Woodrow et al.

BMC Nephrology (2017) 18:333

DOI 10.1186/s12882-017-0687-2

CORRESPONDENCE Open Access

Renal Association Clinical Practice Guideline

on peritoneal dialysis in adults and children
Graham Woodrow1*, Stanley L. Fan2, Christopher Reid3, Jeannette Denning4 and Andrew Neil Pyrah5

Abstract
These guidelines cover all aspects of the care of patients who are treated with peritoneal dialysis. This includes
equipment and resources, preparation for peritoneal dialysis, and adequacy of dialysis (both in terms of removing
waste products and fluid), preventing and treating infections. There is also a section on diagnosis and treatment
of encapsulating peritoneal sclerosis, a rare but serious complication of peritoneal dialysis where fibrotic (scar) tissue
forms around the intestine. The guidelines include recommendations for infants and children, for whom peritoneal
dialysis is recommended over haemodialysis.
Immediately after the introduction there is a statement of all the recommendations. These recommendations are
written in a language that we think should be understandable by many patients, relatives, carers and other interested
people. Consequently we have not reworded or restated them in this lay summary. They are graded 1 or 2 depending
on the strength of the recommendation by the authors, and A-D depending on the quality of the evidence that the
recommendation is based on.

Introduction recommends PD as the initial dialysis treatment of

These guidelines cover the organisation and performance choice of chronic kidney disease stage 5 for children
of peritoneal dialysis as a treatment for kidney patients, aged 2 years or older, people with residual renal function
including infants and children. It includes prevention and and adults without significant associated comorbidities.
treatment of complications. It does not include factors For the first time, this Renal Association guideline
involved in the choice of peritoneal dialysis compared to includes recommendations relating to PD in children.
other options for patients with stage 5 chronic kidney Recommendations in this guideline will refer to both
disease. This document is intended for use by any member adult and paediatric patients, except where the recom-
of the health care team engaged in the care of kidney mendation specifies one of these patient groups or pro-
patients treated with peritoneal dialysis. vides alternative recommendations to them.
Peritoneal dialysis (PD) is long established as a major This guideline is an update of the PD module published
option for renal replacement therapy in patients with on-line on the Renal Association website, [Link]
end-stage renal disease. It is an important part of an in 2010. The English language literature was searched in
integrated service for renal replacement therapy that is December 2016 to identify relevant articles on PD
frequently selected by patients as their preferred initial published between 2008 and 2016 including:
mode of therapy and is a therapeutic option for patients
wishing or needing to swap from HD and after renal
Medline search using ‘peritoneal dialysis’ combined
transplant failure. PD is the best option for infants and with relevant terms from each of the sections -
small children. NICE Clinical Guideline 125 (2011) Equipment & Resources, Training & Catheter
Insertion, Dialysis Clearance, Ultrafiltration &
Overhydration, Infections, Peritonitis, Exit Site
* Correspondence: [Link]@[Link]
RA Guidelines Committee Manager: Melanie Dillon,
Infections, Renal Osteodystrophy & Diabetes
‘[Link]@[Link]’ can be contacted for any Mellitus, Encapsulating Peritoneal Sclerosis, Assisted
correspondence related to this article
1
Peritoneal Dialysis, Icodextrin, Peritoneal Membrane,
St James’s University Hospital Leeds Teaching Hospitals NHS Trust, Leeds,
UK
Urgent Start and Biocompatible Solutions
Full list of author information is available at the end of the article
Cochrane Database of Systematic Reviews

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License ([Link] which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
([Link] applies to the data made available in this article, unless otherwise stated.
Woodrow et al. BMC Nephrology (2017) 18:333 Page 2 of 23

Review of other national/international PD clinical Guideline 1.3 – PD: Equipment and resources
guidelines We recommend that the use of disconnect systems should

Identification of further articles quoted in identified be standard unless clinically contraindicated (1A).
papers

Review of Peritoneal Dialysis International’s table of
Guideline 1.4 – PD: Equipment and resources
contents for articles relating to the content of the
We suggest that biocompatible PD solutions (solutions
guidelines
that have normal pH and/or low concentrations of

Searches within the major renal journals (Journal
glucose degradation products) should be used in patients
of the American Society of Nephrology, Clinical
experiencing infusion pain (2B).
Journal of the American Society of Nephrology,
Nephrology Dialysis Transplantation, Kidney
International, American Journal of Kidney Diseases) for Guideline 1.5 – PD: Equipment and resources
articles with ‘peritoneal dialysis’ in the title/abstract We suggest that biocompatible PD solutions (normal pH
and/or low concentrations of glucose degradation products)
The recommendations in this guideline have been may be considered for better preservation of residual renal
harmonised with other PD guidelines whenever possible function with long term (>12 month) use (2B).
and the recommendations to follow international PD or
other Renal Association guidelines have not been graded.
Peritoneal dialysis (PD) (guidelines PD 2.1–2.4)
Guideline 2.1 – PD: Preparation for peritoneal dialysis
Summary of clinical practice guidelines for We recommend that all patients (and parents of paediatric
peritoneal dialysis patients) should, where possible, be adequately prepared
Peritoneal dialysis (PD) (guidelines PD 1.1–1.5) for renal replacement therapy and this should include re-
Guideline 1.1.1 – PD: Equipment and resources ceiving information and education about PD treatment,
We recommend that Peritoneal Dialysis should be delivered delivered by an experienced member of the MDT. Patients
in the context of a comprehensive and integrated service for commencing RRT in an unplanned fashion for whatever
renal replacement therapies, including haemodialysis reason should receive this information once appropriate
(including temporary backup facilities), transplantation (1C). Fast track education and urgent PD catheter inser-
and conservative care. Both continuous ambulatory tion with acute start of PD should be available, and be
peritoneal dialysis (CAPD) and automated peritoneal offered to suitable patients urgently starting on RRT who
dialysis (APD), in all its forms should be available (1C). wish to avoid temporary haemodialysis (1C).

Guideline 1.1.2 – PD: Equipment and resources Guideline 2.2 – PD: Preparation for peritoneal dialysis
We recommend that a dedicated PD nursing team should We recommend that, where possible, timing of PD catheter
be part of the multidisciplinary team (1C). insertion should be planned to accommodate patient con-
venience, commencement of training between 10 days and
6 weeks and before RRT is essential to enable correction of
Guideline 1.1.3 – PD: Equipment and resources early catheter-related problems without the need for tem-
We recommend that where feasible, each unit has a porary haemodialysis (1C).
designated lead clinician for PD (1C).

Guideline 2.3 – PD: Preparation for peritoneal dialysis

Guideline 1.1.4 – PD: Equipment and resources We recommend that PD catheter insertion practice should
We recommend that assisted PD should be available to be managed according to the Renal Association Peritoneal
patients wishing to have home dialysis treatment but Access Guidelines. Paediatric PD access procedures will rou-
unable to perform self-care PD, including as a temporary tinely be performed under general anaesthetic (Ungraded).
measure where a patient who is, or will become, inde-
pendent is unable to perform PD alone (1C).
Guideline 2.4 – PD: Preparation for peritoneal dialysis
We recommend that peri-operative catheter care and
Guideline 1.2 – PD: Equipment and resources catheter complications (leaks, hernias, obstruction) should
We recommend that all equipment and fluid used in be managed according to the International Society of
the delivery and monitoring of PD therapies should Peritoneal Dialysis guidelines 2005, and for children,
comply with the relevant standards for medical fluids the European Elective Chronic Peritoneal Dialysis Guideline
and devices (1C). 2001 (Ungraded).
Woodrow et al. BMC Nephrology (2017) 18:333 Page 3 of 23

Peritoneal dialysis (PD) (guidelines PD 3.1–3.3) where possible. These include the use of ACEi, ARBs (in
Guideline 3.1 – PD: Solute clearance adults only) and diuretics, and the avoidance of episodes of
We recommend that both residual urine and peritoneal dehydration (1B).
dialysis components of small solute clearance should be
measured at least six monthly or more frequently if Guideline 4.5 – PD: Ultrafiltration and fluid management
dependant on residual renal function to achieve clearance We recommend that anuric patients who are overhydrated
targets or if clinically or biochemically indicated in adults and consistently achieve a daily ultrafiltration of less than
and in children. Both urea and/or creatinine clearances 750 ml in adults (or equivalent volume for body size in
can be used to monitor dialysis adequacy and should be paediatrics) should be closely monitored. These patients
interpreted within the limits of the methods (1C). may benefit from prescription changes and/or modality
switch (1B).
Guideline 3.2.1 – PD: Solute clearance
We recommend that a combined urinary and peritoneal
Peritoneal dialysis (PD) (guidelines PD 5.1–5.2)
Kt/Vurea of 1.7/week or a creatinine clearance of
Guideline 5.1 – PD: Infectious complications
50 L/week/1.73m2 should be considered as minimal
treatment doses for adults (1A). We recommend/sug-
Guideline 5.1.1 – PD infectious complications:
gest that clearance targets for children should be a
Prevention strategies We recommend that PD units
minimum of those for adults (1C).
should undertake regular audit of their peritonitis and
exit-site infection rates, including causative organism,
Guideline 3.2.2 – PD: Solute clearance
treatment and outcomes. They should enter into active
We recommend that the dose of dialysis should be
dialogue with their microbiology department and infec-
increased in patients experiencing uraemic symptoms,
tion control team to develop optimal local treatment
or inadequate growth in children, even if meeting
and prevention protocols (1B).
minimum clearance targets (1B).

Guideline 3.3 – PD: Solute clearance Guideline 5.1.2 – PD infectious complications:

We recommend that a continuous 24 h PD regime is pre- Prevention strategies We recommend that flush-before-
ferred to an intermittent regime for anuric patients (1B). fill dialysis delivery systems should be used for CAPD (1A).

Peritoneal dialysis (PD) (guidelines PD 4.1–4.5) Guideline 5.1.3 – PD infectious complications:

Guideline 4.1 – PD: Ultrafiltration and fluid management Prevention strategies We recommend that patients
We recommend that peritoneal membrane function should (and/or carers or parents) should undergo regular revision
be monitored regularly (6 weeks after commencing treat- of their technique (at least annually or more frequently if
ment and at least annually or when clinically indicated) indicated, such as after an episode of PD-related infection
using a peritoneal equilibration test (PET) or equivalent. or a significant interruption to the patient performing PD)
Daily urine and peritoneal ultrafiltration volumes, with and receive intensified training if this is below standard
appropriate correction for overfill, should be monitored at (1C).
least six-monthly (1C).
Guideline 5.1.4 – PD infectious complications:
Guideline 4.2 – PD: Ultrafiltration and fluid management
Prevention strategies We recommend that initial cath-
We recommend that dialysis regimens resulting in fluid
eter insertion should be accompanied by antibiotic prophy-
reabsorption should be avoided. Patients with high or high
laxis (1B).
average solute transport, at greatest risk of this problem,
should be considered for APD and icodextrin (1A).
Guideline 5.1.5 – PD infectious complications:
Guideline 4.3 – PD: Ultrafiltration and fluid management Prevention strategies We recommend that invasive
We recommend that dialysis regimens resulting in routine procedures should be accompanied by antibiotic prophy-
utilisation of hypertonic (3.86%) glucose exchanges should laxis and emptying the abdomen of dialysis fluid for a
be minimised. Where appropriate this should be achieved period commensurate with the procedure (1C).
by using icodextrin or diuretics (1B).
Guideline 5.1.6 – PD infectious complications:
Guideline 4.4 – PD: Ultrafiltration and fluid management Prevention strategies We recommend that topical
We recommend that treatment strategies that favour antibiotic administration should be used to reduce the
preservation of renal function or volume should be adopted frequency of exit-site infection and peritonitis (1A).
Woodrow et al. BMC Nephrology (2017) 18:333 Page 4 of 23

Guideline 5.2 – PD: Infectious complications 7. Peritoneal dialysis (PD) (guidelines PD 7.1)
Guideline 7.1 – PD: Encapsulating peritoneal sclerosis
Guideline 5.2.1 – PD infectious complications:
Treatment We recommend that exit site infection is Guideline 7.1.1 – PD: Encapsulating peritoneal sclerosis:
suggested by pain, swelling, crusting, erythema and serous Diagnosis We recommend that the diagnosis of encap-
discharge; purulent discharge always indicates infection. sulating peritoneal sclerosis (EPS) requires the presence
Swabs should be taken for culture and initial empiric of a combination of clinical and radiological features of
therapy should be with oral antibiotics that will cover S. intestinal obstruction and encapsulation GRADE 1B.
aureus and P. aeruginosa (1B).

Guideline 7.1.2 – PD: Encapsulating peritoneal

Guideline 5.2.2 – PD infectious complications: sclerosis: Diagnosis We recommend that the radiological
Treatment We recommend that methicillin resistant technique of choice for the diagnosis of encapsulating peri-
organisms (MRSA) will require systemic treatment (e.g. toneal sclerosis (EPS) is CT scanning GRADE 1B.
vancomycin) and will need to comply with local infec-
tion control policies (1C).
Guideline 7.1.3 – PD: Encapsulating peritoneal
sclerosis: Diagnosis We recommend that radiological
Guideline 5.2.3 – PD infectious complications: and biochemical screening methods are NOT of suffi-
Treatment We recommend that initial treatment regi- cient sensitivity and specificity to be used clinically to
mens for peritonitis should include cover for bacterial identify early or imminent development of EPS in
Gram positive and Gram negative organisms including asymptomatic PD patients (GRADE 1C).
Pseudomonas species until result of culture and anti-
biotic sensitivities are obtained (1C).
Guideline 7.2 – PD: Encapsulating peritoneal sclerosis

Peritoneal dialysis (PD) (guidelines PD 6.1–6.4) Guideline 7.2.1 – PD: Encapsulating peritoneal
Guideline 6.1 – PD: Metabolic factors sclerosis: Management We recommend that patients
We recommend that standard strategies to optimise diabetic with suspected encapsulating peritoneal sclerosis (EPS)
control should be used; these should be complemented by should be referred or discussed early with units who have
dialysis prescription regimens that minimise glucose, includ- expertise in EPS surgery. Surgery should be performed by
ing glucose free-solutions (icodextrin and amino-acids), teams experienced in EPS surgery (GRADE 1B).
where possible (1B).

Guideline 7.2.2 – PD: Encapsulating peritoneal

Guideline 6.2 – PD: Metabolic factors sclerosis: Management We recommend that patients
We recommend that plasma bicarbonate should be with EPS should have early dietetic referral and monitoring
maintained within the normal range. This can be of nutritional status, with nutritional support by oral en-
achieved in the vast majority of patients by adjusting the teral, or often parenteral supplementation usually required
dialysis dose and/or dialysate buffer concentration (1B). (GRADE 1C).

Guideline 6.3 – PD: Metabolic factors Guideline 7.2.3 – PD: Encapsulating peritoneal
We suggest that central obesity can worsen or develop sclerosis: Management We suggest that there is no
in some PD patients. The risk of this problem, and asso- clear evidence to support a recommendation for the use
ciated metabolic complications, notably increased ather- of any medical therapy for treating EPS. Corticosteroids,
ogenicity of lipid profiles and insulin resistance, can be immunosuppressants and tamoxifen have been used, and
reduced by avoiding excessive glucose prescription and may be tried at the physician’s discretion (GRADE 2C).
using icodextrin (2C).

