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.

Percutaneous peritoneal dialysis catheter implantation with no break-in period: A viable option for patients requiring unplanned urgent-start peritoneal dialysis

Background

Urgent-start peritoneal dialysis (PD) is applied to patients who need PD within two weeks but are able to wait for more than 48 hours before starting PD. To evaluate the usefulness of percutaneous PD catheter insertion in urgent-start PD, we reviewed the clinical outcomes of percutaneous catheter insertion with immediate start PD and surgical insertion with longer break-in time in Pusan National University Hospital.

Methods

This study included 177 patients who underwent urgent-start PD. Based on the PD catheter insertion techniques, the patients with urgent-start PD were divided into percutaneous (n = 103) and surgical (n = 74) groups. For the percutaneous group, a modified Seldinger percutaneous catheter insertion with immediate initiation of continuous ambulatory PD was performed by nephrologists.

Results

The percutaneous group showed higher serum urea nitrogen, creatinine, and lower serum albumin compared with the surgical group (P < 0.05). Ninety-day infectious and mechanical complications showed no significant differences between the two groups. Ninety-day peritonitis in the percutaneous group was 9.7% compared to 5.4% in the surgical group (P = not significant [NS]). Major leakage was 3.9% in the percutaneous group compared to 1.4% in the surgical group (P = NS). Overall infectious and mechanical complication-free survival was not significantly different between the two groups. The percutaneous group and surgical group showed no statistical difference with respect to catheter survival over the entire observation period (P = NS).

Conclusion

This study suggests that urgent-start PD can be applied safely with percutaneous catheter insertion by nephrologists with no break-in period.

Comparison of outcomes of urgent-start and conventional-start peritoneal dialysis: a single-centre experience

BACKGROUND

There has been a growing interest in urgent-start peritoneal dialysis (PD) in patients with end-stage kidney disease to avoid central venous catheter use and its complications. This study aimed to compare clinical outcomes between urgent-start PD (defined as PD commencement within 2 weeks of PD catheter insertion) and conventional-start PD.

METHODS

This was a single-centre retrospective cohort study of all incident PD patients at Singapore General Hospital between January 2017 and February 2018. The primary outcome was dialysate leak. Secondary outcomes included catheter malfunction, catheter readjustment, exit-site infection, peritonitis, technique and patient survival.

RESULTS

A total of 187 incident PD patients were included. Of these, 66 (35%) initiated urgent-start PD. Dialysate leak was significantly higher in urgent-start PD compared with conventional-start PD groups (7.6% versus 0.8%; p = 0.02) whilst catheter malfunction (4.5% vs. 3.3%; p  = 0.70) and catheter readjustment (1.5% vs. 2.5%; p  = 1.00) were comparable between the two groups. Exit-site infection was comparable (IRR: 0.66 95% CI 0.25-1.74) whilst peritonitis was significantly higher in urgent-start PD compared with conventional-start PD (incidence risk ratio (IRR) 3.10, 95% confidence interval (CI) 1.29-7.44). Time to first episode of peritonitis, particularly Gram-positive peritonitis was significantly shorter with urgent-start PD. Technique survival (hazards ratio (HR) 1.95, 95% CI 0.89-4.31) and patient survival (HR 1.46, 95% CI 0.44-4.87) were comparable between the two groups.

CONCLUSION

Urgent-start PD was associated with higher risks of dialysate leak and peritonitis but comparable technique and patient survival compared to conventional-start PD.