Peritoneal Dialysis

Peritoneal Dialysis is a topic covered in the Washington Manual of Medical Therapeutics.

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General Principles

  • There are two modalities in use: manual exchanges and automated cycler exchanges.
    • The manual modality, also called continuous ambulatory peritoneal dialysis (CAPD), has the patient instill dialysis fluid into the peritoneum for a specified length of time, after which the dialysate is drained and replaced by another dwell.
    • The automated modality, also called continuous cycling peritoneal dialysis (CCPD), typically operates overnight where a machine runs a preprogrammed set of exchanges while the patient sleeps. A final fill usually remains in the peritoneum and is carried during the daytime for continued solute exchange.
  • Both PD modalities require strict adherence to sterile technique, and careful patient selection is necessary. Generally, PD should not be used if there is a history of recent abdominal surgery or if multiple peritoneal adhesions are present.
  • Prescription and adequacy
    • The choice between CAPD and CCPD usually depends on patient preference and on the transport characteristics of the peritoneal membrane. Manual exchanges (i.e., CAPD) can be used as a backup modality, particularly in the hospital where nurse staffing or machine availability may be limited.
    • In writing PD orders, the following variables must be specified: dwell volume, dwell time, number of exchanges, and dextrose concentration of the dialysis solution. 
The dwell volume is typically between 2 and 3 L. The dextrose concentration can be 1.5%, 2.5%, or 4.25%, providing the osmotic gradient for fluid removal. Higher dextrose concentrations allow for greater UF but also lead to more inward glucose diffusion and worsening control of diabetes. Icodextrin is a glucose polymer preparation that can be used in longer dwell because it is minimally absorbed and thus maintains an effective osmotic gradient up to 18 hours. Commercially available PD solutions may have color-coded tabs, and patients may know these better than the actual concentrations (yellow for 1.5%, green for 2.5%, red for 4.25%). A sample order set for manual CAPD would be 2.5 L dwells, four exchanges per day, 6 hours per dwell, with 2.5% dextrose.
    • PD is less efficient than conventional hemodialysis. However, given its continuous nature, solute clearance and UF can approximate that of other modalities. Larger volumes and more frequent exchanges can assist with solute exchange. Increasing the concentration of dextrose can promote greater UF in volume-overloaded patients.
    • Residual renal function is very important in the PD population, and avoidance of nephrotoxins should be practiced.1

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