Urgent-Start Peritoneal Dialysis: A Quality Improvement Report

doi:10.1053/j.ajkd.2011.08.034

American Journal of Kidney Diseases

Volume 59, Issue 3, March 2012, Pages 400-408

https://doi.org/10.1053/j.ajkd.2011.08.034 Get rights and content

Background

Compared with hemodialysis, peritoneal dialysis (PD) is a cost-effective and patient-centered option with an early survival advantage, yet only 7% of patients with end-stage renal disease in the United States receive PD. PD underutilization is due in part to nephrologists' unfamiliarity with directly starting PD in patients who present with kidney failure requiring urgent initiation of dialysis.

Design

Quality improvement report.

Setting & Participants

Single-center study whereby 18 patients who presented urgently with chronic kidney disease stage 5 without a plan for dialysis modality were offered PD as the initial modality of dialysis. Concurrently, 9 patients started on PD therapy nonurgently were included as the comparative group.

Quality Improvement Plan

An urgent-start PD program was developed to support and standardize the process by which patients without a plan for dialysis modality were started on PD. This included rapid PD access placement, PD nursing education, and administrative support. Standardized protocols were created for modality selection, initial prescription, and prevention and management of complications.

Measures

Short-term (90-day) clinical outcomes (Kt/V, hemoglobin, iron saturation, parathyroid hormone, phosphorus, calcium, and albumin) and complications (peritonitis, exit-site infections, leaks, and catheter malfunction) were compared between the urgent-start and non–urgent-start PD groups.

Results

Short-term clinical outcomes were similar between the 2 groups for all parameters except uncorrected serum calcium level, which was lower in the urgent-start group (P = 0.02). Peritonitis, exit-site infection, catheter-related complications, and other complications were similar between the 2 groups, although the number of minor leaks was higher in the urgent-start group.

Limitations

This is a single-center nonrandomized study with a small sample size.

Conclusions

Our structured program shows safety and feasibility in starting PD in patients with kidney failure who present without a plan for dialysis modality. The steps laid out in this report can provide the framework for creating local urgent-start PD programs.

Section snippets

Setting

Selected patients with CKD stage 5 admitted to Los Angeles County + University of Southern California (LAC+USC) Medical Center between March 2010 and March 2011 were evaluated and offered PD therapy if deemed candidates. If urgent PD was required, patients were enrolled in a structured urgent-start program and followed up throughout the study period. A comparison non–urgent-start group also was followed.

Patient Safeguards

Safeguards for patient safety, choice, and privacy were achieved by: (1) using a

Baseline Demographics

At baseline, urgent-start patients had a lower estimated glomerular filtration rate (7.4 ± 4.3 vs 11.3 ± 5.4 mL/min/1.73 m² by the 6-variable MDRD [Modification of Diet in Renal Disease] Study equation) and were less likely to require backup HD therapy (11.1% vs 44%); however, these differences were not statistically significant (P = 0.06 and P = 0.1, respectively). Urgent-start patients were more likely to be men, lack prior renal care, and have uremic symptoms at presentation, but these

Discussion

In certain countries such as Hong Kong, where PD is the dominant dialysis modality, with 80% of the ESRD population on PD therapy, outcomes are similar or better than for HD therapy.19, 20 Many studies have shown an early survival advantage for PD over HD in the first 2 years of therapy, with equivalent outcomes to 5 years.21, 22, 23, 24, 25 Moreover, although overall survival on dialysis therapy has been improving over time, Mehrotra et al²⁶ have shown that patients on PD therapy have had a

Acknowledgements

Support: None.

Financial Disclosure: The author declares that he has no relevant financial interests.

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Cited by (122)

