Speaker: Urgent-start peritoneal dialysis feasible, cost-efficient with support system
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With the proper support system, urgent-start peritoneal dialysis is feasible and cost-efficient, according to a speaker at the virtual Annual Dialysis Conference.
“If patients with advanced chronic kidney disease develop a need for urgent dialysis initiation, we typically put in a temporary or permanent tunneled catheter for hemodialysis. It’s become very easy for us to do that. We either put it in or you would consult radiology to place it in, and then the patient initiates dialysis. This process has been going on for several years now,” Shani Shastri, MD, MPH, MS, an associate professor in the department of internal medicine at the University of Texas Southwestern Medical Center, said. “However, one thing to consider is that patients who actually start hemodialysis get very comfortable remaining on hemodialysis and the chances of them switching to another modality is low.”
Benefits of urgent-start PD include outpatient access, no need for temporary hemodialysis or a tunneled catheter, training concurrent with dialysis and potential preservation of residual renal function.
Shastri said a study showed urgent-start PD cost approximately $3,000 lower than urgent-start hemodialysis during the first 90 days. Results showed that the relationship between the nephrologist, patient, operator, hospital and dialysis unit is crucial for urgent-start PD success.
Another study Shastri referenced showed no difference in mortality and complications in incident urgent-start PD compared with urgent start hemodialysis.
Barriers to urgent-start PD include timely PD catheter insertion which must take place between 24 and 48 hours of the request, lack of education and lack of communication between hospital and outpatient PD center staff. Patients who are not good candidates for urgent-start PD may have a recent abdominal surgery, active inflammatory bowel disease, a large uncorrected abdominal hernia, an unsuitable home environment or physical or mental limitations.
According to Shastri, these barriers can be overcome with a strong support system. Hospitals would need a multidisciplinary patient selection approach, fast patient education process, prompt communication, trained staff, adequate equipment and standardized protocols. Similarly, dialysis centers would need to conduct home visits promptly, evaluate patients within 2 days of hospital discharge, educate staff and patients and prepare an efficient space for dialysis. With a strong support system, Shastri said, urgent-start PD is feasible.
“PD is more cost effective than hemodialysis with superior quality of life, acceptable complication rate, as well as patient and survival technique,” Shastri said. “A sound infrastructure, prompt PD catheter placement and protocols are necessary for a successful program. Ensure that there is low volume and supine exchanges to lower the risk of catheter leaks. Also, urgent start can increase PD utilization. This will be a step forward in fostering the goal set by the advanced American Kidney Health Initiative.”
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Shastri S, et al. Integrating urgent start PD and support team: Making it work. Presented at: Annual Dialysis Conference; March 4-7, 2022 (virtual meeting).
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