Hemodynamics

Intensive care medicine

Intravascular volume status

Kidney disease

Surgery

Cirrhosis

Paracentesis

Hemodialysis

Peritoneal dialysis

Hepatic encephalopathy

Ascites

Internal medicine

Peritoneovenous shunt

Medicine

Dialysis

American Journal of Kidney Diseases

The past few decades have seen steady increase in the prevalence of kidney failure needing kidney replacement therapy. Concomitantly, there has been progressive growth of heart failure and chronic liver disease, and many such patients develop ascites. Therefore, it is not uncommon to encounter patients with kidney failure who concurrently have ascites. The presence of ascites adds many challenges in the management of kidney failure. Poor hemodynamics make volume management difficult. The presence of coagulopathy, malnutrition, and encephalopathy compounds the complexity of the management. Such patients do not tolerate hemodialysis well. However, several concerns have limited the use of peritoneal dialysis (PD), so hemodialysis remains the predominant dialysis modality in these patients. However, observational studies have illustrated that PD provides hemodynamic stability and facilitates better volume management compared with hemodialysis. Moreover, PD obviates the need for therapeutic paracentesis by facilitating continuous drainage of ascites. PD potentially reduces hemorrhagic complications by avoiding routine anticoagulation use. Moreover, small studies have suggested that outcomes such as peritonitis and mechanical complications are comparable to those in PD patients without ascites. PD does not affect transplant candidacy, and these patients can successfully receive combined liver and kidney transplants. Hence, PD should be considered a viable dialysis option in kidney failure patients with ascites. The past few decades have seen steady increase in the prevalence of kidney failure needing kidney replacement therapy. Concomitantly, there has been progressive growth of heart failure and chronic liver disease, and many such patients develop ascites. Therefore, it is not uncommon to encounter patients with kidney failure who concurrently have ascites. The presence of ascites adds many challenges in the management of kidney failure. Poor hemodynamics make volume management difficult. The presence of coagulopathy, malnutrition, and encephalopathy compounds the complexity of the management. Such patients do not tolerate hemodialysis well. However, several concerns have limited the use of peritoneal dialysis (PD), so hemodialysis remains the predominant dialysis modality in these patients. However, observational studies have illustrated that PD provides hemodynamic stability and facilitates better volume management compared with hemodialysis. Moreover, PD obviates the need for therapeutic paracentesis by facilitating continuous drainage of ascites. PD potentially reduces hemorrhagic complications by avoiding routine anticoagulation use. Moreover, small studies have suggested that outcomes such as peritonitis and mechanical complications are comparable to those in PD patients without ascites. PD does not affect transplant candidacy, and these patients can successfully receive combined liver and kidney transplants. Hence, PD should be considered a viable dialysis option in kidney failure patients with ascites. FEATURE EDITORLinda FriedADVISORY BOARDAna RicardoRoger RodbyRobert TotoIn Practice Reviews provide in-depth guidance on clinical topics that nephrologists commonly encounter. Using clinical vignettes, these articles illustrate a complex problem for which optimal diagnostic and/or therapeutic approaches are uncertain. FEATURE EDITOR Linda Fried ADVISORY BOARD Ana Ricardo Roger Rodby Robert Toto In Practice Reviews provide in-depth guidance on clinical topics that nephrologists commonly encounter. Using clinical vignettes, these articles illustrate a complex problem for which optimal diagnostic and/or therapeutic approaches are uncertain. A 65-year-old man has history of hypertension, type 2 diabetes mellitus, hepatitis C–related cirrhosis with ascites, and progressive chronic kidney disease (CKD) due diabetic nephropathy. In the past 3 months, he was hospitalized twice with episodes of spontaneous bacterial peritonitis and hepatic encephalopathy. Lately he had required frequent large volume paracentesis (LVP). His MELD (Model for End-stage Liver Disease) score was 21. His CKD had progressed to stage 5, and he had been educated about kidney replacement therapy options. He expressed a preference for peritoneal dialysis (PD), and voiced interest in kidney-liver transplant. He was referred to surgery for placement of a PD catheter, but was informed that patients with ascites should not get a PD catheter placed. Consequently, he was initiated on in-center hemodialysis (HD). He did not tolerate ultrafiltration due to persistent hypotension and remained volume overloaded. He still needed frequent LVP to manage his ascites. Should this patient be reconsidered for PD?

Peritoneal Dialysis Use in Patients With Ascites: A Review