Feasibility Of Urgent-start Peritoneal Dialysis In Patients With End-stage Renal Disease

Aims The prevalence of end-stage renal disease(ESRD)is on the rise worldwide.Urgent-start dialysis is frequently carried out worldwide,and 30%–50% of patients undergoing dialysis start the procedure urgently.Hemodialysis(HD)employing a temporary central venous catheter(CVC)is frequently used in this situation,resulting in a significantly high inc idence of short-term dialysis-related complications,inc luding catheter-related infections,bacteremia and thrombosis,and as well as higher mortality.Increasing research has suggested that peritoneal dialysis(PD)may be a feasible and safe alternative urgent-start dialysis modality to HD.This present research focus on several questions below by directly comparing the short-term dialysis-related complications and long-term outcomes in urgent-start PD and HD patients:1.To evaluate the safety and feasibility of urgent-start PD in ESRD patients.2.To evaluate the safety and feasibility of urgent-start PD in older patients with ESRD.3.To explore the safety and feasibility of urgent-start PD in patients with ESRD and diabetes.Methods1.In this part of study,ESRD patients aged > 18 years who initiated dialys is urgently at Ren Ji Hospital,School of Medicine,Shanghai Jiao Tong Univers ity from January 2011 to December 2014 were included.Urgent-start dialysis was defined as initiation of PD in patients with newly diagnosed ESRD who are not yet on dialysis and who require dialysis initiation less than two weeks after PD catheter placement but do not require emergent dialys is.Patients unable to tolerate PD catheter insertion or wait for the PD procedure were excluded,inc luding patients with severe respiratory insuffic iency,severe acute heart failure,severe hyperkalemia(>6.5 mmol/L),or severe acidosis(serum bicarbonate [HCO3] <12mmol/L).Patients were grouped according to their dialys is modality(PD and HD).Each patient was followed until death,loss of follow-up or January 2016.Data recorded at the time of initiating dialys is included age,gender,primary etiology of ESRD,use of steroids within 6 months,presence of comorbidities(diabetes,hypertension,cardiovascular disease,chronic heart failure [New York Heart Association(NYHA)stage III–IV],cerebrovascular disease,and malignancy,Charlson co-morbidity index[CCI]),and laboratory parameters,inc luding serum creatinine(Scr),blood urea nitrogen(BUN),estimated glomerular filtration rate(e GFR),brain natriuretic peptide(BNP),serum albumin(Alb),hemoglobin(Hb),serum potassium(K),p H,serum HCO3,serum calcium(Ca),serum corrected calcium(corrected Ca),serum phosphate(P),intact parathyroid hormone(i PTH),triglycerides(TG),total cholesterol(TC),high-density lipoprotein(HDL)and low-dens ity lipoprotein(LDL).Incidence of dialysis-related complications,dialysis-related complications requiring catheter re-insertion,and bacteremia during the first 30 days after catheter insertion,as well as patient survival were compared between two groups.2.In this part of study,ESRD patients aged > 65 years who initiated dialys is urgently at Ren Ji Hospital,School of Medicine,Shanghai Jiao Tong Univers ity from January 2011 to December 2014 were included.Urgent-start PD was defined as initiation of PD in patients with newly diagnosed ESRD who are not yet on dialysis and who require dialysis initiation less than two weeks after PD catheter placement but do not require emergent dialys is.Patients unable to tolerate PD catheter insertion or wait for the PD procedure were excluded,inc luding patients with severe respiratory insuffic iency,severe acute heart failure,severe hyperkalemia(>6.5 mmol/L),or severe acidosis(serum bicarbonate [HCO3] <12mmol/L).Patients were grouped according to their dialys is modality(PD and HD).Each patient was followed until death,loss of follow-up or January 2016.Data recorded at the time of initiating dialys is included age,gender,primary etiology of ESRD,use of steroids within 6 months,presence of comorbidities(diabetes,hypertension,cardiovascular disease,chronic heart failure [NYHA III–IV],cerebrovascular disease,and malignancy),CCI,and laboratory parameters,inc luding Scr,BUN,e GFR,BNP,Alb,Hb,K,p H,HCO3,Ca,corrected Ca,P,i PTH,TG,TC,HDL and LDL.Incidence of dialysis-related complications,dialysis-related complications requiring catheter re-insertion,and bacteremia during the first 30 days after catheter insertion,as well as patient survival were compared between two groups.3.This part of study enrolled patients with ESRD and