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Peritoneal dialysis for the unPeritoneal dialysis for the un--planned planned Peritoneal dialysis for the unPeritoneal dialysis for the un--planned planned
dialysis starterdialysis starter
Th LobbedezTh Lobbedez
Nephrology DepartmentNephrology DepartmentNephrology DepartmentNephrology Department
CHU Caen, FranceCHU Caen, France
Antalya 2010Antalya 2010
DefinitionDefinition
�� UnUn--plannedplanned dialysisdialysis starterstarter:: aa patientpatient whowho startsstartshaemodialysishaemodialysis urgentlyurgently throughthrough aa temporarytemporaryhaemodialysishaemodialysis urgentlyurgently throughthrough aa temporarytemporarycathetercatheter
�� ImpactImpact onon thethe patientpatient survival,survival, onon thethe choicechoice ofof thethedialysisdialysis modalitymodality andand onon thethe departmentdepartment organizationorganization
[The[The unun--scheduledscheduled starterstarter:: aa patientpatient whowho startstart dialysisdialysis[The[The unun--scheduledscheduled starterstarter:: aa patientpatient whowho startstart dialysisdialysisurgentlyurgently withwith oror withoutwithout anyany dialysisdialysis access]access]
Prevalence of the unPrevalence of the un--planned dialysis startplanned dialysis start
90%
100%Catheter
Haemodialysis start with a catheter in Francein France
51%30%
40%
50%
60%
70%
80%
90%Catheter
Urgent start
46% 46% 44%51%
0%
10%
20%
30%
2004 2005 2006 2007
[REIN annual report, www.agence-biomedecine.fr]
The risk of using a catheter in HD patientsThe risk of using a catheter in HD patients
Infectious mortality by access type[ANZDATA 3749 haemodialysis patients]
Hazard ratio [95% CI]Hazard ratio [95% CI]
CrudeCrude AdjustedAdjusted
FistulaFistula 1.01.0 1.01.0
GraftGraft 2.23 [1.042.23 [1.04--4.78]4.78] 1.62 [0.731.62 [0.73--3.59]3.59]GraftGraft 2.23 [1.042.23 [1.04--4.78]4.78] 1.62 [0.731.62 [0.73--3.59]3.59]
CatheterCatheter 3.08 [1.783.08 [1.78--5.35]5.35] 2.59 [1.452.59 [1.45--4.63]4.63]
[stratification for CAD, adjustement for age, gender, late referral, peripheral
vascular disease and cerebral vascular disease]
[KR Polkinghorne J Am Soc Nephrol 2004; 15:477-486]
Catheter infection in haemodialysis patientsCatheter infection in haemodialysis patients
Cumulative incidence of catheter bacteriemia[Single centre. Tunneled catheters. 458 HD patients. US]
[T Lee, Am J Kidney Disease 2005; 46:501-508]
Outcome on dialysis of the unOutcome on dialysis of the un--planned starterplanned starter
Survival according to dialysis initiation[281 planned vs. 257 un-planned start]
[ V Lorenzo Am J Kidney Dis 2004; 43: 999-1007]
Why do we have to deal with so many Why do we have to deal with so many
unun--planned dialysis starter ?planned dialysis starter ?
Early referred CKD PATIENT
Late referred ESRD PATIENT
DIALYSIS START
PLANNED UNPLANNED
UnUn--planned dialysis and late nephrology referralplanned dialysis and late nephrology referral
100%
Follow up duration of less than one month
57%
35%37%
25%
35%
29%
40%
60%
80%
100%
ESRD patients starting dialysis
23% 25%29%
0%
20%
UK Brazil USA Netherlands USA Europe Europe
[G Baer, NDT plus ; 2009]
Dialysis initiation in the ultraDialysis initiation in the ultra--late referredlate referred
100%
Prevalence of emergent haemodialysis [238 incidents patients in one centre]
90%
30%
40%
50%
60%
70%
80%
90%
100%Planned
Emergent
29%
0%
10%
20%
30%
Early Ultra-late
[RJ Schimdt, Am J Kidney Disease 1998; 32: 278-283]
UnUn--planned start in early referred patients planned start in early referred patients
�� WhyWhy ESRDESRD patientspatients knownknown byby aa NephrologistsNephrologists
endend upup asas unun--plannedplanned dialysisdialysis starterstarter ??endend upup asas unun--plannedplanned dialysisdialysis starterstarter ??
�� TheThe patientpatient doesdoes notnot acceptaccept dialysisdialysis accessaccess creationcreation ??
�� ServiceService organizationorganization [late[late oror lacklack ofof referralreferral forfor accessaccess
creation]creation] ??creation]creation] ??
�� AcuteAcute illnessillness [acute[acute renalrenal failurefailure onon chronic]chronic] ??
