Urgent-start peritoneal dialysis results in fewer procedures than hemodialysis

Last updated: 05-28-2019

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Urgent-start peritoneal dialysis results in fewer procedures than hemodialysis

The last decade has seen the emergence of urgent-start peritoneal dialysis (PD) for late-referred end-stage renal disease (ESRD) patients in North America [1–6]. Urgent-start PD refers to the practice of initiating dialysis when required urgently but non-emergently before the traditional 2-week period after PD catheter insertion using low-volume, supine exchanges, primarily to avoid peri-catheter leak [2, 7]. Recent studies compared outcomes between urgent-start PD and hemodialysis (HD) cohorts and reported similar survival rates between the two. Patient survival at 1 year was reported as 92.1 and 93% for PD and HD groups, respectively, in one study [8], and 82.9 and 78.9%, respectively, in another [9]. Koch et al. [10] demonstrated that urgent-start HD patients had a higher half-year overall mortality rate than PD patients (42.1% versus 30%), but the difference did not reach significance (P = 0.191).

Utilization of PD as the initial dialysis modality allows for avoidance of central venous catheters (CVCs) and preservation of residual renal function and vascular access [11–13]. CVC use for dialysis access is associated with a higher risk of mortality, infection and hospitalizations compared with other types of dialysis access, including PD catheters [2, 14–16]. Yet, according to the US Renal Data System, 93% of patients who required dialysis in 2014 were initiated on HD, where the majority (80.3%) had a CVC as their initial access. This practice has changed minimally since 2005 [16].

Although the precise rate of CVC use in urgent-start HD is not known, incident use of acute dialysis catheters (non-tunneled) has been described to be ∼14% in Europe and 34% in the USA according to the Dialysis Outcomes and Practice Patterns Study [17]. In chronic HD, 40–60% of arteriovenous access required procedures for maturation or had primary non-function and up to 65% of fistulas required ongoing treatment to maintain patency [18]. In stable PD patients, only 5–13% of catheters have been reported to require revisions [19, 20]. Direct comparisons of procedures between the chronic dialysis modalities further substantiated higher rates of invasive procedures with HD compared with PD [20].

At our center, a teaching hospital where 20% of chronic dialysis patients receive PD in a hospital-based dialysis clinic, we introduced an urgent-start PD program in 2015. We arranged for


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