How to build a successful urgent-start peritoneal dialysis program

In-center hemodialysis (HD) remains the predominant dialysis therapy in patients with end-stage kidney disease (ESKD). Many patients with ESKD present in late stage requiring urgent dialysis initiation, and the majority start HD with central venous catheters (CVC) that is associated with poor outcomes and high cost of care. PD catheters can be safely placed in such late-presenting ESKD patients, obviating the need for CVC. PD can begin almost immediately in recumbent position using low fill-volumes. Such PD initiations commencing within two weeks of the catheter placement are termed urgent-start PD (USPD). Most patients with intact peritoneal cavity and stable home situation are eligible for USPD. While there is a small risk of PD catheter-related mechanical complications, most can be managed conservatively. Moreover, overall outcomes of USPD are comparable to those with planned-PD initiations in contrast to high rate of catheter-related infections and bacteremia associated with urgent-start HD. The ongoing-COVID-19 pandemic has further exposed the vulnerability of ESKD patients getting in-center HD. PD can mitigate the risk of infection by reducing environmental exposure to the virus. Thus, USPD is a safe and cost effective option for unplanned dialysis initiation in late-presenting ESKD patient. To develop a successful USPD program, strong infrastructure with clear pathways are essential. Coordination of care between nephrologists, surgeons or interventionalists, along with hospital and PD center staff is imperative so that patient-education, home-visit, PD-catheter placement, and urgent PD initiation are accomplished expeditiously. Implementation of urgent-start will help to increase PD-utilization, reduce cost and improve patient outcomes, and will be a step forward in fostering the goal set by the Advancing American Kidney Health initiative.