COMMENTARY

Peritoneal Dialysis Offers Flexibility in Emergent and Austere Environments

Tejas P. Desai, MD

Disclosures

October 26, 2018

Peritoneal dialysis (PD) continues its slow march toward equal popularity within the nephrology community. In most areas of the United States, it is still the minority to the behemoth that is in-center hemodialysis. In many parts of the developed world, peritoneal dialysis is often not the first modality utilized by patients or offered by clinicians.

The relative unpopularity of PD is surprising given the amount of flexibility it offers both patients and providers. Some of the more commonly stated reasons for the lower popularity of PD include poor reimbursement (although that is changing) and/or limited familiarity with the procedure.

The Advantages of PD

PD offers a number of options that make it a more flexible therapy to administer and/or experience. Such flexibility may not be required in the developed world where resources are abundant. Perhaps the flexibility of PD is better appreciated in austere environments in which resources are chronically or temporarily limited because of economic distress or natural calamities. The authors of a review published in the Western Journal of Emergency Medicine, nicely summarize the flexibility of PD as it has been used in conflict zones and areas afflicted by disasters.

The immediate characteristic of PD that makes it suitable in austere environments is its independence from an electrical power source. With the help of atmospheric pressure and gravity, the peritoneal cavity, PD catheter, and exterior world act in a manner similar to a siphon. An electrical pump is not required to infuse or remove dialysate from the patient, which is critical because most austere environments have significant disruptions to the local electrical grid. This electrical independence, however, isn't the only aspect of PD that makes it suitable in difficult environments.

The PD catheter itself offers a number of advantages that are useful in such environments. Any rigid or pliable tube can be inserted on-site with expediency, no general anesthesia, and limited blood loss. Once inserted, the tube can be used nearly immediately for the dialysis procedure. Pliable tubes don't have to be strictly designated for PD; nasogastric tubes, central venous catheters, and even urologic catheters can all be used to perform emergent PD.

Dialysate is often at a premium or completely nonexistent in austere environments. More likely, resuscitative fluids will be available in greater quantities, and can serve as peritoneal dialysate. Two main fluids, normal saline and Ringer's lactate, can serve as dialysate with zero or normal potassium levels, respectively. The osmotic gradient can be established by infusing ampules of D50 (50 mL of 50% dextrose) in which a 1% increase in dialysate dextrose concentration is achieved by infusing 20 mL of D50.

A final unique characteristic of PD is the prescription itself. Various quantities of dialysate can be infused based on resource availability. Dwell times and number of daily exchanges can be modified based on patient feasibility. Prescriptions can be modified quickly, as ground conditions in austere environments usually change hourly or daily.

Final Thoughts

This review article is a welcome addition to the body of knowledge that currently exists for PD. It highlights a number of unique aspects of PD that make it attractive in difficult situations. While austere environments are commonly associated with tragedy, they are also incubators for medical creativity and ingenuity, as is highlighted in this review.

As always, tell us what you think in the comments below and be sure to check out the accompanying infographic for this review.

Follow Tejas P. Desai, MD, on Twitter: @nephondemand

Follow Medscape Nephrology on Twitter for more nephrology news: @MedscapeKidney

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