The role of PD in saving COVID lives

The novel coronavirus disease COVID-19 emerged in December 2019 and within 6 months has developed into a pandemic with more than 5 million people affected globally.  This has had a major impact on the peritoneal dialysis world.  The disease focus shifted from China to Europe and North America by March.  Theoretically, people doing PD in their own homes should fare better than those cohorted on HD units.  In March, as the COVID epidemic escalated in Europe and N America, there was no guidance how PD units should operate.  Amazingly, considering the simultaneous clinical pressures for the individuals in the ISPD guidelines and standards committee, we managed to produce a document “Strategies regarding COVID-19 in PD patients” within a couple of weeks.  This document can be found in our website  The translations into French, Spanish, Chinese, Polish, Hungarian, Portuguese and Japanese that were then spontaneously offered and completed by members of the ISPD demonstrate the truly global nature of COVID-19.   The strategy is simple – keep people doing PD in their own home and away from renal units and hospitals.

The next PD-related crisis was the unexpected demand for renal support in ICUs.  Around 25% of patients on ventilators for COVID-19 develop AKI.  International focus had been on acquiring large numbers of ventilators.  Suddenly there was a shortage of the hardware for renal support in ICU – machines and filters – exacerbated by a clotting problems.  There was therefore an urgent need for alternative ways to deliver renal replacement in the ICU setting – and this led to a demand in many centres to explore PD.  There are, of course, many hurdles – most centres have no experience of PD in ICU, never mind the challenges of catheter insertion, developing appropriate prescriptions, finding staff to manage the PD in the ICU – just to mention a few.  Fortunately, there were a few centres in the UK and US who had started doing PD for these patients, and the ISPD guideline for PD in AKI which had been published in 2014 was in the process of being updated with a final version almost ready.  Given the urgency of the situation, the ISN and the ISPD collaborated in putting together a webinar on PD in COVID-related AKI highlighting the new guideline and UK and US experience – it can be found at this link. This was so popular (almost 1000 people ‘attended’), that a 2nd webinar was run 2 weeks later (link).  The COVID experience has taught us that PD is a viable renal replacement option for AKI in ICU.  The COVID era is with us for some time ahead – perhaps an opportunity for an international multicentre randomised study with haemofiltration?

And now, in many countries we are beyond the peak.  Certainly, in the UK, at least, the experience of COVID-19 in HD units has resulted in an awareness that dialysis at home has many advantages.  There has been a dramatic increase in people choosing PD, even patients with functioning fistulas who were about to start HD.  There will therefore be many clinicians needing PD education.  It is fortuitous that the two most recently published  are related to PD access and PD prescribing.

Edwina Brown, Chair of ISPD guideline and standards committee
Hammersmith Hospital, London, UK