The hidden financial catastrophe of chronic kidney disease under universal coverage and Thai "Peritoneal Dialysis First Policy".

Objective: Universal health coverage can decrease the magnitude of the individual patient's financial burden of chronic kidney disease (CKD), but the residual financial hardship from the patients' perspective has not been well-studied in low and middle-income countries (LMICs). This study aimed to evaluate the residual financial burden in patients with CKD stage 3 to dialysis in the "PD First Policy" under Universal Coverage Scheme (UCS) in Thailand. Methods: This multicenter nationwide cross-sectional study in Thailand enrolled 1,224 patients with pre-dialysis CKD, hemodialysis (HD), and peritoneal dialysis (PD) covered by UCS and other health schemes for employees and civil servants. We interviewed patients to estimate the proportion with catastrophic health expenditure (CHE) and medical impoverishment. The risk factors associated with CHE were analyzed by multivariable logistic regression. Results: Under UCS, the total out-of-pocket expenditure in HD was over two times higher than PD and nearly six times higher than CKD stages 3-4. HD suffered significantly more CHE and medical impoverishment than PD and pre-dialysis CKD [CHE: 8.5, 9.3, 19.5, 50.0% (p < 0.001) and medical impoverishment: 8.0, 3.1, 11.5, 31.6% (p < 0.001) for CKD Stages 3-4, Stage 5, PD, and HD, respectively]. In the poorest quintile of UCS, medical impoverishment was present in all HD and two-thirds of PD patients. Travel cost was the main driver of CHE in HD. In UCS, the adjusted risk of CHE increased in PD and HD (OR: 3.5 and 16.3, respectively) compared to CKD stage 3. Conclusions: Despite universal coverage, the residual financial burden remained high in patients with kidney failure. CHE was considerably lower in PD than HD, although the rates remained alarmingly high in the poor. The "PD First' program" could serve as a model for other LMICs. However, strategies to minimize financial distress should be further developed, especially for the poor.

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

Introduction: We sought to evaluate the efficacy and complications of urgent-start peritoneal dialysis (PD) compared with urgent-start temporary hemodialysis (HD) followed by subsequent elective transfer to PD. Methods: In this multicenter open-label prospective randomized controlled trial, adults with kidney failure who required immediate dialysis but did not have access to definitive dialysis were randomized to receive either urgent-start PD or urgent-start temporary HD over 2 weeks to 4 weeks followed by a transition to a chronic PD program according to the country policy. The primary outcome was the composite end point of operation-related, catheter-related, and dialysis-related complications at 6 weeks. Secondary outcomes were 6-week mortality, 6-week technique survival, and 1-week composite complications. Results: A total of 207 participants requiring urgent-start dialysis were enrolled from 3 tertiary hospitals between November 2018 and February 2020 as follows: 104 were assigned to receive urgent-start PD, and 103 were assigned to urgent-start temporary HD. Compared with urgent-start temporary HD, urgent-start PD had a lower composite complication rate at 6 weeks (19% vs. 37%, risk ratio [RR] 0.52, 95% CI 0.33-0.83), which was primarily accounted for by a reduction in dialysis-related complications (4% vs. 24%, RR 0.16, 95% CI 0.06-0.44). No significant differences were observed between the 2 groups with respect to patient and technique survival rates at 1 week and 6 weeks. Conclusion: An urgent-start PD strategy during the transition of kidney failure to chronic dialysis is safe and has fewer complications commensurate with their reduced exposure to procedural risk than urgent-start temporary HD up to 6 weeks after dialysis commencement.

Metformin-associated lactic acidosis and factors associated with 30-day mortality.

