This document discusses peritoneal dialysis as a viable option for renal replacement therapy. It provides indications for peritoneal dialysis including for chronic kidney disease stage V and acute kidney injury. It highlights advantages of peritoneal dialysis such as flexibility, ease of travel, and lower risk of infections compared to hemodialysis. It also discusses challenges of peritoneal dialysis including catheter complications and metabolic issues. The document concludes that peritoneal dialysis and hemodialysis are not rivals, and that individualizing therapy and timely switching between modalities can improve patient outcomes and survival.

1. PERITONEAL
DIALYSIS
A Viable option for
Renal Replacement Therapy
Dr. Muhammad Mohsin Riaz
FCPS (Nephrology)
ISN Fellow
Fatima Memorial Hospital,
Lahore, Pakistan.

2. Peritoneal Dialysis; Indications
•Chronic Kidney disease stage V requiring renal
replacement therapy
•Acute kidney injury requiring renal replacement
therapy
•Conditions other than kidney injury

3. Peritoneal Dialysis in
Chronic Kidney Disease

4. Modalities for Renal Replacement
Therapy
Ramesh Khanna & Karl D. Nolph

5. Kidney Replacement Therapy:
Modality Choice
• Many patients have a medical contraindication for transplantation
• Far fewer patients have an absolute medical contraindication for one
dialysis therapy over the other
• The majority of patients could do either
• Patient preference should play an important role in the choice of
dialysis modality

6. Most Patients Are Eligible for PD
Jager K et al. Am J Kidney Dis. 2004;43:891-899.
Mehrotra et al. Kidney Int. 2005;68:378-390.
Little et al. Am J Kidney Dis. 2001:37:981-986

7. Patients Choose Home Therapy
When Properly Educated
• 70 patients were randomized to receive standard care alone or
standard care with educational intervention
Standard
Care
Standard Care
+Education
Planning to start self-care
dialysis at baseline
0% 0%
Planning to start self-care
dialysis at study completion
16.7% 64.2%
• Manns BJ, et al. Kidney Int. 2005 Oct;68(4):1777-83

8. Nephrologists choice
Prescribers were asked
to select an ideal mix of
modalities that would
maximize outcomes for
CKD patients
Mendelssohn DC, et al. Am J Kidney Dis. 2001 Jan;37(1):22-29

9. Jung B, et al. Perit Dial Int. 1999;19(3):263-8
Prescribers were asked
to select an ideal mix of
modalities that would
maximize outcomes for
CKD patients
Nephrologists choice

10. Advantages of Peritoneal Dialysis
• Patients more satisfied with overall care compared with HD
• Flexible schedule
• Especially attractive for patients who work or have children at
home
• School children
• Ease of travel
• Partner not required
• Body image
• Catheter concealed under clothing
• No permanent disfiguring of arm seen in haemodialysis access
JAMA. 2004 Feb 11;291(6):697-703.
Walker RC, et al. Am J Kidney Dis. 2015;65(3):451-463

11. • “Needless and bloodless”
• Lower risk bacteremia
• Steady-state treatment
• Better hemodynamic stability.
• Opportunity to control BP with minimal, if any blood
pressure medications
• Diet and prescription appropriately adjusted.
• Requires staff attention to dialysis prescription
Advantages of Peritoneal Dialysis
Gunal AI, et al. Am J Kidney Dis 37:588-593, 2001

12. •Better preservation of residual renal function
•Less “lead time” for access placement.
• Can place PD catheter within 2 weeks of starting PD
• CHD requires months to develop mature AVF.
• 80% of CHD patients start HD with a central venous
dialysis catheter
• Urgent start dialysis
•Lower cost than HD.
Advantages of Peritoneal Dialysis
Jansen MA, et al. Kidney Int 62:1046-1052, 2002

13. Decline of RRF in PD (grey bar) and HD (black bar)
patients during the first 12 months of dialysis treatment NDT Plus (2011) 4: 225–230

14. Kidney Int. 2006 May;69(10):1726-32Why to worry about RRF

15. Nayak KS et a;. Blood Purif. 2018 Jan 30;45(4):313-319
Primary and secondary outcomes in control and study groups

16. Am J Kidney Dis. 2017 Jul;70(1):102-110
Urgent Start PD practice at
Peking University First
Hospital

17. Special population benefiting from PD
• No or difficult venous access
• Central vein occlusion
• “Steal syndrome”
• High risk and morbidity of bacteremia
• Recurrent bacteremia and endocarditis
• Endovascular device: e.g. mechanical valve

18. • Patients who cannot tolerate HD because of cardiomyopathy,
ischemic heart disease or extensive peripheral vascular disease
• Allows for more gentle and continuous fluid removal
• Prolonged ATN
• Bridge to transplant
• Bleeding disorders
Special population benefiting from PD

