REVIEW

CURRENT
OPINION Urgent start peritoneal dialysis
Daniela Ponce a,b, Alexandre Minetto Brabo a, and André Luı´s Balbi a
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Purpose of review
Although historically peritoneal dialysis was widely used in nephrology, it has been underutilized in recent
years. In this review, we present several key opportunities and strategies for revitalization of urgent start
peritoneal dialysis use, and discuss the recent literature on clinical experience with peritoneal dialysis use
in the acute and unplanned setting.
Recent findings
Interest in using urgent start peritoneal dialysis to manage acute kidney injury (AKI) and unplanned chronic
kidney disease (CKD) stage 5 patients has been increasing. To overcome some of the classic limitations of
peritoneal dialysis use in AKI, such as a high chance of infectious and mechanical complications, and no control
of urea, the use of cycles, flexible catheters, and a high volume of dialysis fluid has been proposed. This
knowledge can be used in the case of an unplanned start on chronic peritoneal dialysis, and may be a tool to
increase the peritoneal dialysis penetration rate among incident patients starting chronic dialysis therapy.
Summary
Peritoneal dialysis should be offered in an unbiased way to all patients starting unplanned dialysis, and
without contraindications to peritoneal dialysis. It may be a feasible, well tolerated, and complementary
alternative to hemodialysis, not only in the chronic setting, but also in the acute.
Keywords
acute kidney injury, chronic kidney disease, peritoneal dialysis, urgent start

INTRODUCTION and life-saving renal replacement therapy (RRT)

The role of peritoneal dialysis for acute
kidney injury patients
In the 1970s, acute peritoneal dialysis was widely
accepted for the treatment of acute kidney injury
(AKI), but this practice has declined in favor of hemo-
dialysis [1–5]. Peritoneal dialysis is frequently used
in developing countries because of its lower cost
and minimal infrastructural requirements [4–7].
Peritoneal dialysis offers advantages over hemo-
dialysis, such as technical simplicity and lower risk
of bleeding. The gradual and continuous nature of
peritoneal dialysis ensures that disequilibrium syn-
drome is prevented and that cardiovascular stress is
minimal, which reduces the risk of renal ischemia
and fluid-electrolyte imbalance [1–8].
Apart from the classical indications (volume
overload, electrolyte disorders, uremic symptoms,
or acid–base disturbances), peritoneal dialysis can
also be used to maintain volemic control in patients
with congestive heart failure, and control hyper and
hypothermia. In the setting of natural disasters,
when several victims will develop AKI and damage
to infrastructure makes access to clean water
unavailable, peritoneal dialysis is an important
modality [8–12].
Peritoneal dialysis is relatively contraindicated
in patients with recent abdominal surgery, abdomi-
nal hernia, adynamic ileum, intra-abdominal adhe-
sions, peritoneal fibrosis, or peritonitis. Table 1
shows the advantages and disadvantages of perito-
neal dialysis.
It is also true that peritoneal dialysis is not the
most efficient therapy. Since volume and solute
removal is slow and unpredictable, peritoneal dial-
ysis is not as efficient as extracorporeal blood purifi-
cation techniques for the treatment of emergencies
such as acute pulmonary edema or life-threatening
hyperkalemia [9–16]. Another possible limitation of
peritoneal dialysis in AKI is that associated protein
losses may aggravate malnutrition. Protein loss as
high as 48 g/day has been reported, but some reports
document maintenance of serum albumin levels
a
UNESP – Botucatu School of Medicine, University Sao Paulo State
and bUSP – Dentistry College of Bauru, Course of Medicine, Bauru, São
Paulo State, Brazil
Correspondence to Daniela Ponce, Brazil. E-mail: daniela.ponce@usp.br
Curr Opin Nephrol Hypertens 2018, 27:478–486
DOI:10.1097/MNH.0000000000000451

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 Urgent start peritoneal dialysis Ponce et al.

