You are on page 1of 4


J Vasc Access 2016; 17 (Suppl 1): S56-S59

DOI: 10.5301/jva.5000535

ISSN 1129-7298 Original Article

Urgent peritoneal dialysis or hemodialysis catheter

Charmaine E. Lok

Division of Nephrology, Department of Medicine, University Health Network-Toronto General Hospital, Toronto, Ontario - Canada

Worldwide, there is a steady incident rate of patients with end-stage kidney disease (ESKD) who require renal
replacement therapy. Of these patients, approximately one-third have an “unplanned” or “urgent” start to dialy-
sis. This can be a very challenging situation where patients have either not had adequate time for education and
decision making regarding dialysis modality and appropriate dialysis access, or a decision was made and plans
were altered due to unforeseen circumstances. Despite such unplanned starts, clinicians must still consider the
patient’s ESKD “life-plan”, which includes the best initial dialysis modality and access to suit the patient’s individ-
ual goals and their medical, social, logistic, and facility circumstances. This paper will discuss the considerations of
peritoneal dialysis and a peritoneal dialysis catheter access and hemodialysis and central venous catheter access
in patients who require an urgent start to dialysis.
Keywords: Access, Central venous catheter, Dialysis catheter, Hemodialysis, Urgent dialysis start

Introduction for some patients (6, 7). Perhaps the key points of debate
are not only what type of hemodialysis access should be
Worldwide, more than five million people have stage V used, but in whom. Additional considerations include the
chronic kidney disease (CKD) or have reached end-stage kid- when and why – under what circumstances were decisions
ney disease (ESKD) requiring renal replacement therapy (1). made – or not made – regarding not only the ‘right’ vascular
In the USA, the incidence rate of ESKD peaked in 2006 and access type but the ‘right’ dialysis modality, i.e., the most
has since levelled off, with a recent incidence of approxi- appropriate modality for the individual ESKD patient. While
mately 120,000 new patients starting dialysis in 2013 (2). it is important to consider the right access, in the right pa-
Of these patients, 88.2% began renal replacement therapy tient, and at the right time (6), this paper will discuss some
with hemodialysis, 9.0% with peritoneal dialysis, and 2.6% of these critical issues in choosing the optimal access for a
with a pre-emptive transplant. After a decade, 80% of inci- patient under “urgent start” situations.
dent hemodialysis patients still initiate hemodialysis with
a central venous catheter (CVC) (3). Multiple studies have Preparation and presentation
demonstrated the adverse health outcomes of using a CVC
(4) leading to significant concerns about their use (5). Thus, Indeed, it is the thought that counts. Having CKD and
many have argued that it is crucial to limit CVC exposure, reaching ESKD has many life ramifications – renal replace-
to reduce the risk of CVC-related bacteremia or sepsis, mal- ment therapy is a major life decision that has multiple impli-
function and central venous stenosis – that may prohibit fu- cations for each patient’s individual health, social, financial,
ture arteriovenous (AV) access creation (6). However, others and support systems and related outcomes. Yet in the latest
have also argued that a CVC may be an appropriate choice statistics from the USA, up to 38% of incident ESKD patients
received little or no pre-ESKD nephrology care (2). Late refer-
ral and unplanned dialysis starts have been reported to range
Accepted: January 8, 2016 from 27%-45% (2, 8, 9).
Published online: March 6, 2016 Late referral and “unplanned starts” to dialysis have been
defined differently by clinicians, researchers and institutions.
Corresponding author: Given the complexity of decisions required, the time need-
Charmaine E. Lok, M.D. ed for the planning, creation and post-creation care for a
Division of Nephrology functioning permanent dialysis access, and other necessary
Department of Medicine social, logistic and medical preparations, it is reasonable to
Toronto General Hospital
8NU-844, 200 Elizabeth Street require a minimum of 3 months of pre-dialysis care. Anything
Toronto less than 3 months or initiating dialysis with a temporary
M5G 2C4 Ontario, Canada CVC can be called an “unplanned start”. This can be distin- guished from an “urgent” start – a start where there may

© 2016 Wichtig Publishing

Lok S57

Fig. 1 - Modality and access choices for the urgent start patient.

