Starting PD within 30 days of placing the catheter carried about three times the risk of an early complication

🎧 Listen: Weekly · Nov 2, from 14:54.

The question

The first months on peritoneal dialysis are when patients are most likely to run into trouble and transfer to hemodialysis: catheter flow problems, leaks and pain. Guidelines set targets for when to start dialysis, but they do not distinguish between modalities, and unlike fistula planning there is no guidance on the eGFR at which a PD catheter should be placed.

What the study did

A cohort study using the North American PD Catheter Registry: adults undergoing a first PD catheter insertion before dialysis at 23 institutions in Canada and the United States, November 2015 to October 2022. The exposure was the eGFR recorded at insertion (the decision-making eGFR, reported by local laboratories), 9 or below versus above 9. The primary outcome was PD-related complications within 90 days leading to an emergency department visit, hospitalization, procedure or change in PD therapy. Cause-specific hazards models were stratified by institution, included PD start as a time-dependent covariate, and adjusted for embedded catheters, age, sex, BMI, prior abdominal surgery, insertion method, coronary artery disease, heart failure and liver disease.

What they found

• Of 1,537 patients, 1,033 (67%) had an eGFR of 9 or below at insertion. That group was younger, more often female, and had less diabetes, coronary disease and heart failure.
• Crude 90-day complications: 22% at an eGFR of 9 or below vs 18% above 9 (p=0.4); adjusted hazard ratio 0.90 (95% CI, 0.68 to 1.19). A difference of that size could be chance.
• Within the group placed at an eGFR of 9 or below, each 1 mL/min/1.73 m² lower eGFR was associated with about 10% higher risk (adjusted HR 1.10; 95% CI, 1.01 to 1.19). No association was seen above 9.
• Timing mattered more. Starting PD within 30 days of insertion, compared with starting later, carried an adjusted hazard ratio of 3.15 (95% CI, 1.48 to 6.67); compared with not starting within 90 days, 4.27. Embedded catheters appeared protective (HR 0.30).
• The most common complications were flow restriction (7% vs 5%), leak (4% vs 2%) and pain (3% in both). Complications leading to hemodialysis were 9% vs 7%, with no significant difference.
• Median time from insertion to PD start was 23 days in the low-eGFR group and 37 days above 9.

Why it matters

The authors conclude that where there is no urgency, it may be better to wait more than 30 days before starting PD, and ask whether catheters should be placed at a slightly higher eGFR to allow more time to manage early complications. This fits older work on urgent-start PD, which reported more dialysate leaks when PD began soon after insertion.

Our take: plan the PD catheter the way you would plan a fistula, before you need it, so that there is a month between insertion and the first exchange.

Caveats

Observational, so the timing itself may not be the cause: patients who started sooner may have been sicker or more symptomatic, and the registry did not capture the indication for starting. The eGFR was recorded as whole numbers and not standardized across sites, although a sensitivity analysis using the 2021 CKD-EPI equation did not change the results. The confidence interval around the 30-day finding is wide. Pre-dialysis care duration was not captured.

Funding and ties: funded by the Canadian Institutes of Health Research, with support from the ISPD North American Chapter, the Ontario Renal Network, Vantive Healthcare and Medtronic. Two authors are co-inventors of a dialysis access system, and several report ties to dialysis companies; full disclosures are in the paper.

The source: Dhoot A, Quinn RR, Clarke A, et al. Association of Estimated GFR at the Time of Peritoneal Dialysis Catheter Insertion With Dialysis-Related Complications. Am J Kidney Dis. Published online October 26, 2026. doi:10.1053/j.ajkd.2026.06.031 Read the original

🎧 Listen: Weekly · Nov 2, from 14:54.

Physician-led, AI-assisted. Dr. Wael Hussein chooses every item NephSpace covers and reviews and edits every story before it is published. The first draft was written in our own words with AI (Claude, by Anthropic) from the full text of the paper and checked against our reading notes; Dr. Hussein then reviewed and edited it. For education and information only, not medical advice. Please talk to your own physician or care team about your health. Clinicians: read the original before changing practice. See our disclaimer and disclosures. Spotted an error? Tell us.