1. Urgent-Start & P eritoneal Dialysis : An Alternative Approach DSI Brandon, Florida Cristina Balsera MD, Medical Director Janet Majirsky RN, PD Coordinator Latasha Malone PD RN

2. Objectives ● Review some of literature on D ia lysis modalities. ● Review the alternative approach we have taken in implementing a Peritoneal Dialysis Urgent-Start Program (PD- USP) in our clinic. ● State the necessary for a successful PD program. ● Think possibility of P D more often & as the first option ; in a Step- Process.... a. PD b. Transplant c. HHD d. IC-HD * No Treatment OBJECTIVES

3. Purpose ● History of missed opportunity for use of PD as an option. ● Making PD available in the urgent setting; not defaulting to Hemodialysis (HD). ● Establishing & growing a a PD program. ● Avoid Central Venous Catheters (CVC). *

4. 1) IF YOU HAD TO BE ON DIALYSIS...... WOULD CHOSE PD AS THE FIRST CHOICE MODALITY ? FUN FACTS; TRUE OR FALSE...... 2) RESIDUAL URINE OUTPUT IN DIALYSIS PATIENTS OF JUST A CUP IS NOT IMPORTANT. 3) AV FISTULA HAS LONGER SURVIVAL THAN PD CATHETER. 4) USING A CENTRAL VENOUS CATHETER (CVC) HAS NO EFFECT ON MORTALITY RISK AS LONG AS IT IS REMOVED WITHIN FIRST 30 DAYS. 5) PD CATHETER INFECTION IS MORE COMMON THAN HD ACCESS INFECTION. 6) DOES SIZE MATTER?...........SMALLER PD CENTERS (<25 pts) HAVE MORE 1 TO 1 CARE AND IMPROVED PD PATIENT OUTCOMES.

5. 2) RESIDUAL URINE OUTPUT BEYOND 250CC/DAY IN DIALYSIS PATIENTS IS NOT IMPORTANT. Bargman JM, Relative contribution of residual renal function and peritoneal clearance to adequacy of dialysis: a reanalysis of the CANUSA study. J Am Soc Nephrol2001;12 : 2158-62. "Every 250 mL of urine output daily showed a 36% reduction in mortality." Paniagua R, et al. Effects of increased peritoneal clearances on mortality rates in peritoneal dialysis: ADEMEX, a prospective, randomized, controlled trial. J Am Soc Nephrol2002;13 : 1307-20. "For each 10 L/1.73 m2 weekly increment in RRF, an 11% decrease in the RR of death was observed" Termorshuizen Relative contribution of residual renal function and different measures of adequacy to survival in hemodialysis patients: an analysis of the Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD)-2. J Am Soc Nephrol2004 ; 15:1061 -70. Each weekly increase of 1 unit in renal Kt/V was associated with a RR for death of 0.44........the effect of delivered Kt/V on mortality was strongly dependent on the presence of RRF.

6. 3) AV FISTULA HAS LONGER SURVIVAL THAN PD CATHETER? Y S KimY S Kim, Comparison of peritoneal catheter survival with fistula survival in hemodialysis.Peritoneal dialysis international: journal of the International Society for Peritoneal Dialysis 02/1995; 15(2):147-51. pp.147-51Peritoneal dialysis international: journal of the International Society for Peritoneal Dialysis TimePERITONEAL CATHETERAV FISTULA 1ST YEAR84%74% 2ND YEAR73%61% 3RD YEAR63%48%

7. Coentrao, L. et al; Effects of starting HD with an AVF or CVC compared to PD; a retrospective cohort study. BMC Nephrology 2012 Aug 23;13:88. total of 152 patients; PD= 42 HD-AVF= 59 HD-TTC= 51 4) USING A CENTRAL VENOUS CATHETER (CVC) POSES NO MORTALITY RISK AS LONG AS IT IS REMOVED WITHIN 30 DAYS.

8. 5) PD CATHETER INFECTIONS ARE MORE COMMON THAN HD ACCESS INFECTIONS. Conclusion This study provides evidence that dialysis modality is not an independent predictor of overall infection rate in a cohort of incident dialysis patients but is a strong predictor of the type of infection and the difference in risk during the first 90 d of dialysis. Patients should be informed that there is a high risk for bacteremia when starting dialysis using an HD catheter and that the risk of peritonitis in association with a PD catheter during the first 3 mo of PD is considerably lower than the risk for bacteremia with an HD catheter. Choice of modality should not be dictated by the concern of higher infection rate on PD; rather, it should be based on the individual patient’s preference. Aslam*Aslam*, N. Comparison of Infectious Complications between Incident Hemodialysis and Peritoneal Dialysis Patients CJASN November 2006vol. 1 no. 6 1226-1233

