NephMadness Choosing Wisely Campaign (#NCWC) – PD region (#PDRegion)



The PD region is an interesting one. As a commonly used dialysis modality worldwide it has historically remained under utilised in the US. However its popularity has increased over the last 2 years.

This region pits 2 common PD issues – ‘Volume Issues’ and ‘Solute Issues’ against each other and 2 less common, but important, issues ‘Culture Negative Peritonitis’ and ‘Catheter Dysfunction’ against each other.

An excellent summary of both of these topics is in the scouting report by Amit Langote (@LangoteAmit)

The battle between Volume Issues and Solute Issues

Volume issues come up daily, or multiple time a day in all PD units. The patient’s’ volume status, often expressed in relation to their target weight, is usually recorded daily. This then decides what PD bags they’ll use that day and can influence their symptoms, the amount of input they need from PD nurses and Nephrologists, how often they need to come to the PD unit as well as the frequency of hospitalisations

Although some tools exist to help guide fluid balance such as bioimpedance and lung US the mainstay of volume assessment is daily weights, measurement of drain out volumes, and longitudinal follow up with clinical fluid assessment

In contrast to the low-tech volume issue, solute issues are higher tech and understanding the ins and outs of the three-pore model, PET testing and the ideal peritoneal dialysis prescription for high, average, and low transporters takes a bit more time and reading. Understanding the patients transport status does allow us to ensure the patient is on an appropriate type of PD(i.e. short exchanges usually using overnight APD ±

Daytime exchanges or longer exchanges most suited to CAPD)  for them which ultimately allows the patient to get the most of PD and stay in euvolemic with no uremic.

For true PD bliss it is imperative to get both of these issues right.

However, I would argue that in terms of patients’ symptoms, hospitalisations and day to day management volume issues are much more important than solute issues. But what will the Blue Ribbon Panel think?

The showdown between team Catheter Dysfunction and team Culture Negative Peritonitis

These are less frequent problems than teams Volume V Solute but can cause a lot of trouble when they occur. Culture Negative Peritonitis is often a regular peritonitis (e.g. staph epi) that won’t grow in culture because of prior antibiotic use or incorrect sampling. However sometimes it can be from a non-infectious source e.g. ‘collection from a dry abdomen’ or from an organism that’s hard to grow. TB peritonitis can be a difficult to find and difficult to treat etiology of infectious peritonitis.

Catheter Dysfunction is frequently encountered with different degrees of severity. Fortunately, the most common cause of catheter dysfunction is constipation. This is often dealt with expertly by the PD nurse and may not even find its way to the nephrologist. However, some causes of catheter dysfunction are harder to deal with. For example, the PD catheter can change position in the abdomen or can be wrapped in the omental. This can be addressed by Interventional Radiology or occasionally repeat surgery warranted. Unfortunately this could mean the end for that particular catheter.

I would argue that catheter dysfunction has a bigger impact on patients and on technique survival than culture negative peritonitis

What I think doesn’t matter so can we gain any clues on what the Blue Ribbon Panel may think? All of the panel members have kept quiet on social media about their possible preferences forcing some further digging to try find out their thoughts or biases to further inform your #NephMadness choices. This is what has come up from PubMed searching and a quick view of their social media postings.

Michael Choi @Mike_J_Choi has published a case report on a pleural effusion in a PD patient. Will this swing his vote to Volume issues in PD?

Melanie Hoenig @melhoenig has also written about volume in CKD. Does her interest in volume extend to PD?

Roger Rodby (@NephRodby) has tweeted a few times about PD

Rodby has mentioned encapsulating peritoneal sclerosis (EPS) which could cause volume issues, solute issues, catheter dysfunction, and culture negative peritonitis. He has also tweeted about PD Peritonitis secondary to baby poo. I imagine that isn’t culture negative… Its a coin toss for Rodby

Fiona Loud(@FionaCLoud) is an enthusiastic advocate for Home Therapies, meaning the PD region is right up her street. She has also tweeted about the difficulties of maintaining a strict fluid balance on dialysis. Maybe relevant… Volumes Issues??

Mark Reid (@medicalaxioms) has also tweeted about PD. He has commented on the PD survival advantage

He has also tweeted this…

So there you have it. Although the blue ribbon panel are keeping their choices close to their chest as to their preferences within the PD region, its clear PD is an important issue to many of them. The PD region is likely to go far!

In the absence of any failsafe Blue Ribbon predictions i’ll give you mine:

The battle between Volume Issues and Solute Issues:

Volume issues

The showdown between team Catheter Dysfunction and team Culture Negative Peritonitis:

Catheter issues

Overall winner:

Volume issues

Follow #NCWC for daily region updates.

Read the full AJKD blog (and check out the full scouting report for the #PDRegion Region here).

Submit your NephMadness brackets here.

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