Professional Documents
Culture Documents
Peritoneal Dialysis
Peritoneal Dialysis
Peritoneal Dialysis
Isaac Teitelbaum, MD, and John Burkart, MD
1082 American Journal of Kidney Diseases, Vol 42, No 5 (November), 2003: pp 1082-1096
CORE CURRICULUM IN NEPHROLOGY 1083
acids and polyglucose are available for clinical dothelial cells by diffusion, polyglucose is slowly
use in most countries. absorbed through lymphatics. Thus, it can main-
● Glucose. Standard dialysis solutions contain tain its colloid osmotic force over long dwells of
glucose as the osmotic agent. Glucose has up to 18 hours. Furthermore, the rate of absorp-
been shown to be safe, effective, readily tion is not influenced by peritoneal transport
metabolized, and inexpensive. However, glu- type, as is the absorption rate of glucose by
cose is not an “ideal” osmotic agent because diffusion. The safety of icodextrin use has been
of the following properties or effects: rapid established. Reported side effects include skin
absorption; the potential for metabolic de- rash and sterile peritonitis. Indications for the use
rangements (such as hyperglycemia, hyper- of polyglucose include the long dwell of CAPD
insulinemia, hyperlipidemia, and obesity); (overnight); the daytime dwell of continuous
the necessity for an acidic dialysis pH to
cyclic PD (CCPD); patients with loss of ultrafil-
prevent caramelization; and the potential
tration (high transporters, patients with loss of
nonenzymatic glycosylation of peritoneal
aquaporins); during episodes of peritonitis; and
tissue. Glucose solutions induce a crystal-
loid osmotic gradient to drive ultrafiltration. in patients with diabetes mellitus (to decrease
● Amino Acids. There is an obligatory daily
glucose load).
loss of protein and amino acids into the ● Biocompatibility Issues. In a typical PD
peritoneal effluent. Therefore, a potential patient, the peritoneal cavity is exposed to new
advantage of amino acid–containing fluids dialysis fluids at least 4 times daily. These dialy-
would be that the absorbed osmotic agent sis solutions exert biologically and chemically
would be a non–phosphorous-containing induced effects not only on the peritoneal mem-
protein caloric source and that the amino brane and mesothelial cell, but also on the resi-
acids absorbed would replace or exceed the dent leukocytes, macrophages, and fibroblasts.
obligatory amino acids lost in the effluent Peritoneal biopsies in patients on long-term PD
on a daily basis. However, studies document- have revealed ultrastructural changes (eg, glyco-
ing the long-term efficacy of amino acids as sylation of capillary proteins) possibly induced
a nutritional supplement have been contro- in part by the dialysis solutions. Data suggest
versial. Complications include the develop- that di(2-ethylhexyl)phthalate (DEHP), the most
ment of metabolic acidosis and increased commonly used plasticizer for polyvinylchlo-
levels of serum urea nitrogen. The use of ride, may have adverse effects on macrophage
1.1% amino acid solutions results in ultrafil- function. Furthermore, it has been shown that
tration and solute clearance rates similar to glucose degradation products produced during
those using 1.5% dextrose solutions. heat sterilization and storage of glucose contain-
● Polypeptides/Oligopeptides. Polymers of
ing solutions participate in the nonenzymatic
glucose (icodextrin or polyglucose) can in- cross-linking of proteins leading to the formation
duce a colloid osmotic force to drive ultrafil-
of advanced glycosylation end products (AGEs).
tration. Whereas glucose induces transcapil-
● Conclusions. Although commercially avail-
lary ultrafiltration across both small
able dialysis solutions based on lactate and glu-
interendothelial and ultrasmall transcellular
pores (via crystalloid forces), glucose poly- cose have provided adequate treatment of end-
mers induce ultrafiltration across interendo- stage renal disease for thousands of patients, they
thelial pores and the relatively few large do alter mesothelial cell and peritoneal macro-
pores (via colloid osmotic forces). Ultrafil- phage function. Furthermore, pathologic alter-
tration with glucose is rapid and occurs ations of the peritoneal membrane that may be
early in the dwell (due to large crystalloid related to components of the PD solutions have
osmotic gradient) and decreases with time been described. Newer solutions that address
as glucose is absorbed, whereas with poly- these needs have been developed and are in
glucose, ultrafiltration is constant but slow. clinical use. However, the long-term outcomes/
In contrast to glucose-containing solutions, benefits of such solutions for the patient are not
where the glucose is absorbed via small interen- yet fully understood.
