Urgent‐start peritoneal dialysis versus conventional‐start peritoneal dialysis for people with chronic kidney disease

Htay Htay; David W Johnson; Jonathan C Craig; Armando Teixeira-Pinto; Carmel M Hawley; Yeoungjee Cho

doi:10.1002/14651858.CD012913.pub2

. 2020 Dec 15;2020(12):CD012913. doi: 10.1002/14651858.CD012913.pub2

Urgent‐start peritoneal dialysis versus conventional‐start peritoneal dialysis for people with chronic kidney disease

Htay Htay ¹, David W Johnson ^2,^5,⁶, Jonathan C Craig ^3,⁷, Armando Teixeira-Pinto ^3,⁴, Carmel M Hawley ^2,⁸, Yeoungjee Cho ^2,^8,^✉

Editor: Cochrane Kidney and Transplant Group

PMCID: PMC8094169 PMID: 33320346

Abstract

Background

Urgent‐start peritoneal dialysis (PD), defined as initiation of PD within two weeks of catheter insertion, has been emerging as an alternative mode of dialysis initiation for patients with chronic kidney disease (CKD) requiring urgent dialysis without established permanent dialysis access. Recently, several small studies have reported comparable patient outcomes between urgent‐start and conventional‐start PD.

Objectives

To examine the benefits and harms of urgent‐start PD compared with conventional‐start PD in adults and children with CKD requiring long‐term kidney replacement therapy.

Search methods

We searched the Cochrane Kidney and Transplant Register of Studies up to 25 May 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov.

For non‐randomised controlled trials, MEDLINE (OVID) (1946 to 27 June 2019), EMBASE (OVID) (1980 to 27 June 2019), Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov (up to 27 June 2019) were searched.

Selection criteria

All randomised controlled trials (RCTs) and non‐RCTs comparing the outcomes of urgent‐start PD (within 2 weeks of catheter insertion) and conventional‐start PD ( ≥ 2 weeks of catheter insertion) treatment in children and adults CKD patients requiring long‐term dialysis were included. Studies without a control group were excluded.

Data collection and analysis

Data were extracted and quality of studies were examined by two independent authors. The authors contacted investigators for additional information. Summary estimates of effect were examined using random‐effects model and results were presented as risk ratios (RR) with 95% confidence intervals (CI) as appropriate for the data. The certainty of evidence for individual outcome was assessed using the GRADE approach.

Main results

A total of 16 studies (2953 participants) were included in this review, which included one multicentre RCT (122 participants) and 15 non‐RCTs (2831 participants): 13 cohort studies (2671 participants) and 2 case‐control studies (160 participants). The review included unadjusted data for analyses due to paucity of studies reporting adjusted data.

In low certainty evidence, urgent‐start PD may increase dialysate leak (1 RCT, 122 participants: RR 3.90, 95% CI 1.56 to 9.78) compared with conventional‐start PD which translated into an absolute number of 210 more leaks per 1000 (95% CI 40 to 635).

In very low certainty evidence, it is uncertain whether urgent‐start PD increases catheter blockage (4 cohort studies, 1214 participants: RR 1.33, 95% CI 0.40 to 4.43; 2 case‐control studies, 160 participants: RR 1.89, 95% CI 0.58 to 6.13), catheter malposition (6 cohort studies, 1353 participants: RR 1.63, 95% CI 0.80 to 3.32; 1 case‐control study, 104 participants: RR 3.00, 95% CI 0.64 to 13.96), and PD dialysate flow problems (3 cohort studies, 937 participants: RR 1.44, 95% CI 0.34 to 6.14) compared to conventional‐start PD.

In very low certainty evidence, it is uncertain whether urgent‐start PD increases exit‐site infection (2 cohort studies, 337 participants: RR 1.43, 95% CI 0.24 to 8.61; 1 case‐control study, 104 participants RR 1.20, 95% CI 0.41 to 3.50), exit‐site bleeding (1 RCT, 122 participants: RR 0.70, 95% CI 0.03 to 16.81; 1 cohort study, 27 participants: RR 1.58, 95% CI 0.07 to 35.32), peritonitis (7 cohort studies, 1497 participants: RR 1.00, 95% CI 0.68 to 1.46; 2 case‐control studies, 160 participants: RR 1.09, 95% CI 0.12 to 9.51), catheter readjustment (2 cohort studies, 739 participants: RR 1.27, 95% CI 0.40 to 4.02), or reduces technique survival (1 RCT, 122 participants: RR 1.09, 95% CI 1.00 to 1.20; 8 cohort studies, 1668 participants: RR 0.90, 95% CI 0.76 to 1.07; 2 case‐control studies, 160 participants: RR 0.92, 95% CI 0.79 to 1.06).

In very low certainty evidence, it is uncertain whether urgent‐start PD compared with conventional‐start PD increased death (any cause) (1 RCT, 122 participants: RR 1.49, 95% CI 0.87 to 2.53; 7 cohort studies, 1509 participants: RR 1.89, 95% CI 1.07 to 3.3; 1 case‐control study, 104 participants: RR 0.90, 95% CI 0.27 to 3.02; very low certainty evidence). None of the included studies reported on tunnel tract infection.

Authors' conclusions

In patients with CKD who require dialysis urgently without ready‐to‐use dialysis access in place, urgent‐start PD may increase the risk of dialysate leak and has uncertain effects on catheter blockage, malposition or readjustment, PD dialysate flow problems, infectious complications, exit‐site bleeding, technique survival, and patient survival compared with conventional‐start PD.

Plain language summary

Is urgent‐start peritoneal dialysis safe for patients with chronic kidney disease?

What is the issue?

Peritoneal dialysis is a form of kidney replacement therapy in which the lining of the abdomen is used as a filter for dialysis. The dialysis fluid is introduced via a tube which is placed into the abdomen, called a peritoneal dialysis catheter. Traditionally, dialysis is delayed for two weeks after catheter placement, in order to allow proper wound healing. However, some studies reported that patients with chronic kidney disease who urgently need to start dialysis within two weeks of catheter insertion (urgent‐ start peritoneal dialysis) experienced comparable outcomes to others who commenced dialysis more than two weeks after catheter insertion (conventional‐start peritoneal dialysis).

What did we do?

We conducted a systematic review to examine the complications and outcomes of patients with chronic kidney disease who started peritoneal dialysis urgently within two weeks of insertion of peritoneal dialysis catheter.

What did we find?

We identified 16 studies (2953 participants) examining the outcomes of urgent versus conventional start peritoneal dialysis. When we compared results from patients who initiated dialysis two weeks after catheter insertion, patients who initiated dialysis urgently were more likely to have leakage of dialysis fluid outside the abdominal cavity into the skin near the exit site of peritoneal dialysis catheter. The differences in infection of the lining of the abdomen (peritonitis), infection at the exit point of the peritoneal dialysis catheter (exit‐site infection), mechanical complications of peritoneal dialysis (including catheter blockage, catheter malposition and catheter readjustment), patients remaining on peritoneal dialysis (technique survival), and death between patients who started dialysis urgently and those who waited for two weeks after catheter insertion remain unclear.

Conclusions

In patients with chronic kidney disease who require dialysis urgently without ready‐to‐use dialysis access in place, peritoneal dialysis may increase dialysate leak. However, the overall risks of infectious and other non‐infectious complications between urgent‐start peritoneal dialysis and conventional‐start peritoneal dialysis remains unclear.

Summary of findings

Background

Description of the condition

People with chronic kidney disease (CKD) requiring long‐term kidney replacement therapy (KRT) is a common and growing problem affecting over two million people worldwide (AIHW 2016; Couser 2011; Gilg 2016). In the USA, CKD consumes 6.7% of total Medicare budget to care for less than 1% of the covered population (ISN 2015). Increasing utilization of home‐based dialysis, such as peritoneal dialysis (PD), can lead to an annual cost saving of up to 40% compared to facility haemodialysis (HD) (KHA 2012; KHA 2016).

PD is a type of dialysis that uses the peritoneum in a person’s abdomen as the membrane through which fluid and dissolved substances are exchanged with the blood. Even though PD is a relatively simple technique to master and has been shown to improve many patient‐level clinical outcomes (e.g. an initial survival advantage compared to HD, better preservation of residual kidney function, superior patient‐level satisfaction, and preservation of vascular access for future use (Mehrotra 2016; Tokgoz 2009), only approximately 11% of the global dialysis population are currently receiving PD as their dialysis modality (Jain 2012; Li 2017). One of the main impediments to growth in PD uptake has been a clinician reluctance to utilize PD as the preferred dialysis modality of choice when there is no established functional dialysis access in place (e.g. PD catheter or mature arteriovenous fistula/graft). This has been driven by traditional practice to delay commencement of PD by at least two weeks from the time of PD catheter insertion to prevent complications, as recommended by the International Society for Peritoneal Dialysis (ISPD) and European Renal Best Practice (ERBP) guidelines (Dombros 2005; Figueiredo 2010). These recommendations are based on a weak level of evidence (Dombros 2005; Figueiredo 2010), which has variably shown that early use of a PD catheter shortly after its insertion is associated with increased risks of early complications, such as dialysate leaks, infection and catheter dysfunction (See 2017; Yang 2011). However, there are several advantages of urgent‐start PD, for example, avoiding temporary vascular catheters and their attendant risks (including bloodstream infections), avoiding initiation of a dialysis modality that is contrary to patient choice, and possibly avoiding the risk of patients remaining on in‐centre HD rather than home dialysis. These would have to be balanced against the apparent increased risk of dialysate leaks versus elective PD start. The effect of urgent‐start PD, defined as initiation of PD to treat patients who require dialysis imminently without established dialysis access, on long‐term patient outcomes remains uncertain.

