Our Process and Challenges
Before the COVID-19 pandemic, MMC did not have an established urgent-start PD program for patients with AKI stage 3. MMC surgeons had been placing PD catheters within 48 hours in patients who required urgent-start PD for chronic kidney failure; these patients were then followed up at an outpatient dialysis unit. We routinely provided maintenance manual PD services for inpatients with chronic 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 patients with AKI with manual exchanges (Fig S1) or automated PD (APD) with cyclers (Fig S2). The protocol was based primarily on the International Society of Peritoneal Dialysis guidelines and several other studies.2, 3, 4 , 8 , 9 
PD catheters at MMC were typically placed laparoscopically in the operating room by transplant surgeons before 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 the bedside using laparoscopically assisted techniques for ICU patients while interventional radiologists placed flexible PD catheters under fluoroscopic guidance for non-ICU and nonintubated patients. The PD catheters were used immediately after placement with low volumes (1-1.5 L) for the first 24 hours, which were then increased to full volumes (2-2.5 L) 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 the procurement of PD supplies because we previously only stocked supplies to support the needs of existing maintenance PD patients during an acute hospitalization (~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 1 nephrologist, 1 outpatient PD nurse, and 1 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 ).
Table 1 Summary of Challenges and Solutions Encountered During Startup of Urgent PD Program Abbreviations: AKI, acute kidney injury; CKRT, continuous kidney replacement therapy; ICU, intensive care unit; iHD, intermittent hemodialysis; KRT, kidney replacement therapy; OR, operating room; PD, peritoneal dialysis.Box 1 Total Amount of Supplies Ordered for PD

PD Dialysate Fluid
• For manual PD, ordered 2-L low-calcium (2.5-mEq/L) PD solutions with Y connectors with the following dextrose concentrations:⋄ 1.5% dextrose: enough to supply 25 patients for 14 d⋄ 2.5% dextrose: enough to supply 50 patients for 14 d⋄ 4.25% dextrose: enough to supply 25 patients for 14 d • For cycler-assisted PD, ordered 6-L PD solutions with the following dextrose concentrations:⋄ 4.25% dextrose: enough for 25 patients for 14 d (with expected use of 2 bags/patient/d)⋄ 2.5% dextrose: enough for 50 patients for 14 d⋄ 1.5% dextrose: enough for 25 patients for 14 d

PD Disposables
• Drain bags (15-L capacity): ordered enough for 25 patients for 14 d• Clamps: ordered enough for 25 patients for 14 d• Caps: ordered enough for 100 exchanges for 14 d• Transfer sets and titanium adapters: ordered 50 of each

Cycler Machines and Supplies
• Ordered 15 cycler machines• Cycler manifolds (5-pronged cassettes): enough for 25 patients for 14 d• Drain bags (15-L capacity): enough for 25 patients for 14 d 
Note: Based on predicted use of PD for 25 patients over 2 weeks.Abbreviation: PD, peritoneal dialysis.
Obtaining the necessary supplies was logistically complicated because there was a nationwide shortage and items were backordered. Timely placement of the orders allowed us to deploy supplies to all units in which PD was needed. The decision to start intermittent HD versus CKRT versus PD was made by the treating nephrologist based on several factors, including but not limited to patient’s location, hemodynamic status, need for prone positioning, and availability of supplies and personnel (Box 2 ).Box 2 Factors Affecting Decision to Choose Intermittent HD Versus CKRT Versus PD

Patient Factors
• Some temporary ICUs lacked water connections for iHD so CKRT and PD were the only available options• Patients 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

Availability of Dialysis Equipment
• 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

Shortage of KRT Resources
• 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 1-to-1 nursing care) or PD 
Abbreviations: COVID-19, coronavirus disease 2019; CKRT, continuous kidney replacement therapy; HD, hemodialysis; ICU, intensive care unit; iHD, intermittent hemodialysis; KRT, kidney replacement therapy; PD, peritoneal dialysis.
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 using this modality. On the first day, the PD service consisted of 1 nephrology attending and 1 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 when 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 a supplier) on how to provide a manual PD exchange was shared with all 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 because 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- to 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 the patients receiving PD were receiving mechanical ventilation during their hospitalization. Patients receiving mechanical ventilation were often placed in a prone position to improve oxygenation. PD was discontinued while patients were in a prone position 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 receiving intermittent HD or CKRT treatments was often truncated to maximize the number of patients for whom we could provide those modalities.
Table 2 Descriptive Statistics for the Urgent PD Program Abbreviations: AKI, acute kidney injury; CKRT, continuous kidney replacement therapy; ICU, intensive care unit; iHD, intermittent hemodialysis; KRT, kidney replacement therapy; PD, peritoneal dialysis. a Subgroups are not mutually exclusive.
To reduce the burden of manual exchanges on staff and optimize delivered PD dosing, we sought to implement APD. Because 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 (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 trained on only 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 1 L of dialysate) was instilled to each bag to prevent fibrin clot formation (Figs S1 and S2). This was especially important because patients with COVID-19 had notably increased fibrinogen, D-dimers, lactate dehydrogenase, prothrombin time, and activated partial thromboplastin time values and were at risk for thrombotic complications.11 , 12 Because several patients were receiving multiple antibiotics, fluconazole use for prophylaxis of fungal peritonitis was considered.13 However, due to the risk for QT interval prolongation, particularly in combination with hydroxychloroquine, we opted against prescribing fluconazole.