Division of Nephrology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA.
Am J Kidney Dis. 2012 Mar;59(3):400-8. doi: 10.1053/j.ajkd.2011.08.034. Epub 2011 Oct 22.
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.
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.
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.
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.
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.
This is a single-center nonrandomized study with a small sample size.
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.
与血液透析相比，腹膜透析（peritoneal dialysis，PD）是一种具有成本效益且以患者为中心的选择，具有早期生存优势，但美国只有 7%的终末期肾病患者接受 PD。PD 利用率低的部分原因是肾病医生对在需要紧急开始透析的肾衰竭患者中直接开始 PD 不熟悉。
质量改进报告。
单中心研究，18 例因慢性肾脏病 5 期而紧急就诊且无透析方式计划的患者被提供 PD 作为初始透析方式。同时，纳入 9 例非紧急开始 PD 治疗的患者作为对照组。
制定了紧急开始 PD 计划，以支持和规范对无透析方式计划的患者开始 PD 的流程。这包括快速 PD 通路建立、PD 护理教育和行政支持。为方式选择、初始处方以及并发症的预防和管理制定了标准化方案。
比较紧急开始 PD 和非紧急开始 PD 组的短期（90 天）临床结局（Kt/V、血红蛋白、铁饱和度、甲状旁腺激素、磷、钙和白蛋白）和并发症（腹膜炎、出口部位感染、漏液和导管功能障碍）。
除校正后血清钙水平外，两组在所有参数的短期临床结局均相似，校正后血清钙水平在紧急开始 PD 组较低（P=0.02）。两组间腹膜炎、出口部位感染、导管相关并发症和其他并发症相似，但紧急开始 PD 组的轻微漏液更多。
这是一项单中心、非随机研究，样本量小。
我们的结构化方案表明，在没有透析方式计划的肾衰竭患者中开始 PD 是安全且可行的。本报告中列出的步骤可为创建当地紧急开始 PD 方案提供框架。
