Peritoneal dialysis for acute kidney injury: back on the front-line

Peritoneal dialysis in acute kidney injury: twenty years of experience at a single center in a developing country

BACKGROUND

This study aimed to explore the role of peritoneal dialysis (PD) in patients with acute kidney injury (AKI) in relation to metabolic and fluid control, outcome and risk factors for death.

METHODS

We performed a retrospective cohort study collecting data from a large reference Center in Brazil on patient characteristics, hospitalization, PD prescription and delivery, clinical outcomes and laboratory exams. We evaluated all patients who had been consecutively treated by PD between January 2004 and January 2024.

RESULTS

Four hundred eighty-seven patients were included. Median age was 64.02 ± 15 years, most of the patients were hospitalized in the intensive care unit (ICU) and needed vasoactive drugs and mechanical ventilation. Sepsis was the main cause of AKI followed by cardiorenal syndrome type 1. Uremia was the main indication for dialysis, followed by the need to meet metabolic and fluid demands. Blood urea nitrogen and creatinine levels stabilized after a median of four dialysis sessions. Fluid removal increased progressively and stabilized at around 2.320 ± 0.91 ml after four sessions. Mechanical complications occurred in 9.2% and peritonitis in 6.2% of patients. Regarding AKI outcome, 34.9% recovered renal function, 6.8% remained on dialysis for over 30 days, and 55.8% died. Technique failure occurred in 19.9% of the cases and the main cause was a mechanical complication. Age, hepatorenal syndrome, APACHE score and dropout from PD due to insufficient fluid control were identified as risk factors for death, while cardiorenal syndrome, need to meet metabolic and fluid demand as indication of dialysis, and negative fluid balance after 4 sessions of PD were identified as protective factors.

CONCLUSION

PD may be an effective solution for AKI patients, allowing adequate metabolic and fluid control. Age, APACHE score, hepatorenal syndrome and dropout from PD were associated with death, while cardiorenal syndrome, need to meet metabolic and fluid demands as indication of dialysis, and negative fluid balance were positive prognostic factors.

Heart Failure-Focus on Kidney Replacement Therapy: Why, When, and How?

Heart failure (HF) is a major health problem because of its high prevalence, morbidity, mortality, and cost of care. An important contributor to morbidity and mortality in patients with advanced HF is kidney dysfunction. Almost half of HF patients develop cardiorenal syndrome (CRS). The management of advanced HF complicated by CRS is challenging. Two main strategies have been widely accepted for the management of CRS, namely improving cardiac output and relieving congestion. Diuretics remain the cornerstone and first-line therapy for decongestion; however, a substantial number of CRS patients develop diuretic resistance. In the face of persistent congestion and the progressive deterioration of kidney function, the implementation of kidney replacement therapy may become the only solution. In the review the current evidence on extracorporeal and peritoneal-based kidney replacement techniques for the therapy of CRS patients are presented.

Development of PD in lower-income countries: a rational solution for the management of AKI and ESKD

It is estimated that >50% of patients with end-stage kidney disease (ESKD) in low-resource countries are unable to access dialysis. When hemodialysis is available, it often has high out-of-pocket expenditure and is seldom delivered to the standard recommended by international guidelines. Hemodialysis is a high-cost intervention with significant negative effects on environmental sustainability, especially in resource-poor countries (the ones most likely to be affected by resultant climate change). This review discusses the rationale for peritoneal dialysis (PD) as a more resource and environmentally efficient treatment with the potential to improve dialysis access, especially to vulnerable populations, including women and children, in lower-resource countries. Successful initiatives such as the Saving Young Lives program have demonstrated the benefit of PD for acute kidney injury. This can then serve as a foundation for later development of PD services for end-stage kidney disease programs in these countries. Expansion of PD programs in resource-poor countries has proven to be challenging for various reasons. It is hoped that if some of these issues can be addressed, PD will be able to permit an expansion of end-stage kidney disease care in these countries.

Is It Time to Give Peritoneal Dialysis Its Due Place in Managing Acute Kidney Injury: Lessons Learnt from COVID-19 Pandemic

Despite comparable outcomes with the extracorporeal dialysis modalities, peritoneal dialysis (PD) is seldom considered a viable option for managing acute kidney injury (AKI) in developed and resource-rich countries, where continuous renal replacement therapies (CRRTs) are the mainstay of treating AKI. PD has fewer infrastructure requirements and has been shown to save lives during conflicts, natural disasters, and pandemics. During the ongoing COVID-19 pandemic, the developed world was confronted with a sudden surge in critically ill AKI patients requiring renal replacement therapy. There were acute shortages of CRRT machines and the trained staff to deliver those treatments. Some centres developed acute PD programmes to circumvent these issues with good results. This experience re-emphasised the suitability of PD for managing AKI. It also highlighted the need to review the current management strategies for AKI in developed countries and consider incorporating PD as a viable tool for suitable patients. This article reviews the current evidence of using PD in AKI, attempts to clarify some misconceptions about PD in AKI, and argues in favour of developing acute PD programmes.

Health Systems Preparedness for Infectious Disease Outbreaks: Relevance for Nephrology

The coronavirus disease (COVID-19) crisis glaringly highlighted the critical need to develop resilient health care systems that are better prepared for epidemics. Millions of people died from COVID-19 itself, but almost three times as many died from health system disruptions. People living with kidney disease are highly vulnerable during outbreaks and pandemics and their needs must be included in preparedness planning. Health systems preparedness requires not only early identification and containment of outbreaks and maintenance of critical services during crises, but also bolstering population resilience and ensuring the safety of both health personnel and patients. Planning for surge capacity in an outbreak must include provision for both acute and chronic dialysis, and ensure access to medications for people with kidney diseases. Quality of care should not be compromised and must be monitored and improved where necessary. Technology, such as telemedicine, can support quality and continuity of care and minimize infection risks. Communication at all levels is crucial to ensure all stakeholders, including communities, have the necessary information to support cooperation and collaboration in effective outbreak responses. Research is important during and after pandemics to improve knowledge and build resilience at all levels, from outbreak detection to the development of therapeutics and optimizing equity in access to interventions. Only with adequate preparation and more resilient health systems can we hope, as a global community, to build on the harsh lessons learned during COVID-19, and improve the response to the next infectious disease outbreak, epidemic, or even pandemic.