Journal of Feline Medicine and Surgery (2009) 11, 107e115

doi:10.1016/j.jfms.2008.06.003

Management of acute renal failure in cats using

peritoneal dialysis: a retrospective study of six
cases (2003e2007)
Patricia Dorval DVM*, Søren R Boysen DVM, DACVECC

Department of Veterinary Clinical Information regarding the use and success of peritoneal dialysis (PD) in the
Sciences, Veterinary Teaching management of acute renal failure (ARF) in cats is lacking. The purpose of this
Hospital, Faculty of Veterinary retrospective study is to describe the indications, efficacy, complications and
Medicine, University of Montreal, outcome of cats undergoing PD for ARF. Six cats that underwent PD for
1525 Rue des Veterinaires, Saint- treatment of ARF of various etiologies were included. PD effectively replaced
Hyacinthe, CP 5000, Quebec, renal function in all cats and allowed renal recovery in 5/6 cats. Five cats were
Canada J2S 7C6 discharged and one cat died. Complications were reported in all cats and
included subcutaneous edema (n ¼ 5), hyperglycemia (n ¼ 4), dialysate retention
(n ¼ 3), and hypoalbuminemia (n ¼ 3). A novel technique consisting of a Blake
surgical drain and an intermittent closed suction system was used, which
appears to be a viable option for PD in cats. Although complications are
common, PD is an effective renal replacement therapy for ARF in cats and
carries a reasonable prognosis in selected cases.
Date accepted: 11 June 2008 Ó 2008 ESFM and AAFP. Published by Elsevier Ltd. All rights reserved.

A
dvancements in veterinary medicine only accessible method to replace renal function
have introduced a number of renal re- and prevent systemic imbalances from occurring
placement therapies including continu- during the period of renal recovery.
ous renal replacement therapy (CRRT), PD has been used to treat ARF in humans since
intermittent hemodialysis (IHD) and peritoneal 1923.4 It involves the exchange of solutes and fluid
dialysis (PD). These therapies use principles of between the peritoneal capillary blood and the
diffusion, ultrafiltration and convection to re- dialysis solution across the peritoneal membrane.
move metabolic waste products from the blood- Waste products in higher concentration in the
stream and to re-establish acidebase, electrolyte blood diffuse across the peritoneum into the dial-
and fluid imbalances that have resulted from ysate and are removed with each fluid exchange.
renal dysfunction. To date, only IHD, and more Although the veterinary literature describes the
recently, CRRT, have been reported with success use of PD for many conditions, information is
in the treatment of acute renal failure (ARF) in lacking concerning its use in the management of
cats.1e3 These techniques require specialized naturally occurring ARF in cats.4e6 One retrospec-
equipment and trained personnel, and therefore, tive study mentions the use of PD in the treatment
tend to be limited to referral and academic veter- of ARF in two cats but fails to show its efficacy in
inary hospitals. PD, however, tends to be less replacing renal function in the two cases. More-
technologically demanding, and because most over, no explanation was apparent for the failure
veterinary hospitals already have the equipment of PD in either case.7
necessary to perform PD, it often remains the The objectives of this retrospective study are to
describe the application, efficacy and clinical fea-
tures of cats treated with PD for ARF of different
*Corresponding author. E-mail: patricia.dorval@umontreal.ca etiologies.

1098-612X/08/020107+09 $34.00/0 Ó 2008 ESFM and AAFP. Published by Elsevier Ltd. All rights reserved.
108 P Dorval and SR Boysen

