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PD program for unplanned renal replacement therapy reduced central venous catheter use
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A program that provided specific processes to support the initiation of PD in urgent and unplanned situations reduced both central venous catheter use through hemodialysis and length of hospital stay, according to a published study.
“In most instances, unplanned start of dialysis is often accomplished by hemodialysis (HD) using a central venous catheter (CVC) that exposes the patients to the risks of infection and other catheter-related complications,” Ferruh Artunc, MD, of the University Hospital of Tübingen in Germany, and colleagues wrote. “A study investigating the influence of dialysis timing and access in incident HD patients found that unplanned dialysis start was associated with increased mortality and that patients with unplanned start using a CVC had the highest mortality ... ”
They added, “Urgent start using PD could be an alternative for some of the patients; however, this requires a hospital-based PD center that offers a structured urgent start PD.”
Researchers developed an urgent start PD program, using an automated system that allowed the initiation of PD within a few days. The program was implemented in 2016.
Patient flow charts (or “patient pathways”) describing specific circumstances were used to determine whether a patient should initiate hemodialysis or automated PD. All patients were given information about both options and PD was only used if selected by the patient. PD was offered to patients who required dialysis between 48 hours and 14 days, though patients with an emergent dialysis indication (such as nausea, vomiting, cardiac decompensation, hyperkalemia) were started on hemodialysis.
Trends in hemodialysis vs. PD and related outcomes were compared between 2013 to 2015 (before implementation of urgent start PD) and 2016 to 2018 (after implementation).
Researchers found that, in the 3 years before urgent start PD was implemented, 14% of incident PD patients were initially treated with hemodialysis using central venous catheter. After implementation, 6% were treated with initial hemodialysis, suggesting that the program reduced the need for hemodialysis by 57% in unplanned situations.
The program also appeared to shorten hospital stays, as those treated with urgent start PD had a median stay of 9 days compared with 26 days for those initially treated with hemodialysis.
Despite these positive results, researchers emphasized that not all patients in unplanned situations could be treated with urgent start PD, such as those with life-threatening complications. They also noted that, “urgent start PD is not synonymous with acute PD, and urgent start PD does not apply to patients with acute kidney injury.”
Still, “Implementation and offering of urgent start PD improves the care of ESRD patients with unplanned dialysis start by reducing central venous catheter use and shortening of hospital stay,” they concluded. “The presented patient pathway may serve as a validated model structure for the implementation of urgent start PD in other centers.” – by Melissa J. Webb
Disclosures: Artunc reports receiving speakers honoraria from Baxter. Please see the study for all other authors’ relevant financial disclosures.
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