Peritoneal Dialysis in

Acute Kidney Injury (Adult)

April Sanchez-Garcia, M.D.

Mary Rose Y. Bisquera, M.D.
Increasing Incidence of Acute Kidney Injury

• 1.7 million deaths per year

worldwide from AKI
• 1.4 million deaths per year
from the low and middle-
income countries
Lewington et al., Kidney Int, 2013
 Grade Methodology
• Assigns separate grades for
• Quality of evidence
• Strength of recommendation

A High
1
(strong) B Moderate
Strength of Quality of
Recommendation Evidence C Low
2
(weak) D Very Low

• Opinion or practice point – no evidence exists but there is enough

clinical experience for the committee to make a recommendation
 Questions:
Is PD a suitable modality for treating AKI?

What is the optimal access and fluid delivery for PD in AKI?

Which PD fluid should be used in Acute PD? What to do when it is not available?

How to prescribe PD in AKI?

How to troubleshoot complications?

RRT Modalities in AKI
 Advantages of PD in AKI
Logistical ease of setting up PD

Superior hemodynamic tolerance

Lower risk of dialysis dysequilibrium syndrome

Lack of need for anticoagulation

Hyperalimentation among malnourished patients

In situations when hemodialysis and CRRT are not available

 Gabriel 2008 Ponce 2013 Ponce 2011 Parabipoon 2017 Al Hweish 2018

Intervention HVPD vs daily HVPD vs daily High vs low Intensive vs Minimal Tidal APD vs
HD EHD intensity PD Standard CVVHDF
Population 120 143 61 75 125
Ventilated 68% vs 75% 83% vs 87% 68% vs 72% 87% vs 89% 62% vs 69%
APACHE II 26.9 vs 24.1 27.5 vs 26.7 26.4 vs 24.8 26.9 vs 25.7 21.1 vs 21.3
PD Catheter Flexible (TK) Flexible (TK) Flexible (TK) Flexible (TK) Flexible (TK)
PD Technique Automated Automated Automated Manual Open Automated PD
Homechoice Homechoice Homechoice System, single bag 70% TV,
Cycler Cycler Cycler Biocompatible
Weekly Kt/V 3.6 vs 47 (p <0.01) NR 4.13 vs 3 (p=0.03) 3.3 vs 2.25 (p=0.01) NR
UF (L) 2.1 vs 2.4 (p=0.39) 0.6 vs 1.44 (p <0.01) 2.4 vs 2.1 (p=0.42) 1st: 1.55 vs 0.05 (p <0.01) 0.95 vs 1.39
2nd: 2.1 vs 0.9 (p <0.01)
30 Day 58% vs 53% 63.9% vs 63.4% 55% vs 53% 79% vs 63% 30.2% vs 53.2%
Mortality (p=0.48) (p=0.94) (p=0.42) (p=0.13) (p <0.01)
Renal Recovery 83% vs 77% 93.5% vs 90.3% 86% vs 86% 97.4% vs 91.7% 60.3% vs 35.5%
(p=0.84) at 30 (p=0.23) (p=0.64) at 30 (p=0.29) at 90 days (p <0.01)
days days
 There is little or no difference between PD and
extracorporeal therapy for treating AKI
 Cochrane review of six trials and 484 patients with AKI treated with
PD compared with patients treated with extracorporeal therapies
(HD, extended daily HD, or CRRT)
 Survival and recovery of kidney function (moderate certainty of
evidence)
 Infectious complications (low certainty of evidence)
 Correction of acidosis (very low certainty of evidence)
 Fluid removal (low certainty) and weekly delivered Kt/V (very
low certainty) may be higher with extracorporeal therapy
Lui L, et al, Cochrane Database System Rev
Is PD a suitable modality for treating AKI?

