KDIGO Clinical Practice Guideline for Acute Kidney Injury
Peritoneal dialysis

Peritoneal dialysis

In the developing world, the development of CRRT techniques has resulted in a substantial decline in the expertise with, and use of, PD for treatment of AKI. The use of PD in AKI is mainly confined to pediatrics and in regions with limited resources, because of its ease of use, low cost, and minimal requirements on infrastructure. Other advantages include the lack of a need for vascular access and anticoagulation, the absence of a disequilibrium syndrome and the relatively good hemodynamic tolerance compared to IHD. Disadvantages are the overall lower effectiveness (especially in patients with splanchnic hypoperfusion or who are on vasopressors), the risk of protein loss, the unpredictability of solute and fluid removal, the need for an intact peritoneal cavity, risk of peritonitis, diaphragmatic splinting leading to ventilatory compromise and fluctuating blood glucose levels. Recent developments in the technique of PD (use of flexible and cuffed catheters, automatic cycling, and continuous flow PD) have increased its potential to become an acceptable alternative to other forms of RRT in AKI,^735–737 but direct comparative effectiveness trials are extremely limited. Earlier reports on PD in AKI are mainly uncontrolled observations. Only two relatively recent randomized trials have compared PD to other modalities of RRT in AKI. Phu randomized 70 patients with septic AKI to PD or continuous venovenous hemofiltration (CVVH) and found a better survival with CVVH. However, the PD treatment appeared not to be ‘‘up to date’’ with use of a rigid catheter, manual exchanges with open drainage and acetate buffering.⁷³⁸ The second trial compared daily IHD to highvolume PD (with Tenckhoff catheter and automated cycler) and showed no difference in survival or recovery of kidney function. The duration of RRTwas significantly shorter in the PD group (Suppl Table 35).⁷³⁹ However, this trial has not been published in a peer-reviewed journal and the randomization process is unclear. Currently indications for PD in patients with AKI may include bleeding diathesis, hemodynamic instability and difficulty in obtaining a vascular access. Extremely high catabolism, severe respiratory failure, severe ileus, intra-abdominal hypertension, recent abdominal surgery and diaphragmatic peritoneum-pleura connections are contraindications to PD.