BACKGROUND: Metformin-associated lactic acidosis (MALA) is a rare event but underrecognition may lead to unfavorable outcomes in type 2 diabetes patients. While many risk factors of MALA have been identified, how to reduce mortality from MALA is a matter of debate. This study aimed to explore the factors associated with 30-day mortality amongst MALA patients. METHODS: An observational study enrolled patients diagnosed with MALA between January 2014 and December 2017. MALA was defined by a history of metformin administration, metabolic acidosis (arterial blood gas pH <7.35 or HCO3 <15 mmol/L), and elevated plasma lactate level (>5 mmol/L). We examined risk factors including age, sex, underlying diseases, current medications, blood tests, disease severity, and dialysis data. Mortality status was identified from medical records or report on telephone. RESULTS: We included 105 MALA patients. Most patients (95.2%) were diagnosed acute kidney injury stage 3 according to KDIGO 2012 definition. The 30-day mortality rate was 36.2% and dialysis rate was 85.7%. The survivors had higher proportions of underlying chronic kidney disease, presence of metabolic acidosis, receiving renal replacement therapy within 6 hours, and haemodialysis, whereas the non-survivors had higher percentage of hypertension and disease severity. Lower APACHE II score (HR = 0.95; 95%CI, 0.91-0.99; p = 0.038), time to dialysis < 6 hours (0.31; 0.14-0.69; 0.004), and haemodialysis (0.20;0.06-0.67; 0.010) were associated with lower 30-day mortality, using multivariate Cox-regression analysis. CONCLUSIONS: Mortality rate amongst patients with MALA was high. Early dialysis treatment within 6 hours after admission and haemodialysis were independently associated with lower 30-day mortality. The large scale, well-designed studies need to confirm these encouraging results.

Efficacy of Potassium Supplementation in Hypokalemic Patients Receiving Peritoneal Dialysis: A Randomized Controlled Trial.

RATIONALE & OBJECTIVE: Hypokalemia is a common electrolyte abnormality in patients on peritoneal dialysis (PD) and has been associated with increased risks of peritonitis and death. Whether correction of hypokalemia improves these outcomes is unknown. STUDY DESIGN: Multicenter, open-label, prospective, randomized controlled trial. SETTING & PARTICIPANTS: Adult (aged ≥18 years) PD patients with hypokalemia (defined as at least 3 values or an average value <3.5 mEq/L in the past 6 months). Randomization was stratified according to center and residual urine output (≤100 or >100 mL/day). INTERVENTIONS: Random assignment to either protocol-based potassium supplementation (titratable dose of oral potassium chloride to maintain serum potassium of 4-5 mEq/L) or conventional potassium supplementation (reactive supplementation when serum potassium is <3.5 mEq/L) over 52 weeks. Treatment groups were compared using intention-to-treat analyses implemented using Cox proportional hazards regression. OUTCOME: The primary outcome was time from randomization to first peritonitis episode (any organism). Secondary outcomes were all-cause mortality, cardiovascular mortality, hospitalization, and conversion to hemodialysis. RESULTS: A total of 167 patients with time-averaged serum potassium concentrations of 3.33 ± 0.28 mEq/L were enrolled from 6 PD centers: 85 were assigned to receive protocol-based treatment, and 82 were assigned to conventional treatment. The median follow-up time was 401 (IQR, 315-417) days. During the study period, serum potassium levels in the protocol-based treatment group increased to 4.36 ± 0.70 mEq/L compared with 3.57 ± 0.65 mEq/L in the group treated conventionally (mean difference, 0.66 [95% CI, 0.53-0.79] mEq/L; P < 0.001). The median time to first peritonitis episode was significantly longer in the protocol-based group (223 [IQR, 147-247] vs 133 [IQR, 41-197] days, P = 0.03). Compared with conventional treatment, the protocol-based group had a significantly lower hazard of peritonitis (HR, 0.47 [95% CI, 0.24-0.93]) but did not differ significantly with respect to any of the secondary outcomes. Asymptomatic hyperkalemia (>6 mEq/L) without characteristic electrocardiographic changes occurred in 3 patients (4%) in the protocol-based treatment group. LIMITATIONS: Not double-masked. CONCLUSIONS: Compared with reactive potassium supplementation when the serum potassium level falls below 3.5 mEq/L, protocol-based oral potassium treatment to maintain a serum potassium concentration in the range of 4-5 mEq/L may reduce the risk of peritonitis in patients receiving PD who have hypokalemia. TRIAL REGISTRATION: Registered at the Thai Clinical Trials Registry with study number TCTR20190725004.

