Original Investigation

Urgent-Start Peritoneal Dialysis: A Quality Improvement Report

Arshia Ghaffari, DO, MA, MBA

Background: Compared with hemodialysis, peritoneal dialysis (PD) is a cost-effective and patient-centered
option with an early survival advantage, yet only 7% of patients with end-stage renal disease in the United
States receive PD. PD underutilization is due in part to nephrologists unfamiliarity with directly starting PD in
patients who present with kidney failure requiring urgent initiation of dialysis.
Design: Quality improvement report.
Setting & Participants: Single-center study whereby 18 patients who presented urgently with chronic
kidney disease stage 5 without a plan for dialysis modality were offered PD as the initial modality of dialysis.
Concurrently, 9 patients started on PD therapy nonurgently were included as the comparative group.
Quality Improvement Plan: An urgent-start PD program was developed to support and standardize the
process by which patients without a plan for dialysis modality were started on PD. This included rapid PD
access placement, PD nursing education, and administrative support. Standardized protocols were created for
modality selection, initial prescription, and prevention and management of complications.
Measures: Short-term (90-day) clinical outcomes (Kt/V, hemoglobin, iron saturation, parathyroid hormone,
phosphorus, calcium, and albumin) and complications (peritonitis, exit-site infections, leaks, and catheter
malfunction) were compared between the urgent-start and non urgent-start PD groups.
Results: Short-term clinical outcomes were similar between the 2 groups for all parameters except
uncorrected serum calcium level, which was lower in the urgent-start group (P 0.02). Peritonitis, exit-site
infection, catheter-related complications, and other complications were similar between the 2 groups, although
the number of minor leaks was higher in the urgent-start group.
Limitations: This is a single-center nonrandomized study with a small sample size.
Conclusions: Our structured program shows safety and feasibility in starting PD in patients with kidney
failure who present without a plan for dialysis modality. The steps laid out in this report can provide the
framework for creating local urgent-start PD programs.
Am J Kidney Dis. 59(3):400-408. 2012 by the National Kidney Foundation, Inc.

INDEX WORDS: Peritoneal dialysis; urgent-start peritoneal dialysis; acute-start peritoneal dialysis; late-start
peritoneal dialysis.

Editorial, p. 330 allowed Medicare to cover the expenses of dialysis,

E arly in its history, several limitations precluded
the widespread use of peritoneal dialysis (PD)
for treatment of end-stage renal disease (ESRD).
These included expense, inability to readily obtain
sterile solutions, poor PD catheter function, inad-
equate solute clearance, and high peritonitis rates.
With the design of the double-cuffed PD catheter, use
of reverse osmosis for the production of sterile PD
solutions, introduction of continuous ambulatory PD
(CAPD), and legislation in the United States that
From the Division of Nephrology, Keck School of Medicine,
University of Southern California, Los Angeles, CA.
Received May 3, 2011. Accepted in revised form August 31,
2011. Originally published online October 24, 2011.
Address correspondence to Arshia Ghaffari, DO, MA, MBA,
Division of Nephrology, Keck School of Medicine, University of
Southern California, 1200 North State St, Los Angeles, CA 90033.
E-mail: ghaffari@usc.edu
2012 by the National Kidney Foundation, Inc.
0272-6386/$36.00
doi:10.1053/j.ajkd.2011.08.034
many of these initial obstacles were overcome.1-4
Additional technologic advancements, such as storage
of PD solutions in plastic bags, creation of the Y-set
connector system, development of the spike tech-
nique, and advent of the flush-before-fill technology
led to further improvements in peritonitis rates, which
allowed PD to be brought into the mainstream as an
accepted modality of long-term dialysis.5,6
Despite these significant achievements, the percent-
age of patients on PD in the United States has steadily
decreased from a high of 14.4% in 1995 to a low of
7% in 2007.7 Several factors have negatively affected
PD use (Box 1). Many nephrologists incorrectly per-
ceive PD as having inferior clinical outcomes, high
peritonitis rates, poor small-solute clearance, and a
high rate of ultrafiltration failure. Others incorrectly
consider obesity, poor social or economic status, or
lack of education as contraindications to PD therapy.8
Recent efforts to overcome these factors have in-
cluded: (1) optimizing PD education in fellowship
programs, (2) financially incentivizing PD, (3) optimiz-
ing the timing of referral of patients with known
chronic kidney disease (CKD), and (4) optimizing
predialysis education (Medicare reimbursement for

