In Practice Review

Peritoneal Dialysis Use in Patients With

Ascites: A Review
Nilum Rajora, Lucia De Gregorio, and Ramesh Saxena

The past few decades have seen steady increase in the prevalence of kidney failure needing kidney Complete author and article
replacement therapy. Concomitantly, there has been progressive growth of heart failure and chronic information appears before
references.
liver disease, and many such patients develop ascites. Therefore, it is not uncommon to encounter
patients with kidney failure who concurrently have ascites. The presence of ascites adds many chal- Am J Kidney Dis.
lenges in the management of kidney failure. Poor hemodynamics make volume management difficult. 78(5):728-735. Published
online June 16, 2021.
The presence of coagulopathy, malnutrition, and encephalopathy compounds the complexity of the
management. Such patients do not tolerate hemodialysis well. However, several concerns have limited doi: 10.1053/
the use of peritoneal dialysis (PD), so hemodialysis remains the predominant dialysis modality in these j.ajkd.2021.04.010
patients. However, observational studies have illustrated that PD provides hemodynamic stability and © 2021 by the National
facilitates better volume management compared with hemodialysis. Moreover, PD obviates the need Kidney Foundation, Inc.
for therapeutic paracentesis by facilitating continuous drainage of ascites. PD potentially reduces
hemorrhagic complications by avoiding routine anticoagulation use. Moreover, small studies have
suggested that outcomes such as peritonitis and mechanical complications are comparable to those in
PD patients without ascites. PD does not affect transplant candidacy, and these patients can suc-
cessfully receive combined liver and kidney transplants. Hence, PD should be considered a viable
dialysis option in kidney failure patients with ascites.

Clinical Vignette
A 65-year-old man has history of hyperten-
sion, type 2 diabetes mellitus, hepatitis
C–related cirrhosis with ascites, and progres-
sive chronic kidney disease (CKD) due dia-
betic nephropathy. In the past 3 months, he
was hospitalized twice with episodes of
spontaneous bacterial peritonitis and hepatic
encephalopathy. Lately he had required
frequent large volume paracentesis (LVP). His
MELD (Model for End-stage Liver Disease)
score was 21. His CKD had progressed to stage
5, and he had been educated about kidney
replacement therapy options. He expressed a
preference for peritoneal dialysis (PD), and
voiced interest in kidney-liver transplant. He
was referred to surgery for placement of a PD
catheter, but was informed that patients with
ascites should not get a PD catheter placed.
Consequently, he was initiated on in-center
hemodialysis (HD). He did not tolerate ultra-
filtration due to persistent hypotension and
remained volume overloaded. He still needed
frequent LVP to manage his ascites. Should this
patient be reconsidered for PD?
Introduction
Poor lifestyle behaviors such as smoking,
unhealthy diet, inadequate physical activity,
and excessive alcohol use have led to an
upsurge in chronic diseases like diabetes,
hypertension, metabolic syndrome, and
obesity in the past few decades.1-4 Conse- FEATURE EDITOR
quently, there has been a steady increase in Linda Fried
the prevalence of kidney failure (KF).5 In
parallel, there has been persistent growth of ADVISORY BOARD
heart failure and chronic liver disease (CLD), Ana Ricardo
Roger Rodby
particularly nonalcoholic fatty liver disease, as
Robert Toto
they share the aforesaid risk factors.6-8 Many
patients with CLD and advanced heart failure In Practice Reviews
develop ascites during the course of their provide in-depth
disease.9-12 Therefore, it is not surprising to guidance on clinical
encounter patients with KF who concurrently topics that nephrolo-
gists commonly
have ascites.
encounter. Using
The presence of ascites presents numerous clinical vignettes,
challenges in the overall management of KF. these articles illus-
These patients usually have poor hemody- trate a complex prob-
namics, which makes volume management lem for which optimal
diagnostic and/or
very difficult.13-15 Furthermore, the presence
therapeutic ap-
of coagulopathy, malnutrition, and encepha- proaches are
lopathy compounds the management uncertain.
complexity. Such patients do not tolerate HD
well.16,17 PD, by offering steady-state treat-
ment, may provide hemodynamic stability
and better volume management. Furthermore,
PD eliminates the need for LVP due to regular
drainage of ascites fluid.18-22 However, there
is a perception that use of PD is associated
with higher risk of infections, excessive al-
bumin loss, and overall poor outcomes, and
therefore should not be offered in patients
with KF and ascites.18,19,23 In this review, we
will discuss the challenges, outcomes, and
technical aspects of performing PD in patients
with KF and ascites.