Outcomes after Acute Peritoneal Dialysis for Critical Cardiorenal Syndrome Type 1.

INTRODUCTION: The aim of the study was to demonstrate the outcomes of peritoneal dialysis (PD) in critically ill cardiorenal syndrome type 1 (CRS1). METHODS: A cohort of 147 patients with CRS1 who received PD from 2011 to 2019 in a referral hospital in Thailand was analyzed. The primary outcome was 30-day in-hospital mortality. Ultrafiltration and net fluid balance among survivors and nonsurvivors in the first 5 PD sessions were compared. RESULTS: The 30-day mortality rate was 73.4%. Most patients were critically ill CRS1 (all patients had a respiratory failure of which 68% had cardiogenic shock). Blood urea nitrogen and creatinine at the commencement of PD were 60.1 and 4.05 mg/dL. In multivariable analysis, increasing age, unstable hemodynamics, and positive fluid balance in the first 5 PD sessions were associated with the risk of in-hospital mortality. The change of fluid balance per day during the first 5 dialysis days was significantly different among survivor and nonsurvivor groups (-353 vs. 175 mL per day, p = 0.01). CONCLUSIONS: PD is a viable dialysis option in CRS1, especially in a resource-limited setting. PD can save up to 27% of lives among patients with critically ill CRS1.

ISPD guidelines for peritoneal dialysis in acute kidney injury: 2020 update (adults).

