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Acute Start Peritoneal Dialysis During the COVID-19 Pandemic: Outcomes and Experiences

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Acute Start Peritoneal Dialysis During the COVID-19 Pandemic: Outcomes and Experiences RESEARCH LETTER www.jasn.org Acute Start Peritoneal Dialysis during the COVID-19 Pandemic: Outcomes and Experiences Osama El Shamy ,1 Niralee Patel,1 Mohamed Halim Abdelbaset,1 Linda Chenet,1 Joji Tokita,1 Robert Lookstein,2 David S. Lee,3 Noah A. Cohen,3 Shuchita Sharma,1 and Jaime Uribarri 1 1Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York 2Division of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York 3Division of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York JASN 31: 1680–1682, 2020. doi: https://doi.org/10.1681/ASN.2020050599 Hospitalized patients with AKI rarely describes the implementation process numbers to those reported in a case series initiate peritoneal dialysis (PD) because and this program’s outcomes. of 30 patients from Brazil, in which 57% of of the limited availability of surgeons or We inserted 21 PD catheters in 21 pa- 30 patients with AKI died and 23% had interventionists with experience in placing tients. Table 1 shows patient demographics renal recovery, although only 7% remained PD catheters as well as of nephrologists and and characteristics: mean age (62 years), on dialysis after 30 days.6 It is important to trained nursing staff who can manage and sex (57% men), race (14% white, 52% note that the Brazilian patients were on perform PD. Moreover, to minimize the black, and 33% Hispanic), mean weight high-volume PD, and the study took place incidence of mechanical complications, and body mass index (BMI; 95 kg and before the COVID-19 pandemic, which pericatheter leaks, and infection, the Euro- 33 kg/m2), and comorbidities (diabetes may affect renal recovery rates. pean Best Practice Guidelines for PD rec- mellitus, 12 patients [57%]; hypertension, Table 2 shows baseline laboratory ommend not using PD catheters until 11 patients [52%]). Four had a history of data, both mean values from day 3 of 2 weeks after insertion,1 which is not abdominal surgery. At the time of catheter PD onward and the difference between possible in the inpatient setting where placement, 16 (76%) were receiving me- values on the day before initiating PD there may be an urgent need for dialysis. chanical ventilation, with mean ventilator and the day of PD termination. The The slow clearance of PD, a gentle form settings of tidal volume of 402 ml, respira- mean change in potassium was consis- of RRT, also makes it impractical in these tory rate of 29 breaths per minute, fraction tent with a decrease of 0.7 meq/L; serum circumstances. As a result, patients with of inspired oxygen of 53%, and positive bicarbonate increased by 2.1 meq/L, and serum albumin levels were unchanged. AKI usually undergo placement of a cen- end expiratory pressure of 7 cm H2O. However, there was a greater decrease tral venous catheter to start hemodialysis Patients with obesity are a high-risk in BUN in the last day of treatment or continuous RRT (CRRT) instead. group to treat for COVID-19.2 More- compared with the mean of day 3 on- This process runs smoothly under nor- over, hypertension and diabetes mellitus ward (215.3 versus 29.9 meq/L, respec- mal circumstances, when demand for are both known risk factors for poor out- tively). Factors that may have blunted an RRT is not at the unprecedented levels ex- comes in patients with COVID-19.3,4 In otherwise even larger drop in BUN in- perienced in New York City hospitals dur- addition, COVID-19 acute respiratory cluded incremental increases in average ing the novel coronavirus disease 2019 distress syndrome is associated with pro- protein intake in both tube and oral (COVID-19) pandemic. However, be- longed mechanical ventilation and a feeds (as patients’ BUN values decreased cause of such challenges as staffing issues, high short-term mortality.5 supply shortages, and dialysis circuit clot- To the date of submission, nine ting during this health care crisis, many (43%) of the patients have died. Of the hospitals turned to acute PD to augment 12 who remained alive, 3 (25%) had re- Published online ahead of print. Publication date available at www.jasn.org. their RRT capacity. nal recovery, 2 (17%) were discharged At the Mount Sinai Hospital in New on RRT, and 7 (58%) remained hospital- Correspondence: Dr. Osama El Shamy, Division of Nephrology, Icahn School of Medicine at Mount York City, as demand for RRTmore than ized on RRT. The high proportion of pa- Sinai, 1 Gustave L Levy Place, PO Box 1243, New doubled during the COVID-19 pan- tients with risk factors helps explain why York, NY 10029. Email: [email protected] demic, an acute PD program was swiftly so many died during their hospitaliza- Copyright © 2020 by the American Society of planned and implemented. This article tion. There are some similarities in our Nephrology 1680 ISSN : 1046-6673/3108-1680 JASN 31: 1680–1682, 2020 www.jasn.org RESEARCH LETTER Table 1. Demographics, baseline icodextrin and had no further glycemic time was 86 minutes; drain time was characteristics, and PD catheter issues. 