The unThe un--planned dialysis initiationplanned dialysis initiation
50
Reasons of un-planned dialysis start [49/109 known patients]
21
17
24
20
25
30
35
40
45
50
0
5
10
15
Acute illness Patients related Service related
[ J Buck Nephrol Dial Transplant 2007; 22: 3240-3245]
Peritoneal dialysis is underused in the Peritoneal dialysis is underused in the
unun--planned dialysis starterplanned dialysis starter
Dialysis modality in the late referred patientsDialysis modality in the late referred patients
100%
Dialysis modality according to the referral pattern[EPIREL, 502 incident dialysis patients in Lorraine]
79% 81%86%
98%
30%
40%
50%
60%
70%
80%
90%
100%HD
PD
0%
10%
20%
30%
>12 mo 12-4 mo 4-1 mo < 1mo
[M Kessler Am J Kid Dis 2003; 42:474-485]
PD is underused in the late referred patientsPD is underused in the late referred patients
�� Why PD is not used in late referred patients ?Why PD is not used in late referred patients ?�� Why PD is not used in late referred patients ?Why PD is not used in late referred patients ?
�� Medical decision ?Medical decision ?
�� Result of PD in late referred patients ?Result of PD in late referred patients ?
�� Lack of patients education and information ?Lack of patients education and information ?
Common pathway for the late referred patientsCommon pathway for the late referred patients
Haemodialysis initiation
[Temporary catheter ]2-3 weeks
[Temporary catheter ]
Chronic haemodialysis
[Tunneled catheter]
2-3 weeks
3-6 months
High risk period
Chronic haemodialysis
[Fistula or graft]
Catheter utilization in haemodialysis patientsCatheter utilization in haemodialysis patients
100%
Reasons for the tunneled catheters utilization[Single centre. 108 Tunneled catheters. 458 HD patients. US]
19%
29%
43%
30%
40%
50%
60%
70%
80%
90%
100%
“Impossibility to use PD ?”
19%
9%
0%
10%
20%
30%
No options Immature Scheduled Refusal
[T Lee, Am J Kidney Disease 2005; 46:501-508]
The unThe un--scheduled dialysis initiation in Spainscheduled dialysis initiation in Spain
100%
Education regarding dialysis modality
in un-planned dialysis starter
24%
76%
30%
40%
50%
60%
70%
80%
90%
100%Educated
Non educated
24%
0%
10%
20%
30%
Scheduled Un-scheduled
[ B Marron, Nephrol Dial Transplant 2006; 21 S2: 51-55]
How peritoneal dialysis can help to deal How peritoneal dialysis can help to deal
with unwith un--planned dialysis starter ?planned dialysis starter ?
PD: a possibility to act against the HD PD: a possibility to act against the HD
catheter utilizationcatheter utilization
Haemodialysis initiation 2-3 weeks
Acute start APD
Haemodialysis initiation
[Temporary catheter ]
Chronic haemodialysis
[Tunneled catheter]
2-3 weeks
3-6 months
Early transfer to PD
Chronic haemodialysis
[Fistula or graft]
Late transfer to PD
The acute start on PD procedure for the The acute start on PD procedure for the
late referred patients starting dialysislate referred patients starting dialysis
The acute start APD for late referred patientsThe acute start APD for late referred patients
�� TheThe possibilitypossibility forfor thethe patientpatient toto makemake aa choicechoice
betweenbetween thethe urgenturgent startstart onon PDPD vsvs.. urgenturgent startstart ononbetweenbetween thethe urgenturgent startstart onon PDPD vsvs.. urgenturgent startstart onon
HDHD
�� AnAn agreementagreement withwith thethe surgeonsurgeon teamteam forfor aa 77 daysdays aa
weekweek PDPD cathetercatheter insertioninsertion
�� AcuteAcute startstart onon APDAPD inin supinesupine positionposition withwith aa
standardstandard prescriptionprescription[J Povlsen Nephrol Dial Transplant 2006; 21 S2: 56-59]
The acute start automated PD procedureThe acute start automated PD procedure
Standard prescription for the acute APD start
BodyweightBodyweight < 60 kg< 60 kg > 60kg> 60kg
Time overnightTime overnight 12 h12 h 12 h12 h
Total volumeTotal volume 10 l10 l 14 l14 l
Maximal dwell volumeMaximal dwell volume 1.2 l1.2 l 1.5 l1.5 lMaximal dwell volumeMaximal dwell volume 1.2 l1.2 l 1.5 l1.5 l
Tidal volumeTidal volume 50%50% 50%50%
[JV Povlsen Nephrol Dial Transplant 2006; 21 S2 56-59]
Results of the acute start on PDResults of the acute start on PD
