Acute peritoneal dialysis in COVID-19

In December 2019, the world faced the new challenge of a novel pandemic virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 (COVID-19)). Acute kidney injury (AKI) has been increasingly recognized in those patients with severe disease resulting in a significant strain on dialysis resources and staff even in high resource countries. Health-care systems have been severely impacted due to a rapidly increasing number of patients globally, resulting in significant shortages of medical supplies, especially respirators and personal protective equipment (PPE). A large number of health-care workers have been infected with the virus, resulting in reduced workforce and significant mental stress among staff who are faced with the risks of exposure to COVID-19 patients. Several subspecialties of medicine have put forward their strategies regarding how to respond to COVID-19 pandemic. European Dialysis Working Group, American Society of Nephrology, and International Society for Peritoneal Dialysis have recently announced their recommendation regarding the management of chronic kidney disease patients in hemodialysis and peritoneal dialysis (PD) units during COVID-19. However, dialysis management of AKI from COVID-19 has not gained much attention. The more severe the shortage of resources, the more important exploring the various modalities of dialysis for AKI have become. The massive influx of intensive care unit (ICU) patients has resulted in many units not having sufficient facilities and resources to offer acute hemodialysis (AHD) or continuous extracorporeal renal replacement therapies (CRRTs). Along with this has been the observation that many of the COVID-19 patients have abnormalities of coagulation and repeated clotting of extracorporeal circuits along with running out of dialysate has presented additional problems. PD offers a number of potential advantages in this scenario as it is highly costeffective, requires minimal training of staff, is not affected by hypercoagulability, and, despite its reduced popularity among intensivists, has been shown in randomized trials to have equivalent survival in critically ill patients. This article addresses the key question of whether acute PD has a role to play in COVID-19-induced AKI. COVID-19 predominantly involves the respiratory system. Around 5% of the cases are critically ill patients who develop a pneumonitis which eventually leads to acute respiratory distress syndrome (ARDS). The kidney is not the main target of SARS-CoV-2, but AKI can occur up to 4% to 23%. Direct infection of tubular cells and peritubular capillary thrombosis has been demonstrated, and this along with acute tubular injury associated with multiorgan failure has resulted in approximately 25% of critically ill patients requiring acute dialysis. Extracorporeal therapies have been the mainstay of treatment of AKI in COVID-19, although apart from dialytic management of the AKI, some units have tried hemoperfusion/hemadsorption systems to remove inflammatory cytokines in COVID-19 with cytokine storm syndrome. It is uncertain whether it is a beneficial treatment and needs further clinical evaluation. Severely hypoxic patients may be offered extracorporeal membrane oxygenation (ECMO) therapy which can aggravate AKI, however, CRRT can be incorporated into the main ECMO circuit as a therapeutic option. As the lack of dialysis resources have become more apparent, many units have turned to PD for treatment of AKI for COVID-19 patients. If the natural history of patients with AKI from COVID-19 is similar to those of sepsis, PD could be considered a suitable modality. Two randomized single-center studies in ICU patients showed no significant difference in mortality rates when comparing high volume PD and daily AHD or prolonged intermittent hemodialysis (PIRRT), and another study showed patients randomized to tidal PD resulted in a slightly lower mortality rate than those on CRRT. Moreover, two systematic reviews also demonstrate comparable mortality of PD versus extracorporeal dialysis in critically