Unfortunately, the need to commence dialysis without mature permanent dialysis access in situ is a relatively common phenomena, affecting approximately 20% of patients who present ‘late’ to nephrology service whereby patients need to commence dialysis within three months of being first reviewed by nephrologist (Foote 2014). The practice of urgent‐start PD has been increasingly adopted across both developed (Arramreddy 2014; See 2017) and developing countries (Bitencourt Dias 2017). However, at present, there is no universally agreed definition regarding the duration between PD catheter insertion and commencement that qualifies as urgent‐start PD. Moreover, whether there exists a 'necessary' wait period to minimise the risk of complications within this clinical context is unknown. The ISPD recommends to use PD catheters at least two weeks after their insertion (Figueiredo 2010). Moreover, recently published randomised controlled trial (RCT) demonstrated an increased risk of leaks in patients who started PD at one week compared to those starting at two weeks or later (Timely PD 2010). The variation in duration between PD catheter insertion and commencement, fill volume, methods of catheter insertion across the studies involving urgent‐start PD might potentially influence the observed outcomes. Therefore, it is important to conduct a detailed examination of the effect of urgent‐start PD on both short‐ and long‐term patient‐level outcomes compared to conventional‐start PD treatment regimens including subgroup analyses (e.g. duration between PD catheter placement and commencement, fill volume and insertion technique) to examine their relationship.

Description of the intervention

Unlike conventional‐start PD where initiation of PD occurs > two weeks after PD catheter placement, urgent‐start PD takes an approach to initiate PD within two weeks of PD catheter insertion.

How the intervention might work

Recommendation to delay the initiation of PD till two weeks after PD catheter insertion in conventional‐start PD is to minimize the early complication of PD including leak (Yang 2011). Urgent‐start PD is initiated with low fill volumes in the supine position using a cycler to reduce the intra‐abdominal pressure in order to minimize the risk of pericatheter leak. Treatment can be delivered in both inpatient and outpatient settings.

Why it is important to do this review

Although urgent‐start PD has been received as a conceptually positive initiative with reassuring early outcomes, the vast majority of evidence has been generated from single‐centre observational studies with relatively small patient numbers (Casaretto 2012; Ghaffari 2012; Jo 2007; Koch 2012; Lobbedez 2008), which has resulted in ad hoc implementation rather than a ‘standard’ care across the world. The objective of this review is to conduct a comprehensive examination of the literature to examine all possible outcomes from urgent‐start PD compared to those of conventional‐start PD treatments.

Objectives

This review aims to look at the benefits and harms of urgent‐start PD compared with conventional‐start PD in adults and children with CKD requiring long‐term KRT.

Methods

Criteria for considering studies for this review

Types of studies

All RCTs and non‐RCTs comparing urgent‐start PD to conventional‐start PD treatments.

Types of participants

Inclusion criteria

Participants included in this review were both adults and children with CKD who required dialysis treatment. Participants had a PD catheter inserted, which could be their first PD catheter or any subsequent catheter.

Exclusion criteria

The review did not include data obtained from patients with acute kidney injury as recovery of kidney function may potentially introduce the risk of detection bias (i.e. those with rapid recovery may not remain on PD for 30 or 90 days to capture clinical events of interest).

Types of interventions

Studies comparing two different PD therapy commencement types were included in this review. They could be broadly divided into urgent‐start PD and conventional‐start PD groups.

Intervention: patients commenced on urgent‐start PD, defined as initiation of PD therapy within two weeks of catheter placement.
Comparator: patients commenced on conventional‐start PD, defined as initiation of PD therapy at or after two weeks of catheter placement.

Types of outcome measures

Primary outcomes

Mechanical complications occurring within 30 days (early complication) and 90 days (late complication) of commencement of PD (proportion of patients for each relevant outcome listed below).
- Dialysate leak
- Catheter blockage
- Catheter malposition
- PD dialysate flow problem.
Exit‐site complications occurring within 30 days (early complication) and 90 days (late complication) of commencement of PD.
- Exit‐site infection (proportion of patients with exit‐site infection and episodes of exit‐site infections per patient‐year)
- Tunnel tract infection (proportion of patients with tunnel tract infection and episodes of tunnel tract infections per patient‐year)
- Exit‐site bleeding (proportion of patients developing exit‐site bleeding).
Technique survival (number of patients remaining on PD at study completion).

Secondary outcomes

Peritonitis occurring within 30 days (early complication) and 90 days (late complication) of commencement of PD (proportion of patients developing peritonitis and episodes of peritonitis per patient‐year)
Catheter re‐adjustment within 30 days (early complication) and 90 days (late complication) of commencement of PD (proportion of patients requiring intervention for catheter malfunction
Catheter survival
Interim HD (number of patients requiring temporary HD after PD commencement)
Hospitalisation (average days spent in hospital or number of hospitalisation episodes)
PD training duration (number of days from PD commencement to PD at home)
Death (all causes)
Adverse effects (including pain/discomfort)
Quality of life (QoL)
Cost of dialysis

Search methods for identification of studies

Electronic searches

We searched the Cochrane Kidney and Transplant Register of Studies up to 25 May 2020 through contact with the Information Specialist using search terms relevant to this review. The Register contains studies identified from the following sources.

Monthly searches of the Cochrane Central Register of Controlled Trials (CENTRAL)
Weekly searches of MEDLINE OVID SP
Handsearching of kidney‐related journals and the proceedings of major kidney conferences
Searching of the current year of EMBASE OVID SP
Weekly current awareness alerts for selected kidney and transplant journals
Searches of the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

Studies contained in the Register are identified through search strategies for CENTRAL, MEDLINE, and EMBASE based on the scope of Cochrane Kidney and Transplant. Details of these strategies, as well as a list of hand searched journals, conference proceedings and current awareness alerts, are available in the Specialised Register section of information about Cochrane Kidney and Transplant.

See Appendix 1 for search terms used in strategies for this review.

For non‐randomised controlled trials, MEDLINE (OVID) (1946 ‐ 27 June 2019), EMBASE (OVID) (1980 ‐ 27 June 2019), International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov were searched.

Searching other resources

Reference lists of review articles, relevant studies, and clinical practice guidelines.
Letters seeking information about unpublished or incomplete trials to investigators known to be involved in previous studies.

Data collection and analysis

Selection of studies

The search strategy described was used to obtain titles and abstracts of studies that may be relevant to the review. The titles and abstracts will be screened independently by two authors, who will discard studies that are not applicable; however, studies and reviews that might include relevant data or information on studies will be retained initially. Two authors will independently assess retrieved abstracts and, if necessary, the full text of these studies to determine which studies satisfy the inclusion criteria.

Data extraction and management

Data extraction was carried out independently by two authors using standard data extraction forms. Studies reported in non‐English language journals were translated before assessment. Where more than one publication of one study exists, reports were grouped together and the publication with the most complete data were used in the analyses. Where relevant outcomes are only published in earlier versions, these data were used.

Assessment of risk of bias in included studies

Randomised controlled trials

The following items were independently assessed by two authors using the risk of bias assessment tool for RCTs (Higgins 2011) (see Appendix 2).

Was there adequate sequence generation (selection bias)?
Was allocation adequately concealed (selection bias)?
Was knowledge of the allocated interventions adequately prevented during the study?
- Participants and personnel (performance bias)
- Outcome assessors (detection bias)
Were incomplete outcome data adequately addressed (attrition bias)?
Are reports of the study free of suggestion of selective outcome reporting (reporting bias)?
Was the study apparently free of other problems that could put it at a risk of bias?

Non‐randomised controlled trials

The Newcastle‐Ottawa Scale (www.ohri.ca/programs/clinical_epidemiology/nosgen.pdf) for assessing the quality of non‐randomised studies was used.

