Diálise Urgent-start: comparação de complicações e desfechos entre diálise peritoneal e hemodiálise.
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Data
2018-10-26
Autores
Dias, Dayana Bitencourt [UNESP]
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Universidade Estadual Paulista (Unesp)
Resumo
Introdução: Poucos trabalhos avaliaram a viabilidade e os resultados entre diálise peritoneal (DP) e hemodiálise (HD) no início urgente de terapia renal substitutiva (TRS). Objetivo: Comparar DP e HD como opções de início urgente de TRS, quanto à evolução, desfechos e complicações dos pacientes. Método: Estudo quasi experimental com pacientes incidentes em DP e HD em hospital universitário brasileiro, no período de julho/2014 a dezembro/2016. Incluídos indivíduos DRC estádio final que necessitaram de TRS imediata, ou seja, HD por meio de CVC ou DP cujo cateter foi implantado por nefrologista e utilizado em 72 horas, sem treinamento prévio. Pacientes em DP foram submetidos, inicialmente, a DP de alto volume (DPAV) para compensação metabólica. Após alta hospitalar, permaneciam em DP intermitente na unidade de diálise até efetivação do treinamento. Foram comparados: complicações mecânicas e infecciosas, recuperação de função renal e sobrevida. Resultados: Foram incluídos 93 pacientes em DP (G1) e 91, em HD (G2). Os grupos G1 e G2 foram semelhantes quanto à idade (58+17 vs 60+15; p=0,49), frequência de diabetes mellitus (37,6 vs 50,5%; p=0,10), outras comorbidades (74,1 vs 71,4%; p=0,67) e parâmetros bioquímicos ao início da TRS – creatinina (9,1+4,1 vs 8,0+2,8; p=0,09), albumina sérica (3,1+0,6 vs 3,3+0,6; p=0,06) e hemoglobina (9,5+1,8 vs 9,8+2,0; p=0,44). Após seguimento mínimo de 180 dias e máximo de dois anos, não houve diferença quanto a complicações mecânicas (24,7 vs 37,4%; p=0,06) ou bacteremia (15,0 vs 24,0%; p=0,11), contudo houve diferença em relação a infecção de orifício de saída (25,8 vs 39,5%; p=0,04) e manutenção da diurese (700 (0 – 1500) vs 0 (0 – 500); p<0,001), com melhores resultados no G1. Houve melhor controle de fósforo em 180 dias no G1 (62,4 vs 41,8%; p=0,008), com menor necessidade do uso de quelante (28 vs 55%; p<0,001), de eritropoetina (18,3 vs 49,5%; p<0,001) e anti-hipertensivos (11,8 vs 30,8%; p=0,003). O tempo livre para o óbito foi maior no G1 (Log-rank = 0,02). Em análise multivariada, a DP foi fator protetor para o óbito [OR:0,25 (0,08-0,71)] e preditor de recuperação de função renal [OR:3,95 (1,01-15,4)]. Conclusão: A DP mostrou-se alternativa viável e segura em relação à HD no cenário de início urgente de TRS, com taxas de complicações e desfechos clínicos semelhantes ou melhores em relação a HD, destacando os resultados quanto ao óbito e recuperação de função renal.
