Using manual exchanges for an urgent-start peritoneal dialysis program

Abstract

BackgroundUrgent-start peritoneal dialysis (USPD) was designed to avoid temporary hemodialysis initiation with a hemodialysis catheter. In these patients, PD is initiated within 2 weeks of catheter placement, but typically these prescriptions utilize automated peritoneal dialysis (APD) with a cycler. Manual exchanges have not been reported previously for USPD. We hypothesize that using multiple, low-volume manual exchanges, patients will have similar rates of peritonitis, exit-site infection (ESI), pericatheter leaks and discontinuation of PD in the first 3 months after initiation.MethodsThis retrospective study included patients who initiated PD in our unit from May 2014 until August 2016 using our USPD protocol. Patients with a body surface area <1.7 m2 used 750 mL dwell volumes and those >1.7 m2 used 1000 mL dwell volumes during the first 7 days. Dwell times were 2–2.5 h for two to three exchanges per day. After 7 days of successful therapy, the dwell volumes were doubled. All patients were maintained on furosemide 160 mg twice daily.ResultsThere were 20 patients enrolled in our USPD program. Our rates of peritonitis, ESI, pericatheter leak and discontinuation of PD were 5%, 0%, 5% and 5%, respectively.ConclusionsManual exchange during USPD is a viable modality with similar results as APD. Using manual exchanges allows patients to be more ambulatory during the day when they are not dwelling, allows nurses to evaluate the amount of ultrafiltration and effluent characteristics and allows for training in manual exchanges as well.

The modality of choice, manual or automated, for urgent start peritoneal dialysis

“…From the available evidence, it is safe to say that both PD modalities using manual or automated exchanges can be successfully used for starting PD urgently, within 2 weeks of catheter insertion, for late-presenting ESRD patients. Although, the earlier publications on USPD using automated exchanges reported a relatively higher rate of mechanical complications [6, 7], more recent papers describing USPD protocols using low-volume automated exchanges in a supine posture [10, 11] stated low rates of mechanical complications, comparable with those published in protocols using manual exchanges [1, 4, 5]. In a review published elsewhere, the authors reported that USPD has comparable short-term outcomes to both urgent HD and conventional PD.…”

“…In the CKJ paper in question [1], PD was typically started within 48 h of catheter insertion, using manual exchanges and low dwell volumes in a strict supine position. For patients with a body surface area (BSA) < 1.7 m 2 , an initial dwell volume of 750 mL was used, and for those with a BSA >1.7 m 2 , a dwell volume of 1000 mL was used.…”

“…Different methods of PD catheter insertion were used, including percutaneous [4, 7, 9, 11], laparoscopic [1, 8, 9, 11] and open surgical techniques [5, 6, 10] in studies employing both manual and automated exchanges. The mode of PD catheter insertion does not appear to be a common denominator dictating the outcome in these studies.…”

“…In a recently published paper in the Clinical Kidney Journal (CKJ), Naljayan et al . [1] reported the successful use of manual exchanges for their urgent start peritoneal dialysis (USPD) programme. The article adds to the growing number of publications describing the successful initiation of peritoneal dialysis (PD) before the recommended waiting period of 2 weeks after PD catheter insertion—often referred to as USPD.…”

Is surgical PD catheter insertion safe for urgent‐start peritoneal dialysis?

“…More recently, Naljayan et al published their results with USPD following laparoscopic PD catheter insertion by general surgeons . Peritoneal dialysis was started within 48 hours in the majority of patients.…”