Introduction:
The prevalence of chronic kidney disease (CKD) and the need for dialysis is on the rise. Many patients are unaware of their CKD status and only seek medical help when they have end-stage kidney disease (ESKD) and uraemic symptoms. The standard treatment for most of these patients is haemodialysis using a dialysis catheter, which has led to lower acceptance of peritoneal dialysis.
This study aims to evaluate the feasibility and effectiveness of "immediate-start peritoneal dialysis (ISPD)" as an alternative for patients without vascular access.
Methods:
This retrospective study included patients admitted with chronic kidney disease and end-stage kidney disease (CKD-ESKD) at our hospital between September 2022 and January 2024. Patients requiring dialysis but lacking vascular access were given the choice of haemodialysis or peritoneal dialysis. Those opting for peritoneal dialysis underwent percutaneous insertion of Tenckhoff catheters in the ICU (for unstable patients) or the operating room (for stable patients). Peritoneal dialysis was initiated within 24 hours post-catheter insertion, using automated peritoneal dialysis (APD) with low-volume (500 mL) exchanges in a supine position. On the first day, a total exchange volume of 5 litres was used, increasing to 10 litres/day over the following days. Patients were managed on APD for 7 days, after which they were either continued on APD or transitioned to manual continuous ambulatory peritoneal dialysis (CAPD) based on their preference. Patients were followed for six months to monitor peritonitis episodes, technique failure, mechanical complications, and mortality.
Results:
Of the 78 patients screened, 32 opted for peritoneal dialysis. The Nephrologists performed Catheter insertions percutaneously in all patients, with 26 in the operating room and 6 in the ICU. The median time from catheter insertion to the initiation of peritoneal dialysis was 16.5 hours (range 12-22 hours). Three patients experienced peri-catheter leaks, necessitating a temporary cessation of peritoneal dialysis, which was resumed after 7 days with interim haemodialysis. Two patients reported abdominal discomfort, delaying peritoneal dialysis initiation by 48 hours. No patients experienced inflow or outflow failures requiring significant intervention beyond bowel enemas. All patients responded to PD with normalisation of biochemical parameters and improvement in uremic symptoms. None of the patients had any complications during the PD initiation.
Over the 6-month follow-up, there were 6 peritonitis episodes, and 3 patients were switched to haemodialysis due to refractory peritonitis. None of the peritonitis episodes occurred in the early peri-catheter insertion period. The earliest peritonitis episode was 68 days after catheter insertion. One patient died from acute coronary syndrome-ST elevation myocardial infarction (ACS-STEMI).
Conclusions:
Immediate-start peritoneal dialysis (ISPD) is a feasible and effective method for initiating kidney replacement therapy in ESKD patients, particularly beneficial for "crash-landers" diagnosed with ESKD without prior CKD history or vascular access and in areas without access to HD. Further research and improved implementation strategies may enhance the outcomes of this technique
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.