SUMMARY STATEMENTS: (1) Peritoneal dialysis (PD) should be considered a suitable modality for treatment of acute kidney injury (AKI) in all settings (1B). GUIDELINE 2: ACCESS AND FLUID DELIVERY FOR ACUTE PD IN ADULTS: (2.1) Flexible peritoneal catheters should be used where resources and expertise exist (1B) (optimal).(2.2) Rigid catheters and improvised catheters using nasogastric tubes and other cavity drainage catheters may be used in resource-poor environments where they may still be life-saving (1C) (minimum standard).(2.3) We recommend catheters should be tunnelled to reduce peritonitis and peri-catheter leak (practice point).(2.4) We recommend that the method of catheter implantation should be based on patient factors and locally available skills (1C).(2.5) PD catheter implantation by appropriately trained nephrologists in patients without contraindications is safe and functional results equate to those inserted surgically (1B).(2.6) Nephrologists should receive training and be permitted to insert PD catheters to ensure timely dialysis in the emergency setting (practice point). (2.7) We recommend, when available, percutaneous catheter insertion by a nephrologist should include assessment with ultrasonography (2C).(2.8) Insertion of PD catheter should take place under complete aseptic conditions using sterile technique (practice point).(2.9) We recommend the use of prophylactic antibiotics prior to PD catheter implantation (1B).(2.10) A closed delivery system with a Y connection should be used (1A) (optimal). In resource poor areas, spiking of bags and makeshift connections may be necessary and can be considered (minimum standard).(2.11) The use of automated or manual PD exchanges are acceptable and this will be dependent on local availability and practices (practice point). GUIDELINE 3: PERITONEAL DIALYSIS SOLUTIONS FOR ACUTE PD: (3.1) In patients who are critically ill, especially those with significant liver dysfunction and marked elevation of lactate levels, bicarbonate containing solutions should be used (1B) (optimal). Where these solutions are not available, the use of lactate containing solutions is an alternative (practice point) (minimum standard).(3.2) Commercially prepared solutions should be used (optimal). However, where resources do not permit this, then locally prepared fluids may be life-saving and with careful observation of sterile preparation procedure, peritonitis rates are not increased (1C) (minimum standard).(3.3) Once potassium levels in the serum fall below 4 mmol/L, potassium should be added to dialysate (using strict sterile technique to prevent infection) or alternatively oral or intravenous potassium should be given to maintain potassium levels at 4 mmol/L or above (1C).(3.4) Potassium levels should be measured daily (optimal). Where these facilities do not exist, we recommend that after 24 h of successful dialysis, one consider adding potassium chloride to achieve a concentration of 4 mmol/L in the dialysate (minimum standard) (practice point). GUIDELINE 4: PRESCRIBING AND ACHIEVING ADEQUATE CLEARANCE IN ACUTE PD: (4.1) Targeting a weekly Kt/Vurea of 3.5 provides outcomes comparable to that of daily HD in critically ill patients; targeting higher doses does not improve outcomes (1B). This dose may not be necessary for most patients with AKI and targeting a weekly Kt/V of 2.2 has been shown to be equivalent to higher doses (1B). Tidal automated PD (APD) using 25 L with 70% tidal volume per 24 h shows equivalent survival to continuous venovenous haemodiafiltration with an effluent dose of 23 mL/kg/h (1C).(4.2) Cycle times should be dictated by the clinical circumstances. Short cycle times (1-2 h) are likely to more rapidly correct uraemia, hyperkalaemia, fluid overload and/or metabolic acidosis; however, they may be increased to 4-6 hourly once the above are controlled to reduce costs and facilitate clearance of larger sized solutes (2C).(4.3) The concentration of dextrose should be increased and cycle time reduced to 2 hourly when fluid overload is evident. Once the patient is euvolemic, the dextrose concentration and cycle time should be adjusted to ensure a neutral fluid balance (1C).(4.4) Where resources permit, creatinine, urea, potassium and bicarbonate levels should be measured daily; 24 h Kt/Vurea and creatinine clearance measurement is recommended to assess adequacy when clinically indicated (practice point).(4.5) Interruption of dialysis should be considered once the patient is passing >1 L of urine/24 h and there is a spontaneous reduction in creatinine (practice point).The use of peritoneal dialysis (PD) to treat patients with acute kidney injury (AKI) has become more popular among clinicians following evidence of similar outcomes when compared with other extracorporeal therapies. Although it has been extensively used in low-resource environments for many years, there is now a renewed interest in the use of PD to manage patients with AKI (including patients in intensive care units) in higher income countries. Here we present the update of the International Society for Peritoneal Dialysis guidelines for PD in AKI. These guidelines extensively review the available literature and present updated recommendations regarding peritoneal access, dialysis solutions and prescription of dialysis with revised targets of solute clearance.

Peritoneal dialysis with a lower dosage versus conventional intermittent hemodialysis in acute kidney injury: A propensity-matched study.

BACKGROUND: Literature regarding the outcomes of lower dosage peritoneal dialysis (PD) in treating acute kidney injury (AKI) among resource-limited setting is sparse. This study aims to compare the risk of mortality in patients with AKI receiving lower PD dosage and conventional intermittent hemodialysis (IHD) in Thailand. METHODS: In a tertiary center in Thailand, a matched case-control study using propensity scores in patients with AKI was conducted to compare the outcomes between lower PD dosage (18 L per day for first two sessions, weekly Kt/V 2.2) and IHD (three times a week) from February 2015 to January 2016. The primary outcome was a 30-day in-hospital mortality rate. Secondary outcomes included dialysis dependence at 90 days. RESULTS: Eighty-four patients were included (28 PD and 56 IHD). Patient characteristics were comparable between two treatment groups. Overall, the mean age was 58 years. Most of the patients were critically ill (87% need mechanical ventilator; mean acute physiological and chronic health evaluation (APACHE II) score: 25). The 30-day in-hospital mortality rate was similar between the PD and IHD patients (57% vs. 46%, p = 0.36). The dialysis dependence rate was also comparable at 90 days. The risk of death among AKI patients was higher in those with respiratory failure, higher APACHE II score, and starting dialysis with blood urea nitrogen greater than 70 mg dL-1. CONCLUSION: Clinical outcomes, including risk of mortality and 90-day dialysis dependence among patients with AKI, appear to be comparable between lower dosage PD and IHD.