CORE CURRICULUM IN NEPHROLOGY 1085
solutions (as a result of the sterilization process) the capillaries and the interstitium, and that
will amplify AGE formation. The RCCs and the blood phase is distributed within the
AGEs initiate a number of cellular responses peritoneal interstitium. This model includes
including vascular endothelial growth factor, the theory that the distance between capil-
which interacts with endothelial cells stimulating lary and mesothelial surface, as well as
angiogenesis and increasing vascular permeabil- number of capillaries, influence transport.
ity. Use of more biocompatible solutions my ● “Three-pore” model, yields the most realis-
slow or prevent this process. tic estimations of small-solute reflection co-
efficients, macromolecule transfer, and the
PERITONEUM AS A DIALYSIS SYSTEM effects of lymphatic absorption and ultrafil-
● Resistance to Salt and Water Transport. tration profiles observed clinically even
The barrier for mass transport appears to when high-molecular-weight solutes are used
offer very little resistance to solute trans- as osmotic agents.
port by diffusion but seems to offer signifi-
cant resistance to solute transport by convec- PHYSIOLOGY OF PERITONEAL TRANSPORT
tion. The clinical significance of this is that ● Solute Transport by Diffusion
solute removed by convection is not re- ● Diffusion, defined as a tendency for solutes
moved at the same concentration as it is in to disperse themselves within the space
plasma. There is more resistance to flow for available, is the most important mechanism
these solutes than there is for water. This is responsible for solute transport into the peri-
especially true when ultrafiltration is driven toneum. In PD, the diffusive clearance of
by small osmotic solutes, “crystalloid osmo- any solute depends on the “effective” perito-
sis,” but it is less significant when ultrafiltra- neal membrane surface area, the intrinsic
tion is driven by hydraulic pressure or col- permeability of the membrane, dialysate
loid osmosis. An example of this is sodium flow, concentration gradients, and time al-
“sieving” and the observation that, early in lowed for transport. Overall solute clear-
the dwell with a glucose-containing solu- ance can never exceed the lowest of these
tion, dialysate sodium decreases. parameters. Typical dialysate flow rates are
The interstitium represents the longest dis- markedly lower than those of capillary blood
tance that solutes must traverse. There is increas- flow or membrane transport capabilities.
ing evidence to suggest that the interstitium is Standard PD therapies are therefore limited
one of the major resistance sites for urea and low by dialysate flow.
molecular weight solute transport. The intersti- Diffusion becomes more restricted as molecu-
tium is thought to be represented by a 2-phase lar weight increases (ie, urea diffuses faster than
system that contains a gelatinous mucopolysac- creatinine). In fact, in contrast to what is ob-
charide matrix interspersed with a water-rich, served for small solute clearance where increas-
colloid-poor, free-fluid phase containing aque- ing number of exchanges per day tends to in-
ous channels. crease daily clearance even if already during 24
● Models of Peritoneal Transport hours of dwell, once on 24 hours/day of dwell
Despite the complexity, investigators have at- time, further increases in the number of ex-
tempted to characterize peritoneal membrane changes/day does not increase middle molecule
transport properties in terms of classical mem- clearances.
brane physiology using mathematic models. ● Ultrafiltration: Net ultrafiltration is achieved
These models can help the nephrologist under- clinically by creating an osmotic pressure
stand peritoneal solute and water transport and gradient (crystalloid or colloid) between
guide in individualizing prescriptions for pa- blood and dialysate. Historically, dialysis
tients. fluids achieved this via crystalloid osmosis
● “Distributed” models of peritoneal transport by adding various concentrations of glucose
assume that the barrier separating blood to the solutions. Newer fluids use polyglu-
from dialysate is not homogeneous but is cose to induce colloid-driven ultrafiltration.
