Comparison of immediate-start peritoneal dialysis without break-in period and conventional-start peritoneal dialysis: a two-center retrospective audit.

PURPOSE: Immediate-start peritoneal dialysis (PD) has emerged as a strategy for patients in need of urgent dialysis. However, the ideal timing for initiating this procedure remains uncertain. In this study, we aimed to compare complications and outcomes between immediate-start PD and conventional-start PD. METHODS: We performed a two-center retrospective cohort study between 1 January 2015 and 31 May 2020. Patients who underwent PD were divided into immediate-start PD (without break-in period) and conventional-start PD group (break-in period within at least 14 days). The primary outcomes were the incidence of the mechanical complications and infectious complication. The secondary outcomes were technique failure and patient survival. RESULTS: A total of 209 patients (106 in the immediate-start PD group and 103 in the conventional-start PD group) were included. Immediate-start PD had significantly lower catheter malfunction or migration rate compare with conventional-start PD (2.8% vs. 15.5%, p = 0.003) but comparable rates of dialysate leaks, pleuroperitoneal leaks, and hemoperitoneum. Infectious complications (exit-site infection and peritonitis) were similar between groups. Technique survival was comparable (7.5% vs. 4.8%, p = 0.22), while immediate-start PD exhibited lower mortality rates (0.9% vs. 13.6%, p = 0.001). CONCLUSION: Immediate-start PD appears to be a viable option for patients in need of urgent dialysis, with reduced catheter complications and comparable infectious complications and technique survival when compared to conventional-start PD.

Risk factors for early dialysate leakage around the exit site after catheter placement in pediatric peritoneal dialysis: a single-center experience.

BACKGROUND: Dialysate leakage, a major complication in peritoneal dialysis (PD), causes difficulty in continuing PD. However, literature evaluating risk factors for leakage in detail and the appropriate break-in period to avoid leakage in pediatric patients is scarce. METHODS: We conducted a retrospective study on children aged < 20 years who underwent Tenckhoff catheter placement between April 1, 2002, and December 31, 2021, at our institution. We compared clinical factors between patients with and without leakage within 30 days of catheter insertion. RESULTS: Dialysate leakage occurred in 8 of 102 (7.8%) PD catheters placed in 78 patients. All leaks occurred in children with a break-in period of < 14 days. Leaks were significantly more frequent in patients with low body weight at the catheter insertion, single-cuffed catheter insertion, a break-in period ≤ 7 days, and a long PD treatment time per day. Only one patient who had leakage with a break-in period > 7 days was neonate. PD was suspended in four of the eight patients with leakage and continued in the others. Two of the latter had secondary peritonitis, one of whom required catheter removal, and leakage improved in the remaining patients. Three infants had serious complications from bridge hemodialysis. CONCLUSIONS: A break-in period of > 7 days and if possible 14 days is recommended to avoid leakage in pediatric patients. Whereas infants with low body weight are at high risk of leakage, their difficulty in inserting double-cuffed catheter, hemodialysis complications, and possible leakage even under long break-in period make prevention of leakage challenging.

Optimizing peritoneal dialysis initiation: A comparative cohort study of catheter placement methods for shortening break-in periods.

INTRODUCTION: Peritoneal dialysis (PD) guidelines recommend a 14-day break-in period after catheter placement, yet this period could be shortened with new insertion techniques. METHODS: We conducted a prospective cohort study to compare percutaneous vs. surgical catheter insertion in a newly established PD program. The break-in period was intentionally shortened to <24 h to start PD almost immediately. RESULTS: We included 223 subjects who underwent percutaneous (34%) or surgical (66%) catheter placement. Compared to the surgical group, the percutaneous group had a higher proportion of early dialysis initiation within 24 h (97% vs. 8%, p < 0.001), similar successful initiation rates (87% vs. 92%, p = 0.34), and shorter lengths of stay (12 [9-18] vs. 18 [14-22] days, p < 0.001). Percutaneous insertion increased the likelihood of successful PD initiation within 24 h (OR 74, 95% CI 31-182), without increasing major complications. CONCLUSION: Percutaneous placement could represent a cost-effective and efficient technique to shorten break-in periods.

