Does Peritoneal Dialysis Have Its Place Even in Acute Cases?

Introduction

In the urgent initiation of dialysis, the most commonly used approach is hemodialysis (HD) via a central venous catheter. However, in recent years, studies have emerged pointing to the impact of the type of vascular access on the survival of hemodialysis patients. They suggest that the use of a central venous catheter is directly associated with higher mortality, particularly in the first year of treatment.

As a potentially safer alternative, peritoneal dialysis (PD) presents itself. While recent studies on urgently started PD are available, results in patients whose catheter is directly inserted by a nephrologist using the Seldinger method with immediate device initiation were not previously known. There are also no studies comparing HD and PD in this indication. This comparison, in terms of outcomes and risk factors of long-term complications, was the aim of a recently published Brazilian quasi-experimental study.

Study Aims

This study focused on infectious and mechanical complications associated with urgently started HD and PD. The secondary aim was to identify risk factors for complications and mortality with both methods.

Methodology and Course

Included were patients with the urgent initiation of HD or PD at a university hospital between July 2014 and December 2017. These were individuals in the terminal stage of chronic kidney disease requiring immediate kidney function replacement. They underwent HD via a central venous catheter or PD, during which the catheter was implanted by a nephrologist and used for 72 hours without prior training. Patients with PD were initially indicated for high-volume peritoneal dialysis due to the need for metabolic compensation. After being discharged from the hospital, they continued intermittent PD and attended the dialysis unit until they were thoroughly familiar with the entire procedure.

The main compared parameters were mechanical and infectious complications, renal function recovery, and overall survival.

Results

Ninety-three patients with PD and 91 with HD were evaluated. Both groups were comparable in terms of age (58 + 17 vs. 60 + 15 years; p = 0.49), the occurrence of diabetes (37.6 vs. 50.5%; p = 0.10), other comorbidities (74.1 vs. 71.4%; p = 0.67), and basic biochemical parameters at the start of urgent kidney function replacement – levels of creatinine, serum albumin, and hemoglobin.

Patients were followed for 6 months to 2 years. No significant difference was found in the incidence of mechanical complications (24.7 vs. 37.4%; p = 0.06) or bacteremia (15.0 vs. 24.0%; p = 0.11). However, a significant difference was observed in catheter site infection incidence (25.8 vs. 39.5%; p = 0.04) and maintenance of diuresis (700 [0–1500] vs. 0 [0–500]; p < 0.001), with more favorable results for PD patients. After 180 days, better phosphorus level control (62.4 vs. 41.8%; p = 0.008) was noted in the PD group, with less need for phosphate binders (28 vs. 55%; p < 0.001), erythropoietin (18.3 vs. 49.5%; p < 0.001), and antihypertensives (11.8 vs. 30.8%; p = 0.003). Time to death was similar in both groups. In multivariable analysis, PD was a predictor of renal function recovery (odds ratio [OR] 3.95; 1.01–15.4).

Conclusion

Peritoneal dialysis is a safe alternative to classical hemodialysis in patients needing urgent kidney function replacement. The incidence of complications and clinical outcomes are comparable to hemodialysis, and the chances of renal function recovery are higher with PD.

(pez)

Source: Dias D. B., Mendes M. L., Caramori J. T. et al. Urgent-start dialysis: comparison of complications and outcomes between peritoneal dialysis and haemodialysis. Perit Dial Int 2021 Mar; 41 (2): 244−252, doi: 10.1177/0896860820915021.