Peritoneal Dialysis in adult Intensive Care Unit: Case report and literature review

Authors: Aslanidis Th.^1a*, Martika A.^2b, Spaia S.^3b

¹, MD, PhD, Anesthesiology – Critical Care-Prehospital emergency medicine.
², MD, Nephrology- Critical Care.
³, MD, PhD, Nephrology

^a Intensive Care Unit, Saint Paul (“Agios Pavlos”) General Hospital, Thessaloniki, Greece
^b Department of nephrology, Saint Paul (“Agios Pavlos”) General Hospital, Thessaloniki, Greece

*Corresponding Author: Doridos str 4, PC 54633, Thessaloniki, Greece. E-mail: Tel.: +306972477166.

 

ABSTRACT

Choice of peritoneal dialysis over other renal replacement therapy modalities for adult critically ill patients is still limited; despite the data against it. The present article presents a case of peritoneal dialysis in a patient with intracerebral hemmorhage and reviews the relevant literature.

 

Introduction

Though peritoneal dialysis (PD) is one of the first described renal replacement therapy option (RRT) and its advantages over haemodialysis (HD), its availability worldwide varies between 76-81%^1-2 (Table 1).

Moreover, large inter- and intraregional disparities exist in PD availability, accessibility, affordability, delivery, and reporting of quality outcome measures around the world, with the greatest gaps observed in Africa and South Asia^2-3. When it comes to usage of PD in critical care setting, data get even more limited; since the vast majority of Intensive Care Units’ (ICU) patients receive either continuous or prolonged intermittent haemodialysis therapies (Table 2).

The International Society of Peritoneal Dialysis (ISPD) recommends that PD be considered a suitable modality for treatment of AKI in all settings (1B)⁴. This applies to continuing PD in patients with established kidney failure who have already been on maintenance PD.

 

 

In the present article we present a case report as a starting point for a narrative literature review about the use of PD in ICUs, and we examine the validity of some concerns regarding the application of that therapeutic option in critically ill patients.

CASE REPORT

A 53-year-old man was admitted to our ICU with a diagnosis of intracerebral hemorrhage (ICH). The patient was transferred to Emergency Department (ED) of another hospital due to “acute comatose state”. Medical history included refractory hypertension related end-stage renal disease (ESRD) on PD for the last 5 years, and sleep apnea. ED clinical examination revealed: Glasgow coma scale (GCS): E3/V1/M2-3, mydriasis (4mm/3mm), irregular breathing pattern, heart rate (HR) of 75 bpm and arterial blood pressure (BP) 300/160 mmHg. The patient was intubated, an emergency CT (computed tomography) – revealing a large intracerebral hemorrhage- was conducted, while an intense attempt to control BP was made. After insertion of an external ventricular drain (EVD) for the ICH and an emergency HD session due to increased serum creatinine and urea (20.01 and 292 respectively), the patient was admitted to our hospital.

The patient remained 28 days in our ICU, before transferred to another hospital due to gastric hemorrhage, during which RRT was mainly achieved via PD and two sessions of CVVHDF.  The main determinants for the choice of PD were i) reason of admission, ii) coagulation disturbances and iii) difficulty in vascular access (stenosis of left femoral vein). Calculated weekly Kt/V* achieved was 1.98 and the course of serum creatinine, urea, potassium, calcium and phosphorus are displayed in the following graphs (Graph 1).

 

 

PD and outcomes

Though earlier studies on PD in critically ill have been terminated due to high mortality⁵, subsequent reports showed more promising outcomes⁶. There are even emerging studies examining the use of PD in patients with Acute kidney injury (AKI) and specifically in those with critical illness, that report better results- in term of survival, ICU length of stay, infections’ complications, and recovery of kidney function- in comparison with CRRT⁷.Moreover, the rate of ICU admission among patients on PD is low at 13.3 admissions per 100 patient–years compared to rates of ICU admission in the overall ESKD cohort was greater at 19.5 per 100 patient–years^8-9.