Guideline 7.2.4 – PD: Encapsulating peritoneal

Guideline 6.4 – PD: Metabolic factors sclerosis: Management We suggest that PD should
We recommend that awareness of the effects of icodex- usually be discontinued after diagnosis of EPS with
trin on assays for estimation of amylase and glucose transfer to haemodialysis. However, this should be an in-
(using glucose dehydrogenase) should be disseminated dividual patient decision considering, patient wishes, life
to patients, relatives, laboratory and clinical staff (1C). expectancy and quality of life (GRADE 2C).
Woodrow et al. BMC Nephrology (2017) 18:333 Page 5 of 23

Guideline 7.3 – PD: Encapsulating peritoneal sclerosis
Audit Measure 18: Routine annual audit of infection
prevention strategies
Guideline 7.3 1– PD: Encapsulating peritoneal
Audit Measure 19: Routine annual audit of PD
sclerosis: Duration of PD therapy We recommend peritonitis rates (including proportion of culture
that there is no optimal duration of peritoneal dialysis or negative cases)
indication for routine elective modality switching. Decisions
Audit Measure 20: Routine annual audit of infection
regarding the duration of therapy should be tailored to the outcomes
individual patient, taking into account clinical and social
Audit Measure 21: Cumulative frequency curves of
factors and patient wishes, and should follow the principles plasma bicarbonate
outlined in the ISPD Length of Time on Peritoneal Dialysis
Audit Measure 22: Processes in place to increase
and Encapsulating Peritoneal Sclerosis Position Paper awareness of interference of assays by icodextrin
(GRADE 1C). metabolites

Audit Measure 23: Number of patients with
Summary of audit measures for peritoneal dialysis diagnosis of EPS who are referred to designated
specialist EPS centres.

Audit Measure 1: Availability of modality choice

Audit Measure 2: Monitoring of modality switching Rationale for clinical practice guidelines for

Audit Measure 3: Patient to peritoneal dialysis peritoneal dialysis
nursing staff ratio Peritoneal dialysis (PD) (guidelines PD 1.1–1.5)

Audit Measure 4: Availability of assisted PD, Guideline 1.1 – PD: Equipment and resources
utilisation and outcomes We recommend that Peritoneal Dialysis should be delivered

Audit Measure 5: Systems in place to check in the context of a comprehensive and integrated service for
medical equipment renal replacement therapies, including haemodialysis

Audit Measure 6: Use of non-standard systems (including temporary backup facilities), transplantation
with documentation of clinical indication and conservative care. Both continuous ambulatory

Audit Measure 7: Use of biocompatible solutions peritoneal dialysis (CAPD) and automated peritoneal
and indication for use dialysis (APD), in all its forms should be available (1C).

Audit Measure 8: Audit of care pathway for
dialysis preparation to include information given Guideline 1.1.2 – PD: Equipment and resources
(including proportion of patients offered PD), when We recommend that a dedicated PD nursing team
and who delivers it should be part of the multidisciplinary team (1C).

Audit Measure 9: Audit of information on modality
options provided to patients presenting who urgently Guideline 1.1.3 – PD: Equipment and resources
require RRT, and both initial and subsequent We recommend that where feasible, each unit has a des-
modality of RRT selected by these patients. ignated lead clinician for PD (1C).

Audit Measure 10: Audit of care pathway for
catheter insertion to include timeliness and need for Guideline 1.1.4 – PD: Equipment and resources
temporary haemodialysis We recommend that assisted PD should be available to

Audit Measure 11: Catheter complications and patients wishing to have home dialysis treatment but un-
their resolution able to perform self-care PD, including as a temporary

Audit Measure 12: Frequency of solute clearance measure where a patient who is, or will become, inde-
(residual and peritoneal) estimation pendent is unable to perform PD alone (1C).

Audit Measure 13: Cumulative frequency curves
for the total solute clearance Rationale

Audit Measure 14: Frequency of measurement of Evidence from observational studies or registry data, with
membrane function, residual urine and peritoneal all its limitations, indicate that peritoneal dialysis (PD) used
ultrafiltration volume in the context of an integrated dialysis programme is asso-

Audit Measure 15: Identify patients with fluid ciated with good clinical outcomes, certainly comparable to
reabsorption in long dwell haemodialysis in the medium term (HD) and potentially

Audit Measure 16: Number of patients regularly better in the first 2 years of dialysis [1–10]. NICE recom-
requiring hypertonic (3.86% glucose) exchanges to mends PD as the initial dialysis treatment of choice of
maintain fluid balance chronic kidney disease stage 5 for children aged 2 years or

Audit Measure 17: Identify anuric patients with a older, people with residual renal function and adults
total fluid removal <750 ml per day. without significant associated comorbidities (NICE Clinical
Woodrow et al. BMC Nephrology (2017) 18:333 Page 6 of 23

Guideline 125, 2011). The only randomised study in each unit may help to promote PD as a therapy option
(NECOSAD), comparing HD to PD as a first treatment and to develop clinical management policies.
showed no differences in 2 year quality adjusted life Assisted PD, with provision of nursing support in the
years or 5 year mortality, but the number randomised community to help with part of the workload and proce-
was insufficient to generalize this observation; notably, dures associated with PD, is a useful option to overcome an
most patients in this national study had sufficient life- important barrier to home dialysis therapy [23]. Assisted
style preferences related to one modality to decline APD should be available for patients, who are often but not
randomisation [11]. PD has a significant technique fail- always elderly, wishing to have dialysis at home, but are
ure rate however, so patients need to be able to switch unable to perform self-care PD [24] and may also be used
treatment modality (to either temporary or permanent as a temporary measure for established patients temporarily
HD) in a timely manner, which has implications for unable to perform PD independently or for those unable to
HD capacity and the timing for HD access creation. start PD alone but may later become independent. Assisted
PD modalities (CAPD v. APD) have a different impact PD provides at least equivalent outcomes to in-centre
on life-style; one randomised study found that APD cre- haemodialysis for older patients [25–27], and higher treat-
ates more time for the patient to spend with family or ment satisfaction [27] and is a viable option for expanding
continue employment but is associated with reduced home care in more dependent patients [25, 26].
quality of sleep [12]. APD is usually the preferred modality
for children [13]. There are medical indications for APD
Audit Measure 1: Availability of modality choice
(see sections 2, 3 and 4), but generally initial modality
Audit Measure 2: Monitoring of modality switching
choice is a lifestyle issue. Studies suggest no difference in
Audit Measure 3: Patient to peritoneal dialysis
outcomes resulting from selection of CAPD or APD as nursing staff ratio
initial PD modality [14–16].
Audit Measure 4: Availability of assisted PD,
The success of a PD programme is dependent upon utilisation and outcomes
specialised nurses with appropriate skills in assessing
and training patients for PD, monitoring of treatment
Guideline 1.2 – PD: Equipment and resources
and with sufficient resources to provide continued care
We recommend that all equipment and fluid used in the
in the community. A randomised trial of more intensive
delivery and monitoring of PD therapies should comply
training has shown that this reduces peritonitis risk [17]
with the relevant standards for medical fluids and
and there is some evidence to support the benefit of
devices [1].
regular home reviews of PD technique [18] (see section
5). Several studies have documented the benefits of

Audit Measure 5: Systems in place to check
home visits in identifying new problems, reducing peri-
medical equipment
tonitis and non-compliance [19–21]. The National Renal
Workforce Planning Group, (2002), recommended a case-
This is a legal requirement
load of up to 20 PD patients per nurse. It is important to
note that this was a minimum recommendation. For
smaller adult units, and paediatric units, a significantly Guideline 1.3 – PD: Equipment and resources
greater number of nurses than determined by this ratio We recommend that the use of disconnect systems
will be required to maintain a critical number to provide should be standard unless clinically contraindicated (1A)
adequate specialist nurse cover across the year and to
cover periods of absence. This is increasingly relevant now
Audit Measure 6: Use of non-standard systems
with the decline in PD patient numbers and unit sizes that with documentation of clinical indication
has occurred since the publication of the Workforce Plan-
ning document. It is also of note that the responsibilities
Rationale
of PD nurses vary significantly between units, for example
Disconnect systems have been shown through rando-
in some additionally being responsible for inpatient PD
mised trials to be associated with a lower peritonitis risk,
care, such that the required staffing level will be higher
especially in infections due to touch contamination [28].
than this minimum. Greater numbers of nurses will be
required where assisted PD is performed by staff from the
PD unit rather than other external organisations. The Guideline 1.4 – PD: Equipment and resources
requirement for specialist nurses with the skills to deal We suggest that biocompatible PD solutions (solutions
with complex patient educational issues is highlighted by that have normal pH and/or low concentrations of glu-
the ISPD Guideline (2016) for teaching PD to patients and cose degradation products) should be used in patients
caregivers [22]. Having a designated lead clinician for PD experiencing infusion pain (2B).
Woodrow et al. BMC Nephrology (2017) 18:333 Page 7 of 23

Guideline 1.5 – PD: Equipment and resources adjusted for, so caution should be exercised in the inter-
We suggest that biocompatible PD solutions (normal pH pretation of this study [46]. Similar findings have been re-
and/or low concentrations of glucose degradation prod- ported in a subsequent observational study, which has the
ucts) may be considered for better preservation of residual advantage of including analysis of cohorts matched for
renal function with long term (>12 month) use (2B). factors including cardiovascular comorbidity, socioeco-
nomic status and centre experience [47].

Audit Measure 7: Use of biocompatible solutions However, the limitations of being a non-randomised
and indication for use study with no fixed indication for prescription of bio-
compatible fluid, with potential for selection bias, and
Rationale with differences in characteristics of the unmatched groups
A minority of patients commencing PD will experience still apply [47]. Non-randomised, observational studies have
infusion pain, often severe enough to consider discon- also suggested a beneficial effect of biocompatible solutions
tinuing the therapy. A double blind randomised study on peritonitis rates [48, 49], but the strength of the conclu-
demonstrated that pain could be prevented by using a sions are limited by the non-randomised study design and
normal pH, bicarbonate-lactate buffered dialysis fluid possibility of other factors contributing to observed differ-
(Physioneal) [29]. Subsequent clinical experience has ences in infection rates. A secondary outcome of the rando-
found that the benefit of this more biocompatible solu- mised balANZ trial was of a reduction in peritonitis rates in
tion on infusion pain results in immediate and sustained group receiving biocompatible PD fluid [50]. However, the
benefit, and is probably applicable to other biocompat- most recent and largest registry study reported an increased
ible solutions. risk of peritonitis with biocompatible fluids [51] and a
The evidence of other forms of clinical benefit from recent systematic review has not demonstrated a benefit of
the routine use of biocompatible solutions is more contro- low-GDP biocompatible solutions on peritonitis rates,
versial. Standard solutions are clearly bio-incompatible, patient or technique survival [52]. Thus further studies are
with low pH (~5.2), lactate rather than bicarbonate buffer, required to answer the question regarding the potential ef-
high osmolality and high concentrations of glucose which fect of biocompatible fluids on PD peritonitis. The balANZ
also result in high concentrations of glucose degradation study also demonstrated interesting differences in effect on
products (GDPs). Many in vitro and ex vivo studies have peritoneal membrane function. The biocompatible fluid
demonstrated the relative toxicity of these solutions, with group had a higher initial transport state one month after
all of the bioincompatible features playing their part starting the trial, but transport status was then stable, un-
[30–35]. There is also strong observational evidence like the standard fluid group where transport sate increased
that firstly detrimental functional changes to the peri- progressively [53]. The impact of this effect on outcomes
toneal membrane occur with time on treatment, which including technique survival warrants further study.
are more exaggerated in patients using solutions with The area with the strongest evidence for clinical bene-
high glucose concentration early in their time on ther- fit of biocompatible solutions is in the preservation of
apy [36, 37] and secondly, that morphological changes residual renal function. Several studies have suggested a
occur that are related to time on treatment which in- benefit of low-GDP biocompatible fluids on residual
clude membrane thickening and vascular scarring [38]. function, with the largest being the balANZ trial [54].
Time on treatment is also the greatest risk factor for Whilst differences in ultrafiltration between groups
encapsulating peritoneal sclerosis (EPS) [39, 40]. (which may indirectly affect residual urine via effects on
These observations have led dialysis companies to develop hydration), make interpretation of the actual effect of
and market ‘biocompatible’ solutions, with normalization of the fluids on residual renal function more difficult in
pH, and/or reduction of GDPs and variable approaches to some studies [55], three systematic reviews of existing
buffering. In randomised clinical trials these solutions have trials demonstrate a benefit of biocompatible solutions
been shown to improve the dialysate concentrations of on residual renal function, when used for more than
biomarkers considered to be indicators of mesothelial 12 months [52, 56, 57]. We suggest that biocompatible
cell and possibly membrane health [41–44]. Systemic solutions be considered for preservation of residual
benefits possibly include reduced circulating advanced kidney function. Currently there is insufficient evidence
glycation end-products [44] and better glycaemic control to recommend that all patients should be treated with
in diabetics [45]. Data is currently lacking on hard clinical biocompatible solutions, especially as this may have a
endpoints including technique failure or patient survival. significant cost implication. The argument for their use
One non-randomised, retrospective observational study may be stronger if there was not an economic disad-
has found an improved patient but not technique survival; vantage. However, we note that routine clinical practice
patients in this study using biocompatible solutions were in UK is for children receiving PD to routinely be
younger, suggesting a selection bias that may not be fully treated with biocompatible solutions.
Woodrow et al. BMC Nephrology (2017) 18:333 Page 8 of 23

Peritoneal dialysis (PD) (guidelines PD 2.1–2.4)
Audit Measure 10: Audit of care pathway for
Guideline 2.1 – PD: Preparation for peritoneal dialysis catheter insertion to include timeliness and need for
We recommend that all patients (and parents of paediatric temporary haemodialysis
patients) should, where possible, be adequately prepared
for renal replacement therapy and this should include re- Rationale
ceiving information and education about PD treatment, The arguments and rationale for this guideline relate to
delivered by an experienced member of the MDT. Patients the National Service Framework for Renal Services, Part
commencing RRT in an unplanned fashion for whatever 1. The reader is referred to standard 3, Elective Dialysis
reason should receive this information once appropriate Access Surgery, pp. 24–26. The Moncrief catheter is
(1C). Fast track education and urgent PD catheter inser- buried subcutaneously and is designed to be left in this
tion with acute start of PD should be available, and be position, where it can remain for many months, until
offered to suitable patients urgently starting on RRT who required [62].
wish to avoid temporary haemodialysis, with the associ-
ated negative aspects of temporary vascular access and Guideline 2.3 – PD: Preparation for peritoneal dialysis
disruption to their lives (1C). We recommend that PD catheter insertion practice should
be managed according to the Renal Association Peritoneal

Audit Measure 8: Audit of care pathway for Access Guidelines. Paediatric PD access procedures
dialysis preparation to include information given will routinely be performed under general anaesthetic
(including proportion of patients offered PD), when (Ungraded).
and who delivers it.

Audit Measure 9: Audit of information on modality Guideline 2.4 – PD: Preparation for peritoneal dialysis
options provided to patients presenting who urgently We recommend that peri-operative catheter care and
require RRT, and both initial and subsequent modality catheter complications (leaks, hernias, obstruction) should
of RRT selected by these patients. be managed according to the International Society of
Peritoneal Dialysis guidelines 2005, and for children,
Rationale the European Elective Chronic Peritoneal Dialysis Guide-
The arguments and rationale for this guideline relate to line 2001 (Ungraded).
the National Service Framework for Renal Services, Part
1. The reader is referred to standard 2, Preparation and
Audit Measure 11: Catheter complications and
Choice pp. 21–23. The vast majority of patients com- their resolution
mencing dialysis are medically suitable to receive PD if
they select it. Some commonly perceived medical “con- Rationale
traindications” to PD are overstated. The majority of Recommendations for management of PD catheter in-
patients with a previous history of major abdominal sertion in adults are contained in the Renal Association
surgery may successfully be treated with PD [58]. It is Peritoneal Access Guidelines. The same principles apply
also unusual to be unable to achieve target small solute in paediatric practice, except that procedures in children
clearances in the majority of larger patients (with the will routinely be performed under general anaesthetic.
availability of APD, even when anuric). For management of the catheter in the peri-operative
When patients present needing prompt, unplanned period, for catheter related problems including leak (in-
start to renal replacement therapy, rapid insertion of a ternal and external), poor flow, obstruction and hernias,
PD catheter with acute start of PD, along with fast track the guidelines developed by the International Society of
education regarding dialysis modalities, may allow a Peritoneal Dialysis, [Link] [63, 64] and the European
proportion to commence directly on PD, avoiding tempor- Elective Chronic Peritoneal Guideline [13] should be used.
ary vascular access and urgent haemodialysis [59–61]. Such Catheter problems due to increased intra-peritoneal pres-
patients who initially receive acute start of haemodialysis sure, especially leaks, hernias and prolapse are an important
should receive follow up education regarding RRT options. medical indication for the use of APD either temporarily or
permanently; poor flow or catheter related flow pain should
Guideline 2.2 – PD: Preparation for peritoneal dialysis be treated with tidal APD. In the majority of cases where
We recommend that, where possible, timing of PD catheter surgical repair for mechanical complications is required
insertion should be planned to accommodate patient con- (e.g. catheter replacement, hernia repair) it is possible to
venience, commencement of training between 10 days and avoid the need to temporary haemodialysis. In many PD
6 weeks and before RRT is essential to enable correction of patients, remaining residual renal function may permit an
early catheter-related problems without the need for tem- adequate period post-surgery before dialysis needs to be
porary haemodialysis (1C). recommenced. Where PD does need to start soon after
Woodrow et al. BMC Nephrology (2017) 18:333 Page 9 of 23

surgery, in many cases this may be safely achieved by initial by the difficulty in PD patients of estimating V accur-
use of APD with small volume exchanges and avoiding a ately, whilst peritoneal creatinine clearances are affected
day dwell in ambulant patients [65]. by membrane transport characteristics (see Appendix).

