Infectious and mechanical complications in planned-start vs. urgent-start peritoneal dialysis: a cohort study

Abstract

Background: Few studies have compared the infectious and mechanical complications seen in planned-start and urgent-start peritoneal dialysis (PD) patients. Objectives: To compare the incidence and etiology of mechanical and infectious complications in patients offered planned- and urgent-start PD and assess potential differences in patient survival and time on PD. Methods: This retrospective cohort study included patients with chronic kidney disease on planned- and urgent-start PD seen from 2014 to 2020 and compared them for mechanical and infectious complications, clinical outcome, death rates, and need to switch to hemodialysis. Results: Ninety-nine patients on planned-start PD and 206 on urgent-start PD were included. Incidence of exit-site infection (18.9 vs. 17.17%, p=0.71) and peritonitis (24.27 vs. 27.27%, p=0.57) were similar between patients, while pathogens causing peritonitis were different, although non-fermenting Gram-negative bacilli were more commonly seen in the planned-start PD group. Leakage as a mechanical complication and hospitalization were more common among patients needing urgent-start PD (10.68 vs. 2.02%, p=0.0085 and 35.44 vs. 17.17%, p=0.0011, respectively). Patient survival was similar between groups. Cox regression found an association between death and age (HR=1.051, 95% CI 1.026-1.07, p=0.0001) and albumin (HR=0.66, 95% CI 0.501-0.893, p=0.0064), and between peritonitis and a diagnosis of diabetes (HR=2.016, 95% CI 1.25-3.25, p=0.004). Conclusion: Patient survival and time on PD were similar between the planned- and urgent-start PD groups, while leakage was more frequently seen in the urgent-start PD group. Death was associated with lower albumin levels and older age, while peritonitis was associated with diabetes.

Unplanned-start peritoneal dialysis in Brazil: great results, little application

“…However, a higher incidence of catheter leakage and mechanical dysfunction was observed in the unplanned initiation group 3 . These findings are not different from the still few Brazilian publications on the topic 4,5 , and are now corroborated by Muller and Ponce in a retrospective cohort analysis with more than three hundred patients 6 . The authors compared different outcomes of 206 patients who started PD up to 72 hours (unplanned) after catheter implantation with those of 99 patients whose therapy started after seven days of insertion (defined by the authors as planned) between 2014 and 2020.…”

“…Another unique contribution of the work by Muller and Ponce is the identification of etiological causes of infection, allowing the determination of their patients' microbiota and increasing the chance of treatment success, which impacts technique and patient survival 6 . Given the impact of microbial identification on patient outcomes and treatment success, the updated ISPD peritonitis guideline recommends a negative culture percentage of less than 15% yearly, which is a challenge to many PD services in our country due to the lack of laboratories specialized in those procedures 7 .…”

Diálise peritoneal de início urgente no Brasil: excelentes resultados, pouca aplicação

“…Entretanto, observou-se uma maior incidência de extravazamento do cateter e disfunção mecânica no grupo de início não planejado 3 . Estes achados não diferem das ainda poucas publicações brasileiras sobre o tema 4,5 , e são agora corroborados por Muller e Ponce em uma análise de coorte retrospectiva com mais de trezentos pacientes 6 . Os autores compararam diferentes desfechos de 206 pacientes que iniciaram a DP em até 72 horas (não planejada) após a implantação do cateter com aqueles de 99 pacientes cuja terapia teve início após sete dias da inserção (definida pelos autores como planejada) entre 2014 e 2020.…”

“…Os autores compararam diferentes desfechos de 206 pacientes que iniciaram a DP em até 72 horas (não planejada) após a implantação do cateter com aqueles de 99 pacientes cuja terapia teve início após sete dias da inserção (definida pelos autores como planejada) entre 2014 e 2020. Entre os principais resultados, constatou-se que a técnica e a sobrevida do paciente foram semelhantes em ambos os grupos e que o extravazamento foi mais frequente com o início não planejado da DP 6 .…”

“…Outra contribuição singular do trabalho de Muller e Ponce é a identificação das causas etiológicas da infecção, permitindo a determinação da microbiota de seus pacientes e aumentando as chances de sucesso do tratamento, o que impacta na sobrevida da técnica e do paciente 6 . Dado o impacto da identificação microbiana nos desfechos dos pacientes e no sucesso do tratamento, as diretrizes atualizadas da ISPD sobre peritonite recomendam uma porcentagem de cultura negativa inferior a 15% ao ano, o que é um desafio para muitos serviços de DP em nosso país, devido à falta de laboratórios especializados nesses procedimentos 7 .…”