Faculty Bibliography

CONTEXT/BACKGROUND:Chronic kidney disease (CKD) disproportionately impacts lower socioeconomic groups and is associated with many symptoms and complex decisions. Integration of Kidney Supportive Care (KSC) with CKD care can address these needs. To our knowledge, this approach has not been described in an underserved population. OBJECTIVES/OBJECTIVE:We describe our adaptation of an ambulatory integrated KSC and CKD clinic for implementation in a safety net hospital. We report our utilization metrics; characteristics of the population served; and visit activities. METHODS:We considered modifications from the perspectives of people with CKD, their providers, and the health system. Modifications were informed by meeting notes with key participants (hospital administrators [n = 5], funders [n = 1], and content experts [n = 2]), as well as literature on palliative care program building, safety net hospitals, and KSC. We extracted utilization data for the first 15 months of the clinic's operations, demographics, clinical characteristics, unmet health related social needs, and symptom burden, measured by the Integrated Palliative Outcome Scale-Renal (total Score, and sub-scores of physical, psychological, and practical impact of CKD) from the electronic health record. Results are reported using descriptive statistics. RESULTS:Adaptions were proactive and done by clinical and administrative leaders. Meetings identified challenges of the safety net setting including people presenting with advanced disease and having several social needs. Modifications to our base model were made in staffing, data collection, and work flow. Show rate was approximately 68%, with a majority of people identifying as Black or Hispanic, and uninsured or on Medicaid. Symptom burden was lower than previous reports, driven by a better psychological sub-score. CONCLUSIONS:We describe a feasible ambulatory care model of KSC in a safety net setting that can serve as a framework for the development of other noncancer palliative care ambulatory clinics. Future work will optimize our model.

BACKGROUND/UNASSIGNED:The high incidence of acute kidney injury (AKI) requiring dialysis associated with COVID-19 led to the use of peritoneal dialysis (PD) for the treatment of AKI. This study aims to compare in-hospital all-cause mortality and kidney recovery between patients with AKI who received acute PD versus extracorporeal dialysis (intermittent haemodialysis and continuous kidney replacement therapy). METHODS/UNASSIGNED:In a retrospective observational study of 259 patients with AKI requiring dialysis during the COVID-19 surge during Spring 2020 in New York City, we compared 30-day all-cause mortality and kidney recovery between 93 patients who received acute PD at any time point and 166 patients who only received extracorporeal dialysis. Kaplan-Meier curves, log-rank test and Cox regression were used to compare survival and logistic regression was used to compare kidney recovery. RESULTS/UNASSIGNED:= 0.48). CONCLUSIONS/UNASSIGNED:The use of PD for the treatment of AKI was not associated with worse clinical outcomes when compared to extracorporeal dialysis during the height of the COVID-19 pandemic in New York City. Given the inherent selection biases and residual confounding in our observational study, research with a larger cohort of patients in a more controlled setting is needed to confirm our findings.

To demonstrate feasibility of acute peritoneal dialysis (PD) for acute kidney injury during the coronavirus disease 2019 (COVID-19) pandemic, we performed a multicenter, retrospective, observational study of 94 patients who received acute PD in New York City in the spring of 2020. Patient comorbidities, severity of disease, laboratory values, kidney replacement therapy, and patient outcomes were recorded. The mean age was 61 ± 11 years; 34% were women; 94% had confirmed COVID-19; 32% required mechanical ventilation on admission. Compared to the levels prior to initiation of kidney replacement therapy, the mean serum potassium level decreased from 5.1 ± 0.9 to 4.5 ± 0.7 mEq/L on PD day 3 and 4.2 ± 0.6 mEq/L on day 7 (P < 0.001 for both); mean serum bicarbonate increased from 20 ± 4 to 21 ± 4 mEq/L on PD day 3 (P = 0.002) and 24 ± 4 mEq/L on day 7 (P < 0.001). After a median follow-up of 30 days, 46% of patients had died and 22% had undergone renal recovery. Male sex and mechanical ventilation on admission were significant predictors of mortality. The rapid implementation of an acute PD program was feasible despite resource constraints and can be lifesaving during crises such as the COVID-19 pandemic.

