Urgent-start peritoneal dialysis

INTRODUCTION — 

Urgent-start peritoneal dialysis (PD) is the term used to describe the practice of initiating PD soon after PD catheter placement among patients with end-stage kidney disease (ESKD). Urgent-start PD is useful because it circumvents the need for temporary hemodialysis. Since more than 50 percent of all new dialysis patients do not have a dialysis plan when diagnosed with ESKD, urgent-start PD may increase the number of patients who use PD for kidney replacement therapy since it provides PD as a modality option from the start.

The practice of urgent-start dialysis requires the development of protocols, policies, and procedures to help implement the approach in a timely, efficient, and safe manner.

This review discusses an approach to urgent-start PD. The use of PD in patients with acute kidney injury (AKI), different types of PD, and PD dosing are discussed elsewhere:

●(See "Use of peritoneal dialysis (PD) for the treatment of acute kidney injury (AKI) in adults".)

●(See "Evaluating patients for chronic peritoneal dialysis and selection of modality".)

●(See "Prescribing peritoneal dialysis".)

DEFINITION — 

We define urgent-start peritoneal dialysis (PD) as initiation of PD in patients with newly diagnosed end-stage kidney disease (ESKD) who are not yet on dialysis and who require dialysis initiation less than two weeks after PD catheter placement, but who do not require emergency dialysis. Indications for emergency dialysis include hyperkalemia, volume overload, or marked uremia (see 'Contraindications' below). Urgent-start PD is generally reserved for patients who have no plan for dialysis modality but are considered good candidates for PD.

Our definition of urgent-start PD is widely but not universally used. As an example, some investigators reserve the term "urgent-start PD" to PD started within 72 hours of PD catheter insertion and use the term "early-start PD" for PD started between 72 hours and 14 days after catheter insertion [1].

RATIONALE FOR URGENT-START PD — 

Urgent-start peritoneal dialysis (PD) may increase usage of PD as a modality of kidney replacement therapy for patients with end-stage kidney disease (ESKD) and may prevent the placement of hemodialysis catheters and their associated complications.

●Advantages of PD – PD provides patients with several lifestyle advantages that are not provided by hemodialysis and is typically less costly to the health care system [2,3]. PD also provides short- and long-term clinical outcomes that match or exceed in-center hemodialysis. (See "Dialysis modality and patient outcome".)

●Hemodialysis as the default modality – Despite the advantages of PD, in the United States at least, PD is infrequently offered to patients who require urgent initiation of dialysis. Such patients are usually started on hemodialysis using a hemodialysis catheter. This occurs because most centers have established inpatient and outpatient protocols for performing acute or semiacute hemodialysis, but not for performing urgent PD. As an example, most hospitals/medical centers have a committed and expert surgical or interventional radiology/nephrology staff that can place vascular catheters (which are often required for acute hemodialysis) within 24 hours. Most hospitals have access to a well-trained nursing staff that can provide hemodialysis quickly and safely.

By contrast, there are few medical centers that have committed staff available for the placement of peritoneal catheters semiurgently (ie, within 24 to 48 hours). In addition, few hospitals have committed nursing staff with expertise in PD. Many outpatient PD clinics do not have expertise in starting patients on PD urgently.

In addition, it is conventional practice to avoid using the peritoneal catheter for two to four weeks after placement to minimize pericatheter leaks. Although many reports suggest that it is possible to use catheters before two weeks, experience in doing so is limited [4-9].

As a result, PD is traditionally offered only to patients who have been closely followed by a nephrologist and sufficiently informed about dialysis options prior to needing dialysis. In addition to being sufficiently informed to choose PD, patients need to be trained to perform PD, which usually takes one to two weeks of instruction. As a result, it is challenging to initiate PD in patients who present with advanced chronic kidney disease and require urgent dialysis.

●Using urgent-start PD to avoid hemodialysis – For selected patients, urgent-start PD can obviate the need for temporary hemodialysis. This confers the following potential benefits:

•Patients who successfully undergo urgent-start PD avoid hemodialysis catheters [10], which are associated with a high risk of infection and a higher mortality rate compared with fistulas or grafts [11,12]. The majority of all predialysis patients in the United States start in-center hemodialysis with a central venous catheter as their initial dialysis access [13]. (See "Tunneled hemodialysis catheter-related bloodstream infection (CRBSI): Management and prevention", section on 'Administer antibiotic lock therapy'.)

