Peritoneal dialysis for acute kidney injury

Recent Advances in Kidney Replacement Therapy in Infants: A Review

Kidney replacement therapy (KRT) is used to treat children and adults with acute kidney injury (AKI), fluid overload, kidney failure, inborn errors of metabolism, and severe electrolyte abnormalities. Peritoneal dialysis and extracorporeal hemodialysis/filtration can be performed for different durations (intermittent, prolonged intermittent, and continuous) through either adaptation of adult devices or use of infant-specific devices. Each of these modalities have advantages and disadvantages, and often multiple modalities are used depending on the scenario and patient-specific needs. Traditionally, these therapies have been challenging to deliver in infants due the lack of infant-specific devices, small patient size, required extracorporeal volumes, and the risk of hemodynamic stability during the initiation of KRT. In this review, we discuss challenges, recent advancements, and optimal approaches to provide KRT in hospitalized infants, including a discussion of peritoneal dialysis and extracorporeal therapies. We discuss each specific KRT modality, review newer infant-specific devices, and highlight the benefits and limitations of each modality. We also discuss the ethical implications for the care of infants who need KRT and areas for future research.

Global challenges with providing vascular access care during COVID era

BACKGROUND

The COVID-19 pandemic has adversely affected health care systems and dialysis access care in the US and across the globe. Beyond the initial challenges posed by the pandemic and despite the actions taken by health care leaders/organizations/professional societies such as the "Maintaining Lifelines for ESKD Patients" joint statement, there continues to be delays in providing timely care and performing elective and emergent dialysis access procedures worldwide. The aim of this study was to assess the global challenges associated with providing dialysis vascular access care across the international vascular access community during the pandemic.

METHODS

The American Society of Diagnostic and Interventional Nephrology (ASDIN) conducted an online survey in 2021, that was administered to an expert panel of dialysis vascular access specialists and global leaders spanning across the international community. The respondents who are members of ASDIN, Association of Vascular Access and InTerventionAl Renal physicians (AVATAR), Asia Pacific Society of Dialysis Access (APSDA), Peruvian Vascular Access Society (APDAV), and Australia/New Zealand Society of Interventional Nephrology (ANZSIN) reported their experiences in the care of dialysis vascular access, practice patterns, and challenges faced during the COVID pandemic.

RESULTS

Of the 53 individual surveys sent, 16 were opened and 11 (69%) responses were received from across the world and from different practice settings. The survey revealed the continued challenges facing the international community, the stark disparities in care delivery, supply chain disruption and logistical, regulatory, and financial issues that the global community continues to face in the ongoing pandemic.

CONCLUSIONS

The COVID19 pandemic is far from over, and the challenges and barriers to providing dialysis access care seen on the initial ASDIN survey in the US seem to extend across the globe. We describe those results and discuss options, opportunities, and innovative tools to provide dialysis and access care during these trying times.

New perspectives in pediatric dialysis technologies: the case for neonates and infants with acute kidney injury

Advancements in pediatric dialysis generally rely on adaptation of technology originally developed for adults. However, in the last decade, particular attention has been paid to neonatal extracorporeal therapies for acute kidney care, an area in which technology has made giant strides in recent years. Peritoneal dialysis (PD) is the kidney replacement therapy (KRT) of choice in the youngest age group because of its simplicity and effectiveness. However, extracorporeal blood purification provides more rapid clearance of solutes and faster fluid removal. Hemodialysis (HD) and continuous KRT (CKRT) are thus the most used dialysis modalities for pediatric acute kidney injury (AKI) in developed countries. The utilization of extracorporeal dialysis for small children is associated with a series of clinical and technical challenges which have discouraged the use of CKRT in this population. The revolution in the management of AKI in newborns has started recently with the development of new CKRT machines for small infants. These new devices have a small extracorporeal volume that potentially prevents the use of blood to prime lines and dialyzer, allow a better volume control and the use of small-sized catheter without compromising the blood flow amount. Thanks to the development of new dedicated devices, we are currently dealing with a true "scientific revolution" in the management of neonates and infants who require an acute kidney support.

Archetypal sustained low-efficiency daily diafiltration (SLEDD-f) for critically ill patients requiring kidney replacement therapy: towards an adequate therapy

Sustained low-efficiency dialysis is a hybrid form of kidney replacement therapy that has gained increasing popularity as an alternative to continuous forms of kidney replacement therapy in intensive care unit settings. During the COVID-19 pandemic, the shortage of continuous kidney replacement therapy equipment led to increasing usage of sustained low-efficiency dialysis as an alternative treatment for acute kidney injury. Sustained low-efficiency dialysis is an efficient method for treating hemodynamically unstable patients and is quite widely available, making it especially useful in resource-limited settings. In this review, we aim to discuss the various attributes of sustained low-efficiency dialysis and how it is comparable to continuous kidney replacement therapy in efficacy, in terms of solute kinetics and urea clearance, and the various formulae used to compare intermittent and continuous forms of kidney replacement therapy, along with hemodynamic stability. During the COVID-19 pandemic, there was increased clotting of continuous kidney replacement therapy circuits, which led to increased use of sustained low-efficiency dialysis alone or together with extra corporeal membrane oxygenation circuits. Although sustained low-efficiency dialysis can be delivered with continuous kidney replacement therapy machines, most centers use standard hemodialysis machines or batch dialysis systems. Even though antibiotic dosing differs between continuous kidney replacement therapy and sustained low-efficiency dialysis, reports of patient survival and renal recovery are similar for continuous kidney replacement therapy and sustained low-efficiency dialysis. Health care studies indicate that sustained low-efficiency dialysis has emerged as a cost-effective alternative to continuous kidney replacement therapy. Although there is considerable data to support sustained low-efficiency dialysis treatments for critically ill adult patients with acute kidney injury, there are fewer pediatric data, even so, currently available studies support the use of sustained low-efficiency dialysis for pediatric patients, particularly in resource-limited settings.

Peritoneal dialysis: An effective therapeutic modality in acute kidney injury

Background

Peritoneal dialysis (PD) as a modality of renal replacement therapy (RRT) in acute kidney injury (AKI), continues to be underused. We present our experience with PD in patients with AKI.

Method

The data of patients with AKI requiring RRT were retrospectively analyzed. The primary end point was the adequacy of dialysis, and the secondary end point included hemodynamic stability and procedure-related complications.

Result

A total of 32 patients with AKI requiring RRT were included in the study. The mean age and the blood pressure at the time of hospitalization were 65.3 ± 6.73 years and 73.7 ± 8.4 mm Hg, respectively. All the patients required vasopressor support; 26 (81%) patients required ventilator support. RRT was initiated at a mean serum creatinine of 6.24 ± 1.17 mg/dL. Rigid stylet catheter was used in 9 (28.2%) and Tenckhoff catheter in 23 (71.8%) patients. The average daily ultrafiltration and weekly Kt/V achieved were 1701 ± 327 mL and 2.19, respectively; these were significantly higher in survivors. After the initiation of PD, hemodynamic instability was observed in 10 (31.2%) patients. The major therapy-related complication noted was PD peritonitis.

Conclusions

In a resource-poor environment, PD is an effective modality of RRT for AKI.

Urgent-start peritoneal dialysis

Peritoneal dialysis is an important form of kidney replacement therapy. Most patients presenting with an unplanned, urgent need for dialysis are prescribed haemodialysis, leading to peritoneal dialysis underutilisation. Urgent-start peritoneal dialysis refers to treatment that is commenced within 2 weeks of catheter placement. Urgent-start peritoneal dialysis represents an efficacious, cost-effective alternative to the conventional approach of commencing dialysis. There is a paucity of evidence to guide management, however experience with the technique is increasing. This article overviews the rationale and practical application of urgent-start peritoneal dialysis.

Kidney replacement therapy in neonates: utilization trends and outcomes

BACKGROUND

We aimed to assess prevalence and clinical characteristics of newborns receiving kidney replacement therapy (KRT).

METHODS

We used the National Inpatient Sample (NIS) dataset for the years 2000-2017. Newborns treated with peritoneal dialysis (PD), hemodialysis (HD), and continuous KRT (CKRT) were included. Trend analysis using the Cochran-Armitage test was used to assess prevalence over the years.