Peritoneal dialysis (PD) (guidelines PD 3.1–3.3) Guideline 3.2.1 – PD: Solute clearance
Guideline 3.1 – PD: Solute clearance We recommend that a combined urinary and peritoneal
We recommend that both residual urine and peritoneal Kt/Vurea of 1.7/week or a creatinine clearance of 50 L/
dialysis components of small solute clearance should be week/1.73m2 should be considered as minimal treatment
measured at least six monthly or more frequently if doses for adults (1A). We recommend/suggest that
dependant on residual renal function to achieve clear- clearance targets for children should be a minimum of
ance targets or if clinically or biochemically indicated those for adults (1C).
in adults and in children. Both urea and/or creatinine
clearances can be used to monitor dialysis adequacy Guideline 3.2.2 – PD: Solute clearance
and should be interpreted within the limits of the We recommend that the dose of dialysis should be in-
methods (1C). creased in patients experiencing uraemic symptoms, or
inadequate growth in children, even if meeting mini-

Audit Measure 12: Frequency of solute clearance mum clearance targets (1B).
(residual and peritoneal) estimation
Guideline 3.3 – PD: Solute clearance
Rationale We recommend that a continuous 24 h PD regime is
Small solute clearance is one of the measurements of preferred to an intermittent regime for anuric patients
adequate dialysis treatment. Salt and water removal and (1B).
acid-base balance are considered in sections 4 and 6
respectively. There are two issues in measuring small solute
Audit Measure 13: Cumulative frequency curves
clearance that need to be taken into consideration. for the total solute clearance
First, the relationship to clinical outcomes of residual
renal versus peritoneal small solute clearance is quanti- Rationale
tatively different. Observational studies have shown that Two randomised controlled trials (ADEMEX and Hong
preserved renal clearance, in fact just urine volume, is Kong) have evaluated the impact of peritoneal solute
associated with improved survival, independent of other clearances on clinical endpoints [68, 69]. Neither found
known factors such as age and comorbidity [66, 67]. that an increase of peritoneal Kt/Vurea > 1.7 was associated
Randomised controlled trials designed to replace this with an improvement in survival. Only one of these studies
residual renal function with peritoneal clearance did not (ADEMEX) measured creatinine clearance, which was the
show a proportional survival benefit [68, 69]. The rec- solute used to make decisions in this case; patients in the
ommendation to measure solute clearance six-monthly control group achieved an average peritoneal creatinine
is driven primarily by the residual renal function compo- clearance of 46 L/1.73m2/week and a total (urine plus
nent; indeed if dialysis dose has not been changed the renal) of 54 L/1.73m2/week. In setting a recommendation
peritoneal component will not be different and it would for minimal peritoneal clearances, to be achieved in anuric
be acceptable just to measure the residual renal function. patients, the previous Renal Association guideline of Kt/
Indeed RRF can fall rapidly in some patients, certainly V > 1.7 and creatinine clearance >50 L/1.73m2/week is sup-
within a few weeks. If there are clinical concerns (e.g. if ported by both the randomised and observational data. In
changes in symptoms, blood biochemistry, reported fall the Hong Kong study, patients randomised to a Kt/V < 1.7,
in urine output or after potential insults to residual renal whilst their mortality was not significantly worse they had a
function), or if achievement of solute clearance target is significantly higher drop out rate, more clinical complica-
dependent on residual renal function, this should be tions and worse anaemia. One observational longitudinal
undertaken more frequently. study demonstrated that patients develop malnutrition
Second, there are two potential surrogate solutes, urea once the Kt/V falls below 1.7 with a three-fold increase in
and creatinine, that can be used to measure solute clear- the death rate [70]. The NECOSAD study found that a
ance in PD patients. There is no clear evidence as to creatinine clearance of <40 L/week or a Kt/V urea <1.5 was
which is the more useful clinically, and both have their associated with increased mortality in anuric patients [71].
problems. Current advice, therefore, is that either one or The vast majority of PD patients will be able to reach
both can be used, ensuring that minimal clearances are these clearance targets, especially if APD is employed
achieved for at least one, but clinicians should be aware [72]. These guidelines must however be viewed as rec-
of their differing limitations. Urea clearances are limited ommendations for minimal overall clearance. In patients
Woodrow et al. BMC Nephrology (2017) 18:333 Page 10 of 23

with residual renal function this renal clearance can be Peritoneal dialysis (PD) (guidelines PD 4.1–4.5)
subtracted from the peritoneal clearance with confidence Guideline 4.1 – PD: Ultrafiltration and fluid management
that the value of equivalent renal clearances is greater. We recommend that peritoneal membrane function
Equally, in a patient achieving these clearances but ex- should be monitored regularly (6 weeks after commen-
periencing uraemic symptoms, including reduced appe- cing treatment and at least annually or when clinically
tite or nutritional decline, or failing to achieve adequate indicated) using a peritoneal equilibration test (PET) or
acid base balance (see section 6) then the dialysis dose equivalent. Daily urine and peritoneal ultrafiltration vol-
should be increased. Drop out due to uraemia or death umes, with appropriate correction for overfill, should be
associated with hyperkalaemia and acidosis was signifi- monitored at least six-monthly (1C).
cantly more common in the control patients in the
ADEMEX study [68]. In patients with borderline clear-
Audit Measure 14: Frequency of measurement of
ances, who fail to achieve these clearance targets, other membrane function, residual urine and peritoneal
aspects of patient wellbeing, long-term prognosis from ultrafiltration volume
other comorbidity and patient perspective should be
considered in deciding whether switch of modality to Rationale
haemodialysis is appropriate. It is important to note Assessment of membrane function, specifically solute
that spuriously low Kt/V urea may arise due to over- transport rate and ultrafiltration capacity) is fundamental
estimation of V in patients with significant obesity (see to PD prescription. (See Appendix for methodological
Appendix). description of membrane function tests). This is for the
ADEMEX randomised patients between a “standard” following reasons:
CAPD regime of 4 × 2 l exchanges (rather than a spe-
cific clearance value) vs enhanced prescription to obtain a. There is considerable between-patient variability
specified clearance targets [68]. Thus this study should in both solute transport and ultrafiltration
not be used to justify routine reduction of dialysis pre- capacity that translates into real differences in
scription down to minimum clearance targets. The large achieved solute clearance and ultrafiltration
ANZDATA observational study suggested a lower sur- unless they are accounted for in prescription
vival with low peritoneal Kt/V [73]. One possible inter- practice [78–81]
pretation of the data is that low peritoneal clearances b. Membrane function is an independent predictor of
were linked to reduced dialysis prescription in patients patient survival; specifically high solute transport
with good residual renal function. and low ultrafiltration capacity are associated with
There is a discrepancy between clearance of small sol- worse outcomes [82–86]
utes and larger molecules, which are more dependent on c. Membrane function changes with time on therapy.
time of contact of dialysate with the peritoneal mem- There are early changes – usually during the first
brane than dialysate volume [74]. Thus continuous few weeks of treatment that can be avoided by
regimes are preferred to those with “dry” periods (e.g. performing tests 6 weeks after commencing PD.
NIPD), particularly in anuric patients, even if small Later changes vary between patients but tend to
solute clearance targets can be achieved without con- be increasing solute transport and reduced
tinuous therapy. An exception to this is in the situ- ultrafiltration capacity; the rate of membrane
ation where a patient still has a large residual renal change is accelerated in patients with earlier loss
function. of residual renal function and greater requirement
In paediatrics there is a lack of high quality evidence for hypertonic glucose solutions [87, 88].
to determine clearance targets for children on PD. In
small children and infants, Kt/V is likely to be dispro- The European Renal Best Practice advisory board have
portionately high compared with creatinine clearance produced detailed recommendations for the method-
and adult targets are particularly inadequate in these ology of evaluation of peritoneal membrane function in
patients [75]. It is suggested by British Association of clinical practice, and for utilising the results in PD pre-
Paediatric Nephrology that the adult targets should be scription [89].
considered as minimum desirable, with an increase in Residual renal function, as discussed above, is one of
PD prescription in the presence of features of uraemia, the most important factors, along with age, comorbidity,
including inadequate growth [76]. Evidence in small nutritional status, plasma albumin and membrane func-
numbers of subjects has suggested that in children in- tion that predict survival in PD patients. Its rate of loss
creasing dialysis prescription may reach a point of no is variable and clinically significant changes can occur
further benefit or adverse effects on nutrition due to within 6 months. Total fluid removal is associated with
increased dialysate protein removal [77]. patient survival, especially once anuric [85, 90, 91].
Woodrow et al. BMC Nephrology (2017) 18:333 Page 11 of 23

Guideline 4.2 – PD: Ultrafiltration and fluid management
Audit Measure 16: Number of patients regularly
We recommend that dialysis regimens resulting in fluid requiring hypertonic (3.86% glucose) exchanges to
reabsorption should be avoided. Patients with high or high maintain fluid balance
average solute transport, at greatest risk of this problem,
should be considered for APD and icodextrin (1A). Rationale
There is growing evidence that regular use of hypertonic

Audit Measure 15: Identify patients with fluid glucose dialysis fluid (3.86%), and where possible glucose
reabsorption in long dwell 2.27%, is to be avoided as far as possible. It is associated
with acceleration in the detrimental changes in membrane
function that occur with time on treatment [80, 103], as
Rationale well as several undesirable systemic effects including
Increased solute transport has been repeatedly shown to weight gain [94, 104], poor diabetic control, delayed gas-
be associated with worse survival, especially in CAPD tric emptying [105], hyperinsulinaemia [106] and adverse
patients [82–84, 86]. The explanation for this association haemodynamic effects [107]. In addition to patient educa-
is most likely to be because of its effect on ultrafiltration tion to avoid excessive salt and fluid intake, where possible
when this is achieved with an osmotic gradient (using the use of hypertonic glucose should be minimised by en-
glucose or amino-acid dialysis fluids). The reason is two- hancing residual diureses with the use of diuretics (e.g.
fold: first, due to more rapid absorption of glucose, the frusemide 250 mg daily) [108]. Substituting icodextrin for
osmotic gradient is lost earlier in the cycle resulting in glucose solutions during the long exchange will result in
reduced ultrafiltration capacity. Second, once the osmotic equivalent ultrafiltration whilst avoiding the systemic ef-
gradient is dissipated the rate of fluid reabsorption in high fects of the glucose load [94, 98, 107]. Observational evi-
transport patients is more rapid. This will result in signifi- dence would suggest that icodextrin is associated with less
cant fluid absorption, contributing to a positive fluid bal- functional deterioration in the membrane in APD patients
ance, during the long exchange. [103].
These problems associated with high transport can
be avoided by using APD to shorten dwell length and Guideline 4.4 – PD: Ultrafiltration and fluid management
by using icodextrin for the long exchange to prevent We recommend that treatment strategies that favour
fluid reabsorption. Several randomised controlled tri- preservation of renal function or volume should be adopted
als have shown that icodextrin can achieve sustained where possible. These include the use of ACEi, ARBs (in
ultrafiltration in the long dwell [92–96] and that this adults only) and diuretics, and the avoidance of episodes of
translates into a reduction in extracellular fluid volume dehydration (1B).
[97, 98]. Observational studies indicate that high solute
transport is not associated with increased mortality or Rationale
technique failure in APD patients, especially when there is This is the single most important parameter in PD
also a high use of icodextrin [84, 85, 99]. Results from the patients, and also the one most likely to change with time.
ANZDATA Registry show that in high transport pa- Clinically significant changes can occur within three
tients, treatment with APD was associated with a months. Because secretion of creatinine by the kidney at
superior patient survival compared with CAPD [100]. low levels of function overestimates residual creatinine
Survival in low transport patients in contrast was clearance, it is recommended to express this as the mean
lower with APD. A Korean registry study reported a of the urea and creatinine clearances. Observational and
benefit of icodextrin on patient and PD technique sur- randomised studies have shown that episodes of volume
vival [101] but adequately powered randomised trials depletion, whether unintentional or in response to active
to confirm this are still needed [102]. fluid removal with the intent of changing blood pressure
A difference in practice for paediatrics is that patients or fluid status, are associated with increased risk of loss in
with an underlying diagnosis of renal dysplasia are often residual renal function [97, 98, 109]. Care should be taken
polyuric, and so not so dependent on peritoneal ultrafil- not to volume deplete a PD patient too rapidly or exces-
tration for maintenance of euvolaemia. sively. The need to determine an appropriate target weight
to avoid the cardiac complications of occult fluid overload,
whilst avoiding loss of residual renal function due to ex-
Guideline 4.3 – PD: Ultrafiltration and fluid management cessive fluid removal is a major challenge in the manage-
We recommend that dialysis regimens resulting in rou- ment of the PD patient who has still has a significant
tine utilisation of hypertonic (3.86%) glucose exchanges residual urine output. The use of diuretics to maintain
should be minimised. Where appropriate this should be urine volume is not associated with a risk to renal clear-
achieved by using icodextrin or diuretics (1B). ances [108]. ACE inhibitors, (Ramipril 5 mg) [110] and
Woodrow et al. BMC Nephrology (2017) 18:333 Page 12 of 23

ARBs (valsartan) [111] have been shown in randomised Peritoneal dialysis (PD) (guidelines PD 5.1–5.2)
studies in adults to maintain residual diuresis. A Cochrane Guideline 5.1 – PD: Infectious complications
review also suggested superior preservation of residual
function in PD with ACEis or ARBs [112]. Evidence for a Guideline 5.1.1 – PD infectious complications:
benefit of ACE inhibitors or ARBs to preserve residual Prevention strategies We recommend that PD units
renal function in children is lacking, and a recent report should undertake regular audit of their peritonitis and
from the International Pediatric Peritoneal Dialysis Net- exit-site infection rates, including causative organism,
work registry suggested that renin-angiotensin blockade treatment and outcomes. They should enter into active
could be associated with an increased risk of loss of re- dialogue with their microbiology department and infec-
sidual renal function in children [113], and so these drugs tion control team to develop optimal local treatment
are not recommended for preservation of kidney function and prevention protocols (1B).
in paediatric PD patients. Paediatric practice may also dif-
fer with the management of a subgroup of patients with Guideline 5.1.2 – PD infectious complications:
renal dysplasia and a tendency to polyuria. Prevention strategies We recommend that flush-
before-fill dialysis delivery systems should be used for
Guideline 4.5 – PD: Ultrafiltration and fluid management CAPD (1A).
We recommend that anuric patients who are overhydrated
and consistently achieve a daily ultrafiltration of less than Guideline 5.1.3 – PD infectious complications:
750 ml in adults (or equivalent volume for body size in Prevention strategies We recommend that patients
paediatrics) should be closely monitored. These patients (and/or carers or parents) should undergo regular revision
may benefit from prescription changes and/or modality of their technique (at least annually or more frequently if
switch (1B). indicated, such as after an episode of PD-related infection
or a significant interruption to the patient performing

Audit Measure 17: Identify anuric patients with a PD) and receive intensified training if this is below
total fluid removal <750 ml per day. standard (1C).