For case control studies the following items were evaluated.
- Selection (adequacy of definition, representativeness of the cases, selection of controls, definition of controls)
- Comparability (comparability of cases and controls on the basis of the design or analysis)
- Exposure (ascertainment of exposure, same method of ascertainment for cases and controls, non‐response rate).
For cohort studies the following items were evaluated.
- Selection (representativeness of the exposed cohort, selection of the non‐exposed cohort, ascertainment of exposure, demonstration that outcome of interest was not present at start of study)
- Comparability (comparability of cohorts on the basis of the design or analysis)
- Outcome (assessment of outcome, adequacy of follow‐up and duration of follow‐up).

Measures of treatment effect

For dichotomous outcomes (e.g. death, mechanical complications within one month of commencement of PD) results were expressed as risk ratio (RR) with 95% confidence intervals (CI). Where continuous scales of measurement were used to assess the effects of treatment (e.g. duration of hospitalisation, duration of PD training), the mean difference (MD) was used, or the standardised mean difference (SMD) if different scales had been used. SMD was re‐expressed using a familiar instrument, by applying the calculated SMD back into one of the original studies and depicted on the scale used in that study. Studies may report different risk measures such as hazards ratios, odds ratio (OR) or relative risk. We analysed the studies by the type of measure reported whenever possible. However, in the present review, the event rate was very small for case‐control studies which led to similar values obtained for odds ratio and risk ratio were similar. Hence, we used risk ratio instead of the OR for case‐control studies. The results of studies with the same risk measure were combined using the generic inverse‐variance method and a random effect model.

Unit of analysis issues

The present review included only one RCT, which adopted parallel design. There was no issue with unit of analysis.

Dealing with missing data

Any further information required from the original author was requested by written correspondence (e.g. emailing corresponding author/s) and any relevant information obtained in this manner were included in the review. Evaluation of important numerical data, such as screened, randomised patients as well as intention‐to‐treat, as‐treated and per‐protocol population, was carefully performed. Attrition rates, for example drop‐outs, losses to follow‐up and withdrawals, were investigated. Issues of missing data and imputation methods (for example, last‐observation‐carried‐forward) were critically appraised (Higgins 2011).

Assessment of heterogeneity

The heterogeneity was first assessed by visual inspection of the forest plot. We quantified statistical heterogeneity using the I² statistic, which describes the percentage of total variation across studies that is due to heterogeneity rather than sampling error (Higgins 2003). A guide to the interpretation of I² values was based on the following:

0% to 40%: might not be important
30% to 60%: may represent moderate heterogeneity
50% to 90%: may represent substantial heterogeneity
75% to 100%: considerable heterogeneity.

The importance of the observed value of I² depends on the magnitude and direction of treatment effects and the strength of evidence for heterogeneity (e.g. P‐value from the Chi² test, or a confidence interval for I²) (Higgins 2011).

Assessment of reporting biases

Funnel plots were used to assess for the potential existence of small study bias (Higgins 2011).

Data synthesis

Studies with different designs, RCT and non‐RCT or non‐RCT with dissimilar study design were analysed separately. For dichotomous outcomes, a random effects model was performed to measure treatment effects. In sensitivity analyses, adjusted effect estimates (whenever possible) and their standard errors were used for combining studies in meta‐analyses and the generic inverse‐variance method was used .

Subgroup analysis and investigation of heterogeneity

Subgroup analysis were planned to explore possible sources of heterogeneity (e.g. participants, interventions and study quality including method of PD catheter insertion). Heterogeneity among participants could be related to age and renal pathology (e.g. children versus adults). Heterogeneity in treatments could be related to prior agent(s) used and the agent, dose, and duration of therapy (e.g. initial fill volume). Therefore, subgroup analyses were conducted to evaluate the source of heterogeneity.

Participants
- Adults versus children
- Incident versus prevalent patients
Setting
- Single‐centre versus multi‐centre
Type of treatment utilised
- According to initial fill volume
- Days to PD commencement (e.g. within 24 hours versus 7 days).

Adverse effects were tabulated and assessed with descriptive techniques, as they were likely to be different for the various agents used. Where possible, the risk difference with 95% CI was calculated for each adverse effect, either compared to no treatment or to another agent.

Sensitivity analysis

We performed sensitivity analyses in order to explore the influence of the following factors on effect size.

Repeating the analysis excluding unpublished studies
Repeating the analysis taking account of risk of bias, as specified
Repeating the analysis excluding any very long or large studies to establish how much they dominate the results
Repeating the analysis excluding studies using the following filters: diagnostic criteria, language of publication, source of funding (industry versus other), and country.

'Summary of findings' tables

The main results of the review were presented in 'Summary of findings' tables. These tables present key information concerning the quality of the evidence, the magnitude of the effects of the interventions examined, and the sum of the available data for the main outcomes (Schunemann 2011a). The 'Summary of findings' tables also include an overall grading of the evidence related to each of the main outcomes using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach (GRADE 2008; GRADE 2011). The GRADE approach defines the quality of a body of evidence as the extent to which one can be confident that an estimate of effect or association is close to the true quantity of specific interest. The quality of a body of evidence involves consideration of within‐trial risk of bias (methodological quality), directness of evidence, heterogeneity, precision of effect estimates and risk of publication bias (Schunemann 2011b). We plan to present the following outcomes in the 'Summary of findings' tables.

Mechanical complications: dialysate leak, catheter blockage, catheter malposition, PD dialysate flow problems
Exit‐site complications: exit‐site infection, exit‐site bleeding, tunnel tract infection
Peritonitis
Catheter re‐adjustment within a month of commencement of PD
Technique survival
Interim HD
Duration of hospitalisation.

Results

Description of studies

Results of the search

An electronic search (last search date for RCTs: 25 May 2020; non‐RCTs: 26 June 2019) identified total 219 potentially relevant reports. After removing duplicates and screening through 210 titles and abstracts, 160 reports were excluded. Full text review was conducted of the remaining 56 records (53 studies); 16 studies (19 records) were included, 36 studies (36 records) were excluded, and one study is awaiting classification and will be assessed in a future update of this review (Figure 1).

Included studies

Sixteen studies (2953 participants) (Ghaffari 2012; Jaivid 2017; Kim 2018; Liu 2014; Nayak 2018; Pai 2016; Povlsen 2016; Salari 2018; See 2017; Serrano 2019; Silva 2018; Timely PD 2010; Vlasak 2017; Wojtaszek 2018; Yang 2011; Zhang 2017) were included in this review (see Table 4).

1. Description of studies included in the review.

Study	Country	Study design	Time frame	No. participants (DM)	Follow‐up duration	Break‐in periods for USPD	Break‐in periods for CSPD	Insertion methods	Initial PD regimen
Ghaffari 2012	USA	Prospective cohort (SC)	2010‐2011	27 (52%)	90 days	Not reported	Not reported	Percutaneous (laparoscopic for control)	Based on BSA & GFR*
Jaivid 2017	Singapore	Retrospective cohort (SC)	2015	50 (58%)	180 days	1 to 10 days	2 to 4 weeks	Percutaneous	Not available
Kim 2018	Korea	Retrospective cohort (SC)	2007‐2014	87 (40%)	6 months	0.4 to 5.9 days	20 days	Laparotomy	Day 2: 0.5 L Day 5: 0.75 to 1 L
Liu 2014	China	Retrospective cohort (SC)	2001‐2010	657 (26%)	6 months	≤ 7 days	> 14 days	Laparotomy	0.75 to 1.2 L
Nayak 2018¹	India	Case control (SC)	2016‐2017	56 (not reported)	90 days	Within 48 hours of presentation	> 14 days	Not reported	Not reported
Pai 2016	Taiwan, China	Retrospective cohort (SC)	2006‐2012	149 (43%)	30.5 ± 24.9 months	11 (6 to 13) days	20.7 (14 to 76) days	Laparotomy	Not reported
Povlsen 2016	Denmark	Prospective cohort (multicentre)	2005‐2009	643 (not reported)	Follow‐up till 2012	Not reported	Not reported	Not reported	Not reported
Salari 2018	USA	Retrospective cohort (SC)	2010‐2017	159 (57%)	USPD: 986 ± 634 days CSPD: 1010 ± 732 days	Not reported	Not reported	Not reported	Not reported
See 2017	Australia	Case control (SC)	2010‐2015	104 (35%)	4 weeks	4 (1 to 7) days	Not reported	Laparoscopic	1 to 1.2 L
Serrano 2019	USA	Retrospective cohort (SC)	Not reported	Not reported	6 months	7.3 days	Not reported	Not reported	Not reported
Silva 2018	Brazil	Prospective cohort (SC)	2010‐2018	Not reported	381 days	3 to 14 days	Not reported	Percutaneously inserted	Week 1: 1 L Titrate week 4: 2 L
Timely PD 2010	Australia	RCT (multicentre)	2008‐2013	122 (35%)	180 days	7 days	≥ 14 days	Laparotomy	Day 1: 1 L Day 2: 1.5 L Day 3: 2 L
Vlasak 2017	Czech Republic	Retrospective cohort (SC)	2011	89 (not reported)	4 weeks	Not reported	Not reported	Laparoscopic	Not reported
Wojtaszek 2018	Poland	Retrospective cohort (SC)	2005‐2015	Not reported	USPD: 19 months CSPD: 19.5 months	3.5 ± 2.3 days	16.2 ± 1.7 days	Not reported	Not reported
Yang 2011	Taiwan, China	Retrospective cohort (SC)	2003‐2007	Not reported	USPD: 823 ± 591 days CSPD: 522 ± 319 days	2.0 ± 2.7 days	40.6 ± 42.8 days	Laparotomy	Day 1: 0.5 L Day 6: 0.75 L Day 8: 1 L
Zhang 2017	China	Retrospective cohort (SC)	2014‐2016	Not reported	90 days	1 to 3 days	≥ 14 days	Not reported	Not reported

