Year : 2020 | Volume
: 38 | Issue : 1 | Page : 11--12
Peritoneal dialysis – ideal renal replacement therapy during coronavirus (COVID-19) pandemic
Jeethu Joseph Eapen
Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
Dr. Jeethu Joseph Eapen
Department of Nephrology, Christian Medical College, Vellore - 632 004, Tamil Nadu
Peritoneal dialysis has an important role to play in the ongoing coronavirus pandemic. It can help in maintaining social distancing goals in dialysis patients and hence should be considered as first line renal replacement therapy (RRT) in all incident ESRD patients. There is emerging interest in the role of PD for the treatment of Acute Kidney Injury especially in the setting of overburdened hemodialysis/CRRT services in the ICU. This article discusses the role of PD in managing critically ill COVID patients.
|How to cite this article:|
Eapen JJ. Peritoneal dialysis – ideal renal replacement therapy during coronavirus (COVID-19) pandemic.Indian J Perit Dial 2020;38:11-12
|How to cite this URL:|
Eapen JJ. Peritoneal dialysis – ideal renal replacement therapy during coronavirus (COVID-19) pandemic. Indian J Perit Dial [serial online] 2020 [cited 2023 Mar 31 ];38:11-12
Available from: http://www.ijpd.org.in/text.asp?2020/38/1/11/305755
A novel coronavirus pandemic caused by SARS-CoV-2 has been ravaging the world population since the beginning of January 2020. The virus was first identified as a cause of pneumonia of unknown cause from Wuhan China, which has subsequently spread to the entire world. The disease outbreak named as COVID -19 was declared a Public Health Emergency of International Concern on 30 January 2020 and subsequently a pandemic by World Health Organisation (WHO) on 11 March 2020.
The pandemic presents a challenge for patients with chronic kidney disease and those on dialysis. Older age, presence of comorbidities such as hypertension diabetes and coronary artery disease is associated with increased mortality in these patients. In India the mean age of patients with CKD is 50 years with diabetes and hypertension among the most common reported etiology of CKD. Hence it is likely that this large susceptible population will face the brunt of this disease. Peritoneal dialysis certainly offers advantage to patients with End Stage Renal Disease (ESRD) in maintaining social distancing thus reducing the chance of contracting the disease. Patients on PD require less exposure to medical personnel, less travel to dialysis facilities thus less need to depend on public transportation, all decreasing the chance of being exposed to the disease. Further encouraging PD as modality of renal replacement therapy (RRT) in ESRD patients may help preserve supplies and manpower, for patients who require haemodialysis. Hence peritoneal dialysis should be the preferred modality of RRT in incident ESRD population during this pandemic.
There has also been an increased interest in the role of peritoneal dialysis (PD) in the management of patients with COVID and acute kidney injury (AKI). The incidence of AKI in COVID-19 has been estimated to be around 3% to 15%, in hospitalised patients and even as high as 29% in critically ill patients. This has led to a sudden increase in the requirement of RRT in ICUs, leading to worry about availability of dialysis machines and sparking fear of supply shortages. There have also been reports of clotting of dialysis membranes further leading to increased utilisation of supplies. Thus, it is reasonable to consider PD as a modality of RRT in this setting. A systematic review and a subsequent Cochrane review concluded that there is no significant difference between PD and other extracorporeal therapies in AKI in terms of mortality, recovery of renal functions or infectious complications, although the quality of evidence in both reviews were considered to be low., Though not commonly used, even in the critical care setting, randomised trials have shown PD to be equivalent to haemodialysis in adults with AKI. Further there can be significant cost savings in doing acute PD as compared to continuous renal replacement therapy (CRRT), which is relevant to a country such as ours. The International Society of Peritoneal dialysis (ISPD) has provided recommendations for the use of PD in AKI which can guide PD use.