With COVID-19 pandemic, many ICUs were forced to implement PD programs since other RRT capacities were overwhelmed^10-14. There are even reports from PD application in prone position, with an improvement in post-prone PaO₂/FiO₂ ratio recorded in almost all patients¹¹. The overall results (survival, complications) and the PD mode used, vary from centre to centre, depending on the staffing, organisation, previous experience. Moreover, in several cases a combination of PD – HD modes were used (e.g., APD-CVVHDF, or PD-IHD)¹⁰. Surgical protocols for bedside PD catheter placement in critically ill were also applied¹².

Prescribing dose

The current ISPD guidelines recommended a weekly target Kt/V of 2.2. The prescription is recommended to be of 2 L dwell volume and 2 h dwell time, resulting in approximately 24 L of dialysis per day. The dwell cycles can be increased to 4–6 h following appropriate metabolic control⁴ (Figure 1). However, there are studies that report similar results to HD with a weekly target Kt/V up to 3.6¹⁵. In any case, appropriate dose for acute PD is still to be defined. We usually think PD in weekly Kt/V, but in the dynamic ICU setting daily Kt/V is more useful. We can make this information useful in guiding drug prescription and comparing clearances of PD and CRRT (when a transition is needed). The weekly Kt/V can be used for calculation of clearance of urea K in ml/min. For example, in our patient (BW=75 kg): V=V_{total body water}~0.6 x 75 (BW) =45 lt, Kt/V=1.98ÞK= (1.98 x V)/timeÞ K= 89.1/week=12.73 l/d~8.85 ml/min.

The ISPD guidelines suggest that that a daily Kt/V 0.5 in critically ill patients with AKI provide a comparable to HD outcome⁴.

 

Effects on intraabdominal pressure and mechanical ventilation.

Normal IAP of an empty abdomen is low at 0.5 to 2 cm H₂O, but in the setting of critical illness IAPs of 6 to 9 cm H₂O is usual and can be considered normal. In PD the increase in IAP is proportional to dialysate fluid. In a recent study, theIAP measure pre- and post-PD showed only a temporary increase (maximum was 10.2 ± 5.9 mm Hg) and returned to values very close to basal levels (8 to 9 mm Hg) by the third day¹⁶. In more complex cases, intermittent monitoring of IAP (for maintaining IAP<13 mmHg), can also be used to modify dialysate fluid¹⁶. In the same study, improved respiratory parameters were also recorded: progressive increase in pulmonary compliance, and a significant increase in PaO₂/FiO₂ and FiO₂; a fact that had been long known for paediatric population¹⁷.

Complications and contraindications; care of the PD catheter

Compared to CRRT therapies, mechanical complications and infections are lower with PD⁷. Cost and equipment are lower than CRRT therapies^7,18_. PD is contraindicated in large mesenteric resections, cutaneous feeding tube in situ (gastrostomy), known peritoneal defects or pleural communications (pleuroperitoneal shu-nt), severe active psychosis, severe physical de-formities, large abdominal hernias and other conditions that should be assessed at the bedside (obesity, multiple adhesions, documented type II ultrafiltration failure, active bowel ischemia, abdominal abscess, or in woman din the third semester of pregnancy)¹⁷.

In any case, when we need transition to temporary haemodialysis and the PD catheter is to remain in place, proper care should be taken.

The latter include timely exit site care and intermittent small volume flush to maintain catheter patency (usually every 2-4 weeks) and strategize to preserve any residual renal function (if present) when on HD.

Conclusions

Large, randomised control trials (RCTs) that compare PD to other RRT are limited; thus, future studies may need to change the status of PD in ICU. However, current data- and ISPD guidelines- suggest that PD is a feasible staff-, time- and cost-sparing alternative to other HD modalities for ICU.

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Addittional materials: No

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Acknowledgements:

Not applicable

Authors’ contributions:

TA: conceptualisation and final draft, TA, AM, SS: literature review. All authors read and approved the fnal manuscript.

Funding:

Not applicable.

Availability of supporting data:

Not applicable.

Ethical approval and consent to participate:

No IRB approval required

Competing interests:

The authors declare that they have no competing interests.

Received: July 2022, Accepted: August 2022, Published: September 2022.

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Citation: Aslanidis Th, Martika A, Spaia S. Peritoneal Dialysis in adult Intensive Care Unit: Case report and literature review. Greek e j Perioper Med. 2022;21(b): 62-69.

 

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