Second Spring of Peritoneal Dialysis in Acute Kidney Failure
Until the early 1990s, peritoneal dialysis (PD) was considered a “second class therapy for second class patients by second class doctors” due to higher complication and mortality rates compared to hemodialysis (HD) [1, 2]. Since the mid-1990s, there has been a significant improvement in survival prognosis, so that HD and PD show comparable mortality rates in almost all studies [3]. Nevertheless, PD has been used much less over time in acute kidney failure due to the development of HD modalities [4, 5]. However, in the last 10 years, acute PD has experienced a resurgence through the publication of randomized controlled trials and evidence for its safe use in severe acute kidney failure compared to HD.
Since comprehensive HD is not available in developing and emerging countries, acute PD is routinely used here due to its simple and resource-saving nature. The nursing care of patients is significantly less time- and training-intensive, and neither electricity nor running water is required for performing acute PD [6].
However, during the Covid-19 pandemic, there have also been bottlenecks in the care of patients with dialysis-requiring acute kidney failure in Western countries. Due to temporarily particularly high Covid incidences, emergency PD teams and bedside, non-surgical catheter placement techniques were successfully established in London and New York [7]. Thus, PD could be successfully used in intensive care units for ARDS (“acute respiratory distress syndrome”) [8].
Advantages of PD over HD:
- Presence of the peritoneum as a biocompatible membrane
- no anticoagulation required (elimination of an extracorporeal circuit)
- better tolerance in hemodynamically unstable patients as well as patients who poorly tolerate high volume or electrolyte fluctuations
In HD, disequilibrium* and rapid volume fluctuations are held responsible for the rapid loss of residual renal function. These disadvantages are avoided in PD and hypotensions rarely occur. In two randomized controlled trials on acute kidney failure, the time to recovery of kidney function was shortened by PD compared to HD [9, 10].
(* Disequilibrium: According to current theory, after rapid removal of substances retained in renal insufficiency and osmotically active (e.g., urea), a concentration gradient occurs between blood and intercellular space. This gradient causes fluid influx intracellularly and thus a volume redistribution → nausea, vomiting, hypotension, disturbances of consciousness, muscle cramps, cerebral seizures, cerebral edema.)
In acute PD with its required rapid catheter placement, the dependence on other specialties as well as the availability of operating capacities must be considered. In facilities experienced in acute PD, catheter placement is therefore performed percutaneously in local anesthesia and analgosedation by interventionally experienced nephrologists ultrasound-guided or in blind Seldinger technique [11]. The percutaneous technique of catheter placement is not inferior to laparoscopically guided and open-surgical placement and minimizes the leakage risk compared to open-surgical placement. After major abdominal interventions and suspicion of peritoneal adhesions, the surgical procedures (open, laparoscopic) should be preferred [12, 13].
Comparison of open surgical and laparoscopic implantation technique [14]
In a prospective randomized study of 148 patients (72 “open surgical”, 76 laparoscopic), the complication rate and functional duration were checked over an observation period of 3 years.
Early complications (all): open 33.3 % < > lap. 13.2 %
- Peritonitis 12.5 % < > 2.6 %
- Catheter malfunction 8.3 % < > 7.9 %
- Leakage 11.1 % < >1.3 %
- Colon perforation none < > 1.3 %
- Urinary bladder perforation 1.4 % < > none
Late complications (all): open 61.1 % < > lap. 57.9 %
- Infections 48.6 % < > 48.7 %
- Catheter malfunction 11.1 % < > 7.9 %
- Hernia 1.4 % < > 1.3 %
- Catheter failure 55.2 % < > 32.8 %
Functional duration of the catheter
- after 12 months: open 62 % < > lap. 77.5 %
- after 36 months: open 26 % < > lap. 63 %
An innovative approach to improve the biocompatibility of dialysis solutions is the addition of immunomodulatory adjuvants, which are intended to prevent local immune competence and the loss of peritoneal function [15, 16]. Also, an intensification of the dialysis dose with minimal dialysate volume is achievable, so that the vision of a wearable artificial kidney is currently coming closer [17]. Through the regeneration of dialysate, not only significant amounts of water are saved in times of global warming, but the CO₂ balance is also positively influenced.
(Acute) PD is currently experiencing a second spring.