Urgent Start Peritoneal Dialysis

Bharat Sachdeva M.D.

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Associate Professor Medicine

Fellowship Program Director

Division of Nephrology and Hypertension

LSUHSC, Shreveport LA

bsachd@lsuhsc.edu

Disclaimer

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• My presentation does not include discussion of any commercial products or services used in an unapproved or off-label way.
• I have no disclosures.

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Case 1

• 30 yr old AA male was admitted to our service from ED with Nausea, Malaise, weight loss, remote history of elevated blood pressures not on any medications.
• Labs BUN 142,Cr 19.5,K 3.1,Na 142,CO2 20
• ESRD
• Indications to start RRT: Uremic Symptoms

Case 1 : LABS

Uremic? Yes

Need RRT? Yes

What Modality?..

Case 2

• 57yr old AA female has been followed in CKD Clinic for CKD 5, Hypertension
• Has AVF LUE Brachiocephalic on exam: Soft thrill, Good Augmentation, Collapses
• Indication to start RRT: Persistent Hyperkalemia
• Developed infiltration on first attempt to cannulate AVF, on ultrasound assessment 6-14 mm deep; requires superficialization.

What are the Options for our patients

• Acute presentation of ESRD patients?
• Never Had an AVF established
• CKD patients who have not had an access placed during follow up?
• CKD patients who have immature at time of initiation?

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What are the Options for our patients

• Acute presentation of ESRD patients?
• Never Had an AVF established
• CKD patients who have not had an access placed during follow up?
• CKD patients who have immature at time of initiation?

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• Does access/modality for RRT influence survival?

Adjusted first-year hospital admission rates & days (from day 90) in matched incident hemodialysis & peritoneal dialysis patients�Figure 3.7 (Volume 2)

Incident hemodialysis & peritoneal dialysis patients age 20 & older.

Adj: age/gender/race/primary diagnosis; ref: USRDS 2005 incident hemodialysis & peritoneal dialysis patients.

Cumulative incidence of Bacteremia or septicemia over time in the Wave 2 population

Kidney Int. 2005; 68: 311-318.

What are the Options for my patients

• Acute presentation of ESRD patients
• CKD patients who have not had an access placed during follow up
• Does access for RRT influence survival?

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YES

What are the Options for my patients

• Acute presentation of ESRD patients
• CKD patients who have not had an access placed during follow up.

United States Renal Data Report 2013

Total Medicare ESRD expenditures �per person per year, by modality

$ 87,945

$ 71,630

$ 32,922

Figure 11.7 (Volume 2) USRDS 2013 ADR

Comprehensive education is vital

Hemodialysis

Peritoneal dialysis

Golper T. Nephrol Dial Transplant. 2001;16(suppl):20-24.

Benefits of Urgent-Start PD

• Avoids the placement and use of a central venous catheter (CVC) !!
• 80% start HD dialysis using a catheter [USRDS]
• Infections: Incident HD-­‐CVC patients have an 80% higher risk of death in the first year compared with incident PD patients [Perl J et al. JASN 2011,22(6)]
• Hospitalizations
• Loss of Central vein patency!
• Care can be provided in the outpatient setting
• Training starts concurrent with dialysis
• Cost!

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Urgent Start PD

CKD patient who will need RRT within TWO WEEKS of placement of the PD catheter

Therapy is initiated with SUPINE/LOW VOLUME for a period of two weeks until the Cuff is well healed

Dialysis centers are not equipped to deal with unstable Uremic patients (Volume, Hyperkalemia, Uremic…..)

Selecting the right patients is imperative to the overall success of the program

CHOICES��Open Surgical�Laparoscopic �Fluoroscopic/Peritoneoscopic

STEPS-FLUOROSCOPIC PLACEMENT

https://www.youtube.com/user/LSUNEPHROLOGY

USE THE LINK BELOW TO VIEW A DETAILED DESCRIPTION OF FLUROSCOPIC INSERTION

Catheter Placement

Abdominal Incision

Blunt dissection to anterior rectus sheath

Local lidocaine anesthesia into skin and subcutaneous tissues

Abdominal WALL

Aponeurosis of abdominal

muscles

Anterior rectus sheath

Posterior rectus sheath

Linea alba

Rectus muscle

Subcutaneous fat (fascia)