Safety of a 24-h-or-less break-in period in elderly patients undergoing urgent-start peritoneal dialysis: A multicenter retrospective cohort study.

BACKGROUND: Several elderly patients with end-stage renal disease (ESRD) had to undergo urgent-start peritoneal dialysis (USPD). This study aimed to determine whether break-in period (BI) within 24 h was feasible in elderly patients undergoing USPD. METHODS: Patients with ESRD who underwent PD at five hospitals were screened. Patients were divided into the BI ≤24 h and >24 h groups. Complications were compared between the two groups. Multivariate logistic regression model was used to determine whether BI ≤24 h was associated with complications. RESULTS: A total of 175 elderly patients were included: BI ≤24 h group, 78; and BI >24 h group, 97. There was no significant difference in the rate of complications between the two groups (all p > 0.05). Furthermore, BI ≤24 h was not an independent risk factor for complications (all p > 0.05). CONCLUSIONS: Starting PD within 24 h after PD catheter insertion was feasible in elderly ESRD patients.

Break-in Period ≤24 Hours as an Option for Urgent-start Peritoneal Dialysis in Patients With Diabetes.

Background: The optimal break-in period (BI) of urgent-start peritoneal dialysis (USPD) initiation for patients with end-stage renal disease (ESRD) and diabetes is unclear. We aimed to explore the safety and applicability of a BI ≤24 h in patients with ESRD and diabetes. Methods: We used a retrospective cohort design wherein we recruited patients with ESRD and diabetes who underwent USPD at five institutions in China between January 2013 and August 2020. The enrolled patients were grouped according to BI. The primary outcomes were mechanical and infectious complication occurrences, whereas the secondary outcome was technique survival. Results: We enrolled 310 patients with diabetes, of whom 155 and 155 patients were in the BI ≤24 h and BI >24 h groups, respectively. The two groups showed a comparable incidence of infectious and mechanical complications within 6 months after catheter insertion (p>0.05). Logistic regression analysis revealed that a BI ≤24 h was not an independent risk factor for mechanical or infectious complications. Kaplan-Meier estimates showed no statistically significant between-group differences in technique survival rates (p>0.05). Cox multivariate regression analysis revealed that a BI ≤24 h was not an independent risk factor for technique failure. Conclusion: USPD initiation with a BI ≤24 h may be safe and feasible for patients with ESRD and diabetes.

Analysis of mechanical complications in urgent-start peritoneal dialysis.

BACKGROUND: Peritoneal dialysis (PD) is an excellent, but underutilized dialysis technique. Thus, its implementation may depend also on the chance to offer this modality of treatment to patients referred late to the nephologists. This approach has recently been named "urgent-start peritoneal dialysis" (UPD). The main barrier to this practice is represented by the fear of early mechanical complications. METHODS: All prevalent patients needing urgent-start PD at our institution between 1 January, 2009 and 31 December, 2019 were included in the study. During this period, 242 peritoneal catheters were inserted in 222 patients. In all patients, an anti-leakage/dislocation suture was made. PD was started within 24 h from catheter placement. RESULTS: The early incidence of leakages, catheter dislocations, omental wrappings, bleedings, peritonitis and exit-site infections was 11/242 (4.5%), 5/242 (2%), 3/242 (1.2%), 2/242 (0.8%), 6/242 (2.5%) and 4/242 (1.6%), respectively. No bowel perforations were observed. Nearly one third of the late complications (13/45; 35.2%) resulted in discontinuation of PD, while one fourth (11/45; 24.4%) required surgical revision. The remaining episodes (21/45; 46.6%) were successfully managed by a conservative approach. The survival of the catheter at 3, 6, 12, 24, 36 and 48 months was 93.6, 91.2, 84.8, 77.4, 65.5 and 59.3%, respectively. The technique survival at 3, 6, 12, 24, 36 and 48 months was 97.2, 94.9, 87.6, 78.9, 66.6 and 60.0%, respectively. The main causes of PD drop-out included infectious complications (36.8%) followed by mechanical complications (17.5%). CONCLUSIONS: A tight seal between deep cuff and surrounding tissues (double purse-string technique) in association with a starting low-volume exchange scheme allows to minimize early and late mechanical complication in UPD.

