JVA

J Vasc Access 2016; 17 (Suppl 1): S56-S59

DOI: 10.5301/jva.5000535

ISSN 1129-7298 Original Article

Urgent peritoneal dialysis or hemodialysis catheter

dialysis
Charmaine E. Lok

Division of Nephrology, Department of Medicine, University Health Network-Toronto General Hospital, Toronto, Ontario - Canada

Abstract
Worldwide, there is a steady incident rate of patients with end-stage kidney disease (ESKD) who require renal
replacement therapy. Of these patients, approximately one-third have an “unplanned” or “urgent” start to dialy-
sis. This can be a very challenging situation where patients have either not had adequate time for education and
decision making regarding dialysis modality and appropriate dialysis access, or a decision was made and plans
were altered due to unforeseen circumstances. Despite such unplanned starts, clinicians must still consider the
patient’s ESKD “life-plan”, which includes the best initial dialysis modality and access to suit the patient’s individ-
ual goals and their medical, social, logistic, and facility circumstances. This paper will discuss the considerations of
peritoneal dialysis and a peritoneal dialysis catheter access and hemodialysis and central venous catheter access
in patients who require an urgent start to dialysis.
Keywords: Access, Central venous catheter, Dialysis catheter, Hemodialysis, Urgent dialysis start

Introduction
Worldwide, more than five million people have stage V
chronic kidney disease (CKD) or have reached end-stage kid-
ney disease (ESKD) requiring renal replacement therapy (1).
In the USA, the incidence rate of ESKD peaked in 2006 and
has since levelled off, with a recent incidence of approxi-
mately 120,000 new patients starting dialysis in 2013 (2).
Of these patients, 88.2% began renal replacement therapy
with hemodialysis, 9.0% with peritoneal dialysis, and 2.6%
with a pre-emptive transplant. After a decade, 80% of inci-
dent hemodialysis patients still initiate hemodialysis with
a central venous catheter (CVC) (3). Multiple studies have
demonstrated the adverse health outcomes of using a CVC
(4) leading to significant concerns about their use (5). Thus,
many have argued that it is crucial to limit CVC exposure,
to reduce the risk of CVC-related bacteremia or sepsis, mal-
function and central venous stenosis – that may prohibit fu-
ture arteriovenous (AV) access creation (6). However, others
have also argued that a CVC may be an appropriate choice
Accepted: January 8, 2016
Published online: March 6, 2016
Corresponding author:
Charmaine E. Lok, M.D.
Division of Nephrology
Department of Medicine
Toronto General Hospital
8NU-844, 200 Elizabeth Street
Toronto
M5G 2C4 Ontario, Canada
charmaine.lok@uhn.ca
for some patients (6, 7). Perhaps the key points of debate
are not only what type of hemodialysis access should be
used, but in whom. Additional considerations include the
when and why – under what circumstances were decisions
made – or not made – regarding not only the ‘right’ vascular
access type but the ‘right’ dialysis modality, i.e., the most
appropriate modality for the individual ESKD patient. While
it is important to consider the right access, in the right pa-
tient, and at the right time (6), this paper will discuss some
of these critical issues in choosing the optimal access for a
patient under “urgent start” situations.
Preparation and presentation
Indeed, it is the thought that counts. Having CKD and
reaching ESKD has many life ramifications – renal replace-
ment therapy is a major life decision that has multiple impli-
cations for each patient’s individual health, social, financial,
and support systems and related outcomes. Yet in the latest
statistics from the USA, up to 38% of incident ESKD patients
received little or no pre-ESKD nephrology care (2). Late refer-
ral and unplanned dialysis starts have been reported to range
from 27%-45% (2, 8, 9).
Late referral and “unplanned starts” to dialysis have been
defined differently by clinicians, researchers and institutions.
Given the complexity of decisions required, the time need-
ed for the planning, creation and post-creation care for a
functioning permanent dialysis access, and other necessary
social, logistic and medical preparations, it is reasonable to
require a minimum of 3 months of pre-dialysis care. Anything
less than 3 months or initiating dialysis with a temporary
CVC can be called an “unplanned start”. This can be distin-
guished from an “urgent” start – a start where there may

