Vascular Access in High Risk PD Patients?

Kaplan-Meier estimates of probability for death/withdrawal, first hospitalization, first peritonitis episode, and switch to HD. Fig 2 Pulliam et al AJKD, © National Kidney Foundation.

With the recent changes in the healthcare system brought about by the current economic climate paving the way for “prospective payment bundling,” there has been growing interest in home therapies (e.g., peritoneal dialysis, home hemodialysis) along with its cost advantages.

In a recent retrospective study published in AJKD, Pulliam et al investigated the early outcomes in patients initiating renal replacement therapy via peritoneal dialysis (PD). Although PD has been known to be associated with lower mortality rates during its 1st year of treatment, it is in the first 3-6 months that the risk of complications, such as peritonitis, and in some instances the need for hospitalization tend to peak. Interestingly, a significant number of PD patients may require transition either temporarily or permanently to hemodialysis. This is consistent with the findings of other previously published studies like CHOICE (Jaar et al, 2009) and NECOSAD (Kolesnyk et al, 2010). One of the issues arising from this transition is the potential requirement for a hemodialysis access, such as a central venous catheter (CVC).

I was intrigued at the prospect of “concurrent AV fistula placement in PD patients” as a means to avoid having to insert a CVC (Lacson et al, 2007) (Chiarelli et al, 2008) if PD fails. This practice was highlighted in a recently published study (Jiang et al, 2013) from Hong Kong. From a practical standpoint, I find it challenging to rationalize this need to my patients as there has also been previous literature (Chui et al, 2000) that suggested that ‘such fistulas may not be used or may fail before being used, hence a potential waste of resource.’

Certainly, this transition needs to be well-coordinated via a multi-disciplinary approach involving the nephrologists, nurses, social workers, and others. The authors recommend selecting PD patients for vascular access placement on an individual basis, perhaps excluding those who anticipate kidney transplantation within 6-12 months or whose life expectancy is significantly shortened and those who are thriving on PD.

Despite the retrospective nature of this study (main limitation) that only allows for associations (rather than causation), the authors point out its main strength is that it actually involved a nationally distributed cohort of new dialysis patients whose clinical course was followed very closely throughout their 1st year.  The value of this study lies in re-emphasizing the need for education and supportive care for patients initiating PD, as well as early identification of ‘high risk’ patients who may fail PD  and require transition to HD.

Dr. Edgar V. Lerma
eAJKD Contributor

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