•Once on hemodialysis, many patients never consider PD or abandon prior plans to use PD. Thus, urgent-start PD may increase the overall usage of PD [2].

•Patients who initiate dialysis with PD have higher rates of PD technique survival than patients who transition to PD from hemodialysis [14].

IDENTIFYING APPROPRIATE CANDIDATES — 

Identifying the appropriate urgent-start peritoneal dialysis (PD) candidate increases the chances for successful initiation of dialysis and the probability of long-term technique survival.

Evaluation for urgent-start PD — The ideal patient for urgent-start PD is a suitable candidate for long-term PD who requires chronic dialysis initiation within two weeks but not before two days. The need for emergency dialysis is a contraindication to urgent-start PD (see 'Contraindications' below), and obtaining a PD catheter may take between 24 and 48 hours. The indications to initiate chronic dialysis for patients with end-stage kidney disease (ESKD) are detailed elsewhere. (See "Indications for initiation of dialysis in chronic kidney disease".)

We discuss available chronic dialysis options (ie, PD, in-center hemodialysis, and home hemodialysis) with all patients. For patients interested in pursuing PD, the two main areas evaluated are:

●Social barriers (eg, home status/cleanliness, access to toilet and sink, space for PD supplies, employment status, caregiver support)

●Medical/surgical/psychiatric barriers (eg, functional status [including issues with vision, hearing, or dexterity], abdominal surgeries, psychiatric or memory issues)

Many of these barriers are not absolute contraindications to PD and thus, if resolved, can allow patients to use PD. (See 'Contraindications' below and "Evaluating patients for chronic peritoneal dialysis and selection of modality", section on 'Potential barriers to peritoneal dialysis'.)

Contraindications — The candidate for urgent-start PD must not have an emergency need for dialysis or insurmountable barriers to chronic PD:

●Emergency dialysis – Patients who require emergency dialysis (usually for hyperkalemia, volume overload, or marked uremia) are not good initial candidates for urgent-start peritoneal dialysis (PD), since such patients cannot wait for PD catheter placement. Furthermore, as compared with hemodialysis or continuous kidney replacement therapy (CKRT), it is more difficult to achieve rapid metabolic control with PD. Such patients should be managed with hemodialysis or CKRT using a temporary vascular catheter. Once stabilized, suitable PD candidates may have a PD catheter placed and rapidly transitioned to PD with urgent-start PD protocols.

●Barriers to PD – The only absolute contraindication to treatment with PD is lack of a functional peritoneal membrane. Thus, almost all barriers are relative, depending upon the motivation of the patient/caregiver and the clinical experience of the clinician and the dialysis center. However, there are a few patient factors that could, in some circumstances, cause the provider to recommend against PD. These include severe intraperitoneal adhesions, mental or physical incapacity without an available caregiver, and uncorrectable mechanical defects such as hernia. (See "Evaluating patients for chronic peritoneal dialysis and selection of modality", section on 'Potential barriers to peritoneal dialysis'.)

CLINICAL PATHWAY FOR URGENT-START PD — 

We employ the following clinical pathway for urgent-start peritoneal dialysis (PD) (algorithm 1) [15]:

Rapid catheter placement — Suitable candidates for PD should be referred to an access surgeon or interventional radiologist/nephrologist, who should place a PD catheter within 24 to 48 hours of referral. At the same time, a referral should be placed to a PD clinic that has an established urgent-start PD program.

Our approach to catheter placement in this setting is as follows:

●Prior to catheter placement, orders should include presurgical bathing with antiseptic soap, preoperative antibiotics, and a bowel preparation to minimize bowel distension and risk for postoperative constipation. (See "Placement of the peritoneal dialysis catheter".)

