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Choosing a modality for chronic peritoneal dialysis
Choosing a modality for chronic peritoneal dialysis
Author
John M Burkart, MD
Section Editor
Steve J Schwab, MD
Deputy Editor
Alice M Sheridan, MD
Contributor disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Aug 2016. | This topic last updated: Sep 24, 2014.
INTRODUCTION — Several different techniques are available for performing peritoneal
dialysis. Before discussing these modalities, it is helpful to briefly review the determinants of
solute clearance with peritoneal dialysis. The rates of peritoneal blood flow and dialysate flow
with peritoneal dialysis are well below those achieved with hemodialysis (where both are often
above 400 mL/min). Thus, the clearance of urea and other small solutes per unit time is much
less with peritoneal dialysis than with hemodialysis. However, peritoneal dialysis is often
performed in a continuous fashion so that the weekly solute clearances approach those with
hemodialysis.

When discussing removal of solutes from the body by dialysis, we generally talk about two
processes: diffusion and convection. It is important to appreciate that rates of diffusion for
various solutes vary by molecular weight. The molecular weight for urea is very small, so urea
rapidly diffuses into the peritoneal dialysate (which initially contains no urea) so that the average
dialysate-to-plasma urea ratio is 0.70 at two hours and 0.90 at four hours. Comparable values
for creatinine (a slightly larger molecule) are 0.40 and 0.55, respectively (figure 1); other larger
molecular weight solutes diffuse much more slowly. Thus, urea and other small solutes are
rapidly removed in the first few hours of a dwell; after four hours, there is very little further
removal of small solutes due to near equilibration in concentrations. There is, however,
continued removal of larger solutes, which do not equilibrate as rapidly.

TYPES OF PERITONEAL DIALYSIS — Peritoneal dialysis can be performed in a continuous or

intermittent fashion [1]. Continuous ambulatory peritoneal dialysis (CAPD) involves multiple
exchanges during the day (usually three), followed by an overnight dwell. A modification
involves one nighttime exchange with an exchange device, resulting in two overnight exchanges
and three exchanges during the day [2]. There used to be a device designed specifically for this
option (the nightly exchange device); however, this device is no longer available. As a result,
this modification of CAPD is seldom used; when it is used, a standard cycler is required.

Automated peritoneal dialysis (APD) uses a cycler to perform multiple overnight exchanges.
Modifications to this technique include continuous cycler peritoneal dialysis (CCPD), nightly
intermittent peritoneal dialysis (NIPD), and tidal peritoneal dialysis (TPD) [3]:
 ●CCPD has a long daytime dwell (typically called a "last bag fill" [LBF]) and several
cycles overnight. A minority of patients undergoing CCPD do not have a daytime
dwell ("dry day"), while some patients must also do a "midday exchange" (MDE) to
meet adequacy or ultrafiltration targets [2].
●Some intermittent techniques, such as NIPD or intermittent peritoneal dialysis (IPD),
have treatment periods ("wet" abdomen) alternating with times during which the
peritoneal cavity has been drained of dialysate ("dry" abdomen).
●TPD consists of exchanges in which the peritoneal cavity always contains at least
some dialysate (usually at least one-half full), a feature that improves comfort and
facilitates drainage in some patients [4]. The patient may or may not have a daytime
dwell.

The intermittent regimens typically utilize multiple short dwells and automated technology to
operate at near maximum solute clearance rates. Of the intermittent techniques, TPD is
infrequently used because it is relatively expensive (requires a larger amount of dialysate) and
is technically more difficult to perform. When prescribing, one must remember to not only drain
the tidal volume, but also any expected ultrafiltration that may have occurred during that dwell.
Increased solute clearances have also not been confirmed in all patients, despite such findings
in animal models [2,5]. Most frequently, TPD is used to minimize drainage problems in selected
patients. As recommended in the European Best Practice Guidelines (EBPG), it can also be
used in those with inflow/outflow pain and in patients with slow peritoneal drainage [6].

Continuous flow peritoneal dialysis (CFPD) is another technique in which two peritoneal
catheters or one catheter with two ports provide for the continuous inflow and outflow of
dialysate [7]. Since the dialysate is constantly refreshed, clearances of some solutes similar to
that obtained with short daily hemodialysis can be obtained. CFPD was first introduced decades
ago, but was subsequently abandoned because of technical and financial limitations.