Study	Selection bias		Blinding (performance bias and detection bias)		Attrition bias	Reporting bias	Other
Study	Random sequence generation	Allocation concealment	Blinding of participants and personnel	Blinding of outcome assessment	Incomplete outcome of data	Selective reporting	Other
Timely PD 2010	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk	Unclear

Study	Selection				Comparability	Outcome			Evidence of quality
Study	Representativeness of exposed cohort	Selection of non‐exposed cohort	Ascertainment of exposure	Outcomes not present at start	Comparability	Assessment of outcome	Length of follow‐up	Adequacy of follow‐up	Evidence of quality
Ghaffari 2012	*	*	*	*	‐‐	‐‐	‐‐	‐‐	4
Jaivid 2017	*	*	*	*		‐‐	*	*	6
Kim 2018	*	*	*	*	‐‐	*	*	‐‐	6
Liu 2014	*	*	*	*	*	*	*	‐‐	7
Povlsen 2016	‐‐	‐‐	‐‐	*	‐‐	‐‐	*	‐‐	2
Pai 2016	*	*	*	*	*	*	*	*	8
Salari 2018	*	*	‐‐	*	‐‐	‐‐	*	‐‐	4
Serrano 2019	*	*	‐‐	*	‐‐	‐‐	*	*	5
Silva 2018	*	*	‐‐	*	‐‐	‐‐	*	‐‐	4
Vlasak 2017	*	*	‐‐	*	‐‐	‐‐	*	‐‐	4
Wojtaszek 2018	*	*	‐‐	*	‐‐	‐‐	*	‐‐	4
Yang 2011	*	*	*	*	‐‐	*	*	*	7
Zhang 2017	*	*	‐‐	*	‐‐	‐‐	‐‐	‐‐	3

Urgent‐start peritoneal dialysis versus conventional‐start peritoneal dialysis for people with chronic kidney disease
Patient or population: people with CKD Settings: community Intervention: USPD Comparison: CSPD
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Quality of the evidence (GRADE)
Outcomes	Risk with CSPD	Risk with USPD	Relative effect (95% CI)	No. of participants (studies)	Quality of the evidence (GRADE)
Dialysate leak	72 per 1,000	282 per 1,000 (113 to 707)	RR 3.90 (1.56 to 9.78)	122 (1)	⊕⊕⊝⊝ LOW¹
Catheter blockage	‐	‐	‐	No studies	Absent
Catheter malposition	‐	‐	‐	No studies	Absent
PD dialysate flow problem	‐	‐	‐	No studies	Absent
Exit‐site infection	‐	‐	‐	No studies	Absent
Exit‐site bleeding	12 per 1,000	8 per 1,000 (0 to 203)	RR 0.70 (0.03 to 16.81)	122 (1)	⊕⊝⊝⊝ VERY LOW ²
Tunnel tract infection	‐	‐	‐	No studies	Absent
Peritonitis	‐	‐	‐	No studies	Absent
Catheter readjustment	‐	‐	‐	No studies	Absent
Technique survival	892 per 1,000	972 per 1,000 (892 to 1,000)	RR 1.09 (1.00 to 1.20)	122 (1)	⊕⊝⊝⊝ VERY LOW ²
*The risk in the USPD group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk Ratio; PD: peritoneal dialysis;USPD: urgent‐start PD; CSPD: conventional‐start PD
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.

Adverse events	USPD		CSPD		Study
Adverse events	Events	Total	Events	Total	Study
Pericatheter hernia	1	226	0	84	Yang 2011
Haemoperitoneum	1	226	0	84	Yang 2011
Delayed wound healing	1	39	1	83	Timely PD 2010

Database	Search terms
CENTRAL	MeSH descriptor: [Peritoneal Dialysis] explode all trees peritoneal dialysis:ti,ab,kw (Word variations have been searched) PD or CAPD or CCPD:ti,ab,kw (Word variations have been searched) {or #1‐#3} urgent start:ti,ab,kw (Word variations have been searched) urgent initiation:ti,ab,kw (Word variations have been searched) urgent*:ti,ab,kw (Word variations have been searched) "unplanned":ti,ab,kw (Word variations have been searched) {or #5‐#8} {and #4, #8}
MEDLINE	Renal Replacement Therapy/ exp Peritoneal Dialysis/ peritoneal dialysis.tw. (CAPD or CCPD or APD).tw. or/1‐4 urgent.tw. urgent start.tw. urgent initiation.tw. unplanned.tw or/6‐10 and/5,10
EMBASE	Peritoneal Dialysis/ Continuous Ambulatory Peritoneal Dialysis/ peritoneal dialysis.tw. (PD or CAPD or CCPD or APD).tw. peritoneal dialysis fluid/ renal replacement therapy‐dependent renal disease/ peritoneal dialysis catheter/ or/1‐7 urgent start$.tw. urgent initiation.tw. unplanned.tw. or/9‐11 and/8,12

Potential source of bias	Assessment criteria
Random sequence generation Selection bias (biased allocation to interventions) due to inadequate generation of a randomised sequence	Low risk of bias: Random number table; computer random number generator; coin tossing; shuffling cards or envelopes; throwing dice; drawing of lots; minimisation (minimisation may be implemented without a random element, and this is considered to be equivalent to being random).
	High risk of bias: Sequence generated by odd or even date of birth; date (or day) of admission; sequence generated by hospital or clinic record number; allocation by judgement of the clinician; by preference of the participant; based on the results of a laboratory test or a series of tests; by availability of the intervention.
	Unclear: Insufficient information about the sequence generation process to permit judgement.
Allocation concealment Selection bias (biased allocation to interventions) due to inadequate concealment of allocations prior to assignment	Low risk of bias: Randomisation method described that would not allow investigator/participant to know or influence intervention group before eligible participant entered in the study (e.g. central allocation, including telephone, web‐based, and pharmacy‐controlled, randomisation; sequentially numbered drug containers of identical appearance; sequentially numbered, opaque, sealed envelopes).
	High risk of bias: Using an open random allocation schedule (e.g. a list of random numbers); assignment envelopes were used without appropriate safeguards (e.g. if envelopes were unsealed or non‐opaque or not sequentially numbered); alternation or rotation; date of birth; case record number; any other explicitly unconcealed procedure.
	Unclear: Randomisation stated but no information on method used is available.
Blinding of participants and personnel Performance bias due to knowledge of the allocated interventions by participants and personnel during the study	Low risk of bias: No blinding or incomplete blinding, but the review authors judge that the outcome is not likely to be influenced by lack of blinding; blinding of participants and key study personnel ensured, and unlikely that the blinding could have been broken.
	High risk of bias: No blinding or incomplete blinding, and the outcome is likely to be influenced by lack of blinding; blinding of key study participants and personnel attempted, but likely that the blinding could have been broken, and the outcome is likely to be influenced by lack of blinding.
	Unclear: Insufficient information to permit judgement
Blinding of outcome assessment Detection bias due to knowledge of the allocated interventions by outcome assessors.	Low risk of bias: No blinding of outcome assessment, but the review authors judge that the outcome measurement is not likely to be influenced by lack of blinding; blinding of outcome assessment ensured, and unlikely that the blinding could have been broken.
	High risk of bias: No blinding of outcome assessment, and the outcome measurement is likely to be influenced by lack of blinding; blinding of outcome assessment, but likely that the blinding could have been broken, and the outcome measurement is likely to be influenced by lack of blinding.
	Unclear: Insufficient information to permit judgement
Incomplete outcome data Attrition bias due to amount, nature or handling of incomplete outcome data.	Low risk of bias: No missing outcome data; reasons for missing outcome data unlikely to be related to true outcome (for survival data, censoring unlikely to be introducing bias); missing outcome data balanced in numbers across intervention groups, with similar reasons for missing data across groups; for dichotomous outcome data, the proportion of missing outcomes compared with observed event risk not enough to have a clinically relevant impact on the intervention effect estimate; for continuous outcome data, plausible effect size (difference in means or standardised difference in means) among missing outcomes not enough to have a clinically relevant impact on observed effect size; missing data have been imputed using appropriate methods.
	High risk of bias: Reason for missing outcome data likely to be related to true outcome, with either imbalance in numbers or reasons for missing data across intervention groups; for dichotomous outcome data, the proportion of missing outcomes compared with observed event risk enough to induce clinically relevant bias in intervention effect estimate; for continuous outcome data, plausible effect size (difference in means or standardized difference in means) among missing outcomes enough to induce clinically relevant bias in observed effect size; ‘as‐treated’ analysis done with substantial departure of the intervention received from that assigned at randomisation; potentially inappropriate application of simple imputation.
	Unclear: Insufficient information to permit judgement
Selective reporting Reporting bias due to selective outcome reporting	Low risk of bias: The study protocol is available and all of the study’s pre‐specified (primary and secondary) outcomes that are of interest in the review have been reported in the pre‐specified way; the study protocol is not available but it is clear that the published reports include all expected outcomes, including those that were pre‐specified (convincing text of this nature may be uncommon).
	High risk of bias: Not all of the study’s pre‐specified primary outcomes have been reported; one or more primary outcomes is reported using measurements, analysis methods or subsets of the data (e.g. sub‐scales) that were not pre‐specified; one or more reported primary outcomes were not pre‐specified (unless clear justification for their reporting is provided, such as an unexpected adverse effect); one or more outcomes of interest in the review are reported incompletely so that they cannot be entered in a meta‐analysis; the study report fails to include results for a key outcome that would be expected to have been reported for such a study.
	Unclear: Insufficient information to permit judgement
Other bias Bias due to problems not covered elsewhere in the table	Low risk of bias: The study appears to be free of other sources of bias.
	High risk of bias: Had a potential source of bias related to the specific study design used; stopped early due to some data‐dependent process (including a formal‐stopping rule); had extreme baseline imbalance; has been claimed to have been fraudulent; had some other problem.
	Unclear: Insufficient information to assess whether an important risk of bias exists; insufficient rationale or evidence that an identified problem will introduce bias.