400 Am J Kidney Dis. 2012;59(3):400-408

Urgent-Start Peritoneal Dialysis
Box 1. Factors That Negatively Affect PD Utilization
Provider/Health Care SystemRelated Factors
PD perceived as having inferior clinical outcomes
Increasing age, comorbid conditions, and size perceived as
contraindication to PD
PD perceived as having high peritonitis rates
Inadequate PD education in fellowship programs
Inadequate predialysis patient education and preparedness
programsa
Unoccupied outpatient hemodialysis chairs
Financial incentives favoring hemodialysis
Late referral to nephrologista
Lack of resources for assisted PD in patients unable to care
for self
Lack of opportunity for patients urgently started on hemodialy-
sis to transition to PD therapy
Urgent PD catheter placement not readily availablea
Urgent initiation of PD perceived as having a high rate of
complicationsa
Patient-Related Factors
Patient fear of peritonitis
Patient fear of unassisted PD
Lack of access to primary care
Undetected kidney diseasea
Patient not seeking timely carea
Lack of referral to nephrologista
Late referral to nephrologista
Acute deterioration of kidney diseasea
Inadequate patient education in nephrology clinicsa
Abbreviation: PD, peritoneal dialysis.
a
Factors that are potentially addressed by an urgent-start PD
program.
CKD education partly addresses this issue). However,
most of these efforts fail to address the process by
which PD is offered to the largest portion of our new
patients with ESRD: those who do not have a plan for
dialysis therapy. Classically, long-term PD therapy is
offered to the planned patient who has received
dialysis education well ahead of the time dialysis is
required. Although investigators have shown that early
referral to nephrologists, dialysis education, and pa-
tient awareness greatly affect the selection of PD and
other home modalities, early education and prepara-
tion are not easily achievable in most patients who
present with kidney failure.8-10
A large proportion of patients are either referred
late or end up requiring initiation of dialysis therapy
before ever having established care with a nephrolo-
gist. Many patients lack access to primary health care
and thereby are unaware of kidney disease. Even
when aware, many patients do not seek timely care for
CKD. Some patients with stable CKD have acute
worsening kidney function that is not predictable,
resulting in an urgent need for dialysis. As a result,
60% of patients who progress to ESRD do not have a
distinct plan at the time of dialysis therapy initiation.7
There are a number of problems with the present
approach to providing care for patients who present
Am J Kidney Dis. 2012;59(3):400-408
late. Although some nephrologists are placing late-
presenting patients on PD therapy, most are uncomfort-
able with urgent initiation of PD therapy due to lack of
standards, worries about complications, and inability
to rapidly obtain PD access. Thus, hemodialysis (HD)
through a central venous catheter (CVC) has become
the default dialysis modality. Given the high pro-
portion of patients without a plan at the time of
dialysis therapy initiation, up to 80% start dialysis
therapy with a CVC.7 Many experience the resultant
complications, including sepsis, cardiovascular mor-
bidity and mortality, and increased hospitalization
rates.11-13 This high CVC rate in new HD patients is a
major contributor to the high mortality rate in the first
90 days on dialysis therapy.14-18 Additionally, many
patients end up stuck on HD therapy because PD is
rarely presented as an option after an HD regimen has
been established. Consequently, the overall number of
patients who are offered PD is unacceptably low, and
many patients who would have been candidates are
not presented the option to pursue PD.
The intent of our urgent-start PD program is to set
up the mechanism by which PD could be made
available as an initial modality of dialysis for patients
who require urgent initiation of dialysis therapy.
The primary goal of this study was to show that a
structured urgent-start PD program can result in safe
and effective initiation of PD therapy in patients in
need of urgent dialysis therapy initiation, but lacking
a plan. The effectiveness of our program was assessed
by evaluating short-term clinical outcomes, complica-
tions, technique survival, CVC use, and need for
backup HD therapy.
In the context of this study, we define urgent-start
PD as initiation of PD therapy in a patient with
chronic kidney failure (or transplant recipient whose
transplant has failed) who will require dialysis in less
than 2 weeks, but has not planned for a modality of
long-term dialysis. Urgent-start PD is not acute inpa-
tient PD or the initial modality used for patients who
need emergent dialysis.
METHODS
Setting
Selected patients with CKD stage 5 admitted to Los Angeles
County University of Southern California (LACUSC) Medi-
cal Center between March 2010 and March 2011 were evaluated
and offered PD therapy if deemed candidates. If urgent PD was
required, patients were enrolled in a structured urgent-start pro-
gram and followed up throughout the study period. A comparison
nonurgent-start group also was followed.
Patient Safeguards
Safeguards for patient safety, choice, and privacy were achieved
by: (1) using a standardized questionnaire to minimize bias in the
modality selection process; (2) providing all patients with educa-
401
 Arshia Ghaffari

