| Abstract|| |
There are only a few reports on the role of peritoneal dialysis (PD) in critically ill patients requiring continuous renal replacement therapies (RRT). This study aimed to determine the efficacy and outcome of intermittent PD in acute kidney injury (AKI) patients in intensive care unit setting and to assess the procedure-related complications. This was a prospective, observational study conducted from March 1, 2015, to February 29, 2016, which included patients of either sex, aged ≥18 years, diagnosed with AKI, and undergoing RRT with intermittent PD sessions with more than 48 h of hospital stay. Patients were later shifted to sustained low- efficiency dialysis or hemodialysis, when they became hemodynamically stable. Hence, the patients who received at least 48 h of PD were included in the study. A total of 75 patients were enrolled. Overall, the mean age was 55.75 years, and around 64% were men. The most common indication to start PD was metabolic acidosis, and the most common cause of AKI was sepsis. A total of 21 patients survived, and the mortality rate was 72%. The average peritoneal urea clearance and creatinine clearance were 14.81 mL/min and 12.59 mL/min, respectively. Of the 66 patients on inotropes, 28 patients were tapered from inotropic support. Thirty-nine patients had hyperkalemia, and 27 patients had correction within 1 day of the start of PD. Forty-seven patients had correction of acidosis, and 33 of these achieved pH ≥7.25 within one day of PD. The most common complication that occurred was peri-catheter leaks followed by peritonitis. Acute PD can be an effective, simple, and safe bridge RRT in hemodynamically unstable patients until the achievement of hemodynamic stability to shift them to other modalities of RRT.
|How to cite this article:|
Garg N, Kumar V, Sohal PM, Jain D, Jain A, VikasMakkar, Mehta S. Efficacy and outcome of intermittent peritoneal dialysis in patients with acute kidney injury: A single-center experience. Saudi J Kidney Dis Transpl 2020;31:423-30
|How to cite this URL:|
Garg N, Kumar V, Sohal PM, Jain D, Jain A, VikasMakkar, Mehta S. Efficacy and outcome of intermittent peritoneal dialysis in patients with acute kidney injury: A single-center experience. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2020 Jun 4];31:423-30. Available from: http://www.sjkdt.org/text.asp?2020/31/2/423/284017
| Introduction|| |
Acute kidney injury (AKI) is common in developing countries due to overcrowding, poor socio-economic factors, and environmental conditions. There is no reliable data on the incidence, prevalence, causes, and recovery from the disease., AKI is reported in around 5% of patients hospitalized, of these around 0.5% generally need dialysis support. Even after significant improvement in the care provided to critically ill patients, mortality from this complication is ≥50%. In this patient population, the development of renal failure acts as an independent predictor of mortality, and is associated with a higher rate of dialysis requirement in patients admitted in intensive care units (ICUs) with multiple comorbidities. Two major types of renal replacement modalities are available: hemo- dialysis (HD) and peritoneal dialysis (PD). PD was the first modality used for AKI. Intermittent PD was widely used in the 1970s. Although the use of PD started in the 1920s, it was in 1946 when it was first reported to have saved the life of a patient. Post 1970, the use of PD started declining with the advent of continuous renal replacement therapy (CRRT) in developed countries. However, in resource- poor countries, PD is still used to correct metabolic abnormalities, and there are some studies that have reported a good outcome.,,, Currently, there is a renewed interest in using PD in patients with AKI., Some concerns still exist regarding the efficacy, dosage of PD and the outcome of critically ill AKI patients on PD. Hence, there is a need to further evaluate the use of PD in patients with AKI. This study focuses on the efficacy of PD in the form of improvement in acidosis, hyper- kalemia, and uremia and the outcome of the adult patients with AKI in the critical care setting, and to determine if PD can be used as an effective mode of RRT among these patients.
| Materials and Methods|| |
Study design and population
This was a prospective, observational study conducted at Dayanand Medical College and Hospital, Ludhiana, Punjab, from March 1, 2015, to February 29, 2016, to assess the efficacy of acute intermittent PD in patients with AKI in ICU setting. Patients admitted to the medical department and emergency ICUs and our allied branches for the treatment of RRT were screened. Patients of either sex, aged ≥18 years, with a diagnosis of AKI (defined by Kidney Disease: Improving Global Outcomes criteria), and admitted and undergoing RRT with intermittent PD sessions with more than 48 h of hospital stay were included in the study. Patients who were hemodyna- mically stable and/or discontinued the treatment before completion of 48 h of hospital stay, or patients who were shifted to intermittent HD or sustained low-efficiency dialysis (SLED) before completion of 48 h were excluded from the study.
