Background: Urgent-start peritoneal dialysis (USPD) was designed to avoid temporary hemodialysis initiation with a hemodialysis catheter. In these patients, PD is initiated within 2 weeks of catheter placement, but typically these prescriptions utilize automated peritoneal dialysis (APD) with a cycler. Manual exchanges have not been reported previously for USPD. We hypothesize that using multiple, low-volume manual exchanges, patients will have similar rates of peritonitis, exit-site infection (ESI), pericatheter leaks and discontinuation of PD in the ﬁrst 3 months after initiation. Methods: This retrospective study included patients who initiated PD in our unit from May 2014 until August 2016 using our 2 2 USPD protocol. Patients with a body surface area <1.7 m used 750 mL dwell volumes and those>1.7 m used 1000 mL dwell volumes during the ﬁrst 7 days. Dwell times were 2–2.5 h for two to three exchanges per day. After 7 days of successful therapy, the dwell volumes were doubled. All patients were maintained on furosemide 160 mg twice daily. Results: There were 20 patients enrolled in our USPD program. Our rates of peritonitis, ESI, pericatheter leak and discontinuation of PD were 5%, 0%, 5% and 5%, respectively. Conclusions: Manual exchange during USPD is a viable modality with similar results as APD. Using manual exchanges allows patients to be more ambulatory during the day when they are not dwelling, allows nurses to evaluate the amount of ultraﬁltration and efﬂuent characteristics and allows for training in manual exchanges as well. Key words: cycler, ESRD, manual exchanges, peritoneal dialysis, urgent start Introduction Historically these patients would not be able to intiate PD until Peritoneal dialysis (PD) is a type of renal replacement therapy at least 2 weeks after placement of a PD catheter in order to for patients with end-stage renal disease (ESRD). It involves fill- avoid complications such as abdominal cavity or pericatheter leaks. Many patients who require urgent dialysis typically are ing the peritoneal cavity with a dextrose-containing solution and using the peritoneal membrane as a filter to remove toxins, started on hemodialysis (HD) with a central venous catheter regulate electrolytes and remove volume. Peritoneal dialysis (CVC) and PD is typically reserved for planned starts . can be done with multiple daily manual exchanges or using a Urgent-start PD (USPD) was designed to avoid temporary HD cycler for a fixed period of time every day of the week. initiation while awaiting approval to use a PD catheter. In these Received: September 12, 2017. Editorial decision: December 27, 2017 V C The Author(s) 2018. Published by Oxford University Press on behalf of ERA-EDTA. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact email@example.com 720 Downloaded from https://academic.oup.com/ckj/article-abstract/11/5/720/4850521 by Ed 'DeepDyve' Gillespie user on 17 October 2018 USPD with CAPD | 721 patients, PD is initiated 24–48 h after PD catheter placement, the first month and catheter malfunction, ESI and peritonitis rates were 1.9%, 2.9% and 3.9%, respectively . typically in the outpatient setting . Patients are discharged We hypothesized that using our protocol, which involved after PD catheter placement and PD is initiated in the dialysis multiple, low-volume manual exchanges during the initiation clinic, although this can also be done in the hospital dialysis period, patients would have similar rates of peritonitis, ESI and unit setting. Various dialysis prescriptions have been described pericatheter leaks in the first 3 months after initiation com- in the literature for USPD, but these prescriptions utilize auto- pared with the data presented for the APD and CAPD programs. mated PD (APD) with a cycler . This requires patients to be We also evaluated how many patients remained on PD 12 connected to the cycler 5–12 h during each treatment in the months after USPD for initiation. supine position. The low dwell volumes while in the supine position during these protocols are particularly important to decrease the risk of developing a leak . Other programs have Materials and methods reported their success rates with US PD previously, and rates of Institutional review board approval (protocol #9567) was peritonitis and exit-site infection (ESI) are