diabetes melitius aged > 18 years at Ren Ji Hospital,School of Medicine,Shanghai Jiao Tong University from January 2011 to December 2014.Urgent-start PD was defined as initiation of PD in patients with newly diagnosed ESRD who are not yet on dialys is and who require dialys is initiation less than two weeks after PD catheter placement but do not require emergent dialysis.Patients unable to tolerate PD catheter insertion or wait for the PD procedure were exc luded,inc luding patients with severe respiratory insufficiency,severe acute heart failure,severe hyperkalemia(>6.5mmol/L),or severe acidosis(serum bicarbonate [HCO3] <12 mmol/L).Patients were grouped according to their dialysis modality(PD and HD).Each patient was followed until death,loss of follow-up or January 2016.Data recorded at the time of initiating dialys is included age,gender,primary etiology of ESRD,use of steroids within 6 months,presence of comorbidities(hypertension,cardiovascular disease,chronic heart failure[NYHA III–IV],cerebrovascular disease,and malignancy),CCI,and laboratory parameters,including Scr,BUN,e GFR,BNP,Alb,Hb,K,p H,HCO3,Ca,corrected Ca,P,i PTH,TG,TC,HDL and LDL.Incidence of dialys is-related complications,dialys is-related complications requiring catheter re-insertion,and bacteremia during the first 30 days after catheter insertion,as well as patient survival were compared between two groups.Results1.This part of study enrolled 300 patients.Compared with HD patients,PD patients were elder,and had more diabetes,less heart failure,lower levels of BNP and higher levels of Hb.There were no significant differences in terms of gender,use of steroids,prevalence of diabetic nephropathy,prevalence of comorbidities(hypertension,cerebrovascular diseases,and malignancies),CCI,and baseline Scr?BUN?e GFR?p H?HCO3?K?Alb?Ca?corrected Ca?P?i PTH?TG?TC?HDL?LDL between the groups(all p >0.05).The inc idence of dialysis-related complications,dialys is-related comlications requiring re-insertion and bacteremia during the first 30 days were s ignificantly lower in PD than HD patients.Logistic regression analys is showed that urgent-start HD was an independent risk factor for short-term dialys is-related complications.The patient survival rate was higher in the PD compared with the HD group according to Kaplan–Meier analysis,and urgent-start HD,age and hypokalemia were independent risk factors for patient survival according to multivariate Cox modeling analysis.2.A total of 94 patients were enrolled in this part of study.Patients in the PD group had a higher incidence of diabetic nephropathy,lower e GFR and higher serum P levels.There was no difference in gender,age,use of steroids within 6 months,comorbidities,CCI,Scr,BUN,BNP,Hb,Alb,K,p H,HCO3,Ca,corrected Ca,i PTH,TG,TC,HDL,and LDL between the groups.The incidence of dialysis-related complications and dialysis-related complications requiring re-insertion during the first 30 days were significantly lower in PD compared with HD patients.Logistic regression identified urgent-start HD as an independent risk factor for dialysis-related complications compared with urgent-start PD.There was no significant difference in patient survival between the groups.3.80 patients were included in the study.Compared with the HD group,patients in the PD group had lower inc idences of heart failure and malignancy,lower BNP,lower corrected-Ca and higher i PTH.There was no difference in other baseline characteristics.The incidence of dialys is-related complications and complications requiring reinsertion during the first 30 days were significantly lower in PD patients.Logistic regression identified urgent-start HD as an independent risk factor for dialys is-related complications compared with urgent-start PD.The patient survival rate was higher in the PD compared with the HD group,according to Kaplan–Meier analysis,and urgent-start HD and hypokalemia were independent risk factors for patient survival according to multivariate Cox modeling analysis.Conclusion1.PD may be a safe and feasible alternative to HD for urgent dialys is in ESRD patients at an experienced center,with lower short-term dialysis related complications risk and better patient survival.2.Urgent-start PD appears to be a safe and feasible alternative to HD for older patients with ESRD,with a reduced risk of short-term dialysis-related complications.3.PD may be acceptable,safe,and feasible for urgent-start dialysis in patients with ESRD and diabetes,with lower short-term dialysis related complications risk and better patient survival.