composed of distinct elements, including Solutes present in body fluids can be swept
CORE CURRICULUM IN NEPHROLOGY 1087
along with the bulk solvent flow even in the vents. This is most commonly observed
absence of a concentration difference for net during dwells with solutions containing glu-
diffusion, contributing to overall solute clear- cose as the osmotic agent and is mainly due
ance. This contribution to net solute clear- to water movement across transcellular aqua-
ance has been termed “solvent drag” or porins. The most important clinical conse-
“convection.” quences are those related to the transport of
● Kinetics of Peritoneal Ultrafiltration: In Na⫹. These expected changes in dialysate
addition to ultrafiltration, absorption of Na⫹ concentrations during the dwell can be
fluid from the peritoneal cavity also occurs. helpful in evaluating a patient with loss of
This is mainly due to absorption of fluid ultrafiltration. If a patient is on automated
through the tissues of the anterior abdomi- therapy and there is aggressive overnight
nal wall and by the peritoneal lymphatics. ultrafiltration, there may be relatively more
Intraperitoneal volume at any time is water than sodium removal.
therefore determined by the relative mag- ● Lymphatic Absorption: Intraperitoneal fluid
nitudes of transcapillary ultrafiltration and is continuously absorbed from the perito-
anterior wall plus lymphatic absorption. neal cavity. The fluid can either be absorbed
Polymers of glucose (icodextrin or directly into the subdiaphragmatic perito-
polyglucose) can induce a colloid os- neal lymphatics or through the interstitial
motic force to drive ultrafiltration. tissue of the peritoneal membrane. Hydrau-
Whereas glucose induces transcapillary lic pressure effects when standing or when
ultrafiltration across both small interendo- associated with activity may alter the rela-
thelial and ultrasmall transcellular pores/ tive amount of convective movement of
aquaporins (via crystalloid forces), glu- fluids and solute into the subdiaphragmatic
or other lymphatics. Data suggest that in-
cose polymers only induce ultrafiltration
creases in intraperitoneal pressure are asso-
across interendothelial pores (via colloid
ciated with an increase in lymphatic absorp-
osmotic forces). Ultrafiltration with glu-
tion rates. Measurements of lymphatic
cose is rapid and occurs early in the dwell
absorption rates in CAPD patients using
(due to large crystalloid osmotic gradient)
intraperitoneal dextran as a marker ranged
and decreases with time as glucose is
from 0.1 to 3.5 mL/min with a median value
absorbed, whereas with polyglucose, ultra-
of 1.0 ml/min or about 2.2 L/day.
filtration is constant but slow.
Thus, for 2-L solutions containing 1.5%
dextrose (1.36% glucose), osmotic equi- CLINICAL OBSERVATIONS OF PERITONEAL
librium and maximal drain volume are MEMBRANE FUNCTION
reached after about 2 hours of dwell time Characterization of Peritoneal Membrane
in most patients, whereas peak intraperito- Transport: In the presence of infinite peritoneal
neal volumes are not likely to occur until capillary blood and dialysate flows, solute clear-
after a 3- or 4-hour dwell with 4.25% ance is directly proportional to peritoneal surface
dextrose (3.86% glucose). area and indirectly proportional to overall resis-
● Solute Transport by Convection: Solutes tance. A measurement of clearance under these
present in body fluids can be swept along conditions is a measurement of the intrinsic
with the bulk flow of water during ultrafiltra- transport properties of the peritoneal membrane.
tion even in the absence of a concentration Ideally, these measurements are primarily a func-
gradient for net diffusion. This solvent drag tion of peritoneal diffusive permeability (cm/
or “convective solute” transport does not min) and effective surface membrane area (in
occur in amounts per liter of ultrafiltrate cm2). Measurements of mass transfer area coeffi-
equal to the physiologic concentration of cients (MTACs) are thought to approximate this
solutes in body fluids. In other words, there state. However, as MTAC measurements are
is a sieving effect that depends on resistance relatively complex, the simpler peritoneal equili-
forces intrinsic to the membrane and sol- bration test (PET) has become the standard tool
1088 TEITELBAUM AND BURKART
used clinically to characterize peritoneal mem- As seen in Fig 1, peritoneal membrane trans-
brane transport. The protocol for the standard port is divided into 4 categories: high, high
PET is as follows: average, low average, and low. Patients who
1. The test is performed in the morning after exhibit high membrane transport (lightest quar-
complete drain of the prior long (ⱖ8 hours) tile) will most rapidly equilibrate creatinine (and
dwell. urea) and achieve excellent solute clearance.
