities; an example includes dedicated dialysis education classes taught twice monthly by an experienced nurse practitioner, as well as the utilization of the dialysis educator from a dialysis provider for inpatient education of patients with CKD. The nephrology fellowship curriculum was restructured with emphasis on home modalities, and participation in annual home dialysis conferences has been encouraged. For timely placement and troubleshooting of access for dialysis, we followed a complementary team approach using surgeons and interventional radiologists and nephrologists, driven by a standardized protocol developed at UAB, and comanaged by our access coordinators. A team-based approach, with emphasis on staff engagement and leadership opportunities for dialysis nurses as well as collaborative efforts from a team of clinical nephrologists and the dialysis provider helped maintain efficiency, kindle growth, and provide consistently high-quality clinical care in the home program. Lastly, efforts at reducing burden of disease such as decreased number of monthly visits as well as using innovative strategies, such as telenephrology and assisted PD and HHD, were instrumental in reducing attrition.

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.

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.

Comparison of outcomes between emergent-start and planned-start peritoneal dialysis in incident ESRD patients: a prospective observational study

BACKGROUND

The clinical consequences of starting chronic peritoneal dialysis (PD) after emergent dialysis via a temporary hemodialysis (HD) catheter has rarely been evaluated within a full spectrum of treated end-stage renal disease (ESRD). We investigated the longer-term outcomes of patients undergoing emergent-start PD in comparison with that of other practices of PD or HD in a prospective cohort of new-onset ESRD.

METHODS

This was a 2-year prospective observational study. We enrolled 507 incident ESRD patients, among them 111 chose PD (43 planned-start, 68 emergent-start) and 396 chose HD (116 planned-start, 280 emergent-start) as the long-term dialysis modality. The logistic regression model was used to identify variables associated with emergent-start dialysis. The Kaplan-Meier survival analysis was used to determine patient survival and technique failure. The propensity score-adjusted Cox regression model was used to identify factors associated with patient outcomes.

RESULTS

During the 2-year follow-up, we observed 5 (4.5%) deaths, 15 (13.5%) death-censored technique failures (transfer to HD) and 3 (2.7%) renal transplantations occurring in the PD population. Lack of predialysis education, lower predialysis estimated glomerular filtration rate and serum albumin were predictors of being assigned to emergent dialysis initiation. The emergent starters of PD displayed similar risks of patient survival, technique failure and overall hospitalization, compared with the planned-start counterparts. By contrast, the concurrent planned-start and emergent-start HD patients with an arteriovenous fistula or graft were protected from early overall death and access infection-related mortality, compared with the emergent HD starters using a central venous catheter.

CONCLUSIONS

In late-referred chronic kidney disease patients who have initiated emergent dialysis via a temporary HD catheter, post-initiation PD can be a safe and effective long-term treatment option. Nevertheless, due to the potential complications and cost concerns, such practice of PD initiation would better be replaced with a planned-start mode by employing more effective predialysis therapeutic education and timely catheter placement.

Urgent-Start Peritoneal Dialysis: The First Year of Brazilian Experience

Background: This study aimed to evaluate mechanical and infectious complications associated with urgent-start peritoneal dialysis (PD) and patients and technique survival in the first 180 days. Methods: It was a prospective study that evaluated chronic patients who started unplanned PD using high-volume PD (HVPD) right after (<72 h) PD catheter placement. After hospital discharge, patients were treated with intermittent PD on alternate days in a dialysis unit until family training was provided. Results: Fifty-one patients fulfilling the following criteria were included: age was 62.1 ± 15 years, with diabetes as the main etiology of end-stage renal disease (39%), and uremia as the main dialysis indication (76%). Metabolic and fluid controls were achieved after 3 sessions of HVPD, and patients remained in intermittent PD for 23.2 ± 7.2 days. Mechanical complications occurred in 25.7% and peritonitis rate was 0.5 episode/patient-year. In the first 6 months, technique and patients survival rates were 86 and 82.4% respectively. Conclusion: The PD modality was a feasible and safe alternative to hemodialysis in the urgent-start dialysis.

