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Is Acute Peritoneal Dialysis Feasible for Treatment of
Hospital-Acquired Acute Kidney Injury?
Chang Yin Chionh* and Dinna N. Cruz†
*Division of Renal Medicine, Changi General Hospital, Singapore, and †Division of Nephrology-
Hypertension, Department of Medicine, University of California, San Diego, California
There has been a recent increase in interest in the
use of peritoneal dialysis (PD) in acute kidney
injury (AKI) (1,2). Although extracorporeal blood
purification (EBP) is more commonly employed for
supportive therapy in AKI worldwide, a recent sys-
Address correspondence to: Dinna N. Cruz, MD, MPH, Divi-
sion of Nephrology-Hypertension, University of California,
San Diego, 200 West Arbor Drive #8409, San Diego, CA
92103-8409, Tel.: (619) 471-0753, Fax: (619) 471-0754, or
e-mail: dinnacruzmd@yahoo.com.
Seminars in Dialysis—Vol 27, No 3 (May–June) 2014 pp.
239–242
DOI: 10.1111/sdi.12209
© 2014 Wiley Periodicals, Inc.
239
239
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Saqib N: Simultaneous monitoring of multiple urinary cytokines may
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Han WK, Marcus RJ, Parikh CR: IL-18 and urinary NGAL predict
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2013 Sep 25 [Epub ahead of print]
tematic review demonstrated no significant differ-
ences in outcomes between PD and EBP (3).
Because of its technical simplicity, PD is more
widely used in resource-limited areas and is often
the only form of dialysis available (4,5). In such
areas, community-acquired AKI tended to feature
more prominently, such as AKI due to diarrheal
and other tropical diseases (including malaria, lepto-
spirosis, and dengue), snake bites, and nephrotoxic
drugs (5). In the urban and developed setting,
hospital-acquired AKI is more commonly reported
(6). Indeed the majority of AKI studies from
high-income countries have focused on AKI in the
hospital and intensive care unit (ICU).
240 Chionh and Cruz
While the definitions are not standardized, hospi-
tal-acquired AKI is recognized when the consensus
AKI criteria (7–9) are met during hospitalization
after one or more renal insults. Common causes of
hospital-acquired AKI include volume depletion,
sepsis, postsurgery AKI, radiocontrast media and
drug-induced AKI (10). This article will review the
experience with PD for AKI in this setting.
Pathophysiology of Hospital-Acquired AKI
Are there major differences in the pathophysiol-
ogy of AKI which requires different approaches in
their management? Very often, community-acquired
AKI and hospital-acquired AKI have similar under-
lying pathophysiologic mechanisms. These include
intravascular volume depletion, ischemia/reperfusion
injury related to hypotension or circulatory shock
(e.g. hemorrhagic shock, dehydration), or direct
tubulo-toxic effects of various drugs or poisons. In
such situations, the differences in outcomes between
community-acquired and hospital-acquired AKI are
often due to differences in timing of supportive
therapy initiation.
There exist theoretical postulates that some forms
of hospital-acquired AKI have different underlying
mechanisms of injury. In septic AKI, proinflammatory
cytokines have been postulated to be the main trigger
for the sepsis cascade resulting in AKI. In contrast, an
immunologic-related mechanism has been demon-
strated in cardio-renal syndromes (11).
While there are many studies addressing the
cytokine theory using continuous renal replacement
therapy, only a few studies have utilized PD. The
peritoneal membrane has pores large enough to
theoretically allow clearance of these molecules. A
study in infants after cardio-pulmonary bypass sur-
gery demonstrated effective clearance of IL-6 and
IL-8 using PD, although the clearance was superior
with ultrafiltration (12).
PD for AKI in Specific Populations
In a systematic review of 24 studies (n = 1556
patients), no differences were found in mortality
outcomes between PD and EBP for AKI (pooled
OR 1.11, 95% CI 0.66–1.88) (3). However, there
were multiple etiologies for AKI in each of the
studies, and no study specifically identified hospital-
acquired AKI. Pooled analysis of studies which
included patients who were likely to have developed
AKI in the hospital, such as postsurgical, ICU and
septic patients revealed no significant differences in
mortality outcomes between PD and EBP. Fig. 1
shows subgroup analyses for studies including
patients with sepsis, in the ICU, and postsurgery or
trauma. A few of these studies merit further
discussion.
There have been only a few randomized con-
trolled trials (RCT) that compared PD with EBP,
240
particularly in the context of hospital-acquired
AKI. In one RCT, 120 patients with AKI referred
to their nephrology service after hospital admission
was randomized to treatment with PD or daily
hemodialysis (13). Of the 120 patients, 77.4%
required ICU care and 44.5% were septic. The
RCT demonstrated no differences in mortality, but
noted a significantly shorter time to renal recovery,
with PD patients requiring an average of 5.5 days
of dialysis dependence, as opposed to 7.5 days for
hemodialysis.
Another RCT randomized ICU patients with AKI
to PD with continuous veno-venous hemodiafiltration
(CVVHDF) looking primarily at solute control (cor-
rection of uremia, electrolyte and acid-base disorders),
as well as correction of fluid overload (14). Urea and
creatinine clearances, as well as control of fluid over-
load, were significantly better with CVVHDF than
PD; however, correction of acidosis was better with
PD. PD and CVVHDF were comparable with respect
to correction of hyperkalemia and hemodynamic
disturbances, although the cost of consumables for
CVVHDF was more than twice that of PD.
Sepsis is a common cause of AKI in the hospital
setting. Observational studies including septic
patients with AKI have reported successful
treatment of hospital-acquired AKI with PD. Tech-
niques to achieve a high dialysis dose with high
volume PD have been utilized to enhance clearance
in hypercatabolic patients with AKI(15). The inves-
tigators were able to deliver a weekly Kt/V of
3.56  0.68 which achieved a level of metabolic
control desired in a group of predominantly septic
patients. In a small study of 20 patients, adequate
metabolic control was also achieved using a lower
PD dose, and correction of acidosis was more rapid
with bicarbonate-based rather than lactate-based
solutions (16).
Subset analysis of comparative studies including
septic patients found no differences in outcomes
between PD and EBP, although there is significant
heterogeneity between the studies (Fig. 1). Although
one RCT conducted in Vietnam favored EBP over
PD, most patients in the study had malaria, which
is regarded as a community-related AKI (17). In
addition, such poor outcomes in patients with
malaria were not seen in more recent studies (18).
Data on the use of PD in AKI related to trauma
or surgery are based on much older studies. Camer-
on and colleagues described successful use of PD to
manage uremia in the postsurgery setting (19), while
others described the applicability of PD in critical
trauma (20). Hadidy et al. retrospectively reviewed
102 patients, majority of them having had trauma
or surgery, and the patients who received PD did as
well as those on hemodialysis (21). Two recent stud-
ies that included a small proportion of surgical
patients reported no differences in outcomes with
either PD or EBP (Fig. 1) (13,22). While no techni-
cal difficulties were reported, the studies did not
include patients with major abdominal trauma or
surgery.
 PERITONEAL DIALYSIS IN ACUTE KIDNEY INJURY 241