Guideline 1: PD should be considered a suitable modality for

treatment of AKI in all settings (1B)

The choice of dialysis modality in AKI should made according to the

patient’s clinical symptoms, laboratory indexes and local resources
 Dialysis Access
 Type of Catheters
 Tunneled double-cuff Tenckhoff catheter: optimally
preferred
 Other catheter options: flexible single-cuff, semi-rigid,
rigid
 Improvised catheters: nasogastric tubes, intercostal
drainage catheters
 Advantages and disadvantages of flexible, rigid and
other peritoneal access
Rigid stylet catheter
Flexible catheter
Intercostal drainage tubes,
nasogastric tubes, intercostal
drains, hemodialysis catheters and
percutaneous cavity drainage
catheters
Advantages
1. Inexpensive
2. Can be performed at bedside
3. Easily removed
1. Better flow characteristics
allowing dialysate flow rates
2. Less chance of perforation
3. Less leak
4. Less infection
5. Can be performed at bedside
1. Inexpensive
2. Readily available
Disadvantages
1. Catheter dysfunction
2. Flow-related problems
3. Risk of perforation of blood
vessels or internal organs
1. More expensive
2. Requires more training for
insertion
3. Catheter tip migration
1. Flow related problems
2. Most need surgical placement
3. High risk of leaks
4. Difficulty with achieving
reliable connections
 Guidelines on Catheter Type
 Guideline 2.1: Flexible peritoneal catheters should be used where
resources and expertise exist (1B) (optimal).
 Guideline 2.2: Rigid catheters and improvised catheters using
nasogastic tubes and other cavity drainage catheters may be used in
resource-poor environments where they may still be life-saving (1C)
(minimum standard).
 Guideline 2.3: We recommend catheters should be tunneled to reduce
peritonitis and peri-catheter leak (practice point)
 The most appropriate PD catheter is the one that can be positioned
deep in pelvis, can be kept out of reach of the omentum and can
provide an exit site that is easily visible and free of belt line
 The method of catheter implantation is based on
patient factors and the available skills

 Catheter Implantation Techniques:

 Modified-Seldinger technique: surgeon vs nephrologist
 Laparoscopy
 Laparotomy
 Advantages and disadvantages of different
catheter implantation techniques
Advantages Disadvantages
Percutaneous technique with or without a 1. Can be performed a bedside allowing 1. Risk of bowel or bladder injury (low
peel-away sheath rapid initiation of dialysis risk)
2. Minimally invasive procedure 2. Not suitable for patients with previous
3. Physicians or nurses can be trained to midline surgery or risk factors for
perform the procedure adhesions
4. Use of ultrasound and fluoroscopy may
improve positioning and reduce injury
to internal organs
Open surgical 1. Available in most centers 1. Requires theatre time and anesthetic in
2. Direct visualization of the peritoneum most cases
especially important in those with 2. Higher incidence of leak
previous midline laparotomy and obese 3. Usually catheter placed blindly in the
patients abdomen which may result in the
3. Cost of the consumables less than catheter not reaching the pelvis
laparoscopy

Laparoscopic 1. Lower incidence of pericatheter leak 1. Skilled personnel necessary

