Peritoneal Dialysis for Acute Kidney Injury: Techniques and Dose

Abstract

It has not been clearly shown which modality of dialysis is superior in the management of acute kidney injury (AKI). Most centers in developed countries have adopted extracorporeal blood purification (EBP) strategies, such as continuous or intermittent forms of hemodialysis or hemofiltration, for the supportive management of AKI. On the other hand, the use of peritoneal dialysis (PD) is widespread in developing countries in view of its ease of use, low cost and minimal requirements on infrastructure. The dose of dialysis required for AKI remains controversial, although an augmented dose with a high small solute clearance is advocated until further definitive evidence becomes available. No studies have directly examined the effects of the dose of PD on outcomes in AKI. The targets of dose for PD are inferred from studies conducted with EBP. There are concerns that PD is unable to achieve high clearances required to support a patient with renal failure. However, various techniques have been described which are able to achieve the targets of small solute clearance. These include high volume PD and continuous flow PD. The selection of flexible peritoneal catheters with better catheter function and dialysate flow rates can improve the efficiency of PD. Other aspects of dose should also be examined, including clearance of middle molecular weight toxins as well as adequate fluid removal. With careful selection of techniques to meet the individual demands of the patient, PD is an appropriate modality of dialysis for patients with AKI.

High-Volume Peritoneal Dialysis in Acute Kidney Injury

“…Most of the patients had their catheter removed and dialysis method changed, because no success was obtained with the treatment. The main mechanical complication was early leakage (10%), which is in agreement with other studies (6,9,11,29).…”

“…Our results are similar to the results of previous studies that showed that PD clearance was limited by dialysate flow, membrane permeability, and area (6)(7)(8)(9)(10)(11)(20)(21)(22)(23)(24)(25)(31)(32)(33)(34)(35). A 2-L exchange with a dwell time of 30 minutes can achieve dialysate saturation of around 50%.…”

“…There are few studies on PD in AKI patients, and most studies present conflicting results (6)(7)(8)(9)(10)(11)(20)(21)(22)(23)(24)(25)(26)(27)(28). The work by Chitalia et al (22) elegantly showed that tidal PD and continuous PD should be adequate methods to keep BUN levels around 65 mg/dl in mildly and moderately (24) reported that intermittent PD was not adequate to maintain BUN levels higher than 75 mg/dl.…”

“…Exclusion criteria were age under 18 years, severe CKD (baseline serum creatinine.4 mg/dl), renal transplantation, pregnancy, severe hypercatabolism according to the criteria of Schrier (13), absolute contraindication for PD such as recent abdominal surgery (,1 month), multiple abdominal surgeries (more than three), severe hyperkalemia with electrocardiogram changes, severe respiratory failure (FiO 2 .70%), severe fluid overload, and patients submitted to less than one session of HVPD (6,9,11). If patients presented any one of these contraindications, they were treated by intermittent conventional, prolonged, or continuous hemodialysis (HD) according to their hemodynamic instability.…”

“…However, it is also true that PD is not the most efficient therapy: clearance per exchange can decrease if a shorter dwell time is applied, a lower efficiency can be observed in large-sized and severely hypercatabolic patients, fluid removal can be limited, and there is a high risk of infection and possibility of PD worsening mechanical ventilation, thus impairing respiratory performance (7)(8)(9)(10)(11).…”