Barriers to and constraints of acute peritoneal dialysis in acute kidney injury: A nationwide survey

Abstract

This national survey of barriers to and constraints of acute peritoneal dialysis (aPD) in acute kidney injury (AKI) was performed by distributing an online questionnaire to all medical directors of public dialysis units registered with the Nephrology Society of Thailand during September–November 2019. One hundred and thirteen adult facilities responded to the survey covering 75 from 76 provinces (99%) of Thailand. aPD was performed in 66 centres (58%). In facilities where aPD practice was available, the utilization rate was relatively low (<10 cases/year) and limited to specific conditions, including HIV seropositive patients, previous receiving dialysis education and plan and difficult vascular access creation. Only 9% of facilities performed aPD routinely, but interestingly all such units permitted bedside catheter insertion by the nephrologists or internists. The major constraints placed on aPD practice were PD catheter insertion competency, timely catheter insertion support and the medical supporting team’s knowledge/competency deficits. aPD for AKI is underutilized in Thailand and limited by the inability to undertake timely PD catheter insertion and knowledge and competency deficits.

Is It Time to Give Peritoneal Dialysis Its Due Place in Managing Acute Kidney Injury: Lessons Learnt from COVID-19 Pandemic

“…There has been a general perception that PD might be associated with more infectious and mechanical complications, especially if started acutely [4]. Concerns about mechanical complications such as peri-catheter leaks and catheter malfunctions have been significant barriers to starting PD before the break-in period of 2-4 weeks after PD catheter insertion [1].…”

“…In an international survey conducted in 2018, only 5% of the respondents used PD for AKI [3]. Of interest, in Thailand, a country with a PD-first policy and extensive experience of nephrologists in using PD for ESRD, the uptake of PD for AKI was only 6% [4]. Concerns about the ineffectiveness of PD in removing solutes and fluids, lack of experience and expertise in acute PD, competency of PD catheter insertion, and timely catheter insertion support were the main reasons identified in the nationwide survey [4].…”

“…Of interest, in Thailand, a country with a PD-first policy and extensive experience of nephrologists in using PD for ESRD, the uptake of PD for AKI was only 6% [4]. Concerns about the ineffectiveness of PD in removing solutes and fluids, lack of experience and expertise in acute PD, competency of PD catheter insertion, and timely catheter insertion support were the main reasons identified in the nationwide survey [4]. Physician bias and misconception about the unsuitability of PD for AKI [5], concerns about raised intraperitoneal pressure negatively impacting the ventilatory and circulatory functions, especially in mechanically ventilated patients, risk of mechanical complications, and infections are other perceived barriers (Table 1) [4, 6].…”

Lower-Dosage Acute Peritoneal Dialysis versus Acute Intermittent Hemodialysis in Acute Kidney Injury

“…[4][5][6][7][8] In resource-sufficient settings, PD is underused due to unfamiliar techniques, including PD catheter insertion, a lack of knowledge, and concerns regarding complications. [9][10][11] Inadequate solute clearance and high mortality are one of the two most common concerns for using PD in sepsis-related AKI. 10,[12][13][14] However, amid the coronavirus disease 2019 (COVID-19) pandemic, PD gained much attention as a KRT modality for COVID-19-related AKI based on a simple technique: no circuit blood clotting, less exposure of health care staff to the contagious virus, and less resource utilization.…”

Randomized Study of Urgent-Start Peritoneal Dialysis Versus Urgent-Start Temporary Hemodialysis in Patients Transitioning to Kidney Failure

“…5,6 Usually, these patients are treated with urgent-start HD with a central venous catheter (CVC). [1][2][3]7,8 Several factors contributing to the apparent preference for urgent-start temporary HD over urgent-start PD include the following: (i) HD catheter placement is a routine procedure, whereas the availability of experienced clinicians who are willing and able to place PD catheters at short notice is more limited; 9,10 (ii) nephrology training in PD has been suboptimal compared with HD; 7,10,11 and (iii) financial incentives have historically favored in-center HD. 10 Urgent-start PD, which is generally defined as an initiation of PD during the break-in period (within 14 days postcatheter insertion), 12,13 has been an important strategy to promote home dialysis.…”