RESULTS

A total of 64,532,552 hospitalized newborns were included. Among the 4281 infants treated with KRT, 2501 (58.4%) were treated with PD, 997 (23.3%) had HD, and 783 (18.3%) used CKRT. Associated diagnoses included congenital kidney anomalies (37.4% vs. 15% vs. 9.5%), urinary tract anomalies (35% vs. 12.5% vs. 6.3%), and congenital heart disease (68% vs. 25.7% vs. 72.3%). Median length of stay was longest in PD patients (39 days vs. 18 days vs. 26 days), respectively. However, cost of hospitalization was greatest in CKRT patients (US $490,916 vs. US $218,514 vs. US $621,554), respectively. In the entire cohort, 54,424 newborns had acute kidney injury (AKI); of them 16,999 (31%) died. KRT was used in 2,688 (4.9%) of infants with AKI. Over the study period, trends for utilization of PD (from 0.042 to 0.06%) and CKRT (from 0.03 to 0.21%) increased whereas the hemodialysis trend decreased (from 0.021 to 0.013%).

CONCLUSIONS

Congenital heart disease (CHD) and congenital anomalies of the kidneys and urinary tract (CAKUT) are the major diagnoses in newborns receiving KRT. Utilization of PD was greater than HD and CKRT. Trends of PD and CKRT utilization increased over time. Less than 5% of infants diagnosed with AKI received KRT.

Conversion from Intermittent Hemodialysis to Peritoneal Dialysis in Metastatic Catheter-Related Bloodstream Infection

Of all complications from central venous catheters (CVC) in end-stage renal disease (ESRD) patients, catheter-related bloodstream infection (CRBSI) is one of the most devastating consequences. The option of catheter salvage is not an effective measure with metastatic infections. However, in patients with severe vasculopathy and/or near end-stage vascular disease, preservation of the venous access should be given utmost importance as the luxury of utilizing another vascular site is markedly limited. Providing adequate renal replacement therapy in this group of patients can be remarkably challenging for nephrologists. We are presenting an ESRD patient with advanced vascular disease who developed metastatic CRBSI with worsening uremia who was successfully converted from intermittent hemodialysis (IHD) to peritoneal dialysis (PD). Our rationale was to minimize repeated intravascular procedures coupled with the presence of another intravascular device. This has led to a complete resolution of persistent bacteremia, with a steady improvement in the uremic state. Conversion from IHD to PD for persistent bacteremia with metastatic complications was seldom addressed in literature. In the absence of a significant contraindication to PD, it can be considered as a valid alternative possibility in order to interrupt this viscous cycle, especially in vasculopathic patients.

Outcomes of PD for AKI treatment during COVID-19 in New York City: A multicenter study

BACKGROUND

The high incidence of acute kidney injury (AKI) requiring dialysis associated with COVID-19 led to the use of peritoneal dialysis (PD) for the treatment of AKI. This study aims to compare in-hospital all-cause mortality and kidney recovery between patients with AKI who received acute PD versus extracorporeal dialysis (intermittent haemodialysis and continuous kidney replacement therapy).

METHODS

In a retrospective observational study of 259 patients with AKI requiring dialysis during the COVID-19 surge during Spring 2020 in New York City, we compared 30-day all-cause mortality and kidney recovery between 93 patients who received acute PD at any time point and 166 patients who only received extracorporeal dialysis. Kaplan-Meier curves, log-rank test and Cox regression were used to compare survival and logistic regression was used to compare kidney recovery.

RESULTS

The mean age was 61 ± 11 years; 31% were women; 96% had confirmed COVID-19 with median follow-up of 21 days. After adjusting for demographics, comorbidities, oxygenation and laboratory values prior to starting dialysis, the use of PD was associated with a lower mortality rate compared to extracorporeal dialysis with a hazard ratio of 0.48 (95% confidence interval: 0.27-0.82, p = 0.008). At discharge or on day 30 of hospitalisation, there was no association between dialysis modality and kidney recovery (p = 0.48).

CONCLUSIONS

The use of PD for the treatment of AKI was not associated with worse clinical outcomes when compared to extracorporeal dialysis during the height of the COVID-19 pandemic in New York City. Given the inherent selection biases and residual confounding in our observational study, research with a larger cohort of patients in a more controlled setting is needed to confirm our findings.

Diagnosis and Treatment for Shiga Toxin-Producing Escherichia coli Associated Hemolytic Uremic Syndrome

Shiga toxin-producing Escherichia coli (STEC)-associated hemolytic uremic syndrome (STEC-HUS) is a clinical syndrome involving hemolytic anemia (with fragmented red blood cells), low levels of platelets in the blood (thrombocytopenia), and acute kidney injury (AKI). It is the major infectious cause of AKI in children. In severe cases, neurological complications and even death may occur. Treating STEC-HUS is challenging, as patients often already have organ injuries when they seek medical treatment. Early diagnosis is of great significance for improving prognosis and reducing mortality and sequelae. In this review, we first briefly summarize the diagnostics for STEC-HUS, including history taking, clinical manifestations, fecal and serological detection methods for STEC, and complement activation monitoring. We also summarize preventive and therapeutic strategies for STEC-HUS, such as vaccines, volume expansion, renal replacement therapy (RRT), antibiotics, plasma exchange, antibodies and inhibitors that interfere with receptor binding, and the intracellular trafficking of the Shiga toxin.

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

Peritoneal dialysis (PD) for acute kidney injury (AKI) has been available for nearly 80 years and has been through periods of use and disuse largely determined by availability of other modalities of kidney replacement therapy and the relative enthusiasm of clinicians. In the past 10 years there has been a resurgence in the use of acute PD globally, facilitated by promotion of PD for AKI in lower resource countries by nephrology organizations effected through the Saving Young Lives program and collaborations with the World Health Organisation, the development of guidelines standardizing prescribing practices and finally the COVID-19 pandemic. This review highlights the history of PD for AKI and looks at misconceptions about efficacy as well as the available evidence demonstrating that acute PD is a safe and lifesaving therapy with comparable outcomes to other modalities of treatment.

Hyperkalemia in Chronic Kidney Disease: Links, Risks and Management

Hyperkalemia is a common clinical problem with potentially fatal consequences. The prevalence of hyperkalemia is increasing, partially due to wide-scale utilization of prognostically beneficial medications that inhibit the renin-angiotensin-aldosterone-system (RAASi). Chronic kidney disease (CKD) is one of the multitude of risk factors for and associations with hyperkalemia. Reductions in urinary potassium excretion that occur in CKD can lead to an inability to maintain potassium homeostasis. In CKD patients, there are a variety of strategies to tackle acute and chronic hyperkalemia, including protecting myocardium from arrhythmias, shifting potassium into cells, increasing potassium excretion from the body, addressing dietary intake and treating associated conditions, which may exacerbate problems such as metabolic acidosis. The evidence base is variable but has recently been supplemented with the discovery of novel oral potassium binders, which have shown promise and efficacy in studies. Their use is likely to become widespread and offers another tool to the clinician treating hyperkalemia. Our review article provides an overview of hyperkalemia in CKD patients, including an exploration of relevant guidelines and nuances around management.

Clinical Profile, Outcomes, and Complications in Neonates Undergoing Peritoneal Dialysis in a Tertiary Neonatal Care Unit - An Observational Study

Peritoneal dialysis (PD) is the most common form of renal replacement therapy in neonates and there is a lot of heterogeneity in patient selection and outcomes across the various units. This study aimed to assess the indications, complications, and outcomes in terms of survival of PD. This is a retrospective study of 23 neonates who underwent acute PD at a tertiary care neonatal unit between August 2016 and July 2021. A cross-sectional poll was also conducted among the doctors who have been in the unit for the past 10 years regarding their experience in PD. The baseline, clinical, biochemical parameters, outcomes, and complications were analyzed. All statistical analyses were performed using the IBM SPSS Statistics version 23.0 software. The mean (±standard deviation) gestational age and birth weights of neonates were 32.6 ± 4 weeks and 1743 ± 922 g, respectively. Six (26%) babies had extremely low birth weight, five (22%) very low birth weight (VLBW), and seven (30%) low birth weight. The indications were acute kidney injury [17/23 (74%)], fluid overload [3/23 (17%)], suspected inborn errors of metabolism [2/23 (9%)] and hypernatremia [1/23 (4%)]. A pigtail catheter (74%) was used in most of them. Catheter block was noticed in four babies and peritonitis in two neonates. We did not encounter any complications during the procedure, and PD appears to be practicable across all gestational ages and birth weights.

