Unplanned Dialysis Initiation Research Articles

Nephrologists’ Perspectives on Home Dialysis Utilization: A National Survey From Israel

Nephrologists’ Perspectives on Home Dialysis Utilization: A National Survey From Israel

Comparison of Left Ventricular Diastolic Function Parameters between Patients with Unplanned and Planned Hemodialysis Initiation: A Cross-Sectional Study

Despite the increasing number of dialysis patients, there is still no clear consensus regarding when a permanent access device should be prepared and renal replacement treatment should be undertaken. The purpose of this study was to evaluate left ventricular diastolic function at the start of dialysis between patients in a planned or unplanned manner according to the 2016 recommendations of the American Society of Echocardiography/European Association of Cardiovascular Imaging (ASE/EACVI). We designed a single-center, cross-sectional study to use echocardiography to evaluate and compare left ventricular diastolic function at the onset of dialysis between patients in planned and unplanned groups. A total of 21 patients were included in our analysis (11 initiated dialysis in a planned manner and 10 did so in an unplanned manner). E/A and E/E′ were significantly high in the unplanned dialysis initiation group (p = 0.048 and p = 0.003, respectively). Furthermore, the number of patients with an E/E′ ratio of >14 and tricuspid regurgitation velocity of >2.8 was also significantly high in the unplanned dialysis initiation group (80% vs. 18%; p = 0.009, 40% vs. 0%; p = 0.035, respectively). According to the American Society of Echocardiography and the European Association of Cardiovascular Imaging Recommendation in 2016, the number of patients with left ventricular diastolic dysfunction was significantly high in the unplanned dialysis initiation group (80% vs. 18%; p = 0.009). The current study demonstrated that left ventricular diastolic dysfunction is more apparent in incident dialysis patients in an unplanned manner. Our findings suggest that the assessment of left ventricular diastolic function by echocardiography may be an indication of when to create a permanent access device and initiate dialysis.

PS-C18-3: RENIN-ANGIOTENSIN SYSTEM INHIBITORS IN PATIENTS WITH ADVANCED CHRONIC KIDNEY DISEASE ASSOCIATED WITH A LOWER RISK OF UNPLANNED DIALYSIS INITIATION

Objective: Unplanned dialysis initiation is associated with poor outcomes. Whether patients with advanced chronic kidney disease (CKD) should receive renin-angiotensin system (RAS) inhibitors remains controversial. This study aimed to evaluate the effect of RAS inhibitors in patients with advanced CKD on the incidence of unplanned dialysis initiation. Furthermore, the association between RAS inhibitor therapy and the estimated glomerular filtration rate (eGFR) decline rate for 6 months before dialysis initiation was also investigated. Design and method: This single-center, retrospective study included patients who started maintenance dialysis at our hospital between April 2014 and March 2021. Patients who initiated dialysis within six months of nephrology referral or after kidney transplant were excluded. Unplanned dialysis initiation was defined as urgent hospitalization for starting dialysis or unexpectedly starting dialysis in the hospital for any purpose other than dialysis initiation. Missing values were handled with multiple imputations. Results: Among 334 patients (median age 70.0 [interquartile range 59.0–79.0] years; 28.4% females), 186 (55.7%) and 148 (44.3%) had a planned and unplanned dialysis initiation, respectively. Overall, 144 patients (43.1%) did not use, 51 (15.3%) stopped, 136 (40.7%) continued, and 3 (0.9%) started RAS inhibitors for 6 months before dialysis initiation. Multivariate logistic regression revealed that use of RAS inhibitors was significantly associated with a lower incidence of unplanned dialysis initiation (odds ratio [OR], 0.35; P < 0.01). Female sex (OR, 0.51; P < 0.05), use of potassium binders (OR, 0.25; P < 0.01), earlier referral to nephrology (OR, 0.45; P < 0.01), and earlier discussion of renal replacement therapy (OR, 0.35; P < 0.01) were also significantly associated with a lower incidence, whereas older age (OR, 1.25; P < 0.05), higher Charlson comorbidity index (OR, 1.34; P < 0.01) and faster decline in eGFR (OR, 1.29; P < 0.01) were associated with a higher risk of unplanned dialysis initiation. In multivariate linear regression to assess the rate of eGFR decline for 6 months before dialysis initiation, use of RAS inhibitors (β;, -4.2; P < 0.05) as well as older age (β;, -2.5; P < 0.01), higher geriatric nutritional risk index (β;, -2.9; P < 0.01) and use of bicarbonate (β;, -6.3; P < 0.01) was significantly associated with preserved kidney function. Conclusions: RAS inhibitor therapy in patients with advanced CKD was associated with a lower risk of unplanned dialysis initiation and preserved kidney function.