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1.1 Dialysate leak (RCT)	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected
1.1.1 Dialysate leak (RCT)	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected
1.2 Dialysate leak (non‐RCT)	9		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only
1.2.1 Dialysate leak (cohort studies)	7	1322	Risk Ratio (M‐H, Random, 95% CI)	2.06 [0.80, 5.28]
1.2.2 Dialysate leak (case‐control studies)	2	160	Risk Ratio (M‐H, Random, 95% CI)	7.41 [1.27, 43.36]
1.3 Catheter blockage (non‐RCT)	6		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only
1.3.1 Catheter blockage (cohort studies)	4	1214	Risk Ratio (M‐H, Random, 95% CI)	1.33 [0.40, 4.43]
1.3.2 Catheter blockage (case‐control studies)	2	160	Risk Ratio (M‐H, Random, 95% CI)	1.89 [0.58, 6.13]
1.4 Catheter malposition (non‐RCT)	7		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only
1.4.1 Catheter malposition (cohort studies)	6	1353	Risk Ratio (M‐H, Random, 95% CI)	1.63 [0.80, 3.32]
1.4.2 Catheter malposition (case‐control studies)	1	104	Risk Ratio (M‐H, Random, 95% CI)	3.00 [0.64, 13.96]
1.5 PD dialysate flow problem (non‐RCT)	3	937	Risk Ratio (M‐H, Random, 95% CI)	1.44 [0.34, 6.14]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
2.1 Exit‐site infection (non‐RCT)	3		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only
2.1.1 Exit‐site or tunnel infection (cohort studies)	2	337	Risk Ratio (M‐H, Random, 95% CI)	1.43 [0.24, 8.61]
2.1.2 Exit‐site or tunnel infection (case‐control studies)	1	104	Risk Ratio (M‐H, Random, 95% CI)	1.20 [0.41, 3.50]
2.2 Exit‐site infection rate (non‐RCT)	2	8048	Risk Ratio (M‐H, Random, 95% CI)	1.06 [0.17, 6.75]
2.3 Exit‐site bleeding (RCT)	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected
2.3.1 Exit‐site bleeding (RCT)	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected
2.4 Exit‐site bleeding (non‐RCT)	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected
2.4.1 Exit‐site bleeding (cohort studies)	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
3.1 Peritonitis (non‐RCT)	9		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only
3.1.1 Peritonitis (cohort studies)	7	1497	Risk Ratio (M‐H, Random, 95% CI)	1.00 [0.68, 1.46]
3.1.2 Peritonitis (case‐control studies)	2	160	Risk Ratio (M‐H, Random, 95% CI)	1.09 [0.12, 9.51]
3.2 Peritonitis rate (non‐RCT)	2	8048	Risk Ratio (M‐H, Random, 95% CI)	0.88 [0.23, 3.34]
3.3 Peritonitis (secondary analysis: day 30)	3		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only
3.3.1 Peritonitis (cohort studies)	2	627	Risk Ratio (M‐H, Random, 95% CI)	1.02 [0.59, 1.74]
3.3.2 Peritonitis (case‐control studies)	1	104	Risk Ratio (M‐H, Random, 95% CI)	0.52 [0.22, 1.20]
3.4 Peritonitis (secondary analysis: day 90)	3		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only
3.4.1 Peritonitis (cohort studies)	2	192	Risk Ratio (M‐H, Random, 95% CI)	0.67 [0.17, 2.57]
3.4.2 Peritonitis (case‐control studies)	1	56	Risk Ratio (M‐H, Random, 95% CI)	5.30 [0.29, 98.06]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
5.1 Technique survival (RCT)	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected
5.1.1 Technique survival (RCT)	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected
5.2 Technique survival (non‐RCT)	10		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only
5.2.1 Technique survival (cohort studies)	8	1668	Risk Ratio (M‐H, Random, 95% CI)	0.90 [0.76, 1.07]
5.2.2 Technique survival (case‐control studies)	2	160	Risk Ratio (M‐H, Random, 95% CI)	0.92 [0.79, 1.06]
5.3 Technique survival: secondary analysis (cohort studies ‐ laparotomy)	4		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only
5.3.1 Technique survival (cohort studies)	4	1198	Risk Ratio (M‐H, Random, 95% CI)	0.74 [0.58, 0.94]
5.4 Technique survival: sensitivity analysis (cohort studies ‐ up to 6 months follow‐up)	4		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only
5.4.1 Technique survival (cohort studies)	4	896	Risk Ratio (M‐H, Random, 95% CI)	0.94 [0.78, 1.12]
5.5 Technique survival: sensitivity analysis (cohort studies ‐ more than 6 months follow‐up)	4		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only
5.5.1 Technique survival (cohort studies)	4	772	Risk Ratio (M‐H, Random, 95% CI)	0.87 [0.58, 1.30]
5.6 Technique survival: sensitivity analysis (cohort studies ‐ low risk of bias)	4		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only
5.6.1 Technique survival (cohort studies)	3	418	Risk Ratio (M‐H, Random, 95% CI)	0.87 [0.76, 1.00]
5.6.2 Technique survival (case‐control studies)	1	104	Risk Ratio (M‐H, Random, 95% CI)	0.95 [0.61, 1.47]
5.7 Death‐censored technique survival (RCT)	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected
5.7.1 Death‐censored technique survival (RCT)	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected
5.8 Death‐censored technique survival (non‐RCT)	8		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only
5.8.1 Death‐censored technique survival (cohort studies)	7	1509	Risk Ratio (M‐H, Random, 95% CI)	0.99 [0.88, 1.10]
5.8.2 Death‐censored technique survival (case‐control studies)	1	104	Risk Ratio (M‐H, Random, 95% CI)	0.94 [0.67, 1.33]
5.9 Death‐censored technique survival: secondary analysis (cohort studies ‐ laparotomy)	4		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only
5.9.1 Death‐censored technique survival (cohort studies)	4	1198	Risk Ratio (M‐H, Random, 95% CI)	0.90 [0.81, 1.00]
5.10 Death‐censored technique survival: sensitivity analysis (cohort studies ‐ up to 6 months follow‐up)	4		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only
5.10.1 Death‐censored technique survival (cohort studies)	4	896	Risk Ratio (M‐H, Random, 95% CI)	0.98 [0.91, 1.07]
5.11 Death‐censored technique survival: sensitivity analysis (cohort studies ‐ more than 6 months follow‐up)	3		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only
5.11.1 Death‐censored technique survival (cohort studies)	3	613	Risk Ratio (M‐H, Random, 95% CI)	1.00 [0.69, 1.46]

Methods	Country: USA Type of study: observational Design: cohort study (prospective), single centre Time frame: January 2005 and December 2015 Duration of follow‐up: 365 days
Participants	Number: treatment group (29); control group (211) Mean age, range (years): not reported Sex (males): not reported DM: not reported
Interventions	Treatment group USPD (duration of break‐in period was not reported)
Outcomes	Mechanical complications (leak/catheter blockage, malposition) complication‐free and overall catheter survival at day‐90 and day‐365
Notes	Definition of urgent‐start PD was not reported in the abstract