COVID-19-associated acute kidney injury patients treated with renal replacement therapy in the intensive care unit: A multicenter study in São Paulo, Brazil

INTRODUCTION

Multicenter studies involving patients with acute kidney injury (AKI) associated with the disease caused by the new coronavirus (COVID-19) and treated with renal replacement therapy (RRT) in developing countries are scarce. The objectives of this study were to evaluate the demographic profile, clinical picture, risk factors for mortality, and outcomes of critically ill patients with AKI requiring dialysis (AKI-RRT) and with COVID-19 in the megalopolis of São Paulo, Brazil.

METHODS

This multicenter, retrospective, observational study was conducted in the intensive care units of 13 public and private hospitals in the metropolitan region of the municipality of São Paulo. Patients hospitalized in an intensive care unit, aged ≥ 18 years, and treated with RRT due to COVID-19-associated AKI were included.

RESULTS

The study group consisted of 375 patients (age 64.1 years, 68.8% male). Most (62.1%) had two or more comorbidities: 68.8%, arterial hypertension; 45.3%, diabetes; 36.3%, anemia; 30.9%, obesity; 18.7%, chronic kidney disease; 15.7%, coronary artery disease; 10.4%, heart failure; and 8.5%, chronic obstructive pulmonary disease. Death occurred in 72.5% of the study population (272 patients). Among the 103 survivors, 22.3% (23 patients) were discharged on RRT. In a multiple regression analysis, the independent factors associated with death were the number of organ dysfunctions at admission and RRT efficiency.

CONCLUSION

AKI-RRT associated with COVID-19 occurred in patients with an elevated burden of comorbidities and was associated with high mortality (72.5%). The number of organ dysfunctions during hospitalization and RRT efficiency were independent factors associated with mortality. A meaningful portion of survivors was discharged while dependent on RRT (22.3%).

LA, Vasudevan A. Peritoneal Dialysis with Rigid Catheters in Children with Acute Kidney Injury: A Single-Centre Experience

Peritoneal dialysis (PD) is a simple and preferred modality of dialysis for children with acute kidney injury (AKI) in resource poor countries. The aim of the study is to evaluate the utility and safety of acute PD using rigid catheter in critically ill children admitted to pediatric intensive care unit (PICU) with emphasis on short-term patient and renal outcome and complications. In this retrospective study, outcome and complications of PD using rigid catheter were evaluated in 113 critically ill children admitted in PICU of a tertiary care hospital from 2014 to 2019. The most common causes for AKI were sepsis (39.8%), dengue infection (16.8%), and hemolytic uremic syndrome (13.2%). In 113 patients, 122 PD catheters were inserted, and the median duration of PD was 60 (IQR: 36–89) hours. At the initiation of PD, 64 (56.6%) patients were critically ill requiring mechanical ventilation and inotropes, 26 (23%) had disseminated intravascular coagulation, and 42 (37%) had multiorgan dysfunction syndrome. PD was effective and there was a significant improvement in urea and creatinine, and one-third patients (n = 38; 33.6%) had complete renal recovery at the end of PD. Total complications were seen in 67% children but majority of them were metabolic (39.8%). Total catheter related complications were seen in 21.2% and peritonitis was seen in 4.4%. Catheter removal due to complications was required in 8.8% children. Overall, among children on PD, 53.7% survived. Acute PD with rigid catheters can be performed bedside in absence of soft catheters and significant clearance can be obtained without major life-threatening complications.

Saving critically ill COVID-19 patients with mechanical circulatory support

Background

Coronavirus disease 2019 (COVID-19) is an ongoing public health crisis that has led to many deaths due to multiple organ dysfunction syndromes (MODS). This article describes the clinical characteristics, management, and outcomes of critically ill COVID-19 patients who survived the disease through mechanical circulatory support (MCS).

Methods

We studied 25 critically ill COVID-19 patients who underwent MCS from January 20, 2020, to April 10, 2020, at the Tongji Hospital of Huazhong University of Science and Technology.

Results

Thirteen (52%) of the 25 patients survived with MCS support, while 12 (48%) died. At the time of their hospital admission, we identified significant differences in their peak cardiac troponin I (cTnI) and interleukin 6 (IL-6) levels, as well as in their lymphocyte count and C-reactive protein (CRP) levels. Cox proportional hazards regression model revealed that receipt of renal replacement therapy (RRT) was associated with an approximately 20-fold improvement in survival [hazard ratio (HR) =0.049, 95% confidence interval (CI) =0.008 to 0.305]. The number of days spent on extracorporeal membrane oxygenation (ECMO) support and the use of hydrogen (pH) at the time of MCS was also associated with an increase in survival. This contrasted with high-sensitivity C-reactive proteins (hs-CRP) and lactate, associated with a decrease in survival during MCS. Further analysis of the determinants relating to a COVID-19 patient’s chance of survival on/after MCS was also indicated by levels of IL-6 (β=0.009, P=0.006), IL-8 (β=0.031, P=0.020), and TNF-α (β=0.107, P=0.014), which saw a significant increase in the 12 patients who died. This contrasts with the non-significant decrease in IL-6, IL-8, and TNF-α levels in the 13 patients who survived.

Conclusions

These results indicate that pH, lactate, hs-CRP, ECMO duration, and RRT are important clinical determinants for assessing how MCS can increase the chances of critically ill COVID-19 patients surviving the disease.

Renal replacement therapy in cancer patients with acute kidney injury (Review)

Cancer patients are at high risk for developing acute kidney injury (AKI), which is associated with increased morbidity and mortality in these patients. Despite the progress made in understanding the pathogenic mechanisms and etiology of AKI in these patients, the main prevention consists of avoiding medication and nephrotoxic agents such as non-steroidal anti-inflammatory drugs, contrast agents used in medical imaging and modulation of chemotherapy regimens; when prophylactic measures are overcome and renal impairment becomes unresponsive to treatment, renal replacement therapy (RRT) is required. There are several methods of RRT that can be utilized for patients with malignancies and acute renal impairment; the choice of treatment being based on the patient characteristics. The aim of this article is to review the literature data regarding the epidemiology and management of AKI in cancer patients, the extracorporeal techniques used, choice of the appropriate therapy and the optimal time of initiation, and also the dose-prognosis relationship.

Risk factors for mortality in critically ill infants with acute kidney injury: A resource-limited setting experience

Infants with acute kidney injury (AKI) who are critically ill often will have multiorgan dysfunctions. Objective of the present study was to find out mortality, recovery of kidney function at discharge and at 3 months, and to determine risk factors for mortality. Fifty-two infants (24 newborns and 28 postneonatal) with AKI were included. Staging was done as per Kidney Disease Improving Global Outcomes classification. Patients were subjected to medical treatment and peritoneal dialysis (PD), wherever indicated. Kidney function tests were performed at admission, discharge, and at 3 months follow-up. Median age of neonates was 8 days and postneonatal infants were 4.5 months. Stage 1, 2, and 3 AKI were present in 14 (26.9%), 16 (30.7%), and 22 (42.3%) cases, respectively. PD was required in 22 (42.3%) infants, and significantly higher in postneonatal than in neonates (57.1% vs. 25%, p < 0.05). Significant recovery of kidney function occurred at discharge and cases had normal parameters at 3 months. Mortality was 17.3%. Patients had significantly higher risk of mortality, if they had metabolic acidosis (OR 13.22, CI 2.33-74.94, p = 0.002) and needed ventilation (OR 14.93, 95% CI 1.7-130.97, p = 0.006) and PD (OR 6.53, 95% CI 1.20-35.48, p = 0.026). In logistic regression analysis, fluid overload (p < 001), hypotension (p < 0.01), and higher PRISM-III score (p < 0.05) were found as significant risk factors for mortality. Medical management including PD led to good recovery of kidney function. Presence of fluid overload, hypotension, and higher PRISM-III score adversely affected the outcome.

Training and education, what has changed this last decade?

BACKGROUND

The Dutch manual for the best care regarding training and education of our patients, as created by the special interest group for peritoneal dialysis (SIG PD), was revised.

OBJECTIVES

The aim of this paper is to describe topics learned from the manual revision, supported by noticed response changes in surveys from 2009 to 2019.

