Dialysis For Acute Kidney Injury Research Articles

Recovery Dynamics and Prognosis After Dialysis for Acute Kidney Injury

The interplay among baseline kidney function, severity of acute kidney disease (AKD), and post-AKD kidney function has significant associations with patient outcomes. However, a comprehensive understanding of how these factors are collectively associated with mortality, major adverse cardiac events (MACEs), and end-stage kidney disease (ESKD) in patients with dialysis-requiring acute kidney injury (AKI-D) is yet to be fully explored. To investigate the associations of baseline kidney function, AKD severity, and post-AKD kidney function with mortality, MACEs, and ESKD in patients with AKI-D. This nationwide, population-based cohort study of patients with AKI-D was conducted between January 1, 2015, and December 31, 2018, using data from various health care settings included in the Taiwan nationwide population-based cohort database. Data analysis was conducted from April 28, 2022, to June 30, 2023. Exposure to severe AKI and baseline and post-AKD kidney function. The primary outcomes were all-cause mortality and incident MACEs, and secondary outcomes were risks of permanent dialysis and readmission. A total of 6703 of 22 232 patients (mean [SD] age, 68.0 [14.7] years; 3846 [57.4%] male) with AKI-D with post-AKD kidney function follow-up and AKD stage data were enrolled. During a mean (SD) 1.2 (0.9) years of follow-up, the all-cause mortality rate was 28.3% (n = 1899), while the incidence rates of MACEs and ESKD were 11.1% (n = 746) and 16.7% (n = 1119), respectively. After adjusting for known covariates, both post-AKD kidney function and baseline kidney function, but not AKD severity, were independently associated with all-cause mortality, MACEs, ESKD, and readmission. Moreover, worse post-AKD kidney function correlated with progressive and significant increases in the risk of adverse outcomes. In this cohort study of patients with AKI-D, more than one-quarter of patients died after 1.2 years of follow-up. Baseline and post-AKD kidney functions serve as important factors associated with the long-term prognosis of patients with AKI-D. Therefore, concerted efforts to understand the transition from post-AKD to chronic kidney disease are crucial.

Utilization of peritoneal dialysis for ventilated COVID-19 patients with acute kidney injury

BackgroundPeritoneal dialysis for acute kidney injury is not typically a first-line option for mechanically ventilated patients in the intensive care unit. This series investigates the technical feasibility and clinical implications of bedside peritoneal dialysis catheter placement and utilization for mechanically ventilated COVID-19 patients. MethodsPatient data was retrospectively collected on patient characteristics, hospital course, fluid balance, ventilatory mechanics and associated morbidity and mortality of qualifying patients at a single center from March to April of 2020. Peritoneal dialysis catheters were inserted at bedside in the ICU for use as the primary modality of renal replacement therapy. Ventilatory mechanics were obtained prior to catheter insertion and after the first dwell. Statistics were calculated using GraphPad Prism and Excel. ResultsSeven male ventilated patients ages 52–83 were included. They were primarily Hispanic (71.43%). Comorbidities included chronic kidney disease (14.29%), hypertension (57.14%), hyperlipidemia (42.86%), and diabetes (28.57%). There were no mortalities associated the procedure. All-cause mortality at the time of data collection was 42.8%. Two patients had delayed initiation of peritoneal dialysis due to bleeding. Ventilatory mechanics before and after the first dwell did not demonstrate a significant difference in required FiO2, PEEP, tidal volumes or PaO2 to FiO2 ratios (p = 0.9172, p = 0.7398, p = 0.0924, p = 0.7227). DiscussionBedside placement of catheters was performed quickly and safely. Peritoneal dialysis was utilized for the treatment of acute kidney injury in mechanically ventilated patients with COVID-19 without significantly impacting respiratory mechanics. Peritoneal dialysis should be considered for similar ICU patients needing renal replacement therapy.

Early outcomes of a triple-branched stent graft implantation in elderly patients with acute type a aortic dissection