Association of inadequate energy intake on admission with activities of daily living at discharge in patients undergoing unplanned hemodialysis initiation: a retrospective case-series study

BackgroundIn a previous study, patients who underwent unplanned hemodialysis initiation did not have improved nutritional status and activities of daily living (ADL) at discharge compared with patients whose initiation of hemodialysis was planned. Therefore, the aim of this study was to analyze the factors that delayed or made it difficult to improve nutritional status and ADL in patients undergoing unplanned hemodialysis initiation.MethodsParticipants were patients with end-stage kidney disease who experienced unplanned initiation of new maintenance hemodialysis between April 2017 and March 2020. Patients were divided into two groups: a group who required assistance with ADL at discharge (assistance group) and a group who did not require assistance (independence group). Patient characteristics, nutritional management, and blood tests data obtained from medical records were retrospectively analyzed using univariate and multivariate analyses.ResultsIn total, 95 patients who experienced unplanned dialysis initiation were included in the analysis. Of these, 55 (58%) patients were in the assistance group and 40 (42%) were in the independence group. The assistance group was significantly older than the independence group and contained significantly fewer male patients. In the assistance group, energy intake on admission and serum albumin at discharge were significantly lower, and C-reactive protein was significantly higher, than in the independence group. The multivariate analysis showed that age, sex, and energy intake on admission were associated with requirement for assistance with ADL at discharge.ConclusionsInadequate energy intake on admission was associated with requirement for assistance with ADL at discharge for patients who experienced unplanned hemodialysis initiation. This suggests that active nutritional management from the time of admission could reduce the requirement for assistance with ADL and could increase independence.

Effects of renin-angiotensin system inhibitors on the incidence of unplanned dialysis.

Unplanned dialysis initiation is associated with poor outcomes. It is controversial whether patients with advanced chronic kidney disease (CKD) should receive renin-angiotensin system (RAS) inhibitor therapy. The aim of this study was to evaluate the effect of RAS inhibitor therapy in patients with advanced CKD on the incidence of unplanned dialysis initiation. This single-center, retrospective study included patients who started maintenance dialysis at our hospital between April 2014 and March 2021. Patients who initiated dialysis within 6 months of nephrology referral or after kidney transplant were excluded. Among 334 patients (aged 70.0 [59.0-79.0] years; 28.4% women), 186 (55.7%) and 148 (44.3%) had planned and unplanned dialysis initiation, respectively. Multivariate logistic regression analysis revealed that the use of RAS inhibitors was significantly associated with a lower incidence of unplanned dialysis initiation (odds ratio [OR], 0.36; P < 0.01). Female sex (OR, 0.41; P < 0.05), use of potassium binders (OR, 0.28; P < 0.001), earlier referral to nephrology (OR, 0.39; P < 0.01), and earlier discussion of renal replacement therapy (OR, 0.33; P < 0.001) were also significantly associated with a lower incidence, whereas older age (OR, 1.28; P < 0.05), higher Charlson Comorbidity Index (OR, 1.24; P < 0.05), and faster decline in kidney function (OR, 1.29; P < 0.01) were associated with a higher risk of unplanned dialysis initiation. RAS inhibitor therapy in patients with advanced CKD is associated with a lower risk of unplanned dialysis initiation.

The ratio of measured to estimated glomerular filtration rate may be a marker of early mortality and dialysis requirement

BackgroundIt has been suggested that, in patients with CKD stage 5, measured GFR (mGFR), defined as the mean of urea and creatinine clearance, as measured by a 24-h urine collection, is a better measure of renal function than estimated GFR (eGFR), based on the CKD-EPI formula. This could be due to reduced muscle mass in this group. Its use is recommended in the ERBP guidelines. Unplanned dialysis initiation (DI) is associated with increased morbidity, mortality, and reduced modality choice and is generally considered undesirable. We hypothesized that the ratio mGFR/eGFR (M/E) aids prediction of death and DI.MethodsAll 24-h measurements of urea and creatinine excretion were extracted from the clinical biochemistry databases in Zealand. Data concerning renal diagnosis, comorbidity, biochemistry, medical treatment, mortality and date of DI, were extracted from patient notes, the National Patient Registry and the Danish Nephrology Registry. Patients were included if their eGFR was < 30 ml/min/1.73m2. The last available value for each patient was included. Follow-up was 12 months.ResultsOne thousand two hundred sixty-five patients were included. M/E was median 0.91 ± 0.43. It was highly correlated to previous determinations. It was negatively correlated to eGFR, comorbidity, high age and female sex. It was positively related to albumin and negatively to C-reactive protein. M/E was higher in patients treated with ACE inhibitors and diuretics but no other treatment groups.On a multivariate analysis, M/E was negatively correlated with mortality and combined mortality/DI, but not DI. A post hoc analysis showed a negative correlation to DI at 3 months. For patients with an eGFR 10–15 ml/min/1.73m2, combined mortality and DI at 3 months was for low M/E (< 0.75) 36%, medium (0.75–1.25) 20%, high (> 1.25) 8%. A low M/E predicted increased need for unplanned DI.A supplementary analysis in 519 patients where body surface area values were available, allowing BSA-corrected M/E to be analyzed, revealed similar results.ConclusionA low mGFR/eGFR ratio is associated with comorbidity, malnutrition, and inflammation. It is a marker of early DI, mortality, and unplanned dialysis initiation, independently of eGFR, age and comorbidity. Particular attention paid to patients with a low M/E may lower the incidence of unplanned dialysis requirement.