nondiabetic patients. This is easily correctable

KEY POINTS
 Interest in using urgent start peritoneal dialysis to
manage AKI and unplanned CKD stage 5 patients has
been increasing.
 In AKI patients treated by peritoneal dialysis, an
improvement in patient and technique survival over the
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through intravenous or intraperitoneal administra-
tion of insulin.
Peritonitis occurring in patients with AKI using
peritoneal dialysis as a modality of RRT can lead to
very poor outcomes, and older studies report a fre-
quency as high as 40% [2,3,6]. With better catheter

years have been observed. implantation techniques and automated methods,

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the incidence of peritonitis has been reduced and

 Data on unplanned initiation of chronic peritoneal the risk of infection in peritoneal dialysis is similar
dialysis indicate that mortality is the same or even to other forms of extracorporeal blood purification
better than in cases of unplanned initiation of
for AKI [2,3].
hemodialysis.
Previous studies have reported that peritoneal
 Urgent start peritoneal dialysis may be a tool to dialysis can increase intra-abdominal pressure (IAP),
increase the peritoneal dialysis penetration rate among which leads to impaired diaphragm mobilization,
incident patients starting chronic dialysis therapy. and decreased pulmonary compliance and ventila-
 Urgent start peritoneal dialysis is a feasible and well tion, which may cause or worsen respiratory failure
tolerated alternative to hemodialysis and should be [21,22]. However, peritoneal dialysis is seldom the
offered in an unbiased way to all patients without cause of ventilation impairment in patients without
contraindications to peritoneal dialysis starting pulmonary disease. Results from our group suggest
unplanned dialysis. increases in the pulmonary compliance without
changes in IAP in AKI patients treated with perito-
neal dialysis [23].
[17–20]. Protein supplementation, either enteral or
parenteral (1.5 g/kg/day) is recommended for AKI
Evidences and guidelines
patients on peritoneal dialysis [21,22].
The high glucose concentrations in perito- The first question that must be asked is whether
neal dialysate may cause hyperglycemia, even in peritoneal dialysis can provide adequate clearance
in the treatment of AKI patients. Our study group
have demonstrated that critically ill AKI patients
Table 1. Advantages and disadvantages of peritoneal can be successfully treated with peritoneal dialysis
dialysis in AKI [2,10,23–26]. To overcome some of the classic lim-
itations of peritoneal dialysis use in AKI (such as a
Advantages Disadvantages
low rate of ultrafiltration, high chance of infectious
It is simple to initiate It needs an intact and mechanical complications, and no metabolic
It can be initiated anywhere peritoneal cavity with control), we proposed the use of cyclers, flexible
No need for highly skilled adequate peritoneal catheters, continuous therapy (24 h), and high vol-
personnel clearance capacity
ume of dialysis fluid.
No need for vascular access Adequacy is of concern in
No need for expensive hypercatabolic patients We assessed the efficacy of high volume perito-
equipment It is not adequate for neal dialysis (HVPD) in a prospective study of 30
It is biocompatible severe acute pulmonary consecutive AKI patients [10]. The prescribed Kt/V
No need for anticoagulation edema or high value was 0.65 per session, the duration of each
It ensures minimum blood loss potassium life-threatening
session was 24 h, and total dialysate volume was
It does not delay the recovery situations
of renal function Ultrafiltration and 36–44 l/day. HVPD was effective in the correction
It is of special benefit in select clearance cannot be of blood urea nitrogen (BUN), creatinine, bicarbon-
patient populations exactly predicted ate, and fluid overload. Weekly Kt/V was 3.8  0.6
(children, heart failure, Infection (peritonitis) can and the mortality was 57%. Five years later, we
hemodynamic instability, occur
performed another prospective study on 204 AKI
bleeding diathesis, The buffer used is rarely
cholesterol atheroembolic bicarbonate patients treated with HVPD (prescribed Kt/V ¼ 0.60/
disease) There is concern about session), and it presented similar results. Older age,
It is a form of continuous renal protein losses sepsis, low urine output, negative nitrogen balance
replacement therapy It can promote and ultrafiltration lower than 500 ml per three ses-
It is useful in all types of AKI hyperglycemia
sions were identified as risk factors for death [26].
It can impair respiratory
mechanics We concluded that HVPD is effective in selected
patients. However, if after three sessions, ultra-
AKI, acute kidney injury. filtration is low or nitrogen balance is negative,

