Summary statements: (1) Peritoneal dialysis (PD) should be considered a suitable modality for treatment of acute kidney injury (AKI) in all settings (1B). Guideline 2: Access and fluid delivery for acute PD in adults: (2.1) Flexible peritoneal catheters should be used where resources and expertise exist (1B) (optimal). (2.2) Rigid catheters and improvised catheters using nasogastric tubes and other cavity drainage catheters may be used in resource-poor environments where they may still be life-saving (1C) (minimum standard). (2.3) We recommend catheters should be tunnelled to reduce peritonitis and peri-catheter leak (practice point). (2.4) We recommend that the method of catheter implantation should be based on patient factors and locally available skills (1C). (2.5) PD catheter implantation by appropriately trained nephrologists in patients without contraindications is safe and functional results equate to those inserted surgically (1B). (2.6) Nephrologists should receive training and be permitted to insert PD catheters to ensure timely dialysis in the emergency setting (practice point). (2.7) We recommend, when available, percutaneous catheter insertion by a nephrologist should include assessment with ultrasonography (2C). (2.8) Insertion of PD catheter should take place under complete aseptic conditions using sterile technique (practice point). (2.9) We recommend the use of prophylactic antibiotics prior to PD catheter implantation (1B). (2.10) A closed delivery system with a Y connection should be used (1A) (optimal). In resource poor areas, spiking of bags and makeshift connections may be necessary and can be considered (minimum standard). (2.11) The use of automated or manual PD exchanges are acceptable and this will be dependent on local availability and practices (practice point). Guideline 3: Peritoneal dialysis solutions for acute PD: (3.1) In patients who are critically ill, especially those with significant liver dysfunction and marked elevation of lactate levels, bicarbonate containing solutions should be used (1B) (optimal). Where these solutions are not available, the use of lactate containing solutions is an alternative (practice point) (minimum standard). (3.2) Commercially prepared solutions should be used (optimal). However, where resources do not permit this, then locally prepared fluids may be life-saving and with careful observation of sterile preparation procedure, peritonitis rates are not increased (1C) (minimum standard). (3.3) Once potassium levels in the serum fall below 4 mmol/L, potassium should be added to dialysate (using strict sterile technique to prevent infection) or alternatively oral or intravenous potassium should be given to maintain potassium levels at 4 mmol/L or above (1C). (3.4) Potassium levels should be measured daily (optimal). Where these facilities do not exist, we recommend that after 24 h of successful dialysis, one consider adding potassium chloride to achieve a concentration of 4 mmol/L in the dialysate (minimum standard) (practice point). Guideline 4: Prescribing and achieving adequate clearance in acute PD: (4.1) Targeting a weekly K _t/ V _urea of 3.5 provides outcomes comparable to that of daily HD in critically ill patients; targeting higher doses does not improve outcomes (1B). This dose may not be necessary for most patients with AKI and targeting a weekly K _t/ V of 2.2 has been shown to be equivalent to higher doses (1B). Tidal automated PD (APD) using 25 L with 70% tidal volume per 24 h shows equivalent survival to continuous venovenous haemodiafiltration with an effluent dose of 23 mL/kg/h (1C). (4.2) Cycle times should be dictated by the clinical circumstances. Short cycle times (1–2 h) are likely to more rapidly correct uraemia, hyperkalaemia, fluid overload and/or metabolic acidosis; however, they may be increased to 4–6 hourly once the above are controlled to reduce costs and facilitate clearance of larger sized solutes (2C). (4.3) The concentration of dextrose should be increased and cycle time reduced to 2 hourly when fluid overload is evident. Once the patient is euvolemic, the dextrose concentration and cycle time should be adjusted to ensure a neutral fluid balance (1C). (4.4) Where resources permit, creatinine, urea, potassium and bicarbonate levels should be measured daily; 24 h K _t/ V _urea and creatinine clearance measurement is recommended to assess adequacy when clinically indicated (practice point). (4.5) Interruption of dialysis should be considered once the patient is passing >1 L of urine/24 h and there is a spontaneous reduction in creatinine (practice point). The use of peritoneal dialysis (PD) to treat patients with acute kidney injury (AKI) has become more popular among clinicians following evidence of similar outcomes when compared with other extracorporeal therapies. Although it has been extensively used in low-resource environments for many years, there is now a renewed interest in the use of PD to manage patients with AKI (including patients in intensive care units) in higher income countries. Here we present the update of the International Society for Peritoneal Dialysis guidelines for PD in AKI. These guidelines extensively review the available literature and present updated recommendations regarding peritoneal access, dialysis solutions and prescription of dialysis with revised targets of solute clearance.