DESIGN

Quantitative nursing research, using similar surveys to compare training and education over the last decade. Additionally, a brief search for literature was performed.

PARTICIPANTS

Dutch dialysis nurses.

APPROACH

In 2009, nurses were approached through an online survey sent to all dialysis centres in the Netherlands. In 2019, a similar survey was distributed during our annual Dutch nephrology days. Both surveys were compared and conclusions were drawn.

FINDINGS

Retrieved information was divided into basic topics and compared. More important, our findings show that even after a decade, there is still no special education for the nurses and patient training is given based on experience alone. Furthermore, multiple nurses are involved in patient training, with varying materials. There are more home visits with training at home and retraining is more suitable. A growth in assisted PD implies more involvement by community nurses. Also, more acute PD is seen, with a different structure of training.

CONCLUSIONS

The manual was revised with input from our nurses and new guidelines, so we can uplift the education of peritoneal dialysis for the benefit of our patients, caretakers, and community nurses. As SIG PD we can support the dialysis nurses.

Acute peritoneal dialysis, complications and outcomes in 389 children with STEC-HUS: a multicenter experience

BACKGROUND

Management of acute kidney injury (AKI) in children with hemolytic uremic syndrome induced by a Shiga toxin-producing Escherichia coli infection (STEC-HUS) is supportive; however, 40 to 60% of cases need kidney replacement therapy (KRT). The aim of this study was to analyze procedure complications, especially peritonitis, and clinical outcomes in children with AKI secondary to STEC-HUS treated with acute PD.

METHODS

This is a multicenter retrospective study conducted among thirty-seven Argentinian centers. We reviewed medical records of 389 children with STEC-HUS hospitalized between January 2015 and February 2019 that required PD.

RESULTS

Complications associated with PD were catheter malfunction (n = 93, 24%), peritonitis (n = 75, 19%), fluid leaks (n = 45, 11.5%), bleeding events (n = 23, 6%), and hyperglycemia (n = 8, 2%). In the multivariate analysis, the use of antibiotic prophylaxis was independently associated with a decreased risk of peritonitis (hazard ratio 0.49, IC 95% 0.29-0.81; p = 0.001), and open-surgery catheter insertion was independently associated with a higher risk (hazard ratio 2.8, IC 95% 1.21-6.82; p = 0.001). Discontinuation of PD due to peritonitis, severe leak, or mechanical complications occurred in 3.8% of patients. No patient needed to be transitioned to other modality of KRT due to inefficacy of the technique. Mortality during the acute phase occurred in 2.8% patients due to extrarenal complications (neurological and cardiac involvement), not related to PD.

CONCLUSIONS

Acute PD was a safe and effective method to manage AKI in children with STEC-HUS. Prophylactic antibiotics prior to insertion of the PD catheter should be considered to decrease the incidence of peritonitis.

Modalities of renal replacement therapy and clinical outcomes of patients with acute kidney injury in a resource-limited setting: Results from a SEA-AKI study

PURPOSE

To determine the effects of modalities of renal replacement therapy (RRT) on the 30-d mortality and renal recovery in patients with acute kidney injury (AKI).

MATERIALS AND METHODS

A multicenter cohort study was conducted in 17 hospitals from Thailand and Indonesia. We recruited patients who were admitted to the Intensive care unit and diagnosed with AKI. Relevant mode of RRT, as intermittent hemodialysis (IHD), continuous renal replacement therapy (CRRT), peritoneal dialysis (PD), or sustained low efficiency dialysis (SLED), was initiated as indicated.

RESULTS

From 2844 patients with AKI, 449 cases (8.1%) received RRT. There were no significant differences in the 30-d mortality between those initially treated with CRRT, PD, and SLED compared to those treated with IHD. The renal recovery was similar for each RRT mode. The three independent factors of death were the primary diagnosis of kidney disease, higher APACHE II score, and non-renal SOFA score. Only 48 (10.7%) patients had been switched to another mode of RRT.

CONCLUSIONS

All four modes of RRT (IHD, CRRT, PD, and SLED) are acceptable treatments for severe AKI and gave a similar survival rate.

Comparing Renal Replacement Therapy Modalities in Critically Ill Patients With Acute Kidney Injury: A Systematic Review and Network Meta-Analysis

Supplemental Digital Content is available in the text.

Objectives:

To compare different modalities of renal replacement therapy in critically ill adults with acute kidney injury.

Data Sources:

We searched Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov from inception to 25 May, 2020. We included randomized controlled trials comparing the efficacy and safety of different renal replacement therapy modalities in critically ill patients with acute kidney injury.

Study Selection:

Ten reviewers (working in pairs) independently screened studies for eligibility, extracted data, and assessed risk of bias.

Data Extraction:

We performed random-effects frequentist network meta-analyses and used the Grading of Recommendations, Assessment, Development, and Evaluation approach to assess certainty of evidence. The primary analysis was a four-node analysis: continuous renal replacement therapy, intermittent hemodialysis, slow efficiency extended dialysis, and peritoneal dialysis. The secondary analysis subdivided these four nodes into nine nodes including continuous veno-venous hemofiltration, continuous veno-venous hemodialysis, continuous veno-venous hemodiafiltration, continuous arterio-venous hemodiafiltration, intermittent hemodialysis, intermittent hemodialysis with hemofiltration, slow efficiency extended dialysis, slow efficiency extended dialysis with hemofiltration, and peritoneal dialysis. We set the minimal important difference threshold for mortality as 2.5% (relative difference, 0.04).

Data Synthesis:

Thirty randomized controlled trials (n = 3,774 patients) proved eligible. There may be no difference in mortality between continuous renal replacement therapy and intermittent hemodialysis (relative risk, 1.04; 95% CI, 0.93–1.18; low certainty), whereas continuous renal replacement therapy demonstrated a possible increase in mortality compared with slow efficiency extended dialysis (relative risk, 1.06; 95% CI, 0.85–1.33; low certainty) and peritoneal dialysis (relative risk, 1.16; 95% CI, 0.92–1.49; low certainty). Continuous renal replacement therapy may increase renal recovery compared with intermittent hemodialysis (relative risk, 1.15; 95% CI, 0.91–1.45; low certainty), whereas both continuous renal replacement therapy and intermittent hemodialysis may be worse for renal recovery compared with slow efficiency extended dialysis and peritoneal dialysis (low certainty). Peritoneal dialysis was probably associated with the shortest duration of renal support and length of ICU stay compared with other interventions (low certainty for most comparisons). Slow efficiency extended dialysis may be associated with shortest length of hospital stay (low or moderate certainty for all comparisons) and days of mechanical ventilation (low certainty for all comparisons) compared with other interventions. There was no difference between continuous renal replacement therapy and intermittent hemodialysis in terms of hypotension (relative risk, 0.92; 95% CI, 0.72–1.16; moderate certainty) or other complications of therapy, but an increased risk of hypotension and bleeding was seen with both modalities compared with peritoneal dialysis (low or moderate certainty). Complications of slow efficiency extended dialysis were not sufficiently reported to inform comparisons.

Conclusions:

The results of this network meta-analysis suggest there is no difference in mortality between continuous renal replacement therapy and intermittent hemodialysis although continuous renal replacement therapy may increases renal recovery compared with intermittent hemodialysis. Slow efficiency extended dialysis with hemofiltration may be the most effective intervention at reducing mortality. Peritoneal dialysis is associated with good efficacy, and the least number of complications however may not be practical in all settings. Importantly, all conclusions are based on very low to moderate certainty evidence, limited by imprecision. At the very least, ICU clinicians should feel comfortable that the differences between continuous renal replacement therapy, intermittent hemodialysis, slow efficiency extended dialysis, and, where clinically appropriate, peritoneal dialysis are likely small, and any of these modalities is a reasonable option to employ in critically ill patients.

Renal replacement therapy modality in critically ill patients with acute kidney injury - A network meta-analysis of randomized controlled trials

PURPOSE

This network meta-analysis aims to compare the efficacy and safety of various renal replacement therapy (RRT) modalities in critically ill patients with acute kidney injury (AKI).

MATERIALS AND METHODS

We searched the electronic databases for randomized controlled trials (RCTs) comparing different RRT modalities, including continuous RRT, intermittent RRT, hybrid RRT, and peritoneal dialysis (PD), in critically ill patients with AKI through July 26, 2020. The primary outcomes were renal recovery and short-term mortality. The study protocol was registered with PROSPERO (CRD42020188115).