Guideline 5.1.4 – PD infectious complications:

Rationale
Prevention strategies We recommend that initial
Observational studies have consistently shown that re-
catheter insertion should be accompanied by antibiotic
duced peritoneal ultrafiltration is associated with worse
prophylaxis (1B).
survival rates; whilst this is seen in studies with or with-
out residual urine [90], this effect is most marked in
anuric patients [85]. In the only prospective study to Guideline 5.1.5 – PD infectious complications:
have pre-set an ultrafiltration target (750 ml/day), patients Prevention strategies We recommend that invasive
who remained below this had higher mortality after cor- procedures should be accompanied by antibiotic prophy-
recting for age, time on dialysis, comorbidity and nutri- laxis and emptying the abdomen of dialysis fluid for a
tional status. It is likely this association is multifactorial, period commensurate with the procedure (1C).
but failure to prescribe sufficient glucose or icodextrin
and a lower ultrafiltration capacity of the membrane were Guideline 5.1.6 – PD infectious complications:
factors in this study and should be considered [85, 114]. Prevention strategies We recommend that topical
The European guidelines have suggested a 1 l minimal antibiotic administration should be used to reduce the
daily ultrafiltration target [115] but there is insufficient frequency of exit-site infection and peritonitis (1A).
evidence to say that such a target must be met at this
stage. It is possible that in some patients with low ultrafil-
Audit Measure 18: Routine annual audit of
tration, this is appropriate to their low fluid intake, and infection prevention strategies
that in these cases decreased survival possibly results from
Audit Measure 19: Routine annual audit of PD
poor nutrition rather than fluid excess, and that increasing peritonitis rates (including proportion of culture
ultrafiltration would simply result in dehydration with its negative cases)
adverse effects. Blood pressure, salt (and fluid) intake,
nutritional and fluid status, and presence of any features Rationale
of uraemia should be taken into account. Nevertheless The rationale underpinning the guidelines in this section
patients with less than 750 ml ultrafiltration once anuric is laid out in a series of documents published by the
should be very closely monitored and the potential bene- International Society of Peritoneal Dialysis, available on
fits of modality switch considered. their web-site: [Link].
Woodrow et al. BMC Nephrology (2017) 18:333 Page 13 of 23

Prevention strategies: The ISPD 2016 PD-related Guideline 5.2 – PD: Infectious complications
infections guideline, the ISPD 2011 position statement
on reducing the incidence of PD-related infections, 2017 Guideline 5.2.1 – PD infectious complications:
ISPD catheter-related infection recommendations and Treatment We recommend that exit site infection is
the 2012 ISPD guideline for prevention and treatment of suggested by pain, swelling, crusting, erythema and serous
catheter-related infections and peritonitis in paediatric discharge; purulent discharge always indicates infection.
patients receiving PD [116–119] place increasing em- Swabs should be taken for culture and initial empiric
phasis on prevention strategies. Regular audit is essential therapy should be with oral antibiotics that will cover
to this progress with a team approach to quality im- S. aureus and P. aeruginosa (1B).
provement [117] and the following standards should be
considered as minimal: Guideline 5.2.2 – PD infectious complications:
Treatment We recommend that methicillin resistant
1. Peritonitis rates of less than 0.5 episode per patient organisms (MRSA) will require systemic treatment (e.g.
year in adults and children vancomycin) and will need to comply with local infec-
2. A primary cure rate of >80% tion control policies (1C).
3. A culture negative rate of <20%

Patient training to perform PD technique by experi- Guideline 5.2.3 – PD infectious complications:

enced PD nurses trained to do this as part of a forma- Treatment We recommend that initial treatment regi-
lised training programme is essential in patients mens for peritonitis should include cover for bacterial
commencing PD [120]. Greater experience of nurses Gram positive and Gram negative organisms including
providing training is associated with greater time to Pseudomonas species until result of culture and antibiotic
initial episode of peritonitis [121]. It is recommended sensitivities are obtained (1C).
that review of patient PD technique is performed on a
regular basis, at least annually, or more frequently if
Audit Measure 20: Routine annual audit of
there is evidence of inadequate technique or develop- infection outcomes
ment of PD –related infection, or a significant inter-
ruption in the performing PD e.g. after a significant Rationale
period of hospitalisation). Approaches that have been The International Society of Peritoneal Dialysis (ISPD)
shown to reduce infection rates in randomised studies has developed a simple scoring system for exit site signs
include increased intensity of training, use of flush be- and symptoms which is easy to use and gives guidance
fore fill systems, antibiotic prophylaxis to cover cath- on when to treat immediately rather than waiting for a
eter insertion and prevention of exit-site infections swab result. Purulent discharge is an absolute indicator
[116, 117]. Several studies have addressed the latter for antibiotic treatment [126].
issue; following demonstration that the risk of Staph The ISPD has become less dogmatic about the initial
aureus exit site infection (the organism most fre- choice of antibiotic treatment for peritonitis, provided
quently responsible) is associated with pre-existing that gram positive and negative infections are covered
skin carriage, several randomised studies demonstrated [116]. It is recognised that patterns of resistance vary
that clinical exit-site infection and associated periton- considerably and thus a local policy must be developed.
itis could be reduced by either nasal or exit-site appli- Studies do not currently demonstrate a favoured regime
cation of mupirocin. This has led to the practice of [127]. For exit site infections the presence of a tunnel
applying mupirocin to all patients [122, 123] and this infection should be recognised as it may require more
approach should be discussed with the local microbiol- aggressive management. We concur with the ISPD guide-
ogy and infection control team. A systematic review lines that suggest suitable antibiotic dosing regimens, in-
has confirmed the benefits of prophylactic mupirocin cluding options for intermittent and continuous dosing of
in preventing exit-site infections and Staph aureus intraperitoneal antibiotics. We also note their comment
peritonitis [124] A more recent study, comparing that infections from Gram negative organisms are more
mupirocin with gentamicin cream, found that the lat- likely to lead to refractory or recurrent peritonitis. A single
ter prevented both Staph aureus and Pseudomonas study suggested that treating Gram negative peritonitis
exit-site infections and peritonitis episodes [125]. This with 2 appropriate antibiotics might be associated with
approach should be considered in patients with a better outcomes. It is also important to be aware of the
known history of Pseudomonas infections; again the potential for impaired absorption of oral antibiotics in
policy should be discussed and agreed with the local some situations, e.g. co-prescription of ciprofloxacin with
microbiology team. some phosphate binders [128].
Woodrow et al. BMC Nephrology (2017) 18:333 Page 14 of 23

We would emphasise the ISPD guidelines that it is im- the vast majority of patients by adjusting the dialysis dose
portant that timely PD catheter removal is undertaken and/or dialysate buffer concentration (1B).
in refractory PD peritonitis [116]. PD catheter removal
or swap is also required in refractory exit site infections,
Audit measure 21: Cumulative frequency curves of
and may be required earlier where there is a Pseudomonas plasma bicarbonate
infection or associated tunnel infection, which can be con-
firmed by ultrasound imaging [126, 129].
Rationale
There will be a lower threshold in paediatrics for
Two randomised controlled trials have suggested that
admission for IV antibiotics (at least for first 48 h), espe-
clinical outcomes, including gaining lean body mass and
cially in infants and small children where oral antibiotics
reduced hospital admissions are achieved if the plasma
commonly cause diarrhoea/feed intolerance.
bicarbonate is kept within the upper half of the normal
range [132, 133]. Generally this can be achieved by using
Peritoneal dialysis (PD) (guidelines PD 6.1–6.4) dialysis fluids with a 40 mmol buffer capacity (lactate or
Guideline 6.1 – PD: Metabolic factors bicarbonate results in similar plasma bicarbonate levels
We recommend that standard strategies to optimise [134] and ensuring that the dialysis dose is adequate (see
diabetic control should be used; these should be comple- section 3 (b), above) [135]. However, for solutions with a
mented by dialysis prescription regimens that minimise lower buffering capacity, when patients are switched
glucose, including glucose-free solutions (icodextrin and from an all lactate (35 mmol/l) to a 25 mmol bicarbonate:
amino-acids), where possible (1B). 10 mmol lactate mix, there is a significant improvement
in plasma bicarbonate (24.4 to 26.1 mmol/l), such that a
Rationale higher proportion of patients will fall within the normal
Glycaemic control can be made worse by glucose ab- range [136]. Whilst bicarbonate solutions may have a role
sorption across the peritoneal membrane. Dialysis regi- in biocompatibility (see section 1(e), above), they are
mens that incorporate less glucose and more glucose generally not required to achieve satisfactory acid-base
free (amino acid, icodextrin) solutions have been shown balance in adults. The main reason for using a 35 mmol
to improve glycaemic control [130, 131]. Diabetes is a buffer capacity solution (25:10 bicarbonate:lactate mix)
rare cause of end-stage renal failure in paediatrics, but is to avoid excessive alkalinisation [137]. Plasma bicar-
these principles would also apply to children on PD who bonate will also be affected by some phosphate binders
have diabetes. The IMPENDIA-EDEN randomised con- that either increase, or occasionally (sevelamer hydro-
trolled study compared all-glucose regimes with regimes chloride) decrease concentrations. In paediatric prac-
including both icodextrin and amino acid PD dialysis tice in UK, use of neutral pH/low GDP solutions is
fluids in diabetic patients on PD demonstrated a 0.5% routine.
reduction in glycated haemoglobin [131]. Serum trigly- Control of acidosis is especially important in mal-
ceride, very-low-density lipoprotein, and apolipoprotein nourished patients who may benefit from the glucose
B also improved. However it is important to note that available in dialysis solutions as a calories source.
the intervention group suffered an increase in adverse Amino acid solutions were developed in an attempt to
events and deaths, including events related to extracellu- address protein calorie malnutrition and several rando-
lar fluid expansion [131]. It is therefore critical that this mised studies have been conducted. In using amino
approach with use of low-glucose solutions is accompan- acid solutions it is essential to ensure that acidosis
ied by careful monitoring of hydration and is not at the does not develop and to use the solution at the same
expense of a decline in fluid management. It also should time as there is a significant intake of carbohydrate
not be an alternative to appropriate use of hypoglycaemic [138]. Despite demonstration that amino acids deliv-
drugs, and monitoring for hypoglycaemia is important in ered in dialysis fluids are incorporated into tissue pro-
patients where dialysate glucose load is reduced. tein, the randomised trials have failed to show benefit
Although there is no strong equivalent evidence in in terms of hard clinical endpoints [139, 140].
paediatrics, it is suggested that the principles of mini-
misation of peritoneal glucose exposure to avoid obesity Guideline 6.3 – PD: Metabolic factors
and reduce the adverse effects on peritoneal membrane We suggest that central obesity can worsen or develop
function should also apply to children. in some PD patients. The risk of this problem, and asso-
ciated metabolic complications, notably increased ather-
Guideline 6.2 – PD: Metabolic factors ogenicity of lipid profiles and insulin resistance, can be
We recommend that plasma bicarbonate should be main- reduced by avoiding excessive glucose prescription and
tained within the normal range. This can be achieved in using icodextrin (2C).
Woodrow et al. BMC Nephrology (2017) 18:333 Page 15 of 23

Rationale to diagnose hypoglycaemia. This has been reported on

Weight gain, or regain, is common after starting peritoneal several occasions in the literature and has contributed to
dialysis and this is associated with a worsening in the lipid at least one death. Typically these errors occur in places
profile [141, 142], though there may not be a significant and circumstances in which staff not familiar with peri-
difference from haemodialysis [143]. Randomised studies toneal dialysis work, for example emergency rooms and
comparing glucose 2.27% with icodextrin in the long ex- non-renal wards. A number of solutions to this problem
change have shown that the latter prevents weight gain, are under active review (e.g. use of alarm bracelets) but it
which in body composition studies is at least in part fat is also the responsibility of health-care professionals to en-
weight. Substituting icodextrin for 2.27% glucose in the sure that clinical environments in which their patients
long dwell also improves insulin resistance [144]. There is using icodextrin may find themselves are notified of this
limited available trial data on the benefit of statins in PD issue on a routine basis.
patients with a hard clinical endpoint. The 4D and AUR-
ORA studies did not include PD patients, and whilst Peritoneal dialysis (PD) (guidelines PD 7.1–7.3)
SHARP included 33% dialysis patients, only 5% of the study Guideline 7.1 – PD: Encapsulating peritoneal sclerosis
patients were receiving PD. There is no data on the effects
of lipid-lowering in children on PD. There are good reasons Guideline 7.1.1 – PD: Encapsulating peritoneal
for believing that the lipid abnormalities in the PD patient sclerosis: Diagnosis We recommend that the diagnosis
population may be different to patients on HD, and poten- of encapsulating peritoneal sclerosis (EPS) requires the
tially more atherogenic. The KDIGO guideline for lipid presence of a combination of clinical and radiological
management in CKD suggests that statins and/or ezetimibe features of intestinal obstruction and encapsulation
are not commenced in dialysis patients, but that they are GRADE 1B.
continued if a patient is receiving them before stating dialy-
sis [145] though it is important to note that the majority of Guideline 7.1.2 – PD: Encapsulating peritoneal
evidence this is based on is derived in haemodialysis sclerosis: Diagnosis We recommend that the radiological
patients. Observational data in one trial of adults has sug- technique of choice for the diagnosis of encapsulating
gested a possible benefit of statins in adults receiving PD peritoneal sclerosis (EPS) is CT scanning GRADE 1B.
[146]. The Canadian Society of Nephrology Guidelines
suggest that statins and/or ezetimibe should be considered Guideline 7.1.3 – PD: Encapsulating peritoneal
for adult PD patients [147]. sclerosis: Diagnosis We recommend that radiological
and biochemical screening methods are NOT of sufficient
Guideline 6.4 – PD: Metabolic factors sensitivity and specificity to be used clinically to identify
We recommend that awareness of the effects of Icodextrin early or imminent development of EPS in asymptomatic
on assays for estimation of amylase and glucose (using PD patients (GRADE 1C).
glucose dehydrogenase) should be disseminated to patients,
relatives, laboratory and clinical staff (1C). Rationale
Encapsulating peritoneal sclerosis (EPS) is rare, but serious

Audit Measure 22: Processes in place to increase complication of long-term PD. It involves formation of an
awareness of interference of assays by icodextrin inflammatory, and later fibrotic, “cocoon” surrounding the
metabolites gastrointestinal tract [156]. This results in features of ab-
dominal inflammation and intestinal obstruction. Symp-
Rationale toms may include abdominal pain, nausea, vomiting and
Use of icodextrin is associated with circulating levels of haemoperitoneum and may predate definitive diagnosis by
metabolites that can interfere with laboratory assays for significant time periods in some instances. Typical appear-
amylase (or actually suppress amylase activity) [148–151] ances will be noted at laparotomy or laparoscopy. EPS
and for glucose when finger-prick tests that utilise glucose should be distinguished from the thickening of the periton-
dehydrogenase as their substrate are employed (manufac- eal membrane that typically occurs with time on PD, but
tured by Boehringer Mannheim) [152–155]. In the case of which is not associated with obstructive features. Changes
amylase, the measured level will be reduced by 90%, leading in peritoneal membrane small solute transport and ultrafil-
to the potential failure in the diagnosis of pancreatitis. No tration capacity often occur [157–159], but are also com-
adverse events have been reported, but clinicians should be mon in long-term PD and not always present in EPS, so are
aware of this possibility. If clinical concern remains not of diagnostic value for EPS. There is no gold standard
then plasma lipase can be used. In the case of glucose for the diagnosis of EPS, and it is recommended that the
measurements, the methods using glucose dehydrogenase condition is diagnosed by the presence of the combination
will overestimate blood glucose levels, leading to a failure of characteristic clinical and radiological features [160, 161].
Woodrow et al. BMC Nephrology (2017) 18:333 Page 16 of 23