2. Ability to perform adjunctive 2. High cost of consumables
procedures such as rectus sheath
tunneling and omentopexy
3. Ability to place the catheter in the pelvis
under vision
Catheter Implantation Techniques
 Guidelines on Catheter Implantation
 Guideline 2.4: We recommend that the method of catheter implantation should be based on
patient factors and locally available skills (IC).
 Guideline 2.5: PD catheter implantation by appropriately trained nephrologists in patients
without contraindications is safe and functional results equate to those inserted surgically
(1B).
 Guideline 2.6: Nephrologists should receive training and be permitted to insert PD catheters
to ensure timely dialysis in the emergency setting (practice point).
 Guideline 2.7: We recommend, when available, percutaneous catheter insertion by a
nephrologist should include assessment with ultrasonography (2C).
 Guideline 2.8: Insertion of PD catheter should take place under complete aseptic conditions
using sterile technique (practice point).
 Guideline 2.9: We recommend the use of prophylactic antibiotics prior to PD catheter
implantation (1B).
 Guidelines on Fluid Delivery
 Guideline 2.10: A closed delivery system with a Y connection should
be used (1A) (optimal). In resource poor areas, spiking of bags and
makeshift connections may be necessary and can be considered
(minimimum standard).
 Guideline 2.11: The use of automated or manual PD exchanges are
acceptable and this will be dependent on local availability and practices
(practice point).
 Guidelines on PD Solutions for Acute PD
 Guideline 3.1: In patients who are critically ill, especially those with
significant liver dysfunction and marked elevation of lactate levels,
bicarbonate containing solutions be used (1B) (optimal). Where these
solutions are not available, the use of lactate containing solutions is an
alternative (practice point) (minimum standard).
 Guideline 3.2: Commercially prepared solutions should be used
(optimal). However, where resources do not permit this, then locally
prepared fluids may be life-saving and with careful observation of sterile
preparation procedure, peritonitis rates are not increased (1C)
(minimum standard).
 General rules when preparing dialysis solutions
 The concentrations of the well-known IV solutions may vary from
country to country so check concentrations before mixing
 Maintain absolute strict sterile technique when mixing solutions
 The fewer components added to the solution, the lower the risk of
infection and error
 Avoid mixing bicarbonate and calcium as they will precipitate
 PD Solutions for AKI
 Commercially prepared dextrose-based solutions
 In resource-limited settings: locally prepare a cost-effective and improvised make-shift
solutions
 The choice of dialysis solutions is based on the ultrafiltration requirements, and the patient’s
hemodynamic parameters
 With a standard regimen of 2L exchange and one-hour dwell time, the following are the
approximate ultrafiltration over a 24-hour period:
 2.5 L with 1.5% dextrose
 4.5L with 2.5% dextrose
 8.5L with 4.25% dextrose
 A practical way to achieve adequate fluid removal is to alternate by mixing and matching low
and high dextrose concentration solutions
 Amino acid solutions and icodextrin have limited role in the AKI setting
 Guidelines on Potassium Additive in Acute PD
 Guideline 3.3: Once potassium levels in the serum fall below 4 mmol/L,
potassium should be added to dialysate (using strict sterile technique to
prevent infection) or alternatively oral or intravenous potassium should
be given to maintain potassium levels at 4mmol/L or above (1C).
 Guideline 3.4: Potassium levels should be measured daily (optimal).
Where these facilities do not exist, we recommend that after 24 hours of
successful dialysis, one consider adding potassium chloride to achieve
a concentration of 4mmol/L in the dialysate (minimum standard)
(practice point).
 Guidelines on prescription in Acute PD
 Guideline 4.2: Cycle times should be dictated by the clinical
circumstances. Short cycle times (1-2h) are likely to more rapidly
correct uraemia, hyperkalemia, fluid overload and/or metabolic acidosis;
however, they may be increased to 4-6 hourly once the above are
controlled to reduce costs and facilitate clearance of larger sized
solutes (2C).
 Guideline 4.3: The concentration of dextrose should be increased, and
cycle time reduced to 2 hourly when fluid overload is evident. Once the
patient is euvolemic, the dextrose concentration and cycle time should
be adjusted to ensure neutral fluid balance (1C).
 PD Modalities
 Intermittent vs continuous
 Dependent on the desired amount of solute and fluid removal
 Manual vs use of automated cycler
