Discussion
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 levels of 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 time. As mentioned in El Shamy et al,16 PD training is less technically challenging as compared with 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 the morbidity of patients with severe AKI.4 , 5 , 9 However, 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, PD use accounted for less than one-third of patients, whereas CKRT modalities were used in almost half.1 Although there are many reasons for this incongruence, there have been studies that demonstrate the use of urgent PD in AKI settings with success.3, 4, 5 , 17 Gabriel et al5 (2008) demonstrated that high-volume continuous PD proved to be an effective form of dialysis in patients with AKI with multiple comorbid conditions, including those with a high level of acuity requiring ICU admission.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 because clinicians understood the dire situation given the severe shortage of intermittent HD and CKRT resources and staff. We do not have data for reimbursement for PD procedures because 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 patients with AKI requiring KRT.