30 minutes; and the ultrafiltration rate outcomes Prior to PD initiation, 12 patients re- was 405 ml/d, with a mean urine output Characteristic Outcome quired hemodialysis, continuous veno- of 622 ml/d. The average protein intake Age, yr 62 (IQR, 53–67.5) venous hemofiltration (CVVH), or was 75.4 g/d. Men 12 (57%) both. Nineteen central venous catheters We calculated weekly Kt/V values for Race were placed for 21 hemodialysis and 6 eight patients from 16 urine and 17 di- White 3 (14%) CVVH treatments. Mean times on he- alysate samples, finding a mean total Black 11 (52%) modialysis and CVVH were 1.9 and weekly Kt/V of 2.18, meeting the Inter- Other (Latino) 7 (33%) 57 hours, respectively. Mean blood flow national Society for Peritoneal Dialysis Weight, kg 95 (IQR, rate was 251.2 ml/min. Nine hemodial- recommendation of 2.10 Kt/V or – 79 114.5) ysis treatments (43%) were terminated greater.8 The authors recognize, how- BMI, kg/m2 33 (IQR, early because of hypotension or access ever, that urea clearance may be a sub- 26.5–40.9) 9 Past medical history clotting issues. Severe hypercoagulability optimal marker for dialysis adequacy. A Diabetes mellitus 12 (57%) is a well documented complication of comparison of hemodialysis needs before Hypertension 11 (52%) COVID-19, with patients demonstrat- and during acute PD is in Supplemental Abdominal surgery 4 (19%) ing markedly elevated fibrinogen and Material, section 5. COVID-19 positive 20 (95%) D-dimer plasma levels.7 Only one patient The acute PD program successfully Ventilated 16 (76%) required another form of RRT during helped mitigate the demand for RRT Catheter insertion time on PD. Acute PD provided an alter- during the COVID-19 pandemic’s Surgery 16 (76%) native form of RRT that bypassed the peak at Mount Sinai Hospital. It was a Interventional radiology 5 (24%) issue of hypercoagulability. challenging process that required im- Time to catheter use, h On average, six patients were on PD plementation of a treatment protocol, ,6 2 (10%) per day; mean PD duration was 8 days. collaboration with interventional radiol- 6–12 8 (38%) 12–24 11 (52%) For catheter placement, 76% were ogy and surgery for catheter placement, Complications placed surgically at the bedside, and and hiring of additional nursing staff. We Mechanical flow 4 (19%) 24% were placed percutaneously in the were able to provide our patients with disruption interventional radiology suite. Eleven this life-sustaining treatment and aid in Scrotal edema 3 (14%) patients had no PD-related complica- their care. We hope that our experience Pericatheter leak 2 (10%) tions, and three developed scrotal demonstrates the feasibility of initiating Peritonitis 1 (5%) edema. Four had mechanical flow dis- an acute PD program during a health No complications 11 (52%) ruptions; tidal PD may have helped re- care crisis that results in increased de- IQR, interquartile range. mediate this issue in two patients, mand for RRT. whereas the other two, both of whom while on dialysis) and the initiation of had a past abdominal surgery, were un- intravenous methylprednisolone in able to start PD. A limitation of bedside METHODS three patients. Medical management catheter placement is the inability to lyse largely maintained normoglycemia, al- intra-abdominal adhesions or perform From April 8, 2020 to April 26, 2020, we though one patient who developed se- an omentopexy, if needed. Despite the considered PD catheter placement for vere hyperglycemia on day 3 of PD was initiation of PD ,24 hours after catheter patientswhorequiredRRTandmet converted to a prescription of exclusively placement in a cohort with a high BMI, one of the following criteria, regardless only two patients had a pericatheter leak. of their COVID-19 status, weight, BMI, One leak resolved after 48 hours with or past medical history: AKI necessitat- Table 2. Laboratory data prior to and lowering of the fill volume to 0.75 L be- ing initiation of RRT; AKI already on changes achieved while on PD fore gradually increasing it; the other de- RRT, with an expected prolonged hospi- Pre-PD 2 veloped on day 19 of PD treatment and tal stay; or AKI on RRT with multiple Serum Laboratory Mean a Post-PD resulted in treatment termination. One dialysis circuit clotting issues. Prior ab- Potassium, meq/L 4.7 20.7 patient developed bacterial peritonitis, dominal surgery was not an absolute BUN, mg/dl 129.2 215.3 which responded to intraperitoneal contraindication. Prone patients were Creatinine, mg/dl 8.2 21.0 antibiotics.
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