Figure 1. Algorithm by which patients with kidney failure without a plan for dialysis modality were started on peritoneal dialysis (PD)
therapy. *Emergent dialysis defined as having any indication for dialysis that could not wait 48 hours. Urgent dialysis defined as
requiring dialysis in less than 2 weeks time, but able to wait more than 48 hours. Non urgent-start PD group also included patients
with a plan to start PD and patients on in-center hemodialysis (HD) who transitioned to PD therapy. Abbreviations: AVF, arteriovenous
fistula; CKD, chronic kidney disease; CVC, central venous catheter; PDC, peritoneal dialysis catheter; RRT, renal replacement therapy.

tion about renal replacement therapy (RRT) modalities; (3) provid-
ing a modality recommendation, but having patients freely choose
the modality; (4) creating guidelines for the prevention and man-
agement of complications; (5) setting up continuous quality moni-
toring standards; (6) close monitoring of complications with correc-
tive actions; (7) developing standardized practices in addressing
complications; (8) following HIPPA (Health Information and Por-
tability Act) regulations; (9) storing all patient-related information
in a designated secure password-encoded computer; and (10)
obtaining approval from the University of Southern California
Institutional Review Board to review patient medical records for
research purposes.
Planning
In the planning phase, steps were taken to secure administrative,
nursing, and PD access support. Administrative support was ob-
tained by highlighting patient benefits (optimizing modality op-
tions, maintenance of employment, and minimizing CVC use) and
economic benefits (potential for decreased length of stay because
patients would be discharged soon after PD catheter placement).
We detailed the specific equipment and supplies (catheters, trans-
fer sets, peritoneal dialysate solution, etc) that would need to be
made available.
Nursing support was secured by providing education about
urgent-start PD and involving nurses in the design of both inpatient
and outpatient protocols to assist in the management of urgent-start
PD patients (see Items S1-S6, available as online supplementary
material). Close physician involvement was provided for the first
series of patients placed on this modality. Nurses were assured that
medically unstable patients would not be admitted to the PD unit.
The ability to rapidly obtain effective PD access was the
critical step in setting up our urgent-start program. Although PD
access at most US institutions involves surgical placement of
PD catheters, at our medical center, the interventional radiology
group is the main group placing urgent tunneled HD catheters
and therefore was the ideal service for placing urgent PD
catheters, essentially substituting one procedure for another.
Our interventional radiology group had vast experience with the
placement of other forms of intra-abdominal catheters (for
chemotherapy, ascites drainage, etc), but less experience with
cuffed PD catheters. To ensure use of a standard technique, the
interventional radiology group was provided with a presenta-
tion and literature about the percutaneous technique of placing
PD catheters and referred to an outside academic interventional
radiology group that routinely places PD catheters. Dual-cuff,
swan-neck, coiled PD catheters were selected for percutaneous
placement. Pre- and postprocedure orders to minimize early
surgical-related complications were created.
Implementation
The algorithm for choosing patients for the urgent-start
program is shown in Fig 1. Patients presenting as late referrals
with CKD stage 5 (lacking overt uremic symptoms) to our clinic
or hospital were given RRT education. Candidacy for PD

