Year : 2007 | Volume
: 18 | Issue : 2 | Page : 195--199
Peritoneal dialysis for adults with acute renal failure: An underutilized modality
A Hayat, MA Kamili, R Samia, M Yaseen, R Shakeel, W Qureshi, GM Malik
Department of Medicine and Nephrology Government Medical College, Srinagar, Kashmir, India
Consultant Nephrologist King Fahd Medical City, P.O. Box 11525, Riyadh 59046, Saudi Arabia
In order to evaluate the effects of peritoneal dialysis as a modality of renal replacement therapy for adults with acute renal failure (ARF) of varied etiologies, we studied 43 ARF patients who underwent peritoneal dialysis at our hospital from April 2004 to November 2005. The age of the patients ranged from 18 to 75 years with a mean of 35 years. There was no significant difference in the incidence of ARF between males and females. Acute tubular necrosis secondary to acute gastroenteritis was the cause of ARF in 32 (80%) patients; four (10%) patients expired secondary to ARF. There was an average fall of around 60% in the S. creatinine at the end of PD. We did not notice any significant complications related to the procedure. We conclude that peritoneal dialysis is still a good option for the treatment of patients with ATN.
|How to cite this article:|
Hayat A, Kamili M A, Samia R, Yaseen M, Shakeel R, Qureshi W, Malik G M. Peritoneal dialysis for adults with acute renal failure: An underutilized modality.Saudi J Kidney Dis Transpl 2007;18:195-199
|How to cite this URL:|
Hayat A, Kamili M A, Samia R, Yaseen M, Shakeel R, Qureshi W, Malik G M. Peritoneal dialysis for adults with acute renal failure: An underutilized modality. Saudi J Kidney Dis Transpl [serial online] 2007 [cited 2021 Oct 18 ];18:195-199
Available from: https://www.sjkdt.org/text.asp?2007/18/2/195/32309
Acute renal failure (ARF) is defined as an abrupt or rapid decline in renal function. A rise in serum blood urea nitrogen (BUN) or serum creatinine concentrations, with or without a decrement in urine output, usually is evidence of ARF. The condition is often transient and completely reversible.,
Patients with chronic renal failure also may present with superimposed ARF. Approximately 1% of patients admitted to hospitals have ARF at the time of admission, and the estimated incidence of ARF is 2-5% after admission.
The principal methods of renal replacement therapy (RRT) are intermittent hemodialysis (IHD), continuous renal replacement therapy (CRRT), and peritoneal dialysis (PD). Each has advantages and limitations. IHD is widely available, has only moderate technical difficulty and is the most efficient way of removing a volume or solute from the vascular compartment quickly.
Since 1962, peritoneal dialysis (PD) has been used especially in patients who are not adequately hemodynamically stable to receive hemodialysis. The use of PD in patients with acute renal failure decreased when hemodialysis became available in the mid 1970s. 
In this study, we report the safety and efficacy as well as outcome of ARF patients who received PD as the first option of renal replacement therapy at our hospital.
Materials and Methods
We studied 43 (20 (47%) males, 23(53 %) females) ARF patients who underwent PD in the Department of Medicine at Government Medical College, Srinagar Kashmir, India, from April 2004 to November 2005. The age range was 18-75 years with a mean age of 35 years.
Acute tubular necrosis secondary to acute gastroenteritis and fluid losses was the cause of ARF in 32 (80%) patients, Leptospirosis in two (2.5%) patients, falciparum malaria in one (2.5%) patient, acute CRF with underlying chronic glomerulonephritis in two patients (5%), and septicemia-related ARF in two patients (5%). Four patients underwent kidney biopsy for evaluation of ARF; two (5%) patients had cresentic glomerulonephritis, another one (2.5%) had SLE stage IV and a third one (2.5%) had multiple myeloma cast nephro-pathy [Table 1].
Most of the patients 38 (88%) who underwent PD were in various stages of encephalopathy ranging from drowsiness to coma. Metabolic acidosis was present in 37 (86%) patients, dehydration in 32 (74%), fluid overload in four (9%), pericarditis in six (14%), and hypotension (systolic BP + > 16.5 mmol/L), acid-base imbalance, symptomatic uremia (pericarditis, encephalopathy, bleeding dyscrasia, nausea, vomiting, and uremia (BUN >100 mg/L). Patients who had contraindications to PD, such as recent abdominal surgery, were referred to hemodialysis in another center.
PD was performed by using a rigid Teflon cannula inserted over a trocar into the peritoneum after priming the abdomen with two liters of peritoneal fluid. Each exchange of PD consisted of 2 L of fluid. Each exchange of PD lasted for around 1 hr; inflow time was 10 minutes, dwell 30 minutes and drainage time 20 minutes. All patients underwent, on average, 30 exchanges of PD. The PD catheter was removed after a period of about 48 hours and was reinserted if dialysis was required again. Standard 1.5% dextrose was used as the PD fluid, and 100 mLs of 25% dextrose was added to each PD exchanges for obtaining negative balance if required.