9. 6) DOES SIZE MATTER?...........PD CENTER SIZE IN RESPECT TO PATIENT OUTCOMES? Afolalu BAfolalu B, Technique failure and center size in a large cohort of peritoneal dialysis patients in a defined geographic area. Perit Dial Int. 2009 May-Jun;29(3):292-6. Perit Dial Int. OBJECTIVE: To examine the relationship between center size and PD technique failure. DESIGN: Retrospective review of NW1 database. PATIENTS AND METHODS: 5003 incident PD patients between 2001 and 2005 in 105 PD units were included. Patients were grouped into 2 based on center size: group A, patients in units with 25 patients. Outcome measures were analyzed for the first and second years of PD therapy. Patients were censored at transplantation, transfer to HD, or death. RESULTS: Technique failure rates were significantly higher in group A for year 1 (odds ratio: 1.36, p = 0.005) and for year 2 (odds ratio: 1.35, p = 0.03). Mortality rates were not statistically different between the 2 groups. CONCLUSION: Technique failure was higher in units with 25 patients. There was no difference in mortality between the 2 groups. The majority of patients in NW1 receive care in small units.

10. 6) DOES SIZE MATTER?...........PD CENTER SIZE IN RESPECT TO PATIENT OUTCOMES? DOES EXPERIENCE WITH PD MATTER? Beth Piraino*, Perit Dial Int May-June 2009 vol. 29 no. 3 256-261 Beth Piraino* Huisman RM, Patient-related and centre-related factors influencing technique survival of peritoneal dialysis in The Netherlands. Nephrol Dial Transplant. 2002 Sep;17(9):1655-60. Huisman RM Nephrol Dial Transplant. Low technique survival rates occurred mainly in centres with less than 20 patients on PD: relative risk for technique failure 1.68 as compared with larger centres. Plantinga Plantinga Association of peritoneal dialysis clinic size with clinical outcomes. Perit Dial Int. 2009 May-Jun;29(3):285-91. Perit Dial Int. Conclusion PD patients that are treated at clinics with greater numbers of PD patients may have better outcomes in terms of technique failure and cardiovascular morbidity. PD clinic size may act as a proxy of greater PD experience, more focus on the modality, and better PD practices at the clinic, resulting in better outcomes.

12. URGENT START PD............ WITHIN 2 WEEKS

14. INTRA-ABDOMINAL PRESSURE

15. Ghaffari 1 Ghaffari 1 AJKD Vol (59) 2012 *

16. Casaretto et al; 2 Casaretto, A., Rosario, R., Kotzker, W., Rosario-Pagan, Y., Groenhoff, C., Guest, S. Urgent-Start Peritoneal Dialysis: Report from a U.S. Private Nephrology Practice. Advances in Peritoneal Dialysis, Vol 28: 102- 105, 2012. page page 104 paragraph 4 second column *

17. Balsera et al; ● Different from Ghaffari and Casaretto ; both used the cycler for Intermittent Automated Peritoneal Dialysis (IPD). ● O ur program, we elected to do Daily Ambulatory Peritoneal Dialysis....although, interestingly, they do not ambulate.......... YET. *

18. Method 1/2 ● Incorporated Chronic Kidney Disease (CKD) education with the PD-USP population. ● PD catheters were all surgically placed within 72 hours; 7 laparoscopic tech 3 open technique ● Post-op day (POD)#1 : All patients were started with a Preliminary Prescription Plan (PPP). ● 7/10 starts were done at our outpatient dialysis clinic. ● 3 /10 starts where started first 24-hrs in hospital setting. ● Supine ● Low volume ● No patients had critical volume overload issues. All patients on high dose diuretics (160-320mg of furosemide +/-metolazone). *

19. Method 2/2 ● S tarting point for PD-USP dialysis or The Preliminary Prescription Plan (PPP) Week 1;(supine) 3-5 c onsecutive days at outpatient facility clinically judged by disappearance of their presenting gross uremic symptoms. Week 2; (supine) convert to intermittent M-W-F therapy at outpatient facility. Week 3;CAPD training with desired volume prescription. Week 4 ;CCPD cycler training done at home + home visit. *

20. Alternative PD-USP Results 1/3 ● 19 total PD starts at our clinic in 2012 ;10 (53%) were PD-USP. ● 2/10 (20%) were true late referrals. ● * 8/10 (80% ) actually were followed at kidney clinic, attended CKD- 4 education class. Decided on PD as a modality choice, but....... *

21. Alternative PD-USP Results 2/3 ● Reported problems; > 6 months out. minor pericatheter leak = 1 remains functional and has healed well. ( patient ambulated to rest room during week 1 prior to draining). infections exit site =none tunnel = none peritonitis = none Catheter Dysfxn = 1 revision at 6 months. 1 migration at 3 mo. patient satisfaction= 100% including patients who did not remain on PD... *

22. Alternative PD-USP Results 3/3 ● 7 /10( 7 0%) PD-USP patients remained on therapy at 4 months vs. 6/9 (66%) non-urgent starts. ● The 3 patients lost in USP had no cause related to urgent implementation... Patient 1- immediate PD-related hydrothorax/retried 1 mo. & failed; Hospice 2nd option. Patient 2- at week 3 transferred to HD. psychosocial issue 84 yr old female felt it would be too much for her, as she lives alone with little support.She also stopped HD and chose NO TX. Patient 3- inexperienced hospital staff with PD and Urgent/acute starts. Presents at clinic the Tuesday before T hanksgiving......... (infrastructure issue). *

