Tidal Peritoneal Dialysis to Achieve Comfort in Chronic Peritoneal Dialysis Patients
Peter H. Juergensen,1,2,3 A. Lola Murphy,1,2 Kathy A. Pherson,1,2 Wendy S. Chorney,1,2 Alan S. Kliger,1,2,3 Fredric O. Finkelstein1,2,3
Patients with end-stage renal disease on
chronic peritoneal dialysis (CPD) can usually
tolerate continuous ambulatory peritoneal dialysis
(CAPD) or continuous cycling peritoneal dialysis
(CCPD) without abdominal discomfort or pain. In
some patients, pain or discomfort occurs with
complete drain of the peritoneal dialysis solution or
upon initiation of dialysis filling when the peritoneal
cavity is empty.
We report on the use of tidal peritoneal
dialysis (TPD) as a modality to alleviate this pain. Of
136 patients in our CPD unit, 18 (13%) were
complaining of pain with complete drain or upon instillation
of PD fluid. All were placed on TPD after other
causes for abdominal pain were excluded. Six patients
were placed on 25% TPD, and 12 patients on 50%
TPD. The mean Kt/V of the patients on TPD was
2.46 ± 0.68.
With TPD, all patients had complete relief
of abdominal discomfort. Patients who develop abdominal pain with complete drain or fill when
the abdominal cavity is empty would benefit from
TPD and be able to continue with CPD.
Tidal modality, pain, discomfort, Kt/V, creatinine clearance
From:New Haven CPD,1 Renal Research
Institute,2 Yale University School of
Medicine,3 New Haven, Connecticut 06511 U.S.A.
Patient dropout from chronic peritoneal
dialysis (CPD) has numerous etiologies, including
peritonitis, technique failure, and loss of ultrafiltration
(1). Another, less common, cause for a patient's
wishing to discontinue CPD is the presence of pain
during drainage or during instillation of peritoneal
dialysis solution. We have noted that patients who develop
such pain with dialysis exchanges obtain relief of
their pain with tidal peritoneal dialysis (TPD). We
report our findings in regard to CPD patients at the
New Haven CPD unit that were placed on TPD for
relief of pain.
A retrospective review was done of all patients
who were started on TPD for pain with complete drain
of peritoneal fluid or with instillation of fluid into
an empty peritoneal cavity. Other causes for
abdominal pain or discomfort, including peritonitis, hernia,
or other obvious peritoneal pathology, were excluded.
Tidal PD was performed using the Home
Choice cycler (Baxter Healthcare Corporation,
Deerfield, Illinois, U.S.A.) programmed to deliver the
prescribed volume overnight, usually over 8 - 9 hours.
Fill volumes of 25 - 30 mL/kg were calculated using
an adjustment in body weight as previously
described (2). The tidal volume was either 25% or 50% of
the fill volume and was infused at equally spaced intervals over the 8 - 9 hour period.
Adequacy of dialysis was also monitored
while on TPD by obtaining Kt/V urea and creatinine clearance (CC) values. Basic demographic data
was obtained, including age, sex, and race. Total
Kt/V, peritoneal Kt/V (Kpt/V), total CC and peritoneal
CC (CCp) were calculated using the PD Adequest
system (Baxter Healthcare Corporation) (3).
Mean ± standard deviation (SD) was
calculated for age, time on CPD prior to start of TPD,
weight, total peritoneal dialysis volume used in 24
hours while on TPD, Ktp/V, total Kt/V,
CCp, and total CC.
Of 136 patients in the New Haven CPD unit, 18
(13%) complained of pain with infusion of
peritoneal dialysis solution into an empty peritoneal cavity
or with total drain of peritoneal fluid.
Of the patients with pain, 11 were female, 8
were African-American, 8 were Caucasian, and 2 were
Hispanic. The mean age was 48.7 ± 8.7 years.
The patients were maintained on CPD (prior to the
start of TPD) for between 1 and 39 months (mean:
12.2 ± 8.7 months).
Twelve patients were placed on 50% TPD, and
6 patients were started on 25% TPD.
Table I shows time on CPD, weight, total
peritoneal dialysis volume used per 24 hours,
Kpt/V, total Kt/V, CCp, and total CC. As noted in Table I, the
mean total Kt/V and total CC were 2.46 ± 0.68 and
33.8 L/week/1.73 m2 respectively.
All patients had complete relief of abdominal
pain while on TPD. The only time that patients had discomfort while on TPD was during the
last exchange when the abdomen is completely
drained. Pain was also present in some patients at the onset
of TPD when the abdomen is empty and then filled again. All patients were willing to accept these
two periods of abdominal discomfort and chose to continue TPD.
The mean total Kt/V and the total CC
were maintained above the recommended Dialysis Outcomes Quality Initiative (DOQI) guidelines
(4) while the patients were on TPD.
Abdominal pain or discomfort during complete
drain of dialysis solution or during instillation of
peritoneal dialysis solution into an empty peritoneal cavity
is an infrequent finding in CPD patients. Usually
the pain is noted during the drain phase, near the end
of drain. The pain is described as "pulling, tugging,
or cramping", usually in the pelvic or lower
abdominal area. Our group had previously noted in a preliminary
study that TPD was helpful in improving pain
or discomfort in selected CPD patients (5). We retrospectively reviewed the records of all
patients in the New Haven CPD unit who complained of
pain and were placed on TPD to alleviate the pain.
We noted that 13% of our patients developed
pain with complete drain of the peritoneal cavity or
with fill into an empty peritoneal cavity. All of the
patients improved and were able to continue with CPD
once they started TPD. The mean Kt/V and
creatinine clearances were kept above DOQI guidelines
while the patients were on TPD.
The etiology of the pain or discomfort is not
clear, but it is relieved by maintaining a reservoir of
solution in the peritoneal cavity. It would seem prudent
to initiate TPD in this group of patients, to
minimize their periods of discomfort, to improve their
quality of life, and to permit continuation of CPD.
- Finkelstein FO, Nolph KD, Sorkin F, Crampton C. Initiatives in peritoneal dialysis: Where do we go from here? Perit Dial Int 1991; 11:274-8.
- Norwood K, Collins-Thayer P, Stover J. Nutrition assessment in chronic renal failure. In: Stover J, ed. Nutrition care in end-stage renal disease. Chicago: The American Dietetic Association, 1994:5-7.
- Keshaviah PR, Nolph KD, Prowant B, et al. Defining adequacy of CAPD with urea kinetics. In: Khanna R, Nolph KD, Prowant BF, Twardowski ZJ, Oreopoulos DG, eds. Advances in peritoneal dialysis. Toronto: Peritoneal Dialysis Bulletin, 1990; 6:173-7.
- Golper TA, and the National Kidney Foundation Dialysis Outcomes Quality Initiative Peritoneal Adequacy Work Group. Adequate dose of peritoneal dialysis. Am J Kidney Dis 1997; 30(Suppl 2): S86-92.
- Juergensen PH, Murphy AL, Allen JR, Kliger AS, Finkelstein FO. Tidal peritoneal dialysis (TPD): Our experience in 16 CPD patients [Abstract]. Perit Dial Int 1998; 18(Suppl 1):S5.
Corresponding author:Peter H. Juergensen, pa, New Haven CPD, 136
Sherman Avenue, New Haven, Connecticut 06511 U.S.A.