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
6.1 Death (any cause) (RCT)	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected
6.1.1 Death (any cause) (RCT)	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected
6.2 Death (any cause) (non‐RCT)	8		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only
6.2.1 Death (any cause) (cohort studies)	7	1509	Risk Ratio (M‐H, Random, 95% CI)	1.89 [1.07, 3.32]
6.2.2 Death (any cause) (case‐control studies)	1	104	Risk Ratio (M‐H, Random, 95% CI)	0.90 [0.27, 3.02]
6.3 Death (any cause): secondary analysis (cohort studies ‐ laparotomy)	4		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only
6.3.1 Death (any cause) (cohort studies)	4	1198	Risk Ratio (M‐H, Random, 95% CI)	2.29 [1.14, 4.61]
6.4 Death (any cause): sensitivity analysis (cohort studies‐up to 6 months follow‐up)	4		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only
6.4.1 Death (any cause) (cohort studies)	4	896	Risk Ratio (M‐H, Random, 95% CI)	1.75 [0.47, 6.48]
6.5 Death (any cause): sensitivity analysis (cohort studies ‐ more than 6 months follow‐up)	3		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only
6.5.1 Death (any cause) (cohort studies)	3	613	Risk Ratio (M‐H, Random, 95% CI)	1.82 [1.01, 3.26]
6.6 Death (any cause): sensitivity analysis (cohort studies ‐ low risk of bias)	3		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only
6.6.1 Death (any cause) (cohort studies)	3	418	Risk Ratio (M‐H, Random, 95% CI)	1.37 [0.81, 2.30]

Outcome or subgroup title	No. of studies	Statistical method	Effect size
7.1 Pericatheter hernia	1	Risk Difference (M‐H, Random, 95% CI)	Totals not selected
7.2 Haemoperitoneum	1	Risk Difference (M‐H, Random, 95% CI)	Totals not selected
7.3 Delayed wound healing	1	Risk Difference (M‐H, Random, 95% CI)	Totals not selected

*Study characteristics*
Methods	Country: USA Type of study: observational Design: cohort study (prospective), single centre Time frame: March 2010 and March 2011 Duration of follow‐up: short‐term (90 days)
Participants	Inclusion criteria USPD group: CKD stage 5 patients who required urgent‐start PD CSPD group: not reported Number: treatment group (18); control group (9) Mean age ± SD (years): treatment group (45.1 ± 13.7); control group (53.6 ± 19.1) Sex (males): treatment group (13, 72%); control group (4, 44%) DM: treatment group (9, 50%): control group (5, 56%) Exclusion criteria: not reported
Interventions	Treatment group Started PD within 2 weeks but 48 hours after PD catheter insertion Control group Started PD 2 weeks after catheter insertion
Outcomes	Peritonitis incidence Exit‐site tract infection Mechanical complications (leak/catheter blockage, malposition) Exit‐site bleeding
Notes	Catheter placement was different with mainly percutaneous method for USPD and laparoscopic placement for planned group
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Selection: representativeness of exposed cohort	Low risk	Cohorts are true representative of CKD 5 patients in the community
Selection: non exposed cohort	Low risk	Non‐exposed drawn from the same community as exposed cohorts
Selection: ascertainment of exposure	Low risk	Ascertainment of exposure by secure record
Selection: demonstration that outcome of interest was not present at the start of the study	Low risk	Outcome of interest was unlikely to be present before the study
Comparability of cohorts on basis of design or analysis	High risk	Data were not adjusted for potential confounders, used percutaneous method for urgent‐start group and laparoscopic method for non‐urgent start group. In addition, study did not adjust for potential confounders.
Outcome: assessment	Unclear risk	Insufficient information to permit judgement
Outcome: follow‐up length	Unclear risk	Follow‐up: 90 days
Outcome: adequacy of follow‐up	Unclear risk	Insufficient information to permit judgement

*Study characteristics*
Methods	Country: Singapore Type of study: observational Design: cohort study (retrospective), single centre Time frame: July 2015 Duration of follow‐up: 180 days
Participants	Number: treatment group (17); control group (33) Mean age, range (years): treatment group (56, 25 to 87); control group (62, 27 to 84) Sex (males): not reported DM: treatment group (41%); control group (67%)
Interventions	Treatment group USPD, in which PD was initiated within 2 weeks of catheter insertion
Outcomes	Mechanical complications (leak/catheter blockage, malposition) (adjusted for method of catheter insertion for outcome ‐ dialysate leak) Technique survival Death (any cause) Hospitalisation
Notes	Laparoscopic PD catheter insertions for patients not suitable for percutaneous insertions A significantly higher number of patients in the urgent‐start group had percutaneous PD catheter insertions, 82% versus 39% (P = 0.0064).
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Selection: representativeness of exposed cohort	Low risk	Representative of the average CKD stage 5 patients without having planned dialysis in the community
Selection: non exposed cohort	Low risk	Same cohort
Selection: ascertainment of exposure	Low risk	Secure record
Selection: demonstration that outcome of interest was not present at the start of the study	Low risk	Outcome of interest was unlikely to be present before the study
Comparability of cohorts on basis of design or analysis	High risk	Significantly higher number of laparoscopic assisted catheter insertion in control group than urgent‐start group, and data were not adjusted for all potential confounders
Outcome: assessment	Unclear risk	Insufficient information to permit judgement
Outcome: follow‐up length	Low risk	180 days, long enough to examine the main outcomes of interest
Outcome: adequacy of follow‐up	Low risk	8% dropout

*Study characteristics*
Methods	Country: Korea Type of study: observational Design: cohort study (retrospective), single centre Time frame: January 2007 to December 2014 Duration of follow‐up: 6 months
Participants	Number Treatment group: P1 (initiated within 48 hours; 103), P2 (initiated 2 to 13 days; 87) Control group: 29 Mean age ± SD (years) Treatment group: P1 (58 ± 12.5); P2 (58.2 ± 14.8) Sex (males): treatment group (119, 63%); control group (15, 51.7%) DM: treatment group (41%); control group (34.5%)
Interventions	Treatment group Started PD within 2 weeks after PD catheter insertion Control group Started PD 2 weeks after catheter insertion
Outcomes	Mechanical complications (leak/catheter blockage, malposition) Peritonitis Technique survival Death (any cause)
Notes	BUN and Cr level were significantly higher and serum albumin was lower in the urgent‐start PD group compared with conventional‐start PD group Outcomes were unadjusted for potential confounders
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Selection: representativeness of exposed cohort	Low risk	Representative of CKD stage 5 patients who initiated PD urgently in a hospital
Selection: non exposed cohort	Low risk	These patients were selected from the same hospital as exposed cohort
Selection: ascertainment of exposure	Low risk	Secure record
Selection: demonstration that outcome of interest was not present at the start of the study	Low risk	Outcome of interest was unlikely to be present before the study
Comparability of cohorts on basis of design or analysis	High risk	Baseline characteristics were significantly different between the two groups, the outcomes were not adjusted for potential confounders
Outcome: assessment	Low risk	Medical record
Outcome: follow‐up length	Low risk	Adequate for study of short term outcomes
Outcome: adequacy of follow‐up	Unclear risk	Insufficient information to permit judgement

*Study characteristics*
Methods	Country: China Type of study: observational Design: cohort study Time frame: between 1 January 2001 and 31 December 2010 Duration of follow up: 6 months
Participants	Inclusion criteria: all patients who underwent Tenckhoff catheter implantation and initiated PD in Renji Hospital, Shanghai Jiao Tong University School of Medicine Number: treatment group (344); control group (176) Mean age ± SD (years): treatment group (52.6 ± 17.7); control group (56.2 ± 15.5) Sex (male): treatment group (159, 46.2%); control group (79, 45.1%) DM (%): treatment group (78, 22.7%); control group (36, 20.6%) Exclusion criteria: not reported
Interventions	Treatment group To start PD within 14 days of catheter insertion (≤ 7 days) Control group To start PD > 14 days after catheter insertion The choice of when to start dialysis after catheter implantation was made by the nephrologists based on the clinical condition of individual patients
Outcomes	Peritonitis incidence (early/late) Mechanical complications (leak/catheter blockage, malposition) (adjusted for age, sex, BMI, comorbidities, history of abdominal surgery, use of steroids) Technique survival (adjusted for age, gender, comorbidities, break‐in period) Death (any cause)
Notes	This study was funded by a grant from the Science and Technology Commission of Shanghai Municipality
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Selection: representativeness of exposed cohort	Low risk	Representative of the average CKD stage 5 patients in the community
Selection: non exposed cohort	Low risk	Same cohort
Selection: ascertainment of exposure	Low risk	Secure record
Selection: demonstration that outcome of interest was not present at the start of the study	Low risk	All patients were not on dialysis before the study
Comparability of cohorts on basis of design or analysis	Low risk	Age and baseline albumin were different between groups, however, data were adjusted for potential confounders including age, gender, comorbidities
Outcome: assessment	Low risk	Medical record
Outcome: follow‐up length	Low risk	6 months, long enough to examine the primary outcomes of interest
Outcome: adequacy of follow‐up	Unclear risk	No description of lost to follow‐up