There was briefly a renewed interest in this technique because of the increased recognition of
frequently inadequate clearances with other peritoneal dialysis modalities and the introduction
of technical innovations that made CFPD more feasible. One crossover study of five patients
found that CFPD enhanced diffusive transport and the mean ultrafiltration rate, compared with
NIPD and nightly TPD [8]. Additional study is required to better understand the practicality of
this technique. This technology would have required use of increased amounts of peritoneal
dialysis fluids or reprocessing of the spent dialysate, both increasing the cost over that of
conventional peritoneal dialysis therapies. As of 2014, in the United States, there is no method
to supplement the typical reimbursement for peritoneal dialysis. It is thus possible that the lack
of interest in CFPD is related to the financial constraints of peritoneal dialysis reimbursement
combined with the success of current technologies for daily hemodialysis.

CONTINUOUS AMBULATORY PERITONEAL DIALYSIS VERSUS AUTOMATED

PERITONEAL DIALYSIS — An important question is whether there are unique clinical
advantages among the different continuous ambulatory peritoneal dialysis (CAPD) or
automated peritoneal dialysis (APD) modalities. Although there is a paucity of data, CAPD and
APD appear to provide similar selected clinical outcomes, including mortality [9-12]:
 ●This was shown in a systematic review of three randomized controlled trials that
consisted of 139 patients undergoing either APD or CAPD [9,10]. Both peritoneal
dialysis modalities resulted in similar mortality and hospitalization rates, risk of
peritonitis, and fluid leaks. APD may be associated with relatively more time for work
and social activities.
●In a prospective, multicenter, cohort, five-year study of 87 APD and 562 CAPD
patients, overall mortality and the incidence of technique failure were the same with
both techniques [11].
•In a retrospective review of the United States Renal Data System (USRDS)
data set including 66,381 patients (42,942 on CAPD and 23,439 on APD), there
was no significant difference in technique survival or all-cause mortality [12].
•In a retrospective single-center review including 282 patients on peritoneal
dialysis in Taiwan (121 on CAPD and 161 on APD), there was a lower all-cause
mortality in APD patients as a group, but in a subgroup analysis of patients over
65 years of age, APD was associated with a higher mortality [13].

One review of nine studies (including one small, randomized controlled trial and eight
retrospective, observational, cohort studies) comparing CAPD and APD suggested that the
selection of PD modality is not an important determinant of death risk for peritoneal dialysis
patients [14].

The relative effects of CAPD and APD on residual renal function, peritonitis, volume control, and
technique survival are controversial. A clinically relevant difference between modalities on
residual kidney function has not been proven [14]. As an example, a large, observational study
of 505 CAPD and 78 APD patients showed a higher risk of complete loss of renal function in the
first year associated with APD, compared with CAPD (adjusted hazard ratio [HR] 2.66, 95% CI
1.60-4.44) [15]. However, no difference was detected in the systemic review cited above [9,10].
Larger randomized trials are needed to definitively answer this question.

Similarly, there appear to be no differences between modalities in other outcomes (peritonitis,

volume management, and technique survival) [14,16]. However, there may be some differences
in outcomes that are related to the understanding and utilization of the modality, rather than the
modality (CAPD or APD) itself.

DIALYSIS PRESCRIPTION — How to choose between the modalities will be reviewed below.
At the start of dialysis, when patients have some residual renal function, most patients could do
any peritoneal dialysis technique and usually be able to achieve their Kt/V and volume control
targets. However, once residual kidney function is negligible, modality choice may need to
change and better match dwell times to peritoneal transport characteristics to optimize solute
clearance and ultrafiltration. Despite those theoretical considerations, however, most patients
could do continuous ambulatory peritoneal dialysis (CAPD) or automated peritoneal dialysis
(APD), if one is willing to individualize the patient's prescription. To optimize ultrafiltration and
solute clearance, it is helpful to first discuss the factors that determine the dialysis prescription.