Complications and outcome
Acute startAcute start
[n=52][n=52]
PlannedPlanned
[n=88] [n=88] pp
InfectionsInfections 19%19% 21%21% NSNS
MechanicalMechanical 29%29% 8%8% <0.05<0.05MechanicalMechanical 29%29% 8%8% <0.05<0.05
Technique survivalTechnique survival 75%75% 86%86% NSNS
[JV Povlsen Nephrol Dial Transplant 2006; 21 S2 56-59]
ContraContra--indications for the acute startindications for the acute start
�� These patients were considered as contraindicated These patients were considered as contraindicated
for acute PD and started on haemodialysisfor acute PD and started on haemodialysisfor acute PD and started on haemodialysisfor acute PD and started on haemodialysis
�� Severe hypertensionSevere hypertension
�� Severe overhydrationSevere overhydration
�� Hyperkalemia (>6.5 mmol/l)Hyperkalemia (>6.5 mmol/l)
�� Uremic pericarditisUremic pericarditis
�� ColitisColitis
[JV Povlsen Nephrol Dial Transplant 2006; 21 S2 56-59]
The early transfer on peritoneal dialysisThe early transfer on peritoneal dialysis
Arguments for the early transfer on PDArguments for the early transfer on PD
Infections rate by dialysis modality[Single centre. 181 dialysis patients]
HD PD p
Bacteremia in the first 3 mo 0.47 0 <0.001
Peritonitis in the first 3 mo 0 0.22 <0.001
Total [infection rate per year] 0.77 0.86 NS
[N Aslam Clin J Am Soc Nephrol 2006; 1: 1226-1233]
The early transfer on peritoneal dialysisThe early transfer on peritoneal dialysis
HD THROUGH TEMPORARY LINE
HD with tunneled line Acute APD start
Patients choice
HD with Fistula Peritoneal dialysis
The early transfer on peritoneal dialysisThe early transfer on peritoneal dialysis
Patients characteristics at dialysis startPatients characteristics at dialysis start
Definition: un-planned=temporary catheter
Variables PD (n=34) HD (n=26) p
Age [yrs] 65 ± 2 64 ± 18 NS
Sex ratio [M/F] 19/15 17/9 NS
Patients characteristics at dialysis startPatients characteristics at dialysis start[n=60 un[n=60 un--planned dialysis starter]planned dialysis starter]
Sex ratio [M/F] 19/15 17/9 NS
Charlson [units] 5.9 ± 2.4 7.2 ± 3.1 NS
Charlson Modified 4.4 ± 1.85 5.9 ± 2.4 < 0,01
Renal functionRenal function
Anuria at dialysis start Renal function
10
15
20
25
30
35
Non anuric
Anuric
Renal function
2
3
4
5
HD
DP
p<0,05
0
5
10
HD DP
0
1
M3 M12
Choice of the dialysis modalityChoice of the dialysis modality
� Reasons for not using peritoneal dialysis in 60
unplanned dialysis starter:
Unplanned dialysis starter
unplanned dialysis starter:
� Contraindication to PD: n=19
� Patients choice: n=7
Unplanned dialysis starter
PD [n=34] HD [n=26] p
Catheter duration 26.1 ± 20.6 32.4 ± 29.2 NS
Initial hospitalization (d) 24 ± 28 29 ± 33 NS
Tunneled catheter 3/34 23/26 <0.01
Patients outcome on dialysisPatients outcome on dialysis
Patients survival on dialysis
,2
,4
,6
,8
1PD
HD
p<0,05
0
0 3 6 9 12 15 18 21 24 27 30 33
[No difference after adjustment for the CCI]
Patients outcome on dialysisPatients outcome on dialysis
Survival free of re-hospitalization
,4
,6
,8
1
DP
0
,2
0 3 6 9 12 15 18 21 24 27 30 33
HD
Patients outcome on peritoneal dialysisPatients outcome on peritoneal dialysis
�� Technique survivalTechnique survival
� PD initiation [median]: 4 days� PD initiation [median]: 4 days
� Acute APD duration: 9±3 days
� Peritoneal leak: 2/34
� Technique survival at one year: 88%
�� Survival free of peritonitisSurvival free of peritonitis
� 73% at 6 months, 55% at one year
Patients outcome on peritoneal dialysisPatients outcome on peritoneal dialysis
Assisted PD: 17
After being discharged from the hospital
� 34 acute starter on PD
Assisted PD: 17
Self care PD: 17
APD: 21
� 34 acute starter on PD
APD: 21
CAPD: 13
The early transfer on peritoneal dialysisThe early transfer on peritoneal dialysis
�� PeritonealPeritoneal dialysisdialysis isis aa suitablesuitable methodmethod toto treattreat unun--plannedplanned dialysisdialysis starterstarterplannedplanned dialysisdialysis starterstarter
�� BUTBUT somesome pointspoints mustmust bebe takentaken intointo accountaccount::
�� AnAn agreementagreement withwith thethe surgeonsurgeon teamteam isis necessarynecessary