RESULTS

Twenty-three studies were included. No difference in the renal recovery or short-term mortality was observed among the four RRT modalities (low certainty). The four RRT modalities had similar effects on the incidence of infectious complications (low certainty). PD was associated with less fluid removal volume and lower incidence of hypotension compared with the extracorporeal modalities, yet no difference in the two outcomes was identified among the extracorporeal modalities (very low to moderate certainty).

CONCLUSIONS

No superiority of one particular RRT modality over another in terms of renal recovery and short-term mortality in critically ill patients with AKI. PD exhibited worse fluid removal and better safety in the prevention of hypotension than the extracorporeal modalities.

Acute Kidney Injury following Cardiopulmonary Bypass: A Challenging Picture

Recent studies have recognized several risk factors for cardiopulmonary bypass- (CPB-) associated acute kidney injury (AKI). However, the lack of early biomarkers for AKI prevents practitioners from intervening in a timely manner. We reviewed the literature with the aim of improving our understanding of the risk factors for CPB-associated AKI, which may increase our ability to prevent or improve this condition. Some novel early biomarkers for AKI have been introduced. In particular, a combinational use of these biomarkers would be helpful to improve clinical outcomes. Furthermore, we discuss several interventions that are aimed at managing CPB-associated AKI, may increase the effect of renal replacement therapy (RRT), and may contribute to preventing CPB-associated AKI. Collectively, the conclusions of this paper are limited by the availability of clinical trial evidence and conflicting definitions of AKI. A guideline is urgently needed for CPB-associated AKI.

Renal Recovery and Mortality Risk among Patients with Hepatorenal Syndrome Receiving Chronic Maintenance Dialysis

Background

Kidney replacement therapy is controversial for patients with hepatorenal syndrome who may not be liver transplant candidates. Data surrounding the likelihood of recovery of kidney function and mortality after outpatient dialysis initiation in patients with dialysis-requiring hepatorenal syndrome could inform discussions between patients and providers.

Methods

We performed a retrospective cohort study of patients with hepatorenal syndrome who were registered in the United States Renal Data System between 1996 and 2015 (n=7830) as receiving maintenance dialysis. We characterized patients with hepatorenal syndrome by recovery of kidney function using Fine and Gray models. We also examined hazard of recovery of kidney function and death among those with hepatorenal syndrome versus those with acute tubular necrosis (n=48,861) using adjusted Fine-Gray and Cox models, respectively.

Results

Of the patients with hepatorenal syndrome, 11% recovered kidney function. Those with higher likelihood of recovery were younger, non-Hispanic White, and had a history of alcohol use. Compared with patients with acute tubular necrosis, patients with hepatorenal syndrome as the attributed cause of kidney disease had a lower hazard of recovery (HR, 0.22; 95% CI, 0.21 to 0.24) and higher hazard of death within 1 year (HR, 3.10; 95% CI, 2.99 to 3.23) in fully adjusted models.

Conclusions

Patients with hepatorenal syndrome receiving chronic maintenance dialysis had a lower likelihood of recovery of kidney function and higher mortality risk compared with patients with acute tubular necrosis. Among patients with hepatorenal syndrome, those most likely to recover kidney function were younger, had a history of alcohol use, and lacked comorbid conditions. These data may inform prognosis and discussions surrounding treatment options when patients with hepatorenal syndrome need chronic maintenance dialysis therapy.

Peritoneal Dialysis Following Left Ventricular Assist Device Placement and Kidney Recovery: A Case Report

Acute kidney injury (AKI) complicates up to 50% of left ventricular assist device (LVAD) placements and up to 30% of these patients require dialysis. Despite advances in LVAD technology since the first-generation devices, the risk for AKI remains high. We present a case of a woman in her 50s with previously stable stage C heart failure who developed critical cardiogenic shock and resultant AKI. She required continuous kidney replacement therapy both before and after placement of an LVAD. Following multiple inpatient and outpatient hemodialysis sessions complicated by hypotension, she was transitioned to peritoneal dialysis (PD). She tolerated PD well, and her kidney function continued to improve during the following weeks. After 6 weeks of outpatient PD, she recovered kidney function, allowing for cessation of dialysis. PD is a good option for patients with advanced heart failure who receive an LVAD due to gentler ultrafiltration, decreased risk for bacteremia, and better preservation of kidney function as compared with hemodialysis.

Canadian Association of Paediatric Nephrologists COVID-19 Rapid Response: Guidelines for Management of Acute Kidney Injury in Children

PURPOSE

This article provides guidance on managing acute kidney injury (AKI) and kidney replacement therapy (KRT) in pediatrics during the COVID-19 pandemic in the Canadian context. It is adapted from recently published rapid guidelines on the management of AKI and KRT in adults, from the Canadian Society of Nephrology (CSN). The goal is to provide the best possible care for pediatric patients with kidney disease during the pandemic and ensure the health care team's safety.

INFORMATION SOURCES

The Canadian Association of Paediatric Nephrologists (CAPN) COVID-19 Rapid Response team derived these rapid guidelines from the CSN consensus recommendations for adult patients with AKI. We have also consulted specific documents from other national and international agencies focused on pediatric kidney health. We identified additional information by reviewing the published academic literature relevant to pediatric AKI and KRT, including recent journal articles and preprints related to COVID-19 in children. Finally, our group also sought expert opinions from pediatric nephrologists across Canada.

METHODS

The leadership of the CAPN, which is affiliated with the CSN, solicited a team of clinicians and researchers with expertise in pediatric AKI and acute KRT. The goal was to adapt the guidelines recently adopted for Canadian adult patients for pediatric-specific settings. These included specific COVID-19-related themes relevant to AKI and KRT in a Canadian setting, as determined by a group of kidney disease experts and leaders. An expert group of clinicians in pediatric AKI and acute KRT reviewed the revised pediatric guidelines.

KEY FINDINGS

(1) Current Canadian data do not suggest an imminent threat of an increase in acute KRT needs in children because of COVID-19; however, close coordination between nephrology programs and critical care programs is crucial as the pandemic continues to evolve. (2) Pediatric centers should prepare to reallocate resources to adult centers as needed based on broader health care needs during the COVID-19 pandemic. (3) Specific suggestions pertinent to the optimal management of AKI and KRT in COVID-19 patients are provided. These suggestions include but are not limited to aspects of fluid management, KRT vascular access, and KRT modality choice. (4) Considerations to ensure adequate provision of KRT if resources become scarce during the COVID-19 pandemic.

LIMITATIONS

We did not conduct a formal systematic review or meta-analysis. We did not evaluate our specific suggestions in the clinical environment. The local context, including how the provision of care for AKI and acute KRT is organized, may impede the implementation of many suggestions. As knowledge is advancing rapidly in the area of COVID-19, suggestions may become outdated quickly. Finally, most of the literature for AKI and KRT in COVID-19 comes from adult data, and there are few pediatric-specific studies.

IMPLICATIONS

Given that most acute KRT related to COVID-19 is likely to be required in the pediatric intensive care unit initial setting, close collaboration and planning between critical care and pediatric nephrology programs are needed. Our group will update these suggestions with a supplement if necessary as newer evidence becomes available that may change or add to the recommendations provided.

Strategies for Management of Peritoneal Dialysis Patients in Singapore during COVID-19 Pandemic

Peritoneal dialysis (PD) is the only well-established home-based dialysis therapy in Singapore. As it is a home-based modality, PD should be considered as a preferred mode of kidney replacement therapy (KRT) for patients with kidney failure during this COVID-19 pandemic as it avoids frequent visits to hospitals and/or satellite dialysis centres. The highly infectious nature of this virus has led to the implementation of the Disease Outbreak Response System Condition orange status in Singapore since early February 2020. This paper summarises the strategies for management of several aspects of PD in Singapore during this COVID-19 pandemic, including PD catheter insertion, PD training, home visit and assisted PD, outpatient PD clinic, inpatient management of PD patients with or without COVID-19 infection, PD as KRT for COVID-19 patients with acute kidney injury, management of common complications in PD (peritonitis and fluid overload), and management of PD inventory.

