PD does not require direct access to the circulation; rather, it obligates placement of a peritoneal catheter that allows infusion of a dialysate solution into the abdominal cavity; this allows transfer of solutes (i.e., urea, potassium, other uremic molecules) across the peritoneal membrane, which serves as the “artificial kidney.” This solution is similar to that used for hemodialysis, except that it must be sterile, and it uses lactate, rather than bicarbonate, to provide base equivalents. PD is far less efficient at cleansing the bloodstream than hemodialysis and therefore requires a much longer duration of therapy. Pts generally have the choice of performing their own “exchanges” (2-3 L of dialysate, 4-5 times during daytime hours) or using an automated device at night. Compared with hemodialysis, PD offers the major advantages of (1) independence and flexibility, and (2) a more gentle hemodynamic profile, with better preservation of residual renal function. Again, for pts with known, progressive CKD, planning of future PD is critical, often involving creation of an “embedded” PD catheter that can be utilized months or even years later at the onset of ESRD.

Complications are outlined in Table 143-2 Complications of Peritoneal Dialysis. Peritonitis is the most important complication. The clinical presentation typically consists of abdominal pain and cloudy dialysate; peritoneal fluid leukocyte count is typically >100/µL, 50% neutrophils. In addition to the negative effects of the systemic inflammatory response, protein loss is magnified severalfold during the peritonitis episode. If severe or prolonged, an episode of peritonitis may prompt removal of the peritoneal catheter or even discontinuation of the modality (i.e., switch to hemodialysis). Gram-positive organisms (especially Staphylococcus aureus and other Staphylococcus spp.) predominate; Pseudomonas or fungal (usually Candida) infections tend to be more resistant to medical therapy and typically obligate catheter removal. Antibiotic administration may be intravenous or intraperitoneal when intensive therapy is required.