Peritoneal Dialysis Use in Patients With Ascites: A Review

Abstract

The past few decades have seen steady increase in the prevalence of kidney failure needing kidney replacement therapy. Concomitantly, there has been progressive growth of heart failure and chronic liver disease, and many such patients develop ascites. Therefore, it is not uncommon to encounter patients with kidney failure who concurrently have ascites. The presence of ascites adds many challenges in the management of kidney failure. Poor hemodynamics make volume management difficult. The presence of coagulopathy, malnutrition, and encephalopathy compounds the complexity of the management. Such patients do not tolerate hemodialysis well. However, several concerns have limited the use of peritoneal dialysis (PD), so hemodialysis remains the predominant dialysis modality in these patients. However, observational studies have illustrated that PD provides hemodynamic stability and facilitates better volume management compared with hemodialysis. Moreover, PD obviates the need for therapeutic paracentesis by facilitating continuous drainage of ascites. PD potentially reduces hemorrhagic complications by avoiding routine anticoagulation use. Moreover, small studies have suggested that outcomes such as peritonitis and mechanical complications are comparable to those in PD patients without ascites. PD does not affect transplant candidacy, and these patients can successfully receive combined liver and kidney transplants. Hence, PD should be considered a viable dialysis option in kidney failure patients with ascites. Clinical VignetteA 65-year-old man has history of hypertension, type 2 diabetes mellitus, hepatitis C-related cirrhosis with ascites, and progressive chronic kidney disease (CKD) due diabetic nephropathy. In the past 3 months, he was hospitalized twice with episodes of spontaneous bacterial peritonitis and hepatic encephalopathy. Lately he had required frequent large volume paracentesis (LVP). His MELD (Model for End-stage Liver Disease) score was 21. His CKD had progressed to stage 5, and he had been educated about kidney replacement therapy options. He expressed a preference for peritoneal dialysis (PD), and voiced interest in kidney-liver transplant. He was referred to surgery for placement of a PD catheter, but was informed that patients with ascites should not get a PD catheter placed. Consequently, he was initiated on in-center hemodialysis (HD). He did not tolerate ultrafiltration due to persistent hypotension and remained volume overloaded. He still needed frequent LVP to manage his ascites. Should this patient be reconsidered for PD?Complete author and article information appears before references.

Pharmacologic Inhibition of Histone Deacetylase 6 Prevents the Progression of Chlorhexidine Gluconate-Induced Peritoneal Fibrosis by Blockade of M2 Macrophage Polarization

“…It has been reported the prevalence of end-stage kidney diseases (ESKD) is continually increasing ( 1 ), and peritoneal dialysis (PD) is an alternative way of renal replacement therapy for patients with ESKD ( 2 ). Despite the similar outcome with hemodialysis ( 3 ), PD is still not the first choice for most patients with chronic kidney disease stage 5.…”

Reversal of hepatorenal syndrome and kidney recovery: When renal has more to offer

“…24 On the other hand, there's a growing attention towards the successful use of PD in patients with cirrhosis. 25 As a home-based, steady-state treatment, PD has many potential benefits compared to HD, such as no need for anti-coagulation, maintain hemodynamic stability, continuous ascitic drainage, better balance between volume control and kidney function preservation, higher energy provisions, lower cost, and improved quality of life. Theoretically, PD increases intra-abdominal pressure which may generate counter pressure opposes portal pressure, leading to decreased ascites formation and protein losses.…”

“…Ninety‐day survival after KRT initiation for nonlisted patients with HRS‐1 was only 15% 24 . On the other hand, there's a growing attention towards the successful use of PD in patients with cirrhosis 25 . As a home‐based, steady‐state treatment, PD has many potential benefits compared to HD, such as no need for anti‐coagulation, maintain hemodynamic stability, continuous ascitic drainage, better balance between volume control and kidney function preservation, higher energy provisions, lower cost, and improved quality of life.…”

Liver cirrhosis with encapsulating peritoneal sclerosis after 4 years of peritoneal dialysis

“…[ 9 ] Recently, PD has been reported to have the potential to overcome hemodialytic complications and manage large-volume ascites in cirrhotic patients, with comparable mortality, infection, and mechanical complication rates to the control PD population. [ 3 , 7 , 8 ] Furthermore, cirrhotic patients undergoing PD have retrospectively shown lower all-cause mortality compared with those undergoing HD. [ 10 ] Therefore, PD may become a feasible therapeutic option for cirrhotic patients with ESRD.…”

“…[ 6 ] Although hemodialysis is the predominant dialysis modality in cirrhotic patients with ESRD, PD has recently been recognized as a feasible therapeutic option for those patients to avoid hemodialytic complications such as unstable hemodynamics, as well as to control refractory ascites. [ 7 , 8 ]…”