Adequate and appropriate history was noted including the comorbidities and the duration of the same, along with general physical examination and systemic examination. The following investigations were done: hemogram; renal function test (RFT); liver function test (RFT); electrocardiogram; chest X-ray; urine routine examination; protein thiolation index; and peritoneal fluid urea/creatinine (Cr) ratio at day 1, day 2, day 3, and at the end of intermittent PD. Peritoneal fluid cytology and culture was done when necessary. Hemo- dynamic status of the patient was also noted. For the patients who were on inotropic support, the hemodynamic status and the rate of inotrope infusion were noted at admission; at the start of intermittent PD; and day 1 (24 h), day 2 (48 h), day 3 (72 h), and at the end of intermittent PD. The procedure-related complications and the duration of ICU stay were also noted. APACHE II score at admission was calculated.
The outcomes of the study were: the proportion of survivors and non-survivors; improvement in hemodynamic status of the patient after PD in the form of inotropes being tapered off; improvement in acidosis and hyperkalemia (pH ≥7.25 and K+ <5.5 mmol/L); requirement of shifting to other modality of RRT (i.e., HD and SLED during hospital stay); efficacy of PD in the form of urea reduction ratio (URR) and peritoneal urea clearance; and complications that occurred in patients on PD.
The study protocol was approved by the institutional ethics committee. The study was conducted in accordance with the approved protocol, International Conference on Harmonisation - Good Clinical Practice, and the Declaration of Helsinki 2013. A written informed consent was obtained from each study participant before any study-related procedure.
All the statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) software version 17.0 (SPSS Inc., Chicago, IL, USA). Data were presented as mean ± standard deviation (SD) values or as absolute numbers with percentages. Comparisons between groups were performed using the Student’s t-test, one-way analysis of variance, the Chi-square test, and ANOVA as appropriate.
| Results|| |
A total of 402 patients were screened, and 75 patients met the study inclusion criteria and were enrolled in the study. Overall, the mean (SD) age was 55.75 (14.88) years. The study population included patients in the age range of 22 to 88 years. Most patients belonged to the age group of 51-60 years [26 (34.7%)] followed by 61-70 years [17 (22.7%)]. The age group of 41-50 years and ≥70 years comprised 10 (13.3%) patients. Among the study population, 48 (64%) were males and 25 (32%) were females, with a male:female ratio of 1.7:1. In the study population, the most common cause leading to AKI was sepsis [52 (69.3%) patients], which included urinary tract infections, spontaneous bacterial peritonitis, cellulitis, and pneumonia. This was followed by cardiogenic shock [10 (13.3%) patients] [Table 1].
The mean (SD) duration of ICU stay was 7.96 (4.62) days. A total of 55 (73.3%) patients required ventilator support. This study showed that most patients had multiple organ involvement. Thirty-nine (52%) patients had four organs involved, followed by 19 (25.3%) patients with three organs involved and 17 (22.7%) patients with five organs involved. Overall, 49 (65.3%) patients had comorbi- dities. Diabetes mellitus was the most common comorbidity (n = 36, 48%) followed by hypertension (n = 30, 40%). Preexisting CKD occurred in 23 (30.7%) patients.
The most common indication of RRT encountered in the study population was metabolic acidosis in 60 (80%) patients followed by fluid overload in 43 (57.3%) patients and hyperkalemia in 39 (52%) patients [Table 1]. The patients had a mean (SD) ultrafiltrate 1.5 (1.6) L/day, ranging from gain of fluid up to 2 L/day to fluid removal of 5.7 L/day. The patients in the study population had the peritoneal urea and Cr clearance (CrCl) in the range of 4.55 to 46.52 mL/min and 4.20 to 32.84 mL/min, respectively. The mean (SD) peritoneal urea and CrCl was found to be 14.81 (6.93) mL/min and 12.59 (6.13) mL/min, respectively. The URR was 16.33% (35.22%).