*Study characteristics*
Methods	Country: India Type of study: observational Design: single centre, case control study Time frame: March 2016 to August 2017 Duration of follow‐up: 90 days
Participants	Number: treatment group (32); control group (24) Mean age ± SD (years): not reported Sex (males): not reported DM: not reported
Interventions	Treatment group Started PD within 48 hours of presentation Control group Started PD 14 days or more after PD catheter insertion
Outcomes	Peritonitis at day 90 Exit‐site infection at day 90 Catheter blockage Technique survival at day 90
Notes	Did not match between case and control group, emergent‐start group had significantly higher PVD than control group
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Case definition	Unclear risk	Insufficient information to permit judgement
Representativeness of the case	Unclear risk	Insufficient information to permit judgement
Selection: control	Low risk	Control from same community
Definition of control	Low risk	Initiation of PD 14 days after catheter insertion
Comparability of cases and controls on basis of design or analysis	High risk	Data were not matched, PVD was significantly higher in emergent start group, data were not adjusted for potential confounders
Exposure: ascertainment of exposure	Unclear risk	Insufficient information to permit judgement
Exposure: same methods for case and control	Unclear risk	Insufficient information to permit judgement
Exposure: non‐response rate	Unclear risk	insufficient information to permit judgement

*Study characteristics*
Methods	Country: Denmark Type of study: observational Design: cohort study (prospective), multicentre Time frame: 2005 to 2009 Duration of follow‐up: at least 2 years
Participants	Number: treatment group (338); control group (255) Mean age ± SD (years): not reported Sex (male): not reported DM: not reported
Interventions	Treatment group Unplanned start PD, PD initiation within 2 weeks of PD catheter insertion Control group Planned start with PD initiation > 2 weeks after catheter insertion
Outcomes	Technique survival
Notes	Contacted authors but unable to get additional information
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Selection: representativeness of exposed cohort	Unclear risk	Insufficient information to permit judgement
Selection: non exposed cohort	Unclear risk	Insufficient information to permit judgement
Selection: ascertainment of exposure	Unclear risk	Insufficient information to permit judgement
Selection: demonstration that outcome of interest was not present at the start of the study	Low risk	Outcome of interest was unlikely to be present before the study
Comparability of cohorts on basis of design or analysis	Unclear risk	Insufficient information to permit judgement
Outcome: assessment	Unclear risk	Insufficient information to permit judgement
Outcome: follow‐up length	Low risk	Adequate for outcomes of interest
Outcome: adequacy of follow‐up	Unclear risk	Insufficient information to permit judgement

*Study characteristics*
Methods	Country: Australia Type of study: observational Design: matched case‐control study (1:3), single centre study Time frame: 1 January 2010 to 30 June 2015 Duration of follow up: 4 weeks
Participants	Inclusion criteria: patients with advanced CKD who required urgent KRT, had no established access, and were suitable for PD were enrolled in a structured USPD program Number: treatment group (26); control group (78) Mean age ± SD (years): treatment group (51.0 ± 14.5); control group (50.6 ± 13.0) Sex (male): treatment group (17, 65%); control group (49, 63%) DM: treatment group (9, 35%); control group (27, 35%) Exclusion criteria: not reported
Interventions	Treatment group USPD within 2 weeks of catheter insertion Control group CSPD > 2 weeks after catheter insertion
Outcomes	Peritonitis incidence (early/late) Exit‐site infection (early/late) Mechanical complications (leak/catheter blockage, malposition) Technique survival (adjusted for obesity, late referral status) Death (any cause)
Notes	Compared with CSPD patients, USPD patients were more likely to be referred late (73% versus 1%, P < 0.001) and were less likely to be obese (23% versus 50%, P = 0.02)
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Case definition	Low risk	Independent validation – from unit database, further confirmed using hospital medical records
Representativeness of the case	Low risk	All eligible cases with outcome of interest over a defined period of time were included
Selection: control	Low risk	Control from same community
Definition of control	Low risk	Initiation of PD > 2 weeks after catheter placement
Comparability of cases and controls on basis of design or analysis	Low risk	Matched for confounders: age, diabetic status
Exposure: ascertainment of exposure	Low risk	Hospital records
Exposure: same methods for case and control	Low risk	Yes
Exposure: non‐response rate	Unclear risk	Unclear

*Study characteristics*
Methods	Country: Brazil Type of study: observational Design: Prospective cohorts, single centre study Time frame: December 2010 to January 2018 Duration of follow‐up: median time of 381 days
Participants	Inclusion criteria: not reported Number: treatment group (40); control group (114) Mean age, range (years): treatment group (56, 40 to 70); control group (48, 32 to 63) Gender (male): treatment group (24, 60%); control group (55, 48%) DM: treatment group (24, 41%); control group (31, 27%) Exclusion criteria: not reported
Interventions	Treatment group USPD within 3 to 14 days of catheter insertion Control group CSPD > 2 weeks after catheter insertion
Outcomes	Technique failure (adjusted for DM, BMI, and mode of PD initiation (USPD urgent versus CSPD)
Notes	Higher number of heart failure in USPD, unequal follow‐up duration, reported slightly lower in the USPD
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Selection: representativeness of exposed cohort	Low risk	CKD stage 5 patients admitted to hospital requiring urgent‐dialysis
Selection: non exposed cohort	Low risk	Recruited from the same hospital as exposed cohort
Selection: ascertainment of exposure	Unclear risk	Insufficient information to permit judgement
Selection: demonstration that outcome of interest was not present at the start of the study	Low risk	Outcome unlikely to be present before the study
Comparability of cohorts on basis of design or analysis	High risk	Unequal baseline characteristics between groups with higher number of heart failure among urgent‐start group. The analysis only adjusted for DM, BMI and mode of PD imitation (USPD versus CSPD)
Outcome: assessment	Unclear risk	Insufficient information to permit judgement
Outcome: follow‐up length	Low risk	Median follow‐up duration 381 days
Outcome: adequacy of follow‐up	Unclear risk	Insufficient information to permit judgement
Other bias	High risk	Reporting bias

PERMALINK

Urgent‐start peritoneal dialysis versus conventional‐start peritoneal dialysis for people with chronic kidney disease

Htay Htay

David W Johnson

Jonathan C Craig

Armando Teixeira-Pinto

Carmel M Hawley

Yeoungjee Cho

Abstract

Background

Objectives

Search methods

Selection criteria

Data collection and analysis

Main results

Authors' conclusions

Plain language summary

Summary of findings

Background

Description of the condition

Description of the intervention

How the intervention might work

Why it is important to do this review

Objectives

Methods

Criteria for considering studies for this review

Types of studies

Types of participants

Inclusion criteria

Exclusion criteria

Types of interventions

Types of outcome measures

Primary outcomes

Secondary outcomes

Search methods for identification of studies

Electronic searches

Searching other resources

Data collection and analysis

Selection of studies

Data extraction and management

Assessment of risk of bias in included studies

Randomised controlled trials

Non‐randomised controlled trials

Measures of treatment effect

Unit of analysis issues

Dealing with missing data

Assessment of heterogeneity

Assessment of reporting biases

Data synthesis

Subgroup analysis and investigation of heterogeneity

Sensitivity analysis

'Summary of findings' tables

Results

Description of studies

Results of the search

1.

Included studies

1. Description of studies included in the review.

Excluded studies

Risk of bias in included studies

Risk of bias for randomised controlled trials

2. Assessment of quality of studies (randomised controlled studies).

Allocation

Blinding

Incomplete outcome data

Selective reporting

Risk of bias for observational studies

3. Assessment of quality of studies (cohort studies).

4. Assessment of quality of studies (case‐control study).

Selection

Comparability of groups of study

Outcome

Exposure

Other potential sources of bias

Effects of interventions

Summary of findings 1. Summary of findings of randomised controlled trials.

Summary of findings 2. Summary of findings of non‐randomised study interventions: cohort studies.

Summary of findings 3. Summary of findings of non‐randomised study interventions: case‐control studies.