2. Using 2.5% dextrose dialysate, the pa- However, they also rapidly absorb glucose from
tient’s usual fill volume is infused. the peritoneal cavity, thereby dissipating the os-
3. A sample of dialysate for determination of motic gradient favoring ultrafiltration. There-
creatinine, urea, and glucose is taken imme- fore, they have low drain volumes and will often,
diately after infusion and at 2 and 4 hours. in fact, reabsorb fluid from the peritoneal cavity
4. A blood sample for determination of creati- during long dwells. These patients will often
nine, urea, and glucose is taken 2 hours benefit from performing CCPD with more fre-
after infusion. quent exchanges and shorter dwell times. They
5. The dialysate is drained after 4 hours, and may also benefit from the use of icodextrin
the drain volume is recorded. during their long day dwell. Conversely, patients
6. The dialysate to plasma (D/P) ratios for who exhibit slow membrane transport (darkest
creatinine and urea and the ratio of glucose quartile) have poorer solute clearance. There-
in the dialysate compared to its initial con- fore, these patients may benefit from longer
centration (D/D0) at times 2 and 4 hours are dwell times (CAPD) and larger exchange vol-
calculated and plotted on the standard PET umes. However, because they dissipate their os-
graph (Fig 1). motic gradient slowly as well, these patients
CORE CURRICULUM IN NEPHROLOGY 1089
ing on peritoneal clearance alone if indi- renal function was similar in the 2 groups. Pa-
cated. If residual renal clearances are in- tient survival was similar in the interventional
cluded, the calculations for Kt/Vurea are and standard groups, even after adjustment for
obtained using urea clearance, while one comorbid conditions such as age, presence of
uses an estimation of glomerular filtration diabetes mellitus, serum albumin levels, anuria,
rate (the mean of the urea and creatinine and normalized protein equivalent of total nitro-
clearances) for the weekly creatinine clear- gen appearance. As a result, guidelines for ad-
ance measure. equacy of PD are likely to be revised.
● Adequate Dose of Peritoneal Dialysis:
Based on the results of many clinical stud- WRITING THE DIALYSIS PRESCRIPTION
ies performed during the past 10 years, the ● Initial Prescription: The PD prescription
NKF/DOQI workgroup has developed can be developed either empirically or
guidelines for an adequate dose of dialysis. through the use of a computer-modeling
For CAPD patients, the delivered PD dose program using data based on the patient’s
for Kt/Vurea should be at least 2.0. The weight, residual renal function, and any
recommended weekly creatinine clearance lifestyle constraints that may be present.
dose is based on the patient’s transport ● Adjustments to the Initial Dialysis Prescrip-
characteristics. For patients who are high or tion: Two to 4 weeks following the initia-
high average transporters, the total creati- tion of PD, 24-hour collections of urine and
nine clearance should be at least 60 L/wk/ dialysate should be performed, along with
1.73 m2. For patients who are low or low serum chemistries and a complete blood
average transporters, the weekly creatinine count, in order to calculate the weekly Kt/
clearance should be at least 50 L/wk/1.7 Vurea and creatinine clearance. The initial
m2. The dosage recommendations for auto- PET should be performed approximately 1
mated techniques are based on whether the month after the initiation of dialysis. This
patient also has daytime exchanges. For waiting period is recommended as the PET
patients using the cycler who have a dry results can change during the first month of
day, the total Kt/Vurea should be at least 2.2 dialysis. The PET is performed to rule out
and the weekly total creatinine clearance unexpected problems and also to identify
should be at least 66 L/wk/1.73 m2. For patients who are either high or low transport-
patients using the cycler who have at least 1 ers. High transporters will likely need short
daytime dwell, the total Kt/Vurea should be dwell prescriptions and may develop ultra-
at least 2.1 and the total weekly creatinine filtration problems as residual kidney func-
clearance should be at least 63 L/wk/1.73 tion fails. Low transporters usually require
m2. In malnourished patients, the estimate high dose CAPD or CCPD in order to
of body size is adjusted up to ideal body maintain adequate dialysis as residual renal
weight. Thus, for Kt/V urea, the target dose function decreases. If clearances are at or
is increased by the ratio Vdesired/Vactual, while above target, then monitor adequacy at regu-
for creatinine clearance the target dose is lar intervals as noted in the section measure-
increased by the ratio BSAdesired/BSAactual. ment of PD dose above. If clearances are
After the last PD guidelines were revised by below target, then modify the prescription
the NKF/DOQI workgroup, the ADEquacy of and repeat adequacy testing.
