Acute Kidney Injury in Critically Ill Patients: A Prospective Randomized Study of Tidal Peritoneal Dialysis Versus Continuous Renal Replacement Therapy

Abstract

Few studies have discussed the role of peritoneal dialysis (PD) in managing acute kidney injury (AKI) in critically ill patients. The present study compares the outcome of AKI in intensive care unit (ICU) patients randomized to treatment with tidal PD (TPD) or continuous venovenous hemodiafiltration (CVVHDF). One hundred and twenty-five ICU patients with AKI were randomly allotted to CVVHDF, (Group A, N = 62) or TPD, (group B, N = 63). Cause and severity of renal injury were assessed at the time of initiating dialysis. The primary outcome was hospital mortality at 28 days, and secondary outcomes were time to recovery of renal function, duration of stay in the ICU, metabolic and fluid control, and improvement of sensorial and hemodynamic parameters. No statistically significant differences were observed between groups in regard to patients' characteristics. The survival at 28 days was significantly better in the patients treated with TPD when compared to CVVHDF (69.8% vs. 46.8%, P < 0.01). Infectious complications were significantly less (P < 0.01) in the TPD group (9.5%) when compared to the CVVHDF group (17.7%). Recovery of kidney function (60.3% vs. 35.5%), median time to resolution of AKI and the median duration of ICU stay of 9 days (7-11) vs. 19 days (13-20) were all in favor of TPD (P < 0.01). This study suggests that there are better outcomes with TPD compared to CRRT in the treatment of critically ill patients with AKI.

Peritoneal Dialysis for Acute Kidney Injury Treatment in the United States: Brought to You by the COVID-19 Pandemic

“…The utility and efficacy of PD to treat patients with AKI was reexamined after the publication of a series of articles from Brazil, including a randomized trial, demonstrating that PD provided acceptable care and was not inferior to daily HD in treating acutely ill patients with AKI in terms of patient mortality and was associated with a shorter duration of AKI and need for renal replacement therapy 4,5 . These findings were confirmed in a randomized trial from Saudi Arabia comparing PD to hemodiafiltration 6 . AKI-PD expanded dramatically in lower resource countries with the advent of the Saving Young Lives Program in 2012 which promoted the use of PD because of minimal infrastructural requirements, including a lack of need for water or electricity, the ease of training staff, and low costs.…”

“…In AKI-PD, the time between PD catheter placement and initial use is short and PD fluid leaks represent a complication seen with higher frequency compared to elective PD starts which usually have at least two weeks of healing time from catheter insertion to first use 22,23 . Nevertheless, the leak rates in the Brazilian and Saudi experience using high volume PD therapy immediately after catheter placement was extremely low 5,6 .…”

Acute Peritoneal Dialysis During the COVID-19 Pandemic at Bellevue Hospital in New York City

“…We had to educate ICU doctors and nurses about acute PD in AKI and the equivalence of PD to other KRT modalities, and how its use would avoid rationing. [9][10][11][12]…”

Briefly Noted

“…Tidal PD was associated with better 28 day survival (70% 47%), fewer infections (10% v 18%), faster renal recovery (5 v 8 days) and shorter ICU stays (9 v 19 days). 5 A study of protein and nitrogen losses during HD (N = 40) and PD (N = 68) found greater weekly protein losses in PD (mean, 46.6 gm) than in HD (25.9 gm) but similar nitrogen losses. Notably, only about 70% of these nitrogen losses were due to losses of urea and protein suggesting that far more losses of peptides, nucleotides, organic acids and amino acids occur than is commonly believed to be the case.…”

“…A randomized study of 125 ICU patients with AKI compared CVVHDF (30 mL/kg/h) to tidal PD (70% tidal, 24 L/d). Tidal PD was associated with better 28 day survival (70% 47%), fewer infections (10% v 18%), faster renal recovery (5 v 8 days) and shorter ICU stays (9 v 19 days) …”