key: cord-0883204-57i4q1yy
authors: Srivatana, Vesh; Shankaranarayanan, Divya; Neupane, Sanjay P.; Varma, Elly; Shimonov, Daniil; Gerardine, Supriya; Bhasin, Aarti; Lamba, Perola; Leuprecht, Lorenz; Salinas, Thalia; Afaneh, Cheguevara; Bellorin-Marin, Omar E.
title: Peritoneal Dialysis for Acute Kidney Injury during the COVID-19 Pandemic in New York City
date: 2020-07-23
journal: Kidney Int Rep
DOI: 10.1016/j.ekir.2020.07.017
sha: cbcf7bd318af69063676191ef8247856d46cd40e
doc_id: 883204
cord_uid: 57i4q1yy

nan

in the number of patients requiring Renal replacement Therapy (RRT), high rate of clotting in Continuous Renal Replacement Therapy (CRRT) circuits, limited dialysis supplies and shortages of dialysis staff due to illness or quarantine [1] [2] [3] [4] [5] . This created an opportunity to utilize peritoneal dialysis (PD) for acute kidney injury (AKI).

Patients treated with acute PD (AKI-PD) at our New York City hospital from 4/1/2020 to 4/30/2020 were retrospectively analyzed. Overall, 40 patients were screened and 11 were suitable for AKI-PD. AKI was defined as any patient with Acute Kidney Injury/Network (AKIN) stage 1 or greater; all patients in the cohort were AKIN stage 3. The nephrology consultant determined the need and timing for RRT initiation based on usual clinical indications. These patients were then referred to the AKI-PD team composed of an attending nephrologist and surgeon to determine candidacy for AKI-PD. Patients were excluded if they had significant abdominal surgical scars, uncorrected hernias, high likelihood of prone ventilation, active gastrointestinal issues such as ileus or small bowel obstruction, or were on dual antiplatelet therapy with aspirin and clopidogrel. Body Mass Index (BMI) greater than 30 kg/m 2 was a relative contraindication and candidacy discussed on a case by case basis. All 11 patients underwent bedside placement of a swan neck double-cuff Tenckhoff tunneled PD catheter, with additional purse-string suture at the surgeon's discretion. Bedside placement of the catheters by a surgeon and an assistant alone was chosen to limit COVID-19 exposure of additional healthcare professionals. All patients received a bowel regimen to ensure 1-2 bowel movements daily, the choice of laxative was at the discretion of primary treating service.

The median age of the cohort was 65 years (Interquartile range [IQR] 52-76); predominantly (91%) male (Table 1) . Median BMI was 26 kg/m 2 (IQR 23-30). Two patients had history of chronic kidney disease (CKD). One patient had a history of abdominal surgery.

Median Sequential Organ Failure Assessment score (SOFA) score was 9 (IQR 6-10). All patients were on invasive mechanical ventilation and 45% required vasopressors. Acute Respiratory Distress Syndrome (ARDS), as defined by the Berlin criteria 6 , was mild in 73% and moderate in 27%. Median baseline creatinine was 1mg/dl (IQR 0.9-1.44). Median time from admission to the development of AKI was 1 day (IQR 0-3). Median peak creatinine was 6.6 mg/dl (IQR 5.6 -8.15) and median daily urine output (UOP) was 230ml (IQR 150-392) at initiation of RRT. In 73% of the patients, CRRT or intermittent hemodialysis (HD) was used as the initial RRT modality and switched to PD at a later date; time interval between discontinuation of CRRT/HD and initiating PD was less than 24 hours in these patients. CRRT circuit clotting was the primary reason for switching to PD in 2 patients.

At the time of PD initiation, median blood urea nitrogen (BUN) was 99mg/dl (IQR 70-118), creatinine 6mg/dl (IQR 4.7-6.4), and serum albumin 1.6g/dl (IQR 1.5-1.7). Six patients had serum potassium > 5mmol/dl and 1 had greater than 6 mmol/dl. Median time for potassium levels to return to normal range was 2 days (IQR 0-3) using PD combined with medical therapies, including oral potassium binder, insulin, and diuretics in these 7 patients. Median time for correction of metabolic acidosis was 3 days (IQR 0-4). While on PD, the median daily UOP was 497ml (IQR 137-1612) and median daily ultrafiltration (UF) was 681ml (IQR 262-1351).

Seven of the 11 patients were continued on diuretics. At 30 days, median BUN, creatinine and albumin were 44 mg/dl (IQR 24-61), 1.9 mg/dl (IQR 1.3-3.1) and 2.1g/dl (IQR 1.4-2.6) respectively.

