Urgent peritoneal dialysis or hemodialysis catheter dialysis

The influence of different peritoneal dialysis techniques on wound infection in patients with peritoneal dialysis tube

More and more research has started to investigate the effect of peritoneal dialysis treatment on the incidence of pericatheter wound complications in chronic kidney disease (CKD). This meta-study evaluated the effect of emergency peritoneal dialysis (EPD) with conventional peritoneal dialysis (CPD) in patients with catheter-related complications. We looked up 4 databases: PubMed, EMBASE, Cochrane, and Web of Science, and analysed the data with RevMan 5. There were a total of 15 studies with 3034 participants. While the quality of the research included was fairly good, the evidence was mediocre. In the meta-analyses, the risk of leak in the conduit with PD was very high (OR, 2.48; 95% CI, 1.72, 3.59, p < 0.00001). However, for those treated with urgent medical method prior to initiation of PD, the risk for peritonitis, catheter dysfunction and bleeding was similar compared with CPD. Based on limited information, immediate initiation of PDs is advised in order to increase the quality of life for people in urgent need, except if there is no consideration for loss of fluid. The low quality of the evidence is holding up the evidence. This research, however, is also informative because of the large number of available data. Consequently, additional high quality, large, randomized controlled studies are required to establish.

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.

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 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.

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.

New Insights into Dialysis Vascular Access: What Is the Optimal Vascular Access Type and Timing of Access Creation in CKD and Dialysis Patients?

Optimal vascular access planning begins when the patient is in the predialysis stages of CKD. The choice of optimal vascular access for an individual patient and determining timing of access creation are dependent on a multitude of factors that can vary widely with each patient, including demographics, comorbidities, anatomy, and personal preferences. It is important to consider every patient's ESRD life plan (hence, their overall dialysis access life plan for every vascular access creation or placement). Optimal access type and timing of access creation are also influenced by factors external to the patient, such as surgeon experience and processes of care. In this review, we will discuss the key determinants in optimal access type and timing of access creation for upper extremity arteriovenous fistulas and grafts.

American Society of Nephrology Quiz and Questionnaire 2015: ESRD/RRT

The Nephrology Quiz and Questionnaire remains an extremely popular session for attendees of the Annual Kidney Week Meeting of the American Society of Nephrology. During the 2015 meeting, the conference hall was once again overflowing with eager quiz participants. Topics covered by the experts included electrolyte and acid-base disorders, glomerular disease, ESRD and dialysis, and kidney transplantation. Complex cases representing each of these categories together with single best answer questions were prepared and submitted by the panel of experts. Before the meeting, training program directors of nephrology fellowship programs and nephrology fellows in the United States answered the questions through an internet-based questionnaire. During the live session, members of the audience tested their knowledge and judgment on the same series of case-oriented questions in a quiz. The audience compared their answers in real time using a cellphone application containing the answers of the nephrology fellows and training program directors. The results of the online questionnaire were displayed, and then, the quiz answers were discussed. As always, the audience, lecturers, and moderators enjoyed this highly educational session. This article recapitulates the session and reproduces selected content of educational value for the readers of the Clinical Journal of the American Society of Nephrology Enjoy the clinical cases and expert discussions.