In PD, the peritoneal membrane inside a patient’s body is used as a natural semipermeable membrane.

Waste and water move from the blood, across the peritoneal membrane, and into the peritoneal cavity.
Then the solution, now called the effluent, is removed from the peritoneal cavity. This process is
repeated many times in the course of one treatment to remove solutes and water from the patient.
Diffusion refers to the movement of solutes from an area of high concentration to an area of low
concentration. Only substances to which the membrane is permeable can diffuse across it, and diffusion
is specific for a given substance.

In dialysis, we can take advantage of this by adjusting the concentrations of different substances:

By increasing the concentration of a substance in the dialysate, we promote movement of desired

substances into the bloodstream.

By decreasing the concentration of a substance in the dialysate, we promote movement of undesired

substances out of the bloodstream. This is called clearance of solutes.
Convection refers to movement of solute with fluid across a semipermeable membrane due to both a
hydrostatic and an osmotic pressure gradient. These pressure gradients cause fluid to flow across the
membrane, taking solutes with it by mass transport. Both the kidneys and dialysis use diffusion and
convection to achieve solute and fluid removal.

Hydrostatic pressure: the physical pressure that a fluid exerts on the walls of its container.

Osmotic pressure: the pressure required to maintain an equilibrium, or no net movement of water,
across a membrane.

The rate of convection depends upon:

Hydrostatic pressure

Osmotic pressure

Porosity of the membrane

The peritoneal membrane is used as a semipermeable membrane that allows movement of solutes and
water during PD. The peritoneum serves as a good membrane for dialysis because of its extensive
capillary surface area, providing ample opportunity for diffusion and ultrafiltration to occur between
blood and dialysate.

The peritoneum consists of three layers: the mesothelial cell layer, the interstitium, and the capillary
wall. The layer of mesothelial cells allows solute and water to transport easily. The interstitium and
capillary wall are size-selective.
Choosing PD vs. HD depends on local resources and expertise as well as the child’s specific clinical
condition. PD may be indicated for:

a. Children with acute or chronic kidney injury who require:

Ultrafiltration – for volume overload and/or provision of necessary treatments, including treatments
that result in fluid accumulation, such as IV medications and parenteral nutrition

Solute clearance – hyperkalemia, hyperammonemia, uremia, metabolic acidosis

Removal of dialyzable toxin or drug that cannot be cleared sufficiently with other medical maneuvers
and in patients who are not suitable candidates for HD

b. Patients needing dialysis with limited vascular access or in a center where HD access is not offered.

c. Special case: Children following congenital heart disease repair may return fluid overloaded secondary
to capillary leak and may develop oliguric acute kidney injury secondary to time on the bypass pump. PD
catheter placement during or after surgery allows for ultrafiltration and/or solute clearance post-
operatively.
Ultrafiltration is the term used in dialysis to quantify the net removal of water. In PD, ultrafiltration is
driven by an osmotic gradient, provided by high dextrose concentrations in the dialysate compared to
blood glucose levels. Higher dextrose concentrations usually result in greater ultrafiltration.

The dextrose concentration can be altered to meet the ultrafiltration goal, which is patient-dependent.
Variables to consider in setting the goal ultrafiltration for a patient include:

Pre-existing degree of volume overload

Ongoing urine output

Changes in daily weight

Total fluid balance

Cardiorespiratory status

Physical examination findings consistent with volume overload

At the end of each dialysis cycle, it is important to calculate and record the ultrafiltration (UF): UF =
Volume removed – Fill volume
Clearance is the term used in dialysis to quantify or measure the removal of certain substances, such as
urea and creatinine. It is accomplished as solutes move down a concentration gradient, so clearance can
be adjusted by changing the concentrations of different substances in the dialysate. Clearance is the
mechanism by which harmful solutes such as toxins can be removed from the bloodstream and into the
effluent.

To avoid clearance of important substances from the bloodstream, dialysate solution contains buffers.
For example, dialysate typically contains a buffer such as bicarbonate to control acidosis, and other salts
in physiologic concentrations to avoid their removal from the bloodstream.
PD is a sterile process, as the peritoneum has no defense against infection. Insertion of the catheter
must be sterile, and connections in the system should be opened only when necessary. This is an issue
that is especially important when setting up PD at the bedside, as in acute cases. In order to prevent
infection, the catheter should be flushed only when truly warranted. Any time that connections in the
system must be opened, care must be taken to ensure the dialysate’s sterility is maintained.
To meet ultrafiltration goals, the peritoneal dialysate is deliberately rendered hyperosmolar relative to
plasma, to create an osmotic gradient that favors net movement of water from the bloodstream and
into the peritoneal cavity.

