Check out the Evidence

Lee MB et al. Myths in peritoneal dialysis. Curr Opin Nephrol Hypertens. 2016;25(6):602–608.

Select Patient Types

Patients with diabetes

Diabetes is the most common cause of chronic kidney disease, often causing the accelerated deterioration of kidney function and subsequent need for renal replacement therapy.

Diabetic patients have unique challenges associated with clinical management once on dialysis that are related to:

  • A higher prevalence of cardiovascular comorbidity,1 peripheral vascular disease, hypoalbumineria, and hyperparathyroidism2
  • Excessive accumulation of advanced glycosylated end products (AGEs)2
  • HbA1c levels being falsely elevated or decreased in patients with CKD2

Given conflicting observational trial results, there is no evidence-based outcome that supports the selection of PD or HD as the treatment of choice in Stage 5 CKD patients with diabetes.3

Check out the Evidence

Chung SH, Noh H, Ha H, Lee HB. Optimal use of peritoneal dialysis in patients with diabetes. Perit Dial Int. 2009 Feb;29 Suppl 2:S132–S134. PMID: 19270202.

Passadakis PS, Oreopoulos DG. Diabetic patients on peritoneal dialysis. Semin Dial. 2010;23(2):191–197.

Couchoud C et al. Dialysis modality choice in diabetic patients with end-stage kidney disease: a systematic review of the available evidence. Nephrol Dial Transplant. 2015;30(2):310–320.

Patients who are elderly

By 2030, 72 million Americans will be > 65 years of age (~20% of the US population). In 2021, this age group accounted for 34% of the chronic kidney disease population.1,2

There is no straight answer when it comes to choosing between HD and PD in these patients. Factors that may affect outcomes, life expectancy, and needs include:

  • The number of comorbidities
  • Overall day-to-day functioning (physical and mental)
  • Frailty3

PD has been shown to be an acceptable modality of renal replacement therapy in elderly patients, with no observed differences in survival, technique survival, or complication rates.4 A 2018 review article that investigated comparisons between PD and HD outcomes in elderly patients found that PD is not inferior to HD when looking at technique and elderly patient survival.5

Check out the Evidence

Centers for Disease Control and Prevention. The state of aging and health in America, 2013. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2013.

Centers for Disease Control and Prevention. Chronic kidney disease in the United States, 2023. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2023.

Brown EA et al. Peritoneal or hemodialysis for the frail elderly patient, the choice of 2 evils? Kidney Int. 2017;91(2):294–303.

Smyth A et al. Peritoneal dialysis in an ageing population: a 10-year experience. Int Urol Nephrol. 2011;44(1):283–293.

Lança A et al. Peritoneal dialysis in the elderly: challenge accepted. Port J Nephrol Hypert. 2018;32(2):101–109.

Patients who are obese

Obesity is highly prevalent among the chronic kidney disease population and has an impact on health and outcomes.1

Previously, PD was considered not a treatment of choice for obese patients. However, a variety of clinical trials demonstrate similar results in obese compared to non-obese PD patients.1,2

A 2013 study of body size and longitudinal body weight changes in Brazilian PD patients found that being overweight or obese did not increase mortality in the studied population.2

Check out the Evidence

Quero M et al. Impact of obesity on the evolution of outcomes in peritoneal dialysis patients. Clin Kidney J. 2020;14(3):969–982.

Fernandes NM et al. Body size and longitudinal body weight changes do not increase mortality in incident peritoneal dialysis patients of the Brazilian peritoneal dialysis multicenter study. Clinics. (Sao Paulo) 2013;68(1):51–58.

Patients who “crash start”* onto dialysis

Despite efforts to reduce unplanned dialysis starts, “crash starts” and unplanned dialysis initiation remain a challenge.

This remains a concern due to the fact that unplanned dialysis starts in North America generally result in one option: HD with a central venous catheter.2

These patients have not had the opportunity to select the modality that best suits their personal situation.

In the past decade, PD has been more widely used for patients initiating dialysis urgently or in a crash manner. The data shows:

  • Survival1,3
  • Catheter patency2
  • Low incidence of catheter-related complications2
  • High retention rates1

Check out the Evidence

Bahalla NM et al. Urgent start peritoneal dialysis: a population-based cohort study. Kidney Med. 2022;4(3):100414.

Ye H et al. Urgent-start peritoneal dialysis for patients with end stage renal disease: a 10-year retrospective study. BMC Nephrol. 2019;20(1):238.

Karpinski S et al. Urgent-start peritoneal dialysis: Association with outcomes. Perit Dial Int. 2023;43(2):186–189.

*Patients who present urgently with CKD Stage 5 without a plan for dialysis modality.

Patients with autosomal dominant polycystic kidney disease (ADPKD)

Concerns about a higher kidney volume reducing the effective peritoneal surface as well as increased intraperitoneal pressure are reasons that some nephrologists wonder about the applicability of PD for patients with ADPKD.1

There are a number of publications that compare results between:

  • PD patients with and without ADPKD1
  • ADPKD patients on HD vs. PD2

These studies show either a favourability to PD for ADPKD patients or no difference in outcomes. Use of PD in patients with ADPKD is safe and effective and should be offered to these patients.1,2

Check out the Evidence

Dupont V et al. Outcome of polycystic kidney disease patients on peritoneal dialysis: Systematic review of literature and meta-analysis. PLoS ONE. 2018;13(5):e0196769.