728 AJKD Vol 78 | Iss 5 | November 2021

Rajora et al
Kidney Failure and Ascites
Epidemiology and Outcomes
Most early reports of ascites in KF patients described
nephrogenic ascites in HD patients, with variable incidence
rates (0.7%-20%) and poor survival (7.0-10.7
months).24,25 In contemporary times, nephrogenic ascites
in KF patients is mainly observed in severely underdialyzed
or malnourished HD patients,25-27 and will not be dis-
cussed in this review. The prevalence of ascites in KF due
to cirrhosis and other causes remains uncertain. Small
studies from Asia have observed a 4% to 6% incidence of
cirrhosis in KF, but the incidence of ascites has not been
reported in all studies.28-31 In one study of 1,069 adult KF
patients from South Korea, 4.1% had cirrhosis, and 1.1%
had ascites.28 The presence of cirrhosis increases the
overall mortality risk in KF patients. In a Taiwanese na-
tional cohort, cirrhosis was found to be an independent
predictor of mortality in dialysis patients.29 Likewise, in
the Korean study, the cirrhotic patients had a significantly
lower 1-, 3-, and 5-year survival compared with non-
cirrhotic KF patients.28
Kidney Replacement Therapy in Patients With KF
and Ascites
The presence of ascites in KF patients poses many
challenges that make dialysis treatment arduous. Patients
with ascites are overall hypervolemic, but they have low
effective arterial blood volume. Rapid removal of fluid
from the intravascular compartment during HD may
thus produce severe hypovolemia and hypotension.13-15
This may preclude adequate ultrafiltration and result in
insufficient fluid removal, progressive volume overload,
and worsening ascites. Furthermore, hemodynamic
instability may necessitate early termination of HD,
thereby compromising adequate solute clearance and
predisposing uremic state. Such a uremic state along
with rapid osmotic shifts during HD treatment can alter
cerebral water content and predispose patients to
encephalopathy.16,17
Moreover, patients with cirrhosis frequently have
multiple abnormalities of hemostatic function that may
increase the risk of bleeding as well as thrombosis.32-34
Coexisting uremia may further exacerbate platelet
dysfunction and increase the risk of bleeding complica-
tions. Use of anticoagulation in HD can aggravate the risks
of gastrointestinal hemorrhage and excessive bleeding at
the cannulation site.
Despite these challenges, HD remains the predominant
dialysis modality among KF patients with ascites and the
use of PD remains negligible. In a study using a nationwide
inpatient sample, less than 1% of KF patients with cirrhosis
and ascites were initiated on PD.35 There are several con-
cerns—namely, higher risks of infections or technique
failure, excessive albumin loss, poor candidacy for com-
bined kidney-liver transplant, and overall poor
AJKD Vol 78 | Iss 5 | November 2021
outcomes—that raise doubts over the viability of PD in KF
patients with ascites (Box 1).18,19,21,23
While there may be potential drawbacks to PD such as
albumin loss, inherent risk of peritonitis, and the need for
a stable home and psychosocial situation, there are many
potential benefits that may outweigh the risks. PD provides
slow and steady-state treatment that maintains hemody-
namic stability and provides continuous drainage of ascites
with daily exchanges. Because PD does not require anti-
coagulation, it can potentially reduce the risk of hemor-
rhage. Additionally, PD may serve as a much needed
source of calories in malnourished KF patients with ascites
(Box 1).36 Therefore, PD should be considered a viable and
perhaps the preferred dialysis option in KF patients with
ascites.
Outcomes of PD in Patients With KF and Ascites
Impact of Nutritional Status
Patients with advanced cirrhosis and ascites are consider-
ably malnourished due to inadequate dietary intake,
impaired digestion and absorption, and altered metabolism
of nutrients.37 In addition, cirrhosis is associated with
reduced synthesis of creatine, the precursor of creatinine.
This may lead to lower serum creatinine levels in patients
with cirrhosis, resulting in overestimation of the glomer-
ular filtration rate. Thus, the diagnosis of KF and initiation
of dialysis can be delayed, which may result in a persistent
uremic state and further worsening of the patient’s nutri-
tional status.38,39
Hypoalbuminemia is a predictor of mortality in KF
patients and an independent risk factor for peritonitis in
PD.40-42 Hence, given low baseline serum albumin levels
in patients with KF and ascites, concerns have been raised
that excessive loss of proteins in PD effluent may exacer-
bate hypoalbuminemia and result in poor clinical out-
comes. However, most of the available data do not support
Box 1. Potential Advantages and Disadvantages of Peritoneal
Dialysis in Patients With Kidney Failure and Ascites
Advantages
• Better hemodynamic stability
• No need for anticoagulation
• Lower risk of hepatitis B and C virus transmission
• Continuous drainage of ascites—no need for serial therapeutic
paracentesis
• Provision of caloric load
Disadvantages
• Protein loss in dialysate effluent
• Risk of peritonitis
• Potential risks of pericatheter leaks, hernia, and other
mechanical complications
• Need for stable home situation
• Inability to perform peritoneal dialysis in the setting of physical
or mental incapacity in the absence of assistance
729
 Rajora et al