19. Current status of utilization of PD
2015 USRDS
Total Dialysis Population
466,607

20. Current status of PD
• Berns JS, et al. Clin J Am Soc Nephrol. 2010 Mar;5(3):490-6
Survey of ASN members

21. In a survey of 67 Nephrology fellows:
• 50% were from programs offering 3 or
fewer months of exposure to outpatient
hemodialysis
• 25% reported no exposure to PD
• Of more concern, 25% reported no "official
rounds" with an attending nephrologist on
dialysis patients
• Nissenson AR, et al. Semin Dial. 2004;17(5):380-97

22. PD: Contraindications
• Absolute
• Large mesenteric resections
• Cutaneous feeding tubes
• Known peritoneal defects or pleural communications
• Severe chronic obstructive disorders

23. • Psychosis
• Severe physical deformities
• Ostomies, urostomies
• Multiple adhesions
• Large abdominal hernias
• ?Obesity (more than 125 kg)
• Blindness
• Polycystic kidney disease with large kidneys
PD: Contraindications; Relative

24. Common PD misconceptions
• “Survival is worse”
• 5 year survival similar for HD and PD patients at 33.5% and 33.9%,
respectively
• “Can’t achieve adequate solute clearance”
• 2000 KDOQI recommended Kt/V of 2.0 but based on subsequent
RCT the target was set at 1.7. It is fairly easy to achieve this goal in
most patients.
United States Renal Data System 2009. Chapter 6: Morbidity and
Mortality. Retrieved July 20, 2007

25. USRDS 5-year survival probability (2008
cohort):
All dialysis: 40.9%
All hemodialysis: 40.2%
Peritoneal dialysis: 50.6%
Adjusted survival probabilities, from day one, in the ESRD population.
Adjusted for age, sex, race, Hispanic ethnicity, and primary diagnosis.
United States Renal Data Systems. 2015 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. Bethesda,
MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 20

26. United States Renal Data Systems. 2015 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. Bethesda,
MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 20
Improving Survival
in PD patients

27. Mehrotra R, et al, Arch Intern Med. 171:110-118, 2011
All-cause mortality
according to dialysis
modality in the whole
cohort of 902 patients

28. Kumar VA, et al. Kidney Int. 2014;86(5):1016-22
Initial
Survival benefit
of PD

29. • “Infection rate too high”
• Peritonitis rates are decreasing- see next slide. Furthermore risk of
bacteremia is lower on PD than HD and bacteremia is associated
with significant morbidity and cardiovascular death.
Common PD misconceptions

30. Bender FH et al. Kidney Int, 70(suppl):S44-S54, 2006
Peritonitis in episodes per dialysis year at risk at the dialysis
unit affiliated with the University of Pittsburgh.

31. Bender FH et al. Kidney Int, 70(suppl):S44-S54, 2006
Catheter infections in episodes per dialysis year at risk at the dialysis
unit affiliated with the University of Pittsburgh

32. • “Patients don’t want PD”
• Just not true – see next slide
Common PD misconceptions

33. Patient involvement in selection of mode of
renal replacement therapy
Golper T. Nephrol Dial Transplant. 16(suppl):20-24, 2001

34. Golper T. Nephrol Dial Transplant. 16(suppl):20-24, 2001
Modality selected vs initiated vs incidental
start

35. PD: Challenges
•Catheter insertion and mechanical complications
• Hernias and catheter malfunction
• Requires committed surgeon

36. Access-Related Interventions
• PD was associated with a significantly lower risk of access-related
interventions compared to HD (P < 0.001)
Modality N
# of access-related
interventions per pt-year at
risk (mean ± SD)
Mean dialysis access-related
cost per pt-year at risk
(*US$)
PD 65 1.54 ± 0.73 1535
HD AVF 45 2.38 ± 2.06 2022
HD TCC 42 3.67 ± 2.50 5471
Perit Dial Int. 2013;33(6):662-670

37. • Metabolic complications
• Protein losses
• Hyperglycemia
• Hypertriglyceridemia
• Weight gain
• Icodextrin can mitigate hyperglycemia, hypertriglyceridemia and
weight gain
• Body image
PD: Challenges

38. • No days off
• Patient and family burnout
• If significant residual renal function, can decrease prescription and possibly
provide days off
• APD
• Can give more day time freedom
• Hybrid therapy
• Can have off days
• Better symptomatic control
PD: Challenges
Maruyama and Yokoyama Renal Replacement Therapy (2016)

39. PD: Challenges
• Technique failure
• Better in larger programs
• Supply space
• Smaller living spaces may not have room for supplies and might
require more frequent home deliveries

40. Kidney Int. 2001;60(4):1517-1524
Technique failure decrease with increased numbers
of patients treated
75% increased risk of
technique failure for those
centers initiating less than
30% of patients on PD
compared to those choosing
PD for over 60% of patients.