At times, it will be important to individualize the patient's dwell times and dwell volumes so that
the target dose of peritoneal dialysis can be achieved. As an example, peritoneal dialysis is
considered adequate in most patients if the weekly total Kt/V for urea is at least 1.7 and, if
considering creatinine clearance, the weekly creatinine clearance is at least 50 to 60 L/week per
1.73 m2 body surface area (with some variation based upon transporter status) (see next
section). Attainment of these goals must be documented and then monitored over time. It is
often necessary, for example, to increase the patient's dialysis prescription (usually by
increasing the number of exchanges or the dwell volume/exchange) as residual renal function is
lost or there is a decrease in the peritoneal membrane transport characteristics. (See
"Prescribing and assessing adequate peritoneal dialysis".)

Peritoneal equilibration test — At the start of dialysis, peritoneal membrane transport is not
known. Once stable on peritoneal dialysis, in order to optimize a peritoneal dialysis prescription,
a test to characterize peritoneal dialysis membrane transport (such as a peritoneal equilibration
test [PET]) is recommended [17]. (See "Peritoneal equilibration test".) Based upon published
norms, the patient's transport characteristics are classified (figure 2). The dwell time can then be
matched to the transport type in an effort to maximize daily clearances and ultrafiltration while
minimizing glucose absorption [18]. The PET is usually performed after approximately one
month on peritoneal dialysis to minimize early effects peritoneal dialysis fluids may have on
membrane transport. However, during training, the observed drain volume after a two-hour
dwell with 2.5 percent dextrose tends to be predictive of transport type.

Rapid transporters — Consider, for example, the problem in "rapid" transporters of creatinine
from the blood to dialysate. These patients achieve almost total equilibration between plasma
and dialysate for urea and creatinine in a few hours. They also are rapid absorbers of dialysate
glucose, thereby removing the osmotic stimulus to ultrafiltration (figure 2). The net effect is that
they often begin to absorb dialysate after two to three hours, resulting in reductions in
ultrafiltration volume and net solute clearance (as the solutes that have diffused into the
dialysate are also absorbed back into the systemic circulation) (figure 3). In this setting,
standard CAPD, which utilizes prolonged dwell times, might not produce sufficient fluid or solute
removal. This would necessitate the more frequent use of hypertonic dialysate (2.5 or 4.25
percent dextrose), potentially inducing hyperglycemia, hypertriglyceridemia, and/or weight gain
from the increase in glucose absorption, or icodextrin. A better alternative in many cases is
multiple short dwells with standard dialysate, as with nightly intermittent peritoneal dialysis
(NIPD). (See "Rapid transporters on maintenance peritoneal dialysis".)

Slow transporters — The findings are different in "slow" transporters, which need long dwell
times to adequately remove small solutes. Ultrafiltration is not a problem in this setting since
glucose is also slowly absorbed. The figure, for example, shows the findings of a two-liter dwell
volume with a four-hour dwell time using 2.5 percent dextrose dialysate (figure 3). A slow
transporter will have an adequate drain volume of 2.7 liters, but only 1.2 liters of creatinine
clearance. A rapid transporter, on the other hand, will have a higher solute clearance, but may
have a drain volume that is actually less than the instilled volume. (See "Rapid transporters on
maintenance peritoneal dialysis".)

Residual renal function — Patients typically have some residual renal function when they are
started on maintenance dialysis. In this setting, it may not be as important to match dwell time
with transporter type since the urine volume can replace the need for ultrafiltration and the
minimal renal solute excretion augments that due to dialysis. Many patients present with uremia
or biochemical findings that necessitate the urgent start of dialysis. These patients may have
enough residual kidney function so that a full dose of dialysis is not needed. One often starts
peritoneal dialysis in both the ”planned start” setting and the "urgent start" setting with a dialysis
dose that, when added to the residual renal clearance, results in a total (residual kidney and
peritoneal) solute clearance or removal that is at target. As the residual kidney function
decreases, the peritoneal component of the total is increased. This is termed "incremental"
dialysis dosing. In these cases, one might only need to do two exchanges a day (one overnight
dwell and one daytime dwell [a form of CAPD] or two overnight dwells [a form of APD]), or a
form of intermittent peritoneal dialysis (IPD) at initiation (see 'Intermittent peritoneal dialysis'
below). Often, in these cases, as the residual renal function gradually decreases over time,
matching of dwell time to transport type becomes increasingly important [19]. (See "Prescribing
and assessing adequate peritoneal dialysis".)