Facliform ligament

Transversalis fascia

Peritoneum

Blunt Dissection

Anterior Rectus Sheath

Rectus Sheath

Anterior rectus sheath

Posterior rectus sheath

Rectus muscle

Peritoneum

Inferior epigastric artery

Inferior epigastric artery

Ultrasound guided entry into peritoneum

• Advantage
• Visualizes the epigastric artery
• Identify bowel loops

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Fluoroscopic and Sonographic Guidance to Place Peritoneal Catheters: How We Do It. AJR 2009; 192:1085-1089

Radio contrast Injection

The radio contrast outlines the bowel and puddles in the pelvis

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Introduce 0.035 glide wire into the abdomen; easy entry and looping of the wire in the pelvis is seen

Radio contrast Injection

The radio contrast outlines the bowel and puddles in the pelvis

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Introduce 0.035 glide wire into the abdomen; easy entry and looping of the wire in the pelvis is seen

Radio contrast Injection

The radio contrast outlines the bowel and puddles in the pelvis

​

Introduce 0.035 glide wire into the abdomen; easy entry and looping of the wire in the pelvis is seen

Radio contrast Injection

The radio contrast outlines the bowel and puddles in the pelvis

​

Introduce 0.035 glide wire into the abdomen; easy entry and looping of the wire in the pelvis is seen

Radio contrast Injection

The radio contrast outlines the bowel and puddles in the pelvis

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Introduce 0.035 glide wire into the abdomen; easy entry and looping of the wire in the pelvis is seen

Graded Dilation over Glide Wire

Sequential dilation over wire from 12F to 18F

Finally introduce the 18F dilator with the peel-away sheath

Insertion of catheter

The PD catheter is introduced over the glide wire

Insertion of Catheter

Catheter loop is confirmed to fall in the pelvis

Purse String Suture

Purse String Suture

Retrospective review of medical charts of 89 patients with fluoscopic placement of peritoneal dialysis catheters from 2000 to 2012 to review intraoperative and immediate postoperative complications. All patients with Fluoroscopic PDC placement were included in the study. Patients with prior extensive abdominal surgery, bowel resection and morbid obesity were excluded from the study. Intra-operative complications were defined as bowel/bladder perforation, bleeding/ hematoma, acute abdomen, procedure abandonment, any complication requiring higher level of care or surgical intervention, and death. Immediate postoperative complications were defined as those occurring within 24 hours after PDC placement.

Timely placement of Peritoneal Dialysis catheter (PDC) remains a major hurdle for patients starting Peritoneal Dialysis (PD) and has spurred the growth of non-surgical PD catheter placement. Techniques of catheter placement differ in required resources, selection criteria, procedure anesthesia, procedure complications, postoperative recovery time, and cost amongst others. Fluoroscopic PDC placement have equivalent outcomes and has been increasingly used. A single center review of immediate complications of Fluoroscopic PDC placement is presented here.

Intra-operative complications: bowel/bladder perforation, intra-peritoneal/abdominal hematoma, acute abdomen, procedure failure from any cause, any complication requiring higher level of care, and death.

Immediate post-op complications: those occurring within 24 hours after PDC placement and included catheter flow dysfunction, fluid leak, acute abdomen, or any complication necessitating open laparotomy or surgical laparoscopic intervention, and death.

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FLUOROSCOPIC PERITONEAL DIALYSIS CATHETER PLACEMENT

AN OUTPATIENT PROCEDURE

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Ishwinder Sidhu, M.D., Mukesh Sharma, M.D., Kenneth Abreo, M.D., Bharat Sachdeva, M.D.

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Louisiana State University Health Sciences Center, Shreveport, LA

Background

Definitions

Purpose of the Study

Conclusions

Results

To assess the risk of immediate complications associated with fluoroscopic placement of peritoneal dialysis catheters with an aim to evaluate if this procedure can be safely performed in an out patient setting.

Patients and Methods

Procedure

Fluoroscopic Peritoneal Dialysis Catheter placement is a safe procedure and has a high technical success rate. Intra-Op complications are minimal; bowel puncture can be prevented using a blunt tip needle for peritoneal entry. Patients can be discharged once recovered from procedure sedation analgesia.