PurposeOlder patients with acute type A aortic dissection (ATAAD) have higher risk of mortality than that of younger patients when a total arch reconstruction (TAR) is required. Triple-branched stent graft (TBSG) implantation is a novel technique for TAR. However, early outcomes of a TBSG implantation in older patients have not been reported. This study aimed to evaluate the early outcomes of the TBSG technique in older patients with ATAAD.MethodsFrom February 2015 to December 2020, 640 patients who simultaneously underwent an emergent open aortic surgery and TBSG implantation for ATAAD were enrolled in this study. They were categorized into the younger (age ≤ 70 years old, n = 573) and older groups (age > 70 years, n = 67). Clinical data of all patients were retrospectively reviewed.ResultThe mean ages of the patients in the younger and older groups were 45.3 ± 9.6 years old and 73.5 ± 3.0 years old, respectively. Preoperative characteristics were similar between the two groups, except for weight and incidence of moderate or greater aortic regurgitation, which were lower in the older group than those in the younger group. Surgical procedure and duration (i.e., duration for cardiopulmonary bypass, aortic cross-clamp, selected cerebral perfusion, and total circulation arrest) were comparable between the two groups (p > 0.05). Patients in the older group had higher incidence of dialysis for acute kidney injury and longer ICU stay compared with those in the younger group. However, the incidences of 30-day mortality (5.1% in younger group vs. 7.5% in older group, p = 0.407) and other major complications (i.e., neurological adverse events) were similar between the two groups.ConclusionTBSG implantation for ATAAD resulted in an acceptable mortality rate in patients above 70 years old, thus, it could be a feasible surgical procedure to perform in older patients with ATAAD when a TAR is required.

Timing of dialysis in acute kidney injury using routinely collected data and dynamic treatment regimes

Background and objectivesDefining the optimal moment to start renal replacement therapy (RRT) in acute kidney injury (AKI) remains challenging. Multiple randomized controlled trials (RCTs) addressed this question whilst using absolute criteria such as pH or serum potassium. However, there is a need for identification of the most optimal cut-offs of these criteria. We conducted a causal analysis on routinely collected data (RCD) to compare the impact of different pre-specified dynamic treatment regimes (DTRs) for RRT initiation based on time-updated levels of potassium, pH, and urinary output on 30-day ICU mortality.Design, setting, participants, and measurementsPatients in the ICU of Ghent University Hospital were included at the time they met KDIGO-AKI-stage ≥ 2. We applied inverse-probability-of-censoring-weighted Aalen–Johansen estimators to evaluate 30-day survival under 81 DTRs prescribing RRT initiation under different thresholds of potassium, pH, or persisting oliguria.ResultsOut of 13,403 eligible patients (60.8 ± 16.8 years, SOFA 7.0 ± 4.1), 5622 (63.4 ± 15.3 years, SOFA 8.2 ± 4.2) met KDIGO-AKI-stage ≥ 2. The DTR that delayed RRT until potassium ≥ 7 mmol/l, persisting oliguria for 24–36 h, and/or pH < 7.0 (non-oliguric) or < 7.2 (oliguric) despite maximal conservative treatment resulted in a reduced 30-day ICU mortality (from 12.7% [95% CI 11.9–13.6%] under current standard of care to 10.5% [95% CI 9.5–11.7%]; risk difference 2.2% [95% CI 1.3–3.8%]) with no increase in patients starting RRT (from 471 [95% CI 430–511] to 475 [95% CI 342–572]). The fivefold cross-validation benchmark for the optimal DTR resulted in 30-day ICU mortality of 10.7%.ConclusionsOur causal analysis of RCD to compare RRT initiation at different thresholds of refractory low pH, high potassium, and persisting oliguria identified a DTR that resulted in a decrease in 30-day ICU mortality without increase in number of RRTs. Our results suggest that the current criteria to start RRT as implemented in most RCTs may be suboptimal. However, as our analysis is hypothesis generating, this optimal DTR should ideally be validated in a multicentric RCT.

Peritoneal dialysis for acute kidney injury: back on the front-line.

Peritoneal dialysis (PD) for acute kidney injury (AKI) has been available for nearly 80 years and has been through periods of use and disuse largely determined by availability of other modalities of kidney replacement therapy and the relative enthusiasm of clinicians. In the past 10 years there has been a resurgence in the use of acute PD globally, facilitated by promotion of PD for AKI in lower resource countries by nephrology organizations effected through the Saving Young Lives program and collaborations with the World Health Organisation, the development of guidelines standardizing prescribing practices and finally the COVID-19 pandemic. This review highlights the history of PD for AKI and looks at misconceptions about efficacy as well as the available evidence demonstrating that acute PD is a safe and lifesaving therapy with comparable outcomes to other modalities of treatment.

Mobile Virtual Assistant for Continuous Ambulatory Peritoneal Dialysis Complication Detection

Peritoneal dialysis (PD) is an alternative treatment of home-based dialysis for Acute Kidney Injury (AKI). A patient who undergoes PD requires self-management skills to deliver and manage dialysis at home effectively. The effluent dialysate of PD patients can be an indicator for early diagnosis complications in Peritoneal dialysis. Under normal circumstances, the appearance of effluent dialysate is transparent to yellowish clear. Changes in turbidity level or color of effluent dialysate indicate an extra or intraperitoneal abnormality. This study aims to develop an image processing model to detect and classify effluent dialysate of PD patients for early warning of complications. The model was built into the mobile application system. The dataset was obtained from patients, and secondary data were used. Image augmentation is used to enhance the quantity of data by nine times. The data set were divided for train and validation within the 8:2 ratio. The result shows that our system has a high accuracy of 94.7% and minimal loss.