similar, with a obtained for this study. We performed a retrospective review of slightly increased risk of pericatheter leaks that have been our USPD patient records from May 2014 to August 2016 in our controlled with holding PD for a short period and then restart- PD unit. All patients in our USPD program followed our protocol ing therapy [5, 6]. In one study of 52 patients, rates of peritonitis, using manual exchanges. For our protocol, all patients were ESI and pericatheter leak were 15.4%, 3.9% and 7.7%, respec- started on PD within 2 weeks of catheter placement (most tively . patients within 48 h of catheter placement). Any patient who While the majority of studies published on USPD programs started PD 2 weeks after catheter placement were excluded use APD, we did find one study published in 2007 by Jo et al. 2 from this study. Patients with a body surface area (BSA)<1.7 m that evaluated 51 patients who had a PD catheter placed and 2 used 750 mL dwell volumes and those with a BSA >1.7 m used initated on continuous ambulatory PD (CAPD) immediately after 1000 mL dwell volumes during the first 7 days. Dwell times were placement without a break-in period. The patients had 500 mL 2–2.5 h for two to three exchanges per day, 4–5 days per week. instilled every 3 h for the first 3 days and patients were kept in After 7 days of successful therapy the dwell volumes were the supine position during this time with minimal ambulation. doubled (see Figure 1). All patients were maintained on furose- They then increased the dwell volume to 1 L every 4 h for the mide 160 mg twice daily. There were no significant side effects next 4 days. Seven 7 days after the catheter insertion, they with this dosage of furosemide, such as hearing loss. Urine out- began 2 L exchanges with a dwell time of 4 h. In this study the put was not measured during the initiation period. One patient authors found only one pericatheter leak that occurred within was initiated on PD secondary to loss of all vascular access after Fig. 1. USPD manual exchange protocol. It includes a 16-step process that is followed in the clinic. Downloaded from https://academic.oup.com/ckj/article-abstract/11/5/720/4850521 by Ed 'DeepDyve' Gillespie user on 17 October 2018 722 | M. V. Naljayan et al. Table 1. Baseline characteristics Patient Age (years) Sex Race ESRD etiology eGFR (mL/min) Reason to initiate Setting 1 25 Male Black HIV nephropathy 4 Uremia/volume overload Inpatient 2 46 Female White PKD 12 Uremia Outpatient 3 38 Female Black Lupus nephritis 4 Uremia/volume overload Inpatient 4 44 Female Black Diabetes and hypertension 12 Uremia Inpatient 5 51 Male Black Hypertension 10 Hyperkalemia Inpatient 6 47 Male Black Hypertension 7 Uremia Inpatient 7 40 Male Black Diabetes and hypertension 7 Uremia/volume overload Inpatient 8 65 Female Black Hypertension 11 Uremia Inpatient 9 47 Female Black Diabetes and hypertension 14 Uremia/volume overload Outpatient 10 43 Male Black Hypertension 6 Uremia Inpatient 11 41 Female Black Hypertension 0 Loss of vascular access Inpatient 12 53 Male Black Hypertension 13 Uremia/volume overload Inpatient 13 42 Male Black Hypertension 12 Uremia/volume overload Inpatient 14 39 Male Black Diabetes and hypertension 10 Uremia/volume overload Inpatient 15 46 Male Black Diabetes and hypertension 9 Uremia/volume overload Inpatient 16 61 Male Black Diabetes and hypertension 18 Uremia/hyperkalemia Inpatient 17 64 Female Black Diabetes and hypertension 6 Uremia Outpatient 18 51 Male Black Hypertension 11 Uremia Outpatient 19 57 Male Black Hypertension 2 Uremia Inpatient 20 60 Male Black Hypertension 24 Volume overload (systolic CHF) Inpatient eGFR, estimated glomerular ﬁltration rate; PKD, polycystic kidney disease; CHF, congestive heart failure. being on HD for >5 years and therefore she had no residual Table 2. Summary of baseline characteristics urine output. We had two PD nurses in our clinic who evaluated Age (years) 48 (range 25–65) patients and performed all of the exchanges. Based on clinical Sex, n (%) assessments, patients would receive additional treatments Male 13 (65) (three per day) or additional days (6 per week) for reasons such Female 7 (35) as edema or uremic symptoms. We also evaluated the number Race or ethnic group, n (%) of patients who developed peritonitis, ESI, abdominal or