Peritoneal Dialysis in Acute Renal Failure

Abstract

The definition of adequate dialysis in acute renal failure (ARF) is complex and involves the time of referral to dialysis, dose, and dialytic method. Nephrologist experience with a specific procedure and the availability of different dialysis modalities play an important role in these choices. There is no consensus in literature on the best method or ideal dialysis dose in ARF. Peritoneal dialysis (PD) is used less and less in ARF patients, and is being replaced by continuous venovenous therapies. However, it should not be discarded as a worthless therapeutic option for ARF patients. PD offers several advantages over hemodialysis, such as its technical simplicity, excellent cardiovascular tolerance, absence of an extracorporeal circuit, lack of bleeding risk, and low risk of hydro-electrolyte imbalance. PD also has some limitations, though: it needs an intact peritoneal cavity, carries risks of peritoneal infection and protein losses, and has an overall lower effectiveness. Because daily solute clearance is lower with PD than with daily HD, there have been concerns that PD cannot control uremia in ARF patients. Controversies exist concerning its use in patients with severe hypercatabolism; in these cases, daily hemodialysis or continuous venovenous therapy have been preferred. There is little literature on PD in ARF patients, and what exists does not address fundamental parameters such as adequate quantification of dialysis and patient catabolism. Given these limitations, there is a pressing need to re-evaluate the adequacy of PD in ARF using accepted standards. Therefore, new studies should be undertaken to resolve these problems.

Use of Peritoneal Dialysis in AKI

“…Four studies (19,20,31,32) did not report parameters that indicate the risk profile of the cohort, such as the proportion of septic and ICU patients. Only seven studies reported an illness severity score (10,15,18,25,27,29,37).…”

“…The mean age of patients ranged from 29.1 to 75.6 years. The causes of AKI were variable, with the most common causes being reported as sepsis (10,15,17,18,22,25,(27)(28)(29)(30)(33)(34)(35)(36)(37), prerenal causes or hypovolemia (6,17,22,26,28,30,32,(35)(36)(37), cardiac failure (10,18,22,30,35,36), postsurgery (10,18,19,26,31,35), and nephrotoxic agents (22,26,35,36). Mortality was reported at hospital discharge (6,15,23,35), at 30 days (10,17,18,27), or not specified.…”

“…Details of the PD technique were often not reported. Where data were available, the studies used either rigid catheters (19,26,28,33,35,37) or flexible Tenckhoff catheters (10,15,17,18,21,23,27,34). The automated cycler was used in four studies (10,17,18,23,26,27), and closed drainage systems were commonly used (10,15,17,18,22,23,26,27,37).…”

“…The number of patients, results, and percentages represent only patients who received RRT. Thirteen studies (n=597 patients) were descriptive in nature, in which PD was the only mode of RRT (Table 1) (6,(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28). Three studies compared different subtypes of PD (18,25,26).…”

“…The automated cycler was used in four studies (10,17,18,23,26,27), and closed drainage systems were commonly used (10,15,17,18,22,23,26,27,37). As buffer, lactate (n=10 studies) (10,15,(17)(18)(19)22,23,(25)(26)(27), acetate (n=3) (24,33,37), and bicarbonate (n=1) were used (25). PD dose is discussed separately below.…”