FC 053RATIO OF MEASURED GFR TO ESTIMATED GFR MAY PREDICT EARLY DEATH AND REQUIREMENT FOR DIALYSIS

Abstract Background and Aims It has been suggested that, in patients with CKD stage 5, measured GFR (mGFR), defined as the mean of urea and creatinine clearance as measured by a 24-hour urine collection, is a better measure of renal function than estimated GFR (eGFR), based on the CKD-EPI formula. This could be due to reduced muscle mass in this group. Its use is recommended in the ERBP guidelines. Unplanned dialysis initiation (UDI) is associated with increased morbidity, mortality, and reduced modality choice. It is generally considered undesirable. We hypothesized that the ratio mGFR/eGFR (R) aids prediction of death and end stage kidney disease (ESKD), as defined by permanent dialysis requirement or transplantation. Method All 24-hour measurements of urea and creatinine excretion were extracted from the clinical biochemistry databases in Zealand. Data concerning renal diagnosis, comorbidity, biochemistry, medical treatment, mortality and date of ESKD, were extracted from patient notes, the National Patient Registry and the Danish Nephrology Registry. Patients were included if their eGFR was &amp;lt;30 ml/min/1.73m2. The last available value for each patient was included. Results 1265 patients were included. In 519, body surface area (BSA) was available, and the corrected ratio (RBSA) could be calculated. The urea clearance was 49 ±24% of creatinine clearance. R was median 0.88 (IQR 0.63-1.15), RBSA 0.87 (0.68-1.06). R was not related to eGFR. Comorbidity was associated with lower R, e.g. atherosclerosis (0.90 ±0.41 vs. 0.97 ±0.49*), heart failure (0.80 ±0.37 vs. 0.95 ±0.44*), pulmonary disease (0.80 ±0.37 vs. 0.94 ±0.44***), hepatic disease (0.67 ±0.41 vs. 0.92 ±0.43***), but not diabetes mellitus. It was related to albumin (r=0.24***), C-reactive protein (-0.22***) and biochemical markers of uraemia, e.g. bicarbonate (-0.19***). Medical treatment data was available in 137 patients. R was higher in patients treated with ACE inhibitors (1.20 ±0.50 vs. 1.01 ±0.36*) and diuretics (1.09 ±0.40 vs. 0.94 ±0.35*), but no other treatment groups. Patients were grouped as high R (H, &amp;gt;1.25), medium (M, 0.75-1.25) or low (L, &amp;lt;0.75). R was not associated with prognosis at one year, but L patients had a significantly higher ESKD and mortality incidence at 3 months. For patients with eGFR 10-15 ml/min/1.73m2, ESKD incidence was L 22%, M 15%, H 5%, mortality 19, 5, and 2% respectively. Similar findings were seen in other groups, e.g. eGFR 15-20 ml/min/1.73m2: ESKD 11, 2, and 0%; death 11, 5, and 1%. UDI was higher for L patients. For patients with eGFR 10-15 ml/min/1.73m2, UDI occurred in L: 47%, M:27%, H:25%. For patients with eGFR 10-15 ml/min/1.73m2 the figures were 51, 38 and 12% respectively. Findings for the subgroup of patients with RBSA measurements were similar. *:p&amp;lt;0.05; **:p&amp;lt;001;***:p&amp;lt;0.001 Conclusion A low mGFR/eGFR ratio is associated with comorbidity, malnutrition, inflammation and biochemical uraemia. It a marker of early ESKD, death and unplanned dialysis initiation, independently of eGFR. Particular attention paid to patients with a low R may lower the incidence of unplanned dialysis requirement.

The Impact of Clinical Presentation on Survival in Patients Requiring Hemodialysis Catheters for Acute and Unplanned Dialysis: A Prospective Observational Study.