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

Since the advent and predominant use of extracorporeal therapies for renal replacement therapies for acute kidney injury, the use of peritoneal dialysis has largely been limited to specific resource-limited settings. This review highlights the current data available for the utilization of peritoneal dialysis for acute kidney injury. Though the current randomized controlled trials have small patient numbers, they have demonstrated peritoneal dialysis to be an appropriate modality for dialysis therapy in acute kidney injury. Current outcomes do not show a difference in mortality, renal recovery rates, or infectious complications when compared to extracorporeal treatments. However, there is a marked heterogeneity in these trials, and more standardized reporting of trial design, techniques, complications, and outcomes is needed.

POS-179 Outcomes of Acute Kidney Injury in Patients Requiring Dialysis in Nephrology Department of a Tertiary Care Hospital in Bangladesh

Acute kidney injury (AKI) requiring dialysis is an important health care burdenand is associated with very high in-hospital mortality. As no specific treatment is available toreverse AKI, the management remains supportive, including optimized fluid, electrolyte andacid-base balance, adjusting the dose of potentially nephrotoxic medications or avoidingsecondary haemodynamic and nephrotoxic kidney injury with timely initiation of dialysis.Timely initiation of dialysis in AKI is fundamental to achieve treatment goals and to providesolute clearance and removal of excess fluid while awaiting recovery of kidney function.

COVID-19-related acute kidney injury and dialysis: What are the outcomes in South Africa?

Introduction: Acute kidney injury (AKI) in hospitalized patients infected with COVID-19 is associated with an elevated mortality rate compared to non-infected patients (39% versus 24%). This is despite a lower prevalence of AKI in COVID-19-infected patients (17 vs 22%). The reasons are multifactorial and have been well documented in developed countries, whereas in developing countries there are scant data. Methods: This study aimed to document the mortality in COVID-19-infected South African patients who required dialysis for AKI. Exclusion criteria included any chronic kidney replacement therapy (transplantation or dialysis). A REDCap survey of South African nephrologists and nephrology fellows registered with the South African Nephrology Society was conducted. The primary outcome was all-cause in-hospital mortality, while additional points of interest included comorbidities, dialysis modality and intervention required. Univariate analysis of mortality predictors was performed. Results: The COVID-19-related AKI mortality rate was 58.9%. Significant predictors included continuous veno-venous haemodialysis therapy, invasive ventilation, use of inotropes and the presence of shock. Ischaemic heart disease, heart failure and admission to a private healthcare facility were associated with lower mortality. No significant associations were found with ethnicity, sex, hypertension, diabetes, HIV infection or the use of other modes of dialysis. Conclusions: In South African patients, we report similar outcomes in critically ill patients requiring dialysis for AKI, relative to international data. The predictors of mortality most likely reflect the severity of the illness in our patients. The data suggest that continuous veno-venous haemodiafiltration or slow low efficiency dialysis may be the preferred dialysis modalities in these patients.

IN-HOSPITAL MORTALITY OF ACUTE KIDNEY INJURY: AN EXPERIENCE FROM SOUTH RAJASTHAN.

