Peritoneal Dialysis in Liver Disorders

Abstract

The purpose of this paper is to review the specific role of peritoneal dialysis (PD) in patients with liver disorders. We will pay attention to the confluence of liver diseases and situations for which chronic dialysis treatment is required. Hemodialysis (HD) and peritoneal membranes are safe barriers against the passage of the hepatitis C virus; consequently, while peritoneal effluent or HD ultrafiltrate drained from hepatitis S patients/carriers is infective, that from hepatitis C patients does not appear to present this risk. An important issue is horizontal transmission, which appears to occur with both viruses in HD units, and which is absent in peritoneal dialysis units. The incidence of hepatitis C among continuous ambulatory peritoneal dialysis (CAPD) patients is quite low, while it may reach almost 50% -60% of HD patients in some units. While hepatitis C transmission mechanisms are not completely understood and a vaccine is not available, PD provides some degree of protection when compared with HD, for end-stage renal disease patients. In summary, our experience and that of others, with a total of 19 PD-treated chronic liver disease patients, supports CAPD as the treatment of choice for cirrhotic patients with ascites who require chronic dialysis. Data on peritoneal diffusion of low molecular weight substances revealed a marked increase in most patients. The ultrafiltration capacity was clearly augmented with respect to noncirrhotic patients, making the use of hypertonic bags unnecessary. Hemodynamic tolerance was excellent. Complications and death were mainly related to liver disease complications. Spontaneous bacterial peritonitis (SSP), caused by gram-negative germs, is the most important complication directly related to ascites and may have some points in common with PD-related peritonitis. However, and in contrast to most PD peritonitis, two pathogenetic mechanisms have been suggested for SSP: (1) translocation of bacteria from the gut to the mesenteric lymph nodes, and (2) bacteremia in these patients is secondary to the general abnormal host defense mechanisms. Local factors such as intrahepatic shunting and the impairment of bactericidal activity in ascitic fluid favor the bacteria ascites. The hypothesis of a direct transmural contamination from bowel to ascitic fluid has been relegated to secondary bacterial peritonitis. Would cirrhotic patients with temporal or permanent renal function compromise benefit from peritoneal catheter placement and other PD practices to perform repetitive small ascitic drainages at home? Perhaps the time has arrived when hepatologists and PD nephrologists begin to work shoulder to shoulder in this particular field, as we have a common problem, the peritoneal cavity filled with fluid.

Peritoneal Dialysis is Associated With A Better Survival in Cirrhotic Patients With Chronic Kidney Disease

“…The treatment for cirrhotic patients with chronic kidney disease stage 5 who required dialysis (CKD 5D) is complicated by the decreased effective intravascular volume and the subsequential hemodynamic instability. 1 , 2 Hemodialysis (HD) associated hypotension is a common complication 3 and is associated with higher mortality in patients with CKD 5 who require dialysis. 4 Multiple techniques are currently available to prevent hypotension during HD including thermal balance, 5 biofeedback systems, 6 and midodrine.…”

Circulating Bacterial-Derived DNA Fragment Level Is a Strong Predictor of Cardiovascular Disease in Peritoneal Dialysis Patients

“…The intestinal mucosa barrier is impaired and bacterial translocation occurs in experimental uremia [ 15 ]. Translocation of bowel flora is a cause of gram negative peritonitis in peritoneal dialysis (PD) patients [ 16 ]. A number of previous studies showed that LPS is detectable in the serum of many dialysis patients, and serum LPS level correlates with the severity of systemic inflammation and features of atherosclerosis [ 17 – 19 ].…”

A Case Report of a Diabetic Nephropathy Patient With Cirrhotic Ascites Treated by Peritoneal Dialysis

“…Hemodialysis in patients with chronic liver disease and ascites, who require dialysis for chronic renal failure, might be further complicated by intradialytic hypotension. In particular, in patients with diabetic neuropathy such as ours, limiting the amount of ultrafiltration results in residual (10). CAPD could be the treatment of choice for cirrhotic patients, particularly in cases caused by hepatitis C virus infection, with ascetic patients who require chronic dialysis (10).…”