Background:Most studies addressing hemodialysis initiation with a dialysis catheter focus on patients entering maintenance dialysis programs and exclude other patients, such as those with acute kidney injury (AKI), making interpretation and application of the results difficult for clinicians managing patients at the time of dialysis commencement.Objective:To compare the survival of all patients requiring a catheter for hemodialysis access according to the nature of clinical presentation.Design:Prospective observational.Setting:An Australian tertiary renal unit.Patients:All patients requiring a central venous catheter (CVC) for hemodialysis access between 2005 and 2015.Measurements:Baseline comorbidities, demographics, and nature of clinical presentation. Data regarding each episode of dialysis access insufficiency and each CVC were collected. The primary outcome was all-cause mortality.Methods:Patients were classified into 1 of 3 groups based on physician assessment at the time of presentation: patients believed to have AKI with expected renal recovery (AKI), patients considered to be entering the maintenance dialysis program without a functioning dialysis access (Maintenance Dialysis), patients unable to perform peritoneal dialysis, or use their existing hemodialysis access (Access Failure). Time-split multivariable Cox regression analyses were used to compare survival between groups.Results:A total of 557 eligible patients had complete prospective data regarding CVC use and were included in the analyses. The majority of patients were in the AKI (246/557, 44%) and Maintenance Dialysis groups (182/557, 33%) compared with the Access Failure group (129/557, 23%). During a median follow-up of 3 years, 302 (54%) of the 557 patients died. Following adjustment, risk of all-cause mortality was higher in the AKI group (hazard ratio [HR]: 2.01, 95% confidence interval [CI]: 1.31-3.60, P = .001) during the first 2 years after catheter insertion and lower in years 2 to 4 (HR: 0.42, 95% CI: 0.20-0.88, P = .02) than in the reference Maintenance Dialysis group. No difference in mortality risk between the Access Failure and reference group was found.Limitations:Single-center study. Possible residual confounding owing to the observational study design.Conclusions:Patients requiring acute or unplanned hemodialysis experience high mortality, and the nature of clinical presentation does influence outcomes. Most notable is the greater early mortality experienced by patients with AKI compared to other patient groups. Prospective definition of the nature of unplanned dialysis initiation is important to accurately measure and improve outcomes in this high-risk patient population.Human Research Ethics Committee Approval NumberCH62/6/2017-042.

Choice of dialysis modality among patients initiating dialysis: results of the Peridialysis study.

BackgroundIn patients with end-stage kidney disease (ESKD), home dialysis offers socio-economic and health benefits compared with in-centre dialysis but is generally underutilized. We hypothesized that the pre-dialysis course and institutional factors affect the choice of dialysis modality after dialysis initiation (DI).MethodsThe Peridialysis study is a multinational, multicentre prospective observational study assessing the causes and timing of DI and consequences of suboptimal DI. Clinical and biochemical data, details of the pre-dialytic course, reasons for DI and causes of the choice of dialysis modality were registered.ResultsAmong 1587 included patients, 516 (32.5%) were judged unsuitable for home dialysis due to contraindications [384 ( 24.2%)] or no assessment [106 (6.7%); mainly due to late referral and/or suboptimal DI] or death [26 (1.6%)]. Older age, comorbidity, late referral, suboptimal DI, acute illness and rapid loss of renal function associated with unsuitability. Of the remaining 1071 patients, 700 (65.4%) chose peritoneal dialysis (61.7%) or home haemodialysis (HD; 3.6%), while 371 (34.6%) chose in-centre HD. Somatic differences between patients choosing home dialysis and in-centre dialysis were minor; factors linked to the choice of in-centre dialysis were late referral, suboptimal DI, acute illness and absence of a ‘home dialysis first’ institutional policy.ConclusionsGiven a personal choice with shared decision making, 65.4% of ESKD patients choose home dialysis. Our data indicate that the incidence of home dialysis potentially could be further increased to reduce the incidence of late referral and unplanned DI and, in acutely ill patients, by implementing an educational programme after improvement of their clinical condition.

How To Build a Successful Urgent-Start Peritoneal Dialysis Program.