●Immediately after placement, catheters are tested for patency, functionality, and for the presence of blood with low-volume exchanges (ie, 500 mL). If the effluent is clear and the catheter functions normally, the abdomen is fully drained and left empty until the patient is seen in the dialysis unit for urgent-start PD initiation. If the effluent is blood tinged, low-volume exchanges are continued until the blood clears the abdomen. If the patient is hemodynamically stable, heparin (500 units/L) is added to minimize the risk for clotting. If the bleeding fails to clear with three or four exchanges, the patient will need further evaluation to rule out internal bleeding (table 1). (See "Noninfectious complications of peritoneal dialysis catheters", section on 'Complications of insertion'.)

●After catheter placement, as long as the patient does not have another medical indication to remain hospitalized, the patient can be discharged with close follow-up at the designated PD clinic. For patients who are discharged, we ensure the following:

•Strict postoperative orders are provided to avoid manipulating the catheter dressing (table 1).

•A postoperative bowel regimen is prescribed to prevent constipation and associated catheter malfunction. (See "Placement of the peritoneal dialysis catheter".)

Determine dialysis schedule — If necessary, PD can be initiated immediately after catheter placement. However, provided it is safe to do so, we prefer to manage the patient medically for approximately 72 hours after catheter placement since the risk of catheter dysfunction is relatively high in the immediate post-operative period. As such, we evaluate the patient as soon as possible after catheter placement to determine the urgency of PD initiation (table 2). A history and physical examination is performed to assess for signs and symptoms of severe uremia and volume overload (see "Indications for initiation of dialysis in chronic kidney disease", section on 'Indications for initiation of chronic dialysis'), and repeat laboratory work is reviewed, in particular for hyperkalemia. Our subsequent management depends on the need for immediate dialysis:

●If immediate dialysis is required, the patient is started on nurse-assisted, low-volume, recumbent, automated intermittent peritoneal dialysis (IPD) or daily automated peritoneal dialysis (APD) (see 'Initial dialysis prescription' below) [16]. Dialysis is usually performed in an outpatient PD clinic for a period of two to three weeks, until patients are sufficiently trained to perform dialysis at home. However, if the patient has indications to be hospitalized, nurse-assisted, low-volume PD can be performed in the inpatient setting until the patient is stable for discharge.

If a cycler is not available, urgent-start PD can be accomplished with low-volume manual exchanges, although care must be taken by nursing staff not to accidentally instill larger-than-intended volume of PD fluid into the peritoneum.

●If there is no indication for immediate dialysis initiation, training can commence. The patient's clinical status is monitored at each visit (typically twice weekly) and laboratory work is obtained at minimum weekly. Dialysis therapy should be started when appropriate. In our practice, the average time for early-start patients between catheter placement and initiation of PD is approximately five days.

Initial dialysis prescription — The dialysis prescription must be modified from the usual continuous ambulatory peritoneal dialysis (CAPD) or APD prescription to avoid pericatheter leak and other complications that may result from use of the catheter before the incision is completely healed from surgery and before the patient is trained to perform the dialysis alone.

The initial PD prescription depends on the degree of residual kidney function, patient size (body surface area), and clinical indicators as per the patient evaluation. Initial fill volumes are limited to 750 to 1250 mL, depending on the patient’s body surface area (table 3). Time on therapy and number of cycles are determined by the patient’s residual kidney function and specific clinical parameters (including signs and symptoms of uremia, electrolyte and acid-base disorders, disorders of mineral metabolism). (See "Indications for initiation of dialysis in chronic kidney disease".)

A typical prescription for a patient who has some residual kidney function is four to six cycles over a five- to eight-hour period. Therapy is usually done on an alternate-day basis in the first two weeks after catheter placement. This allows for alternate dry days, which increase surgical healing. However, if needed, daily therapy can be provided. Strict measures are to be taken to avoid increase in intra-abdominal pressure to avoid leaks. These measures include a bowel regimen for all patients to avoid straining with bowel movement; cough suppressants, if needed; and draining patients when sitting up, eating, or ambulating (table 3).