Customized versus conventional video counseling for peritoneal dialysis decision-making in patients with stage 5 chronic kidney disease under a PD-first policy: a randomized controlled study.

BACKGROUND: Indecision regarding the start of peritoneal dialysis (PD) is a challenging problem in chronic kidney disease (CKD) stage 5 patients who receive conventional video counseling. This study aimed to evaluate the effect of video counseling customized to the local context versus conventional video counseling on PD decision-making in CKD stage 5 patients under PD-first policy. METHODS: We enrolled 120 patients with stage 5 CKD in Thailand who initiate PD between May 2016 to January 2017 in a randomized, open-label, controlled study. Patients were randomized to either a customized or conventional video counseling group. The primary outcome was PD acceptance rate with complete PD catheter insertion on schedule. The secondary outcomes were change in patient knowledge and confidence in PD and reasons for indecision PD. RESULTS: We analyzed 120 patients (customized, n = 60 vs. conventional, n = 60). The two groups were similar for age (55 vs. 56 years), blood urea nitrogen (89 vs. 86 mg/dL), creatinine (10.37 vs. 11.29 mg/dL), and eGFR (4.7 vs. 5.6 mL/min/1.73 m2). The PD acceptance rate along with PD catheter insertion on schedule in the customized video counseling group was not significantly different from that in the conventional video counseling group (66.6% vs. 63.3%, relative risk: 0.97, 95% confidence interval: 0.73 to 1.29; P = 0.86). Patient knowledge of and confidence in PD increased after counseling, but the difference was not significant. CONCLUSION: Among stage 5 CKD patients, counseling content customized to a local context did not differ in a rate of acceptance for beginning PD with PD catheter insertion on schedule compared with conventional video counseling.

Intensive Versus Minimal Standard Dosage for Peritoneal Dialysis in Acute Kidney Injury: A Randomized Pilot Study.

BACKGROUND: Dosage for peritoneal dialysis (PD) in acute kidney injury (AKI) is controversial. This study aims to find benefits and risks of intensive versus minimal standard dosage of PD in AKI. METHODS: In a tertiary-hospital, 93 AKI patients who required PD between May 2015 and January 2016 were enrolled in a randomized, open-label controlled study. Patients were randomized to intensive group (> 30 L) and minimal standard group (< 20 L) of PD volume per day for the first 2 consecutive days. The primary outcome was in-hospital mortality. The secondary outcomes were peritonitis rate, dialysis dependence, and PD leakage. RESULTS: Seventy-five patients were analyzed (intensive PD n = 39; minimal standard PD n = 36). Mean age was 60 years. Most patients were in critical care (72% unstable hemodynamic, mean APACHE II score 26.2). Kt/V delivery per session was 0.61 and 0.38 in intensive and minimal standard PD dosage for the first 2 consecutive sessions. According to intention-to-treat analysis, the in-hospital mortality rate of intensive PD dosage was not significantly different from the minimal standard PD dosage (79% vs 63%, relative risk [RR] 1.11, 95% confidence interval [CI] 0.80 to 1.51, p = 0.13). The dialysis dependence rate and PD leakage were not significantly different between the 2 groups. The rate of PD peritonitis was slightly higher in the intensive PD dosage group (15.3% vs 8.3%, p = 0.34). CONCLUSION: Among AKI patients who required PD, there was no significant difference in in-hospital mortality between intensive and minimal standard PD dosage.