Peritoneal Dialysis solutions

• Chronic Kidney Disease (CKD) Stage 5 (End-Stage Renal Disease - ESRD):
  Used for renal replacement therapy to remove waste products, excess fluid, and toxins when kidneys fail to maintain homeostasis.
• Acute Kidney Injury (AKI):
  Temporary dialysis in critically ill patients when hemodialysis is contraindicated or unavailable.
• Fluid Overload Management:
  In patients with refractory volume overload not responding to diuretics.
• Electrolyte and Acid-Base Imbalances:
  Correction of hyperkalemia, metabolic acidosis, and other disturbances associated with renal failure.
• Alternative to Hemodialysis:
  For patients with vascular access issues, cardiovascular instability, or preference for home dialysis.

• Route of Administration: Intraperitoneal instillation via peritoneal catheter.
• Types of Solutions:
• Dextrose-based solutions (e.g., 1.5%, 2.5%, 4.25%)
• Icodextrin-based solutions (for sustained ultrafiltration)
• Bicarbonate or lactate-buffered solutions
• Typical Dosing Regimens:
• Continuous Ambulatory Peritoneal Dialysis (CAPD): 4–5 exchanges/day with 1.5–2 liters per exchange, dwell times 4–6 hours.
• Automated Peritoneal Dialysis (APD): Usually performed overnight with 4–8 exchanges of 1.5–2 liters each, with daytime dwell.
• Special Populations:
• Pediatrics: Volume adjusted by body surface area (~600–1000 mL/m² per exchange).
• Elderly: Adjust exchange volume based on abdominal cavity size and tolerance.
• Renal or hepatic impairment: Not applicable as therapy replaces kidney function.
• Duration:
  Lifelong in ESRD patients or until kidney transplantation.
• Administration Precautions:
• Use aseptic technique to prevent peritonitis.
• Monitor fluid removal and ultrafiltration volumes carefully.
• Adjust solution concentration based on patient ultrafiltration needs and glucose absorption.

Peritoneal dialysis solutions work by instilling a sterile dialysate into the peritoneal cavity through a catheter. The peritoneal membrane acts as a semipermeable barrier allowing diffusion and osmosis. Metabolic waste products (e.g., urea, creatinine), excess electrolytes, and fluid move from the blood across the peritoneal membrane into the dialysate due to concentration gradients. The glucose or icodextrin in the solution creates an osmotic gradient facilitating fluid removal (ultrafiltration). After a prescribed dwell time, the solution containing toxins and excess fluid is drained and replaced by fresh dialysate, thus cleansing the blood continuously or intermittently.

• Absorption:
  Glucose in the dialysate is absorbed systemically; absorption rate depends on glucose concentration and dwell time.
• Distribution:
  Dialysate remains in the peritoneal cavity; solutes and fluid exchange occurs across the peritoneal membrane into capillary blood.
• Metabolism:
  Systemic glucose absorbed is metabolized normally. Icodextrin is metabolized by alpha-amylase into oligosaccharides.
• Elimination:
  Toxins and excess solutes are removed from blood into dialysate, which is drained. Metabolites of glucose and icodextrin are cleared by kidneys or metabolism.
• Onset of action:
  Immediate upon instillation, but effectiveness depends on dwell time and peritoneal membrane characteristics.

• Pregnancy:
  Peritoneal dialysis solutions are considered compatible with pregnancy when dialysis is medically indicated; close monitoring is essential to maintain fluid and electrolyte balance. No specific FDA pregnancy category assigned.
• Lactation:
  No direct contraindication; however, metabolic and fluid status must be monitored closely in breastfeeding mothers undergoing peritoneal dialysis.
• Data:
  Limited formal studies; clinical experience supports cautious use with individualized management.

• Primary Class: Renal Replacement Therapy Solutions
• Subclass: Peritoneal Dialysis Fluids

• Known hypersensitivity to any component of the dialysate solutions.
• Recent major abdominal surgery or severe abdominal adhesions preventing dialysate circulation.
• Active peritonitis or intra-abdominal infection.
• Severe respiratory insufficiency where increased intra-abdominal pressure is detrimental.
• Hemodynamic instability precluding peritoneal dialysis.

• Peritonitis risk: Strict aseptic technique required to avoid infection. Early signs include abdominal pain, cloudy effluent, fever.
• Glucose load: High glucose concentration may worsen hyperglycemia or cause weight gain.
• Fluid overload or depletion: Careful ultrafiltration and fluid balance monitoring required to avoid heart failure or dehydration.
• Electrolyte imbalance: Monitor serum electrolytes regularly to avoid hypo/hyperkalemia, hyponatremia.
• Membrane function deterioration: Long-term use may lead to peritoneal membrane fibrosis or failure.
• Allergic reactions: Rare but possible; monitor for hypersensitivity.

• Common:
• Abdominal discomfort or bloating
• Peritoneal catheter site infections
• Hyperglycemia (with glucose-based solutions)
• Fluid retention or edema
• Serious/Rare:
• Peritonitis (potentially life-threatening)
• Encapsulating peritoneal sclerosis (EPS) – a rare fibrotic complication
• Electrolyte disturbances (e.g., hyperkalemia, hypokalemia)
• Hernias due to increased intra-abdominal pressure
• Allergic reactions to dialysate components

• No direct pharmacokinetic drug interactions; however, concomitant medications may require dose adjustment due to altered renal clearance.
• Use caution with drugs that affect fluid/electrolyte balance (e.g., diuretics, ACE inhibitors).
• Antibiotics may be added intraperitoneally to dialysate in case of peritonitis treatment.
• Monitor anticoagulants carefully due to altered volume status.

• ISPD 2022 Guidelines:
  Emphasize individualized dialysis prescription based on peritoneal membrane transport status, with consideration for glucose-sparing solutions such as icodextrin or amino acid-based dialysate.
• Updated Recommendations:
  Encouragement of biocompatible, neutral pH, low GDP (glucose degradation products) solutions to reduce membrane toxicity.
• WHO/ERA-EDTA:
  Endorse peritoneal dialysis as an effective alternative to hemodialysis with patient-centered approach in ESRD management.

• Store peritoneal dialysis solutions at 20°C to 30°C (68°F to 86°F).
• Protect from freezing, direct sunlight, and contamination.
• Maintain in sterile, sealed bags until use.
• Do not use if packaging is damaged or solution is cloudy.
• No reconstitution required; solutions are ready to use.
• Use within expiry date marked on packaging.