Transition to full-volume PD and training — After seven days of urgent-start therapy, we increase the fill volume by 250 to 500 mL per exchange from the initial prescription provided there are no catheter leaks or other complications. We generally increase to full volume exchanges 14 days after starting urgent-start PD, although full dose dialysis may not be necessary in some patients. (See "Prescribing peritoneal dialysis", section on 'Targeted versus untargeted dialysis'.)

After the first week of nurse-assisted PD, PD training is initiated for patients who are ready and clinically stable. By the end of the third week of PD, most patients are adequately trained to be able to transition to self-care at home.

OUTCOMES — 

Observational data suggest that urgent-start peritoneal dialysis (PD) has a similar or lower risk of mortality compared with urgent-start hemodialysis [17-22]. In a propensity-matched observational study including over 1400 patients, urgent-start PD was associated with a 24 percent reduction in hospitalizations compared with initiation of hemodialysis with a central venous catheter [23].

Patients treated with urgent-start PD also may have fewer short-term, dialysis-related complications than patients treated with urgent-start hemodialysis [24,25]. In a trial that randomly assigned over 200 patients to urgent-start PD or urgent-start hemodialysis, the composite complication rate was lower in the urgent-start PD group (19 versus 37 percent) [24]. Similar findings have been reported among older adults, a population traditionally considered to fare poorly with self-care modalities such as PD [19,26].

A 2020 Cochrane review of nearly 3000 patients (one trial and 15 observational studies) compared urgent-start PD with conventional PD [27]. With the exception of possible increased risk of dialysate leaks (relative risk 3.90, 95% CI 1.56-9.78), there appeared to be no other major increase in the risk of complications among patients who received urgent-start PD compared with conventional PD. Specifically, there were no definitive differences between urgent-start and conventional PD with regards to the risk of catheter blockage, malposition or readjustment, PD dialysate flow problems, infectious complications, exit-site bleeding, technique survival, or patient survival.

Despite the higher incidence of dialysate leaks observed with urgent-start PD in some studies, there does not appear to be a discernable increase in the risk of adverse patient outcomes or of patient dropout to hemodialysis [28-31]. Most leaks can be managed conservatively without need for replacement of the PD catheter. The risk of leakage can be minimized by appropriate catheter placement techniques and the use of smaller volumes of dialysate. (See "Placement of the peritoneal dialysis catheter".)

SETTING UP AN URGENT-START PD PROGRAM — 

Establishing a successful urgent-start peritoneal dialysis (PD) program requires administrative support and the commitment of multiple disciplines [32]. There are four key elements to creating a successful program [15]:

●Ability to place peritoneal catheters within 48 hours – Rapid peritoneal catheter placement is the rate-limiting step in any urgent-start program. If PD catheters cannot be placed as quickly as tunneled hemodialysis catheters, the default pathway for late-referred patients will be hemodialysis. The major barrier to an urgent-start peritoneal dialysis (PD) program is the lack of surgeons or interventionalists (radiologists or nephrologists) who can place a PD catheter within 48 hours.

Peritoneal catheters may be placed percutaneously (typically by interventional radiologists or nephrologists) or laparoscopically (typically by surgeons). Irrespective of the method of catheter placement, there must be a commitment by the dialysis access team to place catheters within 24 to 48 hours of request and to manage catheter complications in a timely manner. The method of placing the catheter may require modification to minimize the risk of pericatheter leaks [4]. Surgeons should be assured that the medical and nursing team will take specific steps to minimize the risk of early catheter complications despite early use of the catheter.

●Staff education – Inpatient and outpatient PD nurses should be familiar with methods that minimize the risk of catheter complications (such as catheter leaks) in patients undergoing urgent-start PD. These methods include the use of low-volume exchanges and having the patient in a recumbent position. Nurses should also be capable of managing early complications, such as catheter leaks. (See "Noninfectious complications of peritoneal dialysis catheters", section on 'Pericatheter leakage'.)

Ideally, there should be more than one nurse available who has sufficient expertise with early-start PD. This is especially important in outpatient facilities, where the urgent-start patient may be dialyzed on-site, while other aspects of the PD program are ongoing.