402 Am J Kidney Dis. 2012;59(3):400-408

Urgent-Start Peritoneal Dialysis

Table 1. Baseline Demographics emergent dialysis therapy were removed before discharge if
clinically feasible.
Urgent-Start NonUrgent-
PD (n 18) Start PDa (n 9) Pb Measures
To assess the effectiveness of our program, short-term (90-day)
Age (y) 45.1 13.7 53.6 19.1 0.2c clinical outcomes (Kt/V, hemoglobin, iron saturation, parathyroid
Men 13 (72) 4 (44) 0.2 hormone, phosphorus, calcium, and albumin) and complications
Diabetes 9 (50) 5 (56) 0.9 (peritonitis, exit-site infections, leaks, catheter malfunction, and
Baseline eGFR (mL/min/ 7.4 4.3 11.3 5.4 0.06c other complications) in the urgent-start group were compared with
1.73 m2)d patients started on PD therapy in a nonurgent manner during the
same period. Each complication was reviewed in detail on a rolling
Prior renal care 4 (22) 5 (56) 0.1
basis, and ongoing steps were taken to avoid similar complica-
Uremic on presentatione 7 (39) 0 (0) 0.06 tions. We also evaluated 90-day patient and technique survival and
Central venous access 5 (27)f 5 (56) 0.2 need for CVCs and backup HD.
g
Backup hemodialysis 2 (11) 4 (44) 0.1
Statistics
Note: Continuous values presented as mean standard
deviation; categorical variables, as number (percentage). Baseline demographic and short-term (90-day) clinical out-
Abbreviations: eGFR, estimated glomerular filtration rate; PD, comes were compared between the urgent-start and nonurgent-
peritoneal dialysis. start groups that concurrently started PD therapy. P values were
a
Nonurgent-start group included planned patients, unplanned determined by using Fischer exact test for comparing propor-
patients who did not require urgent dialysis, and patients started tions and Wilcoxon rank sum test for comparing averages (see
on hemodialysis who transitioned to PD therapy. the first and second tables). P 0.05 was considered statisti-
b
P value based on Fischer exact test for comparing propor- cally significant. Complications were reported with absolute
tions. rates and numbers without statistics due to the small number of
c
P values based on Wilcoxon rank sum test. events (see Table 3).
d
Based on 6-variable Modification of Diet in Renal Disease
Study equation. RESULTS
e
Based on a set of standardized criteria (See Item S5, avail-
able as online supplementary material).
Baseline Demographics
f
Central venous catheters were used in 3 patients who needed At baseline, urgent-start patients had a lower esti-
emergent dialysis for uremia and then removed before dis- mated glomerular filtration rate (7.4 4.3 vs 11.3
charge; therefore, no backup hemodialysis was required.
g
Backup hemodialysis was required in 2 urgent-start patients
5.4 mL/min/1.73 m2 by the 6-variable MDRD [Modi-
with initial catheter problems. fication of Diet in Renal Disease] Study equation) and
were less likely to require backup HD therapy (11.1%
vs 44%); however, these differences were not statisti-
therapy with the use of a standardized questionnaire was used cally significant (P 0.06 and P 0.1, respectively).
(see Item S1, available as online supplementary material). If
deemed a PD candidate, a formal recommendation was made to
Urgent-start patients were more likely to be men, lack
the patient and family with regard to the optimal modality for
that patient. If PD was chosen by the patient as the modality he Table 2. Comparison of Short-term (90-day) Clinical Outcomes
or she wished to pursue, referral to interventional radiology was
made for rapid placement of a PD catheter. The patient was Urgent-Start NonUrgent-
informed of the risks and benefits of the procedure of percutane- PD (n 15) Start PD (n 6) Pa
ous PD catheter placement, and informed consent was obtained.
The patient was provided with pre- and postprocedure instruc- Kt/Vtotal 2.7 0.9 3.0 0.7 0.6
tions and orders. PD catheters usually were placed within 1-2 Anemia
days. Barring complications, the patient was discharged the Hemoglobin (g/dL) 11.9 1.8 11.6 2.3 0.6
same day and seen in our outpatient dialysis unit within 24-72 Iron saturation (%) 30.2 12.2 35.5 19.1 0.7
hours of access placement. At that time, using a protocol to
evaluate for uremia, a decision was made whether the patient Metabolic bone disease
needed immediate PD therapy (Item S5, available as online Parathyroid hormone 484.3 210.0 329.8 171.2 0.2
supplementary material). If so, the patient was placed on (pg/mL)
in-center intermittent PD 3 times per week based on a protocol- Calcium (mg/dL) 7.8 0.9 9.1 0.7 0.02
driven prescription (Item S6, available as online supplementary Phosphorus (mg/dL) 5.1 1.3 4.5 1.0 0.2
material). If it was believed that the patient could wait for 1-2
weeks, PD training was initiated and the patient was assessed at Nutrition
every visit to see if more urgent PD was needed. Albumin (g/dL) 3.50 0.5 3.90 0.4 0.08
If a patient presented with overt uremic symptoms requiring Note: Limited to patients who had 90-day data available at time
emergent dialysis, a temporary HD catheter was inserted and of article submission. Values presented as mean standard
the patient was initiated on HD or continuous RRT until deviation. Conversion factors for units: hemoglobin and albumin
stabilized. When stabilized, the patient was educated about RRT in g/dL to g/L, 10; calcium in mg/dL to mmol/L, 0.2495;
options, provided with a questionnaire to determine PD candi- phosphorus in mg/dL to mmol/L, 0.3229.
dacy, referred for inpatient PD catheter placement, and dis- Abbreviation: PD, peritoneal dialysis.
a
charged to the dialysis unit per the steps outlined. CVCs for P Values based on Wilcoxon rank sum test.