Background: Few studies have evaluated the feasibility and results of peritoneal dialysis (PD) and hemodialysis (HD) at the urgent-start of renal replacement therapy (RRT). Objective: We compared PD and HD as options for urgent-start of RRT regarding the evolution, complications and outcomes of patients. Method: End-stage renal disease (ESRD) patients who initiated dialysis urgently without a pre-established functional vascular acess or PD catheter were included in a period between July/2014 to December/2016, from a Brazilian single centre. In urgent-start PD, nephrologists performed the Tenckhoff catheter insertions. It was used high volume PD (HVPD) right after 72 hours PD catheter placement, and it was kept until metabolic and fluid control. After hospital discharge, patients were treated with intermittent PD on alternate days at the dialysis unit, until family training. Results: Ninety-three patients in PD (G1) and 91 in HD (G2) were included. Comparing the G1 group with G2, they were similar in age (58±17 vs 60±15; p= 0.49), frequency of diabetes mellitus (37.6 vs 50.5%; p= 0.10), others comorbidities (74.1 vs 71.4%; p= 0.67) and biochemical parameters to early RRT - creatinine (9.1+4.1 vs 8.0+2.8; p= 0.09), serum albumin (3.1+0.6 vs 3.3+0.6; p= 0.06) and hemoglobin (9.5+1.8 vs 9.8+2.0; p= 0.44). There was no difference between the groups in mechanical complications (24.7 vs 37.4%; p= 0.06) and bacteremia (15 vs 24%; p= 0.11). Exit site infection (ESI) (25.8 vs 39.5%; p = 0.04) and residual diuresis (700 (0 – 1500) vs 0 (0 – 500); p<0.001). There was better control of phosphorus in 180 days in G1 (62.4% vs 41.8%; p= 0.008), with less need for phosphorus-chelating (28.0% vs 55.0%, p<0.001), erythropoietin (18.3% vs 49.5%; p<0.001) and antihypertensive drugs (11.8% vs 30.8%; p= 0.003). The survival curve was better in G1 (Log-rank = 0.02). In multivariate analysis, PD was a protective factor for death [OR: 0.25 (0.08-0.71)] and a predictor of renal function recovery [OR: 3.95 (1.01-15.4)]. Conclusion: PD was a viable and safe alternative to HD in the scenario of urgent-start of RRT, with similar or better clinical and complication rates relative to HD, highlighting the results regarding death and recovery of renal function.
Background: Few studies have evaluated the feasibility and results of peritoneal dialysis (PD) and hemodialysis (HD) at the urgent-start of renal replacement therapy (RRT). Objective: We compared PD and HD as options for urgent-start of RRT regarding the evolution, complications and outcomes of patients. Method: End-stage renal disease (ESRD) patients who initiated dialysis urgently without a pre-established functional vascular acess or PD catheter were included in a period between July/2014 to December/2016, from a Brazilian single centre. In urgent-start PD, nephrologists performed the Tenckhoff catheter insertions. It was used high volume PD (HVPD) right after 72 hours PD catheter placement, and it was kept until metabolic and fluid control. After hospital discharge, patients were treated with intermittent PD on alternate days at the dialysis unit, until family training. Results: Ninety-three patients in PD (G1) and 91 in HD (G2) were included. Comparing the G1 group with G2, they were similar in age (58±17 vs 60±15; p= 0.49), frequency of diabetes mellitus (37.6 vs 50.5%; p= 0.10), others comorbidities (74.1 vs 71.4%; p= 0.67) and biochemical parameters to early RRT - creatinine (9.1+4.1 vs 8.0+2.8; p= 0.09), serum albumin (3.1+0.6 vs 3.3+0.6; p= 0.06) and hemoglobin (9.5+1.8 vs 9.8+2.0; p= 0.44). There was no difference between the groups in mechanical complications (24.7 vs 37.4%; p= 0.06) and bacteremia (15 vs 24%; p= 0.11). Exit site infection (ESI) (25.8 vs 39.5%; p = 0.04) and residual diuresis (700 (0 – 1500) vs 0 (0 – 500); p<0.001). There was better control of phosphorus in 180 days in G1 (62.4% vs 41.8%; p= 0.008), with less need for phosphorus-chelating (28.0% vs 55.0%, p<0.001), erythropoietin (18.3% vs 49.5%; p<0.001) and antihypertensive drugs (11.8% vs 30.8%; p= 0.003). The survival curve was better in G1 (Log-rank = 0.02). In multivariate analysis, PD was a protective factor for death [OR: 0.25 (0.08-0.71)] and a predictor of renal function recovery [OR: 3.95 (1.01-15.4)]. Conclusion: PD was a viable and safe alternative to HD in the scenario of urgent-start of RRT, with similar or better clinical and complication rates relative to HD, highlighting the results regarding death and recovery of renal function.
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Palavras-chave
diálise peritoneal urgent-start, diálise peritoneal não planejada, diálise urgent-start, unplanned peritoneal dialysis, urgent-start peritoneal dialysis