Materials and methods post-dialysis serum BUN and creatinine were

performed using a Wilcoxon signed rank test;
Criteria for selection of cases P  0.05 was considered significant.
The medical records of cats managed with PD for
ARF between January 2003 and December 2007 Results
at the University of Montreal Veterinary Teaching
Six cats met the criteria for study inclusion.
Hospital were reviewed. All cats managed with
Breeds included four domestic shorthair, one
PD for ARF during the study period were included.
Maine Coon, and one domestic longhair cat.
Only cats diagnosed with ARF and a potentially
There were four castrated males and two spayed
reversible underlying disease were selected for
females. Median age was 6.5 years (range 2e9).
PD. Cats with signs suggestive of chronic kidney
All cats were indoor cats. Clinical signs at presen-
disease and cats believed to have an irreversible
tation included anorexia (n ¼ 6), vomiting (n ¼ 6),
underlying disease were not selected for PD.
lethargy (n ¼ 5), painful abdomen (n ¼ 2), dysp-
nea (n ¼ 2), dysuria (n ¼ 1), weight loss (n ¼ 1), fa-
Data collection cial twitch (n ¼ 1) and cardiac arrhythmias
The following information was recorded: age, (n ¼ 1). Polyuria/polydipsia were not reported
sex, breed, clinical signs and history at presenta- in any of the cats. All cats were referred for eval-
tion, suspected or definitive cause of ARF, treat- uation of ARF and possible PD. All cats were
ment prior to PD, urine output and indication treated with intravenous fluids and furosemide
for PD. Indications for PD included presence (Salix; Intervet) for a median of 2.5 days (range
of severe azotemia (blood urea nitrogen 14 h to 7 days) prior to initiation of PD. One cat re-
(BUN) > 100 mg/dl and creatinine > 10 mg/dl) ceived mannitol (Osmitrol 20%; Baxter). Dopa-
that is unresponsive to more than 24 h of medical mine was not used in any of the cats.
management (rehydration, osmotic or chemical All cats had a biochemistry profile, venous
diuresis), worsening azotemia with signs of fluid blood gas and urinalysis done pre- and post-dial-
overload, and persistent oliguria (<1 ml/kg/h) ysis. Median USG prior to PD was 1012 (range
or anuria (0 ml/kg/h).4,5,8 Overhydration was 1010e1016). Values for BUN, creatinine, potas-
defined as the presence of >pleural effusion, pul- sium and urine output are reported in Table 1.
monary edema, ascites, subcutaneous edema or Hypoalbuminemia was present in one cat (cat
a combination of these factors. Severe hyperkale- 5) prior to starting PD, which got worse during
mia (Kþ > 8 mmol/l) and/or severe acidebase PD. Hypoalbuminemia developed during PD in
disturbances (pH < 7.2) were considered sup- two other cats (cats 3 and 4). All cats had meta-
porting indications for PD.6 Serum biochemistry bolic acidosis at the time PD was initiated, five
and venous blood gas results before, during and of which were considered severe (median 7.2,
after PD were recorded. The technique for PD range 7.05e7.33). Several diagnostic tests were
catheter placement, type of dialysis catheter, performed in an effort to identify the underlying
type of dialysate, number and volume of ex- cause of ARF including urinalysis (n ¼ 6), urine
changes, duration of PD, urine output during culture and sensitivity (n ¼ 6), kidney cytology
PD, complications associated with PD and dura- (n ¼ 3) and pyelocentesis (n ¼ 3). The urinalysis
tion of hospitalization were also recorded. Ab- revealed abnormalities in five cats, which in-
dominal sonography, abdominal and thoracic cluded hematuria (n ¼ 4), pyuria (n ¼ 2), and glu-
radiography, urinalysis, and final outcome of cosuria (n ¼ 2). There was one positive urine
the patients were collected. One-year follow-up culture (Escherichia coli). Kidney cytology was
was recorded when available. An acute onset of unremarkable for two cats and non-diagnostic
clinical signs, elevated renal parameters with for one cat. Urine cytology following pyelocente-
low urine specific gravity (USG) and the absence sis was suggestive of pyelonephritis (pyuria) in
of ultrasonographic evidence of chronic renal one case and was normal in two cases. These
disease were defined as ARF. Outcome was clas- findings were similar to the urinalysis of the re-
sified as discharged, died or euthanased. spective cats. Leptospirosis serology was nega-
tive for the one cat in which it was evaluated.
Snap tests for feline immunodeficiency virus
Statistical analysis
and feline leukemia virus were negative for all
Results are presented as mean (SD) or median cats. Abdominal ultrasound revealed abnormali-
and range. Statistical comparisons of pre- and ties in all six cats which included dilated renal
 Management of ARF in cats using PD 109