Mechanical complications

Dialysate leak

*Study characteristics*
Methods	Country: Australia Type of study: RCT Setting/Design: multicentre Time frame (year of study): 1 March 2008 to 31 May 2013 Duration of follow‐up: 180 days
Participants	Inclusion criteria: 18 years of age, who will receive PD within four weeks of insertion of PD catheter Treatment group (week 1) (urgent‐start PD) Number: treatment group (39); control group 1 (42); control group 2 (41) Mean age ± SD (years): treatment group (60.92 ± 15.2); control group 1 (57.55 ± 17.9); control group 2 (54.41 ± 15.5) Sex (male): treatment group (22, 56.4%); control group 1 (20, 47.6%); control group 2 (26, 63.4%) DM: treatment group (15, 38.5%); control group 1 (14, 33.3%); control group 2 (14, 34.2%) Exclusion criteria: history of psychological illness or condition which interferes with their ability to understand or comply with the requirements of the study or if they had an acute infectious episode in the last month before enrolment
Interventions	Treatment group Time to start of PD: at week 1 Control group 1 Time to start of PD: at week 2 Control group 2 Time to start of PD: at week 4
Outcomes	Incidence of peritoneal fluid leaks (adjusted for DM) PD‐related infection, tunnel infection, and/or peritonitis Occurrence of mechanical complications (hematoma, outflow failure, total blockage) PD catheter revision Conversion to HD Technique failure at 180 days after catheter insertion
Notes	The study was stopped early when the interim analysis found a significantly higher percentage of complications in treatment group. There was protocol violation in both groups This study is partly funded by unrestricted research grants from the Baxter Renal Division Clinical Evidence Council
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Block randomised (permuted block)
Allocation concealment (selection bias)	Low risk	Used sealed envelopes
Blinding (performance bias and detection bias) All outcomes	Low risk	Not blinded, unlikely to influence the outcomes
Blinding of participants and personnel (performance bias) All outcomes	Low risk	Not blinded, unlikely to influence the outcomes
Blinding of outcome assessment (detection bias) All outcomes	Low risk	Not blinded, unlikely to influence the outcomes
Incomplete outcome data (attrition bias) All outcomes	Low risk	All patients were followed till at the end of study period
Selective reporting (reporting bias)	Low risk	Published protocol before the study
Other bias	Unclear risk	Insufficient information to permit judgement

*Study characteristics*
Methods	Country: Czech Republic Study design: retrospective observational study, single centre Time frame: commenced 2011 Duration of follow‐up: 4 weeks
Participants	Inclusion criteria: not reported Number: treatment group (15), control group (74) Mean age ± SD (years): not reported Sex (male): not reported Exclusion criteria: not reported
Interventions	Treatment group PD was initiated < 2 weeks after catheter insertion Control group PD was initiated ≥ 2 weeks after catheter insertion
Outcomes	Dialysate leak Early catheter migration Infection‐related complications
Notes	Funding source: not reported
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Selection: representativeness of exposed cohort	Low risk	Represent kidney failure patients who chose PD from the single centre
Selection: non exposed cohort	Low risk	Same cohort
Selection: ascertainment of exposure	Unclear risk	Insufficient information to permit judgement
Selection: demonstration that outcome of interest was not present at the start of the study	Low risk	Outcomes of interest were unlikely to be present before the study
Comparability of cohorts on basis of design or analysis	Unclear risk	Insufficient information to permit judgement
Outcome: assessment	Unclear risk	Insufficient information to permit judgement
Outcome: follow‐up length	High risk	Follow‐up 4 weeks only
Outcome: adequacy of follow‐up	Unclear risk	Insufficient information to permit judgement

*Study characteristics*
Methods	Country: Poland Type of study: observational Design: retrospective cohort single centre study Time frame: January 2005 to December 2015 Duration of follow‐up: mean follow‐up of 17.6 ± 11.09 months (median: 19.0) was in the USPD group and 28.6 ± 26.6 months (median: 19.5) in the CSPD group
Participants	Inclusion criteria: not reported Treatment group Number: treatment group (35); control group (94) Mean age ± SD (years): not reported Sex (male): not reported DM: not reported Exclusion criteria: not reported
Interventions	Treatment group USPD within 2 weeks of catheter insertion (mean break‐in period 3.5 ± 2.3 days) Control group CSPD > 2 weeks after catheter insertion (mean break‐in period 16.2 ± 1.7 days)
Outcomes	Mechanical complications Technique survival Patient survival (adjusted for Charlson comorbidity index)
Notes	The durations of follow‐up were different between the two groups
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Selection: representativeness of exposed cohort	Low risk	The study included all incident PD patients from the same hospital during the study period
Selection: non exposed cohort	Low risk	Non‐exposed cohorts were from the same hospital as exposed cohorts
Selection: ascertainment of exposure	Unclear risk	Insufficient information to permit judgement
Selection: demonstration that outcome of interest was not present at the start of the study	Low risk	Outcomes unlikely to be present before the study
Comparability of cohorts on basis of design or analysis	Unclear risk	Insufficient information to permit judgement
Outcome: assessment	Unclear risk	Insufficient information to permit judgement
Outcome: follow‐up length	Low risk	Long enough for short‐term outcomes
Outcome: adequacy of follow‐up	Unclear risk	Insufficient information to permit judgement

*Study characteristics*
Methods	Country: Taiwan Type of study: observational Design: cohort study (retrospective), single centre Time frame: January 2003 to October 2007 Duration of follow‐up: 823 ± 591 days in USPD and 522 ± 319 days in CSPD group
Participants	Number: treatment group (226); control group (84) Mean age ± SD (years): treatment group (57.1 ± 14.9); control group (54.8 ± 13.1) Sex (male): treatment group (82, 36.3%); control group (44, 52.4%) DM (%): not reported
Interventions	Treatment group USPD Control group CSPD
Outcomes	Peritonitis incidence Exit‐site infection Mechanical complications (leak/catheter blockage, malposition) Technique survival Death (any cause)
Notes	The patients with complications tended to be heavier and taller: body weight was 63.2 ± 15.2 kg in patients with complications and 58.2 ± 10.2 kg in patients without complications (P = 0.04); body height was 160.4 ± 9.2 cm in patients with complications and 157.2 ± 8.4 cm in patients without complications (P = 0.03) The duration of follow up were largely different ( 823 ± 591 days in USPD and 522 ± 319 days in CSPD groups) The study was partly supported by grants from the China Medical University Hospital
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Selection: representativeness of exposed cohort	Low risk	Representative of new CKD stage 5 patients in the community
Selection: non exposed cohort	Low risk	Same community
Selection: ascertainment of exposure	Low risk	Secure record
Selection: demonstration that outcome of interest was not present at the start of the study	Low risk	Outcome of interest was unlikely to be present before the study
Comparability of cohorts on basis of design or analysis	High risk	No adjustment was done for potential confounders. There were significant different in baseline data, serum albumin, gender, HD before PD etc. Different follow up period between the two groups
Outcome: assessment	Low risk	Medical record review
Outcome: follow‐up length	Low risk	6 months, enough to examine the outcome of interest
Outcome: adequacy of follow‐up	Low risk	5% lost to follow‐up

Study	Reason for exclusion
Abdel 2018	Wrong comparison: compared different methods of catheter insertion
Abid 2014	Control group was not CSPD
Alkatheeri 2016	Control group was not CSPD
Banli 2005	No control group for the study
Bhalla 2017	Wrong comparison: control group was HD patients
Bitencourt Dias 2017	No control group for the study
Brabo 2018	Wrong comparison: control group was HD patients
Casaretto 2012	No control group for the study
Davis 2018	No control group for the study
Dias 2016	No control group for the study
Ghaffari 2015	Wrong comparison: control group was HD patients
Jin 2016	Wrong comparison: control group was HD patients
Jin 2018	Wrong comparison: control group was HD patients
Jin 2019	Wrong comparison: control group was HD patients
Jo 2007	No control group for the study
Kim 2016	No control group for the study
Koch 2012	Wrong comparison: control group was HD patients
Li 2017a	Wrong comparison: treatment group was emergent start group which required emergency HD using central venous catheter, followed by insertion of PD catheter but authors did not indicate the urgent PD initiation in this group
Liu 2014a	Wrong comparison: control group was HD patients
Liu 2018a	Wrong comparison: compared different modality of PD
Lobbedez 2008	Wrong comparison: control group is urgent‐start HD
Machowska 2017	Wrong intervention: study the impact of educational programme on the choice of KRT modality in unplanned kidney failure patients
Masseur 2014	Control group was not CSPD
Naljayan 2018	No control group for the study
NCT02946528	Wrong comparison: compared USPD and HD
NCT03474367	Wrong comparison: compared USPD and HD
Povlsen 2006	Wrong comparison: conventional‐start group initiated PD > 12 days
Povlsen 2009	Review article
Serrano 2014	Wrong definition of USPD: average break‐in period was 15 days for USPD
Song 2000	Wrong intervention: compared the effect of different fill volume on outcomes in USPD patients
Soto‐Vargas 2017	No control group for the study
Tannus 2017	Control arm was HD patients
TCTR20140814001	Comparison of early versus late initiation of dialysis, which are not the subject of the review
Vlasak 2017b	No control arm which is CSPD group
Wang 2017	Wrong comparison: control group was HD patients
Wong 2016	No control group for the study
Xu 2017	No control group for the study