INTRODUCTION: There are few studies on in-hospital mortality among medical intensive care unit (MICU) patients with acute kidney injury (AKI). We assessed the clinical characteristics of AKI at MICU admission, its impact on mortality during the current hospitalization, and whether the inuence of AKI varied in subgroups of AKI patients. METHODS: We identied all adult aged 12 years and above having medical etiology related community acquired AKI who were admitted to MICU at Pacic Medical College and Hospital, Udaipur, India; from 2015 to 2019. AKI was dened based on the Kidney Disease Improving Global Outcomes (KDIGO) criteria; based on serum creatinine (SCr). Dialysis requiring AKI (D-AKI) was dened as needing acute dialysis at or after MICU admission. Among 2440 MICU patients; 516 patients (21.1%) had AKI. We analyzed in-hospital mortality for subgroups of AKI: stage1, stage2 and stage3: with different etiology, comorbidity levels, acute risk factors, primary hospital diagnosis, and treatment with mechanical ventilation, vasopressors and dialysis. RESULTS: Maximum number of AKI patients (57.8%) were in KDIGO Stage3, while stage1 and stage2 had 17.8% and 24.4% respectively. 51.4% patients were male, median age was 54.81 years and average length of ICU stay was 11.73 days. The most common primary diagnosis and etiology was sepsis (31.4%), the most common acute risk factor was hypovolemia (18.8%), the common chronic comorbidity were diabetes (17.0%) and hypertension (10.0%). The most common presenting symptoms was oliguria (43.8 %), while commonest sign on admission was edema (28.1%). Common indications for dialysis were oliguria (75%), hyperkalemia (38.2%), refractory uid overload (36.2%) and metabolic acidosis (35.2%). Overall common critical care treatment required in AKI patients were acute dialysis (58.9%), vasopressor support (16.5%) and ventilator support (14%). The requirement of dialysis was 0.0%, 4.8% and 100%; among stage1, stage2 and stage3 respectively. The overall AKI mortality was 9.9% (95% condence interval (CI) 7% to 12% ). The associations between AKI and mortality were 10.87% (95% CI 5% to 17%) for the AKI-stage1, 13.49% (95% CI 8% to 19% ) for the AKI-stage2 and 8.05% (95% CI 5% to 11%) for the AKI-stage3. The mortality in D-AKI group was 8.6% (95% CI 5 % to 12 %) compared to the mortality in ND-AKI group 11.8% (95% CI 7 % to 16 %). The association between AKI and in-hospital mortality was evident in all subgroups of AKI; association was more pronounced in stage2 AKI, mostly due to worsening of complications which suggests that KDIGO stage2 AKI is a transition zone among D-AKI and ND-AKI groups. Further, it may be needed to lower the threshold for dialysis criteria in AKI. CONCLUSIONS: Any degree of AKI was associated with increased mortality. Timely and early initiation of dialysis in AKI was an important prognostic factor for the reduction of in-hospital mortality.

Changing trends in dialysis modalities utilization and mortality in children, adolescents and young adults with acute kidney injury, 2010\u20132017

The aim of the study was to assess trends in the relative use of dialysis modalities in the hospital-based pediatric cohort and to determine risk factors associated with in-hospital morality among pediatric patients receiving dialysis for acute kidney injury (AKI). Patients aged < 20 years who received dialysis between 2010 and 2017 were identified from electronic health records databases of a Taiwan’s healthcare delivery system. The annual uses of intermittent hemodialysis (HD), continuous and automated peritoneal dialysis (PD) and continuous kidney replacement therapy (CKRT) were assessed using Cochran-Armitage Tests for trend. Among patients who received their first dialysis as inpatients for AKI, a multivariate logistic regression model was employed to assess mortality risks associated with dialysis modalities, patient demographics, complexity of baseline chronic disease, and healthcare service use during their hospital stays. Kidney dialysis was performed 37.9 per patient per year over the study period. Intermittent hemodialysis (HD) (73.3%) was the most frequently used dialysis modality. In the inpatient setting, the relative annual use of CKRT increased over the study period, while HD use concomitantly declined (P < 0.0001). The overall in-hospital mortality rate after dialysis for AKI was 33.6%, which remained steady over time (P = 0.2411). Patients aged < 2 years [adjusted odds ratio: (aOR) 3.36; 95% confidence interval (CI) 1.34–8.93] and greater vasoactive regimen use (aOR: 17.1; 95% CI: 5.3–55.21) were significantly associated with dialysis-related mortality. Overall treatment modality used for dialysis in pediatric patients increased slowly in the study period, and HD and CRKT modality uses largely evolved in the inpatient setting. Younger ages and use of more vasoactive medication regimens were independently associated with increased early mortality in patients on AKI-dialysis.

Should PLEX Be Used for Severe AKI and/or Pulmonary Hemorrhage in ANCA-Associated Vasculitis (AAV)? CON.