PD in MEXico (ADEMEX) trial was published. ● Further Adjustments to the Dialysis Pre-
A total of 965 subjects were randomized to either scription: For CAPD patients, there are 2
standard care, where patients continued on their methods that can be used to increase dialy-
present PD prescriptions, or to an interventional sis adequacy. The most common approach
group, in which the dialysis prescriptions were is to increase the dwell volume/exchange.
modified to achieve a peritoneal creatinine clear- One could also increase the number of
ance of 60 L/wk/1.73 m2. The mean separation in exchanges/day. Alternatively, a nocturnal
peritoneal creatinine clearances in the 2 groups exchange device is available that provides
was approximately 10 L/wk/1.73 m2. Residual an extra exchange overnight, thus provid-
CORE CURRICULUM IN NEPHROLOGY 1091
ing the patient with a total of 5 exchanges ides, juxtaperitoneal infection, malignancy, or
per day. For cycler patients, there are sev- allergic reactions should be considered.
eral methods available for improving ad- ● Microbiology
equacy. These methods include increasing Sixty to seventy percent of episodes are due to
the dwell volume/exchange, increasing the Gram-positive cocci, most commonly Staphylo-
time spent overnight on the cycler, increas- coccus aureus or epidermidis. Gram-negative
ing the number of exchanges on the cycler, rods account for 15% to 25% and fungi for 2% to
or increasing the number of daytime dwells. 3%. In approximately 15% of episodes, no organ-
Sometimes a combination of the above mea- ism is cultured. Tuberculosis is a rare cause of
sures is used in an individual patient. peritonitis in the United States.
The finding of anaerobic and/or polymicrobial
COMPLICATIONS OF PERITONEAL DIALYSIS peritonitis should raise the question of an intraab-
dominal catastrophe and prompt a surgical evalu-
Patients performing PD may experience either
ation. When due to pancreatitis or a ruptured
infectious or noninfectious complications.
viscus, peritonitis may be associated with an
elevated amylase (⬎50 IU/L) in the dialysate.
● Infectious Complications
● Treatment
Infectious complications account for approxi- Send dialysate for cell count with differential
mately two thirds of all PD catheter losses and and Gram stain. Initiate therapy guided by Gram
around one third of all transfers to hemodialysis. stain results.
The major infectious complications of PD are The International Society for Peritoneal Dialy-
peritonitis and exit-site or tunnel infections. sis (ISPD) recommendations for the initial/
● Peritonitis
empiric therapy of peritonitis have changed over
The most common infectious complication of
the years. The current recommendations are:
PD.
● A significant cause of hospitalization, cath-
Gram Stain Results Therapy
eter loss, malnutrition, peritoneal mem-
brane failure, and occasionally death. Gram-positive First-generation cephalosporin
● Average frequency approximately 1 episode Gram-negative Third-generation cephalosporin
per 20 to 30 patient-months. The use of (an aminoglycoside may be
disconnect systems has played a major used for patients with
residual urine output
role in lowering this frequency from the ⬍100 cc/d)
prior rate of 1 episode per 6 to 18 patient- No organism seen Combination of above agents
months.
● Diagnosed when at least 2 of the following The use of vancomycin remains controversial.
are present: The ISPD no longer recommends routine use of
vancomycin for fear of inducing vancomycin resis-
Cloudy dialysis effluent with white blood tance in enterococci. However, other authors still
cell count ⬎100 cells/mm3 (usually prefer it because of the high frequency of methi-
⬎50% are polymorphonuclear neutro- cillin-resistant, coagulase-negative staphylococci.
phils)—present in 98% of cases Attempts at treating fungal peritonitis with
Abdominal pain—present in approximately amphotericin or a combination of fluconazole
75% of cases and flucytosine virtually always fail. Catheter
Positive culture from dialysate removal should be considered very early.