CHOICE OF PERITONEAL DIALYSIS MODALITY — Most patients on maintenance peritoneal

dialysis need continuous dialysis with continuous ambulatory peritoneal dialysis (CAPD) or
continuous cycler peritoneal dialysis (CCPD, a form of automated peritoneal dialysis [APD]) to
achieve adequate weekly solute clearances. CAPD can be used, with a typical minimum
dialysis prescription of four two-liter exchanges per day, including one overnight exchange. This
standard regimen can be modified by changing dwell time, volume/exchange, or the number of
exchanges per day. The exchanges are performed manually.

In comparison, CCPD is an automated form of therapy in which a cycler delivers three to six
exchanges while the patient sleeps, with a 12- to 15-hour daytime dwell (or last bag fill [LBF]).
Weekly clearances are similar to those obtained with CAPD, but more dialysate fluid is generally
required each day. Some evidence suggests that ultrafiltration rates may be lower with
automated forms of therapy, unless one carefully modifies the prescription [20]. In our unit, over
75 percent of patients use CCPD, and we are able to achieve adequacy and ultrafiltration goals
by individualizing their prescriptions.

We usually let the patient choose between CAPD and CCPD based upon lifestyle or personal
issues (such as the desire to work, wish to not do any exchanges during the day, or in a patient
who is not able to do the exchanges themselves). In a prospective randomized study, CCPD
provided significantly more time for work, family, and social activities than CAPD [21]. Sleep
apnea may also be more responsive to nocturnal peritoneal dialysis [22].

Further recommendations are made after the dialysis dose has been documented with a 24-
hour dialysate collection for volume and creatinine clearance or Kt/V, or it is determined from
the peritoneal equilibration test (PET) that a change in prescription is needed.

The patient should also be monitored over time for the loss of residual renal function. The
associated fall in solute clearance can usually be reversed by increasing the dialysis
prescription via an increase in the dwell volume or the number of exchanges per day. Either of
these modalities will raise the net dialysate flow rate, thereby enhancing the clearance of urea
and other small solutes by maintaining a favorable concentration gradient for solute diffusion
(figure 4).

In general, APD is superior to CAPD in optimizing fluid and small solute removal in some
patients [23]. This is because automated techniques can combine larger dwell volumes, long
nocturnal sessions, and add daytime exchanges, thereby moderately increasing solute and fluid
removal.

Body surface area — In addition to transport type, residual renal function, and lifestyle choice,
another factor to consider when prescribing peritoneal dialysis is body surface area because
both the preferred urea-based metric (Kt/V) and the weekly creatinine clearance are normalized
to body size. For example, an absolute creatinine clearance of 60 L/week represents different
degrees of dialytic solute removal in small versus large patients since the absolute clearance of
creatinine in L/week is then normalized to body surface area (ie, per 1.72 m 2).

Large patients typically need high-dialysate volumes, particularly if they are slow transporters
and have no residual renal function. With CAPD, the dwell volume is typically 2.5 or 3 liters, and
some patients require five exchanges per day.

Large, anuric patients who are on CCPD will often need 12 to 14 hours of dwell time while on
the cycler with a LBF, using large instilled volumes of dialysate; an alternative is a shorter cycler
time (9 to 11 hours) plus one or two daytime exchanges. A large instilled volume is also
required during the daytime dwell, and some patients need to perform one manual CAPD
exchange to meet the goal for solute clearance. However, increasing the nightly dialysate flow
may be superior to adding a manual daytime exchange [24]. One should remember that there
are ways to disconnect from the cycler and then reconnect to do an exchange. With this "break
away or high-dose CCPD" mode, the patient includes the manual exchanges he or she will be
making when they set up the cycler so that time spent doing exchanges is shorter.