Am J Kidney Dis. 2012;59(3):400-408 403

 Arshia Ghaffari

Table 3. Infectious and Mechanical Complications patients to our in-center HD program. As a percentage
of all admissions to our dialysis unit, PD accounted
Urgent-Start NonUrgent-
Complications PD (n 18) Start PD (n 9) for 39.7% and in-center HD accounted for 60.3%. At
this time, we do not have a home HD program.
No. of peritonitis episodes 1 1
Peritonitis rate (/patient-month) 1/110 1/42 DISCUSSION
No. of exit-site infections 2 1 In certain countries such as Hong Kong, where PD
Exit-site infection (/patient-month) 1/55 1/42 is the dominant dialysis modality, with 80% of the
Minor leaks 4 (22.2) 1 (11.1) ESRD population on PD therapy, outcomes are simi-
Major leaks 2 (11.1) 0 (0) lar or better than for HD therapy.19,20 Many studies
Poor initial drain 0 (0) 1 (11.1) have shown an early survival advantage for PD over
Primary nonfunction 2 (11.2) 2 (22.2) HD in the first 2 years of therapy, with equivalent
Hematoma 1 (5.6) 0 (0) outcomes to 5 years.21-25 Moreover, although overall
Bowel perforation 0 (0) 0 (0) survival on dialysis therapy has been improving over
Note: Unless otherwise indicated, values shown are number time, Mehrotra et al26 have shown that patients on PD
(percentage). therapy have had a greater increase in survival by
Abbreviation: PD, peritoneal dialysis.
studying survival trends in cohorts in different peri-
ods. Moreover, the same investigators have dispelled
prior renal care, and have uremic symptoms at presen- the perception that increasing age, comorbid condi-
tation, but these trends failed to reach statistical signifi- tions, and body mass index of the dialysis population
cance. There was no difference in baseline age or are contraindications to PD use.27
diagnosis of diabetes (Table 1). With PD and HD providing similar outcomes in
most patients and studies suggesting that patients are
Short-Term Results more satisfied with PD compared with in-center HD
There was no statistically significant difference in therapy,28 it makes clinical sense to attempt to expand
common short-term clinical end points studied (Kt/ the role of PD as a dialysis modality. Given that most
Vtotal, hemoglobin, iron saturation, parathyroid hor- patients start dialysis therapy without a distinct plan,
mone, calcium, phosphorus, and albumin values) at to make PD a real option, it needs to be made
90 days between the 2 groups except for uncorrected available as an initial modality of dialysis, even when
serum calcium level, which was significantly lower in urgent dialysis is needed.
the urgent-start group (7.8 0.9 vs 9.1 0.7 mg/dL; Our structured program addresses these needs by
P 0.02; Table 2). allowing safe and effective initiation of PD therapy in
patients with chronic kidney failure who require ur-
Complications gent dialysis. With planning, preparation, and precau-
Infectious complication rates (peritonitis and exit- tions, many of the possible early complications are
site and tunnel infections) were similar between the 2 avoided. Outcomes for our urgent-start patients have
groups. The incidence of early mechanical complica- been similar to those started on PD nonurgently.
tions was similar between the 2 groups. Although Moreover, our program has allowed for decreased
there was a higher rate of pericatheter leak in the CVC use, in line with the PEAK (Performance Excel-
urgent-start group, most leaks were minor and man- lence and Accountability in Kidney Care) initiative, a
aged conservatively with temporary stoppage of PD voluntary quality improvement campaign that at-
therapy. However, in 2 instances (11.1%), catheter tempts to address the high mortality rate in the first
replacement was required (Table 3). year of dialysis therapy.29
Limitations of our study include the small sample
Patient Retention size, short (90-day) follow-up, and unique patient
We instituted our urgent-start PD program in March population, which is predominantly indigent, unin-
2010. In the ensuing year, we admitted 27 patients to sured, and without primary medical or nephrology
our PD program, 18 by way of the urgent pathway and care. Additionally, the mechanism for PD catheter
9 by way of the nonurgent pathway. For those who placement was mainly percutaneous for the urgent-
had 90-day data available at the time of study submis- start group, whereas planned catheters were placed
sion, 15 of 15 urgent-start patients were alive and laparoscopically. Therefore, comparison of cathe-
remained on PD therapy. Addition of the urgent-start ter outcomes may be based in part on placement
program resulted in growth of our PD program by technique.
37.5% from 32 to 44 patients in 12 months. In Several investigators have studied early initiation
comparison, during the same period, we admitted 41 of PD therapy in dialysis patients (Table 4). Although