Vasculitis associated with the formation of ANCA manifests in several forms defined by the extent of organ involvement (renal limited or systemic), with or without granulomatous tissue involvement, and by the presence and nature of the ANCA (antimyeloperoxidase or antiproteinase 3 and associated autoantibodies, in particular antiglomerular basement membrane [anti-GBM] autoantibodies) (1). Severe kidney disease with extensive crescentic involvement and a clinical syndrome of rapidly progressive GN is common in all forms of ANCA-associated vasculitis (AAV) (1). Diffuse alveolar hemorrhage (DAH), of varying severity, can be seen in many kinds of GN (Goodpasture syndrome) but is particularly common in AAV, with or without anti-GBM antibody (2). The therapy of AAV has greatly improved in recent years, and the use of rituximab (RTX), cyclophosphamide (CYC), or combinations of RTX and CYC plus moderate doses of steroids can effectively and safely induce a complete or partial remission in the great majority of patients (3 ⇓–5). The role of adjunctive therapy with plasmapheresis (PLEX) has been controversial, except in cases where anti-GBM autoantibody disease is found alone or concomitantly with AAV. The publication of the large Plasma Exchange and glucocorticoid dosing in treatment of anti-neutrophil cytoplasmic antibody associated vasculitis (PEXIVAS) trial in 2020 has generated much attention to this controversy (6). This debate focuses on this controversy by laying out a precise question: should PLEX be used for severe AKI and/or pulmonary hemorrhage in patients with AAV? For this debate, I will interpret “severe” as meaning the need for artificial organ support (dialysis for AKI or mechanical ventilation for DAH). I will also interpret ANCA vasculitis as meaning a positive (antimyeloperoxidase or antiproteinase 3 autoantibody in the absence of anti-GBM antibody and clinical or morphologic evidence of a vasculitis involving the kidney without or with extrarenal involvement, including DAH. …

Use of peritoneal dialysis for acute kidney injury during the COVID-19 pandemic in New York City: a multicenter observational study

To demonstrate feasibility of acute peritoneal dialysis (PD) for acute kidney injury during the coronavirus disease 2019 (COVID-19) pandemic, we performed a multicenter, retrospective, observational study of 94 patients who received acute PD in New York City in the spring of 2020. Patient comorbidities, severity of disease, laboratory values, kidney replacement therapy, and patient outcomes were recorded. The mean age was 61 ± 11 years; 34% were women; 94% had confirmed COVID-19; 32% required mechanical ventilation on admission. Compared to the levels prior to initiation of kidney replacement therapy, the mean serum potassium level decreased from 5.1 ± 0.9 to 4.5 ± 0.7 mEq/L on PD day 3 and 4.2 ± 0.6 mEq/L on day 7 (P < 0.001 for both); mean serum bicarbonate increased from 20 ± 4 to 21 ± 4 mEq/L on PD day 3 (P = 0.002) and 24 ± 4 mEq/L on day 7 (P < 0.001). After a median follow-up of 30 days, 46% of patients died and 22% had renal recovery. Male sex and mechanical ventilation on admission were significant predictors of mortality. The rapid implementation of an acute PD program was feasible despite resource constraints and can be lifesaving during crises such as the COVID-19 pandemic.

Trends in the incidence and prevalence of end-stage renal disease with hemodialysis in entire Korean population: A nationwide population-based study.

Data on the overall epidemiology and temporal trends of end-stage renal disease (ESRD) requiring hemodialysis in Korea are scarce. We aimed to estimate the prevalence and incidence of ESRD requiring hemodialysis in Korea between 2002 and 2017.Using the National Health Insurance Service database, we analyzed data from the entire Korean population between 2002 and 2017. Hemodialysis patients were identified using rare incurable disease codes (V001) or prescription of medical fee codes of hemodialysis (O7020 and O7021). We only included patients who had been maintained on hemodialysis for more than 90 days from the date of dialysis initiation, to exclude patients who required short-term dialysis for acute kidney injury, conversion to peritoneal dialysis, or kidney transplantation.During the 16-year follow-up, the number of hemodialysis patients in Korea has steadily increased from 11,215 in 2002 to 67,486 in 2017. The mean age of these patients has gradually increased from 55.57 ± 13.31 years in 2002 to 62.13 ± 13.23 years in 2017. In 2017, the crude prevalence rate of hemodialysis was 1303.4 per million population. Overall, the number of men tended to be somewhat higher than that of women, and the proportion of men increased slightly from 55.56% in 2002 to 58.45% in 2017. The proportion of diabetic patients increased rapidly from 23.84% to 47.84%, and the percentage of dyslipidemic patients rose from 18.9% to 86.7%. The number of incident hemodialysis patients increased significantly from 4406 in 2003 to 12,134 in 2014, and then decreased to 8090 in 2017. In the incident cases of hemodialysis, the observed increase in the proportion of male patients and in diabetes and dyslipidemia were similar to that of prevalent patients. The more recent era of hemodialysis initiation, the better 5-year survival rates were observed.The prevalence and incidence of hemodialysis in Korea gradually increased between 2002 and 2017. The proportion of men, and patients with diabetes and dyslipidemia requiring hemodialysis also increased continuously. The survival rate of hemodialysis patients was gradually improving. These findings may serve as a reference for future epidemiological studies on hemodialysis in Korea.

