PERITONEAL DIALYSIS

The treatment of one patient with acute kidney failure (acute kidney injury) needs strict attention to body fluids, acid/base, and electrolytes

 

Peritoneal dialysis in treatment of acute kidney failure.

The treatment of one patient with acute kidney failure (called also acute kidney injury) needs strict attention to body fluids, acid/base, and electrolyte (sodium, potassium, etc..), in addition to removing the accumulated uremic toxins. Despite this type of dialysis has been overlooked in the management of patients in need for dialytic support, acute peritoneal dialysis remains a vital choice dedicated for management of acute kidney failure. Examples of cases that peritoneal dialysis is preferred may include:

1)    Patients with unstable hemodynamic states (low blood pressure with weak heart power and poor circulation).

2)    Abnormal blood coagulation profile (bleeding tendency).

3)    Lack of other dialysis options (difficulty in hemodialysis).

In comparison to other dialysis modalities, peritoneal dialysis owns many advantages as renal replacement therapy (modality that replace the kidney function). These advantage may include the following:

1)    It is widely available,

2)    Easily performed.

3)    Easy access placement.

4)    The possibility of removal of large amounts of fluids that is particularly beneficial in hemodynamically unstable (low blood pressure and poor circulation) cases.

5)    Smooth and very gradual normalization of acid-base and electrolyte disturbances.

6)    Administration of anticoagulating medications is not required, and

7)    It is highly biocompatible (in accordance with the normal body physiology). 

 

Types

Application of peritoneal dialysis in acute renal failure has a variety of indications and contraindications that is mostly relative ones. On the other hand, this technique can be performed in intermittent or in continuous manner according to the required amount of fluid and solute removal. Peritoneal dialysis can be also performed manually or via a dedicated machine (automated equipment).

Staff 

As regard the personnel, staff nurse can manage the peritoneal dialysis procedures. However, the use of an automated device or cycler greatly decreases the need for a continuous nurse supervision. However, the prescription of a standardized peritoneal dialysis session may include the following details:

1)    The duration of the peritoneal dialysis session,

2)    Component of the dialysate fluid,

3)    Amount of the exchange volume,

4)    Durations of the Inflow and outflow (drained fluid) periods,

5)    Duration of the dwell timing,

6)    Number of exchange cycles,

7)    Added medications to the dialysate fluid, and

8)    How to monitor fluid balance.

 

Complications

Acute peritoneal dialysis may be complicated by a list of complications, some of them are devastating but may are controllable.

Mechanical complications

Mechanical complications are mostly not serious and not life threatening, but they may affect dialysis adequacy. They include:

1)    Abdominal pain or discomfort: Mild abdominal discomfort is commonly seen and is usually related to abdominal distention. On the other hand, moderate/severe pain may be attributed to a catheter-related complications or infection and needs work up.

2)    Intra-abdominal hemorrhage: 

3)    Mild bleeding is frequently observed and may be noticed with catheter placement. However, severe abdominal bleeding can be observed with semi-rigid catheters in particular.

4)    Leakage: Leakage around the PD catheter site is a commonly observed, which can be improved by decreasing the exchange volume during the first 24 hours. Certain cases, however, may need temporary hold of the peritoneal dialysis. Of note, large bowel evacuation can alleviate this problem.

5)    Inadequate drainage: Incomplete drainage is usually related to diminished bowel motility. Bowel cathartics can enhance drainage in most cases, while catheter manipulation may be another solution.

6)    Bowel perforation: Perforated bowl can be observed, especially with the placement of semi-rigid acute catheters. Clinically, patient can present with intense abdominal pain, blood-colored peritoneal drainage, intra-abdominal bleeding, and may be shock in severe cases. Fecal matter may be noticed in the effluent drain. Treatment may include cessation of the acute peritoneal dialysis session, removing the catheter, intravenous antibiotics, and surgical bowel repair. 

Infectious complications 

Infectious complications are commonly seen in these patients, peritonitis (inflammation of the peritoneal membrane) in particular. Prevalence of peritonitis can be greatly diminished by maintaining strict sterile precautions during catheter placement and by avoiding contamination expected with frequent exchanges. Dialysate leakage may be associated with increased incidence of peritonitis.  Moreover, abscess developed in the puncture site can complicate the bedside placement of acute peritoneal catheters, particularly if meticulous alertness is not driven to sterile technique.

Pulmonary complications

1)    Basal atelectasis and pneumonia: 

2)    Lung collapse and pneumonia can develop from the rise in intra-abdominal pressure that is usually observed with acute peritoneal therapies. Moreover, the elevated intra-abdominal pressure may induce inadequate lung inflation with stagnant secretions.

3)    Pleural effusion: 

4)    Fluid movement into the thoracic cavity, hydrothorax, can develop through a defect in the diaphragm or via diaphragmatic lymphatic system. A right sided effusion is most common. Decreasing intra-abdominal pressure by lowering exchange volumes and performing acute PD in a supine position may help in most situations. Pleurodesis (injection of certain medications into the pleural cavity) usually not required.

5)    Aspiration: 

6)    The elevated intraperitoneal pressure may predispose peritoneal patients to (GERD) gastroesophageal reflux disease and increased risk of aspiration.

Cardiovascular complications

1)    Hypovolemia: Intense ultrafiltration or diaphragmatic rise owing to the higher intra-abdominal pressure (hat result in venous return decline) can decrease the proper tissue perfusion owing to inadequately filled heart.  

2)    Cardiac arrhythmias: Cardiac arrhythmias are common, due most frequently to electrolyte and metabolic alterations, or diaphragm elevation.

3)    Metabolic complications: Metabolic complications are commonly observed and usually preventable.

4)    Hyperglycemia: Hyperglycemia may occur due to high glucose content of the dialysate fluid.

5)    Hypoglycemia: Hypoglycemia may develop after cessation of peritoneal dialysis.

6)    Hypernatremia: 

7)    Hypernatremia may be developed via the loss of free water in the dialysate fluid when hypertonic exchanges (with high osmotic pressure) are frequently used. Sodium may diffuse down its diffusion gradient from blood to dialysate through the small intercellular "pores." Hypernatremia is best corrected by increasing the length of the exchanges so that proper diffusion can occur and/or the use of less hypertonic (more concentrated) fluid. Low sodium content dialysate are currently not available.

8)    Hypokalemia: hypokalemia may ensue because standard PD solutions do not contain any potassium. It can be corrected by addition of potassium salts to the dialysate fluid.

9)    Protein losses: Protein losses occur through the drained dialysate that may exceed 5 gram per day. This complication may be intensified by aggressive ultrafiltration and infectious episodes.