Peritoneal Dialysis

Aka: Peritoneal Dialysis, Continuous Ambulatory Peritoneal Dialysis, Intermittent Peritoneal Dialysis, Continuous Cycling Peritoneal Dialysis

1. See Also
   1. Hemodialysis
   2. Dialysis Emergencies
   3. Hypotension in the Dialysis Patient
   4. End Stage Renal Disease
2. Epidemiology
   1. Accounts for 18% of Dialysis for ESRD in the United States
3. Efficacy
   1. Similar overall mortality rates with Peritoneal Dialysis as with Hemodialysis
   2. Hemodialysis is preferred for solute/electrolyte and volume management
   3. When asked, ESRD patients prefer Peritoneal Dialysis
      1. Rubin (2004) JAMA 291:697-703 [PubMed]
4. Indications
   1. Hemodynamically unstable patient
   2. Difficult vascular access for shunt placement
   3. Mild ESRD
   4. Children
   5. Developing World
5. Mechanism
   1. Based on osmotic pressure gradient between blood and dialysate (chiefly Glucose concentration)
   2. Dialysate is infused via a peritoneal access port
6. Types
   1. Continuous Ambulatory Peritoneal Dialysis (CAPD)
      1. Infuse 2 liters dialysate and allow to dwell for 4-6 hours, then repeat four times daily
      2. Volume infused/day: 8 liters
      3. Volume withdrawn/day: 10 liters
   2. Intermittent Peritoneal Dialysis (IPD)
      1. Rapid dialysate cycling (hourly)
   3. Continuous Cycling Peritoneal Dialysis (CCPD)
      1. Rapid dialysate exchanges overnight (uses an automated device)
7. Complications
   1. Infection
      1. See Dialysis-Related Spontaneous Bacterial Peritonitis
   2. Catheter infections
      1. Findings
         1. Peritoneal access site may present with localized pain, erythema, swelling or discharge
         2. Most commonly infected with Staphylococcus aureus or Pseudomonas aeruginosa
         3. Ultrasound to evaluate for abscess and to direct Incision and Drainage
      2. Management
         1. Incision and Drainage (if needed)
         2. Antibiotics: Cephalexin, Ciprofloxacin or Dicloxacillin
   3. Catheter leaks
      1. Leaks present with abdominal wall edema and clear drainage from catheter skin entry margin
      2. Temporize with Hemodialysis (and stop Peritoneal Dialysis until leak resolves)
      3. Consult nephrology and general surgery
      4. Obtain cultures of dialysate fluid and consider empiric antibiotics
   4. Abdominal Hernias
      1. Due to increased abdominal pressure from dialysate
      2. Referral to general surgery due to incarceration risk
   5. Hydrothorax (rare)
      1. Typically right-sided
      2. Confirmed with methylene blue in dialysate
      3. Temporize with Hemodialysis (and stop Peritoneal Dialysis until leak resolves)
      4. Consult nephrology and thoracic surgery
8. References
   1. Glauser (2013) Crit Dec Emerg Med 27(10): 2-12