Other symptoms such as fever, nausea, or Final therapy should be guided by culture
diarrhea are present in no more than half of results and sensitivities. Treatment should be
all cases. continued for a total course of 2 weeks; infec-
Not all instances of cloudy peritoneal dialy- tions due to S aureus, anaerobes, members of the
sate reflect infectious peritonitis. Depending on Pseudomonas/Stenotrophomonas family, or those
the cellularity of the fluid and the nature of the due to multiple Gram-negative organisms re-
cells found, other causes such as fibrin, triglycer- quire 3 weeks of antibiotic therapy.
1092 TEITELBAUM AND BURKART
patients who are nasal carriers of S aureus. Prophy- • Failure of the PD catheter during infusion
lactic treatment of PD patients with oral rifampin or may reflect intraluminal obstruction by fi-
with mupirocin administered either intranasally or brin or clot. Flushing the catheter with hepa-
topically at the exit-site have all been shown to rinized saline may be beneficial. Thrombo-
markedly reduce the frequency of both exit-site lytic therapy is often needed.
infections and peritonitis. Controversy remains • Distended loops of bowel due to constipa-
as to whether all patients or only documented tion will often impair catheter outflow by
carriers should be treated in this fashion. occluding many of the holes on the distal
● Tunnel Infection end of the PD catheter. This should always
● Defined by the presence of erythema, edema, be considered as the first possible etiology
and/or tenderness over the subcutaneous for outflow obstruction and should be ad-
catheter pathway associated with sangui- dressed with appropriate laxative therapy.
nous, purulent, or thick drainage either spon- • Catheter obstruction may also be due to any
taneously or when pressure is applied to the of a variety of other causes including:
catheter tunnel. Adhesions due to prior peritonitis or sur-
● A loculated abscess involving the tunnel gery may cause the catheter to be trapped in
may present with pain or signs of inflamma- a loculated compartment. Surgical lysis or
tion without discharge. Ultrasonography of catheter repositioning/replacement may be
the tunnel may be helpful in establishing the necessary.
diagnosis. Catheters with the distal tip in the abdo-
● Tunnel infections are commonly associated
men rather than the pelvis may be subject to
with simultaneous exit-site infection with wrapping by active omentum (which does
the same organism; when this is the case the not commonly extend into the pelvis). In
risk of peritonitis is increased. this circumstance inflow of dialysate is usu-
Treatment of tunnel infections is very ally not affected, as the pressure of the
infusing dialysate will displace the offend-
difficult. Antibiotic therapy is often unsuc-
ing “flap” of omentum. Omental wrapping
cessful. Irrigation of the tract with saline or
most commonly presents within the first few
a povidone-iodine solution is rarely benefi-
months of initiating PD and is generally
cial. When due to Gram-positive organisms
painless. Omentectomy is often necessary.
it may be possible to successfully treat the
Peritonitis, particularly that due to fungi,
infection by deroofing a portion of the cath-
may present with catheter obstruction.
eter tunnel; this technique is not successful
● Malposition
for Gram-negative infections. Catheter re-
• Though occasionally due to inappropriate
moval and replacement is frequently neces- catheter placement at the time of insertion,
sary; this may sometimes be accomplished malposition of the PD catheter is more com-
successfully in a single operation as de- monly due to migration of the catheter tip
scribed earlier in the section on peritonitis. out of the pelvic gutter into the upper abdo-
● Noninfectious Complications men. This is often associated with discom-
As is the case for hemodialysis, patients per- fort, localized by the patient to the site of the
forming PD are subject to numerous complica- catheter. Malposition may also be a cause of
tions affecting many organ systems. This portion poor catheter drainage, particularly in pa-
of the curriculum, however, will be confined to a tients attempting to drain in the upright
discussion of complications specific to the perfor- position. Changing position during drain (eg,
mance of PD. lying on the right side for catheters in the
● Catheter Malfunction right upper quadrant) may provide relief.