 Modalities: depends on clinical status of the patient and the availability
of resources (e.g. cycler, nursing support)
 High-volume PD (HVPD): 18 to 22 exchanges/day using a cycler; provides
greatest small-solute clearance and greatest ultrafiltration rate
 AKI with severe metabolic disturbances; pulmonary edema
 Continuous equilibrated PD (CEPD): performed manually or with a cycler
about 4 times daily with dwell times of 4 to 6 hours; helps maintain a fairly
stable fluid and solute balance
 Acute intermittent PD, Tidal PD, Continuous flow PD
 PD Prescription
 Prescription includes the type of PD solution, exchange volume, inflow and outflow
times, dwell times, and number of exchanges
 High frequency of exchanges (every one to two hours) may be necessary in the
first 24 to 48 hours to correct hyperkalemia, fluid overload, and/or metabolic
acidosis
 Reassess every 24 hours to account for clinical changes and revise the evolving
goals in the setting of AKI
 After initial improvement, the PD prescription is altered by increasing the cycle
length to 4 - 6 hours to match the metabolic needs of the patient
 Once euvolemia is achieved, the volume status can generally be maintained with
a 1.5% dextrose dialysis solution
 Dialysate additives can be used when indicated: heparin for prevention of
catheter clotting, insulin for treatment of hyperglycemia, potassium
supplementation for hypokalemia
 Guidelines on adequacy in Acute PD
 Guideline 4.1: Targeting a weekly Kt/V of 3.5 provides outcomes comparable
to that of daily HD in critically ill patients; targeting higher doses does not
improve outcomes (1B). This dose may not be necessary for most patients
with AKI and targeting a weekly Kt/V of 2.2 has been shown to be equivalent
to higher doses (1B). Tidal automated PD (APD) using 25L with 70% tidal
volume per 24 hours shows equivalent survival to continuous venovenous
hemodiafiltration with an effluent dose of 23mL/kg/h (1C).
 Guideline 4.4. Where resources permit, creatinine, urea, potassium and
bicarbonate levels should be measured daily; 24h Kt/V urea and creatinine
clearance measurement is recommended to assess adequacy when clinically
indicated (practice point).
 Guideline on discontinuation of Acute PD
 Guideline 4.5: Interruption of dialysis should be considered once the
patient is passing >1L of urine/24h and there is spontaneous reduction
in creatinine (practice point).
 PD Peritonitis
 daily leukocyte cell count for peritonitis surveillance in patients on acute
PD
 if the above is not feasible, a daily urine dipstick leukocyte esterase is
alternative for screening; >2+ should prompt treatment while waiting for a
confirmatory leukocyte count and cultures
 2-hour dwell PD effluent is sent for CS as per ISPD infection guidelines
 empiric therapy covers both gram-positive and gram-negative organisms
 antibiotic dosing is based on the ISPD guidelines; in rapid cycling,
antibiotics should be added to all bags using the continuous dosing
recommendation
 systemic candidiasis is common among ICU patients; there should be a
high index of suspicion among these patients
 Catheter dysfunction
 most common cause of outflow dysfunction is constipation
 kinking, fibrin, omental wrapping and catheter tip migration are other
causes
 abdominal X-ray is helpful in distinguishing the cause
 treatment:
✓ agents use for bowel preparation for colonoscopy
✓ 20 to 50mL saline flush in a strict sterile manner
✓ fibrinolytic therapy tPA for fibrin or blood clots (1mg/mL; 8mL dwell for 1
hour followed gentle aspiration and flushing)
✓ reposition the catheter with the use of fluoroscopy and a flexible guidewire
✓ if still failed, surgical options need to be entertained
 Pericatheter Leak
 try to keep the patients on bedrest when abdomen is full
 if leak occurs - rest for 24 hours if possible
 reducing fill volumes
 fibrin glue and tissue adhesive may be used
 Metabolic Complications
 Increased protein losses
 5-12 g/day protein loss but can be as high as 48g during peritonitis;
exacerbated with tidal PD, aggressive ultrafiltration, and infection
 negative protein balance is associated with increased mortality
 ensure adequate protein intake aiming for 1.2g/kg protein per 24h
 Hyperglycemia
 from high glucose concentration in PD fluid
 this decreases osmotic gradient; should be treated to enable optimal
ultrafiltration
 maintenance of normoglycemia has also been shown to significantly
improve survival in critically ill patients
 Answering the following questions
Is PD a suitable modality for treating AKI?

What is the optimal access and fluid delivery for PD in AKI?

Which PD fluid should be used in Acute PD? What to do when it is not available?

How to prescribe PD in AKI?

How to troubleshoot complications?