Patients with kidney failure and acute respiratory distress syndrome (ARDS) requiring prone position have not been candidates for peritoneal dialysis (PD) due to concern with increased intra-abdominal pressure, reduction in respiratory system compliance and risks of peritoneal fluid leaks. We describe our experience in delivering acute PD during the surge in Covid-19 acute kidney injury (AKI) in the subset of patients requiring prone positioning. All seven patients included in this report were admitted to the intensive care unit with SARS-CoV-2 infection leading to ARDS, AKI and multisystem organ failure. All required renal replacement therapy, and prone positioning to improve ventilation/perfusion mismatch. All seven were able to continue PD despite prone positioning without any detrimental effects on respiratory mechanics or the need to switch to a different modality. Fluid leakage was noted in 71% of patients, but mild and readily resolved. We were able to successfully implement acute PD in ventilator-dependent prone patients suffering from Covid-19-related AKI. This required a team effort and some modifications in the conventional PD prescription and delivery.

Background: To offset resource constraints that limited the capability to deliver hemodialysis (HD) during the COVID-19 surge, nephrologists in New York City (NYC) rapidly incorporated peritoneal dialysis (PD) for the treatment of acute kidney injury (AKI), which was rarely used in the United States. This study aims to compare the in-hospital all-cause mortality between AKI patients who received PD versus HD during the COVID-19 pandemic.
Method(s): In a retrospective observational study, we collected data on 259 patients with AKI who required kidney replacement therapy (KRT) in four medical centers of NYC during the Spring 2020. Patients who had ever received PD were included in the PD group (n=93), and patients who only received intermittent HD or continuous KRT were included in the HD group (n=166). Kaplan-Meier survival curves, log-rank test and Cox regression were used to compare survival between PD and HD groups.
Result(s): For the entire cohort, the mean age was 61+/-11 years; 31% were women; 96% had confirmed COVID-19. Median follow up was 21 days (IQR 12-30). Mortality was lower in PD group compared to HD group (43% vs. 60%, p=0.01). Time-dependent analyses showed that PD group was at a lower risk for mortality compared to HD group (p<0.001 for Log-rank test; Figure). After adjusting for age, sex, BMI, comorbidities, oxygenation on admission, mechanical ventilation, prone positioning, steroid use and C-reactive protein, the PD group remained to have a lower risk of mortality compared to the HD group with a HR of 0.45 (95% CI: 0.27-0.77, p=0.003).
Conclusion(s): Compared to HD, the use of PD for the treatment of AKI was associated with lower mortality in this cohort of patients treated during the COVID-19 pandemic in the Spring of 2020. Our findings demonstrate that rapid implementation of PD for the treatment of AKI was feasible and may be lifesaving

Background:The COVID-19 pandemic strained hospital resources in New York City, including those for providing dialysis. New York University Medical Center and affiliations, including New York City Health and Hospitals/Bellevue, developed a plan to offset the increased needs for KRT. We established acute peritoneal dialysis (PD) capability, as usual dialysis modalities were overwhelmed by COVID-19 AKI. Methods:Observational study of patients requiring KRT admitted to Bellevue Hospital during the COVID surge. Bellevue Hospital is one of the largest public hospitals in the United States, providing medical care to an underserved population. There were substantial staff, supplies, and equipment shortages. Adult patients admitted with AKI who required KRT were considered for PD. We rapidly established an acute PD program. A surgery team placed catheters at the bedside in the intensive care unit; a nephrology team delivered treatment. We provided an alternative to hemodialysis and continuous venovenous hemofiltration for treating patients in the intensive-care unit, demonstrating efficacy with outcomes comparable to standard care. Results:From April 8, 2020 to May 8, 2020, 39 catheters were placed into ten women and 29 men. By June 10, 39% of the patients started on PD recovered kidney function (average ages 56 years for men and 59.5 years for women); men and women who expired were an average 71.8 and 66.2 years old. No episodes of peritonitis were observed; there were nine incidents of minor leaking. Some patients were treated while ventilated in the prone position. Conclusions:Demand compelled us to utilize acute PD during the COVID-19 pandemic. Our experience is one of the largest recently reported in the United States of which we are aware. Acute PD provided lifesaving care to acutely ill patients when expanding current resources was impossible. Our experience may help other programs to avoid rationing dialysis treatments in health crises.

