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A Randomized Controlled Trial to Determine the Appropriate Time to Initiate Peritoneal Dialysis after Insertion of
Dwarakanathan Ranganathan1, George T John2, Edward Yeoh2
1Department of Renal Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia Dwarakanathan.Ranganathan@health.qld.gov.au.
Insights
Starting peritoneal dialysis (PD) at one week after catheter insertion significantly increases leak risk. Diabetics experienced higher technique failure when PD commenced at four weeks, suggesting a need for individualized timing.
Area of Science:
- Nephrology
- Urology
- Surgical Outcomes
Background:
- The optimal timing for initiating peritoneal dialysis (PD) post-catheter insertion remains uncertain.
- Early PD initiation may reduce morbidity and costs, but risks dialysate leaks and infection.
- This study is the first randomized controlled trial to establish the safest and shortest interval for commencing PD after catheter placement.
Purpose of the Study:
- To determine the safest and shortest interval for commencing peritoneal dialysis (PD) after PD catheter insertion.
- To compare the incidence of peritoneal fluid leaks and PD-related infections at 1, 2, and 4 weeks post-catheter insertion.
Main Methods:
- A randomized controlled trial involving 122 patients undergoing PD catheter insertion.
- Participants were randomized into three groups: commencing PD at 1 week (G1), 2 weeks (G2), or 4 weeks (G3) post-insertion.
- Primary outcomes assessed were peritoneal fluid leaks and PD-related infections within 4 weeks of PD initiation, stratified by hospital and diabetes status.
Main Results:
- Catheter leaks were significantly higher in the 1-week group (G1) compared to the 4-week group (G3) (28.2% vs 2.4%, p=0.001).
- Leaks occurred significantly earlier in G1 compared to other groups (p=0.002).
- Diabetic patients in the 4-week group (G3) showed higher technique failure rates (28.6%) compared to G1 (0%) and G2 (7.1%) (p=0.036).
Conclusions:
- Commencing PD at 1 week post-catheter insertion is associated with a higher incidence of leaks.
- Diabetic patients commencing PD at 4 weeks experienced increased technique failure.
- The findings suggest that a 2-week interval may offer a balance between safety and efficacy, with individualized considerations for diabetic patients.
Background:
The optimal time for the commencement of peritoneal dialysis (PD) after PD catheter insertion is unclear. If dialysis is started too soon after insertion, dialysate leaks and infection could occur. However, by starting PD earlier, morbidity and costs can be reduced through lesser hemodialysis requirements. This is the first randomized controlled trial to determine the safest and shortest interval to commence PD after catheter insertion.
Methods:
All consecutive patients undergoing PD catheter insertion at the Royal Brisbane and Women's Hospital and Rockhampton Hospital from 1 March 2008 to 31 May 2013 who met the inclusion and exclusion criteria were invited to participate in the trial. Participants were randomized to 1 of 3 groups. Group 1 (G1) commenced PD at 1 week, group 2 (G2) at 2 weeks and group 3 (G3) at 4 weeks after PD catheter insertion. These groups were stratified by hospital and the presence of diabetes. Primary outcomes were the incidence of peritoneal fluid leaks or PD-related infection during the 4 weeks after commencement of PD.
Results:
In total 122 participants were recruited, 39, 42, and 41 randomized to G1, G2, and G3, respectively. The primary outcome catheter leak was significantly higher in G1 (28.2%) compared with G3 (2.4%, p = 0.001) but not compared with G2 (9.5%, p = 0.044), based on intention to treat analysis. These differences were even more marked when analyzed with per protocol method: G1 had a significantly higher percentage (32.4 %) compared with G3 (3.3%, p = 0.003) but not compared with G2 (10.5%, p = 0.040). Event percentages of leak were statistically higher in G1 and occurred significantly earlier compared with other groups (p = 0.002). Amongst diabetics, technique failure was significantly higher (28.6%) in G3 compared with 0% in G1 and 7.1% in G2 (p = 0.036) and earlier in G3 at 163.2 days vs 176.8 and 175.8 (p = 0.037) for G1 and G2, respectively.
Conclusion:
Leaks were higher in participants commencing PD at 1 week after catheter insertion compared with the other 2 groups, and technique failure was higher in diabetics starting PD at 4 weeks.