Is urgent-start peritoneal dialysis safe for patients with chronic kidney disease?

What is the issue?

Peritoneal dialysis is a form of kidney replacement therapy in which the lining of the abdomen is used as a filter for dialysis. The dialysis fluid is introduced via a tube which is placed into the abdomen, called a peritoneal dialysis catheter. Traditionally, dialysis is delayed for two weeks after catheter placement, in order to allow proper wound healing. However, some studies reported that patients with chronic kidney disease who urgently need to start dialysis within two weeks of catheter insertion (urgent- start peritoneal dialysis) experienced comparable outcomes to others who commenced dialysis more than two weeks after catheter insertion (conventional-start peritoneal dialysis).

What did we do?

We conducted a systematic review to examine the complications and outcomes of patients with chronic kidney disease who started peritoneal dialysis urgently within two weeks of insertion of peritoneal dialysis catheter.

What did we find?

We identified 16 studies (2953 participants) examining the outcomes of urgent versus conventional start peritoneal dialysis. When we compared results from patients who initiated dialysis two weeks after catheter insertion, patients who initiated dialysis urgently were more likely to have leakage of dialysis fluid outside the abdominal cavity into the skin near the exit site of peritoneal dialysis catheter. The differences in infection of the lining of the abdomen (peritonitis), infection at the exit point of the peritoneal dialysis catheter (exit-site infection), mechanical complications of peritoneal dialysis (including catheter blockage, catheter malposition and catheter readjustment), patients remaining on peritoneal dialysis (technique survival), and death between patients who started dialysis urgently and those who waited for two weeks after catheter insertion remain unclear.

Conclusions

In patients with chronic kidney disease who require dialysis urgently without ready-to-use dialysis access in place, peritoneal dialysis may increase dialysate leak. However, the overall risks of infectious and other non-infectious complications between urgent-start peritoneal dialysis and conventional-start peritoneal dialysis remains unclear.

Authors' conclusions: 

In patients with CKD who require dialysis urgently without ready-to-use dialysis access in place, urgent-start PD may increase the risk of dialysate leak and has uncertain effects on catheter blockage, malposition or readjustment, PD dialysate flow problems, infectious complications, exit-site bleeding, technique survival, and patient survival compared with conventional-start PD.

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Background: 

Urgent-start peritoneal dialysis (PD), defined as initiation of PD within two weeks of catheter insertion, has been emerging as an alternative mode of dialysis initiation for patients with chronic kidney disease (CKD) requiring urgent dialysis without established permanent dialysis access. Recently, several small studies have reported comparable patient outcomes between urgent-start and conventional-start PD.

Objectives: 

To examine the benefits and harms of urgent-start PD compared with conventional-start PD in adults and children with CKD requiring long-term kidney replacement therapy.

Search strategy: 

We searched the Cochrane Kidney and Transplant Register of Studies up to 25 May 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov.

For non-randomised controlled trials, MEDLINE (OVID) (1946 to 27 June 2019), EMBASE (OVID) (1980 to 27 June 2019), Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov (up to 27 June 2019) were searched.

Selection criteria: 

All randomised controlled trials (RCTs) and non-RCTs comparing the outcomes of urgent-start PD (within 2 weeks of catheter insertion) and conventional-start PD ( 2 weeks of catheter insertion) treatment in children and adults CKD patients requiring long-term dialysis were included. Studies without a control group were excluded.

Data collection and analysis: 

Data were extracted and quality of studies were examined by two independent authors. The authors contacted investigators for additional information. Summary estimates of effect were examined using random-effects model and results were presented as risk ratios (RR) with 95% confidence intervals (CI) as appropriate for the data. The certainty of evidence for individual outcome was assessed using the GRADE approach.

Main results: 

A total of 16 studies (2953 participants) were included in this review, which included one multicentre RCT (122 participants) and 15 non-RCTs (2831 participants): 13 cohort studies (2671 participants) and 2 case-control studies (160 participants). The review included unadjusted data for analyses due to paucity of studies reporting adjusted data.

In low certainty evidence, urgent-start PD may increase dialysate leak (1 RCT, 122 participants: RR 3.90, 95% CI 1.56 to 9.78) compared with conventional-start PD which translated into an absolute number of 210 more leaks per 1000 (95% CI 40 to 635).

In very low certainty evidence, it is uncertain whether urgent-start PD increases catheter blockage (4 cohort studies, 1214 participants: RR 1.33, 95% CI 0.40 to 4.43; 2 case-control studies, 160 participants: RR 1.89, 95% CI 0.58 to 6.13), catheter malposition (6 cohort studies, 1353 participants: RR 1.63, 95% CI 0.80 to 3.32; 1 case-control study, 104 participants: RR 3.00, 95% CI 0.64 to 13.96), and PD dialysate flow problems (3 cohort studies, 937 participants: RR 1.44, 95% CI 0.34 to 6.14) compared to conventional-start PD.

In very low certainty evidence, it is uncertain whether urgent-start PD increases exit-site infection (2 cohort studies, 337 participants: RR 1.43, 95% CI 0.24 to 8.61; 1 case-control study, 104 participants RR 1.20, 95% CI 0.41 to 3.50), exit-site bleeding (1 RCT, 122 participants: RR 0.70, 95% CI 0.03 to 16.81; 1 cohort study, 27 participants: RR 1.58, 95% CI 0.07 to 35.32), peritonitis (7 cohort studies, 1497 participants: RR 1.00, 95% CI 0.68 to 1.46; 2 case-control studies, 160 participants: RR 1.09, 95% CI 0.12 to 9.51), catheter readjustment (2 cohort studies, 739 participants: RR 1.27, 95% CI 0.40 to 4.02), or reduces technique survival (1 RCT, 122 participants: RR 1.09, 95% CI 1.00 to 1.20; 8 cohort studies, 1668 participants: RR 0.90, 95% CI 0.76 to 1.07; 2 case-control studies, 160 participants: RR 0.92, 95% CI 0.79 to 1.06).

In very low certainty evidence, it is uncertain whether urgent-start PD compared with conventional-start PD increased death (any cause) (1 RCT, 122 participants: RR 1.49, 95% CI 0.87 to 2.53; 7 cohort studies, 1509 participants: RR 1.89, 95% CI 1.07 to 3.3; 1 case-control study, 104 participants: RR 0.90, 95% CI 0.27 to 3.02; very low certainty evidence). None of the included studies reported on tunnel tract infection.

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