Case series of acute peritoneal dialysis in the prone position for acute kidney injury during the Covid-19 pandemic: Prone to complications?

Abstract

Patients with kidney failure and acute respiratory distress syndrome (ARDS) requiring prone position have not been candidates for peritoneal dialysis (PD) due to concern with increased intra-abdominal pressure, reduction in respiratory system compliance and risks of peritoneal fluid leaks. We describe our experience in delivering acute PD during the surge in Covid-19 acute kidney injury (AKI) in the subset of patients requiring prone positioning. All seven patients included in this report were admitted to the intensive care unit with SARS-CoV-2 infection leading to ARDS, AKI and multisystem organ failure. All required renal replacement therapy, and prone positioning to improve ventilation/perfusion mismatch. All seven were able to continue PD despite prone positioning without any detrimental effects on respiratory mechanics or the need to switch to a different modality. Fluid leakage was noted in 71% of patients, but mild and readily resolved. We were able to successfully implement acute PD in ventilator-dependent prone patients suffering from Covid-19-related AKI. This required a team effort and some modifications in the conventional PD prescription and delivery.

Epidemiology, prognosis and management of potassium disorders in Covid‐19

“…reduce respiratory system compliance, and enhance the risk of fluid leakage. 87 Finally, the correction of potassium abnormalities not only enhances the prognosis of patients with Covid-19, but research has also shown that potassium levels tend to become normalized at the same time as improvements in the disease. 19 Therefore, along with treating Covid-19, clinicians must also be careful to keep potassium levels within the normal range.…”

“…In order to minimize the risk of rebound hyperkalemia, after hemodialysis, it would be better to keep the dialysate potassium concentrations above 2 mmol/L 86 . In comparison to hemodialysis, the rate of potassium removal is much lower in peritoneal dialysis and also its utilization is challenging in critically ill Covid‐19 patients, owing to their prone position that will increase abdominal pressure, reduce respiratory system compliance, and enhance the risk of fluid leakage 87 …”

Outcomes following peritoneal dialysis for COVID-19-induced AKI: A literature review

“…18 Soomro et al reported seven patients on PD in prone position, all had improvement in PF ratios. 9 PD was well tolerated in ventilated patients in supine position. 9,12 Almeida et al also found improvement in PF ratio along with lung compliance and static respiratory system resistance (Rsr) after 3 PD sessions.…”

“…9 PD was well tolerated in ventilated patients in supine position. 9,12 Almeida et al also found improvement in PF ratio along with lung compliance and static respiratory system resistance (Rsr) after 3 PD sessions. 19 Prospective comparison of effect of PD and HD on respiratory mechanics revealed improvement in pulmonary compliance pre and post dialysis time points in both modalities with no statistical difference between two modalities.…”

Peritoneal Dialysis as a Renal Replacement Therapy Modality for Patients with Acute Kidney Injury

“…Ventilator settings for all patients remained stable prior to and within 12–24 h of prone PD initiation. Given the need to minimize nursing staff exposure during the early pandemic, intra-abdominal pressures were not measured and would be interesting to pursue in future studies [ 20 ].…”