It is important that center-specific protocols for urgent-start PD be designed with input from the PD staff. If established urgent-start PD programs exist in the geographic area, collaboration should be encouraged. To minimize concern about patient safety, outpatient PD nurses should be assured that only medically stable patients will be dialyzed urgently in the outpatient dialysis clinics.

●Administrative support – There must be adequate staffing, space, and equipment to establish an urgent-start PD program. This requires the support of hospital and PD clinic administration. Administrators must be aware of the potential benefits of urgent-start PD. These include decreased vascular catheter-related complications, patient benefits, and the potential for decreased rehospitalization as compared with urgent-start hemodialysis. (See 'Rationale for urgent-start PD' above and 'Outcomes' above.)

Hospital administrators must assure adequate surgical staffing, equipment (including catheter kits and peritoneal dialysis supplies), and adequate PD nurse staffing and training. Outpatient administrators must assure adequate space, staffing, and supplies to allow for in-center PD. In outpatient facilities, at least two rooms should be available for PD. This is so that one room may be used for urgent-start patients while the other rooms are used for the usual activities of an outpatient PD clinic (including routine visits of patients maintained on PD and training of patients anticipating routine initiation of PD). A chair that allows a recumbent position should be available to patients on urgent-start PD to minimize increases in intra-abdominal pressure and risk of peritoneal fluid leak.

●Development of protocols – Most successful urgent-start PD programs are protocol driven. As noted above, protocols for urgent-start PD should be designed with input from the PD staff. Examples of urgent-start-specific protocols include the following [33]:

•Assessment for need of immediate dialysis after catheter placement (table 2)

•Initial urgent-start PD prescription (table 3)

•Post-PD catheter patient orders (table 1)

SUMMARY AND RECOMMENDATIONS

●Overview of urgent-start peritoneal dialysis (PD) – Urgent-start PD is the initiation of PD in patients with newly diagnosed end-stage kidney disease (ESKD) who are not yet on dialysis and who require dialysis initiation less than two weeks after PD catheter placement, but who do not require emergency dialysis. It is useful because it circumvents the need for temporary hemodialysis. Urgent-start PD may also increase the number of patients who use PD for kidney replacement therapy. (See 'Definition' above and 'Rationale for urgent-start PD' above.)

●Candidates for urgent-start PD – Patients who require emergency dialysis (usually for hyperkalemia, volume overload, or marked uremia) are not good initial candidates for urgent-start PD, since such patients cannot wait for PD catheter placement. Such patients should be managed with hemodialysis or continuous kidney replacement therapy (CKRT) using a temporary vascular catheter. Once stabilized, suitable PD candidates may have a PD catheter placed and transition to PD with urgent-start PD. (See 'Identifying appropriate candidates' above.)

●Clinical pathway – Suitable candidates for PD should be referred to an access surgeon or interventional radiologist/nephrologist, who should place a PD catheter within 24 to 48 hours of referral (algorithm 1). Following catheter placement, the initial dialysis schedule is determined. The initial PD prescription depends on the degree of residual kidney function, patient size (body surface area), and clinical indications for dialysis. Initial fill volumes are limited to 750 to 1250 mL (table 3). (See 'Clinical pathway for urgent-start PD' above.)

●Avoidance of dialysate leaks – Strict measures should be taken to avoid increase in intra-abdominal pressure to avoid leaks. These measures include a bowel regimen for all patients to avoid straining with bowel movement; cough suppressants, if needed; and draining patients when sitting up, eating, or ambulating. (See 'Initial dialysis prescription' above.)

●Outcomes – Urgent-start PD appears to be as safe as routine (ie, planned) PD, although there may be an increase in the incidence of peritoneal leaks. It is as safe or safer than urgent-start hemodialysis for appropriate candidates. (See 'Outcomes' above.)

●Establishing a program – The rate-limiting step in establishing a successful urgent-start PD program is getting consistent, timely placement of PD catheters. Other key elements to establishing a successful urgent-start program include sufficient numbers of trained PD nurses, administrative support, and a suitable infrastructure and being able to quickly identify appropriate candidates. Establishing and using protocols for every step of the urgent-start process will increase the chances for a successful program. (See 'Setting up an urgent-start PD program' above.)