key: cord-0819422-ow4gcro4 authors: Sourial, Maryanne Y.; Sourial, Mina H.; Dalsan, Rochelle; Graham, Jay; Ross, Michael; Chen, Wei; Golestaneh, Ladan title: Urgent Peritoneal Dialysis in Patients With COVID-19 and Acute Kidney Injury: A Single-Center Experience in a Time of Crisis in the United States date: 2020-06-11 journal: Am J Kidney Dis DOI: 10.1053/j.ajkd.2020.06.001 sha: bc63ddec0712a25542fc1d301c7ef850978391be doc_id: 819422 cord_uid: ow4gcro4 At Montefiore Medical Center, in The Bronx, NY, the first case of coronavirus disease 2019 (COVID-19) was admitted on March 11, 2020. At the height of the pandemic, there were 855 patients with COVID-19 admitted on April 13, 2020. Due to high demand for dialysis and shortages of staff and supplies, we started an urgent peritoneal dialysis (PD) program. From April 1(st) to April 22(nd), 30 patients were started on PD. Of those 30 patients, 14 died during their hospitalization, 8 were discharged, and 8 were still hospitalized as of May 14, 2020. Although the PD program was successful in its ability to provide much-needed kidney replacement therapy (KRT) when hemodialysis was not available, challenges to delivering adequate PD dosage included difficulties in providing nurse training and availability of supplies. Providing adequate clearance and ultrafiltration for patients in intensive care units was especially difficult due to high prevalence of hypercatabolic state, volume overload, and prone positioning. PD was more easily performed in non-critically ill patients outside the intensive care unit. Despite these challenges, we demonstrate that urgent PD is a feasible alternative to hemodialysis in situations with critical resource shortages. In developed countries such as the United States of America (USA), either intermittent hemodialysis (HD) or continuous kidney replacement therapy (CKRT) are the primary modes of KRT for the management of acute kidney injury (AKI) [1] . However, at the peak of the coronavirus disease 19 (COVID-19) pandemic, our medical center's ability to provide intermittent HD and CKRT for the treatment of AKI was overwhelmed due to the surge in the May 2020). Due to the unusually high demand for dialysis at our institution during the COVID-19 pandemic, an urgent peritoneal dialysis (PD) program was initiated. PD is most commonly administered as maintenance therapy in patients with kidney failure but can also be effective in patients with AKI stage 3 [2] [3] [4] [5] . In a randomized controlled trial of patients with AKI stage 3 receiving either PD or HD, metabolic control, mortality, and kidney function recovery rates were similar [5] . Meta-analyses also showed no difference between HD and PD when used for AKI in clinical outcomes including mortality, kidney recovery, and complications [6, 7] . At MMC, the first case of COVID-19 was admitted on March 11, 2020 and the number of cases grew exponentially for several weeks afterward. In the midst of the pandemic, on April 13, 2020, there were 855 patients with COVID-19 admitted to two of Montefiore's major hospitals. To rapidly increase our capacity to provide KRT to meet the needs of the large number of patients with COVID-associated AKI, we initiated an urgent PD program on March 25th. This article describes our experience with the implementation of urgent PD for COVID-19-associated AKI. Prior to the COVID-19 pandemic, MMC did not have an established urgent-start PD program for patients with kidney failure or AKI stage 3. MMC surgeons had been placing PD catheters within 48 hours in those patients who required urgent-start PD for kidney failure; these patients were then followed at an outpatient dialysis unit. We routinely provided maintenance manual PD services for inpatients with kidney failure but not AKI stage 3. We, therefore, rapidly established institutional guidelines for the initiation of urgent PD during the COVID-19 pandemic and devised, and progressively refined, a protocol to provide a unified approach to treating AKI patients with manual exchanges ( Figure S1 ) or automated PD with cyclers ( Figure S2 ). The protocol was based primarily on the International Society of Peritoneal Dialysis (ISPD) guidelines and several other studies [2-4, 8, 9] . PD catheters at MMC were typically placed laparoscopically in the operating room by transplant surgeons prior to the pandemic. Due to the high volume of patients needing PD, and the closure of operating rooms in our institution, a plan was formulated, with the help of the transplant surgeons and interventional radiologists (who did not place PD catheters in the past), to place PD catheters. Similar to the description provided by Srivatana et. al., [10] transplant surgeons placed flexible PD catheters at bedside using laparoscopically-assisted techniques for intensive care unit (ICU) patients while interventional radiologists placed flexible PD catheters under fluoroscopic guidance for non-ICU and non-intubated patients. The PD