Unusually high demand for dialysis to treat acute kidney injury (AKI) in patients hospitalized with COVID-19 led to rapid adoption of acute peritoneal dialysis (PD) programs at some institutions in New York City, according to reports presented at the American Society of Nephrology’s Kidney Week 2020 Reimagined virtual conference.

At Montefiore Medical Center in The Bronx, New York, severe personnel shortages necessitated creation of an urgent PD service, Maryanne Y. Sourial, DO, and colleagues reported in a poster presentation.1 Transplant surgeons performed bedside laparoscopically-assisted flexible PD catheter placement for intubated and intensive care unit (ICU) patients. Interventional radiologists performed fluoroscopy-guided flexible PD catheter placement for non-intubated non-ICU patients. Many residents, fellows, attending physicians, nurse practitioners, and nurses were trained in administering manual PD. Some attending physicians and nurse practitioners were trained in automated PD.

Of 164 patients with severe AKI requiring renal replacement therapy (RRT), 30 were treated with PD. As of May 14, 14 (47%) of the 30 patients started on PD died during their hospitalization. Eight patients were discharged home or to a rehabilitation facility; of these, 3 were receiving PD and 5 no longer needed RRT due to renal recovery by the time of discharge. Eight patients were still hospitalized.


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Of the 8 patients who remained hospitalized, none remained on PD. Four patients were switched to either continuous renal replacement therapy (CRRT) or intermittent hemodialysis (IHD), and 4 patients had renal recovery and no longer needed RRT.

Dr Sourial’s team noted that PD use in the AKI setting has advantages, including no need for vascular access, reduced cost compared with CRRT and IHD, and no need for special plumbing to supply water for dialysate for IHD, “allowing for treatment in hospital rooms without adequate water supply.” In addition, staff can be educated to perform PD safely with few resources over a short period of time compared with other dialysis modalities.

“Based on our experience, urgent PD is a feasible RRT option to treat patients with COVID-19 and AKI,” the authors concluded.

NYU Langone Health in New York, New York, also instituted an acute PD program as a result of a dramatic surge in ICU patients requiring RRT for AKI caused by the COVID-19 pandemic. “Our ability to provide RRT with CVVH and IHD was severely limited by critical shortages of equipment and personnel,” Nina J. Caplin, MD, and colleagues concluded in a study abstract.2

As of May 8, 63 patients were evaluated and 38 patients received PD catheters. The catheters were used for exchanges in 35 patients. Of these, 20 died in less than 30 days and 15 survived more than 30 days. Eight patients recovered renal function.

“Because of the shortage of our typically used dialysis modalities we were compelled to start an acute PD program,” the investigators wrote in a study abstract. “No patient on PD required additional dialytic support with IHD or CVVH. PD was well tolerated by ventilated patients with hemodynamic stability. Acute PD more than adequately filled the gap in treatment options during this unprecedented crisis.”

Also during the conference, Elly Varma, MBBS, and colleagues at Weill Cornell Medicine in New York, New York, reported their experience with the use of acute PD for 11 patients with COVID-19-related AKI that required RRT.3 These patients had undergone bedside PD catheter placement from April 1 to April 30.

The median time from AKI to PD catheter insertion was 5 days. At 1 week, 10 catheters (91%) were functional with no leaks or bleeding detected. Only 1 patient was switched to CRRT due to primary PD catheter nonfunction. The median duration of follow-up from time of PD catheter insertion was 37 days. Of the 11 patients, 4 (36%) died, 5 (45%) had recovery of renal function, and 2 (18%) were alive and on hemodialysis.

“We hypothesize that preservation of residual renal function utilizing PD may have contributed to the high rate of renal recovery observed,” the authors concluded.

The median time from AKI to death was 17 days. Median time from AKI to renal recovery was 34 days.

The rapid embrace of PD to address an explosive demand for dialysis brought on by the COVID-19 pandemic could contribute to increased uptake of the modality generally, according to Virginia Wang, PhD, MSPH, of Duke University School of Medicine in Durham, North Carolina, a coauthor of the study titled “Trends in peritoneal dialysis use in the United States after Medicare payment reform,” which was published in 2019 in the Clinical Journal of the American Society of Nephrology.4

Noting that uptake of PD has risen only moderately in the last few decades, she said, “I’ve wondered whether and what kind of system shocks would propel faster growth in PD use. The COVID-19 pandemic may be one of them, as suggested by these case reports of hospitals’ experiences initiating acute PD programs for patients with COVID-related AKI.”

Only a small minority of patients with end-stage kidney disease (ESKD) in the United States receive PD as their renal replacement therapy. As of December 31, 2017, only 7.1% of prevalent ESKD patients in the United States were being treated with PD (compared with 62.7% received hemodialysis), according to the US Renal Data System 2019 Annual Data Report. Some investigators say PD is underused.

Many factors in the healthcare delivery system are associated with underuse of PD, including lack of earlier CKD identification and timely preparation for kidney failure, inadequate patient education about all treatment options, and lack of PD availability at dialysis facilities, said Dr Wang, who is an associate professor in the Department of Population Health Sciences and Division of General Internal Medicine. Clinician lack of awareness of, and experience with, PD are commonly cited barriers to wider adoption and use of the modality and may be challenging to address, Dr Wang said. Healthcare providers are unable to get hands-on experience with PD because relatively few patients receive this form of dialysis.

With few alternative solutions, the pandemic forced hospitals to train clinicians, including physicians, nurses, and surgeons, in all facets of PD care and in ways that were probably not well established before COVID-19, Dr Wang said. “In this way, the pandemic could inadvertently represent an opportunity for PD growth in the US.”

She pointed out, however, that clinician lack of experience with PD is only one of several barriers to optimizing PD use. “It will be important to assess the impact of these rapidly established acute PD programs on wider PD acceptance over time, especially in these NY metropolitan hospitals. There are so many important lessons to be learned from the NY COVID experience.”

References

  1. Sourial M, Sourial M, Dalsan R, et al. Acute peritoneal dialysis in patients with COVID-19: A single-center experience in a time of crisis in the United States. Presented at: Kidney Week 2020 Reimagined virtual meeting, October 19 to 25. Poster PO0670.
  2. Caplin NJ, Tandon M, Zhdanova O, et al. Acute peritoneal dialysis during the COVID-19 pandemic in New York City. Presented at: Kidney Week 2020 Reimagined virtual meeting, October 19 to 25. Poster PO0100.
  3. Varma E, Shankaranarayanan D, Neupane SP, et al. Renal recovery in COVID-19 with AKI managed on peritoneal dialysis. Presented at: Kidney Week 2020 Reimagined virtual meeting, October 19 to 25. Poster PO0669.
  4.  Sloan CE, Coffman CJ, Sanders LL, et al. Trends in peritoneal dialysis use in the United States after Medicare payment report. Clin J Am Soc Nephrol. 2019;14:1763-1772. doi:10.2215/CJN.05910519