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.

Key words

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.

Introduction


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.

Methods


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.

Results


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 82.4 ± 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.

Discussion


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.

References


  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.