Synopsis
Explain peritoneal dialysis physiology and delivery, monitor prescription and membrane performance, and respond safely to peritonitis, catheter problems and fluid imbalance.
- Peritoneal dialysis uses the patient's peritoneal capillaries as the blood compartment and instilled dialysate as the receiving compartment for diffusive solute clearance and osmotic ultrafiltration.
- Continuous ambulatory peritoneal dialysis uses manual daytime exchanges; automated peritoneal dialysis uses a programmed cycler, usually overnight, and modality choice should reflect physiology, lifestyle and support.
- A clean connection technique, daily exit-site care, a trained patient or assistant and rapid access to the PD team are core safety interventions, not optional extras.
- Cloudy effluent is presumed PD peritonitis until confirmed or excluded: contact the PD unit immediately, send effluent cell count and differential, Gram stain and culture, then start the patient’s current centre-approved empirical intraperitoneal regimen after sampling without waiting for laboratory results.
- Abdominal pain with clear fluid has a broad differential including constipation, hernia, obstruction, pancreatitis and ischaemia; conversely, some peritonitis episodes have little pain.
- Monitor both peritoneal clearance and residual kidney function; preserving urine output can materially improve volume, potassium and overall solute control.
- Repeated use of the strongest glucose solutions increases glucose exposure and can damage membrane and metabolic health; optimise salt intake, dwell design, icodextrin and residual diuresis with the PD team.
- Icodextrin metabolites can cause falsely high glucose readings with incompatible meters, so only the glucose-monitoring technology approved by the renal service should be used.
- Poor drain volume is often mechanical from constipation, catheter migration, kinking or fibrin, but never assume a machine alarm is harmless when pain, leak or infection is present.
Key red flags
Cloudy drained fluid needs same-day renal contact even if pain is mild; delay in effluent testing and antimicrobial treatment increases technique failure and sepsis risk.
Hypotension, altered mental state, rising lactate or severe abdominal guarding with suspected peritonitis demands emergency sepsis and surgical differential assessment.
Sudden breathlessness after fill, pleuritic symptoms or a new unilateral effusion can reflect pleuroperitoneal leak and requires the PD team to stop or modify treatment.
Scrotal, abdominal-wall or wound swelling with loss of ultrafiltration suggests a dialysate leak or hernia and should not be managed by progressively larger fill volumes.
A low bedside glucose reading in an icodextrin user should be treated clinically, while any unexpectedly high reading obtained with an unapproved meter must be confirmed urgently by a compatible method.
Investigation priorities
Confirm inflammatory dialysate and support the diagnosis of PD-associated peritonitis.
Management branches
A PD patient reports cloudy drainage, white flecks, abdominal discomfort or systemic illness.
- Tell the patient to contact the PD unit immediately, retain the bag if locally advised and attend the agreed urgent assessment route rather than waiting for the next exchange.
- Assess sepsis and abdominal red flags, examine the exit site and tunnel, and obtain effluent cell count, differential, Gram stain and culture correctly.
- After sampling, start the patient’s current PD-programme empirical intraperitoneal regimen without waiting for results; it must cover both Gram-positive and Gram-negative organisms. Do not substitute a generic agent or dose: centre resistance, allergy, residual function, APD/CAPD schedule, compatibility and dwell time determine the prescription. Add systemic sepsis treatment when indicated.
- Review clinical response and repeat fluid testing as the protocol directs, narrow treatment to culture and remove the catheter when refractory, fungal or other specialist criteria are met.