this notion. One study comprising 11 KF patients with
cirrhosis observed no change in serum albumin at 6 and
12 months after PD initiation.19 In contrast, a small but
nonsignificant reduction in serum albumin from baseline
was seen in 2 observational studies in patients with KF,
cirrhosis, and ascites, with mean follow-up times of 4.5
and more than 6 years, respectively.21,43 Interestingly,
Selgas et al18 reported excessive protein losses (more than
30 g/d) in the PD effluents initially, but these significantly
decreased subsequently to 7-15 g/d among 8 KF patients
with ascites. In parallel, the serum albumin level increased
after an initial drop in an inverse relation to the peritoneal
protein loss.18 Conceivably, an increase in intra-abdominal
pressure generated by PD fluid may counter portal pressure
and thereby reduce the formation of ascites and ensuing
protein losses.44
In summary, a majority of patients tolerate PD well,
with minimal change in serum albumin.19,21,43 Protein
losses are initially high but reduce with time.18 Even with
the daily loss of protein in peritoneal fluid, a significant
change in serum albumin from the baseline value is not
observed.18,19,21
Infections and Peritonitis
Cirrhosis facilitates translocation of gut microorganisms,
particularly Escherichia coli and other Gram-negative bacteria,
into the peritoneum, which in concurrence with reduced
function of peritoneal phagocytes and complement defi-
ciency causes spontaneous bacterial peritonitis.45-48 There
are concerns that PD may compound the risk of peritonitis
by adding PD catheter–related peritonitis risks to the
inherent risk of spontaneous bacterial peritonitis in these
patients. However, most of the recent data suggest that this
may not be the case (Table 1).
Although 1 small observational study of 11 patients did
report 2.5-fold higher peritonitis rates in KF patients with
cirrhosis and ascites as compared with noncirrhotic PD
patients,18 several other studies have reported similar rates
of peritonitis in cirrhotic and noncirrhotic PD patients with
ascites.19,21,31,44,49 Jones et al21 reported a peritonitis rate