41. Mortality decrease with increased numbers of
patients treated Kidney Int. 2001;60(4):1517-1524

42. Kidney International (2011) 80, 909 – 911

43. Summary: Modality Comparison
Patient Preferences
Haemodialysis Peritoneal Dialysis
Dependent –patients are taken care of Independent: patients are empowered
for self-care
Rigid Schedule – difficult to travel Flexible schedule – easier to travel
Venous access – needle sticks Peritoneal Access – “bloodless”
Access Complications
Bacteremia
Steal
Central vein occlusion
Access Complications
Peritonitis
Fluid leak
Hernia
Home Consideration :None Home Consideration: Storage space
Post-dialysis fatigue: average recovery
8 hours
No post dialysis recovery or fatigue

44. Peritoneal Dialysis in
Acute Kidney Injury

45. • Absolute indication for acute peritoneal dialysis is the need
for dialysis and the inability to perform any other renal
replacement technique.
Indications in Acute Kidney Injury (AKI)
Nolph KD. Peritoneal dialysis for acute renal failure. ASAIO Trans 1988; 34:54.

46. Advantages of Peritoneal Dialysis in AKI
• It is widely available and technically easy to perform.
• Large amounts of fluid can be removed in hemodynamically
unstable patients; this fluid removal may also permit the
administration of parenteral nutrition.
• The absorbed dextrose of the dialysate provides calories.
• Disequilibrium syndrome is not precipitated, because of slow
rate of solute removal. Nolph KD. Peritoneal dialysis for acute renal failure. ASAIO Trans 1988; 34:54.

47. • Peritoneal dialysis access placement is relatively easy,
particularly in children.
• Arterial or venous puncture and anticoagulation are not
required (patients with bleeding diathesis or haemorrhagic
conditions).
• It is a highly biocompatible technique.
Advantages of Peritoneal Dialysis in AKI
Nolph KD. Peritoneal dialysis for acute renal failure. ASAIO Trans 1988; 34:54.

48. • Easy and gradual correction of acid-base and electrolyte imbalance
may be performed.
• Helpful in haemodynamically unstable patients.
• Where IV access is difficult to obtain.
• Dosing is easy, particularly in children.
• Continuous intraperitoneal administration of medications can be
achieved
Advantages of Peritoneal Dialysis in AKI
Nolph KD. Peritoneal dialysis for acute renal failure. ASAIO Trans 1988; 34:54.

49. Peritoneal dialysis versus extracorporeal therapy,
Outcome; All-cause mortality
Outcomes comparable to extracorporeal therapy Liu L, Zhang L, Liu GJ, Fu P. Peritoneal dialysis for acute
kidney injury. The Cochrane Library. 2017.

50. Peritoneal dialysis versus extracorporeal therapy,
Outcome; Recovery from AKI
Outcomes comparable to extracorporeal therapy Liu L, Zhang L, Liu GJ, Fu P. Peritoneal dialysis for acute
kidney injury. The Cochrane Library. 2017.

51. Conditions
other than Kidney Insult

52. Relative indications for
Acute Peritoneal Dialysis
• Removal of high-molecular-weight toxins (>5 kD)
• Clinically significant hypothermia and hyperthermia
• Heart failure refractory to medical management
Nolph KD. Peritoneal dialysis for acute renal failure. ASAIO Trans 1988; 34:54.

53. Relative Contraindications to
Acute Peritoneal Dialysis
• Recent abdominal and/or cardiothoracic surgery
• Diaphragmatic peritoneal-pleural connections
• Severe respiratory failure
• Life-threatening hyperkalemia
• Extremely high catabolism Nolph KD. Peritoneal dialysis for acute renal failure. ASAIO Trans 1988; 34:54.

54. • Severe gastroesophageal reflux disease
• AKI in pregnancy
• Severe volume overload in a patient not on a ventilator
• Poorly controlled glucose intolerance
• Malnutrition where further protein losses are unacceptable
Relative Contraindications to
Acute Peritoneal Dialysis
Nolph KD. Peritoneal dialysis for acute renal failure. ASAIO Trans 1988; 34:54.

55. Take Home Message
• PD and HD are not Rivals
• Therapy should be individualised

56. J Am Soc Nephrol. 2000;11(1):116-125
Over 10 years, survival of
in-center HD and PD patients
were not significantly
different

57. J Am Soc Nephrol. 2000;11(1):116-125
Timely switching
between modalities
improve survival

58. • Hybrid therapy
• Timely switching between the therapies
• More experience; more successful PD program
Take Home Message