This is not a common scenario but we definitely see it. More aggressive dialysis is likely the best treatment if possible not only as far as fluid removal but also as far as clearance. Recommend 4 days per week dialysis. If fluid removal is not adequate then would do large volume peritoneal taps eve...

I haven't had the right patient for this but I would prefer to use PD. The ascites get drained, that in itself should make them feel so much better, they should have better nutritional health, and PD may remove whatever uremic toxin that is causing the serositis better than HD. Of course, transplant...

If unable to fully remove volume during dialysis, adhering to a maximum UFR of 13 ml/kg/hr, I recommend peritoneal tap periodically when the patient develops significant ascites.