Table-1. Experience and Outcomes of PD in Patients With Kidney Failure and Ascites
Peritonitis Mechanical PD Technique
Study Patients Follow-up Period Rate Complications Failure
Marcus et al49 9 with CLD and ascites 3 mo to 8 y 1 episode/1.2 1 pericatheter leak 2
patient-years (resolved by
holding PD)
Chow et al44 25 with hepatitis B Mean FU: 52 mo 1 episode/19.2 NA NA
cirrhosis; 36 with patient-months
hepatitis B and no (cirrhotic) vs 1
cirrhosis episode/20.5
patient-months
(noncirrhotic)
Bajo et al23 5 with cirrhosis with 8-66.5 mo 1 episode/24 4 abdominal 1
ascites patient-months hernias (surgically
corrected)
Huang et al31 30 with cirrhosis (16 with 24-y experience 0.56 episode/ Higher incidence
ascites); 60 noncirrhotic year (cirrhotic) of umbilical hernia
vs 0.39 in cirrhotic vs
episode/year noncirrhotic group
(noncirrhotic) (5 vs 1)
De Vecchi et al19 21 with cirrhosis; 41 Jan 1985-Dec 1999 Overall rate: None No difference
noncirrhotic 0.31 episode/ between
year (no groups (6
difference cirrhotic, 12
between noncirrhotic)
groups)
Lee et al54 33 with cirrhosis (13 with Mean duration: 46.1 mo 1 episode/87.1 No difference No difference
ascites); 33 propensity- patient-months between groups (6 between
matched controls (cirrhotic) vs 1 cirrhotic, 5 control) groups (9
episode/149 cirrhotic, 5
patient-months control)
(control): NS
difference
Selgas et al18 8 with cirrhosis with NA 1 episode/9 4 abdominal NA
ascites patient-months hernias (corrected
(2.5× higher surgically)
than average
incidence)
Jones et al21 12 with liver cirrhosis (7 Mean FU: 54 mo 0.2 episode/ NA None
with ascites) year
Abbreviations: CLD, chronic liver disease; FU, follow-up; NA, not available; NS, not statistically significant; PD, peritoneal dialysis.

730 AJKD Vol 78 | Iss 5 | November 2021

Rajora et al
Table 2. Comparison of Outcomes Between HD and PD in Patients with Kidney Failure and Liver Cirrhosis and Ascites
Study Patients
Nader et al35 26,135 cirrhotic patients with incident KF
(25,686 HD; 449 [1.7%] PD; 1,878 with
ascites, of which 18 [0.96%] on PD)
Chou et al43 Cohort 1: 85 PD and 340 HD patients with KF
and cirrhosis; cohort 2: 279 PD and 1,116 HD
patients with cirrhosis and KF; prevalence of
ascites not available
Kim et al28 44 KF patients with cirrhosis (33 on HD [11
with ascites], 11 on PD [1 with ascites])
Chien et al30 40 PD and 703 HD patients with KF and
cirrhosis (prevalence of ascites not given)
Abbreviations: FU, follow-up; HD, hemodialysis; HR, hazard ratio; KF, kidney failure; LOS, length of stay; NA, not available; PD, peritoneal dialysis.
of 0.2 episodes per patient per year in 12 cirrhotic PD
patients (58% with ascites), which was not different from
that in noncirrhotic PD patients. In a larger report, no
significant difference in peritonitis rate was observed be-
tween 25 patients with hepatitis B cirrhosis and 36 hepa-
titis B patients without cirrhosis.22 Likewise, no difference
in peritonitis-free survival was observed between 30
cirrhotic and 60 noncirrhotic PD patients with 24 years of
follow-up.31
Although the rates of peritonitis may be similar be-
tween cirrhotic and noncirrhotic PD patients, the causative
organisms may differ. One study reported gut-dwelling
Streptococcus, E coli, and other Gram-negative bacteria
caused 43% of the peritonitis cases in cirrhotic PD patients,
compared with only 20% in noncirrhotic patients.18 By
contrast, another study reported that more than 50% of
peritonitis cases in cirrhotic patients resulted from Gram-