peri- Black 19 (95) catheter leaks within the first 3 months of initiation, as well as White 1 (5) whether the patient chose to continue PD after the initiation Diabetes mellitus, n (%) 7 (35) period. Estimated glomerular ﬁltration rate (mL/min) 9.6 Setting (inpatient versus 16 versus 4 outpatient), n (80% inpatient) Results There were 20 patients who were enrolled in our USPD program between May 2014 and August 2016. The group comprised 35% Most treatments included two exchanges a day and most female patients and 65% male patients and the mean age was patients received dialysis at least 4 days each week, with >90% 48 years. The mean initial estimated glomerular filtration rate of patients receiving therapy 5 days a week. Only one patient was 9.6 mL/min prior to starting PD. The majority of our patients (5%) received three exchanges a day and 6 days a week due to initiated dialysis due to uremic symptoms (including but not limited to nausea, vomiting, loss of appetite and asterixis). The severe uremic symptoms and marked volume overload with no residual renal function, as this patient had transitioned from decision to initiate dialysis occurred as an inpatient for 80% of these patients. None of the patients required inpatient PD but HD to PD after losing all vascular access options. This was based were discharged after catheter placement and initiated in the on the clinical judgement of the nephrologist and the PD nurse. Our rates of peritonitis, ESI and abdominal or pericatheter outpatient PD unit within 48 h of catheter placement. General surgeons placed all of the catheters using a laparoscopic leaks were 5%, 0% and 5%, respectively (Table 3). One patient technique. did not continue PD due to housing issues (95% continued PD), Baseline characteristics of the patients are listed in Table 1. otherwise all patients remained on PD at least 12 months after A summary of baseline characteristics is listed in Table 2. Given initiation. All patients initially remained on CAPD until those the variability in patient schedules and transportation issues patients who requested a cycler were able to obtain a cycler. for some of the patients, the dialysis prescriptions varied day to Five of the 20 patients (25%) continued on CAPD without choos- day but stayed within our protocol. The dwell volumes were ing to start cycler therapy after training was complete. No cath- based on BSA (BSA<1.7 m used 750 mL dwell volumes and BSA eter revisions or removals were required. >1.7 m used 1000 mL dwell volumes during the first 7 days and The one patient with peritonitis developed a Pseudomonas then doubled the second week) and were strictly adhered to by peritonitis that was treated for 21 days with intraperitoneal cef- our protocols. The type of dextrose solution (1.5% versus 2.5%) tazidime and oral ciprofloxacin with resolution of the peritoni- was left to the discretion of the nurse and the nephrologist tis. Catheter removal was not necessary. based on the patient’s volume status as assessed by blood pres- For the single patient with the pericatheter leak, we noted sure and edema. the leak on Day 2 of dialysis. PD was discontinued for 2 weeks, Downloaded from https://academic.oup.com/ckj/article-abstract/11/5/720/4850521 by Ed 'DeepDyve' Gillespie user on 17 October 2018 USPD with CAPD | 723 Table 3. Complications exchanges in USPD. Using our protocol, we believe other centers can develop their own USPD programs using CAPD if they felt Type of complication n (%) this to be an option. Further utilization of these CAPD protocols will increase the likelihood of future studies in this area. Abdominal/pericatheter leak 1 (5) Exit-site infection 0 (0) Peritonitis 1 (5) Conclusions Discontinuation of PD therapy 1 (5) Patients who remained on CAPD 5 (25) Our study shows that using manual exchanges for USPD leads to similar or better outcomes as compared with previously reported data in peritonitis, ESI and pericatheter leak rates. while monitoring laboratory results every 4 days, and then Manual exchanges are a viable option for US PD and allows for restarted with low volumes following the USPD protocol with- flexibility in the training schedule. We believe that this method out any further leak. Backup HD was never necessary. allow programs to utilize either APD or manual exchanges for a