Marzo Aprile 2021

Urgent-start PD: a viable approach

Abstract

Despite the many potential benefits of peritoneal dialysis (PD), the percentage of dialysis patients treated with PD is around 10% worldwide. Up to 70% of the subjects who progress to end-stage renal disease (ESRD) start dialysis without a well-defined therapy plan. Most of these patients are unaware of having chronic kidney disease, while others with stable CKD incur in unpredictable and acute worsening of kidney function.

As a matter of fact, 80% of incident HD patients start dialysis with a central venous catheter (CVC) even though starting HD with a CVC is independently associated with increased mortality, high rates of bacteremia, and increased hospitalization rates. Thus, PD is an excellent but underused mode of dialysis. Offering it to patients who present late to dialysis therapy, due to uremic state or hypervolemia, may help increase its application in the future.

This approach has been recently denominated “urgent-start peritoneal dialysis” (UPD). Based on the break-in period, it is possible to differentiate UPD from “early-start peritoneal dialysis” (EPD). The outcome of UPD depends on the right selection of patients, the appropriate placement of the catheter and the adequate education of the nursing and medical staff. Moreover, using modified catheter insertion technique aimed at creating a tight seal between the inner cuff and the abdominal tissues, as well as employing protocols that use low-volume exchanges in a supine posture, could minimize the occurrence of early mechanical complications.

Although the probability of mechanical complications is higher in early-start PD patients, UPD/EPD show a mortality rate, a PD survival and an infectious complication rate comparable with conventional PD. In comparison to urgent-start hemodialysis via a CVC, UPD can be a safe and cost-effective alternative that decreases the incidences of catheter-related bloodstream infections and hemodialysis-related complications. Furthermore, UPD can promote the diffusion of PD.

 

Keywords: peritoneal dialysis, urgent-start, early-start, leakage, displacement, low-volume

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Introduzione

La dialisi peritoneale (PD) possiede diversi benefici rispetto all’emodialisi (HD): una maggiore adattabilità della metodica agli stili di vita individuali, una più lunga conservazione della diuresi residua [1,2], un minore costo economico [3,4] e una sopravvivenza sovrapponibile o, in alcune casistiche, perfino migliore nei primi anni di trattamento [5,6]. Ciò nonostante, solo il 10% dei pazienti con malattia renale terminale (ESRD) viene trattato con la PD.

Fino al 70% dei soggetti affetti da ESRD, per la mancanza di una precedente valutazione nefrologica, o per la necessità di iniziare urgentemente il trattamento sostitutivo, incominciano la terapia dialitica senza una chiara programmazione [7]. Molti di questi pazienti non sono a conoscenza della propria malattia renale cronica (CKD), altri, sebbene consapevoli, trascurano la propria condizione, mentre altri ancora con CKD stabile vanno incontro a un peggioramento acuto della funzione renale a causa di un evento imprevedibile.

 

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