Table 1. Duration of PD, and renal parameters at base-line, start of PD (following at least 24 h of medical
management for ARF), at 12, 48 and 72 h after starting PD, and at the time of discharge
Base-line* Start of PD 12 h 24 h 48 h 72 h Discharge PD
(>24 h duration,
medical h
therapy)
Cat 1 64
BUN (mg/dl) 120 325 277 114 53 30 17.3
Creat (mg/dl) 13.7 27.7 24.7 9.7 5.0 3.3 2.0
Kþ (mEq/l) 8.2 4.2 3.6 3.9
Urine output (ml/kg/h) 0.5 0.3 4.0 7.8 4.4
Cat 2 72
BUN (mg/dl) 164 164 N/A 111 140 105 98.1
Creat (mg/dl) 17.5 17.7 N/A 12.7 12.2 10.2 6.7
Kþ (mEq/l) 3.7 4.2 4.2 3.9 4.0
Urine output (ml/kg/h) 3.0 2.7 4.8 7.2 6.8
Cat 3 78
BUN (mg/dl) 64 202 N/A 127 99 44.8 22.3
Creat (mg/dl) 6.5 18.0 N/A 14.7 10.5 3.8 1.7
Kþ (mEq/l) 10.9 8.8 4.5 3.9
Urine output (ml/kg/h) 0 0 0 2.5 6.3
Cat 4 96
BUN (mg/dl) 49 121 59 38 28 N/A 28
Creat (mg/dl) 3.0 6.2 3.4 N/A 1.6 N/A 1.5
Kþ (mEq/l) 4.57 6.11 3.7 3.7 4.0 3.2
Urine output (ml/kg/h) 4.0 3.0 2.0 N/A N/A
Cat 5 80
BUN (mg/dl) N/A 303 N/A 189 168 127 25.9
Creat (mg/dl) 20.1 24.0 N/A 19.5 17.0 14.6 2.3
Kþ (mEq/l) 4.7 6.2 6.1 4.4 4.4
Urine output (ml/kg/h) 0 0 0 0 1.0
Cat 6 53
BUN (mg/dl) 89 268 149 101 107 Died Died
Creat (mg/dl) 21.9 26.5 16.2 N/A 12.0
Kþ (mEq/l) 7.2 8.11 5.9 4.6
Urine output (ml/kg/h) 0.7 N/A 1.7 1.2
Creat ¼ creatinine, N/A ¼ not available, Kþ ¼ potassium. Reference ranges: BUN 12e30 mg/dl, Creat
0.6e2.0 mg/dl, Kþ 3.6e5.3 mEq/l.
*Base-line values were taken prior to or during medical management, and medical management was continued for
at least 24 h following these values (with the exception of cat 6 that received only 14 h of therapy prior to initiating
PD).

pelvises (n ¼ 4), increased renal cortical echoge- One dialysis drain was placed in each cat us-
nicity (n ¼ 4), renomegaly (n ¼ 3), nephrolithiasis ing sterile technique and general anesthesia. As
(n ¼ 2), perirenal effusion (n ¼ 2), abdominal ef- previously described, a ventral abdominal inci-
fusion (n ¼ 2) and renal mineralization (n ¼ 1). sion 2e3 cm caudal to the umbilicus and just
No cat showed echographic abnormalities com- off the midline was used to place the drains.4 A
patible with chronic kidney disease. An ante- Blake silicon drain, Sil-Med, attached to a closed
mortem diagnosis for the ARF was determined intermittent negative pressure system (J-Vac;
in three cats, suspected in one cat and not deter- Ethicon) was used for all cats. The Blake drains
mined in two cats. Suspected or definitive diag- were connected to warmed dialysate solution
nosis, and indications for PD for each cat are and a closed suction system using a Y-connector,
reported in Table 2. similar to what has been previously described.5
110 P Dorval and SR Boysen

Table 2. Diagnosis, indication for, and complications noted during PD

Diagnosis Indication for PD Complications during PD
Cat 1

Pyelonephritis (E coli) Severe azotemia despite medical Dialysate retention

Nephroliths therapy Subcutaneous edema
Oliguria
Overhydration
Severe hyperkalemia
Severe metabolic acidosis
Cat 2
Easter lily intoxication
Severe azotemia despite medical Dialysate retention
therapy Subcutaneous edema
Overhydration Dialysate leakage
Hypokalemia
Cat 3
Suspected pyelonephritis
Severe azotemia despite medical Loss of J-VAC pressure
therapy Hypoalbuminemia
Anuria
Overhydration
Severe hyperkalemia
Cat 4

Traumatic ARF following bilateral Progressive azotemia despite medical Subcutaneous edema
pyelectomies therapy Hyperglycemia
Nephroliths Overhydration Hypoalbuminemia
Progression of pleural
effusion
Cat 5