404 Am J Kidney Dis. 2012;59(3):400-408

 Table 4. Summary of Urgent-Start PD Studies
Am J Kidney Dis. 2012;59(3):400-408

Urgent-Start Peritoneal Dialysis

PD Catheter
Urgent-Start Placement
Study Design Intervention/Factors Studied End Points Program Technique Time to PD Start Outcomes

Song et al,30 2000 Prospective Group 1 (n 21): gradual 1. Catheter-related Yes Percutaneous 24 h (both groups) 1. Short-term catheter complications (leak,
randomized increase in exchange volume complications malposition, outflow failure): no difference between
comparative Group 2 (n 38): full exchange 2. Infectious complications groups
volume (2 L) 3. 1-y catheter survival 2. Infectious complications (peritonitis,
4. Duration of hospitalization exit-site/tunnel): no difference between groups
3. 1-y catheter survival: group 1, 85.7%; group 2,
84.2% (P NS)
4. Duration of initial hospitalization: group 1, 9.9
0.6 d; group 2, 15 0.8 d (P 0.001)
Banli et al,31 2005 Prospective Early initiation of PD (n 41); Catheter-related No Percutaneous 6 d Pericatheter leak (2; 4.8%); outflow failure (2; 4.8%);
observational no control group complications (short term) peritonitis (1; 2.4%); catheter replacement (1; 2.4%)
Povlsen and Retrospective with Group 1 (n 52): acute 1. Technique survival (3 mo) Yes Open surgical 24 h (acute-start 1. 3-mo technique survival (censored for death and
Ivarsen,32 2006 unmatched automated PD 2. Infectious complications group) transplant): group 1, 86.7%; group 2, 90% (P
controls Group 2 (n 88): planned-start 3. Mechanical complications NS)
group 2. Infectious complications: no difference between
groups
3. Total mechanical complications: group 1, 28.9%;
group 2, 7.7% (P 0.01)
4. Catheter replacement: group 1, 19.2%; group 2,
3.9% (P 0.02)
Jo et al,33 2007 Prospective Early initiation PD Catheter-related Yes Percutaneous Immediate Early/late complications: pericatheter leakage, 2%/
observational complications: early (1 NR; catheter migration, 6%/10%; diminished
mo) and late (1 mo) outflow, 4%/NR; hemoperitoneum, 2%/2%;
catheter replacement, 2%/NR; exit-site infection,
4%/16%; peritonitis 4%/18%; umbilical hernia, NR/
2%
Lobbedez et al,34 Prospective Group 1 (n 34): unplanned Clinical outcomes (relevant): Yes Not specified PD group: 9.6 Initial hospitalization duration: PD group, 30 33 d
2008 observational patients initiated on PD hospitalizations; patient 10.3 d (median, (median, 20 d); HD group, 24 28 d (median,
Group 2 (n 26): unplanned survival 4 d) 17 d); P NS
patients initiated on HD HD group: Survival free of hospitalization at 6 and 12 mo: PD
immediate HD by group, 36% and 21%; HD group, 51% and 36%
catheter (P NS)
Mean duration of hospitalization/patient/mo: PD
group, 7.1 7.8 (median, 4.7); HD group, 6.4 7.0
(median, 3.9); P NS
Unadjusted actuarial patient survival at 1 y: PD group,
83%; HD group 79% (P NS)
Survival adjusted for comorbid conditions: no
difference
Yang et al,35 2010 Retrospective with Group 1 (n 226): early start of Catheter-related Yes Surgical Group 1: 2.0 2.7 d Complications: group 1, 14.6%; group 2, 13.1% (P
unmatched incremental PD complications within 6 mo Group 2: 41 43 d NS)
controls Group 2 (n 84): late-start of catheter insertion Individual complications: leakage, 2.2% vs 2.4%;
group outflow failure, 3.1% vs 6.0%; migration, 3.1% vs
405