Table 1 : Demographics

Table 2 : Complications

Table 3 : Procedure Success Rate

LSU-Shreveport Experience Fluoroscopy (NKF 2012)

R: Randomized; P Prospective; PS: Purse string suture

Five patients who were declared ESRD were selected for this study. Patients were educated on the merits of different dialysis modalities by their Nephrologist and selected PD over HD. Of these Three patients underwent EPD and Two patients underwent UPD. Indications for EPD and UPD are listed in Table 2.

Two EPD and one UPD patients received 1-3 HD treatments through a temporary CVC prior to PDC placement for indications listed in Table 1. Interventional Nephrologists placed Peritoneal Dialysis Catheters within 48 hours of patients choice of PD. All catheters were placed using the modified Seldinger’s technique under fluoroscopy and Procedure Sedation Analgesia(Conscious Sedation). A purse string suture was placed in the anterior rectus sheath encircling the catheter to prevent PD fluid leak in some patients. Patients resumed renal diet within 2 hours post procedure. Low volume (1 liter) exchanges were used with the patient in supine position within 24 hrs in EPD patients and within 2 weeks in UPD patients. Patients were followed in the outpatient PD clinic after discharge for continuation of low volume exchanges and PD training. Regular volume exchanges were started within a month of Peritoneal dialysis catheter placement in all patients.

In the US, 60-80% incident ESRD patients start hemodialysis (HD) with a central venous catheter (CVC), resulting in an unacceptably high morbidity and mortality associated with catheter related infections/inflammation. Selecting Peritoneal Dialysis (PD) as the initial dialysis modality may be an excellent CVC avoidance strategy in selected patients and may help decrease both morbidity and mortality.

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We describe a case series of newly declared ESRD patients without established Arterio-Venous dialysis access, who were initiated on peritoneal dialysis as their initial modality for chronic dialysis.

Emergent Peritoneal Dialysis (EPD): Starting Peritoneal Dialysis immediately (24-48 h) after PD catheter (PDC) placement

Urgent Peritoneal Dialysis (UPD): Starting Peritoneal Dialysis after 48 hours but within 2 weeks of PDC placement.

Emergent and Urgent Peritoneal Dialysis

instead of Hemodialysis with a Central Venous Catheter

Background

Definitions

Purpose of the Study

Conclusions

Table 2: Demographics

Emergent or Urgent PD should be considered in all incident ESRD patients and chronic PD catheter can be placed using minimally invasive technique in an interventional suite. Low volume exchanges in supine position, within 24 hours of PD catheter placement are well tolerated without early leak. Tunneled dialysis catheters can this way be avoided in incident ESRD patients without established Arterio-Venous Access. PDC insertion at short notice is a sine qua non for EPD and UPD.

To demonstrate that Peritoneal Dialysis can be safely used as a choice of dialysis modality in emergent and urgent settings in carefully selected and appropriate patients. This approach avoids placement of Tunneled central venous catheters in ESRD patients without a working vascular access at the time of initiation of dialysis.

Patients and Methods

*One HD treatment for Hyperkalemia each, †HD for 3 days for volume overload,

AA=African American, W=White

Table 1: Laboratory Data

Pre-PD= before start of PD/HD; Discharge=hospital day of discharge, * One HD treatment for Hyperkalemia each, †HD for 3 days for volume overload

Mukesh Sharma, M.D., M.S., Kenneth Abreo, M.D., Bharat Sachdeva, M.D.

Louisiana State University Health Sciences Center, Shreveport, LA

What the Options for my patients

• Acute presentation of ESRD patients or CKD patients who have not had an access placed during follow up
• Does access/modality for RRT influence survival? Yes
• What about the cost! Saving
• What Can I do? Education/Placement
• Can we do PD in Acute Setting? Yes

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Outpatient training/exchanges

Urgent Start: PD Prescription

• Lower volumes (500-1000 ml)
• Glucose concentration and Dwell time (2-4 hours); clinically determined
• Volume, electrolytes, UF goal
• Recumbent position, drain before ambulation
• Daily exchanges, variable time
• Treatment time- during dialysis unit hours of operation, 8a to 5 p
• Labs biweekly

Conclusions

• PD is associated with early survival advantage in large registries
• PD First: Avoids subsequent procedures for permanent access
• PD first approach prior to central venous catheter placement is suitable in majority of patients
• Fluoroscopic technique offers timely PD access with minimal complications
• IPD, recumbent, low volume prescriptions have been described