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 Dialysis and transplantation
substitution or addition of hemodialysis should
be considered.
Dialysis dose adequacy in AKI is a controversial
subject and there are very limited data on the effect
of peritoneal dialysis dose on AKI. Solute clearance
in peritoneal dialysis is limited by dialysate flow,
membrane permeability, and surface area in contact
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with dialysate [2,8–10].
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We performed a trial of 61 septic AKI patients
randomized to receive higher or lower intensity
peritoneal dialysis therapy (prescribed Kt/V of
0.8 vs. 0.5/session). The two groups had similar
mortality after 30 days. We concluded that
increasing the intensity of continuous HVPD ther-
apy does not reduce mortality and does not
improve control of urea, potassium, and bicarbon-
ate levels [27].
According to the International Society for Peri-
toneal Dialysis (ISPD) guidelines, where resources
permit, targeting a weekly Kt/V urea of 3.5 provides
outcomes comparable to that of daily hemodialysis;
targeting higher doses does not improve outcomes.
This dose may not be necessary for many AKI
patients, and targeting a weekly Kt/V of 2.1 may
&&
be acceptable [28 ].
The second question to consider is whether
peritoneal dialysis is comparable to other dialysis
methods in AKI patients. The various modalities
present advantages and disadvantages under spe-
cific circumstances, and these therapies should
therefore be considered more as a continuum than
&&
as a series of modalities to be compared [28 ,29,30].
Phu et al. [15] compared intermittent peritoneal
dialysis with continuous RRT, and demonstrated a
worse outcome in patients treated with peritoneal
dialysis. Such reports should not be underestimated,
although specific factors [such as the use of rigid
catheters, manual exchanges, a too-short dwell time
(15 min), and no dialysis dose quantification] might
be involved.
A randomized study performed by our group in
120 AKI patients compared HVPD vs. daily intermit-
tent hemodialysis [25]. Baseline characteristics were
similar in both groups. Both RRT modalities
achieved metabolic and acid–base control. Mortal-
ity did not differ significantly between the two
groups (58 vs. 53%). Renal recovery was similar
for both modalities, but HVPD was associated with
a significantly shorter time to recovery (7.2  2.6 vs.
10.6  4.7 days).
George et al. [29] performed a randomized study
to compare continuous venovenous hemodiafiltra-
tion (CVVHDF) and peritoneal dialysis in critically
ill patients. No difference was observed in correction
of metabolic parameters and fluid overload. Urea
and creatinine clearances were higher and fluid
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correction was faster with CVVHDF. The mortality
rates in the two study groups were similar.
In another prospective study, we compared the
effect of HVPD against prolonged hemodialysis
(PHD) on AKI patients’ outcome [31]. The PHD
and HVPD groups were similar in sex, severity,
and cause of AKI. Delivered Kt/V and ultrafiltration
were higher in PHD group, and there was no differ-
ence between the two groups in mortality and recov-
ery of kidney function, or there was no need for
chronic dialysis.
A systematic review published by Chionh et al.
[32] concluded that there is, at present, no evidence
to suggest significant differences in mortality
between peritoneal dialysis and extracorporeal
blood purification in AKI.
Recently, we published the largest cohort study
providing patient characteristics, clinical practice,
&&
and their relationship to outcomes [33 ]. Patients
were divided into two groups according to the
year of treatment: 2004–2008 and 2009–2014. A
total of 301 patients were included, though 51 were
transferred to hemodialysis during the study
period. The main causes of technique failure were
mechanical complication followed by peritonitis.
There was a change in technique failure during the
study period; patients treated during 2009–2014
had a relative risk (RR) reduction of 0.86 [95%
confidence interval (CI) 0.77–0.96] compared
with patients treated between 2004 and 2008.
Sepsis and age above 65 years were the others inde-
pendent risk factors for technique failure. There
were 180 deaths (59.8%). Compared with patients
treated from 2004 to 2008, patients treated during
2009–2014 had a RR reduction of 0.87 (95% CI
0.79–0.98). The other independent risk factors for
mortality were sepsis, age above 70 years, and posi-
tive fluid balance. In conclusion, we observed an
improvement in patient survival and technique
failure between the two time periods, even after
correction for several confounders and using a
competing risk approach. We have prepared a flow-
chart of the practical aspects of prescribing, deliv-
ering, and monitoring the HVPD in AKI patients
(Fig. 1).
The role of peritoneal dialysis for unplanned
initiation of chronic dialysis
Although historically peritoneal dialysis was widely
used in nephrology, it has been underutilized in
recent years. Possible reasons for this include the
‘perception’ that it is inferior to hemodialysis,
which is associated with greater technology; the
infectious, mechanical, and metabolic complica-
tions associated with peritoneal dialysis; and the
Volume 27  Number 6  November 2018
 Urgent start peritoneal dialysis Ponce et al.
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FIGURE 1. Flowchart of the practical aspects of prescribing, delivering, and monitoring the high-volume peritoneal dialysis in
acute kidney injury patients.