In-center hemodialysis (HD) remains the predominant dialysis therapy in patients with ESKD. Many patients with ESKD present in late stage, requiring urgent dialysis initiation, and the majority start HD with central venous catheters (CVCs), which are associated with poor outcomes and high cost of care. Peritoneal dialysis (PD) catheters can be safely placed in such patients with late-presenting ESKD, obviating the need for CVCs. PD can begin almost immediately in the recumbent position, using low fill volumes. Such PD initiations, commencing within 2 weeks of the catheter placement, are termed urgent-start PD (USPD). Most patients with an intact peritoneal cavity and stable home situation are eligible for USPD. Although there is a small risk of PD catheter-related mechanical complications, most can be managed conservatively. Moreover, overall outcomes of USPD are comparable to those with planned PD initiations, in contrast to the high rate of catheter-related infections and bacteremia associated with urgent-start HD. The ongoing coronavirus disease 2019 pandemic has further exposed the vulnerability of patients with ESKD getting in-center HD. PD can mitigate the risk of infection by reducing environmental exposure to the virus. Thus, USPD is a safe and cost-effective option for unplanned dialysis initiation in patients with late-presenting ESKD. To develop a successful USPD program, a strong infrastructure with clear pathways is essential. Coordination of care between nephrologists, surgeons or interventionalists, and hospital and PD center staff is imperative so that patient education, home visits, PD catheter placements, and urgent PD initiations are accomplished expeditiously. Implementation of urgent-start PD will help to increase PD use, reduce cost, and improve patient outcomes, and will be a step forward in fostering the goal set by the Advancing American Kidney Health initiative.

P1137FACTORS DETERMINING CHOICE OF DIALYSISI MODALITY AMONG PATIENTS INITIATING DIALYSIS. RESULTS OF THE PERIDIALYSIS STUDY

Abstract Background and Aims Home dialysis with peritoneal dialysis (PD) or home hemodialysis (HD) has medical and socioeconomic benefits but home dialysis is generally underutilized. While many factors determine choice of initial dialysis modality, starting patients on home dialysis requires timely planning, educational activities and an active program to promote home dialysis. Here we investigated factors including patient suitability, pre-dialysis preparations and institutional factors determining choice of dialysis modality among patients initiating dialysis. Method Choice of dialysis modality was investigated in 1588 consecutive patients (age 63.8 ±15.3 years. 35.8% female; diabetic nephropathy 24.4%) participating in the Peridialysis study, a multinational multi-centre prospective study of causes and timing of planned and unplanned dialysis initiation (DI) over a 3-year period in 15 Nordic and Baltic nephrology departments. All dialysis modalities were available and free of charge to patients. All centres offered pre-dialysis education programs to patients with timely referral. Clinical and biochemical data during the pre-dialytic period, centre data, and reasons for DI and choice of dialysis modality were registered. Results: 516 (32.4%) patients were not offered home dialysis because they were judged to be unsuitable (384; 24%): PD was contraindicated in 338 (21.2%) patients - for physical (142; 8.9%), mental (80, 5.0%) or abdominal (116; 7.3%) reasons and HD was contraindicated in 46 (2.9%) patients. In addition, 106 (6.7%) were not offered home dialysis for various reasons; and deaths before modality choice occurred in 26 (1.6%) patients. Factors associated with unsuitability were high age, comorbidity, late referral (risk ratio, RR, 1.9), inflammation (C-reactive protein &amp;gt;50 mg/L (RR 2.6) and rapid loss of renal function (RR 2.0). Patients who were not assessed for home dialysis comprised mainly patients with late referral (RR 5.8) and/or unplanned DI (RR 9.6). Of the remaining 1072 (67.6%) patients, who had a free choice of modality, 700 (65.3%) chose home dialysis, either PD (661; 61.7%) or home HD ( 39 3.6%) while 372 (34.7%) patients chose centre HD. Factors associated with choice of centre dialysis were late referral (RR 1.8), suboptimal DI (RR 2.0), symptomatic uraemia (RR 1.6) and p-urea &amp;gt;30 mM (2.6). Somatic differences between patients choosing home dialysis and centre dialysis were minor. Independent institutional factors reducing information about home dialysis were treatment at a university hospital (RR 4.3) and absence of an active preference for home dialysis, “home dialysis first” policy (RR 3.0). Conclusion The results of the Peridialysis study indicate that the incidence of home dialysis could be increased by a “home dialysis first” department policy and by efforts to reduce the incidence of late referrals and unplanned DI. Acutely ill patients and patients with unplanned DI may be candidates for home dialysis if assessment of home dialysis suitability and dialysis educational program are performed after their clinical condition has improved. Given a free choice, most patients (65%) choose home dialysis.