Of the 75 patients, hyperkalemia (K+ ≥5.5 mmol/L) was reported in 39 patients; of these 39 patients, correction of hyperkalemia could be achieved in 36 (92.3%) patients [Table 2]. Sixty-three (84%) patients had acidosis, and 47 (62.7%) of these patients had correction of acidosis by the end of the study. A total of nine (12%) patients did not require inotropic support. Of the 66 patients who received inotropes, 28 (37.3%) patients were tapered off the inotropes and 38 (50.7%) patients could not be tapered off the inotropes. Of the total 75 patients, 21 (28%) patients survived and were discharged [Table 2]. Fifty-four (72%) of the 75 patients died.
|Table 2: Survival in acute kidney injury patients and improvement of hemodynamic metabolic parameters after completion of peritoneal dialysis.|
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The mean (SD) peritoneal urea clearance was statistically significantly (P = 0.048) higher among survivors [17.34 (8.995) mL/min] than nonsurvivors [13.83 (5.741) mL/min]; however, the peritoneal CrCl was not statistically significant (P = 0.13) among survivors [14.29 (7.484) mL/min] and nonsurvivors [11.93 (5.459) mL/min]. The URR was slightly higher among survivors than nonsurvivors but was not statistically significant (P = 0.125) [Table 3].
|Table 3: Comparison of efficacy of peritoneal dialysis among survivors and non-survivors.|
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Out of the 75 patients, 25 patients were shifted to other modality of RRT, namely,
IHD/SLED and among these, 11 patients survived [Table 4]. Ten patients belonged to the group that did not require to be shifted to any other modality of RRT during the hospital course and were discharged. The survival rates among the patients who were shifted to IHD/SLEDD were more as compared to those who were not shifted, and this was statistically significant (P = 0.029) [Table 4]. There was a significant difference in the duration in ICU stay, with survivors having prolonged ICU stay (11.69 days). The most common complication observed was peri-catheter leaks in 13 (17.3%) patients followed by peritonitis in four (5.33%) patients; two patients each had catheter-site infections and pain at inflow. None of the patients had visceral perforations. These complications did not affect the survival rate in the study.
|Table 4: Patients shifted to other modalities of renal replacement therapy related to outcome.|
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| Discussion|| |
The usage of PD in the Western world has declined due to the improvement in continuous RRT. The survey by Gaiao et al in 2012 showed that a lot of difference in opinion exists among the nephrologists from the Western countries and the developing world regarding the practice of PD. The use of acute PD is limited to resource-limited countries because of the nonavailability of trained technical staff and infrastructure for CRRT/SLED-requiring AKI patients. This study was aimed at determining the efficacy and the outcome of acute PD in AKI patients at a tertiary care center. We enrolled 75 patients who underwent PD for at least 48 h fulfilling the inclusion/exclusion criteria. The primary outcome in the form of number of survivors and nonsurvivors in the study sample was 21 (28%) and 54 (72%), respectively. The lower number of survivors can be due to the comorbidities and involvement of multiple organs. Most patients in our study belong to AKI Stage 3 of AKIN criteria, which explains the mortality of 70% of patients irrespective of the modality used. Similar mortality rates were observed by George et al and Ponce et al. in patients with AKI on acute PD.,, The mortality rates in our study were in concordance with previous reports, which suggest that mortality of AKI patients undergoing different methods of dialysis ranged from 40% to 80%, depending on the AKI etiology and severity of patients.,
A systematic review by Chionh et al in 2013 has shown that the use of PD is limited to small children in the Western countries. It showed that there is no data to support the differences in mortality between PD and extracorporeal blood purification systems in AKI. Multiple randomized controlled trials and cohort studies comparing PD with EBP techniques showed no mortality benefit. [18,,, Most of these data on acute intermittent PD prevail to the developing countries.
In the present study, sepsis was found to be the most common cause leading to AKI followed by cardiogenic shock. Similar trends of sepsis were observed in previous studies by George et al, Mahajan et al, and Bagshaw et al.,, The higher number of patients with sepsis might be attributed to the fact that most patients had multiple comorbidities and acquired nosocomial infections being admitted earlier. Studies in literature opine that most patients have multiple etiologies of AKI occurring at the same time.