A challenge in this is that there is significant heterogeneity of any medical therapy for treating EPS. Corticosteroids,
in the condition with variation of severity and extent of immunosuppressants and tamoxifen have been used, and
peritoneal involvement [156, 162, 163]. The epidemi- may be tried at the physician’s discretion (GRADE 2C).
ology, clinical features, investigation and management
of EPS in paediatric patients is similar to that in adults Guideline 7.2.4 – PD: Encapsulating peritoneal
[164, 165]. Recommendations are developed from the sclerosis: Management We suggest that PD should
UK Encapsulating Peritoneal Sclerosis Clinical Practice usually be discontinued after diagnosis of EPS with
Guidelines 2009 [166]. transfer to haemodialysis. However, this should be an in-
Radiology plays a key role in the diagnosis of EPS. dividual patient decision considering, patient wishes, life
Plain abdominal X-rays may show features of bowel ob- expectancy and quality of life (GRADE 2C).
struction, but are non-diagnostic, except in cases where
peritoneal calcification is present as a feature suggestive
Audit Measure 23: Number of patients with
of EPS. CT scanning is recommended as the definitive diagnosis of EPS who are referred to designated
radiological investigation for the diagnosis of EPS specialist EPS centres.
[167–172]. It has high reproducibility and evaluation
has provided the basis of a standardised approach to Rationale
CT diagnosis of EPS [171]. The presence of peritoneal EPS is a rare and complex condition, whose optimal
calcification, bowel wall thickening, bowel tethering, management requires integrated care from an expert
and bowel dilatation are the features with greatest agree- team experienced in managing this condition. Multiple
ment between reporting radiologists [171]. Abdominal disciplinary input includes PD physicians, nurses, surgeons,
ultrasound may detect characteristic features in EPS [173]. dieticians, radiologists and intensive care physicians.
However, there is a limitation to depth of penetration of There is increasingly strong evidence for a central role
sound waves which may limit ability for thorough evalu- for surgery in the management of EPS [175–178]. Whilst
ation of the abdomen, and it is operator-dependent. Small earlier experience of EPS reported a high mortality for
bowel contrast studies may also have a role in defining the patients with this condition, and complications following
presence of strictures prior to surgery. surgery, in experienced hands, surgery results in high
At present, there are no investigations that can be rec- rates of resolution of symptoms and survival, and possibly
ommended to monitor or screen patients on long-term superior relief of obstruction compared with conservative
PD to identify those who will develop EPS. One study treatment with nutrition and/or drug treatment [178]. Sur-
has demonstrated that in patients developing EPS, who gery should be performed by a surgical team which has a
had abdominal CT scans for other reasons within a high level of expertise and experience with EPS, and the
period of a year or less prior to diagnosis of EPS, there appropriate multidisciplinary input and peri-operative renal
were no radiological abnormalities to suggest imminent and intensive care support. Surgical units at Manchester
development of EPS [174]. (Mr Titus Augustine), and Cambridge (Mr Chris Watson)
are designated as national referral centres for surgery relat-
Guideline 7.2 – PD: Encapsulating peritoneal sclerosis ing to EPS in England by NCG (National Commissioning
Group). An early surgical opinion facilitates decisions re-
Guideline 7.2.1 – PD: Encapsulating peritoneal garding the need for, preparation and timing of surgery.
sclerosis: Management We recommend that patients Indications for surgery include non-responsiveness to med-
with suspected encapsulating peritoneal sclerosis (EPS) ical treatment, bowel obstruction (acute and recurrent sub-
should be referred or discussed early with units who have acute), intraperitoneal bleeds, and peritonitis. A proportion
expertise in EPS surgery. Surgery should be performed by of patients with EPS may have a good outcome without
teams experienced in EPS surgery (GRADE 1B). surgery so further work to define those most likely to bene-
fit from surgery is needed. Where possible, surgery should
Guideline 7.2.2 – PD: Encapsulating peritoneal be timed to take place electively before the patient is too ill
sclerosis: Management We recommend that patients or nutritionally depleted. Surgery involves careful dissection
with EPS should have early dietetic referral and monitor- of thickened peritoneum from bowel loops to achieve max-
ing of nutritional status, with nutritional support by oral imal removal of sclerotic membrane from the bowel wall,
enteral, or often parenteral supplementation usually re- whilst avoiding inadvertent perforation [176].
quired (GRADE 1C). Reduced nutritional intake resulting from intestinal
dysfunction, plus an ongoing inflammatory state in EPS,
Guideline 7.2.3 – PD: Encapsulating peritoneal can lead to severe protein energy wasting [179, 180]. Nu-
sclerosis: Management We suggest that there is no tritional state is associated with survival in EPS. Patients
clear evidence to support a recommendation for the use with EPS should be referred early to a renal dietician to
Woodrow et al. BMC Nephrology (2017) 18:333 Page 17 of 23

allow nutritional assessment, monitoring and institution Rationale

of nutritional support where needed. In more severe cases, The risk of developing EPS is extremely low in the first
parenteral nutrition may be required [180], and in patients 3 years of PD and low before 5 years of therapy. The
where intestinal function does not recover, this may be re- overall reported incidence typically varies between 0.5–
quired on a permanent basis. In milder cases, nutrition 3% in reported series [187–190]. Whilst the risk in-
support may be managed with an energy dense diet or creases with time, the majority of patients on longer
prescription of oral nutritional supplements and anti- term PD will not develop EPS. The Scottish Renal Regis-
emetics. Where patients are unable to tolerate adequate oral try is notable in reporting a steeper rise of incidence
intake, nasogastric or nasojejunal feeding may be utilised. with time on PD, with 8.1% risk of EPS after 4–5 years
Whilst there has been much interest in drug treat- of PD [189]. Thus consideration of management of
ments for EPS, there is no robust evidence to support patients remaining on PD for longer term is warranted.
the use of anti-inflammatory or antifibrotic drugs in this However, it is unknown what impact elective discontinu-
condition. Corticosteroids have been most commonly ation of PD after a certain period of time will have on
used, particularly in the Japanese literature [178]. Any the risk of developing EPS. A significant proportion of
benefit is most likely with use in the early inflammatory cases of EPS occur after discontinuing PD (either trans-
stage of EPS. However there is not strong objective plantation [191, 192] or switching to haemodialysis), so
evidence for their effectiveness, and in EPS side effects it is even possible that elective switching from PD could
of immunosuppression and protein catabolism are a increase, rather than decrease, the risk of developing
particular concern. There are reports of use of immunosup- EPS. Discontinuing PD may also have potentially major
pressants including azathioprine and cyclosporine in EPS. adverse negative medical and social effects in some pa-
However evidence is largely as case reports, and as a com- tients. Concern about EPS risk on long-term PD should
mon setting for development of EPS is following transplant- be balanced against reports showing relatively good out-
ation, in patients taking these drugs, their therapeutic comes for EPS, relative to other competing risks [190],
effectiveness is doubtful. There is increasing interest in the and good outcomes and success rates for EPS surgery
role of tamoxifen, which is effective in other fibrotic condi- when required. Thus routine discontinuation of PD after
tions, in EPS [181, 182]. There is a suggestion from retro- a fixed period of time cannot be recommended. The
spective data of a beneficial effect of tamoxifen on survival risks and benefits of continuing PD or dialysis modality
[183] or that it could even have a preventative role [184], change should be considered and discussed with the in-
but robust evidence is currently lacking. dividual patient, as recommended in the ISPD 2009
PD is usually discontinued and the PD catheter removed Length of Time on Peritoneal Dialysis and Encapsulating
after diagnosis of EPS, with transfer to haemodialysis. How- Peritoneal Sclerosis Position Paper [193] (revised pos-
ever, as some cases are mild, the individual patient’s wishes ition paper will be published 2017).
and clinical state should be considered, as stopping PD may
not be appropriate in a patient with mild symptoms and a Lay summary
poor long term prognosis, where continuation of PD and/ These guidelines cover all aspects of the care of patients
or later conservative management may be appropriate. who are treated with peritoneal dialysis. This includes
Also, there is experience in Japan of leaving the PD catheter equipment and resources, preparation for peritoneal dialy-
in and performing peritoneal lavage after diagnosis of sis, and adequacy of dialysis (both in terms of removing
EPS, with observational non-randomised studies sug- waste products and fluid), preventing and treating infec-
gesting some benefit, though this approach is not wide- tions. There is also a section on diagnosis and treatment
spread in other countries [185, 186]. of encapsulating peritoneal sclerosis, a rare but serious
complication of peritoneal dialysis where fibrotic (scar)
Guideline 7.3 – PD: Encapsulating peritoneal sclerosis tissue forms around the intestine. The guidelines include
recommendations for infants and children, for whom peri-
Guideline 7.3 1– PD: Encapsulating peritoneal toneal dialysis is recommended over haemodialysis.
sclerosis: Duration of PD therapy We recommend Immediately after the introduction there is a statement
that there is no optimal duration of peritoneal dialysis or of all the recommendations. These recommendations
indication for routine elective modality switching. Decisions are written in a language that we think should be under-
regarding the duration of therapy should be tailored to the standable by many patients, relatives, carers and other
individual patient, taking into account clinical and social interested people. Consequently we have not reworded
factors and patient wishes, and should follow the principles or restated them in this lay summary. They are graded 1
outlined in the ISPD Length of Time on Peritoneal or 2 depending on the strength of the recommendation
Dialysis and Encapsulating Peritoneal Sclerosis Position by the authors, and A-D depending on the quality of the
Paper (GRADE 1C). evidence that the recommendation is based on.
Woodrow et al. BMC Nephrology (2017) 18:333 Page 18 of 23

Appendix d. The PET or SPA should be seen as a regular

Assessment of membrane function in adult PD patients screening test to monitor membrane function and in
most cases will explain clinically evident. Ultrafiltration
a. A number of methods to assess peritoneal membrane problems. More detailed assessment of the membrane
have been developed, the most commonly used, can be undertaken, in particular the double mini-PET.
supported by clinical observation being the Peritoneal For further advice on this see the European Renal Best
Equilibration Test (PET). This test measures two Practice Guidelines for assessing membrane function
aspects of membrane function, low molecular weight
solute transport (expressed as the dialysate:plasma ratio Measurement of solute clearance in adult PD patients
of creatinine at four hours), and the ultrafiltration In measuring solute clearance and planning changes to
capacity of the membrane. In the PET as originally the dialysis regime, three clinical parameters are essential:
described, ultrafiltration capacity is the net volume of Estimates of (1) patient size, (2) peritoneal solute transport
ultrafiltration achieved at four hours using a 2.27% and (3) RRF. In each case, the choice of surrogate “toxin”,
glucose exchange [194, 195]. In the simplified Standard urea or creatinine, interacts with each of these parameters
Permeability Analysis (SPA) test, it is the net volume of in different ways. At present, there is no clear evidence
ultrafiltration using a 3.86% exchange [196, 197]. from the literature that one surrogate is superior to an-
b. Using a standard PET, an ultrafiltration capacity of other. Where possible, clinicians should measure both, at-
<200 mls (including overfill) is associated with a 50% tempt to reach at least one of the targets, and understand
risk of achieving <1000 mls ultrafiltration in anuric why there appears to be a discrepancy. A number of com-
patients. Using a SPA test, an ultrafiltration capacity mercial computer programs exist that are designed to aid
of <400 mls indicates ultrafiltration failure. dialysis prescription. Whilst some have been validated,
c. The methods of performing PET and SPA tests are good practice dictates that a change in dialysis prescrip-
well described in the literature, The following points tion is checked for efficacy by repeating clearance studies.
should be remembered in the interpretation of results:

High concentrations of glucose interfere with Patient size
many assays for creatinine. It is important to In calculating urea clearances, patient size is expressed
work with the local biochemists to ensure that as an estimate of the total body water (volume of distri-
the appropriate correction for measurement of bution of urea). It is recommended that the Watson
creatinine in dialysate has been taken into account. formula is used for this [196]:

Remember that dialysis bags are overfilled, mainly
due to the additional fluid volume required to Males : V ¼ 2:447–0:09156 age ðyearsÞ
perform the ‘flush before fill’ procedure. Dialysis þ 0:1074 height ðcmÞ
manufacturers are being encouraged to publish þ 0:3362 weight kgÞ
overfill volumes which differ significantly. The Females : V ¼ −2:097 þ 0:1069 age ðyearsÞ
typical volume is 100-200 ml. The value of þ 0:2466 weight ðkgÞ
200 ml UF capacity defining ultrafiltration failure
quoted above includes the flush volume as this is Anthropometric equations estimating TBW may pro-
easier for patients to perform (the alternative is duce results significantly different to gold standard dilu-
weighing before and after flush which is time tion techniques (REF). This will impact on estimates of
consuming and difficult). Kt/V and is of relevance if borderline Kt/V values are

The patient should follow their usual dialysate obtained [197, 198]. Alternatively 58% of body weight
regime, draining out as completely as possible (kg) may be used; this is less precise, and will give lower
before the test dwell. Large residual volume of values for Kt/V, especially in obese patients. Creatinine
dialysate will affect the results. clearances should be corrected for body surface area,

Intra-patient variability of the ultrafiltration normalising to 1.73 m2.
capacity (~ 20%) is greater than for the solute
transport (<10%). Results of the PET/SPA, in Peritoneal solute transport
particular the ultrafiltration capacity, should Solute transport rates have an important influence on
always be interpreted in the light of additional peritoneal creatinine clearance, but not on urea clear-
exchanges performed during the same 24–48 h ance. This means that it is easier to achieve creatinine
period (usually collected to assess solute clearance targets in high transport patients. It should be
clearance – see below). remembered, however, that these patients might have

The PET/SPA are not surrogates for measuring less satisfactory ultrafiltration. In designing optimum
solute clearance. dialysis regimens, patients with low solute transport will
Woodrow et al. BMC Nephrology (2017) 18:333 Page 19 of 23

require equally spaced medium length dwells, such as Endorsements

are achieved with CAPD and single extra night exchanges The National Institute for Health and Care Excellence (NICE) has accredited the
process used by the Renal Association to produce its Clinical Practice Guidelines.
(e.g. 5 × 2.5 l exchanges). Those with high transport are Accreditation is valid for 5 years from January 2017. More information on
more like to achieve targets with short dwells (APD) plus accreditation can be viewed at [Link]/accreditation.
polyglucose solutions (e.g. 4 × 2.5 l exchanges overnight,
Method used to arrive at a recommendation
1 × 2.5 l evening exchange and 1 × 2.5 l daytime The recommendations for the first draft of this guideline resulted from a collective
icodextrin). decision reached by informal discussion by the authors and, whenever necessary,
with input from the Chair of the Clinical Practice Guidelines Committee. If no
agreement had been reached on the appropriate grading of a recommendation,
Residual renal function (RRF) a vote would have been held and the majority opinion carried. However this was
This is the single most important parameter in PD not necessary for this guideline.
patients, and also the one most likely to change with
Authors’ contributions
time. Clinically significant changes can occur within All authors read and approved the final manuscript.
three months. Because secretion of creatinine by the
kidney at low levels of function overestimates residual Competing interests
creatinine clearance, it is recommended to express this All authors made declarations of interest in line with the policy in the Renal
Association Clinical Practice Guidelines Development Manual. Further details
as the mean of the urea and creatinine clearances. can be obtained on request from the Renal Association.