Intermittent peritoneal dialysis — The use of intermittent therapies has evolved as we have
become better able to match dwell time and volume to transport characteristics. In general,
because of the presence of residual kidney function, many patients can start dialysis with a low
dose of peritoneal dialysis or on an intermittent therapy. However, as residual kidney function
declines, the prescription will likely need to increase. As an example, rapid transporters do best
with short dwells and may initially achieve adequate dialysis clearances with a "dry" day option
on APD. At the initiation of dialysis, if one still had enough residual kidney function, one might
only have to do intermittent peritoneal dialysis (IPD) for a six- to eight-hour session three or four
days a week. In this case, the patient could even get the treatment at a dialysis center ("in-
center peritoneal dialysis," often utilized during the practice of "urgent-start" peritoneal dialysis)
until ready to train for peritoneal dialysis, or a permanent hemodialysis access can be placed.

However, as residual kidney function decreases, the frequency of the IPD treatment will need to
be increased, eventually becoming a daily routine (such as nightly intermittent peritoneal
dialysis [NIPD]). If NIPD is used with 8 to 12 hours of overnight dialysis, the dwell time may be
only one to two hours per exchange with 1.5 to 2.0 liter dwell volumes. This requires the use of
8 to 20 liters of dialysate fluid per day. Adequate solute clearances can be achieved with this
regimen even though the patient has a "dry" day. However, unless residual renal function is
significant, most patients need a "wet" day. Among patients who are rapid transporters, the
solution used for the long dwell should be carefully selected in order to avoid lymphatic
absorption; such patients may need to use an osmotic agent other than dextrose (icodextrin) or
will need to do a midday exchange.

It is currently estimated that 10 to 15 percent of patients might do best with NIPD or daytime
ambulatory peritoneal dialysis (DAPD). DAPD is similar to NIPD, except that the exchanges are
performed manually during the day.

Classic IPD is a form of dialysis in which multiple short exchanges are performed on an
intermittent basis. A typical regimen consists of 12 to 15 two-liter, one-hour dwells performed
three or four days per week. Over 50 hours of dialysis is required to attain clearances similar to
CAPD. However, even higher target doses of dialysis are recommended because of the peaks
in blood urea nitrogen (BUN) occurring on the off-dialysis days. For these reasons, this form of
peritoneal dialysis is not recommended for chronic use.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials,
“The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain
language, at the 5th to 6th grade reading level, and they answer the four or five key questions a
patient might have about a given condition. These articles are best for patients who want a
general overview and who prefer short, easy-to-read materials. Beyond the Basics patient
education pieces are longer, more sophisticated, and more detailed. These articles are written
at the 10th to 12th grade reading level and are best for patients who want in-depth information
and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on “patient info” and the keyword(s) of interest.)

●Basics topic (see "Patient information: Peritoneal dialysis (The Basics)")

●Beyond the Basics topic (see "Patient information: Peritoneal dialysis (Beyond the
Basics)")

SUMMARY AND RECOMMENDATIONS

●Peritoneal dialysis can be performed using several different techniques. Continuous

ambulatory peritoneal dialysis (CAPD) involves multiple exchanges during the day
(usually three), followed by an overnight dwell. Automated peritoneal dialysis (APD)
refers to techniques that use an automated device to do multiple exchanges
overnight, with or without a daytime dwell, such as continuous cycler peritoneal
dialysis (CCPD), nightly intermittent peritoneal dialysis (NIPD), and tidal peritoneal
dialysis (TPD). Of these, CCPD, the most commonly used, has a long daytime dwell
and several cycles overnight. (See 'Types of peritoneal dialysis' above.)
●Upon initiating peritoneal dialysis, we usually let the patient choose the modality
(most commonly either CAPD or CCPD) based upon lifestyle or personal issues
since the choice is unlikely to matter as far as achieving Kt/V and ultrafiltration goals.
This is because most patients initially have significant residual renal function. Over
time, the prescription typically has to be modified because of the loss of renal
function. The principal factors that determine the optimal peritoneal dialysis
prescription are membrane transport type, degree of residual renal function, lifestyle
choice, and body surface area. In general, APD therapies are recommended for rapid
transporters; low transporters who desire to continue with APD therapy will likely
require a midday exchange to achieve adequate fluid/solute removal. (See 'Dialysis
prescription' above and 'Choice of peritoneal dialysis modality' above.)
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