Feasibility of a break-in period of less than 24 hours for urgent start peritoneal dialysis: a multicenter study.

PURPOSE: Urgent start peritoneal dialysis (USPD) is an effective therapeutic method for end-stage renal disease (ESRD). However, whether it is safe to initiate peritoneal dialysis (PD) within 24 h unclear. We examined the short-term outcomes of a break-in period (BI) of 24 h for patients undergoing USPD. METHODS: This real-world, multicenter, retrospective cohort study evaluated USPD patients from five centers from January 2013 to August 2020. Patients were divided into BI ≤ 24 h or BI > 24 h groups. The Primary outcomes included incidence of mechanical and infectious complications. The secondary outcome was technique failure. Moreover, we presented a subgroup analysis for patients who did not receive temporary hemodialysis (HD). RESULTS: A total of 871 USPD patients were included: 470 in the BI ≤ 24 h and 401 in the BI > 24 h groups. Mechanical and infectious complications did not differ between the two groups across the follow-up timepoints (2 weeks, 1 month, 3 months, and 6 months) (p > 0.05). Multiple logistic regression analysis revealed that BI ≤ 24 h was not an independent risk factor for mechanical complications, catheter migration, or infectious complications (p > 0.05). A BI ≤ 24 h was not an independent significant risk factor for technique failure by multivariate Cox regression analysis (p > 0.05). The subgroup analysis of patients who did not receive temporary HD returned the same results. CONCLUSION: Initiating PD within 24 h of catheter insertion was not associated with increased mechanical complications, infectious complications, or technique failures.

Double purse-string around the inner cuff of the peritoneal catheter: A novel technique for an immediate initiation of continuous peritoneal dialysis.

International guidelines recommended a delayed start of peritoneal dialysis at least 2 weeks between catheter insertion and continuous peritoneal dialysis therapy initiation (break-in period). Up to now, the optimal duration of the break-in period is still unclear. The aim of our study was to evaluate in patients, with immediate initiation of continuous peritoneal dialysis, the efficacy of a double purse-string around the inner cuff in preventing mechanical and infectious complications either in semi-surgical or surgical catheter implantation. From January 2011 to December 2018, 135 peritoneal dialysis catheter insertions in 125 patients (90 men and 35 women, mean age 62.02 ± 16.7) were performed. Seventy-seven straight double-cuffed Tenckhoff catheters were implanted semi-surgically on midline under the umbilicus by a trocar, and 58 were surgically implanted through the rectus muscle. In all patients, continuous peritoneal dialysis was started immediately after catheter placement. Mechanical and infectious catheter-related complications during the first 3 months after initiation of continuous peritoneal dialysis were recorded. The overall incidence of leakages, catheter dislocations, peritonitis, and exit-site infections was 4/135 (2.96%), 2/135 (1.48%), 14/135 (10.3%), and 4/135 (2.96%), respectively. Regarding the incidence of catheter-related complications, no bleeding events, bowel perforations, or hernia formations were observed with either the semi-surgical or surgical technique. Double purse-string technique around the inner cuff allows an immediate start of continuous peritoneal dialysis both with semi-surgical and surgical catheter implantation. This technique is a safe and feasible approach in patients needing an urgent peritoneal dialysis.

Application of automated peritoneal dialysis in urgent-start peritoneal dialysis patients during the break-in period.