Estimating Total Ultrafiltration Publisher’s Note

The total achieved ultrafiltration is best measured from Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
the 24-h dialysate collections used to calculate solute
clearance. For APD patients this is simple as machines Author details
1
now calculate the ultrafiltration volumes precisely. Fur- St James’s University Hospital Leeds Teaching Hospitals NHS Trust, Leeds,
UK. 2Royal London Hospital, London, UK. 3Evelina Children’s Hospital, Guy’s
thermore, many models store this information over sev- and St Thomas’ NHS Trust, London, UK. 4Peritoneal Dialysis Unit, St James’s
eral weeks so that an average value can be obtained. In University Hospital Leeds Teaching Hospitals NHS Trust, London, UK. 5Patient
CAPD patients it is important to remember that each Representative, c/o The Renal Association, Bristol, UK.
bag is overfilled to achieve flush before fill; the total di- Received: 10 July 2017 Accepted: 9 August 2017
alysate drain volume must be measured and sampled
from to calculate solute clearance accurately, but the
overfill must then be subtracted to calculate the net References
1. Fenton SSA, Schaubel DE, Desmeules M, et al. Hemodialysis versus
ultrafiltration. If this is not done then over a 24-h period peritoneal dialysis: a comparison of adjusted mortality rates. Am J Kidney
the overestimate of ultrafiltration may be anything from Dis. 1997;30(3):334–42.
200 to 800 ml depending on manufacturer [199, 200]. 2. Vonesh EF, Snyder JJ, Foley RN, Collins AJ. The differential impact of risk
factors on mortality in hemodialysis and peritoneal dialysis. Kidney Int. 2004;
Peritoneal sodium losses are largely determined by 66(6):2389–401.
convection and are thus proportional to the ultrafiltration 3. Heaf JG, Lokkegaard H, Madsen M. Initial survival advantage of peritoneal
volume. Typically 1 l of ultrafiltration results in 100 mmol dialysis relative to haemodialysis. Nephrol Dial Transplant. 2002;17(1):112–7.
4. Termorshuizen F, Korevaar JC, Dekker FW, Van Manen JG, Boeschoten EW,
of sodium loss in CAPD patients and 70–80 mmol in Krediet RT. Hemodialysis and peritoneal dialysis: comparison of adjusted
APD patients. mortality rates according to the duration of dialysis: analysis of the
Netherlands cooperative study on the adequacy of dialysis 2. J Am Soc
Nephrol. 2003;14(11):2851–60.
Assessment of membrane function in Paediatric PD 5. Collins AJ, Hao W, Xia H, et al. Mortality risks of peritoneal dialysis and
patients estimating Total Ultrafiltration hemodialysis. Am J Kidney Dis. 1999;34(6):1065–74.
6. McDonald SP, Marshall MR, Johnson DW, Polkinghome KR. Relationship
Methodology for the measurement of peritoneal membrane between dialysis modality and mortality. J Am Soc Nephrol. 2009;20:155–63.
function by PET and short PET in paediatric patients is 7. Weinhandl ED, Foley RN, Gilbertson DT, Arneson TJ, Snyder JJ, Collins AJ.
described by Warady and Jennings [201]. Propensity-matched mortality comparison of incident hemodialysis and
peritoneal dialysis patients. J Am Soc Nephrol. 2010;21:499–506.
8. Mehrotra R, Chiu Y-W, Kalantar-Zadeh K, Bargman J, Vonesh E. Similar
Measurement of solute clearance in Paediatric PD outcomes with hemodialysis and peritoneal dialysis in patients with end-
stage renal disease. Arch Intern Med. 2011;171:110–8.
patients 9. Yeates K, Zhu N, Vonesh E, Trpeski T, Blake P, Fenton S. Hemodialysis and
Estimation of the volume of total body water for deter- peritoneal dialysis are associated with similar outcomes for end-stage renal
mination of V in Kt/V in children may be by the equations disease treatment in Canada. Nephrol Dial Transplant. 2012;27:3568–75.
10. Lukowsky LR, Mehrotra R, Kheifets L, Arah OA, Nissenson AR, Kalantar-Zadeh
described by Morgenstern et al. [202]. K. Comparing mortality of peritoneal and Hemodialysis patients in the first 2
years of dialysis therapy: a marginal structural model analysis. Clin J Am Soc
Acknowledgements Nephrol. 2013;8:619–28.
This document has been externally reviewed by key stake holders according 11. Korevaar JC, Feith GW, Dekker FW, et al. Effect of starting with hemodialysis
to the process described in the Clinical Practice Guidelines Development compared with peritoneal dialysis in patients new on dialysis treatment: a
Policy Manual. randomized controlled trial. Kidney Int. 2003;64(6):2222–8.
Woodrow et al. BMC Nephrology (2017) 18:333 Page 20 of 23

12. Bro S, Bjorner JB, Tofte-Jensen P, et al. A prospective, randomized multicenter 39. Rigby RJ, Hawley CM. Sclerosing peritonitis: the experience in Australia.
study comparing APD and CAPD treatment. Perit Dial Int. 1999;19(6):526–33. Nephrol Dial Transplant. 1998;13(1):154–9.
13. Watson AR, Gartland C. Guidelines by an ad hoc European committee 40. Lee HY, Kim BS, Choi HY, et al. Sclerosing encapsulating peritonitis as a
for elective chronic peritoneal dialysis in pediatric patients. Perit Dial complication of long-term continuous ambulatory peritoneal dialysis in
Int. 2001;21:240–4. Korea. Nephrology (Carlton). 2003;8(Suppl):S33–9.
14. Rabindranath KS, Adams J, Ali TZ, Daly C, Vale L, AM ML. Automated vs 41. Rippe B, Wieslander A, Musi B. Long-term results with low glucose
continuous ambulatory peritoneal dialysis: a systematic review of degradation product content in peritoneal dialysis fluids. Contrib Nephrol.
randomized controlled trials. Nephrol Dial Transplant. 2007;22:2991–8. 2003;140:47–55.
15. Michels WM, Verduijn M, Boeschoten EW, Dekker FW, Krediet RT. Similar survival 42. Jones S, Holmes CJ, Krediet RT, et al. Bicarbonate/lactate-based peritoneal
on automated peritoneal dialysis and continuous ambulatory peritoneal dialysis dialysis solution increases cancer antigen 125 and decreases hyaluronic acid
in a large prospective cohort. Clin J Am Soc Nephrol. 2009;4:943–9. levels. Kidney Int. 2001;59(4):1529–38.
16. Mehrotra R, Chiu Y-W, Kalantar-Zadeh K, Vonesh E. The outcomes of 43. Jones S, Holmes CJ, Mackenzie RK, et al. Continuous dialysis with
continuous ambulatory and automated peritoneal dialysis are similar. bicarbonate/lactate-buffered peritoneal dialysis fluids results in a long-term
Kidney Int. 2009;76:97–107. improvement in ex vivo peritoneal macrophage function. J Am Soc
17. Hall G, Bogan A, Dreis S, et al. New directions in peritoneal dialysis patient Nephrol. 2002;13(Suppl 1):S97–103.
training. Nephrol Nurs J. 2004;31(2):149–54. 59-63 44. Williams JD, Topley N, Craig KJ, et al. The euro-balance trial: the effect of a
18. Zhang L, Hawley CM, Johnson DW. Focus on peritoneal dialysis training: new biocompatible peritoneal dialysis fluid (balance) on the peritoneal
working to decrease peritonitis rates. Nephrol Dial Transplant. 2015. https:// membrane. Kidney Int. 2004;66(1):408–18.
[Link]/10.1093/ndt/gfu403. 45. Marshall J, Jennings P, Scott A, Fluck RJ, McIntyre CW. Glycemic control in
19. Lewis NM, Pickering KR. Establishment of a formalized CAPD retraining diabetic CAPD patients assessed by continuous glucose monitoring system
program. Perit Dial Int. 1995;15:S58. (CGMS). Kidney Int. 2003;64(4):1480–6.
20. Bernardini J, Piraino B. Compliance in CAPD and CCPD patients as measured 46. Lee HY, Park HC, Seo BJ, et al. Superior patient survival for continuous
by supply inventories during home visits. Am J Kidney Dis. 1998;31(1):101–7. ambulatory peritoneal dialysis patients treated with a peritoneal dialysis
21. Ponferrada L, Prowant BF, Schmidt LM, Burrows LM, Satalowich RJ, Bartelt C. fluid with neutral pH and low glucose degradation product concentration
Home visit effectiveness for peritoneal dialysis patients. Anna J. 1993;20(3):333–6. (balance). Perit Dial Int. 2005;25(3):248–55.
22. Figueiredo AE, Bernadini J, Bowes E, et al. A syllabus for teaching peritoneal 47. Han SH, Ahn SV, Yun JY, Tranaeus A, Han D-S. Mortality and technique
dialysis to patients and caregivers. Perit Dial Int. 2016;36:592–605. failure in peritoneal dialysis using advanced peritoneal dialysis solutions. Am
23. Povlsen JV, Ivarsen P. Assisted automated peritoneal dialysis (AAPD) for the J Kidney Dis. 2009;54:711–20.
functionally dependent and elderly patient. Perit Dial Int. 2005;25(Suppl 3):S60–3. 48. Ahmad S, Sehmi JS, Ahmad-Zakhi KH, Clemenger M, Levy JB, Brown EA.
24. Brown EA, Johansson L. Dialysis options for end-stage renal disease in older Impact of new dialysis solutions on peritonitis rates. Kidney Int. 2006;70:S63–6.
people. Nephron Clinical Practice. 2011;119(Suppl 1):c10–3. 49. Montenegro J, Saracho R, Gallardo I, Martínez I, Muñoz R, Quintanilla N. Use
25. Brown EA, Wilkie M. Assisted peritoneal dialysis as an alternative to in-center of pure bicarbonate-buffered peritoneal dialysis fluid reduces the incidence
haemodialysis. Clin J Am Soc Nephrol. 2016;11:1522–4. of CAPD peritonitis. Nephrol Dial Transplant. 2007;22:1703–8.
26. Oliver MJ, Al-Jaishi AA, Dixon SN, et al. Hospitalization rates for patients on 50. Johnson DW, Brown FG, Clarke M, et al. The effects of biocompatible compared
assisted peritoneal dialysis compared with in-center hemodialysis. Clin J Am with standard peritoneal dialysis solutions on peritonitis microbiology, treatment
Soc Nephrol. 2016;11:1606–14. and outcomes: the BalANZ trial. Perit Dial Int. 2012;32:497–506.
27. Iyasere OU, Brown EA, Johansson L, et al. Quality of life and physical 51. Cho Y, Badve SV, Hawley CM, et al. Association of biocompatible peritoneal
function in older patients on dialysis: a comparison of assisted dialysis solutions with peritonitis risk, treatment and outcomes. J Am Soc
peritonealdialysis with hemodialysis. Clin J Am Soc Nephrol. 2016;11:423–30. Nephrol. 2013;8:1556–63.
28. Daly C, Cody JD, Khan I, Rabindranath KS, Vale L, Wallace SA. Double bag or 52. Cho Y, Johnson DW, Craig JC, Strippoli GFM, Badve SV, Wiggins KJ.
Y-set versus standard transfer systems for continuous ambulatory peritoneal Biocompatible dialysis fluids for peritoneal dialysis. Cochrane Database Syst
dialysis in end-stage kidney disease (Review). Cochrane Database Syst Rev. Rev. 2014;(3):CD007554. [Link]
2014;(8):CD003078. [Link] 53. Johnson DW, Brown FG, Clarke M, et al. The effect of low glucose
29. Mactier RA, Sprosen TS, Gokal R, et al. Bicarbonate and bicarbonate/lactate degradation product, neutral pH versus standard peritoneal dialysis
peritoneal dialysis solutions for the treatment of infusion pain. Kidney Int. solutions on peritoneal function: the balANZ trial. Nephrol Dial Transplant.
1998;53(4):1061–7. 2012;27:4445–53.
30. Liberek T, Topley N, Jorres A, et al. Peritoneal dialysis fluid inhibition of 54. Johnson DW, Brown FG, Clarke M, et al. Effects of biocompatible versus standard
polymorphonuclear leukocyte respiratory burst activation is related to the fluid on peritoneal dialysis outcomes. J Am Soc Nephrol. 2012;23:1097–107.
lowering of intracellular pH. Nephron. 1993;65(2):260–5. 55. Davies SJ. Preserving residual renal function in peritoneal dialysis: volume or
31. Jorres A, Bender TO, Finn A, et al. Biocompatibility and buffers: effect of biocompatibility? Nephrol Dial Transplant. 2009;24:2620–2.
bicarbonate-buffered peritoneal dialysis fluids on peritoneal cell function. 56. Seo E-Y, An SH, Cho JH, et al. Effect of biocompatible peritoneal dialysis
Kidney Int. 1998;54(6):2184–93. solution on residual renal function: a systematic review of randomized
32. Jörres A, Topley N, Steenweg L, Müller C, Köttgen E, Gahl GM. Inhibition of controlled trials. Perit Dial Int. 2014;34:724–31.
cytokine synthesis by peritoneal dialysate persists throughout the CAPD 57. Yohanna S, Alkatheeri AMA, Brimble SK et al. Effect of neutral-pH, low-
cycle. Am J Nephrol. 1992;12(1–2):80–5. glucose degradation product, peritoneal dialysis solutions on residual renal
33. McGregor SJ, Brock JH, Briggs JD, Junor BJ. Longitudinal study of peritoneal function, urine volume and ultrafiltration: A systematic review and meta-
defence mechanisms in patients on continuous ambulatory peritoneal analysis. Clin J Am Soc Nephrol. 2015. published ahead of print June 5 2015.
dialysis (CAPD). Perit Dial Int. 1989;9:115–9. [Link]
34. Topley N. Membrane longevity in peritoneal dialysis: impact of infection 58. Chen S-Y, Chen T-W, Lin S-H, Chen C-J, Yu Y-C, Kin C-H. Does previous
and bio- incompatible solutions. Adv Ren Replace Ther. 1998;5(3):179–84. abdominal surgery increase postoperative complication rates in continuous
35. Topley N, Alobaidi HM, Davies M, Coles GA, Williams JD, Lloyd D. The effect ambulatory peritoneal dialysis? Perit Dial Int. 2007;27:557–9.
of dialysate on peritoneal phagocyte oxidative metabolism. Kidney Int. 1988; 59. Povlsen JV, Ivarsen P. How to start late referred ESRD patient urgently on
34(3):404–11. chronic APD. Nephrol Dial Transplant. 2006;21(Suppl 2):ii56–9.
36. Davies SJ, Phillips L, Naish PF, Russell GI. Peritoneal glucose exposure and 60. Lobbedez T, Lecouf A, Ficheux M, Henri P, de Ligny BH, Ryckelynck J-P. Is
changes in membrane solute transport with time on peritoneal dialysis. J Am rapid initiation of peritoneal dialysis feasible in unplanned dialysis patients?
Soc Nephrol. 2001;12(5):1046–51. A single-centre experience. Nephrol Dial Transplant. 2008;23:3290–4.
37. Davies SJ. Longitudinal relationship between solute transport and ultrafiltration 61. Arramreddy R, Zheng S, Saxena AB, Liebman SE, Wong L. Urgent-start peritoneal
capacity in peritoneal dialysis patients. Kidney Int. 2004;66:2437–45. dialysis: a chance for a new beginning. Am J Kidney Dis. 2014;63:390–5.
38. Williams JD, Craig KJ, Topley N, et al. Morphologic changes in the peritoneal 62. Gokal R, Alexander S, Ash S, et al. Peritoneal catheters and exit-site practices
membrane of patients with renal disease. J Am Soc Nephrol. 2002;13(2): toward optimum peritoneal access: 1998 update. (official report from the
470–9. International Society for Peritoneal Dialysis). Perit Dial Int. 1998;18(1):11–33.
Woodrow et al. BMC Nephrology (2017) 18:333 Page 21 of 23

