When is the best time to initiate peritoneal dialysis in ESKD patients?

A planned start appears to be the best strategy for initiating peritoneal dialysis (PD) in patients with end-stage kidney disease (ESKD), but an early start is a good alternative if a planned start is not possible, suggests a Singapore study. In addition, catheter migration may be more frequent with early-start PD, but it does not seem to affect technique survival.

“In patients with ESKD suitable for PD, PD should ideally be planned and initiated electively (planned-start PD). If patients present late, some centres initiate PD immediately with an urgent-start PD strategy,” the researchers said.

“However, as urgent-start PD is resource intensive, we evaluated another strategy where patients first undergo emergent haemodialysis (HD), followed by early PD catheter insertion, and switch to PD 48–72 hours after PD catheter insertion (early-start PD),” they added.

Normally, patients who present late are often initiated on HD, followed by deferred PD catheter insertion prior to switching to PD ≥14 days after catheter insertion (deferred-start PD).

In this retrospective study of new ESKD patients, the researchers compared the planned-, early-, and deferred-start PD strategies. They then evaluated the outcomes within 1 year of dialysis initiation.

One hundred forty-eight patients with ESKD were included, of whom 57 (38.5 percent) had planned-start, 23 (15.5 percent) had early-start, and 68 (45.9 percent) had deferred-start PD. Baseline biochemical parameters were similar in all subgroups, except for a lower serum urea seen among patients with planned-start PD. [Ann Acad Med Singap 2022;51:213-220]

The primary outcomes of technique and patient survival did not significantly differ across all three subgroups. Early-start PD had a shorter time to catheter migration (hazard ratio [HR], 14.13, 95 percent confidence interval [CI], 1.65‒121.04; p=0.016) compared to planned-start PD, but this did not show a significant impact on technique survival.

“This may be a significant problem in early-start PD, as there is less time to institute conventional prescription for bowel clearance and wait for spontaneous repositioning,” the researchers said. “It is important to be aware of this common complication and assess early for catheter malposition if there are flow issues.” [Perit Dial Int 2015;36:171-176; Am J Kidney Dis 2017;70:102-110]

Furthermore, deferred-start PD patients had a shorter time to first peritonitis (HR, 2.49, 95 percent CI, 1.03‒6.01; p=0.043) and first hospital admission (HR, 2.03, 95 percent CI, 1.35‒3.07; p=0.001) than those in the planned-start PD arm.

Poor survival

An earlier study found that PD patients previously on HD had poorer survival due to a more rapid loss of residual renal function, a major determinant of survival in this population. [Nephrol Dial Transplant 2002;17:112-117; Nephron 1997;77:13-28; ASAIO Trans 1991;37:598-604; J Am Soc Nephrol 2000;11:556-564]

Compared to early-start PD, deferred-start PD had a longer median duration on HD (67 days vs 18 days). The latter also tended to have poor survival, but this did not reach statistical significance.

“Further studies would be needed to investigate if there was an impact on residual renal function and if this was a substantial factor affecting survival,” the researchers said.

Aside from ESKD, the early-start strategy can also be implemented for other PD applications, such as in the management of acute kidney injury or chronic heart failure. [Clin J Am Soc Nephrol 2013;8:1649-1660; Perit Dial Int 2020;40:527-539]

“When patients transit from the acute treatment phase to long-term kidney support, the early-start PD approach may be more practicable with less logistical prerequisites,” the researchers said.