OBJECTIVE: Whether automated peritoneal dialysis (APD) is a feasible strategy for urgent-start peritoneal dialysis (PD) therapy during the break-in period remains unclear. This study was conducted to compare the efficacy as well as complications among three PD modes during the break-in period. METHODS: Ninety-six patients treated with urgent-start PD after catheterization were retrospectively analyzed. Patients were divided into three groups, incremental continuous ambulatory PD (CAPD) group (n = 26); APD group (n = 42); and APD-CAPD group (n = 28). Clinical parameters at the end of the break-in period and 1 month after the initiation of PD treatment were collected and analyzed. RESULTS: Compared with the traditional incremental CAPD, APD and APD-CAPD were superior as they could effectively remove small-molecule uremic toxins and correct electrolyte imbalance (P < 0.05), while did not increase the incidence of early complications during the break-in period (P > 0.05). However, APD led to a significant decline in albumin and pre-albumin, as compared with APD-CAPD and CAPD (P < 0.05). A PD strategy consisting 6 days of APD and 3 days of CAPD showed a great advantage in preventing excessive protein loss. There were no significant differences in all tested biochemical parameters among the three groups at 1 month after treatment (all P > 0.05). CONCLUSION: Application of APD for urgent-start PD during the break-in period is feasible. A combination of APD and CAPD regimens seems to be a more reasonable mode.

Urgent-Start Peritoneal Dialysis Complications: Prevalence and Risk Factors.

BACKGROUND: Mechanical complications are of particular concern in urgent-start peritoneal dialysis (PD) because of the shorter break-in period. However, risk factors have been reported inconsistently and data in urgent-start PD populations are limited. STUDY DESIGN: Observational cohort study. SETTING & PARTICIPANTS: All patients treated with urgent-start PD, defined as PD therapy initiated within 1 week after catheter insertion, January 2003 to May 2013. PREDICTORS: Age, sex, abdominal surgery history, body mass index, hemoglobin level, albumin level, C-reactive protein level, break-in period (period between catheter insertion and PD therapy initiation), dialysate exchange volume, and use of overnight dwell. OUTCOMES: The presence of mechanical complications related to abdominal wall or catheter, including hernia, hydrothorax, hydrocele, subcutaneous leak, pericatheter leak, catheter malposition, omental wrap, and obstruction. RESULTS: 922 patients on urgent-start PD therapy were enrolled (mean age, 59.1±15.0 [SD] years). Prevalences of abdominal wall and catheter complications were 4.8% and 9.5%, respectively. The most common abdominal wall complication was hernia (55%), followed by hydrothorax (25%). On adjustment, male sex (HR, 5.41; 95% CI, 2.15-13.59; P<0.001) and history of abdominal surgery (HR, 2.34; 95% CI, 1.04-5.26; P=0.04) were independently associated with higher risk for developing abdominal wall complications. LIMITATIONS: As a cohort study, comparisons could not be established between urgent-start PD and conventional PD. CONCLUSIONS: Urgent-start PD is a safe and practicable approach. Male sex and history of abdominal surgery could contribute to the development of abdominal wall complications.

A novel technique of catheter placement with fibrin glue to prevent pericatheter leakage and to enable no break-in period in peritoneal dialysis.

OBJECTIVE: Pericatheter leakage is a catheter-related complication of peritoneal dialysis (PD). To prevent pericatheter leakage, a modified technique of PD catheter insertion with fibrin glue was performed in 19 children. METHODS: At the time of PD catheter insertion, as much fibrin glue as possible was injected into the subcutaneous tissue along the tunneled segment of the catheter and then the skin was compressed. RESULTS: There was no occurrence of pericatheter leakage and full PD could be initiated 1 day (median) after implantation. CONCLUSIONS: This technique prevented pericatheter leakage completely even in smaller-weight infants and will enable initiation of full PD with no break-in period.

Impact of break-in period on the short-term outcomes of patients started on peritoneal dialysis.