However, there are multiple challenges to the use of PD in critically ill COVID patients. The placement of PD catheters can be challenging in these patients in view of their need for ventilatory support, difficulty in placing patients in a fully supine position, presence of coagulopathies in sick patients, the need to maintain strict personal protection etc. However, in the hands of an experienced nephrologist bedside placement of PD catheters can be attempted safely with minimal risks. The ISPD recommends the use of tunnelled flexible catheters to decrease the incidence of peritonitis, although in resource poor settings it acknowledges that use of rigid stylet catheters or improvised catheters may be lifesaving. In patients with significant liver dysfunction or severe shock with lactic acidosis, ISPD recommends the use of bicarbonate buffered PD solutions over lactate buffered PD solutions. The availability of bicarbonate buffered PD solutions may limit their use in such patients. There may also be concerns regarding the use of PD in patients requiring prone ventilation in the ICU. Although there is a case report of successful use of PD in a patient receiving prone ventilation, concerns regarding potentials for leaks, dialysis adequacy, draining issues, infections remain. The use of CAPD in an ICU setting on multiple patients is likely to put a major workload on the PD team particularly the PD nurses in performing multiple dialysis exchanges. Training overworked ICU staff in the use of CAPD may also not be feasible. Hence Automated PD done for 12-16 hours a day, would be preferred over CAPD. This however is not feasible in a country like India with limited availability of APD machines. There may also be significant “physician comfort” with dialysis/CRRT among intensivists who manage these patients which may also be a barrier in doing PD. Considering the above difficulties PD may be reserved for select patients or those who are transferring out of ICUs but continue to require RRT.
In summary there is an important role of PD in the management of patients with COVID -19 and renal failure. Encouraging the use of PD as the preferred modality of RRT in incident chronic dialysis patients, prudent selection of patients with AKI who may benefit from PD in an ICU setting, may be the role we as nephrologists have to play during this wretched pandemic.
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Conflicts of interest
There are no conflicts of interest.
|1||Coronavirus Disease (COVID-19) – Events as they Happen. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen. [Last accessed on 2020 Apr 18].|
|2||Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet 2020;395:1054-62.|
|3||Rajapurkar MM, John GT, Kirpalani AL, Abraham G, Agarwal SK, Almeida AF, et al. What do we know about chronic kidney disease in India: First report of the Indian CKD registry. BMC Nephrol 2012;13:10.|
|4||Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive study. Lancet 2020;395:507-13.|
|5||Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: A single-centered, retrospective, observational study. Lancet Respir Med 2020;8:475-81.|
|6||Mahase E. Covid-19: increasing demand for dialysis sparks fears of supply shortage. BMJ 2020;369:m1588.|
|7||Chionh CY, Soni SS, Finkelstein FO, Ronco C, Cruz DN. Use of peritoneal dialysis in AKI: A systematic review. Clin J Am Soc Nephrol 2013;8:1649-60.|
|8||Liu L, Zhang L, Liu GJ, Fu P. Peritoneal dialysis for acute kidney injury. Cochrane Kidney and Transplant Group, ed. Cochrane Database Syst Rev 2017;12:CD011457.|
|9||Gabriel DP, Caramori JT, Martim LC, Barretti P, Balbi AL. High volume peritoneal dialysis vs. daily hemodialysis: A randomized, controlled trial in patients with acute kidney injury. Kidney Int Suppl 2008;73:S87-93.|
|10||George J, Varma S, Kumar S, Thomas J, Gopi S, Pisharody R. Comparing continuous venovenous hemodiafiltration and peritoneal dialysis in critically ill patients with acute kidney injury: A pilot study. Perit Dial Int 2011;31:422-9.|
|11||Cullis B, Abdelraheem M, Abrahams G, Balbi A, Cruz DN, Frishberg Y, et al. Peritoneal dialysis for acute kidney injury. Perit Dial Int J Int Soc Perit Dial 2014;34:494-517.|
|12||Klisnick A, Souweine B, Filaire M, Wauquier JP, Gazuy N, Deteix P, et al. Peritoneal dialysis in a patient receiving mechanical ventilation in prone position. Perit Dial Int 1998;18:536-8.|