higher financial reimbursement with hemodialysis of incident patients within the first 2 years of ther-
use [34–37]. apy [37–42]. Some studies have demonstrated better
There is no evidence of the superiority of one results with peritoneal dialysis in young patient
method over the other in regard to general mortality groups with no comorbidities, whereas other studies

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 Dialysis and transplantation
have shown lower mortality after 2 years of dialysis
in elderly patients with comorbidities treated by
hemodialysis [41–45].
Some authors have recently highlighted the
impact that the use of vascular access has in the
mortality of incident patients in hemodialysis
[39,40]. These studies found that central venous
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catheter (CVC) use is associated with reduced sur-
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vival, especially in the first 90 days of RRT. Further-
more, there is a greater risk of bacteremia, sepsis, and
hospitalization in patients using CVC when com-
pared with patients using arteriovenous fistulas or
peritoneal dialysis [44–46].
In this scenario, peritoneal dialysis appears as an
option in unplanned initiation of chronic dialysis.
Advantages of peritoneal dialysis include the lack of
CVC use, thereby preserving vascular access and
residual renal function (RRF), which can reduce
the morbidity and mortality of these patients
[34,45–54].
Ivarsen and Povlsen [44] reviewed the Danish
Nephrology Registry from 2008 to 2011, and
found that 50% of incident patients on RRT started
the treatment in an unplanned manner. In
Brazil, approximately 60% of incident patients on
RRT have no definitive access and need to be
treated through CVC. Unplanned dialysis may
be defined as the start of hemodialysis without
functioning definitive vascular access, that is,
using CVC, or as the start of peritoneal dialysis
less than 7 days after its implantation [44–50].
This situation is common even for patients
who have attended a previous follow-up with a
nephrologist.
Evidences of urgent start peritoneal dialysis
in the world
There are few studies that describe the peritoneal
dialysis method as an immediate treatment option
in patients without functioning vascular access and
only two small studies that compared unplanned
start of hemodialysis vs. peritoneal dialysis [45–47].
These studies showed that there was no significant
difference in the mortality rates between the two
methods.
Lobbedez et al. [46] followed 60 patients who
started unplanned peritoneal dialysis for a 2-year
period. Only two had mechanical complications
after catheter implantation and showed no signifi-
cant difference in mechanical or infectious compli-
cations when compared with patients who had ‘rest
time’ after catheter insertion. There was no signifi-
cant difference in patient survival between the
two unplanned dialysis methods (78.8 vs. 82.9%;
P ¼ 0.26).
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Koch et al. [45] evaluated 57 incident patients in
unplanned hemodialysis and 66 in unplanned peri-
toneal dialysis. Hemodialysis patients had a higher
rate of bacteremia than peritoneal dialysis patients
in the first 6 months of dialysis, which was associ-
ated with the use of CVC as initial access. However,
there was no significant difference in the mortality
rates between the two methods.
Danish data support the idea that early-
unplanned peritoneal dialysis is associated with
lower risk of infectious complications compared
to the incident hemodialysis patients using CVC
[48]. The authors noted that there was a higher
number of cases of catheter-related mechanical
complications in patients starting unplanned peri-
toneal dialysis compared with those who had ‘rest
time’ after implantation of the peritoneal catheter,
although it did not affect the method or patient
survival.
In the United States and Canada, interest has
also recently been renewed in the more urgent
initiation of peritoneal dialysis to avoid temporary
vascular access catheters in patients who are referred
late to a nephrologist. Casaretto et al. [49] and
Ghaffari et al. [50] described in 2012 and 2013,
respectively, that urgent-start peritoneal dialysis
programs require new infrastructure and processes
of care. Most of the patients do not need intensive
peritoneal dialysis (high volume), so intermittent
peritoneal dialysis may suffice. The ability to start
peritoneal dialysis urgently requires expedited
options education, urgent catheter placement,
unique changes in the peritoneal dialysis unit infra-
structure, nursing support (training and staffing),
hospital and dialysis unit administrative support,
and protocol-driven orders. However, less is known
about early technique success after the urgent initi-
ation of peritoneal dialysis.
In 2009, Povlsen [51] described a program for an
unplanned start to assisted automated peritoneal
dialysis (APD). Using a standard prescription of
12 h overnight APD right after peritoneal dialysis
catheter placement, analysis of the data showed that
an unplanned start to APD has no detrimental
effects on patients when compared with patients
who had an elective start, concerning patient and
technique survival, peritonitis-free survival or the
risk of infectious complications, whereas the risk of
mechanical complications and the need for replace-
ment of a displaced or malfunctioning peritoneal
dialysis catheter may have been increased. The
author concluded that an unplanned start to APD
right after peritoneal dialysis catheter insertion is a
feasible, well tolerated, and efficient procedure.
Alkatheeri et al. [52] recently reported a Cana-
dian experience with 30 urgent-start peritoneal
Volume 27  Number 6  November 2018
 Urgent start peritoneal dialysis Ponce et al.

