Preparing for Success with Urgent-Start Peritoneal Dialysis

More than half of patients who progress to end stage renal disease (ESRD) do not have a distinct plan for treatment at the time of dialysis therapy initiation.¹ Most ESRD patients begin dialysis with a tunneled central venous catheter (CVC),² yet this approach can introduce many potential complications. In many cases, urgent-start peritoneal dialysis (PD) may provide a safer alternative with better clinical results for patients who present for unplanned dialysis starts.^{1, 3–8}

Urgent-start PD involves initiating PD within 24 to 48 hours after PD catheter insertion, which is earlier than the standard two-week healing time. Patients receive low-volume, supine dialysis—typically in an outpatient setting—for one to two weeks until their catheter heals. During this time, patients are educated and trained to be able to perform PD at home after the catheter healing period. After returning home, these patients should have home clinic visits at least once per month and consistent access to the care team via phone to ensure they are increasing their comfort and confidence in receiving PD at home.

Clinical benefits of avoiding a CVC with urgent-start PD may include:^{1, 3–8}

• Lower septicemia, bacteremia, stenosis and thrombosis events
• Lower mortality risk
• Lower chances of hospital readmission
• Not precluded from at-home treatment options
• Preservation of residual renal function, leading to improved adequacy, volume control and lowered mortality rate

While tunneled CVCs should generally be avoided, if immediate dialysis is required to control uremic symptoms or abnormal lab values, a temporary, non-tunneled CVC plus a PD catheter may be a plausible option and may be placed on the same day.

Preparing for Success

Preparing for and providing urgent-start PD requires a team, and there are multiple efforts you can make as a physician to support treatment success. These efforts may include:

• Identify and build relationships with PD catheter operators, such as surgeons, interventional radiologists or interventional nephrologists
• Consider whether any crashing unplanned start patients may be appropriate candidates for urgent-start PD versus cuffed CVC placement
• Work closely with clinic nurses regarding urgent-start patient status and resolving any complications during urgent-start treatment period
• Provide education to patients before they progress to ESRD and identify the modality that would best meet their individual needs

In addition to the clinical benefits patients may experience, in many cases PD may promote a higher quality of life by offering a flexible treatment schedule, greater ability to pursue life and career goals, needle-free treatments and fewer dietary restrictions. It is very important for patients with kidney disease and their families to be educated on dialysis modalities and what they offer, including the potential benefits of PD, and to develop an informed treatment plan before they need dialysis.

_{¹Ghaffari A. Am J Kidney Dis. 2012; 59: 400–408. ²US Renal Data System, 2016 Annual Data Report. ³Ishani A et al. Kidney Int. 2005; 68: 311–318. ⁴Kundu S. Semin Intervent Radiol. 2009; 26(2):115–121. ⁵Baskin JL et al. Lancet. 2009; 374(9684):159–169. ⁶Ravani P et al. J Am Soc Nephrol. 2013; 24:465–473. ⁷He L et al. Perit Dial Int. 2016 May–Jun; 36(3):334–9. ⁸Krediet RT. Clin J Am Soc Nephrol. 2017 Mar 7; 12(3):377–379.}