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Peritoneal Dialysis, Part 1

Paul Simmons, MD and Neda Frayha, MD
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Have you ever had a patient who is on peritoneal dialysis? What does this even mean? How does it work? Neda and Paul answer these questions and more in this 2 part-segment about peritoneal dialysis. 

 

Pearls:

  • Peritoneal dialysis (PD) is a treatment that uses the peritoneum as an exchange membrane and is an alternative to HD for the motivated, relatively healthier and well-supported patient.

  • The main pro of PD includes improved autonomy but can be hard to maintain the required high level of engagement beyond 10 years.

  • As the PCP, don’t forget these patients DO need antibiotic prophylaxis prior to most procedures, especially those involving the GI, GU and dental systems.

 

  • Kidney disease epidemiology:

    • 15% of US population thought to have some variation of chronic kidney disease (CKD)

    • 660,000 in US living with kidney failure

    • 400,000 are on dialysis

    • Globally 1.2 million people die from kidney failure

  • Dialysis:

    • Need to start considering once GFR <30

    • Peritoneal dialysis (PD) accounts for only 7% of the diabetes-dependent population in the US. In Canada it is 50% of those patients. Other countries (China, Thailand, Hong Kong) all have a PD-first approach.

      • May be lower due to inadequate training at the primary care and specialist level in the US

      • Often dialysis is needed urgent so hemodialysis (HD) is started and then there is no discussion of PD

  • Peritoneal dialysis (PD):

    • Good candidate:

      • Motivated

      • High health literacy

      • Home support

      • Clean, cool space

      • Good eyesight and dexterity

      • Decent residual function is better

        • Bargman et. al. study showed for those on PD, every 250ml higher urine volume per day translated to 36% lower 2-year mortality

      • Minimal or no prior abdominal surgeries

    • Contraindications (absolute):

      • Uncorrected abdominal wall hernia

      • Known peritoneal adhesions or sclerosis or pleuroperitoneal leak/shunt

    • How it works:

      • Peritoneum is acting as membrane through which fluid and dissolved substances are exchanged with the blood

    • Process:

      • 1. Placement of peritoneal dialysis catheter (surgically or percutaneously)

        • Generally percutaneous is better than surgical

        • Must be kept clean after placement with restrictions on showering and bathing

      • 2. Two to three weeks of training in nephrology office or dialysis facility

      • 3. Once catheter working and training completed, instill dialysis solution into the peritoneal cavity

      • 4. Water and solutes are exchanged between capillaries and dialysate across peritoneum

        • Solution is a combination of bicarbonate precursor and varying concentrations of osmotic agents (ie: glucose)

          • Pearl: Dialysate solution (icodextrin) can falsely elevate the sugars, alk phos and lower amylase levels

        • You can adjust the glucose concentration to draw more fluid out of the blood if patients are volume-overloaded

    • Options for infusion:

      • Continuous vs. intermittent

        • Multiple times a day

        • Hours at a time, overnight

        • Depends on personal schedule

      • Manually vs. automated

        • Depends on dexterity, eye sight

  • PD Pro’s and Con’s

    • Benefits:

      • Maybe survival:

        • Conflicting data

        • Maybe better survival from 3 months to 2 years

      • Costs

        • $88,000 per year for HD, $71,000 per year for PD

      • Quality of life

        • Flexibility

        • No needles or indwelling venous lines

      • Satisfaction

        • Rubet et. al 2004 JAMA study found PD patients were overall more satisfied

    • Complications:

      • Burnout

        • Cannot skip a day

        • Few patients make it beyond 10 years of PD

      • Requires community and social supports

        • Hard for patients experiencing homelessness to make PD work for them

      • Increased risk of infection (peritonitis)

      • May lead to peritoneal sclerosis, an exaggerated fibrogenic response of the peritoneum

      • Predispose to hernias, hydroceles and genital edema

    • Characteristics of those who do well:

      • Women

      • Lower BMI

      • No diabetes or diabetic nephropathy

      • Lower incidence of peritonitis

      • Higher baseline GFR

      • Lower parathyroid levels

  • Primary care for the patient on PD:

    • Check for catheter site infection

    • Higher index of suspicion for peritonitis if they have fever and abdominal pain

      • Bacteria may come from catheter site, intraluminal or from the bowel

      • 50% are gram-positive

      • 15-35% are gram-negative

      • Tx:

        • Vancomycin or first-gen cephalosporin for gram-positive coverage + third or fourth gen cephalosporin or aminoglycoside or aztreonam for gram-negative coverage x 2-3 weeks given in the intraperitoneal space because high risk of relapsing

        • Do not have to remove the PD cath unless there is relapse or refractory peritonitis (ie: not getting better after 5 days) or fungal or mycobacterial or abscess or perforation

    • Antibiotic prophylaxis: YES!

      • GYN, GI, GU or dental procedures warrant prophylaxis that is usually 1-2 doses given IV preoperatively

      • Pre-op they should drain the peritoneal space

  • Advances in PD:

    • New dialysate solutions

    • IL6 may mediate inflammation and medications modulating it can lead to better dialysate transfer in PD

 

REFERENCES:

  1. Bargman JM, Thorpe KE, Churchill DN; CANUSA Peritoneal Dialysis Study Group. Relative contribution of residual renal function and peritoneal clearance to adequacy of dialysis: a reanalysis of the CANUSA study. J Am Soc Nephrol 12: 2158–2162, 2001. PMID:11562415

  2. Gokal R, Mallick NP. Peritoneal dialysis. Lancet 1999; 353(9155): 823-888.

  3. Heaf J. Underutilization of Peritoneal Dialysis. JAMA 2004;291(6):740–742. doi:10.1001/jama.291.6.740

  4. Jansen MA, Hart AA, Korevaar JC, et al. Predictor of rate of decline of residual renal function in incident dialysis patients. Kidney Int 2002; 62: 1046–53.

  5. Jung HY, Jeon Y, Park Y, et al. Better quality of life of peritoneal dialysis compared to hemodialysis over a two-year period after dialysis initiation. Nature: Scientific Reports 2019; 9 (10266). 

  6. Mehrotra R, Devuyst O, Davies SJ, Johnson DW. The current state of peritoneal dialysis. JASN 2016; 27 (11) 3238-3252. DOI: 10.1681/ASN.2016010112

  7. Rubin HR, Fink NE, Plantinga LC, et al. Patient ratings of dialysis care with peritoneal dialysis vs hemodialysis. JAMA 2004; 291: 697–703.

  8. Sachdeva B, Zulfiqar H, Aeddula NR. Peritoneal Dialysis. [Updated 2019 Jun 24]. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2019 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532979/

  9. Saxena R, West C. Peritoneal dialysis: a primary care perspective. Journal of the American Board of Family Medicine 2006; 19(4): 380-389. https://www.jabfm.org/content/19/4/380.long

  10. Tong M, Wang Y, Ni J, et al. Clinical features of patients treated by peritoneal dialysis for over a decade. Am J Clin Exp Urol. 2017;5(3):49–54. 

  11. Woodrow G, Fan SL, et al. Renal Association Clinical Practice Guideline on peritoneal dialysis in adults and children. BMC Nephrology 2017; 18(333).

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