Background and objectives Peritoneal dialysis is still used for AKI in developing countries despite concerns about its limitations. The objective of this study was to explore the role of high-volume peritoneal dialysis in AKI patients in relation to metabolic and fluid control, outcome, and risk factors associated with death. Design, setting, participants, & measurements A prospective study was performed on 204 AKI patients who were assigned to high-volume peritoneal dialysis (prescribed Kt/V=0.60/session) by flexible catheter and cycler; 150 patients (80.2%) were included in the final analysis. Results Mean age was 63.8±15.8 years, 70% of patients were in the intensive care unit, and sepsis was the main etiology of AKI (54.7%). BUN and creatinine levels stabilized after four sessions at around 50 and 4 mg/dl, respectively. Fluid removal and nitrogen balance increased progressively and stabilized around 1200 ml and −1 g/d after four sessions, respectively. Weekly delivered Kt/V was 3.5±0.68. Regarding AKI outcome, 23% of patients presented renal function recovery, 6.6% of patients remained on dialysis after 30 days, and 57.3% of patients died. Age and sepsis were identified as risk factors for death. In urine output, increase of 1 g in nitrogen balance and increase of 500 ml in ultrafiltration after three sessions were identified as protective factors. Conclusions High-volume peritoneal dialysis is effective for a selected AKI patient group, allowing adequate metabolic and fluid control. Age, sepsis, and urine output as well as nitrogen balance and ultrafiltration after three high-volume peritoneal dialysis sessions were associated significantly with death.

Acute kidney injury (AKI) is characterized by a sudden renal dysfunction with consequent increase of nitrogenous products, hydroelectrolytic and acid–base disorders. Its prevalence is high in hospitalized populations (4.9%–7.2%), especially in intensive care units (ICUs). Despite all the technical and therapeutic advances that have occurred in the last few decades, the overall mortality of AKI patients remains high, reaching 80% in ICU patients. Several conditions predispose a patient to progress with AKI, including age, sepsis, surgeries, and comorbidities, such as systemic arterial hypertension, diabetes mellitus, heart disease, neoplasia, and chronic renal disease. Among these risk factors, age is emphasized, since, due to advances in the health area, there has been an increase in life expectancy, hence an increase in the demand of the elderly population for health services. At the same time, the elderly present a greater predisposition to the development of AKI, either due to kidney senility, or because of the high prevalence of comorbidities present, and medical interventions such as the use of contrasts and medications, which can also trigger AKI. Considering the relevance of the social role of the elderly and the scarcity of studies on AKI in the elderly admitted to the ICU, further studies are needed. This review article was elaborated considering the purpose: to assess incidence, risk factors, and mortality of AKI in elderly patients admitted to ICUs. Published studies were collected using the following inclusion criteria: be accessible in online databases (Lilacs, Scielo, and PubMed), have been published since 2000 and written in English, Portuguese, or Spanish. The descriptors used for the survey were “Acute Kidney Injury”, “Aging”, and “Elderly”. All items that did not fit in the above inclusion criteria were discarded. We have also presented a synthesis of the knowledge acquired during this review.

Background. Patients who develop acute kidney injury (AKI) in the intensive care unit (ICU) have extremely high rates of mortality and morbidity. The objectives of this study were to compare clinical and laboratory characteristics of AKI patients evaluated and not evaluated by nephrologists in ICU and generate the hypothesis of the relationship between timing of nephrology consultation and outcome.