COVID-19 in New Orleans: A Nephrology Clinical and Education Perspective and Lessons Learned

New Orleans' first case of coronavirus disease 2019 (COVID-19) was reported on March 9, 2020, with a subsequent rapid increase in the number of cases throughout the state of Louisiana. Traditional educational efforts were no longer viable with social distancing and stay-at-home orders; therefore, virtual didactics were integrated into our curriculum. Due to an exponential increase in the number of patients with acute kidney injury requiring kidney replacement therapy, the nephrology sections at Louisiana State University School of Medicine and Tulane University School of Medicine adapted their clinical workflows to accommodate these increased clinical volumes by using prolonged intermittent kidney replacement therapies and acute peritoneal dialysis, as well as other strategies to mitigate nursing burnout and decrease scarce resource use. Telehealth was implemented in outpatient clinics and dialysis units to protect vulnerable patients with kidney disease while maintaining access to care. Lessons learned from this pandemic and subsequent response may be used for future responses in similar situations.

Acute Peritoneal Dialysis During the COVID-19 Pandemic at Bellevue Hospital in New York City

Background

The COVID-19 pandemic strained hospital resources in New York City, including those for providing dialysis. New York University Medical Center and affiliations, including New York City Health and Hospitals/Bellevue, developed a plan to offset the increased needs for KRT. We established acute peritoneal dialysis (PD) capability, as usual dialysis modalities were overwhelmed by COVID-19 AKI.

Methods

Observational study of patients requiring KRT admitted to Bellevue Hospital during the COVID surge. Bellevue Hospital is one of the largest public hospitals in the United States, providing medical care to an underserved population. There were substantial staff, supplies, and equipment shortages. Adult patients admitted with AKI who required KRT were considered for PD. We rapidly established an acute PD program. A surgery team placed catheters at the bedside in the intensive care unit; a nephrology team delivered treatment. We provided an alternative to hemodialysis and continuous venovenous hemofiltration for treating patients in the intensive-care unit, demonstrating efficacy with outcomes comparable to standard care.

Results

From April 8, 2020 to May 8, 2020, 39 catheters were placed into ten women and 29 men. By June 10, 39% of the patients started on PD recovered kidney function (average ages 56 years for men and 59.5 years for women); men and women who expired were an average 71.8 and 66.2 years old. No episodes of peritonitis were observed; there were nine incidents of minor leaking. Some patients were treated while ventilated in the prone position.

Conclusions

Demand compelled us to utilize acute PD during the COVID-19 pandemic. Our experience is one of the largest recently reported in the United States of which we are aware. Acute PD provided lifesaving care to acutely ill patients when expanding current resources was impossible. Our experience may help other programs to avoid rationing dialysis treatments in health crises.

Management of status epilepticus in patients with liver or kidney disease: a narrative review

Introduction: Status epilepticus (SE) is a neurologic and medical emergency with significant related morbidity and mortality. Hepatic or renal dysfunction can considerably affect the pharmacokinetics of drugs used for SE through a variety of direct or indirect mechanisms.Areas Covered: This review aims to focus on the therapeutic management of SE in patients with hepatic or renal impairment, highlighting drugs' selection and dose changes that may be necessary due to altered drug metabolism and excretion. The references for this review were identified by searches of PubMed and Google Scholar until May 2020.Expert opinion: According to literature evidence and clinical experience, in patients with renal disease, the authors suggest considering lorazepam as the drug of choice in pre-hospital and intra-hospital early-stage SE, phenytoin in definite SE, propofol in refractory or super-refractory SE. In patients with liver disease, the authors suggest the use of lorazepam as drug of choice in pre-hospital and intra-hospital early-stage SE, lacosamide in definite SE, propofol in refractory or super-refractory SE. A list of preferred drugs for all SE stages is provided.

Optimizing Kidney Replacement Therapy During the COVID-19 Pandemic Across a Complex Healthcare System

The unprecedented surge of nephrology inpatients needing kidney replacement therapy placed hospital systems under extreme stress during the COVID-19 pandemic. In this article, we describe the formation of a cross campus "New-York Presbyterian COVID-19 Kidney Replacement Therapy Task Force" with intercampus physician, nursing, and supply chain representation. We describe several strategies including the development of novel dashboards to track supply/demand of resources, urgent start peritoneal dialysis, in-house preparation of kidney replacement fluid, the use of unconventional personnel resources to ensure the safe and continued provision of kidney replacement therapy in the face of the unanticipated surge. These approaches facilitated equitable sharing of resources across a complex healthcare-system and allowed for the rapid implementation of standardized protocols at each hospital.

Prevention and Therapy of AKI in Asia: A Big Challenge

Asia is the largest and most populous continent and has huge differences in socioeconomic status, development, and health care between the different countries and regions within each country. This manifests in the varied causes of acute kidney injury (AKI), particularly higher rates of community-acquired AKI and in the differential access to health care for the population. Because of resource limitations, prevention and treatment of AKI is a difficult challenge. This review highlights the differences in AKI in Asia compared with the developed world and discusses prevention and treatment of AKI within the context of resource limitations.

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.

Acute Peritoneal Dialysis With Percutaneous Catheter Insertion for COVID-19-Associated Acute Kidney Injury in Intensive Care: Experience From a UK Tertiary Center

Introduction

During the coronavirus disease 2019 (COVID-19) pandemic in 2020, high rates of acute kidney injury (AKI) in critically unwell patients are being reported, leading to an increased demand for renal replacement therapy (RRT). Providing RRT for this large number of patients is proving challenging, and so alternatives to continuous renal replacement therapies (CRRT) in the intensive care unit (ICU) are needed. Peritoneal dialysis (PD) can be initiated immediately after percutaneous insertion of the catheter, but there are concerns about impact on ventilation and RRT efficacy. We sought to describe our recent experience with percutaneous catheter insertion and peritoneal dialysis in patients in the ICU with COVID-19 infection.

Method

Patients were selected according to local protocol, and catheters were inserted percutaneously by experienced operators using a Seldinger technique. Sequential Organ Failure Assessment (SOFA) score and ventilation requirements were recorded at the time of insertion and 24 hours later. Procedural complications, proportion of RRT provided by PD, renal recovery, and RRT parameters (serum potassium and maximum base excess) during PD were assessed.

Results

Percutaneous PD catheters were successfully inserted in 37 of 44 patients (84.1%) after a median of 13.5 days (interquartile range [IQR] = 10.0, 20.3 days) in the ICU. No adverse events were reported; SOFA scores and ventilation requirements were comparable before and after insertion; and adequate RRT parameters were achieved. The median proportion of RRT provided by PD following catheter insertion was 94.6% (IQR = 75.0, 100%).

Conclusion

Peritoneal dialysis provides a safe and effective alternative to CRRT in selected patients with AKI and COVID-19 infection requiring ventilation on intensive care.

Peritoneal dialysis in critically ill children in resource-limited setting: A prospective cohort study

BACKGROUND

Peritoneal dialysis (PD) is easily available and simple lifesaving procedure in children with renal impairment. There is paucity of reports on efficacy of PD in critically ill children in presence of shock and those requiring mechanical ventilation.

METHODS

In this prospective observational study, efficacy and outcome of PD were evaluated in 50 critically ill children aged 1 month to 14 years admitted in pediatric intensive care unit of a tertiary care teaching hospital in India.

RESULTS

Indication of PD was acute kidney injury (AKI) in 66% of patients followed by chronic kidney disease with acute deterioration due to infectious complications in 34%. Bacterial sepsis was the most common cause of AKI (22%), others being malaria (14%) and severe dengue (12%). At initiation of PD, 26% of patients were in shock and 46% were mechanically ventilated. PD was effective and improvement in pH, bicarbonate, and lactate started within hours, with consistent improvement in estimated glomerular filtration rate by 24 h, which continued till the end of procedure, including the subgroup of patients with shock and mechanical ventilation. Total complications were seen in 14% and of which peritonitis was present in 4.0% of patients. Mortality was seen in 14% (7/50) of patients. Shock at initiation of PD (odds ratio (OR), 5.03; 95% confidence interval (CI), 0.95-26.69; p < 0.04) and requirement of mechanical ventilation (OR, 9.17; 95% CI, 1.01-83.10; p < 0.02) were associated with mortality.

