Feasibility, Efficiency, and Adequacy of Peritoneal Dialysis in Acute Kidney Injury

Although the initial reports of peritoneal dialysis (PD) for the management of renal failure were for acute kidney injury (AKI), PD uncommonly is used as renal replacement therapy (RRT) in patients with AKI, at least in developed societies. Developments and refinements in continuous renal replacement therapies (CRRTs), principally venovenous therapy, over the last quarter of a century, along with improving safety and a belief that increasing the dose of dialysis as measured by small solute clearance would improve patient outcomes, have eroded into what was once considered a classical PD pool of patients with unstable hemodynamics and have pushed the considerations for PD mainly for children, and in those with coagulation abnormalities and/or hemodynamic instability, where it has some distinct advantages. Recently, surveys from providers across the world have revealed that even though about 40% to 60% of providers feel that PD is suitable for patients with AKI, fewer than 20% offer it as a therapy in their practice, and true use of PD for the AKI management is even less than that. In these surveys, the largest gap between belief and practice was seen in Europe and North America. To the best of the authors' knowledge, PD for adult AKI in the United States and Canada is anecdotal and is used mainly in circumstances in which alternate forms of extracorporeal therapy are not feasible.

On the other hand, PD continues to be an important modality of RRT for significant populations in the world, especially in Africa, South and Southeast Asia, and South America. Economic considerations and prevalent healthcare infrastructure contribute significantly to this disparity, although similar trends of decline are evident in many urban areas. However, whether the newer, more aggressive and consequently more “sophisticated” forms of extracorporeal therapies, namely hemodialysis or hemofiltration, are better in the critical care setting than PD has been difficult to compare because clinical studies comparing these modalities have been limited in numbers and generalizability.

Therefore important issues while considering PD for AKI appear to be (1) Is PD feasible in patients with AKI? (2) Can PD provide efficient clearance of fluid and solutes? (3) What is that efficient clearance (i.e., how to define the adequacy of such clearance)? (4) Is PD worth the considerations, when compared with the extracorporeal therapies in terms of effort needed to improve its availability and the medical benefits and risks?