have been timely and/or excellent pre-ESKD care, but where peritoneal dialysis when there is time for education and choice
unforeseen circumstances have occurred that may have ex- (14, 15). The considered and appropriate choice of dialysis mo-
pedited the patient’s need for dialysis. An “urgent” start may dality should be the first priority rather than the choice of he-
also be viewed differently than an “emergent” start, where di- modialysis vascular access. Where then, does this leave i) the
alysis is required imminently to correct life-threatening elec- unplanned start patient, or ii) the urgent start patient?
trolyte disturbances, medically refractory pulmonary edema/
volume overload, bleeding or other consequences of uremia, Choices for the patient who has an unplanned
such as pericarditis and altered consciousness or seizures. An start or urgent start to dialysis
urgent start patient may have signs and symptoms of uremia
but non-life threatening conditions where dialysis is anticipat- Regardless of whether the patient is one with an un-
ed to be required in approximately 2 weeks (±1 week). It is the planned or urgent start to dialysis, a key question that should
timeframe in which it is difficult to have an arteriovenous (AV) be considered is whether or not the patient is eligible and
fistula (fistula) planned, created and matured enough to be appropriate for peritoneal dialysis or hemodialysis (Fig. 1).
successfully functional and used for prescribed dialysis (10). There is mounting evidence on the equivalence of peritoneal
There is earlier, strong evidence that support the use of dialysis versus hemodialysis in terms of patient survival; and
timely, multi-disciplinary care models for CKD management and even additional benefits with peritoneal dialysis, with fewer
dialysis preparation before a patient reaches ESKD. Such mod- required access interventions during the first year of dialysis
els have been implemented worldwide and have shown supe- (16, 17). Outcomes may vary by institution or country, thus,
rior outcomes in many key aspects of care, with greater use understanding the practice patterns and outcomes of the fa-
of AV-access (and lower CVC start rate), fewer hospitalizations cility where the patient’s dialysis care will be overseen and
and reduced mortality (11-13). In fact, more patients choose managed, is important (18-20).