Background: During the COVID-19 pandemic, there has been an unparalleled burden on nephrology services to provide kidney replacement therapy to patients admitted to the hospital with COVID-19, who develop severe AKI. Given the unprecedented surge in COVID-19 admissions, ability to provide inpatient hemodialysis and continuous kidney replacement therapy (CKRT) was quickly saturated. We present data from our acute peritoneal dialysis (PD) program that was quickly assembled to provide kidney replacement therapy due to shortage of hemodialysis and CKRT resources.
Method(s): Patients admitted to an academic NYC hospital during COVID-19 pandemic with AKI requiring kidney replacement therapy were evaluated for candidacy for bedside PD catheter placement via cut-down method with the majority having COVID respiratory failure. A dedicated surgery team was assembled to place PD catheters within 12-24 hours of request by the nephrology team. Catheters were placed in patients with BMI up to 51. Patients requiring proning were not excluded. Exclusion criteria were prior lower abdominal surgery, known varices, or imminent death.
Result(s): Thirty-eight PD catheters were placed during the 4 week time period from April 8 to May 8, 2020. Majority of the catheters were placed bedside in an ICU setting (36/38 - 95%), with 2 being placed laparoscopically in the OR. There were no episodes of peritonitis. Three catheters required revision due to poor flows. Six catheters required floseal for bleeding along the catheter tract, which resolved without additional intervention. There were no major bleeding complications during PD catheter placement despite many patients being on systemic anticoagulation. Dwell volumes of up to 2.2L did not appear to have negative effects on the ability to ventilate patients. One patient required transition to hemodialysis due to catheter malfunction.
Conclusion(s): Acute peritoneal dialysis successfully allowed kidney replacement therapy for patients with severe AKI during the peak phase of the COVID-19 pandemic at our hospital in NYC. There were no major complications with acute PD catheter placements

Background: Due to increased risk for infection, fluid leak, metabolic complications and poor uremic solute clearance, concerns have been raised in using peritoneal dialysis in obese patients. However, due to unprecedented need for renal replacement therapy (RRT) in New York City during the COVID-19 pandemic, acute peritoneal dialysis (APD) was initiated in patients regardless of body mass index (BMI).
Method(s): 36 patients who received PD between April 8, 2020 and May 8,2020 were categorized into 3 groups based on BMI calculated using admission height and weight. Group 1 with BMI < 30, Group 2 with BMI 30-40 and Group 3 with BMI > 40 kg/ m². Treatment goals included correction of hyperkalemia, hyperphosphatemia, acid-base abnormalities, reduction in blood urea nitrogen (BUN), creatinine and maintaining euvolemia. All patients were initially started on manual exchanges every 1-2 hours (Total volume 10-13L/24 hours) and eventually most were changed to automated PD (Total volume 18-20L/24 hours). We compared the frequency of treatment-related complications among the groups.
Result(s): Of the 36 patients, 13 had BMI < 30, 18 patients had BMI 30-40, and 5 had BMI > 40, one of whom had BMI > 50 kg/ m². Patients showed improvement in serum creatinine, BUN, phosphorus, potassium, and bicarbonate. All had adequate ultrafiltration and improved volume status after optimization of PD prescription. No differences were observed between groups in achievement of treatment goals. No patients in any group required discontinuation of PD because of treatment-related complications or insufficient dialysis.
Conclusion(s): Acute PD was successfully performed in obese, and morbidly obese patients during the COVID-19 pandemic. Treatment goals were achieved based on relevant parameters and there were no increases of treatment related complications compared to non-obese patients. Acute PD should not be restricted based on elevated BMI