POS-593 ISN SISTER RENAL CENTRES PROGRAMME: ESTABLISHING AND SUSTAINING TUNNELLED VENOUS DIALYSIS LINE PLACEMENT IN PORT HARCOURT, NIGERIA

Under the auspices of the International Society of Nephrology Sisters Renal Centres programme, Renal centres from Port Harcourt, Nigeria and Salford UK have maintained collaboration in various aspects of kidney care. A key issue in sustaining dialysis care in a lower middle income economy is access for haemodialysis (HD). Before this project all HD access was via temporary femoral vein lines inserted for a single dialysis session. Pre-visit video conferencing provided educational and planning opportunities in the delivery of peritoneal dialysis for acute kidney injury (AKI). A Nigerian kidney doctor in training visited the UK centre to gain first-hand experience of line insertion techniques. An initial visit to the sister hospital was undertaken by UK nephrologists with special interests in dialysis and interventional nephrology. A pop-up dialysis access workshop was undertaken in the dialysis unit over 3 days for junior and senior doctors and members of the multi-disciplinary team: Didactic teaching on dialysis access methods Small group teaching on the basics of HD, PD and prescriptions Simple and sustainable training tools for basic surgical procedures, HD and PD catheter insertion and Seldinger technique Dialysis access ultrasound training with volunteers examining abdominal anatomy and vascular access imaging Hands on training with simple access phantoms, made from accessible materials for ongoing practice. Tunnelled haemodialysis line insertion was achieved by local and visiting nephrologists, unique to the dialysis centre which normally relies on temporary femoral venous access. All three patients achieved successful permanent venous line access without complication. The local nephrologist was able to place catheters with the visiting interventional nephrologist closely supervising. The procedures were recorded to allow analysis and reflection on the procedures. Since the 4 lines have been successfully inserted by the local nephrologist. This has been supported with ongoing video and telephone links. This has allowed continued updates on technique, difficulties and complications. One episode of local exit site bleeding was encountered and managed with follow up calls and advice. Covid 19 has precluded the planned follow up visits. This has highlighted the issues of keeping colleagues up to date and maintaining skills when practice is significantly altered. The collaboration is investing in more robust internet communication to facilitate teaching and mentorship while planning the next part of the project to establish a peritoneal dialysis programme. Significant gains have been made on our journey to establishing long term HD vascular access for the dialysis patients in Port Harcourt Teaching Hospital, despite the major obstacles faced.

314 Medicare Coverage for Outpatient Dialysis for Acute Kidney Injury (AKI): Initial Uptake and Outcomes

314 Medicare Coverage for Outpatient Dialysis for Acute Kidney Injury (AKI): Initial Uptake and Outcomes

Barriers to and constraints of acute peritoneal dialysis in acute kidney injury: A nationwide survey.

This national survey of barriers to and constraints of acute peritoneal dialysis (aPD) in acute kidney injury (AKI) was performed by distributing an online questionnaire to all medical directors of public dialysis units registered with the Nephrology Society of Thailand during September-November 2019. One hundred and thirteen adult facilities responded to the survey covering 75 from 76 provinces (99%) of Thailand. aPD was performed in 66 centres (58%). In facilities where aPD practice was available, the utilization rate was relatively low (<10 cases/year) and limited to specific conditions, including HIV seropositive patients, previous receiving dialysis education and plan and difficult vascular access creation. Only 9% of facilities performed aPD routinely, but interestingly all such units permitted bedside catheter insertion by the nephrologists or internists. The major constraints placed on aPD practice were PD catheter insertion competency, timely catheter insertion support and the medical supporting team's knowledge/competency deficits. aPD for AKI is underutilized in Thailand and limited by the inability to undertake timely PD catheter insertion and knowledge and competency deficits.

ISPD guidelines for peritoneal dialysis in acute kidney injury: 2020 Update (paediatrics).