• Catheter tips that have migrated to the left
● Obstruction
upper quadrant may spontaneously reposi-
• PD catheters may exhibit obstruction during tion themselves secondary to the actions of
either the infusion or drain phases of an peristalsis favoring downward movement of
exchange. the catheter on the left side. In contrast,
1094 TEITELBAUM AND BURKART
50% despite medical and surgical treatment. comes manifest within the first month of initi-
The etiology and pathogenesis of SEP are not ating PD; onset later than 1 year after the
well understood. SEP may present years after initiation of PD is uncommon. Peritoneal dia-
discontinuation of PD, even after renal trans- lysate transits the diaphragm either via lym-
plantation. phatics or through congenital diaphragmatic
● Defects in Peritoneal Cavity Boundaries defects. Nearly 90% of cases occur on the
right side. The reason for this is unclear;
• Hernias and Abdominal Wall or Genital
protection of the left hemidiaphragm by the
Edema
heart and pericardium has been postulated, as
Due to the increase in intraabdominal pres- has a “piston” effect of the liver to propel
sure associated with the performance of PD, dialysate across the right hemidiaphragm.
hernia is a relatively common complication Patients most commonly present with pro-
occurring in anywhere from 10% to 25% of all gressive dyspnea and/or orthopnea. Pain and
PD patients. Hernias may be incisional (cath- acute onset of dyspnea are uncommon.
eter site or other), ventral, umbilical, or ingui-
Diagnosis—The pleural fluid is transuda-
nal. It has been suggested that the frequency of
tive and has a high glucose concentration. The
hernias may be increased in females.
cell count is variable. The diagnosis of
Hernias often present with localized swell-
PD-associated hydrothorax is confirmed by
ing that is usually painless. In these instances
demonstrating communication between the
the diagnosis may be established via perito-
peritoneal and pleural spaces. This may be
neal scintigraphy or computed tomographic
accomplished by injecting radiolabeled albu-
peritoneography. It should be noted, however,
min or technetium sulfur colloid into the peri-
that intestinal obstruction due to strangulation
toneal cavity and imaging the chest after allow-
may occur in up to 10% to 15% of hernias,
ing the patient to ambulate for an hour.
particularly those at the catheter site or related
to other abdominal incisions. Treatment—Patients may require thoracen-
Dialysate leakage through congenital (eg, tesis for initial relief of symptoms. PD should
patent processus vaginalis) or acquired (eg, be temporarily discontinued or, at a minimum,
pericatheter or prior incisional site) abdominal changed to a modality associated with lower
wall defects results in dissection of dialysate peak intraabdominal pressures, eg, lower vol-
through soft tissue and fascial planes. This umes or nocturnal intermittent PD. Pleurode-
will present with either genital (scrotal or sis with talc, triamcinolone, autologous blood,
labial) edema or generalized swelling of the tetracycline derivatives, fibrin glue, or Nocar-
abdominal wall and/or upper thigh, frequently dia rubra cytoskeleton may be attempted
with a peau d’orange appearance. Ultrasound in case of recurrence. The procedure is
or computed tomographic peritoneography are often poorly tolerated due to pleural irrita-
usually diagnostic. The latter may be per- tion. Surgical repair via a limited thora-
formed without radiocontrast, as the presence cotomy is indicated if pleurodesis fails. Al-
of the dialysate itself may serve in this fashion ternatively, patients may elect to transfer to
and allow for definition of the defect. hemodialysis.
While dialysate leaks may occasionally ● Metabolic Abnormalities
resolve after temporary cessation of PD or
• Hypoalbuminemia
a switch to nocturnal intermittent PD, surgi-
cal repair is nearly always necessary. Ab- Patients performing PD lose approximately
dominal hernias invariably require surgical 4 to 7 g of albumin per day across the perito-
repair. neal membrane. Therefore, hypoalbuminemia
is more commonly observed than in patients
• Hydrothorax
performing hemodialysis. Consequently, ef-
Hydrothorax is a rare complication (⬍2%) forts should be made to maintain the patients’
of PD. For unknown reasons there is a marked dietary protein intake ⱖ1.2 g/kg/d if at all
female preponderance. It most commonly be- possible.
1096 TEITELBAUM AND BURKART