Undetermined Severe azotemia despite medical Dialysate retention

Suspected obstruction therapy Subcutaneous edema
Anuria Hyperglycemia
Severe metabolic acidosis Hypoalbuminemia
Pleural effusion
Cardiopulmonary arrest
Cat 6

Undetermined Severe azotemia despite medical Loss of JVAC pressure

Chronic severe tubulointerstitial therapy Subcutaneous edema
nephropathy with subacute Oliguria Hyperglycemia
suppurative inflammation Severe metabolic acidosis Facial twitch
Pulmonary adenocarcinoma Severe hyperkalemia Cardiopulmonary arrest
J-VAC Suction Resevoir (Ethicon, Somerville New Jersey).

Omentectomies were not performed. The time depending on the volume status of the patient
required to place the drains was available for when PD was initiated. Bicarbonate 8.4% was
3/6 cats and ranged from 35 to 60 min. added to the dialysate solution of two cats. Hep-
The initial dialysate solution for all cats was arin (250e1000 UI/l) was added to the dialysate
lactate Ringer’s solution mixed with a variable of all cats. Three cats received 10 ml/kg, two re-
dextrose concentration (1.25, 2.5 or 4.5%), ceived 17 ml/kg and one cat received 40 ml/kg
 Management of ARF in cats using PD 111

of dialysate solution during the initial exchanges. to pleural effusion and pulmonary edema
The frequency of dialysate exchanges and dwell showed clinical (improved respiratory effort
times were adjusted for each animal’s individual and improved breath sounds on auscultation of
needs. Initial exchanges were performed hourly the thorax) and radiographic improvement
with a dwell time of 45 min for every cat. Fre- within 24 and 48 h of PD, respectively. Progres-
quency of exchanges were gradually decreased sion of pleural effusion occurred during PD in
in four cats and stopped acutely in two. Subcuta- one cat. One cat with normal thoracic radio-
neous leakage occurred while tapering PD in one graphs prior to PD developed pleural effusion
cat, which necessitated premature stoppage of during dialysis. Subcutaneous edema developed
PD. In two cats PD was acutely stopped due to (n ¼ 2), remained unchanged (n ¼ 1) or pro-
cardiopulmonary arrest. Median duration of the gressed (n ¼ 3) during PD.
PD was 75 h (range 53e96 h). The cat that was Complications associated with PD are re-
unsuccessfully resuscitated had 53 h of PD prior ported in Table 2. Cardiopulmonary arrest oc-
to cardiac arrest. Additional therapies instituted curred in two cats; one that was anuric and one
during PD were based on preferences of the that was oliguric. Cardiopulmonary resuscitation
attending clinician and included antibiotics, (CPR) was successful in the anuric patient whom
calcium gluconate, famotidine (Famotidine; eventually left the hospital while CPR was un-
Omega), Continuous rate infusion (CRI) of insu- successful in the oliguric cat. A CRI of regular in-
lin (HumulinR; Eli Lilly), butorphanol (Torbuge- sulin was used in two cats to treat persistent
sic; Wyeth), metoclopramide (Metoclopramide; hyperglycemia (glucose > 17 mmol/l (305 mg/dl))
Sandoz), odensetron (Zofran; GlaxoSmithKline) that developed during PD. One cat responded
and supplemental oxygen. to the CRI of insulin, which was adjusted to
There was a statistically significant decrease in maintain a glucose concentration between 8
the mean pre- and post-dialysis values for BUN and 13 mmol/l (144 and 234 mg/dl), while the
and creatinine (P < 0.03). The hyperkalemia other cat showed no response to insulin therapy.
noted in five cats resolved within 48 h of PD. Ad- Hyperglycemia in a third cat returned to normal
juvant therapy (dextrose  regular insulin) for with a decrease in the frequency of dialysate
hyperkalemia was administered to four cats. exchanges.
Urine output was measured in all cats. Median Five cats were discharged from hospital and
urine output before PD was 0.6 ml/kg/h (range one died. Median duration of hospitalization
0e4 ml/kg/h). Two cats had urine out- was 11.5 days (range 3e15). All cats were contin-
put > 2 ml/kg/h prior to PD while two were an- ued on intravenous fluids for at least 24 h (me-
uric and two were oliguric. The two anuric cats dian 2 days, range 1e9 days) following PD.
became acutely polyuric (urine output > 2 ml/ Renal parameters of three cats were normal at
kg/h) 48 h (cat 3) and 85 h (cat 5) after the initi- discharge (see Table 1). Two cats were dis-
ation of PD. One of the two oliguric cats became charged with supplemental fluid therapy
polyuric within 17 h of PD (cat 1) while the urine (40 ml/kg sid SQ and 6 ml/kg sid SQ, respec-
production decreased progressively for the sec- tively). The renal profiles of these two cats re-
ond oliguric cat that eventually arrested (cat 6). turned to normal 1 week and 6 months
Nutritional support was provided to five cats following discharge, respectively. The former
during PD. A nasoesophagostomy tube was was on a tapering dose of subcutaneous fluids
placed in two cats, an esophagostomy tube was (12 ml/kg q48 h) and had normal renal parame-
placed in one cat, and force-feeding was used ters at the time this paper was written (3 months
in one cat. Partial parenteral nutrition (PPN) following discharge), while the latter was no lon-
was provided for 72 h in one cat, which was sub- ger receiving subcutaneous fluids. Four cats
sequently switched to total parenteral nutrition were available for 1-year follow-up: no cat re-
(TPN) for an additional 2 days. One cat arrested quired medical therapy for renal disease, all
before institution of nutritional support. Median had normal renal profiles and none were receiv-
time before institution of nutritional support was ing subcutaneous fluids.
48 h (range 24e72 h).
Evidence of overhydration prior to PD was
present in four cats and included subcutaneous Discussion
edema (n ¼ 4) pleural effusion (n ¼ 3), pulmo- PD effectively replaced renal function in all cats
nary edema (n ¼ 2) and ascites (n ¼ 2). Two cats of this study, and allowed renal recovery in
that presented with respiratory signs secondary 83% of cases (5/6). Retrospectively, the rapid
112 P Dorval and SR Boysen