catheters were used immediately after placement with low volumes (1-1.5 liters) for the first 24 hours, which were then increased to full volumes (2-2.5 liters) thereafter. Important challenges and solutions that enabled us to rapidly implement an urgent PD program to accommodate the surge in patients requiring KRT are summarized in Table 1 . First, we increased procurement of PD supplies as we previously only stocked supplies to support the needs of existing maintenance PD patients during an acute hospitalization (roughly 5 admissions to MMC's 3 hospitals per month). For the urgent PD program, a preemptive order had to be placed with our main supplier with the help of one nephrologist, one outpatient PD nurse, and one inpatient pediatric dialysis nurse (who was familiar with inpatient PD) for an adequate supply of PD materials based on the projected use for the period of the COVID-19 surge (duration estimated as 2 weeks; Box 1). Obtaining the necessary supplies was logistically complicated as there was a nationwide shortage and items were backordered. Timely placement of the orders allowed us to deploy supplies to all units where PD was needed. The decision to start intermittent HD vs. CKRT vs. PD was made by the treating nephrologist based on several factors, including but not limited to patient's location, hemodynamic status, need for proning, and availability of supplies and personnel (Box 2). As with all hospitals in New York City, MMC increased its medical ward and ICU capacity to accommodate the surge in patients. To address nursing staff shortages in the ICU and wards, the Division of Nephrology formed an "urgent PD service" to perform bedside rounds of patients treated by this modality. On the first day, the PD service consisted of one nephrology attending and one nephrology fellow. They demonstrated manual exchanges to teach the nursing staff and house staff residents how to do the exchanges for future treatments, conducted rounds, wrote orders, performed catheter exit-site care, and performed manual exchanges for patients where nursing expertise with PD and/or workload were limiting factors. These nephrologists also shared information with the nurses on logistical issues, including how to order and maintain adequate PD supplies from the hospital stockroom, and how to provide exit-site care. We also created laminated cards with instructions on performing manual exchanges (which were provided to nurses) and a link to an instructional video (provided by supplier) on how to provide a manual PD exchange was shared with all the nurse managers. During the first weekend of the urgent PD program, several nephrologists volunteered to receive training on manual PD exchanges and assist the urgent PD service by providing manual exchanges to PD patients. This was essential to patient care as many nurses unfamiliar with PD had not yet been trained to perform manual PD exchanges. Furthermore, to accommodate the surge in patients, nurses in the ICUs and wards had increased patient to nurse ratios, which made it difficult to train nurses to perform PD; this meant that nephrologists frequently had to perform exchanges to compensate. PD exchanges were, therefore, performed during an 8-12 hour period during the daytime shift. Though all patients were prescribed standard PD dosages, technical and logistical challenges often reduced the number of exchanges performed during the height of the crisis. More than half of the patients receiving PD were ventilated during their hospitalization. Ventilated patients were often placed in prone position to improve oxygenation. PD was discontinued while patients were proned to avoid increasing intra-abdominal pressure, which may cause dyssynchrony with the ventilator. This reduced the number of hours available for PD and, given the hypercatabolic state and electrolyte disturbances common in critically ill patients with COVID-19, supplementation of PD with CKRT or intermittent HD was often necessary ( Table 2 ). The determination of which modality to use was made daily by the patient's nephrologist based on criteria mentioned in Box 2. Given limitations in nursing and equipment, the amount of time on intermittent HD or CKRT treatments was often truncated to maximize the number of patients for whom we could provide those modalities. To reduce the burden of manual exchanges on staff and optimize delivered PD dosing, we sought to implement automated PD (APD). Since we had not previously used APD cyclers on our inpatient services, we had to procure cyclers and related supplies from our supplier (Table 1) . On April 6 th (when there were 18 patients receiving urgent PD), members of the urgent PD service team (now comprising 2 attendings and either a nurse practitioner or nephrology fellow) were trained to program and troubleshoot the cyclers for provision of APD. Because the nurses and house staff residents were only trained on manual PD exchanges, the urgent PD service team provided