2.4%; exit-site infection, 1.3% vs 0%; peritonitis, 4%

vs 2.4%; bridge hemodialysis, 31.4% vs 57.1% (P
0.001)

Abbreviations: HD, hemodialysis; PD, peritoneal dialysis; NR, not reported; NS, nonsignificant.

the specifics of these studies vary, many end points
include clinical and catheter-related outcomes. Most
studies involve an inpatient model of care with ex-
tended hospital stays. None of the centers that have
published their results are located in the United States.
In the only prospective randomized study, Song
et al30 compared complication rates in 2 groups of
patients who were started on CAPD therapy imme-
diately after placement of a Tenckhoff PD catheter.
In group 1, exchange volume was increased incre-
mentally during the course of 13 days. In group 2,
patients were started immediately on 2-L ex-
changes. Catheters were placed in a blind manner
by trained nephrologists with the use of a trocar
under local anesthesia. Both groups were placed on
bedrest for the first 3 days. There was no difference
between the 2 groups in early leakage rates (9.5%
in group 1 and 10.5% in group 2). Rates of peritoni-
tis, tunnel or exit-site infections, catheter malposi-
tion, outflow failure, or early catheter loss were not
significantly different between groups. The dura-
tion of hospitalization was shorter in group 2 than
group 1 (9.9 0.6 vs 15.0 0.8 days from the day
of catheter insertion). One-year catheter survival
rates, censored for death and transplant, also were
similar at 85.7% in group 1 and 84.2% in group 2.
In another prospective study, Banli et al31 evaluated
whether a 4- to 6-week waiting period was necessary
after percutaneous placement of PD catheters. Double-
cuff Tenckhoff PD catheters were placed using a
percutaneous technique in 41 patients. PD was started
on average on day 6 after PD catheter insertion. Banli
et al31 showed the technique to be safe and effective,
with low frequencies of pericatheter leak (4.8%),
peritonitis (2.4%), or other complications, although
they did not have a control group.
Povlsen and Ivarsen32 described the feasibility and
safety of initiation of urgent PD therapy in about 50% of
their patients with CKD who presented late without a
plan for dialysis modality at a single center in Denmark
over a 2.5-year period. PD catheters were placed through
open surgery, and patients were started immediately on
overnight 12-hour supine automated PD as inpatients.
Patients started urgently on PD therapy showed equiva-
lent short-term (90-day) PD technique survival rates
(censored for death and transplant) compared with the
planned-start group (86.7% and 90.0%, respectively).
Infectious complication rates also were equivalent. How-
ever, the number of mechanical complications was higher
in the urgent-start group.
In a prospective observational study, Jo et al33
evaluated the effect of a modified percutaneous cath-
eter placement technique and immediate initiation of
CAPD therapy without a break-in period on the devel-
opment of complications. Catheter-related complica-
406
Arshia Ghaffari
tions were evaluated in 51 consecutive patients who
were immediately started on CAPD therapy with the
use of a straight double-cuff Tenckhoff catheter placed
percutaneously. Low-volume supine PD was per-
formed in all patients for the first 7 days. Patients were
followed up for 12 months after CAPD therapy initia-
tion. Pericatheter leakage occurred in only one in-
stance (1.9%) in the entire study period. Early compli-
cations included catheter tip migration in 3 (6%),
diminished outflow volumes in 2 (4%), exit-site infec-
tion in 2 (4%), peritonitis in 2 (4%), and catheter
reinsertion in 1 (2%).
In a prospective observational study, Lobbedez et al34
compared initiation of dialysis therapy with PD versus
HD in a dialysis population that required urgent initia-