development of polyuria and the reversible na- developed in two cats within 48 h of starting
ture of the underlying diseases likely explain PD likely contributed to the resolution of fluid
the high success rate of patients treated with overload, electrolyte, and acidebase disorders,
PD in our study. These results are more encour- however, the same improvements were observed
aging than what has historically been reported in two cats that did not develop polyuria and re-
for PD in the veterinary literature. In a study of mained anuric or oliguric during the same pe-
25 dogs and two cats treated with PD for ARF riod of time. Our results suggest that signs
or azotemia, only 6/27 patients (22%) survived compatible with ARF (or exclusion of signs com-
to discharge.7 However, a more recent study patible with chronic disease), in association with
showed 4/5 dogs (80%) treated with PD for other indications for renal replacement therapy,
ARF secondary to leptospirosis survived to dis- might be sufficient to support the decision of
charge, suggesting that patients with leptospiro- initiating PD even if the inciting cause cannot
sis may have a better prognosis.9 Unfortunately, be confirmed.
data specific to feline ARF treated with PD is lim- The complication rate associated with PD in
ited to experimental studies and a retrospective cats using the current technique is high (100%).
study that evaluated only two cats.7,10 The two Previous reports of PD in small animals have
cats in the latter study had an unsuccessful out- also reported frequent complications including
come, and it is unclear if PD decreased renal pa- hypoalbuminemia, hypochloremia, hypokale-
rameters in these two cases. Although the mia, catheter obstruction, dialysate retention,
number of cases in the current study is small, peritonitis, subcutaneous leakage of dialysate
the results are more in line with the success of and limb edema.7,9,10 Comparison between PD
cats treated with IHD for ARF of various etiolo- and IHD is difficult because of the limited num-
gies (60%) and suggest that PD remains a viable ber of veterinary studies and the small number of
option in the treatment of selected cats with cats in the present study. In one study, 69% of
ARF.1e3 cats treated with IHD had one or more dialysis-
PD was initiated despite the absence of related complications. IHD-related events in-
a definitive diagnosis in half of the patients of cluded hypotension, dialysis dysequilibrium,
this study (3/6). A potentially reversible under- clotting and bleeding.1 Anemia, dyspnea, throm-
lying disease and signs suggestive of ARF influ- bosis in the right atrium, respiratory and cardio-
enced the decision to perform PD. Transient pulmonary arrest are among other significant
ureteral inflammation associated with surgical complications reported to occur with IHD.1,5,11
trauma, pyelnonephritis and possible transient Significant hypothermia and hypocalcemia
ureteral obstruction, which are all reversible con- were the two major complications encountered
ditions, were identified or suspected to be the in an ARF cat treated with CRRT.3
cause of ARF in most of the cats of this study. Subcutaneous edema was the most frequent
It remains speculative if these cats might have complication encountered in this study (83%)
become polyuric and survived with continued and likely resulted from a combination of dialy-
medical therapy if PD had not been initiated. sate leakage, hypoalbuminemia and overhydra-
However, given the progressive nature of the tion. Intermittent wrapping of the limbs, as
azotemia despite more than 24 h of medical ther- previously described, helped to promote mobili-
apy prior to initiating PD, and/or the persistence zation of the edema.8 Dialysate leakage was evi-
of oliguria/anuria with signs of overhydration, dent in one case that resulted in progressive
PD was considered necessary to help re-establish subcutaneous edema and a decrease in the effi-
homeostasis and manage azotemia until renal cacy of the PD. Increased intra-abdominal pres-
function improved. It is anticipated that cases sure associated with the volume of dialysate
that have more intractable underlying renal dis- used may have contributed to dialysate leakage.
ease would have developed more complications Starting the initial exchange volumes at or below
as a result of longer-term PD and the prognosis 10 ml/kg, or decreasing the amount of fluid in-
would not be as favorable. In all cases the azote- fused throughout dialysis may prevent leakage,
mia, electrolyte and acidebase disorders im- although smaller volumes of dialysate could
proved within 24 h of PD. This improvement is also decrease the efficacy of PD. The use of Da-
likely the result of PD as urine output did not cron cuffs for longer-term dialysis, minimizing
change significantly during the first 24 h of dial- manipulations of the PD catheter, optimal surgi-
ysis, with the exception of one cat that developed cal technique and good postoperative care may
polyuria after 17 h of PD. Polyuria that also decrease the risk of dialysate leakage.8,12
 Management of ARF in cats using PD 113

