Peritoneal Dialysis: Indications

1. General Indication - End-Stage Kidney Disease (ESKD)

• Anorexia and nausea not attributable to reversible causes (e.g., peptic ulcer disease)
• Evidence of malnutrition due to uremia
• Fluid and electrolyte abnormalities refractory to conservative measures - particularly hyperkalemia and extracellular fluid volume (ECFV) overload
• Uremic encephalopathy (now rare at presentation due to earlier initiation)
• Uremic pericarditis (also now a late/rare indication)

2. Acute Kidney Injury (AKI) - Indications for Emergent Dialysis (any modality including PD)

3. When PD is Specifically Preferred or Recommended

a. Hemodynamic instability

• Patients with cardiovascular instability or frequent hypotension during standard hemodialysis tolerate PD better, as fluid removal is gradual and continuous.
• Harrison's notes that continuous renal replacement therapy (CRRT) is preferred in severe hemodynamic instability, but PD is a viable alternative when CRRT/HD is unavailable.

b. Poor vascular access

• Patients with exhausted vascular access (multiple prior fistulas, thrombosed grafts, limited central venous access) for whom hemodialysis is technically difficult.

c. Pediatric patients

• PD is the dominant modality in children with chronic kidney disease awaiting transplantation, especially infants and young children. It is often the preferred long-term modality due to simplicity and feasibility of home use.
• (Harriet Lane Handbook, 23rd ed.)

d. Resource-limited or remote settings

• PD requires minimal technology and infrastructure. It is used to treat AKI in LMICs and areas where intensive hemodialysis infrastructure is unavailable.
• A PD catheter can be placed at the bedside; even improvised catheters (Foley, intercostal drains) can be used in emergencies.
• (NKF Primer on Kidney Diseases, 8th ed., Table 49.1)

e. Patient preference for home-based therapy

• PD (particularly CAPD - continuous ambulatory PD, or APD - automated PD) offers home-based, independent therapy with better quality of life for suitable patients.
• Home dialysis is less expensive in most settings and associated with improved quality of life vs. in-center hemodialysis.

f. Preservation of residual renal function

• PD better preserves residual kidney function compared to hemodialysis, which is clinically important for overall solute clearance, fluid management, and cardiovascular outcomes.

g. Diabetes mellitus (with caution)

• PD is not contraindicated in diabetics; evidence suggests outcomes are similar to HD in this group. Insulin can be administered intraperitoneally.

4. Contraindications to PD

Absolute contraindications (few in number):

• Major prior abdominal surgery with significant adhesions - may prevent adequate dialysate distribution
• Active peritonitis or intra-abdominal infection (relative to access)
• Uncorrectable coagulopathy (for catheter placement)
• Abdominal trauma

Relative contraindications:

• Recent abdominal surgery (timing-dependent)
• Abdominal wall defects (hernias, stomas) - can often be corrected
• Severe obesity (manageable with APD)
• Inflammatory bowel disease or colostomy
• Severe respiratory compromise (intraperitoneal fluid may impair diaphragm)
• Inability to perform exchanges or lack of a caregiver/helper (social barrier)

Note: Per a 2023 review in Clinical Kidney Journal, absolute contraindications to any single modality are rare and relative indications should be weighed against patient preferences. Conditions previously considered PD contraindications (obesity, polycystic kidney disease, elderly age) are generally NOT supported by outcome data (Lambie & Davies, PMID 37711635).

5. Comparison with Hemodialysis