PD for AKI: A promising intervention successfully implemented in low-resource countries

Peritoneal dialysis for acute kidney injury has been shown to be a beneficial, cost-effective treatment in low-resource areas such as sub-Saharan Africa and Southeast Asia. One program which has brought PD for AKI to these underserved areas is the Saving Young Lives Program, sponsored by the International Society for Peritoneal Dialysis, International Society of Nephrology, IPNA, and Euro-PD. The program was initially established in 2012 with a grant from the Kaplan Foundation. Saving Young Lives has initiated 16 programs in various low-resource areas and has treated several hundred patients with PD for advanced AKI. With nephrologists in short supply in these regions, physicians and nurses at the sites have received hands-on training in PD and insertion of a Tenckhoff catheter.

“The results have been fabulous,” Fredric Finkelstein, MD, professor of medicine at Yale New Haven hospital and an active participant in the Saving Young Lives Program. “Lives are saved; the mortality rate is about 20% or 30%. It works well, and the complication rate is low.”

Inspired by the success of programs like Saving Young Lives, health care providers have tried to expand the utilization of PD in developed countries to treat patients with AKI. Such programs in Brazil and Saudi Arabia have been associated with excellent results compared to extra-corporeal renal replacement treatments. However, the need for additional patient data and institutional approval has largely stalled these efforts.

“It’s kind of ironic that these poorer nations are able to get this type of program off the ground; most of it is due to low resources,” Laura Troidle, PA, a nephrology physician assistant who works with Finkelstein at Metabolism Associates and Yale New Haven Hospital and has been trying to implement a PD for AKI program there. “Most of its success in undeveloped countries is due to low resources but in the United States, it’s more about the bureaucracy of trying to get this as an accepted therapy.”

Learn from the global experience

Programs in low-resource countries have demonstrated PD programs can be established relatively quickly and with brief, focused training. According to Finkelstein, non-specialists can be trained to put in a Tenckhoff catheter without much difficulty.
“We can take a medical resident, for example, who has no training in nephrology and teach him or her how to do this in a short period of time,” Finkelstein said.

The procedure is also affordable and feasible to provide in low-resource environments, and requires neither electricity or complex equipment. According to a 2017 paper on recent consensus recommendations from the Acute Dialysis Quality Initiative Conference in India, PD for AKI has benefits such as lower costs (as low as $150 to save a life) and technical innovations such as flexible and cuffed catheters, automatic cycling, and locally made solutions . These advantages make it a suitable alternative to other forms of renal replacement therapy. The article notes that decreases in mortality and complications have been reported in places where PD is regularly performed.

A 2008 randomized study conducted in Brazil evaluated continuous PD (CPD) vs. daily hemodialysis (dHD) in patients with AKI. Researchers randomized 120 patients with acute tubular necrosis (ATN) to receive CPD utilizing an automated cycler or dHD. Hospital survival and recovery of renal function were identified as primary endpoints. Secondary endpoints included metabolic and acid-based measures, as well as fluid management. The groups were similar demographically, in terms of age and sex and clinically, in terms of sepsis, shock, severity of ATN and acute physiology and chronic health evaluation score. The high-dose CPD group achieved suitable metabolic and pH control, with a comparable rate to that seen with dHD. Recovery of renal function was attained in the CPD group significantly faster than in the dHD group.
“The advantage of PD with AKI is a more rapid recovery of kidney function,” Finkelstein said. “Studies would suggest that that’s the case. Also, a shorter time that people require dialysis.”

“Saving Young Lives has taught us that PD in patients with AKI is technically easy in low-resource countries where they don’t have machinery or reliable electricity,” Finkelstein said. “We’ve shown you can do this; there are 16 sites where we have set it up. All have done PD and they’ve all done it successfully.”

Roadblocks in the United States
Results achieved with PD for AKI in low-resource countries have generated efforts to incorporate PD for AKI into clinical practice in the United States. Some of the obstacles to integrating this procedure are based on a lack of hospital approval and/or resources.
“It just takes getting the hospital to approve it; you need a safe, sterile facility, too,” Finkelstein said, referring to nephrologist placement of a peritoneal catheter. “In some low-resource countries, they have these facilities that are not as readily available here.”

Troidle added that even with the availability of interventional radiology departments in placing the peritoneal catheter, the lack of radiologists accustomed to placing this catheter presents another issue.

“There are limited interventional radiologists who are experienced in doing this,” she said. “It’s easier to call and get a tunneled central venous catheter and start hemodialysis than it is to start peritoneal dialysis.”
This tendency to default to hemodialysis is common among physicians, nurses, physicians’ assistants and various other providers.
“A lot of the other providers – nurses and residents, for example – are unaware of the value of peritoneal dialysis for AKI,” Troidle said. “There is not an automatic acceptance; there is still a comfort level with doing hemodialysis.”
Finkelstein said urgent start PD, a procedure similar to PD for AKI, is becoming increasingly accepted in the United States. Urgent start PD involves initiating PD in a patient with ESRD before the usual 2 week or more waiting period.
“As urgent start PD grows, PD for AKI will likely become more accepted. I just think there needs to be more discussion of it at national meetings.”
Finkelstein said he believes PD for AKI will become more widely adopted in the United States, particularly as more data become available on its efficacy, affordability and ease of use.
“We’re learning from low-resource countries about how to apply this approach in a high-resource country,” he said. “It is an interesting concept, and I do think it is coming to the United States.” – by Jennifer Byrne

References:

Annigieri RA, et al. Kidney Intern Rep. 2017;doi:10.1016/j.ekir.2017.04.006

Gabriel DP, et al. Kidney International. 2008;doi:10.1038/sj.ki.5002608

For more information:

Fredric Finkelstein, MD, and Laura Troidle, PA, can be reached at 136 Sherman Ave, #405, New Haven, CT 06511; Finkelstein’s email: fof@comcast.net. Troidle’s email: kltroidle@sbcglobal.net

Disclosures: Finkelstein and Troidle report no relevant financial disclosures.