Do you avoid peritoneal dialysis in cirrhotic patients with ascites?

There are two major concerns regarding the performance of PD in patients with ascites: the potential for fluid leakage at the site of the newly placed catheter and the perceived increased potential for peritonitis. In my experience, neither of these is a compelling reason to shy away from PD in a patient who prefers this modality for treatment of ESKD (for purposes of this discussion, I am assuming that we are not discussing treatment of AKI).

1. With the use of a "purse-string" suture at the internal cuff of the catheter, leakage ought not occur, especially if care is taken to decompress the abdomen by daily drainage of fluid via the catheter. Furthermore, if time allows, one may place the PD catheter using the "buried" (Moncrief-Popovich) te...

From a hepatology perspective, we are, in general, wary of peritoneal catheters and drains in cirrhotic patients who have significant recurrent ascites due to a high perceived infection risk, which is why large volume paracentesis (up to weekly) is still the preferred management approach selected by hepatologists for cirrhotic patients with recurrent large ascites or refractory ascites.

The latest AASLD guidance on ascites management: "The safety and efficacy of permanent indwelling peritoneal catheters remain to be established. The studies published so far are of low quality, in which the average bacterial infection rate was 13%." No guidelines from hepatology societies I reviewed (AASLD, British, EASL, KASL) recommend the use of peritoneal...

No, I do not believe cirrhosis with ascites is an absolute contraindication to PD. There are benefits and challenges with the use of PD in cirrhotics with ascites. Some of the benefits of PD in lieu of traditional HD in this patient population include:

• steady state therapy
• slow ultrafiltration rates, leading to less hemodynamic instability compared with hemodialysis
• large volume paracentesis is no longer regularly required
• dextrose-based PD solution is a caloric source, which can be a benefit in cirrhotic patients who have poor appetites with decreased oral intake.

Several potential concerns arise with respect to the use of PD in cirrhotics with ascites, most commonly, (1) peritonitis risk, (2) increased albumin loss. Neither of these issue...