OBJECTIVES: Peritoneal dialysis (PD) is one of the first-line modalities of renal replacement therapy in patients with end-stage renal disease. Guidelines recommended a break-in period of at least 2 weeks before full PD start. However, the optimal duration of the break-in period is still unclear. In the present study, we investigated the effect of various break-in periods on short-term outcomes in patients on PD. ♢ METHODS: All patients who underwent Tenckhoff catheter implantation and initiated PD in Renji Hospital, Shanghai Jiao Tong University School of Medicine, between 1 January 2001 and 31 December 2010 were included. Patients were grouped according to the duration of their break-in period: 7 days or less (BI ≤ 7), 8 - 14 days (BI8-14), and more than 14 days (BI>14). Kaplan-Meier curves and log-rank tests were used to compare short-term outcomes in the various groups. ♢ RESULTS: Our study enrolled 657 patients (44.5% men), of whom 344, 137, and 176 patients were in the respective break-in groups. Compared with BI>14 patients, BI ≤ 7 patients had a lower estimated glomerular filtration rate (5.34 ± 1.86 mL/min/1.73 m(2) vs 6.55 ± 1.71 mL/min/1.73 m(2), p < 0.001) and lower serum albumin (33.29 ± 5.36 g/L vs 36.64 ± 5.40 g/L, p < 0.001). The incidence of mechanical complications during the first 6 months was significantly higher in BI ≤ 7 patients than in BI>14 patients (8.4% vs 1.7%, p = 0.004). However, we observed no significant differences between the three groups with respect to the prevalence of catheter dysfunction requiring surgical intervention (p > 0.05). Logistic regression analysis showed that BI ≤ 7 [relative risk: 4.322; 95% confidence interval (CI): 1.278 to 14.608; p = 0.019] was an independent predictor of catheter dysfunction, but not of catheter dysfunction requiring surgical intervention (p > 0.05). Catheter dysfunction [hazard ratio (HR): 20.087; 95% CI: 7.326 to 55.074; p < 0.001] and peritonitis (HR: 4.533; 95% CI: 1.748 to 11.751; p = 0.002) were risk factors for technique failure during the first 6 months, but BI ≤ 7 was not correlated with technique failure. ♢ CONCLUSIONS: Patients starting PD with a break-in period of less than 1 week might experience a minor increased risk of mechanical complications, but no major effect on technique survival.

The Effect of Hemodialysis During Break-in Period on Residual Renal Function in CAPD Patients / 대한신장학회잡지

To avoid later complication of peritoneal dialysis catheter, it is recommended to delay regular exchange of peritoneal dialysis for about 2-4weeks after insertion of catheter(break-in period). During break-in period some patients need hemodialysis(HD) or other intermittent dialysis. In such cases residual renal function(RRF) can decrease substantially compared with patients who do not need HD during break-in period since RRF is preserved better in CAPD patients than HD patients. This is prospective observational study to examine such an effect of HD during break-in period on residual renal function in CAPD patients. 20 patients who were clinically stable and had been on CAPD since March, 1999 were observed. 6 patients were treated with HD for 1month during break-in period and CAPD thereafter(group A). 14 patients were treated with CAPD without HD(group B). GFR(mean of creatinine and urea clearance of urine) and urine Kt/V urea were measured at start, and 1, 3, 6 months of renal replacement therapy. Covariables analyzed in this study were mean arterial blood pressure, serum albumin, hemoglobin, hematocrit, age, sex, the presence of diabetes mellitus, and peritonitis episode. There was no significant difference in initial RRF, mean arterial blood pressure, serum albumin, hemoglobin, hematocrit, age, sex, and the presence of diabetes mellitus between 2 groups. Initial GFR was a little smaller in group A than group B(45.0+/-10.1 L/week vs. 54.6+/-5.7L/week) which was not statistically significant. GFR after 1, 3 and 6months of dialysis(including 1month of HD in group A) were smaller in group A than B(28.6+/-5.3L/week vs. 54.4+/-5.7L/week, 32.7+/-5.2L/week vs 56.9+/-6.1L/week, 21.0+/-4.1L/week vs 53.6+/-5.4L/week at 1,3,6 months after dialysis in group A and B), which were significant. Urine Kt/V showed same pattern. The change of GFR and urine Kt/V have no correlation with serum albumin, hemoglobin, hematocrit, and change of mean arterial blood pressure and is not affected by sex, and presence of DM or peritonitis. We concluded that HD during break-in period can decrease RRF in CAPD patients, which may not recover after 6months of dialysis. Avoiding HD during break-in period with appropriate preparation can preserve RRF in CAPD patients.