positive bacteria, suggesting a breach of sterile tech-
nique.21 Notwithstanding the cause of peritonitis, the
majority of cases were successfully treated with intraperi-
toneal antibiotics without causing technique failure.18,21,49
Patient Survival and Hemodynamic Stability
There has been a general bias against using PD in patients
with KF and ascites, but several observational studies have
reported the successful use of PD in this population
(Table 1). In a series of 9 KF patients with cirrhosis and
ascites, survival up to 8 years was observed, with 6 of the 9
patients surviving more than 18 months with good control
of uremic symptoms and volume status.49 Similar obser-
vations were made in 2 series of 5 and 8 KF patients with
cirrhosis, who demonstrated good hemodynamic tolerance
with PD.18,23 In fact, 3 of these patients were transferred
from HD due to persistent hemodynamic instability.18,23
In all studies, mortality was related to complications of
cirrhosis and not from PD-associated issues. In a more
AJKD Vol 78 | Iss 5 | November 2021
Outcomes
In-hospital mortality: no significant difference
between PD and HD; among subgroup with
ascites, significantly lower with PD vs HD (0 vs
26.67; P = 0.03)
Hospital LOS: longer in HD vs PD (8.34 vs 7.06
d; P < 0.001)
In-hospital charges: higher with HD vs PD
($74,501 vs $57,460; P < 0.001)
Lower mortality among PD vs HD patients in
cohort 1 (HR, 0.48 [95% CI, 0.31-0.74];
P < 0.01; average FU of 6 y) and cohort 2 (HR,
0.61 [95% CI, 0.47-0.79]; P < 0.01; FU
duration NA)
No difference in mortality between HD and PD
patients (P = 0.562)
Liver cirrhosis is an important predictor of
mortality in KF, but the effect on mortality was
not different between HD and PD patients
recent single-center observational study of 12 patients with
KF and cirrhosis (58% with ascites), no deaths or PD
technique failure were observed over a mean follow-up of
4.5 years.21
Not many studies have compared mortality between HD
and PD among KF patients with ascites (Table 2). A study
from South Korea reported similar mortality between the 2
dialysis modalities over 38 months’ follow-up in cirrhosis
patients,28 and another observational study from the Peo-
ple’s Republic of China reported significantly lower
all-cause mortality with PD as compared with HD in KF
patients with cirrhosis with an average follow-up period of
6 years.43 Likewise, among hospitalized individuals, there
was a nonsignificant mortality difference between the KF
patients with cirrhosis who were treated with PD versus
HD.35 However, among the subgroup of KF patients with
ascites, PD had a significantly lower in-hospital mortality
compared with HD.35
Taken together, the available evidence, though based on
small case series, indicates that PD is a viable option among
patients with KF and cirrhosis with ascites, and has similar
outcomes compared with cirrhotic KF patients with ascites
undergoing HD.
Logistics of Peritoneal Dialysis Initiation in KF
Patients With Ascites
Patient Selection
PD should be considered in KF patients with ascites.
Importantly, dialysis modality education should be pro-
vided to patients and family members, expeditiously if
urgent-start dialysis is expected.50 Home evaluations
should be conducted to determine if the conditions are safe
and supportive of PD. In addition, these patients should be
evaluated by a multidisciplinary team including nephrol-
ogists, surgeons, hepatologists, and other co-managing
731

