Session: Use of Peritoneal Dialysis in Non-Renal Organ End Stage (May 9, 2019)

Speaker: Kunal Chaudhary, MD, and Joanne Bargman, MD

Approximately 4-6% of patients with end-stage renal disease (ESRD) have cirrhosis at the time of initiation of renal replacement therapy. Patients with co-existing liver disease and renal failure pose significant management challenges for nephrologists.

In particular, hemodialysis (HD) can be problematic for a number of reasons including:

• Coagulation and platelet disorders → risk of bleeding with cannulation of AV fistula or graft → high prevalence of dialysis catheters
• Thrombosis of AV access due to hypotension → high prevalence of dialysis catheters
• Intra-dialytic hypotension
• Risk of encephalopathy. Rapid electrolyte and osmolality shifts may result in cerebral edema and can precipitate encephalopathy.
• Over-estimation of dialysis adequacy. Ascites is a large extracellular reservoir and consequently immediate post dialysis urea level may be falsely low resulting in over-estimation of urea reduction ratio.

Meanwhile, peritoneal dialysis (PD) offers several potential advantages over HD in patients with cirrhosis:

• No risk of bleeding with dialysis (once PD catheter has been placed)
• Less intra-dialytic hypotension
• Regular drainage of ascitic fluid which removes the need for paracentesis
• Increases caloric intake with dextrose solutions

However, nephrologists may hesitate to use PD in patients with concomitant liver disease due to concerns such as protein losses with dialysate, increased risk of peritonitis (due to risk of spontaneous bacterial peritonitis), herniation and fluid leaks (due to higher intra-abdominal pressure), and impaired dexterity and frailty of this patient population. While the evidence with regard to modality choice in patients with cirrhosis consists of mostly single-center case control and retrospective studies, the available data provide useful insights.

Survival in Patients with Liver Disease Treated With Peritoneal Dialysis

Cirrhosis is a risk factor for all-cause mortality in patients with ESRD. However, when patients treated with PD with cirrhosis were matched with controls that do not have cirrhosis, similar patient and technique survival were observed.  Furthermore, in an article analyzing two datasets from China and Taiwan in which cirrhotic patients on PD were compared with propensity score matched patients on HD, those treated with PD had similar and perhaps even better survival than their HD counterparts:

Survival of cirrhotic patients on PD with propensity matched patients on HD

Complications While on Peritoneal Dialysis

Peritonitis: Patients with cirrhosis are at risk of spontaneous bacterial peritonitis with the majority of cases being due to a gram-negative organisms. Studies have consistently shown that patients with cirrhosis receiving PD have similar rates of peritonitis as those without cirrhosis. Interestingly, there is no evidence of an increased rate of gram-negative peritonitis suggesting that spontaneous bacterial peritonitis is not a significant issue in PD. There may be a variety of reasons for this somewhat unexpected finding, including use of antibiotic prophylaxis in patients with cirrhosis, close attention to bowel care, as well as altered peritoneal immune function in PD.

Causative organism of PD peritonitis in patients with cirrhosis and controls

Protein loss: Malnutrition is common in patients with cirrhosis. This is of particular concern in patients with cirrhosis managed with PD who have been described to have substantially greater peritoneal protein losses in the months following initiation of PD than those without cirrhosis. The protein loss does reduce over time to levels comparable to those without cirrhosis which may be explained by counterpressure exerted on the peritoneal membrane by the dialysate with reduced ascites formation.

Peritoneal protein loss in cirrhotic patients (▪) at different intervals compared with means ± SDs of controls (bold lines). Figure 3 from De Vecchi, AJKD, © National Kidney Foundation.

Hernias and Fluid Leaks: Studies have inconsistently reported on whether an increased rate of hernias occurs in patients with cirrhosis managed with PD. Fluid leak is a concern due to elevated intra-abdominal pressures at the time of PD initiation in this patient group but Dr Chaudhary reported good results were achieved at his center where the surgical team place a purse string suture in the posterior fascia/peritoneum to prevent leak.

Peritoneal dialysis in patients with a history of liver transplant

In the last presentation of the session, Dr Joanne Bargman gave specific advice on the management of patients with liver transplant who subsequently develop ESRD. In her published experience of patients who developed ESRD a mean of 9.7 years after liver transplant with the etiology due to calcineurin inhibitor toxicity in almost all cases, there appeared to be no specific concern related to patients with liver transplant undergoing PD. Peritonitis and mortality rates were no different from the general PD population and the liver graft was never threatened, even during peritonitis.

Take-home Points

• PD is well-tolerated in ESRD patients with cirrhosis and ascites
• Patients with cirrhosis on PD have similar or perhaps better survival than their HD counterparts (no RCTs exist, and further studies are needed)
• The risk of bacterial peritonitis does not appear to be increased in patients with cirrhosis managed with PD
• There may be a higher risk of hernias and leaks
• Patients with a history of liver transplant at that subsequently develop ESRD should not be denied the option of PD

– Post prepared by Adrian Whelan, AJKD Editorial Intern.

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The NKF Spring Clinical Meeting abstracts are available in the May 2019 issue of AJKD. Check out more AJKDBlog coverage of #NKFClinicals!