© 2016 Wichtig Publishing

Lok
Fig. 1 - Modality and access choices for the urgent start patient.
have been timely and/or excellent pre-ESKD care, but where
unforeseen circumstances have occurred that may have ex-
pedited the patient’s need for dialysis. An “urgent” start may
also be viewed differently than an “emergent” start, where di-
alysis is required imminently to correct life-threatening elec-
trolyte disturbances, medically refractory pulmonary edema/
volume overload, bleeding or other consequences of uremia,
such as pericarditis and altered consciousness or seizures. An
urgent start patient may have signs and symptoms of uremia
but non-life threatening conditions where dialysis is anticipat-
ed to be required in approximately 2 weeks (±1 week). It is the
timeframe in which it is difficult to have an arteriovenous (AV)
fistula (fistula) planned, created and matured enough to be
successfully functional and used for prescribed dialysis (10).
There is earlier, strong evidence that support the use of
timely, multi-disciplinary care models for CKD management and
dialysis preparation before a patient reaches ESKD. Such mod-
els have been implemented worldwide and have shown supe-
rior outcomes in many key aspects of care, with greater use
of AV-access (and lower CVC start rate), fewer hospitalizations
and reduced mortality (11-13). In fact, more patients choose
© 2016 Wichtig Publishing
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peritoneal dialysis when there is time for education and choice
(14, 15). The considered and appropriate choice of dialysis mo-
dality should be the first priority rather than the choice of he-
modialysis vascular access. Where then, does this leave i) the
unplanned start patient, or ii) the urgent start patient?
Choices for the patient who has an unplanned
start or urgent start to dialysis
Regardless of whether the patient is one with an un-
planned or urgent start to dialysis, a key question that should
be considered is whether or not the patient is eligible and
appropriate for peritoneal dialysis or hemodialysis (Fig. 1).
There is mounting evidence on the equivalence of peritoneal
dialysis versus hemodialysis in terms of patient survival; and
even additional benefits with peritoneal dialysis, with fewer
required access interventions during the first year of dialysis
(16, 17). Outcomes may vary by institution or country, thus,
understanding the practice patterns and outcomes of the fa-
cility where the patient’s dialysis care will be overseen and
managed, is important (18-20).
S58
If the patient is eligible for both peritoneal dialysis and
hemodialysis, considering the “life-plan” of the individual
ESKD patient is critical; important factors to be considered
include not only the patient’s age, comorbidities, geography
(location and ease of access to dialysis unit) and social sup-
port system, but also variables such as whether or not the
patient has residual renal function – a benefit, especially for
the patient who initiates peritoneal dialysis (21-23). If a pa-
tient has significant residual renal function, it may be an ide-
al “life-plan” to initiate peritoneal dialysis, and then plan for
an AV access (preferably a fistula) when peritoneal dialysis
becomes technically problematic. Alternatively, combining
peritoneal dialysis and hemodialysis prescriptions may pre-
serve residual renal function longer and provide the most
adequate dialysis compared with isolated hemodialysis. In-
deed, “progressive hemodialysis” is a notion that, while it
remains to be fully tested, seems logical and can be applied
in a variety of situations (24, 25). However, ESKD “life-plans”
must be carefully individualized to meet the patient’s own
needs and goals within the parameters set by their medical,
social and logistic circumstances.
In situations where a patient may be a hemodialysis
patient – unplanned start, urgent start or a patient who initi-
ates peritoneal dialysis then transfers to hemodialysis perma-
nently or in a progressive manner – a functional hemodialysis
access must be in place. There are limited situations where a
CVC should be the appropriate option for an incident dialysis
patient. These situations include patients who are palliative
with limited life expectancy (survival <6 months), patients
with a known living kidney transplant donor (ideally with
a surgical date in the near future i.e., <6 months), patients
who are urgent starts and had previously planned for peri-
toneal dialysis but unforeseen medical issues occurred that
required hemodialysis initiation (with the goal to transfer to
peritoneal dialysis), limited medical conditions that contrain-
dicate an AV-access (e.g., excoriating infective skin condition
which would make infection risk greater with cannulation)
and a truly informed and consenting patient who adamantly
refuses to have an AV access for personal reasons. In all other
circumstances, a CVC should be avoided to limit exposure to
the risks associated with CVC, including that of central steno-
sis. While the risk of CVC-related infection has been reported
close to 50% by 6 months (26), a patient may survive and go
on to have a safer, AV access. However, this may not be pos-
sible if they develop central venous stenosis. Central venous
stenosis is the “less dramatic” and often overlooked or un-
recognized CVC complication amongst nephrologists and care
providers less versed with dialysis access. However, central
vein stenosis is an equally if not more important longer-term
complication than some other CVC-related complications. It
can occur in up to 30%-40% of patients (27). Central stenosis
that prohibits AV-access creation(s) limits the patient’s dialy-
sis “life-line” options and may relegate the patient to life-long
CVC exposure and infection risk.
Peritoneal catheter or central venous catheter
In “emergent” dialysis start patients, most will require a
CVC for hemodialysis. Few centers are able to place a bedside
peritoneal catheter that can be used immediately in these
Peritoneal vs. hemodialysis catheter in urgent dialysis starts
s­ ituations. Preliminary results (n = 53) from our centre have
demonstrated a success rate of 93% (7% primary failure rate)
with 100% used for dialysis. In “urgent start” patients who
are eligible for either peritoneal dialysis or hemodialysis, the
choice will depend on the individual circumstances (above).
Urgent start peritoneal dialysis has been proven effective, even
in the elderly patient population (28). Dialysis access has also
been proven less costly in the first 3 months with urgent peri-
toneal dialysis (US$16,000 total with dialysis access represent-
ing 15% of costs) than urgent hemodialysis (US$19,000 total
with dialysis access representing 27% of costs). If hemodialysis
is chosen, the duration of CVC exposure should be limited and
all efforts should be made to avoid the central veins, including
the use of tunnelled femoral catheters and early cannulation
grafts; however, this again, depends on the individual’s situa-
tion (29). In special circumstances (listed above), the appropri-
ate dialysis and access is hemodialysis via a CVC. In such cases,
the catheter must be meticulously managed with evidenced
based practices to limit or avoid complications.
Conclusion
Urgent dialysis starts are not an uncommon situation
where careful consideration must be made regarding the
initial trajectory of the ESKD patient’s dialysis “life-plan”. If a
patient is eligible for both peritoneal dialysis and hemodialy-
sis, the patient’s individual medical condition(s), social and
logistic situations and facility supports must be considered.
In special situations, hemodialysis with a central venous cath-
eter is the appropriate first choice but the catheter must be
meticulously managed with evidenced based practices to
limit or avoid complications.
Disclosures
Financial support: No grants or funding have been received for this
study.
Conflict of interest: None of the authors has financial interest related
to this study to disclose.
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