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LETTER TO EDITOR
Year : 2020  |  Volume : 14  |  Issue : 2  |  Page : 185-186

Automated peritoneal dialysis is a superior option for the management of postrenal transplant delayed graft function


Department of Nephrology and Renal Transplantation, Virinchi Hospitals, Hyderabad, Telangana, India

Date of Submission28-Aug-2019
Date of Acceptance15-Mar-2020
Date of Web Publication06-Jul-2020

Correspondence Address:
Dr. Praveen Kumar Etta
Department of Nephrology and Renal Transplantation, Virinchi Hospitals, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_43_19

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How to cite this article:
Etta PK. Automated peritoneal dialysis is a superior option for the management of postrenal transplant delayed graft function. Indian J Transplant 2020;14:185-6

How to cite this URL:
Etta PK. Automated peritoneal dialysis is a superior option for the management of postrenal transplant delayed graft function. Indian J Transplant [serial online] 2020 [cited 2020 Aug 5];14:185-6. Available from: http://www.ijtonline.in/text.asp?2020/14/2/185/289039



Dear Editor,

While hemodialysis (HD) is widely utilized as a method of renal replacement therapy (RRT) before and after renal transplantation (RT), the utilization of peritoneal dialysis (PD) is far less, especially in RT recipients (RTRs). The delayed graft function (DGF) is associated with increased risks of acute rejection and poorer graft survival. The frequency of DGF, especially in deceased donor RT (DDRT), is raising probably due to acceptance of marginal donors with prolonged ischemic times. The effect of pretransplant dialysis modality (HD or PD) on posttransplant graft and patient outcomes is controversial. As PD patients are at lesser risk of acquiring viral infections and lesser need of blood transfusions compared to HD patients, their post-RT complication rates seem to be better. Preservation of residual renal function (RRF) is definitely better with PD. PD may also be associated with a lesser risk of DGF, lower risk of death, and graft failure.[1],[2] PD patients can undergo DDRT more conveniently and smoothly without the requirement of urgent HD prior to RT. The appropriate time to undergo PD catheter removal after RT in patients on PD remains unknown. Most of the patients who develop DGF after RT were treated with a similar mode of dialysis as before RT.

To the best of our knowledge, only two retrospective studies have evaluated the effects of post-RT dialysis modality (manual PD vs. HD) in RTRs with DGF on patient and graft outcomes.[3],[4] One study concluded that RTRs with DGF treated with PD led to increased wound infection or leakage but decreased length of hospitalization and duration of RRT.[3] In contrast, the second study showed that PD patients had a higher rate of treatment failure (mainly due to fluid overload), peritonitis, and longer duration of dialysis dependence but no significant difference with respect to acute rejection, patient, and graft survival at 1 year.[4] None of the studies have evaluated the clinical benefits of automated PD (APD) in DGF. It remains unclear, the effects of post-RT dialysis modality in RTRs with DGF on the restoration of renal function, perioperative complications, or patient and graft survival.

Recently, we have treated two patients with end-stage renal disease on manual PD who developed DGF post-DDRT, managed successfully with bedside APD and we have noticed several advantages with this form of therapy compared to both manual PD and HD. HD may be associated with risks of anticoagulation (risk of bleeding in postoperative period), systemic inflammation, blood-borne infections, and hemodynamic effects due to rapid fluid shifts with increased risk for acute tubular necrosis, which may worsen prognosis of DGF. In many centers, there may be a need to shift the patient out of transplant unit for HD; this again exposes these patients to risk of infections. In patients with no permanent vascular access, the risk of infections, central vein stenosis, and thrombosis with catheters is much more pronounced. PD can be done at bedside and the use of PD in patients with DGF may fasten graft functional recovery due to better systemic hemodynamic stability and preservation of local renal hemodynamics compared to HD. PD may be more physiologic and less inflammatory than HD. With APD, the number of connections and disconnections is reduced; thereby, it may reduce the chances of infections including peritonitis. APD has flexibility in changing the prescription of dialysis as per need, with modifications in dwell volume, type of PD solution, each cycle duration, and the total duration of therapy. APD may be better than manual PD for ultrafiltration and it might reduce the rate of treatment failure because of poor capacity control compared to manual PD. With APD, tidal PD and high volume PD can be done in specific circumstances to further improve the clearances.

Of the two patients whom we have treated with APD, one patient had good RRF and was treated only with nocturnal intermittent PD with “day dry: and recovered from DGF after 5 days of therapy. Another patient who was anuric developed disseminated intravascular coagulation like clinical picture with hypotension, fluid over load and hyperkalemia immediately after RT; she was treated with continuous cyclic PD with day dwell and recovered from DGF after 8 days. We conclude that APD is a viable option for the management of post-RT DGF compared to both manual PD and HD. However, it requires further studies on APD usage in DGF to know the clinical benefits, patient, and graft outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Vanholder R, Heering P, Loo AV, Biesen WV, Lambert MC, Hesse U, et al. Reduced incidence of acute renal graft failure in patients treated with peritoneal dialysis compared with hemodialysis. Am J Kidney Dis 1999;33:934-40.  Back to cited text no. 1
    
2.
Goldfarb-Rumyantzev AS, Hurdle JF, Scandling JD, Baird BC, Cheung AK. The role of pretransplantation renal replacement therapy modality in kidney allograft and recipient survival. Am J Kidney Dis 2005;46:537-49.  Back to cited text no. 2
    
3.
Thomson BK, Moser MA, Marek C, Bloch M, Weernink C, Shoker A, et al. Peritoneal dialysis versus hemodialysis in patients with delayed graft function. Clin Transplant 2013;27:E709-14.  Back to cited text no. 3
    
4.
Yan T, Peng W, Lv J, Wu J, Chen J. Hemodialysis or peritoneal dialysis, which is better for patients with delayed graft function? Kidney Blood Press Res 2018;43:1813-21.  Back to cited text no. 4
    




 

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