successful USPD program. Further prospective studies are Discussion needed to better evaluate CAPD compared to APD as a method of USPD initiation. USPD has become a mainstay of PD initiation and decreases the need for CVC placement for urgent initiation of renal replace- ment therapy. To date, most USPD programs utilize an APD pro- Authors’ contributions tocol that requires patients to lay supine for 5–12 h while M.N. and F.Y. were responsible for the research idea, study dwelling. If a patient needs to get up to use the bathroom or eat, design, data acquisition, data analysis and statistical analysis. then the nurse must drain the patient and pause the cycler E.R. was responsible for supervision and mentorship. Each therapy. Using manual exchanges as in our protocol, patients only need to lie supine 2–4 h depending on the prescribed dwell author contributed important intellectual contact during manu- time. Patients can then be ambulatory between exchanges. This script drafting and revision and accepts responsibility for the allows for natural breaks throughout the day to allow patients overall work by ensuring that questions pertaining to the accu- to eat, use the restroom and take breaks. racy or integrity of any portion of the work are appropriately Since our patients are trained in manual exchanges during investigated and resolved. this initiation period, this allows for a higher degree of familiar- ity and comfort performing manual exchanges. In areas where Conflict of interest statement patients may have frequent weather disturbances, electricity outages or cycler malfunctions, being proficient in manual M.N. has received fees as a medical director for DaVita Kidney exchanges is extremely important. Within our patient popula- Care. tion, 25% of patients opted to remain on CAPD rather than tran- sition to cycler-based therapy (Table 3). Our nurses also preferred using manual exchanges, as it allowed them to evalu- References ate fill and drain times of the catheter and ultrafiltration vol- 1. Van Biesen W, Vanholder R, Lameire N. The role of peritoneal ume with each dwell, and there are no alarms due to cycler dialysis as the ﬁrst-line renal replacement modality. Perit Dial issues. This protocol also limits the need for cyclers to be used Int 2000; 20: 375–383 during training, particularly in areas where obtaining a cycler 2. Ghaffari A, Kumar V, Guest S. Infrastructure requirements for may be difficult. an urgent-start peritoneal dialysis program. Perit Dial Int 2013; We acknowledge that a major limitation of our study is the 33: 611–617 relatively small sample size of 20 patients and limited to one 3. Povlsen JV, Ivarsen P. How to start the late referred ESRD center. We believe one strength of our study is that five various patient urgently on chronic APD. Nephrol Dial Transplant 2006; surgeons placed these PD catheters, which leads us to believe 21: ii56–ii59 our success in manual exchanges for initiation was independ- 4. Arramreddy R, Zheng S, Saxena AB et al. Urgent-start perito- ent of surgeon variability. Future directions would include neal dialysis: a chance for a new beginning. Am J Kidney Dis increasing the sample size or the number of programs utilizing 2014; 63: 390–395 this method to evaluate outcomes and performing a large 5. Ghaffari A. Urgent-start peritoneal dialysis: a quality randomized clinical trial comparing manual exchanges and improvement report. Am J Kidney Dis 2012; 59: 400–408 cycler therapy for USPD. Another future direction would be to 6. Casaretto A, Rosario R, Kotzker WR et al. Urgent-start perito- evaluate patient and nurse satisfaction with manual versus neal dialysis: report from a U.S. private nephrology practice. cycler training during initiation and to evaluate how many Adv Perit Dial 2012; 28: 102–105 patients remain on CAPD versus APD due to initial manual 7. Jo Y, Sin S, Lee J et al. Immediate initiation of CAPD following exchange training. We recognize that this is a retrospective study and realize a randomized and controlled study would bet- percutaneous catheter placement without break-in proce- ter elucidate differences in outcomes in cycler versus manual dure. Perit Dial Int 2007; 23: 179–183
Clinical Kidney Journal – Oxford University Press
Published: Oct 1, 2018
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