�� NursesNurses inin thethe nephrologynephrology wardward mustmust bebe trainedtrained toto APDAPD�� NursesNurses inin thethe nephrologynephrology wardward mustmust bebe trainedtrained toto APDAPD
�� AssistedAssisted PDPD isis mandatorymandatory pendingpending patientspatients educationeducation
�� MedicalMedical decisiondecision toto proposepropose bothboth optionoption toto thethe patientpatient
Late transfer from chronic HD to PDLate transfer from chronic HD to PD
Late transfer on peritoneal dialysisLate transfer on peritoneal dialysis
100%
Causes of the late transfer from HD to PD
64%
21%30%
40%
50%
60%
70%
80%
90%
21%15%
0%
10%
20%
30%
Access Heart failure Hypotension
[T Liberek Nephrol Dial Transplant 2009; 24:2889-2894]
Late transfer on peritoneal dialysisLate transfer on peritoneal dialysis
Patients survival on peritoneal dialysis
[T Liberek Nephrol Dial Transplant 2009; 24:2889-2894]
Late transfer on peritoneal dialysisLate transfer on peritoneal dialysis
Technique’s survival on peritoneal dialysis
[T Liberek Nephrol Dial Transplant 2009; 24:2889-2894]
The late transfer from HD to PDThe late transfer from HD to PD
�� UnUn--plannedplanned dialysisdialysis starterstarter cancan bebe transferredtransferred onon
PDPD afterafter moremore thanthan 33 monthsmonths onon HDHDPDPD afterafter moremore thanthan 33 monthsmonths onon HDHD
�� BUTBUT somesome pointspoints mustmust bebe takentaken intointo accountaccount::
�� InformationInformation [and[and education]education] aboutabout thethe possibilitypossibility toto bebe
transferredtransferred onon PDPD mustmust bebe providedprovided toto thethe patientpatienttransferredtransferred onon PDPD mustmust bebe providedprovided toto thethe patientpatient
�� NephrologistsNephrologists mustmust consideredconsidered PDPD insteadinstead ofof HDHD inin
casecase ofof tunneledtunneled lineline utilizationutilization
CONCLUSIONCONCLUSION
�� PeritonealPeritoneal dialysisdialysis isis aa suitablesuitable methodmethod toto treattreat latelate referredreferredpatientspatients andand unun--plannedplanned dialysisdialysis starterstarterpatientspatients andand unun--plannedplanned dialysisdialysis starterstarter
�� PeritonealPeritoneal dialysisdialysis presentpresent thethe advantageadvantage toto reducereduce thethe useuse ofofHDHD cathetercatheter
�� BUT,BUT, forfor nono clearclear reasonreason peritonealperitoneal dialysisdialysis isis underusedunderused ininthethe unun--plannedplanned starterstarterthethe unun--plannedplanned starterstarter
�� AtAt leastleast PDPD couldcould bebe usedused pendingpending thethe vascularvascular accessaccesscreationcreation ifif HDHD isis chosenchosen
Back up slides in case of…Back up slides in case of…
Dialysis initiationDialysis initiation
Urgent dialysis start
15
20
25
30
35
40
Non urgent
Urgent
0
5
10
HD DP
The pathway for the late referred patientsThe pathway for the late referred patients
100%
Vascular access type in haemodialysis patients[The CHOICE study, 356 haemodialysis patients]
65%60%
40%
30%35%
40%
60%
70%
30%
40%
50%
60%
70%
80%
90%
100%Catheter
Fistula/graft
0%
10%
20%
30%
Initiation 1 months 3 months 6 months
[Astor BC Am J Kidney Dis 2009; 38: 494-501]
The early transfer on peritoneal dialysisThe early transfer on peritoneal dialysis
�� CatheterCatheter insertioninsertion withinwithin 1010 daysdays followingfollowing dialysisdialysis
initiationinitiation..initiationinitiation..
�� StandardStandard prescriptionprescription forfor thethe earlyearly startstart onon
peritonealperitoneal dialysisdialysis
�� APDAPD inin supinesupine positionposition
LowLow fillfill volumevolume ((11 liter)liter)�� LowLow fillfill volumevolume ((11 liter)liter)
�� LidocaineLidocaine intointo thethe firstfirst PDPD bagsbags ((55 mlml 11%% inin 55 liters)liters)
�� NoNo PDPD exchangesexchanges duringduring dayday timetime
Dialysis modality in the ultraDialysis modality in the ultra--late referredlate referred
91%100%
PD utilization 4 months after dialysis start[238 incidents patients in one centre]
28%
91%
66%
30%
40%
50%
60%
70%
80%
90%
100%PD
HD
9%
28%
0%
10%
20%
30%
Initial 4 months
[RJ Schimdt, Am J Kidney Disease 1998; 32: 278-283]