dialysis patients. Three patients (10%) developed
a minor pericatheter leak during the first week
of treatment, which was managed conservatively.
There were no episodes of peritonitis or exit-
site infection during the first 4 weeks after
insertion. Six patients (20%) developed catheter
dysfunction due to migration, which was managed
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by repositioning, without the need for catheter
replacement or modality change. The authors
concluded that urgent-start peritoneal dialysis
is an acceptable and well tolerated alternative
to hemodialysis in patients who need to start
dialysis urgently without an established dialysis
access.

FIGURE 2. Flowchart of the practical aspects of treating patients by urgent dialysis start.

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 Dialysis and transplantation
In 2014, Liu et al. [53] analyzed the costs associ-
ated with urgent-start peritoneal dialysis and hemo-
dialysis over the first 90 days of treatment from a
provider perspective. A survey of practitioners
from five clinics known to use urgent-start perito-
neal dialysis was conducted to provide inputs for a
cost model representing typical patients. The esti-
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mated per patient cost over the first 90 days for
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urgent-start peritoneal dialysis was $16 398 and for
urgent-start hemodialysis was $19 352. The authors
concluded that urgent-start peritoneal dialysis may
offer a cost saving approach for the initiation of
dialysis in eligible patients requiring an urgent start
to dialysis.
Study conducted in China evaluated early com-
plications associated with urgent-start dialysis (96 in
peritoneal dialysis and 82 in hemodialysis) in 178
patients. Patients treated by hemodialysis had sig-
nificantly higher infectious and mechanical com-
plications related to dialysis (2.1 vs. 11% and 3.1 vs.
13.4%, including bleeding, vein thrombosis, and
device expulsion, respectively). At the multivariate
analysis, urgent-start hemodialysis was an indepen-
dent predictor of complications associated with the
dialysis [47].
Urgent start peritoneal dialysis in Brazil
Since July 2014, we have offered peritoneal dialysis
as urgent start for chronic patients. According to the
following flowchart (Fig. 2), in patients without
contraindication to the peritoneal dialysis, the cath-
eter implant was performed and peritoneal dialysis
is initiated within 48 h after Tenckhoff catheter
implantation without previous family and/or
patient training [55–57]. After the training, the
patient was included in the chronic peritoneal dial-
ysis program, with home treatment and monthly
outpatient visits [55].
Table 2. Main studies on urgent-start peritoneal dialysis
Authors Year Study
Ivarsen and Povlsen [44] 2013 Review
Koch et al. [45] 2012 Prospective observational
Lobbedez et al. [46] 2008 Prospective observational
Jin et al. [47] 2016 Prospective observational
Polvsen et al. [51] 2015 Prospective observational
Alkatheeri et al. [52] 2015 Prospective observational
Dias et al. [57] 2016 Prospective observational
Dias et al. [58 ] 2017 Prospective observational
&&
HD, hemodialysis; PD, peritoneal dialysis.
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HVPD was prescribed until metabolic and fluid
control was achieved [10]. After hospital discharge,
patients were treated by intermittent peritoneal
dialysis on alternate days or daily at the dialysis unit
according to the clinical-laboratory evaluation of
the medical team until family training [56,57].
In the first 6 months of the program, data from
35 patients treated by urgent-start peritoneal dialy-
sis were analyzed. Mean age was 57.7  19.2 years,