1.1 Peritoneal dialysis is a suitable renal replacement therapy modality for treatment of acute kidney injury in children. (1C)2. Access and fluid delivery for acute PD in children.2.1 We recommend a Tenckhoff catheter inserted by a surgeon in the operating theatre as the optimal choice for PD access. (1B) (optimal)2.2 Insertion of a PD catheter with an insertion kit and using Seldinger technique is an acceptable alternative. (1C) (optimal)2.3 Interventional radiological placement of PD catheters combining ultrasound and fluoroscopy is an acceptable alternative. (1D) (optimal)2.4 Rigid catheters placed using a stylet should only be used when soft Seldinger catheters are not available, with the duration of use limited to <3 days to minimize the risk of complications. (1C) (minimum standard)2.5 Improvised PD catheters should only be used when no standard PD access is available. (practice point) (minimum standard)2.6 We recommend the use of prophylactic antibiotics prior to PD catheter insertion. (1B) (optimal)2.7 A closed delivery system with a Y connection should be used. (1A) (optimal) A system utilizing buretrols to measure fill and drainage volumes should be used when performing manual PD in small children. (practice point) (optimal)2.8 In resource limited settings, an open system with spiking of bags may be used; however, this should be designed to limit the number of potential sites for contamination and ensure precise measurement of fill and drainage volumes. (practice point) (minimum standard)2.9 Automated peritoneal dialysis is suitable for the management of paediatric AKI, except in neonates for whom fill volumes are too small for currently available machines. (1D)3. Peritoneal dialysis solutions for acute PD in children3.1 The composition of the acute peritoneal dialysis solution should include dextrose in a concentration designed to achieve the target ultrafiltration. (practice point)3.2  Once potassium levels in the serum fall below 4 mmol/l, potassium should be added to dialysate using sterile technique. (practice point) (optimal) If no facilities exist to measure the serum potassium, consideration should be given for the empiric addition of potassium to the dialysis solution after 12 h of continuous PD to achieve a dialysate concentration of 3-4 mmol/l. (practice point) (minimum standard)3.3  Serum concentrations of electrolytes should be measured 12 hourly for the first 24 h and daily once stable. (practice point) (optimal) In resource poor settings, sodium and potassium should be measured daily, if practical. (practice point) (minimum standard)3.4  In the setting of hepatic dysfunction, hemodynamic instability and persistent/worsening metabolic acidosis, it is preferable to use bicarbonate containing solutions. (1D) (optimal) Where these solutions are not available, the use of lactate containing solutions is an alternative. (2D) (minimum standard)3.5  Commercially prepared dialysis solutions should be used. (1C) (optimal) However, where resources do not permit this, locally prepared fluids may be used with careful observation of sterile preparation procedures and patient outcomes (e.g. rate of peritonitis). (1C) (minimum standard)4. Prescription of acute PD in paediatric patients4.1 The initial fill volume should be limited to 10-20 ml/kg to minimize the risk of dialysate leakage; a gradual increase in the volume to approximately 30-40 ml/kg (800-1100 ml/m2) may occur as tolerated by the patient. (practice point)4.2 The initial exchange duration, including inflow, dwell and drain times, should generally be every 60-90 min; gradual prolongation of the dwell time can occur as fluid and solute removal targets are achieved. In neonates and small infants, the cycle duration may need to be reduced to achieve adequate ultrafiltration. (practice point)4.3 Close monitoring of total fluid intake and output is mandatory with a goal to achieve and maintain normotension and euvolemia. (1B)4.4 Acute PD should be continuous throughout the full 24-h period for the initial 1-3 days of therapy. (1C)4.5  Close monitoring of drug dosages and levels, where available, should be conducted when providing acute PD. (practice point)5. Continuous flow peritoneal dialysis (CFPD)5.1   Continuous flow peritoneal dialysis can be considered as a PD treatment option when an increase in solute clearance and ultrafiltration is desired but cannot be achieved with standard acute PD. Therapy with this technique should be considered experimental since experience with the therapy is limited. (practice point) 5.2  Continuous flow peritoneal dialysis can be considered for dialysis therapy in children with AKI when the use of only very small fill volumes is preferred (e.g. children with high ventilator pressures). (practice point).

Peritoneal dialysis in dogs and cats

Dialysis represents the separation process of a colloidal dispersion substance from molecular dispersion particles, based on the property of certain membranes to retain only colloidal particles. In veterinary medicine, the most common use for peritoneal dialysis is the therapy of acute kidney injury, although it can be employed for removing dialyzable toxins and treating pancreatitis, electrolyte disorders and acid-base imbalances, refractory congestive heart failure and metabolic congenital disorders. Peritoneal dialysis is contraindicated in patients with peritoneal adhesions, fibrosis or abdominal malignant tumours. The ideal catheter for dialysis allows for an adequate administration and evacuation of the dialysate, it determines minimum subcutaneous losses, it minimizes infection both in the peritoneal cavity and in the subcutaneous tissue. The placement method for peritoneal dialysis catheters depends on the catheter itself, on the patient and on the approximate duration of the dialysis. In cases of extreme emergency, when the peritoneal dialysis should not be used more than 72 hours, the placement of a short-term catheter is justified. The peritoneal dialysis system is placed immediately after the peritoneal dialysis catheter is inserted and attached to a closed collection system, being carefully prepped in place with dry sterile dressings. The ideal peritoneal dialysis solution should achieve the low absorption clearance of osmotic agents, provide missing or insufficient electrolytes and nutrients, correct acid-base imbalances, inhibit growth of microorganisms, and be inert with regard to the peritoneum. When initiating peritoneal dialysis in acute kidney injury, the main goal is not to immediately normalize uraemia. The initial objectives should be to normalize the hemodynamic status of the patient and the acid-base and electrolyte imbalances, as well as to reduce uraemia to a BUN of 60-100 mg/dl and to reach a creatinine of 4.0-6.0 mg/dl in 24-48 hours. Complications of peritoneal dialysis are common, but they can be easily managed if discovered or addressed in due time. The most common complications are: peritoneal catheter obstruction, electrolyte imbalances, hypoalbuminemia and bacterial peritonitis.