The median time from diagnosis of AKI to PD catheter insertion was 5 days (IQR 2-14) .

The time from PD catheter placement to initiation of PD was less than 24 hours in 55% and between 24 to 48 hours in the remainder. The decision to start on continuous ambulatory peritoneal dialysis (CAPD) or automated PD (APD) was based on the availability of cyclers and nursing familiarity with each modality. Five of the 6 patients who were started on CAPD tolerated an initial dwell volume of 2000mL with no leaks; the 6th patient was switched to APD when a cycler was available. For those on CAPD the initial prescription was 2000mL every 6 hours. In the 5 patients initiated on APD, the initial dwell volume was between 1000-1500mL and total therapy volume of 8000mL to 10,500mL over 12 hours total (1000mLx8 or 1500mLx7) which is in keeping with recently published acute PD protocols. 7 In four patients the abdomen was empty while off APD, however, one patient was treated with consecutive 12-hour treatments due to hyperkalemia until the potassium normalized. In terms of ventilator parameters, plateau pressures were less than 30cm H 2 O in all patients, except one patient with moderate-to-severe ARDS with plateau pressure of 33 to 38 cmH 2 O. No changes in plateau pressure was noted while on PD for any patients and none of the patients were in prone position while on PD.

The median hospital length of stay was 42 days (IQR 19-70). Four patients (36%) died and the median time from AKI to death was 17 days (IQR 14-22). Six patients had renal recovery defined as dialysis independence as determined by the treating nephrologist. Median time from AKI to renal recovery was 37 days (IQR 25-41). One patient was discharged and remained dialysis dependent. One patient who recovered renal function remains hospitalized at the time of writing.

Regarding PD catheter outcomes, patients were treated with PD for a median duration of 14 days (IQR 10-20). Ten catheters (91%) remained functional during the duration of the follow up. One patient was switched to CRRT due to primary PD catheter non-function; this patient had BMI greater than 35 kg/m2 and a history of appendectomy. There was one episode of leak which was resolved with temporary reduction of dwell volume and the patient was able to continue PD.

There were no episodes of peritonitis observed. One patient was switched to HD at the time of discharge to a skilled nursing facility that did not have PD available. One patient was converted to CRRT prior to death at the discretion of the intensivist though the PD catheter was functional.

Two patients required CRRT/HD supplementation for variable UF and active gastrointestinal bleeding but were able to return to PD prior to renal recovery.

In our cohort, 6 patients (54%) of the patients had renal recovery with a median follow up of 35 days. Remarkably, these 6 patients survived their acute critical illness, and were all subsequently discharged. We hypothesize that preservation of residual renal function utilizing PD may have contributed to the high rate of renal recovery observed 8 . Two of our patients converted from CRRT to PD due to repeated filter clotting. We did not observe any bleeding complications in our cohort, though we had the benefit of experienced operators. We hypothesize that hypercoagulable COVID-19 patients may potentially have a lower risk of bleeding complications and consequently be excellent candidates for PD. The PD prescriptions utilized were variable, but each able to control metabolic parameters and provide adequate volume control.

The primary limitation of our study is the small number of patients. However, this cohort represented about 20% of all patients requiring RRT in our hospital at the peak of the demand.

Our report demonstrates the value of even a modest amount of PD in a time of crisis to be able to provide RRT for all patients who need it. Additionally, although all patients were mechanically ventilated and critically ill, there is a potential for selection bias resulting in the high observed rate of renal recovery. Long term outcome studies in a larger cohort are needed to confirm these findings. In summary, the practical utility and potential for a higher rate of renal recovery combines for an attractive and unique rationale for the use of AKI-PD in the critically ill COVID-19 population.

Impending Shortages of Kidney Replacement Therapy for COVID-19 Patients

Clinical Characteristics of Covid-19 in

Acute Kidney Injury in Patients Hospitalized with Covid-19

Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study. The Lancet

Case 17-2020: A 68-Year-Old Man with Covid-19 and Acute Kidney Injury

The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material

Peritoneal Dialysis for Acute Kidney Injury Treatment in the United States: Brought to you by the COVID-19 Pandemic

Predictors of the rate of decline of residual renal function in incident dialysis patients

We would like to acknowledge the extraordinary effort of our nurses and staff who are on the front lines of the COVID-19 crisis each day. Your patients and doctors thank you.

Vesh Srivatana reports speaker fees from Baxter International.

Supplementary Information is available at KI Report's website.

 Table 1 .