Hypoalbuminemia occurred in 50% of cats PD cannot be made at this time, however, if

(3/6) in the present study, which is similar to a CRI of regular insulin is started the patient
what has previously been reported.9 Hypoalbu- should be closely monitored for the development
minemia secondary to PD is likely the result of of hypoglycemia. Glucose-sparing dialysate so-
loss of albumin in the dialysate. Gastrointestinal lutions containing icodextrin or amino acids
and renal losses, uremic catabolism, concurrent have been investigated in people in an effort to
disease, production of acute phase proteins, avoid the metabolic complications of glucose,
and low protein intake are additional causes however, long-term studies are lacking and dex-
that likely contribute to the development of hy- trose solutions currently remain the most com-
poalbuminemia in uremic patients. The fact mon solution used in people and veterinary
that hypoalbuminemia is a frequent complica- patients.9,12
tion of dialysis indicates that attention should Facial twitching was present in one cat at the
be given to nutritional intake. In people, there time of admission, and developed in a second
is evidence to suggest that protein malnutrition cat shortly after starting PD. Serum calcium
is a significant risk factor for morbidity and mor- and magnesium were assessed in both cats and
tality in dialysis patients.13 All of the hypoalbu- were normal. Uremic encephalopathy was sus-
minemic cats in the current study received pected to be the cause of twitching in both cats
some form of nutritional support, however, as the twitching gradually decreased following
given they were anorexic for several days prior initiation or continuation of PD, with no other
starting PD, earlier nutritional support may therapies being administered for the twitching.
have prevented or decreased the severity of hy- Dialysis dysequilibrium syndrome could not be
poalbuminemia. In addition, the amount of pro- ruled out for the second cat as the twitching de-
tein provided via PPN and TPN was 1.5 g/kg/ veloped after the initiation of PD and dialysis
day and 2 g/kg/day, respectively, which may disequilibrium symptoms may resemble signs
be suboptimal for patients undergoing dialysis.6 of uremic encephalopathy.17
The use of amino acid based dialysate solutions Although catheter obstruction has been re-
may provide a means to decrease the develop- ported as high as 20e30% in small animals un-
ment of hypoalbuminemia during PD. A study dergoing PD,7,9 it was not a problem in the cats
in people evaluating daily protein losses with of the present study. The use of heparin in the di-
the use of a 1.1% amino acid dialysate solution alysate to decrease fibrin formation may have
showed that the amino acids absorbed during helped prevent obstructions. The use of a Blake
PD more than adequately replaced typical daily surgical drain, which is based on a fluted design,
dialysate protein losses.14 Ultrafiltration rates may have also helped prevent catheter obstruc-
for 1.1% amino acid solutions have been shown tion. The Blake surgical drain has been used
to be similar to 1.5% dextrose solutions.14 Clini- with success for PD in human infants,8 but to
cal studies evaluating the risks and benefits of the author’s knowledge has never been used
amino acid solutions in veterinary patients clinically for PD in veterinary patients. This
have not been performed. drain functions similar to the fluted T drain
Hyperglycemia, which has been reported in which has been investigated in dogs and demon-
cats receiving nutritional support,15 was present strated a low rate of obstruction when compared
in 3/6 cats. Rapid absorption of glucose from to other PD catheter types.6 Although not specif-
the dialysate into the blood, which is reported ically designed for PD, the Blake drain allowed