P1448FACTORS ASSOCIATED WITH INCREASED MORTALITY AFTER DIALYSIS INITIATION. RESULTS OF THE PERIDIALYSIS STUDY

Abstract Background and Aims Home dialysis with peritoneal dialysis (PD) or home hemodialysis (HD) has medical and socioeconomic benefits but home dialysis is generally underutilized. While many factors determine choice of initial dialysis modality, starting patients on home dialysis requires timely planning, educational activities and an active program to promote home dialysis. Here we investigated factors including patient suitability, pre-dialysis preparations and institutional factors determining choice of dialysis modality among patients initiating dialysis. Method Choice of dialysis modality was investigated in 1588 consecutive patients (age 63.8 ±15.3 years. 35.8% female; diabetic nephropathy 24.4%) participating in the Peridialysis study, a multinational multi-centre prospective study of causes and timing of planned and unplanned dialysis initiation (DI) over a 3-year period in 15 Nordic and Baltic nephrology departments. All dialysis modalities were available and free of charge to patients. All centres offered pre-dialysis education programs to patients with timely referral. Clinical and biochemical data during the pre-dialytic period, centre data, and reasons for DI and choice of dialysis modality were registered. Results: 516 (32.4%) patients were not offered home dialysis because they were judged to be unsuitable (384; 24%): PD was contraindicated in 338 (21.2%) patients - for physical (142; 8.9%), mental (80, 5.0%) or abdominal (116; 7.3%) reasons and HD was contraindicated in 46 (2.9%) patients. In addition, 106 (6.7%) were not offered home dialysis for various reasons; and deaths before modality choice occurred in 26 (1.6%) patients. Factors associated with unsuitability were high age, comorbidity, late referral (risk ratio, RR, 1.9), inflammation (C-reactive protein &amp;gt;50 mg/L (RR 2.6) and rapid loss of renal function (RR 2.0). Patients who were not assessed for home dialysis comprised mainly patients with late referral (RR 5.8) and/or unplanned DI (RR 9.6). Of the remaining 1072 (67.6%) patients, who had a free choice of modality, 700 (65.3%) chose home dialysis, either PD (661; 61.7%) or home HD ( 39 3.6%) while 372 (34.7%) patients chose centre HD. Factors associated with choice of centre dialysis were late referral (RR 1.8), suboptimal DI (RR 2.0), symptomatic uraemia (RR 1.6) and p-urea &amp;gt;30 mM (2.6). Somatic differences between patients choosing home dialysis and centre dialysis were minor. Independent institutional factors reducing information about home dialysis were treatment at a university hospital (RR 4.3) and absence of an active preference for home dialysis, “home dialysis first” policy (RR 3.0). Conclusion The results of the Peridialysis study indicate that the incidence of home dialysis could be increased by a “home dialysis first” department policy and by efforts to reduce the incidence of late referrals and unplanned DI. Acutely ill patients and patients with unplanned DI may be candidates for home dialysis if assessment of home dialysis suitability and dialysis educational program are performed after their clinical condition has improved. Given a free choice, most patients (65%) choose home dialysis.

Early-start and conventional-start peritoneal dialysis: a Chinese cohort study on outcome

Background Early-start peritoneal dialysis (PD) is an effective option for patients need unplanned dialysis. However, there are few studies on the long-term prognosis of early-start PD patients. Methods In this retrospective study, 635 eligible patients from 1 March 1996 to 30 September 2016 were included, and divided into three groups according to the duration of break-in period: 3 days or less, 4–13 days and more than 14 days. Patients started PD within 2 weeks and after 2 weeks were defined as early-start and conventional-start, respectively. The primary outcome was all-cause mortality, and the secondary outcome measures were peritonitis free survival and technical survival. Mechanical and infectious complications in the first 180 days were also analyzed. Results Early-start PD patients were more likely to have higher serum total carbon dioxide and creatinine levels and lower serum albumin, Kt/v, creatinine clearance (Ccr) and residual glomerular filtration rate (rGFR) levels at the start of PD. The median follow-up period was 30 months (interquartile range, 13-53 months). A worse survival was observed in the early-start group than that in the conventional-start group (p < 0.001), even adjustment for the covariates (HR 1.549, 95%CI 1.104–2.173, p = 0.011). In the subgroup analysis, in patients commencing PD after 2006 early-start and conventional-start PD patients had comparable survival. No differences were observed in the rate of infectious and mechanical complications, peritonitis-free survival and technique survival between early-start and conventional-start PD patients. Conclusions Early-start PD could be a safe and effective strategy for patients needing unplanned dialysis initiation with the progress of technology on PD.

Risk Factors for Unplanned Dialysis Initiation: A Systematic Review of the Literature.