Dextrose is used as the osmotic agent to promote this ultrafiltration. The greater the dextrose, the
greater the ultrafiltration. Dextrose concentrations range from 1.5% to 4.25%. This is equivalent to a
glucose concentration of 1500-4250 mg/dL. In this simulator, you can set your dextrose level at 1.5%,
2.5% or 4.25%, depending on the patient’s ultrafiltration goals.

One should always use the lowest possible dextrose concentration, as higher concentrations of dextrose
can lead to peritoneal fibrosis and higher carbohydrate load for the patient over time. For an initial
prescription, set your dextrose at the lowest available concentration, then adjust the concentration to
meet ultrafiltration goals, as needed.
Initial fill volumes are typically 5-10 mL/kg, with gradual increases up to 20 to 25 mL/kg in smaller
infants, and 30-45 mL/kg in older children. In this simulator, start your fill volumes at 5 mL/kg, and
increase your fill volumes to promote increased clearance as needed.

The volume of each fill limits the amount of clearance that one can achieve, as molecules can only move
down a concentration gradient. Thus, the volume of dialysate instilled in a 24-hour period is the total
maximum clearance achieved, assuming 100% efficacy.

With shorter cycles, one never reaches equilibrium between blood and dialysate, and thus the clearance
may be less than the volume of dialysate.

Fill time is ideally 5-10 minutes to maximize time spent with dialysate in the abdomen and to allow for
the most effective clearance and ultrafiltration. In this simulator, the fill time will be set at 10 minutes.

Some patients may fill much more quickly than the prescribed time. Other patients may take a longer
time to fill, fill incompletely, or not at all due to:

Catheter malposition or occlusion

Constipation

Abdominal scarring
Drain time is ideally no more than 10 minutes, to maximize time spent with dialysate in the abdomen
and to allow for the most effective clearance and ultrafiltration. In this simulator, the drain time will be
set at 10 minutes.

Patients may take longer to drain completely due to:

Catheter malposition or obstruction

Kinking of the catheter external to the patient

Dwell time is often initially calculated by subtracting the fill and drain times from the desired cycle time
(most often 60 min).

The dwell time is the amount of time the dialysate remains in the peritoneal cavity prior to draining. The
ideal amount of time differs depending on the goals of dialysis. In general, the larger the molecule, the
longer the dwell time required for clearance. However, the most effective clearance and ultrafiltration
are achieved by doing more frequent exchanges.
In this simulator, for a new patient starting on PD in the acute intensive care setting, an initial
prescription should include:

Sodium: 132 mEq/L, slightly less than plasma sodium concentration.

Potassium: Add to the dialysate if the patient is hypokalemic or normokalemic.

Dextrose: Start at the lowest possible concentration, 1.5%, and increase slowly depending on the
patient’s ultrafiltration goals.

Heparin: Add after initial catheter placement and if concerned for peritonitis.

Antibiotics: Add if concerned for peritonitis.

Fill Volume: Start at 5 mL/kg, and increase to promote clearance as needed.

Cycles: In the acute setting, start continuous PD with 24 one-hour cycles/day.

The flow of fluid in PD is dependent on gravity, unless an automated PD machine is available for use. The
bag of dialysate filling the patient (fill bag) must be higher than the patient. The drain bag must be lower
than the patient.

Once you have selected the bag of dialysate appropriate for the patient, this bag is placed on a pole
higher than the patient, and attached to the buretrol device, or in-line sterile graduated cylinder. In
neonates, it is imperative to have a measuring device such as a buretrol to ensure that the fluid is being
administered in a controlled fashion.

The buretrol connects to the patient’s dialysis catheter through a stopcock or Y set. Then, a drainage line
is attached to the other limb of the stopcock or Y set. With this system, one can go through all of the
steps in a PD cycle without opening the system and exposing patients to risk of infection.
There is a roller clamp to allow fluid into the buretrol, then auxiliary clamps to allow fluid into the
peritoneum, and into the drainage. When beginning, ensure that all clamps are closed.

