Randomized Study of Urgent-Start Peritoneal Dialysis Versus Urgent-Start Temporary Hemodialysis in Patients Transitioning to Kidney Failure

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.

Shared decision making in elderly patients with kidney failure

'Elderly' is most commonly defined as an individual aged 65 years or older. However, this definition fails to account for the differences in genetics, lifestyle and overall health that contribute to significant heterogeneity among the elderly beyond chronological age. As the world population continues to age, the prevalence of chronic diseases, including chronic kidney disease (CKD), is increasing and CKD frequently progresses to kidney failure. Moreover, frailty represents a multidimensional clinical entity highly prevalent in this population, which needs to be adequately assessed to inform and support medical decisions. Selecting the optimal treatment pathway for the elderly and frail kidney failure population, be it haemodialysis, peritoneal dialysis or conservative kidney management, is complex because of the presence of comorbidities associated with low survival rates and impaired quality of life. Management of these patients should involve a multidisciplinary approach including doctors from various specialties, nurses, psychologists, dieticians and physiotherapists. Studies are mostly retrospective and observational, lacking adjustment for confounders or addressing selection and indication biases, making it difficult to use these data to guide treatment decisions. Throughout this review we discuss the difficulty of making a one-size-fits-all recommendation for the clinical needs of older patients with kidney failure. We advocate that a research agenda for optimization of the critical issues we present in this review be implemented. We recommend prospective studies that address these issues, and systematic reviews incorporating the complementary evidence of both observational and interventional studies. Furthermore, we strongly support a shared decision-making process matching evidence with patient preferences to ensure that individualized choices are made regarding dialysis vs conservative kidney management, dialysis modality and optimal vascular access.

An update on absolute and relative indications for dialysis treatment modalities

Background

Choosing a dialysis modality is an important decision for people to make as their kidney failure progresses. In doing so, their options should be informed by any absolute or relative indications that may favour one modality over another.

Methods

In creating this update, we reviewed literature using a framework that considered first, high-level outcomes (survival and modality transition) from large registry data and cohort studies when considering optimal patient pathways; second, factors at a dialysis provider level that might affect relative indications; and third, specific patient-level factors. Both main types of dialysis modality, peritoneal (PD) and haemodialysis (HD), and their subtypes were considered.

Results

For most people starting dialysis, survival is independent of modality, including those with diabetes. Better survival is seen in those with less comorbidity starting with PD or home HD, reflecting continued improvements over recent decades that have been greater than improvements seen for centre HD. There are provider-level differences in the perceived relative indications for home dialysis that appear to reflect variability in experience, prejudice, enthusiasm, and support for patients and carers. Absolute contraindications are uncommon and, in most cases, where modality prejudice exists, e.g. obesity, Adult Polycystic Kidney Disease, and social factors, this is not supported by reported outcomes.

Conclusion

Absolute contraindications to a particular dialysis modality are rare. Relative indications for or against particular modalities should be considered but are rarely more important than patient preferences.

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.