Background:Unplanned dialysis initiation is common in patients with chronic kidney disease (CKD).Objective:To determine common definitions and patient risk factors for unplanned dialysis.Design:Systematic review.Setting:MEDLINE, EMBASE, and the Cochrane Library were searched from inception to February 2018.Patients:Studies that included incident chronic dialysis patients or patients with CKD that cited a definition or examined risk factors for unplanned dialysis were included.Measurements:Definitions and criteria for unplanned dialysis reported across studies. Patient characteristics associated with unplanned dialysis.Methods:Two reviewers independently extracted data using a standardized data abstraction form and assessed study quality using a modified New Castle Ottawa Scale.Results:From 2797 citations, 48 met eligibility criteria. Reported definitions for unplanned dialysis were variable. Most publications cited dialysis initiation under emergency conditions and/or with a central venous catheter. The association of patient characteristics with unplanned dialysis was reported in 26 studies, 18 were retrospective and 21 included incident dialysis patients. The most common risk factors in univariate analyses were (number of studies) increased age (n = 7), cause of kidney disease (n = 6), presence of cardiovascular disease (n = 7), lower serum hemoglobin (n = 9), lower serum albumin (n = 10), higher serum phosphate (n = 6), higher serum creatinine or lower estimated glomerular filtration rate (eGFR) at dialysis initiation (n = 7), late referral (n = 5), lack of dialysis education (n = 6), and lack of follow-up in a predialysis clinic prior to dialysis initiation (n = 5). A minority of studies performed multivariable analyses (n = 10); the most common risk factors were increased age (n = 4), increased comorbidity score (n = 3), late referral (n = 5), and lower eGFR at dialysis initiation (n = 3).Limitations:Comparison of results across studies was limited by inconsistent definitions for unplanned dialysis. High-quality data on patient risk factors for unplanned dialysis are lacking.Conclusions:Well-designed prospective studies to determine modifiable risk factors are needed. The lack of a consensus definition for unplanned dialysis makes research and quality improvement initiatives in this area more challenging.

Peritoneal Dialysis as an Option for Unplanned Dialysis Initiation in Patients with End-Stage Renal Disease and Diabetes Mellitus

Aims: This study aimed to compare the short-term complications and long-term prognosis between urgent-start peritoneal dialysis (PD) and hemodialysis (HD), and explore the safety and feasibility of PD in end-stage renal disease (ESRD) patients with diabetes. Methods: This retrospective study enrolled ESRD patients with diabetes who required urgent-start dialysis at a single center from January 2011 to December 2014. Short-term (30-day) dialysis-related complications and patient survival trends were compared between patients receiving PD and HD. Results: Eighty patients were included in the study, including 50 (62.5%) who underwent PD. The incidence of dialysis-related complications and complications requiring reinsertion during the first 30 days was significantly lower in PD patients. Logistic regression identified urgent-start HD as an independent risk factor for dialysis-related complications compared with urgent-start PD. The patient survival rate was higher in the PD compared to that in the HD group. Conclusions: PD may be acceptable, safe, and feasible for urgent-start dialysis in ESRD patients with diabetes.

Why do physicians prescribe dialysis? A prospective questionnaire study.

IntroductionThe incidence of unplanned dialysis initiation (DI) with consequent increased comorbidity, mortality and reduced modality choice remains high, but the optimal timing of dialysis initiation (DI) remains controversial, and there is a lack of studies of specific reasons for DI. We investigated why and when physicians prescribe dialysis and hypothesized that physician motivation for DI is an independent factor which may have clinical consequences.MethodsIn the Peridialysis study, an ongoing multicenter prospective study assessing the causes and timing of DI and consequences of unplanned dialysis, physicians in 11 hospitals were asked to describe their primary, secondary and further reasons for prescribing DI. The stated reasons for DI were analyzed in relation to clinical and biochemical data at DI, and characteristics of physicians.ResultsIn 446 patients (median age 67 years; 38% females; diabetes 25.6%), DI was prescribed by 84 doctors who stated 23 different primary reasons for DI. The primary indication was clinical in 63% and biochemical in 37%; 23% started for life-threatening conditions. Reduced renal function accounted for only 19% of primary reasons for DI but was a primary or contributing reason in 69%. The eGFR at DI was 7.2 ±3.4 ml/min/1.73 m2, but varied according to comorbidity and cause of DI. Patients with cachexia, anorexia and pulmonary stasis (34% with heart failure) had the highest eGFR (8.2–9.8 ml/min/1.73 m2), and those with edema, “low GFR”, and acidosis, the lowest (4.6–6.1 ml/min/1.73 m2). Patients with multiple comorbidity including diabetes started at a high eGFR (8.7 ml/min/1.73 m2). Physician experience played a role in dialysis prescription. Non-specialists were more likely to prescribe dialysis for life-threatening conditions, while older and more experienced physicians were more likely to start dialysis for clinical reasons, and at a lower eGFR. Female doctors started dialysis at a higher eGFR than males (8.0 vs. 7.1 ml/min/1.73 m2).ConclusionsDI was prescribed mainly based on clinical reasons in accordance with current recommendations while low renal function accounted for only 19% of primary reasons for DI. There are considerable differences in physicians´ stated motivations for DI, related to their age, clinical experience and interpretation of biochemical variables. These differences may be an independent factor in the clinical treatment of patients, with consequences for the risk of unplanned DI.