63. Flanigan M, Gokal R. Peritoneal catheters and exit-site practices toward 88. del Peso G, Fernandez-Reyes MJ, Hevia C, et al. Factors influencing
optimum peritoneal access: a review of current developments. Perit Dial Int. peritoneal transport parameters during the first year on peritoneal dialysis:
2005;25(2):132–9. peritonitis is the main factor. Nephrol Dial Transplant. 2005;20(6):1201–6.
64. Crabtree JH. Rescue and salvage procedures for mechanical and infectious 89. Van Biesen W, Heimburger O, Krediet R, Rippe B, La Milia V, Covic A, Vanholder
complications of peritoneal dialysis. Int J Artif Organs. 2006;29(1):67–84. R, for the ERBP working group on peritoneal dialysis. Evaluation of peritoneal
65. Shah H, Chu M, Bargman JM. Perioperative management of peritoneal membrane characteristics: a clinical advice for prescription management by
dialysis patients undergoing hernia surgery without use of interim the ERBP working group. Nephrol Dial Transplant 2010 (in press).
hemodialysis. Perit Dial Int. 2006;26:684–7. 90. Ates K, Nergizoglu G, Keven K, et al. Effect of fluid and sodium removal on
66. Churchill DN, Taylor DW, Keshaviah PR. Adequacy of dialysis and nutrition in mortality in peritoneal dialysis patients. Kidney Int. 2001;60(2):767–76.
continuous peritoneal dialysis: association with clinical outcome. J Am Soc 91. Paniagua R, Amato D, Mulais S, Vonesh E, Ramos A, Correa-Rotter R, Horl WH.
Nephrol. 1996;7:198–207. Predictive value of brain natriuretic peptides in patients on peritoneal dialysis:
67. Bargman JM, Thorpe KE, Churchill DN. Relative contribution of residual renal results from the ADEMEX trial. Clin J Am Soc Nephrol. 2008;3:407–15.
function and peritoneal clearance to adequacy of dialysis: a reanalysis of the 92. Posthuma N, ter Wee PM, Verbrugh HA, et al. Icodextrin instead of glucose
CANUSA study. J Am Soc Nephrol. 2001;12(10):2158–62. during the daytime dwell in CCPD increases ultrafiltration and 24-h
68. Paniagua R, Amato D, Vonesh E, et al. Effects of increased peritoneal dialysate creatinine clearance. Nephrol Dial Transplant. 1997;12(3):550–3.
clearances on mortality rates in peritoneal dialysis: ADEMEX, a prospective, 93. Plum J, Gentile S, Verger C, et al. Efficacy and safety of a 7.5% icodextrin
randomized, controlled trial. J Am Soc Nephrol. 2002;13(5):1307–20. peritoneal dialysis solution in patients treated with automated peritoneal
69. Lo WK, Ho YW, Li CS, et al. Effect of Kt/V on survival and clinical outcome in dialysis. Am J Kidney Dis. 2002;39(4):862–71.
CAPD patients in a randomized prospective study. Kidney Int. 2003;64(2):649–56. 94. Wolfson M, Piraino B, Hamburger RJ, Morton AR. A randomized controlled
70. Davies SJ, Phillips L, Russell L, Naish PF, Russell GI. An analysis of the effects trial to evaluate the efficacy and safety of icodextrin in peritoneal dialysis.
of increasing delivered dialysis treatment to malnourished peritoneal Am J Kidney Dis. 2002;40(5):1055–65.
dialysis patients. Kidney Int. 2000;57(4):1743–54. 95. Ota K, Akiba T, Nakao T, et al. Peritoneal ultrafiltration and serum icodextrin
71. Jansen MA, Termorshuizen F, Korevaar JC, Dekker FW, Boeschoten E, Krediet concentration during dialysis with 7.5% icodextrin solution in Japanese
RT. Predictors of survival in anuric peritoneal dialysis patients. Kidney Int. patients. Perit Dial Int. 2003;23(4):356–61.
2005;68(3):1199–205. 96. Finkelstein F, Healy H, Abu-Alfa A, et al. Superiority of icodextrin compared
72. Brown EA, Davies SJ, Heimburger O, et al. Adequacy targets can be met in with 4.25+ACU- dextrose for peritoneal ultrafiltration. J Am Soc Nephrol.
anuric patients by automated peritoneal dialysis: baseline data from EAPOS. 2005;16(2):546–54.
Perit Dial Int. 2001;21(Suppl 3):S133–7. 97. Konings CJ, Kooman JP, Schonck M, et al. Effect of icodextrin on volume
73. Rumpsfeld M, McDonald SP, Johnson DW. Peritoneal small solute clearance status, blood pressure and echocardiographic parameters: a randomized
is non-linearly related to patient survival in the Australian and New Zealand study. Kidney Int. 2003;63(4):1556–63.
peritoneal dialysis patient populations. Perit Dial Int. 2009;29:637–46. 98. Davies SJ, Woodrow G, Donovan K, et al. Icodextrin improves the fluid
74. Kim DJ, Do JH, Huh WS, Kim YG, Oh HY. Dissociation between clearances of status of peritoneal dialysis patients: results of a double-blind randomized
small and middle molecules in incremental peritoneal dialysis. Perit Dial Int. controlled trial. J Am Soc Nephrol. 2003;14(9):2338–44.
2001;21:462–6. 99. Davies SJ. Mitigating peritoneal membrane characteristics in modern PD
75. Fischbach M, Stefanidis CJ, Watson AR. Guidelines by an ad hoc European therapy. Kidney Int. 2006;103:S76–83.
committee on the adequacy of the paediatric peritoneal dialysis 100. Johnson DW, Hawley CM, McDonald SP, Brown FG, Rosman JB, Wiggins K,
prescription. Nephrol Dial Transplant. 2002;17:380–5. Bannister KM, Badve SV. Superior survival of high transporters treated with
76. [Link] automated versus continuous ambulatory peritoneal dialysis. Nephrol Dial
standards/[Link]?sfvrsn=2. Accessed Apr 2017. Transplant. 2010;25:1973–9.
77. Rees L, Shaw V. Nutrition in children with CRF and on dialysis. Paediatric 101. Han SH, Ahn SV, Yun JY, Tranaeus A, Han D-S. Effects of icodextrin on
Nephrol. 2007;22:1689–702. patient survival and technique success in patients undergoing peritoneal
78. Twardowski ZJ, Nolph KD, Khanna R, et al. Peritoneal Equilibration Test. Perit dialysis. Nephrol Dial Transplant. 2012;27:2044–50.
Dial Bull. 1987;7:138–47. 102. Cho Y, Johnson DW, Badve S, Craig JC, Strippoli GFK, Wiggins KJ. Impact of
79. Smit W, van Dijk P, Langedijk MJ, et al. Peritoneal function and assessment of icodextrin on clinical outcomes in peritoneal dialysis: a systematic review of
reference values using a 3.86% glucose solution. Perit Dial Int. 2003;23(5):440–9. randomized controlled trials. Nephrol Dial Transplant. 2013;28:1899–907.
80. Smit W, Schouten N, van den Berg N, Langedijk MJ, Struijk DG, Krediet RT. 103. Davies SJ, Brown EA, Frandsen NE, et al. Longitudinal membrane function in
Analysis of the prevalence and causes of ultrafiltration failure during long-term functionally anuric patients treated with APD : data from EAPOS on the effects
peritoneal dialysis: a cross-sectional study. Perit Dial Int. 2004;24(6):562–70. of glucose and icodextrin prescription. Kidney Int. 2005;67(4):1609–15.
81. Selgas R, Bajo MA, Cirugeda A, et al. Ultrafiltration and small solute transport 104. Fernstrom A, Hylander B, Moritz A, Jacobsson H, Rossner S. Increase of intra-
at initiation of PD : questioning the paradigm of peritoneal function. Perit abdominal fat in patients treated with continuous ambulatory peritoneal
Dial Int. 2005;25(1):68–76. dialysis. Perit Dial Int. 1998;18(2):166–71.
82. Davies SJ, Phillips L, Naish PF, Russell G. Quantifying comorbidity in 105. Van V, Schoonjans RS, Struijk DG, et al. Influence of dialysate on gastric
peritoneal dialysis patients and its relationship to other predictors of emptying time in peritoneal dialysis patients. Perit Dial Int. 2002;22(1):
survival. Nephrol Dial Transplant. 2002;17(6):1085–92. 32–8.
83. Churchill DN, Thorpe KE, Nolph KD, Keshaviah PR, Oreopoulos DG, Page D. 106. de Moraes TP, Andreoli MCC, Canziani ME, et al. Icodextrin reduces insulin
Increased peritoneal membrane transport is associated with decreased patient resistance in non-diabetic patients undergoing automated peritoneal
and technique survival for continuous peritoneal dialysis patients. J Am Soc dialysis: results of a randomized controlled trial (STARCH). Nephrol Dial
Nephrol. 1998;9:1285–92. Transplant. 2015;30:1905–11.
84. Rumpsfeld M, McDonald SP, Johnson DW. Higher peritoneal transport status 107. Selby NM, Fonseca S, Hulme L, Fluck RJ, Taal MW, McIntyre CW. Hypertonic
is associated with higher mortality and technique failure in the Australian glucose-based peritoneal dialysate is associated with higher blood pressure
and New Zealand peritoneal dialysis patient populations. J Am Soc Nephrol. and adverse haemodynamics as compared with icodextrin. Nephrol Dial
2006;17(1):271–8. Epub 2005 Nov 23 Transplant. 2005;20(9):1848–53.
85. Brown EA, Davies SJ, Rutherford P, et al. Survival of functionally Anuric 108. Medcalf JF, Harris KP, Walls J. Role of diuretics in the preservation of residual
patients on automated peritoneal dialysis: the European APD outcome renal function in patients on continuous ambulatory peritoneal dialysis.
study. J Am Soc Nephrol. 2003;14(11):2948–57. Kidney Int. 2001;59(3):1128–33.
86. Brimble KS, Walker M, Margetts PJ, Kundhal KK, Rabbat CG. Meta-analysis: 109. Gunal AI, Duman S, Ozkahya M, et al. Strict volume control normalizes
peritoneal membrane transport, mortality, and technique failure in hypertension in peritoneal dialysis patients. Am J Kidney Dis. 2001;37(3):588–93.
peritoneal dialysis. J Am Soc Nephrol. 2006;17(9):2591–8. Epub 006 Aug 2 110. Li PK, Chow KM, Wong TY, Leung CB, Szeto CC. Effects of an angiotensin-
87. Heimburger O, Wang T, Lindholm B. Alterations in water and solute converting enzyme inhibitor on residual renal function in patients receiving
transport with time on peritoneal dialysis. Perit Dial Int. 1999;19(Suppl 2): peritoneal dialysis. A randomized, controlled study. Ann Intern Med. 2003;
S83–90. 139(2):105–12.
Woodrow et al. BMC Nephrology (2017) 18:333 Page 22 of 23