at rates of up to 80% in people,13 likely contrib- easy ingress and egress of dialysate exchanges
uted to the incidence of hyperglycemia in our with no catheter obstruction. It has also been
study. The fact that hyperglycemia tended to de- suggested that omentectomies may be helpful
velop prior to nutrition initiation also support in decreasing the risk of PD catheter obstruction,
that PD played a major role in this complication. however, they were not performed in the current
Hyperglycemia is a documented complication in study due to the prolonged anesthesia required
humans undergoing PD and a negative associa- to perform an omentectomy.
tion between the severity of hyperglycemia and The use of negative pressure during the egress
outcome has been reported. For this reason, insu- phase of PD has been reported in people18 and
lin therapy is sometimes used in non-diabetic may have further contributed to the success of
people that develop hyperglycemia during peritoneal drainage in the cats of the current
PD.16 Recommendations regarding the treatment study. The advantage of intermittent closed suc-
of persistent hyperglycemia in cats undergoing tion drainage during PD is that it may help
114 P Dorval and SR Boysen

decrease abdominal dialysate retention by ac- that the rapid absorption of dextrose from the
tively removing fluid from the peritoneal cavity peritoneum into the vascular system may limit
during the egress phase. It may also allow the effectiveness of dextrose solutions in achiev-
more complete dialysate exchanges over a shorter ing ultrafiltration and prevent PD from optimiz-
period of time, thereby improving the efficacy of ing volume control.13
PD.18 However, there were complications associ- This is the first study to describe and report
ated with the J-Vac, which included loss of nega- positive outcomes in cats treated with PD for
tive pressure due to breakdown of the reservoir ARF. PD represents an effective renal replace-
material. This was easily corrected by replacing ment therapy for ARF in cats non-responsive to
the negative pressure collection system. medical therapy and carries a reasonable prog-
Dialysate retention has been described as the nosis in selected cases. Although short-term
failure to recover 90% of the dialysate volume in- complications are common, they can usually be
fused and occurred in three cats of the current managed and are rarely fatal. Despite the small
study.8 Subcutaneous dialysate leakage and/or number of cases, our results suggest complete re-
abdominal absorption of dialysate solution nal recovery is possible following PD, and that
were believed to be the causes of dialysate reten- long-term complications associated with its use
tion. The significance of dialysate retention de- are uncommon. The Blake surgical drain and
pends upon the hydration status of the patient, an intermittent closed suction system appear to
the location where the positive fluid balance ac- be a reasonable choice for PD in cats. Although
cumulates, the quantity of dialysate retained, morbidity associated with PD in our study was
the underlying renal function and the patient’s high it remains a viable alternative to veterinar-
ability to excrete excess fluids, and concurrent ians in private practice that may not have access
underlying disease conditions such as heart fail- to IHD or CRRT.
ure. In two cats that showed signs of overhydra-
tion during PD, dialysate retention was also
present, suggesting it may have contributed to References
the state of overhydration. Promoting ultrafiltra-
1. Langston CE, Cowgill LD, Spano JA. Applications and
tion by using higher dextrose concentrations outcome of hemodialysis in cats: a review of 29 cases. J
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