The coronavirus (SARS-CoV-2) pandemic of 2019 is an unparalleled time in our history with an unprecedented strain on the US healthcare system, particularly in terms of resources available for patients requiring kidney replacement therapy (KRT). The efficacy of peritoneal dialysis (PD) to treat acute kidney injury (AKI) was brought to light after a randomized control trial demonstrated PD is not inferior to intermittent hemodialysis (iHD) for treating acutely ill patients with AKI stage 3 in terms of mortality. Additionally, its ability to be used with minimal infrastructure in place, including the lack of need for water or electricity, made it a novel therapy in many third-world countries.
In a recent Perspective published in AJKD, Sourial et al describe the implementation of an urgent PD program at Montefiore Medical Center in the Bronx, NY, from March 11-April 26, 2020 for critically ill patients requiring KRT. At the height of the pandemic, there were 855 patients with COVID-19 hospitalized on April 13, with 3,345 patients with confirmed COVID hospitalized in a 6-week period.
From March 11th to April 26th, 27 of 164 patients requiring KRT were placed on PD as the initial mode of dialysis whereas 3 were switched from continuous kidney replacement therapy (CKRT) or iHD to PD. Catheters (which traditionally had been placed laparoscopically in the OR prior to pandemic) were placed by interventional radiology or by transplant surgeons at bedside with immediate low-volume dwells. Automated cyclers were used to reduce the staff burden of manual exchanges and to minimize SARS-CoV-2 exposure. The typical prescription was a 2L fill volume with 6 exchanges per day and a dwell time of 3 hours. Assuming a 2L ultrafiltration rate per day, this would confer a weekly Kt/V of 2.52 (which is within the goal for PD in the setting of AKI).
As of May 14, 2020, 14 of the 30 patients (47%) who were started on PD died during the hospitalization, 22 were intubated prior to PD initiation, 8 were discharged, and 8 patients remained hospitalized. Of those 8 patients who remained hospitalized, 4 were switched to CKRT or iHD. Overall, it was demonstrated that PD for severe AKI can be a cost-effective modality of KRT in times of substantial need such as a pandemic when resources are significantly limited.
Implementing urgent PD presents certain challenges and barriers. First, clearance and ultrafiltration rates are less predictable in patients who are hypercatabolic from severe sepsis, and such patients likely benefit from transitioning to iHD or CKRT. Additionally, lack of training and knowledge with PD in hospital ICUs also requires education and patience. In this Perspective, Sourial et al discuss the initiative that experienced nephrologists and dialysis nurses took to lead hands-on training of capable and interested personnel. A major concern of PD for critically ill individuals is the increase in intra-abdominal pressure which may becomes a significant issue when patients are proned for treatment of acute respiratory distress syndrome. Table 1 provides potential solutions for overcoming the challenges of urgent PD:
Sourial et al point out the lack of data supporting the efficacy of PD versus other forms of dialysis in relation to morbidity and mortality in patients treated in ICU and medical ward settings. However, as noted in this Perspective, urgent PD may be a sustainable model of dialysis and a feasible alternative to hemodialysis (HD) during times of crises when resources are limited and healthcare systems are strained.
Title: Urgent Peritoneal Dialysis in Patients With COVID-19 and Acute Kidney Injury: A Single-Center Experience in a Time of Crisis in the United States
Authors: M.Y. Sourial, M.H. Sourial, R. Dalsan, J. Graham, M. Ross, W. Chen, and L. Golestaneh
In the face of the unprecedented public health crisis posed by the current pandemic, this special collection gathers COVID-19–related publications from the NKF family of journals. All articles in the collection are freely available.