Using automated peritoneal dialysis for unplanned dialysis initiation

Immediate-start peritoneal dialysis (PD) is defined as initiation of treatment within 2 weeks of catheter placement. However, a timely catheter placement is not always possible in patients with advanced chronic kidney disease (CKD), and immediate-start PD is a viable option. Venkat Rama Reddy Gangaram et al report their experience of treating patients with advanced CKD with this treatment programme.

Impact of an in-Hospital Patient Education Program on Choice of Renal Replacement Modality in Unplanned Dialysis Initiation

Background/Aims: Up to 50% patients requiring dialysis receive an urgent, unplanned start (UPS) to renal replacement therapy (RRT). Most of these are initiated with an intravenous catheter and commenced and maintained on hemodialysis (HD). Although peritoneal dialysis (PD) could be an equipotent initial modality for RRT, it is used less frequently as long-term RRT in UPS patients. This multicenter-study aimed to evaluate the impact of a structured, in-hospital education program and factors influencing PD rates, especially in UPS patients. Methods: Three German nephrology departments collaborated to implement an in-hospital education program. Retrospective analysis included 336 subjects and compared the rates of HD and PD in consecutive patients who started RRT 12 months prior (two centers) and for 12 months after (three centers) implementing the education program. Results: PD rates increased significantly (p < 0.05) by 66% in all planned and unplanned dialysis starts after implementation of a structured, patient-centered education program. A highly significant (p < 0.0001) rise in utilization of PD was found, especially in UPS patients. In logistic regression analysis, PD modality choice was significantly influenced by age (p < 0.0001) and gender (p = 0.006). Conclusions: A structured, patient-centered in-hospital education program increases the frequency of PD in patients needing unplanned RRT. PD modality choice is significantly higher in young (p < 0.0001) and male (p = 0.006) patients.

We Use Permcaths Instead of Peritoneal Catheters for Acute Kidney Injury and Urgent-Start Dialysis.

The rising tide of severe acute kidney injury requiring dialysis (AKI-D) and unplanned dialysis initiation for advanced CKD patients remains a major problem for the nephrology community worldwide. Hemodialysis (HD) through a central venous catheter remains the most common practice for both. Peritoneal dialysis (PD) remains greatly underutilized despite mounting evidence of equipoise with HD for a significant proportion of patients. PD is technically simpler, requires less infrastructure, and costs less. However, the structure of our healthcare system, hospital logistics, and the current state of nephrology training all contribute to the reflexive consult for a central venous catheter. As clinicians, we must ask ourselves if we are doing our patients and our healthcare system a disservice by not offering PD in AKI and urgent-start situations.

Factors Associated with Unplanned Dialysis Starts in Patients followed by Nephrologists: A Retropective Cohort Study.

The number of patients starting dialysis is increasing world wide. Unplanned dialysis starts (patients urgently starting dialysis in hospital) is associated with increased costs and high morbidity and mortality. Risk factors for starting dialysis urgently in hospital have not been well studied. The primary objective of this study was to identify risk factors for unplanned dialysis starts in patients followed in a multidisciplinary chronic kidney disease (CKD) clinic. We performed a retrospective cohort study of 649 advanced CKD patients followed in a multidisciplinary CKD clinic at a tertiary care hospital from January 01, 2010 to April 30, 2013. Patients were classified as unplanned start (in hospital) or elective start. Multivariable logistic regression was used to identify variables associated with unplanned dialysis initiation. 184 patients (28.4%) initiated dialysis, of which 76 patients (41.3%) initiated dialysis in an unplanned fashion and 108 (58.7%) starting electively. Unplanned start patients were more likely to have diabetes (68.4% versus 51.9%; p = 0.04), CAD (42.1% versus 24.1%; p = 0.02), congestive heart failure (36.8% versus 17.6%; p = 0.01), and were less likely to receive modality education (64.5% vs 89.8%; p < 0.01) or be assessed by a surgeon for access creation (40.8% vesrus78.7% p < 0.01). On multivariable analysis, higher body mass index (OR 1.07, 95% CI 1.02, 1.13), and a history of congestive heart failure (OR 2.41, 95% CI 1.09, 5.41) were independently associated with an unplanned start. Unplanned dialysis initiation is common among advanced CKD patients, even if they are followed in a multidisciplinary chronic kidney disease clinic. Timely education and access creation in patients at risk may lead to lower costs and less morbidity and mortality.