Peritoneal dialysis (PD) is a patient-centered and cost-effective option for ESRD patients, yet only 7% of prevalent US patients are on PD. This relative underutilization may be due in part to physician preference, lack of training during fellowship, and familiarity with commencing hemodialysis in patients who “crash-land” with advanced CKD stage 5 who need imminent renal replacement therapy. Therefore, urgent-start PD is gathering interest (it was a NephMadness 2014 Filtered Four competitor after all) and is more widely employed in countries outside of the US.
A recent AJKD article by Xu et al describes complications associated with an observational cohort of 922 Chinese patients commenced on PD within 1 week of catheter insertion. The mean age of the patients was 59 years, diabetic nephropathy was the cause of ESRD in a third, and 14% had previous abdominal surgery. The mean BMI was 23. Roughly half were female and almost half of the cohort started PD within 1 day of catheter placement. Mean dwells were 1.6 L, although the investigators started with 500-800 mL volumes. After a median follow-up of 31 months, 42.6% of patients had died, 8.7% were transplanted, and 11.6% transferred to hemodialysis. While the transfer rate seems reasonable, the death rate appears high. Apart from baseline demographics and laboratory results, the patients are not described in detail. Presumably because of their urgent-start status, they had minimal exposure to healthcare prior to “crash-landing,” which likely portends a worse prognosis than patients with planned PD starts.
The main results of the paper focus on mechanical complications. Interestingly, only 44 (4.8%) patients developed abdominal wall complications at a median of 5.2 months, with 9 complications in the first month. Complications included hernia (55%), hydrothorax (25%), hydrocele (14%), and subcutaneous leak (5%). In a multi-factorial model, male sex (HR 5.41) and previous abdominal surgery (HR 2.34) significantly associated with a higher risk. Data on catheter complications was available on the 189 patients enrolled after 2010, which occurred in 18 (9.5%) patients. These included 13 catheter obstructions (72.2%), 4 catheter malpositions (22.2%), and 1 omental wrap (5.5%). All of these complications occurred within the first month and most were managed with conservative therapy (although 3 of 4 catheter shifts needed laparoscopic repositioning).
The authors state their findings support the application of urgent-start PD as a safe and practical strategy while reminding physicians to be cautious with urgent starters. Their excellent early results vindicate their initial cautious approach, and the overall technique (in survivors at least!) appears good. Whether this would translate into American or European patients is debatable. Good outcomes have been reported in US patients previously, albeit in tiny numbers. Despite the low complication rate in this cohort, the study has no comparator group precluding comparisons to usual PD starts. Overall, this large series of urgent-start PD suggests it may be an appropriate approach for more ESRD patients, with a reasonable expected complication rate.
Title: Urgent-Start Peritoneal Dialysis Complications: Prevalence and Risk Factors
Authors: D. Xu, T. Liu, and J. Dong