The comparison between the survivors and the nonsurvivors in the study population has shown that there is no significant difference in the baseline parameters of the patients, including mean serum urea, Cr, average serum potassium, and pH at admission, thus helping in removing the selection bias.
Initiation of RRT was done according to the standard indications of dialysis. Most patients were started on RRT in the presence of pressing indications of severe metabolic aci- dosis and hyperkalemia. The most common indication for starting RRT was metabolic acidosis followed by fluid overload and hyper- kalemia. The other indications were uremic encephalopathy and severe hyponatremia. Usually, these indications co-existed in a patient at the time of initiation of therapy. In our study, 32 patients had co-existing metabolic acidosis and hyperkalemia. There are multiple indications of starting RRT in the study population at the same time, so none of the published studies have commented on the most common indication.
PD, in our study, achieved an average ultra- filtrate of 1.5 L/day and might help in correction of the fluid overload. There is limited literature available on fluid removal with PD and is needed to be further evaluated and compared to other modalities.
In our study, the mean peritoneal urea and CrCl were comparable with the study done by Gabriel et al, Chitalia et al, and George et al, who used Tenckhoff catheter and automated cyclers compared to the traditional rigid PD catheter and manual exchanges used in our study. The outcome analysis suggested that the survivors had better urea clearance than the nonsurvivors (P = 0.048). This observation can be explained by the improvement in the hemodynamics, hence having better splanchnic circulation and thus, better clearance. However, better clearance associated with better survival still needs to be clarified with further studies.
The comparison of the URR among the survivors and nonsurvivors suggests that there is no statistically significant difference in the outcome (P = 0.125). This can be explained as critically ill patients with AKI are often hyper- catabolic and in negative nitrogen balance. The volume of distribution of urea in AKI is altered, which often exceeded total body water, hence complicating the applications of urea kinetics to the acute setting. The URR in our study can be explained by the decreased perfusion of the splanchnic circulation due to worsening hemodynamics, the use of ino- tropes, worsening of underlying condition, moderately high APACHE II score, and sepsis, thus leading to poor exchange of solutes.
Most patients in the study were hemo- dynamically unstable. When PD was continued for about 48-72 h, the average time to taper off inotropic support was 4.15 days and after tapering the inotropes, we were able to shift them to another modality of RRT, namely IHD or SLEDD, when required. The improvement in hemodynamic status resulted in better survivor outcome, and this improvement may be attributed to factors such as control of sepsis and recovery of the renal function. The nonsurvivors could not be tapered off the inotropes as they did not respond to the therapy because of multiple organ failure and severity of the underlying disease.
In our study, 39 patients had hyperkalemia and 36 (92.3%) of these patients had correction of hyperkalemia. This shows that PD is effective in correcting hyperkalemia, as also suggested by George et al.
Among the study population in our study, 63 patients had acidosis and with treatment, 47 had correction of acidosis (pH ≥7.25). Correction of acidosis is faster with other modalities as we know PD is a slow continuous process and has a slower rate of solute removal. Twenty- six patients achieved correction of acidosis on PD, but later had worsening of acidosis due to severity of the basic disease or because of worsening of shock, leading to accumulation of lactate. The outcome analysis suggested that lactate levels were significantly high among the nonsurvivors; this can be explained by worsening of hemodynamics and the severity of the underlying disease. The use of lactate- based solutions may lead to further increase in lactate levels, thus leading to more metabolic acidosis. Various complications arising during PD did not affect the survivor rate in the study patients as the results were not significant.
| Conclusion|| |
PD is effective in slow correction of the solutes and can be used in patients with hemo- dynamic instability. The time to improve the renal function depends on the underlying condition. The gradual solute correction can help patients to tolerate AKI, and patients who do not exhibit recovery in renal function can be shifted to conventional hemodialysis after improvement in hemodynamic status. Thus, PD can be used as a bridge modality in severely ill hemodynamically unstable patients, and its efficacy to be used as a primary modality in critically ill AKI patients needs to be evaluated with further studies.
Conflict of interest: None declared.
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Preet Mohinder Sohal
Department of Nephrology, Dayanand Medical College and Hospital, Ludhiana, Punjab
[Table 1], [Table 2], [Table 3], [Table 4]