the APD setup for each patient on a cycler. They also obtained data from the cyclers for the therapy session completed, discarded the cassettes and used PD bags, and set up the new prescription and dialysate bags for that day's therapy. Heparin (500 U per liter of dialysate) was instilled to each bag to prevent fibrin clot formation ( Figures S1-S2) . This was especially important as patients with COVID-19 infection had notably increased fibrinogen, D-dimers, lactate dehydrogenase, prothrombin time, and activated partial thromboplastin time levels and were at risk for thrombotic complications [11, 12] . As several patients were receiving multiple antibiotics, fluconazole use for prophylaxis of fungal peritonitis was considered [13] , however, due to the risk of QT prolongation, particularly in combination with hydroxychloroquine, we opted against prescribing fluconazole. From March 11 th to April 26 th , MMC had a total of 164 patients with severe AKI that required KRT (M. Fisher, personal communication, May 2020). Of these, 27 (16.5%) received PD as the initial mode of dialysis. An additional 3 patients were switched from another modality to PD; 2 patients who were on intermittent HD initially were switched to PD once it became available in the MMC Weiler Hospital, and 1 patient who was on CKRT was switched to PD at Ultimately, 2 of the 5 patients remained on CKRT and PD was discontinued. In one patient, PD was discontinued due to fungemia but peritoneal fluid fungal cultures remained negative. The second patient was taken off PD due to positive peritoneal fluid fungal culture, however, this was preceded by positive fungal blood cultures. Six of the 30 patients required intermittent HD supplementation during their hospitalization. Of those 6 patients, 2 needed supplementation with intermittent HD for additional clearance and 4 patients needed additional ultrafiltration due to refractory volume overload despite high-dextrose PD dialysate solution (icodextrin was not available). Of the 6 patients who needed intermittent HD supplementation, 4 were ultimately switched to intermittent HD and PD was discontinued (due to ultrafiltration failure and fluid retention on PD). In addition, 3 patients were switched to intermittent HD from PD (without concurrent intermittent HD supplementation while on PD) for a total of 7 patients that were ultimately switched to intermittent HD. One of those additional 3 patients was switched due to hypercatabolic state leading to severe electrolyte derangements necessitating higher clearance rates. One patient was switched due to persistent peritoneal fluid leak from the PD catheter exit site. One patient was switched due to peritoneal catheter malfunction leading to intraperitoneal bleeding ( Table 2 ). Due to hemodynamic instability, the patient with the persistent peritoneal fluid leak was not a candidate for laparoscopic repair in the operating room (as multiple bedside repairs were unsuccessful in stopping the leak). Typically, the average prescribed dose for patients receiving manual PD (for a 70 kilogram male) after the initial 48-72 hours of PD was a 2 L fill volume, 6 exchanges per day, with a dwell time of 3 hours ( Figure S1 ). Assuming a 2 L ultrafiltration rate per day, this prescription would confer a weekly Kt/V of 2.52 (a weekly Kt/V of 2.1-3.5 is the goal for PD in the AKI setting) [2] . The average prescribed dose for APD (for a 70 kilogram male) after the initial 48-72 hours of PD was 2 L fill volume, total daily volume of dialysate of 16 L, 2 hour dwell time, with 8 exchanges per day for an average duration of 20 hours on APD. Assuming a 2 L ultrafiltrate volume, this prescription would confer a weekly Kt/V of 3.24. Due to the feasibility issues mentioned previously and in Table 1 , the actual dose of PD received by the patient varied and supplementation with CKRT or intermittent HD was necessary in many cases in order to provide additional clearance. There are many advantages to using PD in the setting of AKI stage 3. First, there is no need for vascular access. Patients with elevated D-dimers and fibrin degradation products, as seen in COVID-19, are more likely to have disseminated intravascular coagulation [14, 15] . Due to severe sepsis and the concomitant coagulopathy associated with COVID-19, it is preferred to avoid vascular access when possible. Second, the overall cost of PD is significantly less than intermittent HD or CKRT, which require more expensive machinery and supplies. Third, staff can be educated on how to safely perform PD with few resources and in a short period of time. As mentioned in El-Shamy et al., [16] PD training is less technically challenging as compared to intermittent HD or CKRT machine training and is, therefore, an obvious choice for nurse and technician training during a pandemic. Finally, unlike intermittent HD, PD does not require a dialysate supply water connection, which was a limiting factor in several temporary ICU