111. Suzuki H, Kanno Y, Sugahara S, Okada H, Nakamoto H. Effects of an 136. Otte K, Gonzalez MT, Bajo MA, et al. Clinical experience with a new
angiotensin II receptor blocker, valsartan, on residual renal function in bicarbonate (25 mmol/L)/lactate (10 mmol/L) peritoneal dialysis solution.
patients on CAPD. Am J Kidney Dis. 2004;43(6):1056–64. Perit Dial Int. 2003;23(2):138–45.
112. Zhang L, Zeng X, Fu P, Wu HM. Angiotensin-converting enzyme inhibitors 137. Dratwa M, Wilkie M, Ryckelynck JP, et al. Clinical experience with two
and angiotensin receptor blockers for preserving residual kidney function in physiologic bicarbonate/lactate peritoneal dialysis solutions in automated
peritoneal dialysis patients (Review). Cochrane Database Syst Rev. 2014;(6): peritoneal dialysis. Kidney Int. 2003;88:S105–13.
CD009120. [Link] 138. Kopple JD, Bernard D, Messana J, et al. Treatment of malnourished CAPD
113. Ha I-S, Yap HK, Munarriz RL et al. Risk factors for loss of residual renal function patients with an amino acid based dialysate. Kidney Int. 1995;47(4):1148–57.
in children treated with chronic peritoneal dialysis. Kidney Int. Advance online 139. Li FK, Chan LY, Woo JC, et al. A 3-year, prospective, randomized, controlled
publication, 15 April 2015. [Link] study on amino acid dialysate in patients on CAPD. Am J Kidney Dis. 2003;
114. Davies SJ, Brown E, Riegel W, et al. What is the link between poor 42(1):173–83.
ultrafiltration and increased mortality in anuric APD patients? Analysis of 140. Jones M, Hagen T, Boyle CA, et al. Treatment of malnutrition with 1.1%
data from EAPOS. Perit Dial Int. 2006;26(4):458–65. amino acid peritoneal dialysis solution: results of a multicenter outpatient
115. Dombros N, Dratwa M, Feriani M, et al. European best practice guidelines study. Am J Kidney Dis. 1998;32(5):761–9.
for peritoneal dialysis. 7 adequacy of peritoneal dialysis. Nephrol Dial 141. Little J, Phillips L, Russell L, Griffiths A, Russell GI, Davies SJ. Longitudinal lipid
Transplant. 2005;20(Suppl 9):ix24–ix7. profiles on CAPD : their relationship to weight gain, comorbidity, and
116. Li PK-T, Szeto CC, Piraino B, et al. ISPD peritonitis recommendations: 2016 dialysis factors. J Am Soc Nephrol. 1998;9(10):1931–9.
update on prevention and treatment. Perit Dial Int. 2016;36:481–508. 142. Choi SJ, Kim NR, Hong SA, et al. Changes in body fat mass in patients after
117. Piraino B, Bernadini J, Brown EA, et al. ISPD position statement on reducing the starting peritoneal dialysis. Perit Dial Int. 2011;31:67–73.
risks of peritoneal dialysis-related infections. Perit Dial Int. 2011;31:614–30. 143. van Biesen W, Claes K, Covic A, et al. A multicentric, international matched
118. Warady BA, Bakkaloglu S, Newland J, et al. Consensus guidelines for the pair analysis of body composition in peritoneal dialysis versus haemodialysis
prevention and treatment of catheter-related infections and peritonitis in patients. Nephrol Dial Transplant. 2013;28:2620–8.
pediatric patients receiving peritoneal dialysis: 2012 update. Perit Dial Int. 144. deMoraes TP, Andreoli MCC, Canziani ME, et al. Icodextrin reduces insulin
2012;32:S39–86. resistance in non-diabetic patients undergoing automated peritoneal
119. Szeto CC, Li PK-T, Johnson DW, et al. ISPD catheter-related infection dialysis: results of a randomized controlled trial: STARCH. Nephrol Dial
recommendations: 2017 update. Perit Dial Int. 2017;37:141–54. Transplant. 2015;30:1905–11.
120. Bernadinini J, Price V, Figueiredo A. Peritoneal dialysis patient training, 2006. 145. KDIGO Clinical Practice Guideline for Lipid Management in Chronic Kidney
Perit Dial Int. 2006;26:625–32. Disease. Chapter 2: Pharmacological cholesterol-lowering treatment in
121. Chow KM, Szeto CC, Law MC, Fung JSF, Li PK-T. Influence of peritoneal adults. Kidney International Supplements 2013 (Suppl 3), 271–279.
dialysis training nurses’ experience on peritonitis rates. Clin J Am Soc 146. Lee JE, Oh K-H, Choi KH, et al. Statin therapy is associated with improved
Nephrol. 2007;2:647–52. survival in incident peritoneal dialysis patients: propensity-matched
122. Bernardini J, Piraino B, Holley J, Johnston JR, Lutes R. A randomized trial of comparison. Nephrol Dial Transplant. 2011;26:4090–4.
Staphylococcus Aureus prophylaxis in peritoneal dialysis patients: mupirocin 147. Blake PG, Bargman JM, Brimble KS, et al. Clinical practice guidelines and
calcium ointment 2% applied to the exit site versus cyclic oral rifampin. Am recommendations on peritoneal dialysis adequacy 2011. Perit Dial Int. 2011;
J Kidney Dis. 1996;27(5):695–700. 31:218–39.
123. Piraino B. Staphylococcus Aureus infections in dialysis patients: focus on 148. Schoenicke G, Grabensee B, Plum J. Dialysis with icodextrin interferes with
prevention. ASAIO J. 2000;46(6):S13–7. measurement of serum alpha-amylase activity. Nephrol Dial Transplant.
124. Xu G, Tu W, Xu C. Mupirocin for preventing exit-site infection and peritonitis 2002;17(11):1988–92.
in patients undergoing peritoneal dialysis. Nephrol Dial Transplant. 2010;25: 149. Wang R, Leesch V, Turner P, Moberly JB, Martis L. Kinetic analysis of icodextrin
587–92. interference with serum amylase assays. Adv Perit Dial. 2002;18:96–9.
125. Bernardini J, Bender F, Florio T, et al. Randomized, double-blind trial of 150. Anderstam B, Garcia-Lopez E, Heimburger O, Lindholm B. Determination of
antibiotic exit site cream for prevention of exit site infection in peritoneal alpha-amylase activity in serum and dialysate from patients using
dialysis patients. J Am Soc Nephrol. 2005;16(2):539–45. Epub 2004 Dec 29 icodextrin-based peritoneal dialysis fluid. Perit Dial Int. 2003;23(2):146–50.
126. Li PK-T, Szeto CC, Piraino B, et al. Peritoneal dialysis-related infections 151. Garcia-Lopez E, Anderstam B, Heimburger O, Amici G, Werynski A, Lindholm
recommendations: 2010 update. Perit Dial Int. 2010;30:393–423. B. Determination of high and low molecular weight molecules of icodextrin
127. Ballinger AE, Palmer SC, Wiggins KJ et al. Treatment for peritoneal dialysis- in plasma and dialysate, using gel filtration chromatography, in peritoneal
associated peritonitis (Review). Cochrane Database Syst Rev. 2014;(4): dialysis patients. Perit Dial Int. 2005;25(2):181–91.
CD005284. [Link] 152. Wens R, Taminne M, Devriendt J, et al. A previously undescribed side effect
128. Kays MB, Overholser BR, Mueller BA, Moe SM, Sowinski KM. Effects of of icodextrin: overestimation of glycemia by glucose analyzer. Perit Dial Int.
sevelamer hydrochloride and calcium acetate on the oral bioavailability of 1998;18(6):603–9.
ciprofloxacin. Am J Kidney Dis. 2003;42(6):1253–9. 153. Oyibo SO, Pritchard GM, McLay L, et al. Blood glucose overestimation in
129. Kwan TH, Tong MK, Siu YP, Leung KT, Luk SH, Cheung YK. Ultrasonography diabetic patients on continuous ambulatory peritoneal dialysis for end-stage
in the management of exit site infections in peritoneal dialysis patients. renal disease. Diabet Med. 2002;19(8):693–6.
Nephrology (Carlton). 2004;9:348–52. 154. Mehmet S, Quan G, Thomas S, Goldsmith D. Important causes of hypoglycaemia
130. Panigua R, Ventura M-d-J, Avila-Díaz M, Cisneros A, Vicenté-Martinez M, in patients with diabetes on peritoneal dialysis. Diabet Med. 2001;18(8):679–82.
Furlong M-d-C, Garcia-Gonzalez Z, Villanueva D, Orihuela O, Prado-Uribe M- 155. Janssen W, Harff G, Caers M, Schellekens A. Positive interference of
d-C, Alcantara G, Amato D. Icodextrin improves metabolic and fluid icodextrin metabolites in some enzymatic glucose methods. Clin Chem.
management in high and high-average transport diabetic patients. Perit 1998;44(11):2379–80.
Dial Int. 2009;29:422–32. 156. Latus J, Ulmer C, Fritz P, et al. Phenotypes of encapsulating peritoneal
131. Li PKT, Culleton BF, Ariza A, et al. Randomised, controlled trial of glucose-sparing sclerosis - macroscopic appearance, histologic findings and outcome. Perit
peritoneal dialysis in diabetic patients. J Am Soc Nephrol. 2013;24:1889–900. Dial Int. 2013;33:495–502.
132. Stein A, Moorhouse J, Iles-Smith H, et al. Role of an improvement in acid- 157. Krediet RT, Struijk DG, Boeschoten EW, et al. The time course of peritoneal
base status and nutrition in CAPD patients. Kidney Int. 1997;52(4):1089–95. transport kinetics in continuous ambulatory peritoneal dialysis patients who
133. Szeto CC, Wong TY, Chow KM, Leung CB, Li PK. Oral sodium bicarbonate for develop sclerosing peritonitis. Am J Kidney Dis. 1989;4:299–307.
the treatment of metabolic acidosis in peritoneal dialysis patients: a 158. Yamamoto R, Nakayama M, Hasegawa T, et al. High-transport
randomized placebo-control trial. J Am Soc Nephrol. 2003;14(8):2119–26. membrane is a risk factor for encapsulating peritoneal sclerosis
134. Coles GA, Gokal R, Ogg C, et al. A randomized controlled trial of a developing after long-term continuous ambulatory peritoneal dialysis.
bicarbonate- and a bicarbonate/lactate-containing dialysis solution in CAPD. Adv Perit Dial. 2002;18:131–4.
Perit Dial Int. 1997;17(1):48–51. 159. Balasubramaniam G, Brown EA, Davenport A, et al. The pan-Thames EPS
135. Mujais S. Acid base profile in patients on PD. Kidney Int. 2003;64(Suppl. 88): study: treatment and outcomes of encapsulating peritoneal sclerosis.
S26–36. Nephrol Dial Transplant. 2009;24:3209–15.
Woodrow et al. BMC Nephrology (2017) 18:333 Page 23 of 23

160. Kawaguchi Y, Kawanishi H, Mujais S, Topley N, Oreopoulos DG. 184. De Sousa-Amorim E, Del Peso G, Bajo MA, Alvarez L, Ossorio M, Gil F, Bellon
Encapsulating peritoneal sclerosis: definition, etiology, diagnosis and T, Selgas R. Can EPS development be avoided with early interventions? The
treatment. Perit Dial Int. 2000;20(Suppl 4):S43–55. potential of tamoxifen - a single-center study. Perit Dial Int. 2014;34:582–93.
161. Nakamoto H. Encapsulating peritoneal sclerosis - a clinician’s guide to 185. Moriishi M, Kawanishi H, Kawai T el al. Preservation of peritoneal catheter for
diagnosis and medical management. Perit Dial Int. 2005;25(Suppl 4):S30–8. prevention of encapsulating peritoneal sclerosis. Adv Perit Dial 2002; 18: 149-153.
162. Lambie M, Braun N, Davies SJ. Towards standardized reporting in studies of 186. Yamamoto Y, Nagasue K, Okuno S, Yamakawa T. The role of peritoneal
encapsulating peritoneal sclerosis. Perit Dial Int. 2013;33:482–6. lavage and the prognostic significance of the mesothelial cell area in
163. Watson CJE, Butler AJ, Bradley JA. Classification of encapsulating peritoneal preventing encapsulating peritoneal sclerosis. Perit Dial Int. 2010;30:343–52.
sclerosis is important but must encapsulate the entire spectrum of the 187. Nomoto Y, Kawaguchi Y, Kubo H, Hirano H, Sakai S, Kurokawa K. Sclerosing
disease. Perit Dial Int. 2013;33:479–81. encapsulating peritonitis in patients undergoing continuous ambulatory
164. Shroff R, Stefanidis CJ, Askiti V, et al. Encapsulating peritoneal sclerosis in peritoneal dialysis: a report of the Japanese Sclerosing encapsulating
children on chronic PD: a survey from the European Paediatric dialysis peritonitis study group. Am J Kidney Dis. 1996;28:420–7.
working group. Nephrol Dial Transplant. 2013;28:1908–14. 188. Kawanishi H, Moriishi M. Epidemiology of encapsulating peritoneal sclerosis
165. Hoshii S, Honda M, Itami N, et al. Sclerosing encapsulating peritonitis in in Japan. Perit Dial Int. 2005;25(Suppl 4):S14–8.
pediatric peritoneal dialysis patients. Pediatr Nephrol. 2000;14:275–9. 189. Brown MC, Simpson K, Kerssens J, Mactier R, on behalf of the Scottish Renal
166. Woodrow G, Augustine T, Brown EA, Cowling M, El-Sherbini N, Hurst H, Registry. Encapsulating peritoneal sclerosis in the new millennium: a
Williams PF, Williams R. UK Encapsulating Peritoneal Sclerosis Clinical national cohort study. Clin JASN. 2009;4:1222–9.
Practice Guidelines, July 2007 at [Link] 190. Johnson DW, Cho Y, Livingston BER, Hawley CM, McDonald SP, Brown FG,
guidelines-resources/Encapsulating_Peritoneal_Sclerosis_guidelines_UK_ Rosman JB, Bannister KM, Wiggins KJ. Encapsulating peritoneal sclerosis:
EPS_Group_Final_July_2009.pdf?sfvrsn=0. Accessed Apr 2017. incidence, predictors, and outcomes. Kidney Int. 2010;77:904–12.
167. Hur J, Kim KW, Park MS, Yu JS. Abdominal cocoon: preoperative diagnostic 191. Fieren MWJA, Betjes MGH, Korte MR, Boer WH. Post transplant
clues from radiologic imaging and pathologic correlation. Am J Roentgenol. encapsulating peritoneal sclerosis: a worrying new trend? Perit Dial Int.
2004;182:639–41. 2007;27:619–24.
168. Krestin GP, Kacl G, Hauser M, Kesch G, Burger HR, Hoffman R. Imaging 192. Korte MR, Sampimon DE, Lingsma HF, Fieren MW, Looman CWN, Zietse R.
diagnosis of sclerosing peritonitis and relation of radiologic signs to the Weimar W,4 and Betjes MGH. Risk factors associated with encapsulating
extent of the disease. Abdom Imaging. 1995;20:414–20. peritoneal sclerosis in Dutch EPS study. Perit Dial Int. 2011;31:269–78.
169. Korzets A, Korztes Z, Peer G, et al. Sclerosing peritonitis. Possible early 193. Brown EA, Van Biesen W, Finkelstein FO, Hurst H, Johnson DW, Kawanishi H,
diagnosis by computerised tomography of the abdomen. Am J Nephrol. Pecoits-Filho R, Woodrow G. Length of time on peritoneal dialysis and
1988;8:143–6. encapsulating peritoneal sclerosis: position paper for ISPD. Perit Dial Int.
170. Stafford-Johnson DB, Wilson TE, Francis IR, Swartz R. CT appearance of 2009;29:595–600.
sclerosing peritonitis in patients with chronic ambulatory peritoneal dialysis. 194. Davies SJ, Brown B, Bryan J, Russell GI. Clinical evaluation of the peritoneal
J Comput Assist Tomog. 1998;22:295–9. equilibration test: a population-based study. Nephrol Dial Transplant. 1993;
171. Tarzi RM, Lim A, Moser S, et al. Assessing the validity of an abdominal CT 8(1):64–70.
scoring system in the diagnosis of encapsulating peritoneal sclerosis. CJASN. 195. Ho-dac-Pannekeet MM, Atasever B, Struijk DG, Krediet RT. Analysis of
2008;3:1702–10. ultrafiltration failure in peritoneal dialysis patients by means of standard
172. Vlijm A, Stoker J, Bipat S, Spijkerboer AM, Phoa SSKS, Maes R, Struijk DG. And. peritoneal permeability analysis. Perit Dial Intl. 1997;17(2):144–50.
Krediet RT. computed tomographic findings characteristic for encapsulating 196. Watson PE, Watson ID, Batt RD. Total body water volume for adult males
peritoneal sclerosis: a case control study. Perit Dial Int. 2009;29:517–22. and females estimated from simple anthropometric measurements. Am J
173. Hollman AS, McMillan MA, Briggs JD, Junor BJ, Morley P. Ultrasound Clin Nutr. 1980;33:27–39.
changes in sclerosing peritonitis following continuous ambulatory dialysis. 197. Woodrow G, Oldroyd B, Turney JH, Davies PSW, Day JME, Smith MA.
Clin Radiol. 1991;43:176–9. Measurement of total body water and urea kinetic modelling in peritoneal
174. Goodlad C, Tarzi R, Gedroyc W, Lim A, Moser S, Edwina A. Brown EA. Screening dialysis. Clin Nephrol. 1997;47:52–7.
for encapsulating peritoneal sclerosis in patients on peritoneal dialysis: role of 198. Woodrow G, Oldroyd B, Wright A, Coward A, Truscott JG, Turney JH,
CT scanning. Nephrol Dial Transplant 2011; 26: 1374-1379. Brownjohn AM, Smith MA. Comparison of anthropometric equations for
estimation of total body water in peritoneal dialysis patients. Nephrol Dial
175. Kawanishi H, Watanabe H, Moriishi M, Tsuchiya S. Successful surgical
Transplant. 2003;18:384–9.
management of encapsulating peritoneal sclerosis. Perit Dial Int. 2005;
199. McCafferty K, Fan S. Are we underestimating the problem of ultrafiltration in
25(Suppl 4):S39–47.
peritoneal dialysis patients? Perit Dial Int. 2006;26(3):349–52.
176. Kawanishi H, Moriishi M, Ide K, Dohi K. Recommendation of the surgical
200. La Milia V, Pozzoni P, Crepaldi C, Locatelli F. The overfill of bags for
option for treatment of encapsulating peritoneal sclerosis. Perit Dial Int.
peritoneal dialysis as a cause of underestimation of ultrafiltration failure.
2008;28(Suppl 3):S205–10.
Perit Dial Int. 2006;26(4):503–5.
177. Kawanishi H, Shintaku S, Moriishi M, Dohi K, Tsuchiya S. Seventeen years’
201. Warady BA, Jennings J. The short PET in pediatrics. Perit Dial Int. 2007;27(4):
experience of surgical options for encapsulating peritoneal sclerosis. Adv
441–5.
Perit Dial. 2011;27:53–8.
202. Morgenstern BZ, Wühl E, Nair KS, Warady BA, Schaefer F. Anthropometric
178. Kawanishi H, Kawaguchi Y, Fukui H, et al. Encapsulating peritoneal sclerosis
prediction of Total body water in children who are on pediatric peritoneal
in Japan: a prospective controlled multicenter study. Am J Kidney Dis. 2004;
dialysis. J Am Soc Nephrol. 2006;17:285–93.
44:729–37.
179. De Freitas D, Jordaan A, Williams R, et al. Nutritional management of
patients undergoing surgery following diagnosis with encapsulating Submit your next manuscript to BioMed Central
peritoneal sclerosis. Perit Dial Int. 2008;28:271–6. and we will help you at every step:
180. El-Sherbini N, Duncan N, Hickson M, Johansson L, Brown EA. Nutrition
changes in conservatively treated patients with encapsulating peritoneal • We accept pre-submission inquiries
sclerosis. Perit Dial Int. 2013;33:538–43. • Our selector tool helps you to find the most relevant journal
181. Summers AM, Clancy MJ, Syed F, et al. Single-center experience of
• We provide round the clock customer support
encapsulating peritoneal sclerosis in patients on peritoneal dialysis for end-
stage renal failure. Kidney Int. 2005;68:2381–8. • Convenient online submission
182. Eltoum MA, Wright S, Atchley J, Mason JC. Four consecutive cases of • Thorough peer review
peritoneal dialysis-related encapsulating peritoneal sclerosis treated
• Inclusion in PubMed and all major indexing services
successfully with tamoxifen. Perit Dial Int. 2006;26:203–6.
183. Korte MR, Fieren MW, Sampimon DE, Lingsma HF, Weimar W, Betjes MGH. • Maximum visibility for your research
Tamoxifen is associated with lower mortality of encapsulating peritoneal sclerosis:
results of the Dutch multicentre EPS study. Nephrol Dial Transplant. 2011;26:691–7. Submit your manuscript at
[Link]/submit