© 2016 Wichtig Publishing

S58 Peritoneal vs. hemodialysis catheter in urgent dialysis starts

If the patient is eligible for both peritoneal dialysis and s­ ituations. Preliminary results (n = 53) from our centre have
hemodialysis, considering the “life-plan” of the individual demonstrated a success rate of 93% (7% primary failure rate)
ESKD patient is critical; important factors to be considered with 100% used for dialysis. In “urgent start” patients who
include not only the patient’s age, comorbidities, geography are eligible for either peritoneal dialysis or hemodialysis, the
(location and ease of access to dialysis unit) and social sup- choice will depend on the individual circumstances (above).
port system, but also variables such as whether or not the Urgent start peritoneal dialysis has been proven effective, even
patient has residual renal function – a benefit, especially for in the elderly patient population (28). Dialysis access has also
the patient who initiates peritoneal dialysis (21-23). If a pa- been proven less costly in the first 3 months with urgent peri-
tient has significant residual renal function, it may be an ide- toneal dialysis (US$16,000 total with dialysis access represent-
al “life-plan” to initiate peritoneal dialysis, and then plan for ing 15% of costs) than urgent hemodialysis (US$19,000 total
an AV access (preferably a fistula) when peritoneal dialysis with dialysis access representing 27% of costs). If hemodialysis
becomes technically problematic. Alternatively, combining is chosen, the duration of CVC exposure should be limited and
peritoneal dialysis and hemodialysis prescriptions may pre- all efforts should be made to avoid the central veins, including
serve residual renal function longer and provide the most the use of tunnelled femoral catheters and early cannulation
adequate dialysis compared with isolated hemodialysis. In- grafts; however, this again, depends on the individual’s situa-
deed, “progressive hemodialysis” is a notion that, while it tion (29). In special circumstances (listed above), the appropri-
remains to be fully tested, seems logical and can be applied ate dialysis and access is hemodialysis via a CVC. In such cases,
in a variety of situations (24, 25). However, ESKD “life-plans” the catheter must be meticulously managed with evidenced
must be carefully individualized to meet the patient’s own based practices to limit or avoid complications.
needs and goals within the parameters set by their medical,
social and logistic circumstances. Conclusion
In situations where a patient may be a hemodialysis
patient – unplanned start, urgent start or a patient who initi- Urgent dialysis starts are not an uncommon situation
ates peritoneal dialysis then transfers to hemodialysis perma- where careful consideration must be made regarding the
nently or in a progressive manner – a functional hemodialysis initial trajectory of the ESKD patient’s dialysis “life-plan”. If a
access must be in place. There are limited situations where a patient is eligible for both peritoneal dialysis and hemodialy-
CVC should be the appropriate option for an incident dialysis sis, the patient’s individual medical condition(s), social and
patient. These situations include patients who are palliative logistic situations and facility supports must be considered.
with limited life expectancy (survival <6 months), patients In special situations, hemodialysis with a central venous cath-
with a known living kidney transplant donor (ideally with eter is the appropriate first choice but the catheter must be
a surgical date in the near future i.e., <6 months), patients meticulously managed with evidenced based practices to
who are urgent starts and had previously planned for peri- limit or avoid complications.
toneal dialysis but unforeseen medical issues occurred that
required hemodialysis initiation (with the goal to transfer to Disclosures
peritoneal dialysis), limited medical conditions that contrain-
Financial support: No grants or funding have been received for this
dicate an AV-access (e.g., excoriating infective skin condition study.
which would make infection risk greater with cannulation) Conflict of interest: None of the authors has financial interest related
and a truly informed and consenting patient who adamantly to this study to disclose.
refuses to have an AV access for personal reasons. In all other
circumstances, a CVC should be avoided to limit exposure to
the risks associated with CVC, including that of central steno- References
sis. While the risk of CVC-related infection has been reported 1. Liyanage T, Ninomiya T, Jha V, et al. Worldwide access to treat-
close to 50% by 6 months (26), a patient may survive and go ment for end-stage kidney disease: a systematic review. Lan-
on to have a safer, AV access. However, this may not be pos- cet. 2015;385(9981):1975-1982.
sible if they develop central venous stenosis. Central venous 2. United States Renal Data System. USRDS 2015 Annual Data Re-
stenosis is the “less dramatic” and often overlooked or un- port: Atlas of Chronic Kidney Disease and End-Stage Renal Dis-
recognized CVC complication amongst nephrologists and care ease in the United States. Vol. 2. Ch. 1: Incidence, prevalence,
patient characteristics, and treatment modalities. Bethesda,
providers less versed with dialysis access. However, central MD, National Institutes of Health, National Institute of Diabe-
vein stenosis is an equally if not more important longer-term tes and Digestive and Kidney Diseases, 2015. Available from:
complication than some other CVC-related complications. It Accessed Jan
can occur in up to 30%-40% of patients (27). Central stenosis 12, 2016.
that prohibits AV-access creation(s) limits the patient’s dialy- 3. United States Renal Data System. USRDS 2015 Annual Data
sis “life-line” options and may relegate the patient to life-long ­Report: Atlas of Chronic Kidney Disease and End-Stage Renal
CVC exposure and infection risk. Disease in the United States. Vol. 2. Ch. 4: Vascular access.
Bethesda, MD, National Institutes of Health, National Institute
of Diabetes and Digestive and Kidney Diseases, 2015. Available
Peritoneal catheter or central venous catheter from: Accessed
Jan 12, 2016.
In “emergent” dialysis start patients, most will require a 4. Ravani P, Palmer SC, Oliver MJ, et al. Associations between
CVC for hemodialysis. Few centers are able to place a bedside hemodialysis access type and clinical outcomes: a systematic
peritoneal catheter that can be used immediately in these review. J Am Soc Nephrol. 2013;24(3):465-473.