locations constructed in our medical center in response to the COVID-19 surge. With adequate PD, solute clearance, ultrafiltration, and correction of metabolic acidosis can improve morbidity of patients with severe AKI [4, 5, 9] . Yet, there is a notable discrepancy in the frequency of use comparing intermittent HD and CKRT with PD as the primary choice for dialysis in patients with AKI stage 3 [1]. In an international survey of nephrologists and intensivists, in this setting, PD use accounted for less than one third of patients while CKRT modalities were used in almost half [1] . Although there are many reasons for this incongruence, there have been studies that demonstrate the utilization of urgent PD in AKI settings with success [3] [4] [5] 17] . Gabriel et al. (2008) demonstrated that high-volume continuous PD proved to be an effective form of dialysis in AKI patients with multiple comorbidities including those with high level of acuity requiring ICU admission [5, 17] . Because the pandemic overwhelmed our capacity to provide intermittent HD or CKRT to all patients needing dialysis at MMC, an urgent PD program was started to accommodate the surge in patients with AKI requiring KRT. As expected, clearance and ultrafiltration rates were less predictable in patients who were hypercatabolic from severe sepsis [18] . This prompted supplemental intermittent HD or CKRT use in several patients, which meant additional catheter placement and, therefore, increased catheter-related infection risk and clotting. Although we expected some resistance from critical care physicians who were not familiar with PD, this was extremely rare as clinicians understood the dire situation given the severe shortage of intermittent HD and CKRT resources and staff. We do not have data on reimbursement for PD procedures, as review of billing submissions revealed that nearly all nephrologists billed for follow-up consult evaluation and management services and not the PD procedure. Based on our experience, urgent PD was feasible in a time of crisis. We are currently investigating the efficacy of PD in relation to morbidity and mortality in patients treated in both the ICU and medical wards during the COVID-19 pandemic. We hope that our experience can help others prepare for any future surge in AKI patients requiring KRT. Figure S1 : Manual PD algorithm. Figure S2 : Cycler PD algorithm. As the program grew rapidly, the urgent PD service was becoming overwhelmed as demand increased Urgent PD service increased in staff and more time was spent educating nurses and residents caring for PD patients on how to perform manual exchanges of PD; availability of cyclers helped workload of the urgent PD service nephrologists as well as the patients' nurses since interaction with machine was limited once the nephrologists set up the machine for each patient Prone positioning Limited the use of PD to when patients were supine to avoid increased intraabdominal pressure during proning, which may cause dyssynchrony with the ventilator Supplemental iHD or CKRT was provided while patients were prone depending on patient location (some units did not have water connections available for iHD) as well as machine, dialysate, and nursing staff availability; patients received PD when supine but this was often limited to 1-4 exchanges depending on the duration of supination • Some temporary ICUs lacked water connections for iHD so CKRT and PD were the only available options • Patients who receiving vasopressors for hemodynamic support were placed on either CKRT or PD to avoid worsening hemodynamics when possible • Patients who required prone positioning for the treatment of hypoxemia due to ARDS were placed on CKRT or iHD • When CKRT machines were in limited supply, this necessitated increased use of iHD and PD • When ICU staffing levels limited ability to perform CKRT, PD could allow for increased accessibility to KRT • Due to nationwide shortage of CKRT solutions, urgent PD and iHD in critically ill patients was necessary to maximize access to KRT for critically ill patients • Shortage of iHD machines and dialysis nurses (due to illness and increased demand for dialysis) contributed to increased need for CKRT and PD • Initially, the inpatient dialysis unit was closed to COVID-19 positive patients, which limited our ability to use iHD; all inpatients received iHD in private rooms (which are limited and required one-to-one nursing care) or PD Management of severe acute renal failure in critically ill patients: an international survey in 345 centres Peritoneal Dialysis for Acute Kidney Injury Peritoneal dialysis in acute renal failure High volume peritoneal dialysis for acute renal failure High volume peritoneal dialysis vs daily hemodialysis: a randomized, controlled trial in patients with acute kidney injury Use of peritoneal dialysis in AKI: a systematic review Peritoneal dialysis for acute kidney injury. 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