tion. The main goal of the study was to assess whether a
dialysis policy for patients who needed urgent dialysis
therapy would affect PD use and whether it would
reduce the need for tunneled dialysis accesses. All pa-
tients who needed immediate dialysis received a tempo-
rary venous catheter for HD therapy initiation. Subse-
quently, PD was offered to patients believed to be
appropriate candidates. Of 60 patients, only 27 needed
urgent initiation of RRT (PD, 16 of 34; HD, 11 of 28).
For those who chose PD therapy and needed immediate
dialysis, acute inpatient automated PD was initiated
shortly (median, 4 days) after surgical placement of a PD
catheter. Comparing outcomes in PD and HD patients,
survival, hospitalization rates, and hospitalization dura-
tions were similar in the 2 groups. Moreover, comparing
patients who started acute automated PD versus those
who started delayed PD, technique survival, patient
survival, peritonitis rates, and residual glomerular filtra-
tion rates at 12 months were not significantly different.
In a large retrospective study from Taiwan, Yang
et al35 investigated the safety and feasibility of
urgent-start CAPD after surgical implantation of a
PD catheter. They compared the incidence of cath-
eter-related complications in 2 groups: (1) the early
group, which consisted of 226 patients, started
CAPD therapy less than 14 days after catheter
implantation (2.2 2.7 days); and (2) the late
group, consisting of 84 patients who started CAPD
more than 14 days (40.6 42.8 days) after catheter
implantation. Overall, 14.6% of the early group and
13.1% of the late group developed catheter-related
complications within 6 months of starting PD
therapy (P 0.74). Rates of catheter leakage were
similar between the 2 groups (2.2% vs 2.4%). Other
complications also were similar in the 2 groups,
including percentage of patients with outflow prob-
lems, catheter tip migration, and exit-site and peri-
tonitis episodes. They also showed a significantly
lower number of patients in the early-start group
needed bridge HD therapy (31.4% vs 57.1%). Over-
Am J Kidney Dis. 2012;59(3):400-408
Urgent-Start Peritoneal Dialysis
all, they were able to show success with early start
of PD therapy with no increase in number of
complications despite a surgical approach to PD
catheter placement.
In summary, PD is a dialysis modality that is
grossly underused in the United States. Although
many barriers have prevented its growth, successful
future growth will depend on being able to offer this
modality to patients who present late to dialysis
therapy. Our model of urgent-start PD provides pa-
tients with kidney failure who present without a plan
for dialysis modality with the option of being directly
started on PD therapy. It differs from other models of
early-start PD therapy in that it is mainly an outpatient
model of care.
Our urgent-start PD program can serve as a model
to initiate PD therapy in late-presenting patients with
CKD while doing so in a safe and effective manner.
Although each PD program will require specific mea-
sures to institute a successful urgent-start PD pro-
gram, the steps laid out in this report can provide a
framework in creating a program unique to each
dialysis environment.
ACKNOWLEDGEMENTS
Support: None.
Financial Disclosure: The author declares that he has no rel-
evant financial interests.
SUPPLEMENTARY MATERIAL
Item S1: Questionnaire to define optimal dialysis modality.
Item S2: PD catheter preprocedure orders.
Item S3: PD catheter postprocedure orders.
Item S4: Postprocedure patient instructions.
Item S5: Outpatient evaluation for urgent initiation of PD.
Item S6: Urgent-start PD prescription.
Note: The supplementary material accompanying this article
(doi:10.1053/j.ajkd.2011.08.034) is available at www.ajkd.org.
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