© 2016 Wichtig Publishing

Lok S59

5. Rehman R, Schmidt RJ, Moss AH. Ethical and legal obligation in patients with end-stage renal disease. Arch Intern Med.
to avoid long-term tunneled catheter access. Clin J Am Soc 2011;171(2):110-118.
Nephrol. 2009;4(2):456-460. 17. Oliver MJ, Verrelli M, Zacharias JM, et al. Choosing perito-
6. Drew DA, Lok CE. Strategies for planning the optimal dialysis neal dialysis reduces the risk of invasive access interventions.
access for an individual patient. Curr Opin Nephrol Hypertens. Nephrol Dial Transplant. 2012;27(2):810-816.
2014;23(3):314-320. 18. Kasza J, Wolfe R, McDonald SP, Marshall MR, Polkinghorne KR.
7. Quinn RR, Ravani P. Fistula-first and catheter-last: fading Dialysis modality, vascular access and mortality in end-stage
certainties and growing doubts. Nephrol Dial Transplant. kidney disease: a bi-national registry-based cohort study.
2014;29(4):727-730. Nephrology (Carlton). 2015; Dec 2. doi: 10.1111/nep.12688.
8. Danish Nephrology Registry, Annual Report 2013, 2015 [In Dan- [Epub ahead of print]
ish]. Available from: 19. Otero González A, Iglesias Forneiro A, Camba Caride MJ, et al.
Landsregister/%C3%85rsrapport%202013.pdf. Accessed Jan Survival for haemodialysis vs. peritoneal dialysis and technique
12, 2016. transference. Experience in Ourense, Spain, from 1976 to 2012.
9. Canadian Organ Replacement Register - CORR. 2015 CORR Re- Nefrologia. 2015;35(6):562-566.
port. Treatment of End-Stage Organ Failure in Canada: Ch. 2: 20. Yeates K, Zhu N, Vonesh E, Trpeski L, Blake P, Fenton S. He-
Renal replacement therapy for end-stage kidney disease. 2015. modialysis and peritoneal dialysis are associated with similar
Available from: outcomes for end-stage renal disease treatment in Canada.
Accessed Jan 12, 2016. Nephrol Dial Transplant. 2012;27(9):3568-3575.
10. Rayner HC, Pisoni RL, Gillespie BW, et al. Dialysis Outcomes and 21. Perl J, Bargman JM. The importance of residual kidney func-
Practice Patterns Study. Creation, cannulation and survival of tion for patients on dialysis: a critical review. Am J Kidney Dis.
arteriovenous fistulae: data from the Dialysis Outcomes and 2009;53(6):1068-1081.
Practice Patterns Study. Kidney Int. 2003;63(1):323-330. 22. Marrón B, Remón C, Pérez-Fontán M, Quirós P, Ortíz A. Benefits
11. Jungers P, Massy ZA, Nguyen-Khoa T, et al. Longer duration of preserving residual renal function in peritoneal dialysis. Kid-
of predialysis nephrological care is associated with improved ney Int Suppl. 2008;73(108)(Suppl):S42-S51.
long-term survival of dialysis patients. Nephrol Dial Transplant. 23. Wang AY, Lai KN. The importance of residual renal function in
2001;16(12):2357-2364. dialysis patients. Kidney Int. 2006;69(10):1726-1732.
12. Goldstein M, Yassa T, Dacouris N, McFarlane P. Multidisci- 24. Suzuki H, Hoshi H, Inoue T, et al. Long-term survival benefits of
plinary predialysis care and morbidity and mortality of patients combined hemodialysis and peritoneal dialysis. Adv Perit Dial.
on dialysis. Am J Kidney Dis. 2004;44(4):706-714. 2014;30:31-35.
13. Hemmelgarn BR, Manns BJ, Zhang J, et al. Association be- 25. Libetta C, Nissani P, Dal Canton A. Progressive hemodialysis: is
tween multidisciplinary care and survival for elderly patients it the future? Semin Dial. 2015;n/a.
with chronic kidney disease. J Am Soc Nephrol. 2007;18(3): 26. Lee T, Barker J, Allon M. Tunneled catheters in hemodialysis
993-999. patients: reasons and subsequent outcomes. Am J Kidney Dis.
14. Marrón B, Ortiz A, de Sequera P, et al; Spanish Group for CKD. 2005;46(3):501-508.
Impact of end-stage renal disease care in planned dialysis 27. MacRae JM, Ahmed A, Johnson N, Levin A, Kiaii M. Central
start and type of renal replacement therapy—a Spanish multi- vein stenosis: a common problem in patients on hemodialysis.
centre experience. Nephrol Dial Transplant. 2006;21(Suppl 2): ASAIO J. 2005;51(1):77-81.
ii51-ii55. 28. Povlsen JV, Sorensen AB, Ivarsen P. Unplanned start on peritone-
15. Lacson E Jr, Wang W, DeVries C, et al. Effects of a nationwide pre- al dialysis right after PD catheter implantation for older people
dialysis educational program on modality choice, vascular access, with end-stage renal disease. Perit Dial Int. 2015;35(6):622-624.
and patient outcomes. Am J Kidney Dis. 2011;58(2):235-242. 29. Hingwala J, Bhola C, Lok CE. Using tunneled femoral vein cath-
16. Mehrotra R, Chiu YW, Kalantar-Zadeh K, Bargman J, Vonesh eters for “urgent start” dialysis patients: a preliminary report.
E. Similar outcomes with hemodialysis and peritoneal ­dialysis J Vasc Access. 2014;15(Suppl 7):S101-S108.

© 2016 Wichtig Publishing