Patient Outcomes
From March 11 to April 26, 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 receiving intermittent HD initially were switched to PD when it became available in the MMC Weiler Hospital, and 1 patient who was receiving CKRT was switched to PD at MMC Moses Division. As of May 14, 2020, a total of 14 of the 30 (47%) patients who were started on PD died during the hospitalization (of whom 1 had kidney recovery and dialysis was discontinued before death), 8 patients were discharged to home or rehabilitation facilities (of whom 3 were receiving PD and 5 no longer needed KRT due to kidney recovery by the time of discharge), and 8 patients were still hospitalized. Of those 8 patients who remained hospitalized, no patient remained on PD; 4 patients were switched to either CKRT or intermittent HD, and 4 patients had kidney recovery and no longer needed KRT (Table 2).
Of the 30 patients started on PD in the first 22 days of April, 22 patients were intubated before the start of PD and 8 were started on PD and were never intubated. There were no patients who were intubated after starting PD. Sixteen of the 22 intubated patients required prone positioning for treatment of hypoxemia. One of the 8 nonintubated patients was also placed in prone positioning for treatment of hypoxemia. Of the 30 patients receiving PD, 5 patients were supplemented with CKRT during their hospitalization, 4 of whom needed supplementation with CKRT due to prone positioning limiting PD exchanges and 1 due to persistent hyperkalemia. Ultimately, 2 of the 5 patients remained on CKRT and PD was discontinued. In 1 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 while receiving PD). In addition, 3 patients were switched to intermittent HD from PD (without concurrent intermittent HD supplementation while receiving PD) for a total of 7 patients who were ultimately switched to intermittent HD. One of those additional 3 patients was switched due to a hypercatabolic state leading to severe electrolyte derangements necessitating higher clearance rates. One patient was switched due to a 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 (multiple bedside repairs were unsuccessful in stopping the leak).
Typically, the average prescribed dose for patients receiving manual PD (for a 70-kg male) after the initial 48 to 72 hours of PD was a 2-L fill volume, 6 exchanges per day, with a dwell time of 3 hours (Fig 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-kg male) after the initial 48 to 72 hours of PD was a 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 receiving 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 to provide additional clearance.