Parapiboon W, et al. Kidney Int Rep.2022;doi:10.1016/j.ekir.2022.05.032.

Parapiboon W, et al. Kidney Int Rep.2022;doi:10.1016/j.ekir.2022.05.032.

Compared with patients who had urgent-start temporary hemodialysis, patients who underwent urgent-start peritoneal dialysis during the transition of kidney failure to chronic dialysis showed fewer complications up to 6 weeks after dialysis.

“The transition from chronic kidney disease to dialysis commencement is both crucial and challenging. Unfortunately, more than half of kidney failure patients worldwide start dialysis in an unplanned fashion despite such unplanned starts being associated with higher risks of morbidity and mortality compared with planned dialysis initiation,” Watanyu Parapiboon, MD, from the nephrology unit in the department of medicine at Maharat Nakhonratchasima Hospital in Thailand, and colleagues wrote. They added, “In the present study, we sought to evaluate the efficiency and complications of both modalities [urgent-start PD and urgent-start temporary hemodialysis] in a randomized controlled trial fashion.”

In a multicenter, open-label, prospective, randomized controlled trial, researchers evaluated 207 adults with kidney failure requiring urgent-start dialysis from three tertiary hospitals between November 2018 and February 2020. Researchers randomly placed patients in a 1:1 ratio to either urgent-start PD (n=104) or urgent-start temporary hemodialysis (n=103) for 2 to 4 weeks. Afterward, patients were allowed to transition to PD if they elected to do so.

Researchers considered the composite endpoint of operation-related, catheter-related and dialysis-related complications at 6 weeks to be the primary outcome. Secondary outcomes consisted of 6-week mortality, 6-week technique survival and 1-week composite complications.

Using Kaplan-Meier curves and log-rank tests, researchers measured outcomes with time-to-event data. Additionally, researchers conducted several sensitivity and survival analyses.

Overall, urgent-start PD showed a lower composite complication rate at 6 weeks (19%) compared with urgent-start temporary hemodialysis (37%) due to a reduction in dialysis-related complications. Similarly, urgent-start temporary hemodialysis showed higher peritonitis rates, while 1-week catheter-related complications and intradialytic hypotension only occurred in patients receiving urgent-start PD and temporary hemodialysis.

The median time to death was 28 days, and a total of nine patients died (four in the urgent-start PD group and five in the urgent-start temporary hemodialysis group). Researchers did not identify any significant differences between the two groups at 1 or 6 weeks.

“Urgent-start PD strategy is a viable option for patients transitioning from kidney failure to dialysis. In the setting where PD is the final modality of choice, urgent-start PD is safe, requiring only a single operation and avoiding temporary central venous catheter, leading to fewer overall complications than urgent-start temporary hemodialysis during the transition period,” Parapiboon and colleagues wrote. “In addition, using an urgent-start PD strategy also provided comparable patient and technique survivals to urgent-start temporary hemodialysis strategy up to 6 weeks after dialysis commencement.”

Researchers noted the results may not be generalizable to other countries with high BMI populations or where PD catheter placement is not performed by nephrologists.

Historically, only 10% of dialysis patients in the United States undergo peritoneal dialysis. The Advancing American Kidney Health (AAKH) Executive Order signed in 2019 and the COVID-19 pandemic have increased the focus on home dialysis in the United States. Urgent-start peritoneal dialysis (USPD) is an important strategy to promote home dialysis, as previously seen in Brazil, where USPD resulted in a 256% increase in chronic peritoneal dialysis (PD) patients in a 3-year period. Results from the only randomized controlled study of USPD vs. urgent-start temporary hemodialysis (USHD) in patients transitioning to ESKD in KI Reports are exciting.

This multicenter, open-label, intention-to-treat randomized controlled trial (RCT) of 207 patients without immediate dialysis access who required urgent dialysis were randomized to either a USPD or USHD group, the latter defined as temporary HD during 2 to 4 weeks, followed by transition to chronic PD, with the PD catheter placed by nephrologists after 8 to 15 days of the HD start. The primary endpoint was a composite outcome of operation, catheter and dialysis-related complications at 6 weeks. The USPD group had a statistically significant lower composite complication rate (19% vs. 37%), which was primarily due to fewer dialysis-related complications. Importantly, however, there was one USPD patient death due to uremic encephalopathy, suggesting that patient selection is crucial.

The strengths of this study include: 1) the RCT and intention-to-treat study design, 2) excellent intervention adherence (93%) and 3) avoidance of temporary central venous catheter resulting in lower risk of bacteremia and necessitating only a single operation. The limitations of the study include: 1) study done only in Thailand, which has a “PD-first” policy and may be difficult to generalize, 2) length of hospital stay was not mentioned, 3) residual renal function was not measured and 4) open-label design and non-blinded outcome assessors.

This study can help hospitals, dialysis organizations, nephrologists and others to “buy-in” to the idea that USPD as a method to start urgent dialysis is a safe and effective strategy compared with HD. This can also assist in reaching AAKH goals of increasing the number of patients getting home dialysis. In addition, nephrology fellows will need more exposure to USPD in their training to increase USPD going forward. In the U.S., the ease and comfort that nephrologists have with starting HD first is likely a large limiting factor to expanding PD. These results from a well-designed RCT reinforce that USPD is relatively safe, effective and may have fewer complications than USHD.

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