teams for any medical, psychosocial, and surgical barriers
to PD.
There are a few contraindications to use of PD in KF
with ascites. Patients with a poor home situation, who are
not motivated, or who have malignant ascites are not
candidates for PD.50,51 Additionally, patients with recent
abdominal surgery, acute bowel inflammation, and un-
corrected hernias are not eligible for PD. Moreover, acute
liver failure, acute hepatitis, hepatorenal syndrome, or
severe chronic hepatitis with severe coagulopathy (pro-
thrombin time greater than 3 seconds despite vitamin K
administration, or platelet count of less than 50,000/dL)
are also considered as contraindications for surgery.34,52
Similarly, patients with hepatic encephalopathy are not
PD candidates, unless the option for assisted PD, either at
home or in a nursing facility, is available.
In general, patients with ascites from cirrhosis are at
higher risk for perioperative complications such as
bleeding, hypotension, and liver injury from drugs used
during anesthesia. Preoperative planning in these patients
should be meticulous and should take into consideration
the severity of liver disease, type of surgery, and the
method of anesthesia so as to allow patient optimization
and even consideration for alternative procedures such as
percutaneous placement or bridge with HD until the pa-
tient can be optimized for general anesthesia.34,52,53
PD Catheter Placement
Currently, there is no unanimity on optimal PD catheter
insertion technique in KF patients with ascites. Nephrol-
ogists at one center placed PD catheters by the percuta-
neous technique,49 but the open surgical technique was
employed by others.18,19,23,54 Similarly, successful lapa-
roscopic PD catheter placement has been described in this
patient population.55 Neither bleeding complications nor
intestinal perforations have been reported to occur more
often in patients with KF and ascites.18 Even in patients
with prolonged coagulation times, successful percutaneous
catheter placement has been performed without bleeding
complications.49
Overall, the risks of mechanical complications after PD
catheter placement in KF patients with ascites have been
quite low and can be successfully managed without
causing technique failure (Table 1). De Vecchi et al19
observed no surgical or mechanical problems in 21 pa-
tients with KF and cirrhosis (12 patients with ascites). One
study reported a higher incidence of umbilical hernia in
cirrhotic KF patients, but no difference in catheter
migration, leakage, or hydrothorax when compared with
noncirrhotic KF patients.31 Marcus et al49 observed peri-
catheter leak in 1 patient, which resolved with temporarily
discontinuing PD for 2 days. Bajo et al23 noted the
development of abdominal hernia in 4 patients with KF
and ascites; in each case this was corrected without
discontinuation of PD (Table 1). Likewise, no significant
732
Rajora et al
difference in technical complications was observed be-
tween KF patients with cirrhosis (40% had ascites) and
propensity-matched noncirrhotic KF patients (Table 1).54
Although the current guidelines do not recommend a
particular catheter placement procedure for this special
population, the health care professional who performs the
procedure (surgeon, nephrologist, or interventional radi-
ologist) and the technique (open-surgical, laparoscopic, or
percutaneous) should be determined by center experience
and the established mechanism for catheter placement at
the individual site. Perioperative antibiotics should be
administered to reduce the incidence of early peritonitis.
The choice of prophylactic antibiotic should depend upon
the spectrum of antibiotic resistance of the individual
center.56
PD Initiation
Unless there are medical reasons for urgent-start PD in the
hospital, the patient should be seen in the outpatient PD
center within 7 days after PD catheter placement. During
the initial evaluation, the urgency of starting PD should be
determined based on assessment of volume status and
uremic symptoms. If there is no immediate need to initiate
PD, initiation can be delayed 2-4 weeks to promote heal-
ing of the surgical site and reduce the risks of catheter
complications.57 However, even if PD initiation is delayed,
the ascites fluid should be frequently drained and the
catheter concomitantly flushed to ensure patency and
monitor any leaks (Fig 1).
There is no unanimity on the amount of ascites fluid to
be initially drained. Drainage of 5-6 L of ascites fluid has
been described on the initial visit in patients with tense
ascites.18 On subsequent visits, different strategies have
been used to determine the volume of ascites fluid to be
drained. Some centers have drained 10% to 20% extra fluid
over the instilled fill volume (FV) with every ex-
change.18,23 Others have drained 400-600 mL above the
instilled FV until the ascites fluid is completely
drained.19,54,58 Still others have not specified the volume
of ascites drained on each visit.21 Some centers have
infused albumin while draining ascites, while others have
not.18,19,21,23,54,58
There is no consensus on the initial dialysate FV to be
instilled. While Selgas et al18 initiated with 2 L FV from the
outset, De Vecchi et al19 started with 1,000 mL, and Lee
et al54 used 500 mL with stepwise increase to 2 L. In
general, a typical starting FV is 500-750 mL. Every 3-4
days, the FV should be gradually increased, as tolerated,
while being vigilant for catheter leaks and overfills, until
the patient reaches a maximum prescribed FV, usually 1.5-
2.5 L and usually in 2-4 weeks. All exchanges and drains
should be performed in supine position until the catheter
site is completely healed (Fig 1).
In summary, the amount of ascites fluid drained and
the FV of the infused dialysate should be set depending
AJKD Vol 78 | Iss 5 | November 2021
Rajora et al