Fig. 1. Comparison of peritoneal dialysis (PD) with extra-corporeal blood purification (EBP) in studies which included (A) Septic
patients, (B) Intensive care unit (ICU) patients, (C) Post-surgical or trauma patients. Odds ratio with 95% confidence intervals (CI) was
calculated using the Mantel-Haenszel (M-H) random-effects model. Chow et al. described two study cohorts 10 years apart and data
were analyzed separately, represented as (A) and (B).

Performing PD for AKI bags and makeshift connections may be necessary

Appropriate patient selection and PD technique,
as well as center experience, are important determi-
nants of the feasibility and success of PD as a ther-
apy for AKI. Where other EBP modalities are
easily available, PD would probably be more appro-
priate for patients with only one or two organ fail-
ures. Patients with multiple organ failure, previous
midline surgical scars or high risk of peritoneal
adhesions may be more appropriately managed with
EBP. On the other hand, patients with advanced
CKD who have superimposed AKI could poten-
tially be well-served by PD. In the event of a delay
in, or lack of, significant renal recovery, it may
facilitate the transition to outpatient peritoneal
dialysis (23).
Flexible peritoneal catheters are preferred and
should ideally be used where resources and expertise
exist, in view of lower incidence of peritoneal fluid
leakage and infection (24). Prophylactic antibiotics
prior to insertion of the PD catheter have been
associated with a significant reduction in the inci-
dence of peritonitis (25). A closed fluid delivery
system with Y connection is also ideal to minimize
infection, although it is recognized that spiking of
in resource-poor settings. There is no convincing
evidence that automated PD is safer or more effec-
tive than manual exchanges.
In patients with shock or liver failure, bicarbon-
ate containing solutions may be preferable to lac-
tate, especially in the setting of metabolic acidosis.
As noted above, correction of metabolic acidosis
was more rapid with bicarbonate compared to lac-
tate-based PD solutions, although hard clinical
outcomes were comparable (16).
During the initial 24 hours of therapy, short cycle
times (e.g. 1–2 hours) may be necessary to correct
fluid overload, hyperkalemia, and/or metabolic aci-
dosis. Thereafter, the cycle time may be increased to
4–6 hours depending on the clinical circumstances.
The optimal dose of PD for AKI is unclear, result-
ing in ambiguity among practitioners (26). A single
center study, targeting a weekly Kt/V urea of 3.5,
demonstrated comparable outcomes for PD and
daily HD (13). However, other studies have shown
good outcomes using lower doses (27,28). Extrapo-
lating from data on EBP, targeting a weekly KT/V
of 2.1 may represent a minimum clearance standard
(29). Higher small solute clearances may be neces-
sary in hypercatabolic AKI patients.

241
242 Chionh and Cruz
Due to the high glucose concentration in PD
fluid, there is concern regarding hyperglycemia
with acute PD. The incidence of this complication
is generally poorly reported in studies (3). How-
ever, in the randomized trial comparing PD to
daily hemodialysis, glucose levels were similar
between the two modalities (13). No patient had
uncontrolled hyperglycemia in either group. Hyper-
glycemia can be treated with insulin subcutane-
ously, intravenously, or by adding it to the
peritoneal fluid. There is no evidence to support
the superiority of any particular approach. In
AKI, the exposure to high glucose concentration is
expected to be short-term. There are no data on
its long-term consequences.
Lastly, peritonitis is an important complication of
PD. Its diagnosis may be challenging when dwell
times are short. Nevertheless, a daily PD fluid leu-
kocyte count may be useful for peritonitis surveil-
lance. Diagnosis and treatment should be based on
existing ISPD guidelines (30), in the absence of
specific guidelines for acute PD.
Is Acute Peritoneal Dialysis Feasible for
Treatment of Hospital-Acquired AKI?
To answer the question, there is no evidence to
indicate inferiority of PD for management of hospi-
tal-acquired AKI. As such, PD should be consid-
ered a viable modality option. The feasibility and
success of PD for AKI depends on appropriate
patient selection, proper PD technique, and center
experience. While expert practice recommendations
exist for EBP, none currently exist for PD, resulting
in variability in practice (26). The International
Society of Peritoneal Dialysis is developing consen-
sus guidelines to address this knowledge gap.
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