Statistical analysis was performed using two proportion tests at a 95% confidence interval (95%) and a p value <0.05 was considered significant.
Thirty-nine (90%) patients who underwent PD survived, while only four (10%) patients died; two patients who expired had underlying pneumonia and septicemia, another had acute gastroenteritis with hypotension as well as shock with severe metabolic acidosis, and one had underlying gout with chronic interstitial nephritis with drug-induced ARF with sepsis.
There was an average fall of around 60% in the serum creatinine at the end of PD treatment session (30 hours), and the average ultrafiltation achieved was around 2L (range: 1-4L). Out of 64 sessions of PD in 43 study patients, we observed minor and manageable complications related to the procedure in seven (11%) patients; two patients had hemorrhagic drain because of coagulation defects that were transient, one patient had hypokalemia that required potassium supplementation in PD fluid, one patient had bleeding from the puncture site that abated after local compression, one patient developed respiratory distress that required intubation and reduction in the PD volume, and three patients developed peritonitis that subsided with intravenous antibiotics.
All of our study patients recovered their renal function to normal within a period of 4 - 6 weeks, and none required maintenance dialysis. One patient with multiple myeloma was treated with a melphalan/prednisolone combination, and patients with SLE and RPGN were treated with prednisolone and cytotoxic therapy and renal function normalized subsequently. [Table 3] summarizes the improvement of the different clinical and laboratory parameters.
Of all the known renal replacement therapies by dialysis, peritoneal dialysis is the least expensive, most widely available, and the least complicated by hypotension. However, it is not capable of removing large volumes of fluid or solutes. Its use is most popular in children.
Since our center lacked the facility for HD, all study patients underwent peritoneal dialysis as the first option for treatment of ARF. We found excellent results in the patients with ARF as 90% survived in comparison to the overall mortality of around 50% in western studies, and a mortality of 55% in our previous study.,, The higher survival in our study may be due to the fact that the majority of our patients had acute gastroenteritis as the cause of ARF with no significant co-morbidity and were relatively young. Furthermore, none of the patients had surgical or obstetrical ARF, which carried high mortality (80% and 60%, respectively) in our previous study, or in comparison to (~60%) western studies.,
The average fall in serum creatinine at the end of PD was around 60%. There were no significantly observed complications as a result of the procedure. None of the patients required transfer to HD. There was also no problem observed in ultrafiltration, as the average fluid loss was around 2 kg/PD session. Six liters of ultrafiltration could be attained in some patients with fluid overload. There was no fluctuation in blood pressure during dialysis, blood pressure improved following dialysis in patients with fluid overload and hypertension. Moreover, patients with a volume deficit normalized their blood pressure (BP) following correction of the fluid deficit. All patients recovered their renal functions to normal within a period of 4-6 weeks, and none required chronic maintenance dialysis.
We believe that if PD is performed by well-trained personnel, the procedure is comparable in its outcome to HD as our results demonstrated. If HD facilities are not available, PD is a viable alternative.
We conclude that peritoneal dialysis is still a good option for the treatment of patients with ATN. It is cost effective and can be performed where hemodialysis facilities are not available
|1||Thadhani R, Pascual M, Bonventre JV. Acute renal failure. N Engl J Med 1996; 334(22): 1448-60.|
|2||Chandial V, Hayat A, Najar S. Prognostic factors in acute renal failure. Accepted for publication Indian society of nephrology July 2005.|
|3||Mehta RL. Therapeutic alternatives to renal replacement for critically ill patients in acute renal failure. Semin Nephrol 1994; 14:64-82.|
|4||Howdieshell TR, Blalock WE, Bowen PA, Hawkins ML, Hess C. Management of post-traumatic acute renal failure with peritoneal dialysis. Am Surg 1992; 58:378-82.|
|5||Bellomo R, Parkin G, Love J, Boyce N. A prospective comparative study of continuous arteriovenous hemo-diafiltration and continuous veno-venous hemodiafiltration in critically ill patients. Am J Kidney Dis 1993; 21:400-4.|
|6||Strazdins V, Watson AR, Harvey B; European Pediatric Peritoneal Dialysis Working Group. Renal replacement therapy for acute renal failure in children: European guide-lines. Pediatr Nephrol 2004; 19(2):199-207.|
|7||Chertow GM, Christiansen CL, Cleary PD, Munroc, Lagarus JM. Prognostic stratification in critically ill patients with acute renal failure requiring dialysis. Arch Intern Med 1995; 155(14): 1505-11.|