and diabetes kidney disease was the main cause of
CKD (54.3%). Metabolic control was achieved after
five sessions of HVPD and for the period of inter-
mittent peritoneal dialysis was 11.5 sessions [57].
The percentage of mechanical complication requir-
ing intervention was 17.1% and of peritonitis was
14.2%. Survival after 90 days was 80% and the
impact on the growth of the chronic peritoneal
dialysis program was 41%.
Our first year of experience on urgent start peri-
toneal dialysis was described and recently published
&&
[58 ]. Fifty-five patients were included from July
2014 to July 2015. Uremia was the main dialysis
indication (54.3%). Metabolic and fluid controls
were achieved after five sessions of HVPD and
patients received 11.5  3.1 intermittent peritoneal
dialysis sessions (in 23.2  7.2 days). Peritonitis and
mechanical complications occurred in 14.2 and
25.7% of patients, respectively, within 90 days.
The mortality rate was 20% and technique survival
was 85.7% in the first 90 days. The chronic perito-
neal dialysis program presented growth of 79%.
Table 2 summarizes the main publications of the
last decade on urgent-start peritoneal dialysis.
CONCLUSION
Peritoneal dialysis is a simple, well tolerated, and
efficient way to correct metabolic, electrolytic,
acid–base, and volume disturbances generated by
n Groups Results
– PD vs. HD No difference in patient survival
123 PD vs. HD Higher rate of bacteremia in HD
60 PD vs. HD No difference in patient survival
178 PD vs. HD HD: risk factor for dialysis Complications
- PD urgent-start Survival 90% (3 months) and 80% (1 year)
30 PD urgent-start Absence of early infectious complication
35 PD urgent-start Survival 80% (90 days) and growth
of 41% in chronic PD
51 PD urgent-start Patient survival: 82%; Growth
of chronic PD: 95%
Volume 27  Number 6  November 2018

AKI; it can be used as a RRT modality to treat AKI,
either in or out of the ICU setting. We have recently
observed an improvement in patient and technique
survival over the years even after correction for
several confounders.
Although data on unplanned initiation of
chronic peritoneal dialysis are scarce, they indicate
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that mortality is the same or even better than in
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cases of unplanned initiation of hemodialysis, and
that the number of infectious complications includ-
ing bacteremia appear lessened. It is clear that peri-
toneal dialysis is a suitable method for unplanned
dialysis patients and that acute automated perito-
neal dialysis may help nephrologists to deal with
patients without any permanent vascular access at
dialysis initiation.
To conclude, our observations suggest that the
peritoneal dialysis modality may be a feasible and
well tolerated alternative to hemodialysis not only
in planned, but also in urgent start in the chronic
and acute setting. Moreover, the concept of
unplanned start on chronic peritoneal dialysis
may be a tool to increase the peritoneal dialysis
penetration rate among incident patients starting
chronic dialysis therapy. Urgent-start peritoneal
dialysis is an option and should be offered in an
unbiased way to all patients without contrain-
dications to peritoneal dialysis starting unplanned
dialysis.
Acknowledgements
We would like to thank Professor Pasqual Barretti and Dr
Dayana Bittencourt Dias for their assistance with the
study.
Financial support and sponsorship
None.
Conflicts of interest
All authors (DP, AMB, and ALB) declare that there is no
conflict of interest.
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& of special interest
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Volume 27  Number 6  November 2018