Urgent-start peritoneal dialysis
2023, Nefrologia
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.
La diálisis peritoneal es una forma importante de terapia de reemplazo renal. A la mayoría de los pacientes que presentan una necesidad urgente e imprevista de diálisis se les prescribe hemodiálisis, lo que lleva a la infrautilización de la diálisis peritoneal. La diálisis peritoneal de inicio urgente se refiere al tratamiento que se inicia dentro de las 2 semanas posteriores a la colocación del catéter. La diálisis peritoneal de inicio urgente representa una alternativa eficaz y rentable al enfoque convencional de iniciar la diálisis. Hay escasez de evidencia para guiar el manejo, sin embargo, la experiencia con la técnica está aumentando. Este artículo describe la justificación y la aplicación práctica de la diálisis peritoneal de inicio urgente.
Urgent Start Peritoneal Dialysis: A Population-Based Cohort Study
2022, Kidney Medicine
It is a common practice to start patients in urgent need of dialysis on hemodialysis via a central venous catheter. Because central venous catheter use is associated with increased risk of infections, hospitalizations, and mortality, urgent start peritoneal dialysis (PD) increasingly represents a viable alternative. This study aimed to examine clinical outcomes, complications, mortality, and modality retention in patients who initiated urgent start PD.
Retrospective cohort study.
Eighty-four adult members of a large integrated health care system who initiated urgent start PD between January 1, 2011, and December 31, 2014.
Urgent start PD.
Retention rates at 30, 90, and 365 days; time to the development of noninfectious and infectious complications, modality failure, and all-cause mortality.
Cumulative incidence of all-cause mortality was estimated using the Kaplan-Meier method. Retention rates for PD were computed using binomial proportions.
Occurrence of major complications was less than 5%. Catheter malfunction occurred in 6% of cases; of those, catheter patency could be established in 80%. Infectious complications occurred in 20% of patients who initiated PD and included peritonitis and exit site infections. At 365 days after initiation, the cumulative incidence of all-cause mortality was 9.7% (95% CI, 4.7%-19.4%). PD retention rates were 98.8%, 91.3%, and 80.0% at 30 days, 90 days, and 1 year, respectively.
Retrospective cohort design, a well-matched comparable group of urgent start hemodialysis patients could not be identified, small number of patients in a single integrated health care system, uncertain or limited generalizability of findings to other health care systems.
At 1 year after initiation, patients who initiated urgent start PD had high survival and modality retention rates. In unplanned initiation of dialysis, urgent start PD is a viable and sustainable option and should be considered in selected patients to optimize care.
Urgent start peritoneal dialysis: Is there room for more?
2021, Nefrologia
Despite the increasing prevalence of end-stage renal disease, peritoneal dialysis (PD) is still offered to a minor subset of patients. One way to increment the utilization rates of this technique is the early start of PD after catheter placement, but there are several concerns related to this approach.
Retrospective analysis in a single-center; 52 patients, 34.6% of the patients started in the first 14 days after catheter placement (Urgent start Group – Group 1) and percentage started PD in a conventional mode (Non-urgent start Group – Group 2). Baseline data, short-term (90-day) clinical outcomes, mechanical complications and infectious episodes were compared among Groups.
At baseline, Group 1 had an higher Charlson Comobidity Index (CCI). Exchange volumes were significantly lower in Group 1, as expected. Short-term outcomes were equal except for iPTH and albumin, both lower in urgent-start Group (p < 0.05). Episodes of leak, catheter dysfunction and rate of infections were similar among Groups (p > 0.05). In Urgent-start Group we didn’t observed a higher risk for the first peritonitis episode (HR 0.68; 95% CI 0.24–1.99; p > 0.05), higher dropout rate or risk to quit the technique (long rank test, p > 0.05; HR 0.57; 95% CI 0.29–1.13; p > 0.05).
According to our observations, urgent-start PD seems to be a valid and safe alternative to urgent hemodialysis with central venous catheter and should be offered to patients without major contraindications.
A pesar de la creciente prevalencia de la enfermedad renal terminal, la diálisis peritoneal (DP) sigue ofreciéndose a un reducido subconjunto de pacientes. Una forma de incrementar las tasas de utilización de esta técnica es el inicio temprano de la DP después de la colocación del catéter, pero existen varias dudas respecto a esta estrategia.
Análisis retrospectivo en un único centro; 52 pacientes; en el 34,6% de los pacientes se inició en los 14 primeros días tras la colocación del catéter (grupo de inicio urgente [grupo 1]) y el resto comenzó la DP de forma convencional (grupo de inicio no urgente [grupo 2]). Se compararon los datos iniciales, los resultados clínicos a corto plazo (90 días), las complicaciones mecánicas y los episodios infecciosos entre los grupos.
Al inicio del estudio, el grupo 1 tenía un índice de comorbilidad de Charlson (ICC) más alto. Los volúmenes de intercambio fueron significativamente menores en el grupo 1, como se esperaba. Los resultados a corto plazo fueron iguales, excepto para la hormona paratiroidea intacta (HPTi) y la albúmina, ambas inferiores en el grupo de inicio urgente (p < 0,05). Los episodios de fuga y de disfunción del catéter, así como la tasa de infecciones, fueron similares entre los grupos (p > 0,05). En el grupo de inicio urgente no se observó un mayor riesgo de sufrir el primer episodio de peritonitis (CRI: 0,68; IC del 95%: 0,24-1,99; p > 0,05), ni una mayor tasa de abandono o riesgo de abandonar la técnica (prueba del orden logarítmico, p > 0,05; CRI:0,57; IC del 95%: 0,29-1,13; p > 0,05).
Según nuestras observaciones, la DP de inicio urgente parece ser una alternativa válida y segura a la hemodiálisis urgente con catéter venoso central, y debería ofrecerse a los pacientes sin contraindicaciones importantes.
Comparison of Unplanned/Urgent-Start Versus Conventional-Start Peritoneal Dialysis: A Systematic Review and Meta-Analysis
2024, Seminars in Dialysis
Comparison of immediate-start peritoneal dialysis without break-in period and conventional-start peritoneal dialysis: a two-center retrospective audit
2024, International Urology and Nephrology
Prognosis of urgent initiation of peritoneal dialysis: a systematic review and meta-analysis
2024, Renal Failure

View all citing articles on Scopus

: Originally published online October 24, 2011.

View full text

Original InvestigationDialysisUrgent-Start Peritoneal Dialysis: A Quality Improvement Report

Background

Design

Setting & Participants

Quality Improvement Plan

Measures

Results

Limitations

Conclusions

Section snippets

Setting

Patient Safeguards

Baseline Demographics

Discussion

Acknowledgements

Am J Kidney Dis

Kidney Int

Am J Kidney Dis

Am J Kidney Dis

Kidney Int

Kidney Int

Am J Kidney Dis

Am J Kidney Dis

A bacteriologically safe peritoneal access device

Trans Am Soc Artif Intern Organs

A simplified automatic peritoneal dialysis system

Trans Am Soc Artif Organs

Making the first steps towards automated chronic peritoneal dialysis

Perit Dial Int

A backward look at the first 20 years of CAPD

Ann Intern Med

A simple and safe technique for continuous ambulatory peritoneal dialysis (CAPD)

Trans Am Soc Artif Intern Organs

USRDS Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States

Am J Kidney Dis

Patient awareness and initiation of peritoneal dialysis

Arch Intern Med

Effect of an in-hospital chronic kidney disease education program among patients with unplanned urgent-start dialysis

Clin J Am Soc Nephrol

Increased hemodialysis catheter use in Canada and associated mortality risk: data from the Canadian Organ Replacement Registry 2001-2004

Clin J Am Soc Nephrol

Original Investigation
Dialysis
Urgent-Start Peritoneal Dialysis: A Quality Improvement Report