Dialysis access: issues related to conversion from peritoneal dialysis to hemodialysis and vice versa

Hemodialysis (HD) and peritoneal dialysis (PD) represent two complementary modalities of renal replacement therapy (RRT) for end-stage renal disease patients. Conversion between the two modalities is frequent and more likely to happen from PD to HD. Every year, 10% of PD patients convert to HD, suggesting the need for recommendations on how to proceed with the creation of a vascular access in these patients. Criteria for selecting patients who would likely fail PD, and therefore take advantage of a backup access, are undefined. Creating backup fistulas at the time of PD treatment start to allow emergency access for HD has proved to be inefficient, but it may be considered in patients with progressive difficulty in achieving adequate depuration and/or peritoneal ultrafiltration. A big challenge is represented by patients switching from PD to HD for unexpected infectious complications. Those patients need to start HD with a central venous catheter (CVC), but an alternative approach might be using an early cannulation graft, provided that infection has been cleared by the circulation. An early cannulation graft might also be used to considerably shorten the time spent using a CVC. In patients who need a conversion from HD to PD, urgent-start PD is now an accepted and well-established approach.

Ensuring Patient Safety During the Transition to ESRD

Patients with chronic kidney disease (CKD) are at risk for complications both inherent to the disease and as a consequence of its treatment. The dangers that CKD patients face change across the spectrum of the disease. Providers who are well-versed in these safety threats are best poised to safeguard patients as their CKD progresses.

Feasibility of Urgent-Start Peritoneal Dialysis in Older Patients with End-Stage Renal Disease: A Single-Center Experience

Background

Patients with end-stage renal disease (ESRD) frequently require urgent-start dialysis. Recent evidence suggests that peritoneal dialysis (PD) might be a feasible alternative to hemodialysis (HD) in these patients, including in older patients.

Methods

This retrospective study enrolled patients aged > 65 years with ESRD who underwent urgent dialysis without functional vascular access or PD catheter at a single center, from January 2011 to December 2014. Patients were grouped based on their dialysis modality (PD or HD). Patients unable to tolerate PD catheter insertion or wait for PD were excluded. Each patient was followed for at least 30 days after catheter insertion. Short-term (30-day) dialysis-related complications and patient survival were compared between the 2 groups.

Results

A total of 94 patients were enrolled, including 53 (56.4%) who underwent PD. The incidence of dialysis-related complications during the first 30 days was significantly lower in PD compared with HD patients (3 [5.7%] vs 10 [24.4%], p = 0.009). Logistic regression identified urgent-start HD as an independent risk factor for dialysis-related complications compared with urgent-start PD (odds ratio 4.760 [1.183 – 19.147], p = 0.028). The 6-, 12-, 24-, and 36-month survival rates in the PD and HD groups were 92.3% vs 94.6%, 82.4% vs 81.3%, 75.7% vs 74.2%, and 69.5% vs 60.6%, respectively, with no significant differences between the groups (log-rank = 0.011, p = 0.915).

Conclusion

Urgent-start PD was associated with fewer short-term dialysis-related complications and similar survival to urgent-start HD in older patients with ESRD. Peritoneal dialysis may thus be a safe and effective dialysis modality for older ESRD patients requiring urgent dialysis.

Urgent peritoneal dialysis or hemodialysis catheter dialysis

Worldwide, there is a steady incident rate of patients with end-stage kidney disease (ESKD) who require renal replacement therapy. Of these patients, approximately one-third have an "unplanned" or "urgent" start to dialysis. This can be a very challenging situation where patients have either not had adequate time for education and decision making regarding dialysis modality and appropriate dialysis access, or a decision was made and plans were altered due to unforeseen circumstances. Despite such unplanned starts, clinicians must still consider the patient's ESKD "life-plan", which includes the best initial dialysis modality and access to suit the patient's individual goals and their medical, social, logistic, and facility circumstances. This paper will discuss the considerations of peritoneal dialysis and a peritoneal dialysis catheter access and hemodialysis and central venous catheter access in patients who require an urgent start to dialysis.