After you have measured the desired amount of fluid into your buretrol, the first auxiliary clamp is
opened to allow the fluid to fill into the abdomen. This is known as the fill phase, during which time the
dialysate is infused into the peritoneum.

If the flow is proceeding smoothly, you can be assured that you entered the peritoneum. If not, consider
that your catheter is not in the peritoneum and reassess your set up. Problems with the fill phase of
dialysis can be due to:

Inappropriate fill bag height

Clamped catheter

Catheter malposition or kinking

Intraluminal or extraluminal catheter occlusion

Once the fluid has entered the abdomen, one can close the auxiliary clamp leading to the abdomen and
allow the dialysate to sit within the peritoneum (dwell phase). While the dialysate remains in the
peritoneal cavity, diffusion and ultrafiltration occur. Dwell time is prescribed by the caregiver and
depends on a patient's needs. Please see the knowledge guide section on dwell time for more
information. In this simulator, for all tactics and cases that do not describe inflow or outflow problems,
please assume the patient is in their dwell phase.

The last phase is the drain phase. During this phase, the dialysate and diffused wastes, fluid, and
electrolytes are drained from the peritoneum. In order to begin this phase, open the auxiliary clamp
leading to the drain bag.

If fluid is not draining, consider a partial obstruction and reassess. Problems with the drain phase of
dialysis can be due to:

Inappropriate drain bag height

Clamped catheter

Constipation/obstipation

Catheter malposition or kinking

Intraluminal or extraluminal catheter occlusion

At the end, ensure that all clamps are closed. It is important to measure the drainage volume very
carefully, calculate and record the ultrafiltration, as described in the knowledge guide section on
ultrafiltration. One way to achieve this is to use a buretrol on the exit line.
The fluid that drains out is the effluent fluid. The effluent fluid is composed of: dialysate fluid + patient’s
excess water + patient’s waste products (creatinine, urea, electrolytes)
Peritonitis is an infection or inflammation of the peritoneal cavity. This is a life-threatening complication
and must be recognized and treated rapidly. Signs of peritonitis include:

Cloudy effluent (you should be able to read through the bag of fluid – if not, suspect peritonitis)

Abdominal pain

Nausea, vomiting

Fever

Leukocytosis

Peritoneal signs

Peritonitis is diagnosed by obtaining a cell count and culture from the effluent, which under normal
circumstances is sterile. In a patient on PD receiving ongoing exchanges, peritonitis is diagnosed when
effluent:

White blood cell count > 100 WBC / mm3

> 50% of the cells are polymorphonuclear leukocytes

Other criteria apply when the catheter is not being actively used. The main treatment strategy is use of
appropriate antimicrobial therapy given intraperitoneally. Additional therapies may include fibrinolytic
agents and peritoneal lavage. If peritonitis cannot be cleared by these measures, one must consider
removal of the catheter. While the dialysate remains cloudy, heparin is usually added to help prevent
fibrin clots. Furthermore, the peritoneum is cleaned by multiple rapid exchanges.
When the catheter is obstructed, a patient might present with:

Poor ultrafiltration

Pain during drain time

Impaired outflow during drain time

The catheter is most commonly obstructed by omentum. In some institutions, an omentectomy is

performed during placement of the PD catheter, reducing the risk for obstruction. However, the
catheter can also be caught in the liver, fallopian tubes, abdominal adhesions, or between loops of
bowel.

If catheter obstruction is suspected, the catheter should be flushed, which can help with both diagnosis
and management. Also, fibrinolytics should be considered.

Initial evaluation is with an abdominal x-ray to determine the position of the

catheter requires surgical exploration, either invasive or laparoscopic.

Effluent removed from the patient is isotonic. Thus, if large amounts of fluid are removed by
ultrafiltration and there is not equivalent sodium intake, the patient will develop a net negative sodium
balance. Sodium can be corrected by giving enteral sodium supplementation or increasing the salinity of
the intravenous fluids or peripheral nutrition. Adjustment of the sodium content in the dialysate is also
an option, but this depends on local practice and availability of resources to make such changes.