Sigogne M et al. Outcome of autosomal dominant polycystic kidney disease patients on peritoneal dialysis: a national retrospective study based on two French registries (the French Language Peritoneal Dialysis Registry and the French Renal Epidemiology and Information Network). Nephrol Dial Transplant. 2018;33(11):2020–2026.

Patients with prior abdominal surgery

The belief that patients with prior abdominal surgery are not candidates for PD is not supported by clinical evidence.1,2,3

In fact, studies have shown that “scars on the abdomen and prior peritonitis do not predict the extent of adhesions and should not be used to judge eligibility for peritoneal dialysis.”1

In 2021, a study was published that assessed 171 PD patients. This study found that “prior abdominal surgical procedures do not appear to compromise peritoneal membrane function or technique survival in patients successfully started on PD.”3

Check out the Evidence

Crabtree JH, Burchette RJ. Effect of prior abdominal surgery, peritonitis, and adhesions on catheter function and long-term outcome on peritoneal dialysis. Am Surg. 2009;75(2):140–147.

Aziz F, Chaudhary K. Peritoneal dialysis in patients with abdominal surgeries and abdominal complications. Adv Perit Dial. 2017;33:40–46.

Da Silva AD et al. Does prior abdominal surgery influence peritoneal transport characteristics or technique survival of peritoneal dialysis patients? Blood Purif. 2021;50(3):328–335.

Patients about to undergo abdominal surgery

Depending on a patient’s wishes, they might prefer to remain on PD rather than temporarily being transferred to HD if they require an abdominal surgery. There are a number of reports demonstrating the feasibility and process by which to maintain these patients on PD.1,2,3,4

Check out the Evidence

Lew SQ. Peritoneal dialysis immediately after abdominal surgery. Perit Dial Int. 2018;38:5–8.

Shah H et al. Perioperative management of peritoneal dialysis patients undergoing hernia surgery without the use of interim hemodialysis. Perit Dial Int. 2006(6);26:684–687.

Fahad Aziz et al. Peritoneal dialysis in patients with abdominal surgeries and abdominal complications. Adv Perit Dial. 2017;33;40–46.

Kleinpeter MA, Krane NK. Perioperative management of peritoneal dialysis patients: review of abdominal surgery. Adv Perit Dial. 2006;22:119–123.

Patients with a left-ventricular assist device (LVAD)

LVADs are increasingly being used as a bridge to transplantation or therapy in patients with end-stage heart failure (HF) refractory to conventional medical therapy. Nearly two-thirds of hospitalized patients with HF also have CKD, with 44%,14%, and 7% having CKD Stage 3, 4, and 5 respectively.1

Although there are no RCTs comparing the use of LVADs in HD and PD patients, there are data that suggest reasons for PD to be the preferred therapy for these patients:

  1. HD is associated with a higher incidence of bacteremia than PD.2,3
  2. The continuous ultrafiltration of PD creates more hemodynamic stability.2
  3. Residual renal function is preserved with PD.4,5

Check out the Evidence

Patel AM et al. Renal failure in patients with left ventricular assist devices. Clin J Am Soc Nephrol. 2013;8(3):484–496.

Ross DW et al. Left ventricular assist devices and the kidney. Clin J Am Soc Nephrol. 2018;13(2):348–355.

Thomas BE et al. Renal replacement therapy in congestive heart failure requiring left ventricular assist device augmentation. Perit Dial Int. 2012;32(4):386–392.

Guglielmi A et al. Peritoneal dialysis after left ventricular assist device placement. ASAIO Journal. 2014;60(1):127–128.

Ajuria M et al. Peritoneal dialysis following left ventricular assist device placement and kidney recovery: a case report. Kidney Med. 2021;3(3):438–441.

Patients with ascites

There are unique challenges in managing the cirrhotic patient with ascites population while on dialysis that include:

  • Hemodynamics and the bleeding risk with HD
  • Risk of early catheter leak
  • Risk of spontaneous bacterial peritonitis and protein losses in the dialysate with PD1

A recent review article concluded that:

  • There are no differences in outcomes between patients with and without ascites on PD vs. HD
  • PD provides hemodynamic stability and facilitates better volume management compared with HD
  • PD provides continuous drainage of ascites, thus mitigating the need for large-volume paracentesis2

Check out the Evidence

Guest S. Peritoneal dialysis in patients with cirrhosis and ascites. Adv Perit Dial. 2010;26:82–87.

Rajora N et al. Peritoneal dialysis use in patients with ascites: a review. Am J Kidney Disease. 2021;78(5):728–735.

Patients with a colostomy or other stoma

PD use in patients with colostomy or other stoma is possible.

Presternal catheters can help to reduce the risk of infection in adults and children because the exit site is distant from the ostomy.1,2

Check out the Evidence

Twardowski ZJ. Presternal peritoneal catheter. Adv Ren Replace Ther. 2002;9(2):125–132.

Chadha V, Jones LL, Ramirez ZD, Warady BA. Chest wall peritoneal dialysis catheter placement in infants with a colostomy. Adv Perit Dial. 2000;16:318–320.