CONCLUSIONS

Acute PD in critically ill children with renal impairment is a lifesaving procedure. Treatment of shock with resuscitative measures and respiratory failure with mechanical ventilation, along with PD, resulted in favorable renal outcome.

ISPD guidelines for peritoneal dialysis in acute kidney injury: 2020 update (adults)

SUMMARY STATEMENTS

(1) Peritoneal dialysis (PD) should be considered a suitable modality for treatment of acute kidney injury (AKI) in all settings (1B).

GUIDELINE 2: ACCESS AND FLUID DELIVERY FOR ACUTE PD IN ADULTS

(2.1) Flexible peritoneal catheters should be used where resources and expertise exist (1B) (optimal).(2.2) Rigid catheters and improvised catheters using nasogastric tubes and other cavity drainage catheters may be used in resource-poor environments where they may still be life-saving (1C) (minimum standard).(2.3) We recommend catheters should be tunnelled to reduce peritonitis and peri-catheter leak (practice point).(2.4) We recommend that the method of catheter implantation should be based on patient factors and locally available skills (1C).(2.5) PD catheter implantation by appropriately trained nephrologists in patients without contraindications is safe and functional results equate to those inserted surgically (1B).(2.6) Nephrologists should receive training and be permitted to insert PD catheters to ensure timely dialysis in the emergency setting (practice point). (2.7) We recommend, when available, percutaneous catheter insertion by a nephrologist should include assessment with ultrasonography (2C).(2.8) Insertion of PD catheter should take place under complete aseptic conditions using sterile technique (practice point).(2.9) We recommend the use of prophylactic antibiotics prior to PD catheter implantation (1B).(2.10) A closed delivery system with a Y connection should be used (1A) (optimal). In resource poor areas, spiking of bags and makeshift connections may be necessary and can be considered (minimum standard).(2.11) The use of automated or manual PD exchanges are acceptable and this will be dependent on local availability and practices (practice point).

GUIDELINE 3: PERITONEAL DIALYSIS SOLUTIONS FOR ACUTE PD

(3.1) In patients who are critically ill, especially those with significant liver dysfunction and marked elevation of lactate levels, bicarbonate containing solutions should be used (1B) (optimal). Where these solutions are not available, the use of lactate containing solutions is an alternative (practice point) (minimum standard).(3.2) Commercially prepared solutions should be used (optimal). However, where resources do not permit this, then locally prepared fluids may be life-saving and with careful observation of sterile preparation procedure, peritonitis rates are not increased (1C) (minimum standard).(3.3) Once potassium levels in the serum fall below 4 mmol/L, potassium should be added to dialysate (using strict sterile technique to prevent infection) or alternatively oral or intravenous potassium should be given to maintain potassium levels at 4 mmol/L or above (1C).(3.4) Potassium levels should be measured daily (optimal). Where these facilities do not exist, we recommend that after 24 h of successful dialysis, one consider adding potassium chloride to achieve a concentration of 4 mmol/L in the dialysate (minimum standard) (practice point).

GUIDELINE 4: PRESCRIBING AND ACHIEVING ADEQUATE CLEARANCE IN ACUTE PD

(4.1) Targeting a weekly K _t/V _urea of 3.5 provides outcomes comparable to that of daily HD in critically ill patients; targeting higher doses does not improve outcomes (1B). This dose may not be necessary for most patients with AKI and targeting a weekly K _t/V of 2.2 has been shown to be equivalent to higher doses (1B). Tidal automated PD (APD) using 25 L with 70% tidal volume per 24 h shows equivalent survival to continuous venovenous haemodiafiltration with an effluent dose of 23 mL/kg/h (1C).(4.2) Cycle times should be dictated by the clinical circumstances. Short cycle times (1-2 h) are likely to more rapidly correct uraemia, hyperkalaemia, fluid overload and/or metabolic acidosis; however, they may be increased to 4-6 hourly once the above are controlled to reduce costs and facilitate clearance of larger sized solutes (2C).(4.3) The concentration of dextrose should be increased and cycle time reduced to 2 hourly when fluid overload is evident. Once the patient is euvolemic, the dextrose concentration and cycle time should be adjusted to ensure a neutral fluid balance (1C).(4.4) Where resources permit, creatinine, urea, potassium and bicarbonate levels should be measured daily; 24 h K _t/V _urea and creatinine clearance measurement is recommended to assess adequacy when clinically indicated (practice point).(4.5) Interruption of dialysis should be considered once the patient is passing >1 L of urine/24 h and there is a spontaneous reduction in creatinine (practice point).

The use of peritoneal dialysis (PD) to treat patients with acute kidney injury (AKI) has become more popular among clinicians following evidence of similar outcomes when compared with other extracorporeal therapies. Although it has been extensively used in low-resource environments for many years, there is now a renewed interest in the use of PD to manage patients with AKI (including patients in intensive care units) in higher income countries. Here we present the update of the International Society for Peritoneal Dialysis guidelines for PD in AKI. These guidelines extensively review the available literature and present updated recommendations regarding peritoneal access, dialysis solutions and prescription of dialysis with revised targets of solute clearance.

Peritoneal dialysis with a lower dosage versus conventional intermittent hemodialysis in acute kidney injury: A propensity-matched study

BACKGROUND

Literature regarding the outcomes of lower dosage peritoneal dialysis (PD) in treating acute kidney injury (AKI) among resource-limited setting is sparse. This study aims to compare the risk of mortality in patients with AKI receiving lower PD dosage and conventional intermittent hemodialysis (IHD) in Thailand.

METHODS

In a tertiary center in Thailand, a matched case-control study using propensity scores in patients with AKI was conducted to compare the outcomes between lower PD dosage (18 L per day for first two sessions, weekly Kt/V 2.2) and IHD (three times a week) from February 2015 to January 2016. The primary outcome was a 30-day in-hospital mortality rate. Secondary outcomes included dialysis dependence at 90 days.

RESULTS

Eighty-four patients were included (28 PD and 56 IHD). Patient characteristics were comparable between two treatment groups. Overall, the mean age was 58 years. Most of the patients were critically ill (87% need mechanical ventilator; mean acute physiological and chronic health evaluation (APACHE II) score: 25). The 30-day in-hospital mortality rate was similar between the PD and IHD patients (57% vs. 46%, p = 0.36). The dialysis dependence rate was also comparable at 90 days. The risk of death among AKI patients was higher in those with respiratory failure, higher APACHE II score, and starting dialysis with blood urea nitrogen greater than 70 mg dL^-1.

CONCLUSION

Clinical outcomes, including risk of mortality and 90-day dialysis dependence among patients with AKI, appear to be comparable between lower dosage PD and IHD.

Peritoneal dialysis for acute kidney injury: Equations for dosing in pandemics, disasters, and beyond

BACKGROUND

Peritoneal dialysis (PD) is a viable option for renal replacement therapy in acute kidney injury (AKI), especially in challenging times during disasters and pandemics when resources are limited. While PD techniques are well described, there is uncertainty about how to determine the amount of PD to be prescribed toward a target dose. The aim of this study is to derive practical equations to assist with the prescription of PD for AKI.

METHODS

Using established physiological principles behind PD clearance and membrane transport, a primary determinant of dose delivery, equations were mathematically derived to estimate dialysate volume required to achieve a target dose of PD.

RESULTS

The main derivative equation is V_D = (1.2 × std-Kt/V × TBW)/(t_dwell + 4), where V_D is the total dialysate volume per day, std-Kt/V is the desired weekly dose, TBW is the total body water, and t_dwell is the dwell time. V_D can be expressed in terms of dwell volume, v_dwell, by V_D = (0.3 × std-Kt/V × TBW) - (6 × v_dwell). Two further equations were derived which directly describe the mathematical relationship between t_dwell and v_dwell. A calculator is included as an Online Supplementary Material.

CONCLUSIONS

The equations are intended as a practical tool to estimate solute clearances and guide prescription of continuous PD. The estimated dialysate volume required for any dose target can be calculated from cycle duration or dwell volume. However, the exact target dose of PD is uncertain and should be adjusted according to the clinical circumstances and response to treatment. The equations presented in this article facilitate the adjustment of PD prescription toward the targeted solute clearance.