23. Alternative PD-USP Procedure Description ● There 1 manual connection. ● A flush before fill approach with a 2 liter Ultrabag hangs from a spring scale. ● One liter is infused at a time. The patient dwells x 3 hours. ● The second L iter remaining in the bag is kept warm by way of a heating pad. ● During first 2 weeks patients are supine & watch the Ultrabag video in preparation for week 3 training. ● P atients are ass essed daily by our PD Nurse to report if any changes to PPP may need to be made. ● Physician sees patient in clinic within first 5 days.(optional) *

24. Alternative PD-USP Discussion 1/2 ● Variety/ flexibility of urgent start programs ; Dr Ghaffari & Casaretto implemented intermittent CCPD. We started with daily CAPD, followed by intermittent, and finally graduated to the cycler. ● By providing incremental dialysis with a PPP no significant complications were noted. ● T ime management was not an issue ; our 2 nurses made the choice to do manuals; while still running the clinic with training other patients, running labs, and handling 18-27 PD patients. ● Like Dr Ghaffari and Casaretto, we found that 2 nurses is imperative to incorporating an urgent start program. *

25. Alternative PD-USP Discussion 2/2 ● Experience center vs inexperienced; changing the infrastructure of your region/networking * Motivated Nephrologist access surgeons & interventional radiologist DEDICATED PD STAFF/ UNIT Community Hospitals & Community Nephrologists

26. Conclusion ● We discovered that although we have educated CKD patients, many variables can lead to untimely preparation for our established patients. ● PD First is a viable option even when patients present late. ● PD can be done effectively in an urgent setting ; eliminating the myth of perceived high rate of complications,....in addition to avoiding extra procedures, health care cost, and hospitalization while providing patient satisfaction and control of their therapy. *

27. Return to our objectives........ ● Hopefully now you are able to: ● Be familiar with the referenced Literature on PD Urgent-St art s & their methods and be able to compare the alternative approach we have implement ed. ● Understand that whichever method used; complication rate is not an issue and should not deter Nephrologist from offering urgent starts in their practice. ● Know that it requires investment & commitment to implement PD-U S P. *

28. Cristina Balsera MD Thank you cbalsera@brandonkidneyclinic.com Keep it home..... *

29. References Bargman JM, Relative contribution of residual renal function and peritoneal clearance to adequacy of dialysis: a reanalysis of the CANUSA study. J Am Soc Nephrol2001;12 : 2158-62. Paniagua R, et al. Effects of increased peritoneal clearances on mortality rates in peritoneal dialysis: ADEMEX, a prospective, randomized, controlled trial. J Am Soc Nephrol2002;13 : 1307-20. Termorshuizen Relative contribution of residual renal function and different measures of adequacy to survival in hemodialysis patients: an analysis of the Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD)-2. J Am Soc Nephrol2004 ; 15:1061 -70. *

30. References Ghaffari, A. Urgent-Start Peritoneal Dialysis: A Quality Improvement Report. Am J Kidney Dis. 2012; 59(3) pp:400-408 Casaretto, A., Rosario, R., Kotzker, W., Rosario-Pagan, Y., Groenhoff, C., Guest, S. Urgent-Start Peritoneal Dialysis: Report from a U.S. Private Nephrology Practice. Advances in Peritoneal Dialysis, Vol 28: 102-105, 2012. page page 104 paragraph 4 second column. Technique failure and center size in a large cohort of peritoneal dialysis patients in a defined geographic area. Afolalu B, Troidle L, Osayimwen O, Bhargava J, Kitsen J, Finkelstein FO.Perit Dial Int. 2009 May-Jun;29(3):292-6.Afolalu B Troidle LOsayimwen OBhargava JKitsen JFinkelstein FOPerit Dial Int. Association of peritoneal dialysis clinic size with clinical outcomes.Plantinga LC, Fink NE, Finkelstein FO, Powe NR, Jaar BG.Perit Dial Int. 2009 May-Jun;29(3):285-91.Plantinga LCFink NEFinkelstein FOPowe NRJaar BGPerit Dial Int. DOES EXPERIENCE WITH PD MATTER? Beth Piraino*, Perit Dial Int May-June 2009 vol. 29 no. 3 256-261 Beth Piraino* Comparison of Infectious Complications between Incident Hemodialysis and Peritoneal Dialysis Patients Nabeel Aslam*, a,CJASN November 2006vol. 1 no. 6 1226-1233Nabeel Aslam* a *

31. Bertolt Brecht, Life of Galileo "The aim in science is not to open the door to infinite wisdom, but to set a limit of infinite error."

32. Dr. Evert Dorhout-Mees; The Netherlands...I WILL ADVISE YOU TO LOOK AT THE PATIENT,..

33. Dr. Claudio Ponticelli

34. words of wisdom from Nephrology pioneers...