Because solutes move down a concentration gradient, as PD is initiated some patients develop
hypokalemia. To avoid worsening hypokalemia, potassium should be added to the dialysate if the
patient’s potassium is lower than desired. If potassium is added to the dialysate, it should never be
added in concentrations greater than physiologic concentrations. If the serum potassium is dangerously
low, potassium can be administered either orally or intravenously.

When hyperkalemia is diagnosed from the serum lab results (potassium level greater than 6 mEq/L), it is
important to order an EKG to determine if there is risk for cardiac arrhythmia. Then, hyperkalemia
should be treated by removing the potassium from the dialysate. If the dialysate already contains no
additional potassium, one can increase clearance to decrease the potassium level. This can be done by
increasing fill volumes and/or cycle number.

In cases of symptomatic or severe hyperkalemia (EKG changes or when potassium levels exceed 6.5
mEql/L), one should consider administration of:

Calcium to stabilize the myocardium

Kayexalate to bind excess potassium

Beta-agonist therapy, insulin, glucose, and/or sodium bicarbonate to shift potassium intracellularly
Catheter use immediately after placement is often associated with leaking due to lack of healing of the
tunnel and exit site. This can be prevented by waiting for the catheter to heal or using surgical glue
around the exit site. Delaying use of a PD catheter allows for better wound healing, but is not always
possible in acute situations. Thus, fill volumes of 10 mL/kg or less should initially be employed. Catheter
leaks can also occur if the fill volume is increased too rapidly.

The leakage may be dialysate or serosanguinous fluid from the subcutaneous tissue. If this is unclear,
check the glucose concentration of the leaking fluid. Dialysate will have an extremely high glucose
concentration. Management centers on decreasing exertional activity of the patient and decreasing the
dialysate volume (lower fill volumes). Leaks that do not respond to conservative management may
require minor surgical repair of the deep cuff or, rarely, catheter replacement.

Peritoneal fluid leakage predisposes to infection, particularly as the dialysate contains dextrose.
Therefore, one must monitor vigilantly for signs and symptoms of peritonitis.
Suspect poor ultrafiltration in a patient who remains fluid-overloaded, continues to gain weight or fails
to lose weight at the expected rate. The differential diagnosis for patients with signs of poor
ultrafiltration includes:

Dietary or intravenous fluid overload

Changes in cardiovascular or renal function

Peritoneal membrane transport properties

Inappropriate PD prescription

Assess all fluids being administered, and ensure that the patient is not retaining dialysate by checking
that drain volume is greater than fill volume. Remember that ultrafiltration is fluid removal only from
the vascular space. If the patient is edematous and has significant capillary leak/third spacing,
ultrafiltration may result in decreased effective circulating volume. In acutely ill patients, ensure serum
albumin is adequate to provide oncotic pressure to maintain intravascular volume.

Options to increase ultrafiltration are to use more frequent and/or more hypertonic exchanges by:

Increasing the dextrose concentration - this is preferred initially, especially in a patient with a new PD
catheter, where increasing the fill volume or cycle number too rapidly can lead to catheter leakage or
patient discomfort

Increasing the fill volume

Increasing the cycle number

Other: Consider diuretics in patients with some urine output (in this simulator, all patients are anuric
while receiving PD).

Remember that only one parameter should be adjusted at a time, with subsequent monitoring, although
here in the knowledge guide, we will expose you to multiple possible actions.
Possible causes for inflow or outflow failure are:

Inadequate fill bag height above the patient to promote flow of dialysate into the abdomen

Inadequate drain bag height below the patient to promote flow of dialysate out of the patient’s
abdomen

Constipation/obstipation

Catheter malposition

Intraluminal catheter occlusion (usually a thrombus or fibrin)

Extraluminal catheter occlusion (omentum/adhesions)

Catheter clamping/kinking/mechanical errors

Use a systematic approach to evaluate the patient:

Reposition the patient.

Evaluate catheter site and catheter for leakage or clamping.

Evaluate set-up, assess fill and drain bag heights.

Flush catheter, assess for blockage in inflow or outflow. Do not flush the catheter until after the other
maneuvers have been attempted. Flushing the catheter predisposes the patient to infection.

Consider a KUB to look for improper catheter position, if the cause is unclear.

Treat underlying constipation/obstipation.