ISPD guidelines for peritoneal dialysis in acute kidney injury: 2020 update (adults)

(1) Peritoneal dialysis (PD) should be considered a suitable modality for treatment of acute kidney injury (AKI) in all settings (1B). (2.1) Flexible peritoneal catheters should be used where resources and expertise exist (1B) (optimal).(2.2) Rigid catheters and improvised catheters using nasogastric tubes and other cavity drainage catheters may be used in resource-poor environments where they may still be life-saving (1C) (minimum standard).(2.3) We recommend catheters should be tunnelled to reduce peritonitis and peri-catheter leak (practice point).(2.4) We recommend that the method of catheter implantation should be based on patient factors and locally available skills (1C).(2.5) PD catheter implantation by appropriately trained nephrologists in patients without contraindications is safe and functional results equate to those inserted surgically (1B).(2.6) Nephrologists should receive training and be permitted to insert PD catheters to ensure timely dialysis in the emergency setting (practice point). (2.7) We recommend, when available, percutaneous catheter insertion by a nephrologist should include assessment with ultrasonography (2C).(2.8) Insertion of PD catheter should take place under complete aseptic conditions using sterile technique (practice point).(2.9) We recommend the use of prophylactic antibiotics prior to PD catheter implantation (1B).(2.10) A closed delivery system with a Y connection should be used (1A) (optimal). In resource poor areas, spiking of bags and makeshift connections may be necessary and can be considered (minimum standard).(2.11) The use of automated or manual PD exchanges are acceptable and this will be dependent on local availability and practices (practice point). (3.1) In patients who are critically ill, especially those with significant liver dysfunction and marked elevation of lactate levels, bicarbonate containing solutions should be used (1B) (optimal). Where these solutions are not available, the use of lactate containing solutions is an alternative (practice point) (minimum standard).(3.2) Commercially prepared solutions should be used (optimal). However, where resources do not permit this, then locally prepared fluids may be life-saving and with careful observation of sterile preparation procedure, peritonitis rates are not increased (1C) (minimum standard).(3.3) Once potassium levels in the serum fall below 4 mmol/L, potassium should be added to dialysate (using strict sterile technique to prevent infection) or alternatively oral or intravenous potassium should be given to maintain potassium levels at 4 mmol/L or above (1C).(3.4) Potassium levels should be measured daily (optimal). Where these facilities do not exist, we recommend that after 24 h of successful dialysis, one consider adding potassium chloride to achieve a concentration of 4 mmol/L in the dialysate (minimum standard) (practice point). (4.1) Targeting a weekly K t/V urea of 3.5 provides outcomes comparable to that of daily HD in critically ill patients; targeting higher doses does not improve outcomes (1B). This dose may not be necessary for most patients with AKI and targeting a weekly K t/V of 2.2 has been shown to be equivalent to higher doses (1B). Tidal automated PD (APD) using 25 L with 70% tidal volume per 24 h shows equivalent survival to continuous venovenous haemodiafiltration with an effluent dose of 23 mL/kg/h (1C).(4.2) Cycle times should be dictated by the clinical circumstances. Short cycle times (1-2 h) are likely to more rapidly correct uraemia, hyperkalaemia, fluid overload and/or metabolic acidosis; however, they may be increased to 4-6 hourly once the above are controlled to reduce costs and facilitate clearance of larger sized solutes (2C).(4.3) The concentration of dextrose should be increased and cycle time reduced to 2 hourly when fluid overload is evident. Once the patient is euvolemic, the dextrose concentration and cycle time should be adjusted to ensure a neutral fluid balance (1C).(4.4) Where resources permit, creatinine, urea, potassium and bicarbonate levels should be measured daily; 24 h K t/V urea and creatinine clearance measurement is recommended to assess adequacy when clinically indicated (practice point).(4.5) Interruption of dialysis should be considered once the patient is passing >1 L of urine/24 h and there is a spontaneous reduction in creatinine (practice point).