The COVID-19 nephrology compendium: AKI, CKD, ESKD and transplantation

The pandemic of coronavirus disease 2019 (CoVID-19) has been an unprecedented period. The disease afflicts multiple organ systems, with acute kidney injury (AKI) a major complication in seriously ill patients. The incidence of AKI in patients with CoVID-19 is variable across numerous international studies, but the high incidence of AKI and its associated worse outcomes in the critical care setting are a consistent finding. A multitude of patterns and mechanisms of AKI have been elucidated, and novel strategies to address shortage of renal replacement therapy equipment have been implemented. The disease also has had consequences on longitudinal management of patients with chronic kidney disease and end stage kidney disease. Kidney transplant recipients may be especially susceptible to CoVID-19 as a result of immunosuppression, with preliminary studies demonstrating high mortality rates. Increased surveillance of disease with low threshold for testing and adjustment of immunosuppression regimen during acute periods of illness have been recommended.

Comorbidities and the COVID-19 pandemic dynamics in Africa

The debate around the COVID‐19 response in Africa has mostly focused on effects and implications of public health measures, in light of the socio‐economic peculiarities of the continent. However, there has been limited exploration of the impact of differences in epidemiology of key comorbidities, and related healthcare factors, on the course and parameters of the pandemic. We summarise what is known about (a) the pathophysiological processes underlying the interaction of coinfections and comorbidities in shaping prognosis of COVID‐19 patients, (b) the epidemiology of key coinfections and comorbidities, and the state of related healthcare infrastructure that might shape the course of the pandemic, and (c) implications of (a) and (b) for pandemic management and post‐pandemic priorities. There is a critical need to generate empirical data on clinical profiles and the predictors of morbidity and mortality from COVID‐19. Improved protocols for acute febrile illness and access to diagnostic facilities, not just for SARS‐CoV‐2 but also other viral infections, are of urgent importance. The role of malaria, HIV/TB and chronic malnutrition on pandemic dynamics should be further investigated. Although chronic non‐communicable diseases account for a relatively lighter burden, they have a significant effect on COVID‐19 prognosis, and the fragility of care delivery systems implies that adjustments to clinical procedures and re‐organisation of care delivery that have been useful in other regions are unlikely to be feasible. Africa is a large region with local variations in factors that can shape pandemic dynamics. A one‐size‐fits‐all response is not optimal, but there are broad lessons relating to differences in epidemiology and healthcare delivery factors, that should be considered as part of a regional COVID‐19 response framework.

Peritoneal dialysis patient selection from a comorbidity perspective

Despite many medical and socioeconomic advantages, peritoneal dialysis (PD) is an underutilized dialysis modality that in most countries is used by only 5%-20% of dialysis patients, while the vast majority are treated with in-center hemodialysis. Several factors may explain this paradox, such as lack of experience and infrastructure for training and monitoring of PD patients, organizational issues, overcapacity of hemodialysis facilities, and lack of economic incentives for dialysis centers to use PD instead of HD. In addition, medical conditions that are perceived (rightly or wrongly) as contraindications to PD represent barriers for the use of PD because of their purported potential negative impact on clinical outcomes in patients starting PD. While there are few absolute contraindications to PD, high age, comorbidities such as diabetes mellitus, obesity, polycystic kidney disease, heart failure, and previous history of abdominal surgery and renal allograft failure, may be seen (rightly or wrongly) as relative contraindications and thus barriers to initiation of PD. In this brief review, we discuss how the presence of these conditions may influence the strategy of selecting patients for PD, focusing on measures that can be taken to overcome potential problems.

Successfully treating three patients with acute kidney injury secondary to COVID-19 by peritoneal dialysis: Case report and literature review

Coronavirus Disease 2019 (COVID-19) is a pandemic disease that increased the burden on health-care system. In the Kingdom of Saudi Arabia, 74,795 cases have been reported until 26 May 2020 and the number of cases is rapidly increasing. The mortality rate of COVID-19 worldwide is 6.37%. Here we report three cases of acute kidney injury (AKI) secondary to pneumonia of severe COVID-19; they were treated with automated peritoneal dialysis (PD) with full recovery. To the best of our knowledge, few reports in the literature have discussed the use of PD in AKI secondary to COVID-19.

Peritoneal Dialysis Is an Option for Acute Kidney Injury Management in Patients with COVID-19

In December 2019, cases of acute respiratory illness of unknown origin were reported in Wuhan, China. The disease is caused by "severe acute respiratory syndrome coronavirus 2". After identifying severe lung damage, injury to other organs, such as the kidney, has been identified. Peritoneal dialysis is a renal replacement therapy (RRT) and is at least as effective as other extracorporeal therapy options, with significant cost-effective advantages. However, this strategy is rarely used for the management of acute kidney injury in severe lung disease. In this review, we explore PD as an RRT strategy that may be a key instrument in countries and hospitals with limited access to all RRTs.

Challenges of access to kidney care for children in low-resource settings

Kidney disease is a global public health concern across the age spectrum, including in children. However, our understanding of the true burden of kidney disease in low-resource areas is often hampered by a lack of disease awareness and access to diagnosis. Chronic kidney disease (CKD) in low-resource settings poses multiple challenges, including late diagnosis, the need for ongoing access to care and the frequent unavailability of costly therapies such as dialysis and transplantation. Moreover, children in such settings are at particular risk of acute kidney injury (AKI) owing to preventable and/or reversible causes - many children likely die from potentially reversible kidney disease because they lack access to appropriate care. Acute peritoneal dialysis (PD) is an important low-cost treatment option. Initiatives, such as the Saving Young Lives programme, to train local medical staff from low-resource areas to provide care for AKI, including acute PD, have already saved hundreds of children. Future priorities include capacity building for both educational purposes and to provide further resources for AKI management. As local knowledge and confidence increase, CKD management strategies should also develop. Increased awareness and advocacy at both the local government and international levels will be required to continue to improve the diagnosis and treatment of AKI and CKD in children worldwide.

Acute Renal Replacement Therapy in Intensive Care Units versus Outside Intensive Care Units: Are They Different?

Introduction

Acute renal replacement therapy (RRT) is indicated when metabolic and fluid demands exceed total kidney capacity, and demand for kidney function is determined by non-renal comorbidities, severity of acute disease and solute and fluid burden; therefore, the criteria for commencing RRT and dialysis in intensive care units (ICUs) may be different to those outside ICUs.

Objective

We investigated whether criteria for commencing acute RRT and dialysis outside ICU were different to those in ICU and whether these differences affected patient mortality in either setting.

Methods

We performed a retrospective observational study evaluating acute kidney injury (AKI), Kidney Disease Improving Global Outcome 3 (KDIGO3) in adult patients undergoing RRT “in and outside” ICU from 2012 to 2018, in a Brazilian teaching hospital.

Results

We evaluated 913 adults with AKI KDIGO3 undergoing RRT; 629 (68.9%) outside ICU and 284 (31.1%) in ICU. Infections were the main cause of hospitalisation (34.4%). Septic and ischaemic AKI were the main aetiologies of AKI (50.8% and 32.9%, respectively), metabolic and fluid demand to capacity imbalance were the main indications for dialysis (69.7%), and intermittent haemodialysis (IHD) was the primary dialysis method (59.2%). The general mortality rate after 30 days was 59%. There were no differences in gender, age and main diagnosis between groups. Both groups were different in acute tubular necrosis index specific scores (ATN-ISS), AKI aetiology, elderly population, indications for dialysis, dialysis methods and mortality rates. In ICU, patients older than 65 years old, with septic AKI were more prevalent (49.1 versus 41.4%, and 55.1 versus 37.5%, respectively), while ischaemic and nephrotoxic AKI were less frequent (24.3 versus 37 and 10.2 versus 16.3%, respectively), and ATN-ISS was higher (0.74 ± 0.31 versus 0.58 ± 0.16). Similarly, metabolic and fluid demand to capacity imbalance as an indication for acute RRT, prolonged intermittent haemodialysis (PIRRT) and continuous renal replacement therapy (CRRT) were more frequent, while peritoneal dialysis (PD) was less frequent (74.6 versus 69.7%, 31.6 versus 22.4%, and 5.3 versus 17.8%, respectively), and mortality was higher (69 versus 54.7%, respectively). Logistic regression revealed that age, septic AKI and being “in” ICU were factors associated with death.

Conclusion

The criteria for commencing RRT and dialysis in ICU were different to those outside ICU; however, they did not impact on patient outcomes.

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.