KF paent with ascites

Dialysis modality educaon and paent evaluaon Evaluate paent for uremic symptoms and volume overload

No Candidate for PD? Urgent PD indicated ?

Start HD Yes
No Yes
Evaluaon for PD catheter placement
Drain ascites Start in-center/in-paent PD:
Flush PD catheter 1-3 Drain ascites
No surgical contraindicaons mes/week Low volume (500-750 mL)
Recumbent posion
Place PD catheter 3-5 exchanges over 4-8 hours/day
Start training 3-5 mes/week
Start training

Training completed Increase FV and

frequency of exchanges
Start home PD as tolerated

Figure 1. Initiation of peritoneal dialysis in patients with kidney failure with ascites. Abbreviations: FV, fill volume; HD, hemodialysis;
KF, kidney failure; PD, peritoneal dialysis.

on the size and comfort of the patient. The tonicity of Outcome of the Clinical Vignette and Summary
the dialysate and number and frequency of PD exchanges
The patient eventually had a PD catheter placed by the
are dictated by the hemodynamic state, severity of
transplant surgeon. He did very well on PD. His volume
symptoms, and volume status. When urgent start is
status improved, and his blood pressure remained stable.
needed, typically 2-5 exchanges over 4-6 hours a day are
He did not require any LVP while on PD. He had 1 episode
performed by the PD nurse, 2-5 days a week, with
of peritonitis caused by coagulase-negative Staphylococcus,
frequent adjustments of the PD prescription according to
suggesting a breach in sterile technique as the root cause
the patient’s clinical status. If urgent start is not needed,
rather than spontaneous bacterial peritonitis. After about 3
PD flushes with concurrent ascites fluid drainage should
years on PD, he received SLKT.
be done frequently, typically 1-3 times a week,
In summary, PD is a viable dialysis modality in pa-
depending on the clinical situation and the patient’s
tients with KF and ascites. It provides hemodynamic
schedule.
stability and facilitates better volume management
PD in KF With Ascites and Liver Transplant compared with HD. Moreover, it provides continuous
drainage of ascites, thus mitigating the need for LVP. PD
Simultaneous kidney and liver transplant (SLKT) is
potentially reduces hemorrhagic complications by
considered the preferred option in patients with
avoiding routine anticoagulation use. Moreover, the
concomitant liver and kidney failure needing transplant.
outcomes such as peritonitis and mechanical complica-
Patients with KF who receive liver transplant alone and
tions are comparable to the control PD population.
remain on dialysis have poor allograft and patient sur-
Although there may be initial drop in serum albumin
vival.59 On the other hand, compared with liver transplant
level, this is short-lasting and does not affect the overall
alone, SLKT is more cost effective. Moreover, SLKT is
outcomes. Furthermore, PD does not affect transplant
associated with lower exposure to anesthesia and the
candidacy and these patients can successfully receive
related risks, as compared to liver transplant alone fol-
SLKT.
lowed by kidney transplant.60,61
There are perceptions that initiating PD in patients with Article Information
KF and ascites will hamper their candidacy for liver
transplant.21 However, data to support this dogma are Authors’ Full Names and Academic Degrees: Nilum Rajora, MD,
Lucia De Gregorio MD, and Ramesh Saxena, MD, PhD.
lacking. In fact, in a study of 12 PD patients with KF and
Authors’ Affiliations: Division of Nephrology, Department of
cirrhosis (7 with ascites), 3 patients underwent successful Medicine (NR, RS), and Division of Transplant Surgery,
SLKT, 4 additional patients remained active on the trans- Department of Surgery (LD), University of Texas Southwestern
plant wait-list, and 5 were deemed not transplant candi- Medical Center, Dallas, Texas.
dates due to comorbidities.21 By the same token, PD has Address for Correspondence: Ramesh Saxena, MD, PhD, 5939
been successfully performed in liver transplant recipients Harry Hines Blvd, MC 8516, Dallas, TX 75390. Email: ramesh.
who later develop KF.62 saxena@utsouthwestern.edu

AJKD Vol 78 | Iss 5 | November 2021 733


Support: This work was supported by the George M. O’Brien
Kidney Research Core Center (US National Institutes of Health
grant P30DK079328) (to RS). The funders had no role in defining
the content of this review.
Financial Disclosure: The authors declare that they have no
relevant financial interests.
Peer Review: Received January 15, 2021 in response to an
invitation from the journal. Evaluated by 2 external peer reviewers
and a member of the Feature Advisory Board, with direct editorial
input from the Feature Editor and a Deputy Editor. Accepted in
revised form April 13, 2021.
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