Applied Nephrology Master Series

Chapter 16 Special Populations and Difficult PD Prescriptions

CHAPTER MISSION Turn “special population” from a list of contraindications into a design problem: identify the clinical goal, the patient-specific constraint, the support that can replace unsafe tasks, the prescription lever that addresses the physiology, and the reassessment endpoint that proves the plan is both effective and sustainable.

Figure 16.1 — Special-population PD is constraint-based design. The membrane physiology is unchanged; the limiting constraint may be function, cognition, anatomy, metabolism, hemodynamics, caregiver capacity or competing goals.

MASTER PRINCIPLE Do not ask whether a patient “fits PD.” Ask what PD must accomplish, what threatens safe delivery, and whether anatomy, assistance, prescription or goals can be redesigned around that constraint.

0. One-page chapter map

Table 16.1 — The eight decisions that govern difficult PD prescriptions.

Decision	Core question	Bedside output
1. Goal	What matters most now: survival, symptom control, home time, decongestion, independence or metabolic stability?	Named treatment goal
2. Constraint	What is the dominant barrier: frailty, cognition, vision/dexterity, obesity/anatomy, glucose burden, hypotension or ascites?	Constraint phenotype
3. Capability	Which PD tasks can the patient perform safely?	Task-by-task capability map
4. Support	Which missing tasks can a care partner, staff member or system safely supply?	Assistance plan
5. Physiology	What does this patient need from dwell time, UF, sodium removal, RKF and glucose exposure?	Mechanism-based prescription
6. Burden	What treatment workload, sleep disruption, caregiver load or risk is acceptable?	Sustainability boundary
7. Safety	What red flag would make the current plan unsafe or ineffective?	Escalation/transition trigger
8. Verify	Did symptoms, volume, function, safety and life goals improve?	Clinical reassessment

Learning outcomes

Use a goal–constraint–support–prescription framework rather than treating age, obesity, diabetes, frailty, heart failure or cirrhosis as automatic modality exclusions.
Assess frailty, cognition, functional capacity and home-task capability separately in older adults.
Use assisted PD to replace unsafe tasks while preserving autonomy when reliable support exists.
Balance glycemic burden against ultrafiltration and sodium-volume control in diabetes.
Treat obesity primarily as an access, body-composition, pressure and prescription-planning problem rather than a PD contraindication.
Use PD in heart failure as a gentle decongestion strategy while acknowledging the very-low-certainty evidence base.
Assess cirrhosis/ascites through hemodynamic, infection, nutrition, abdominal-wall and transplant considerations rather than historical bias alone.
Simplify prescriptions for multimorbidity when additional dialysis burden does not improve patient-important outcomes.
Define explicit triggers for reassessment, assistance escalation or planned modality transition.

EVIDENCE POSTURE ISPD 2020 goal-directed PD recommendations and person-centered prescribing govern the chapter. The 2025 ISPD training position paper supports individualized patient/care-partner education and competency assessment. KDIGO 2022 remains the current finalized diabetes-in-CKD guideline in 2026; it specifically notes that HbA1c is less reliable in dialysis, while its numeric HbA1c target recommendation applies to CKD not treated with dialysis. Evidence for assisted PD, obesity, heart-failure PD and cirrhosis/ascites is largely observational, implementation-based or systematic review of nonrandomized studies; recommendations in these areas are therefore framed as supported practice or lower-certainty expert practice rather than universal rules. [1–18]

1. Core concept: special populations are not exceptions to physiology

The same peritoneal membrane, osmotic gradients, sodium-water balance, catheter mechanics and residual kidney function govern PD in every adult. What changes in a “special population” is the constraint that determines whether the therapy can be delivered safely and whether its benefits are worth the workload. In a frail patient the limiting variable may be transfers and aseptic technique; in diabetes it may be glucose burden; in obesity, exit-site visibility and abdominal pressure; in heart failure, decongestion without hypotension; in cirrhosis, ascites, infection, malnutrition and hemodynamic fragility. [1–4]

Table 16.2 — Population label → real clinical problem.

Population label	The real constraint	Do not reduce it to
Older/frail	Function, cognition, falls, caregiver capacity, symptom priorities	Chronological age
Reduced vision/dexterity/cognition	Specific unsafe PD tasks	“Cannot do home dialysis”
Diabetes	Glucose exposure, hypoglycemia risk, vision/dexterity, infection and vascular disease	HbA1c alone
Obesity	Exit-site geometry, pressure, body composition, metabolic burden	BMI veto
Heart failure	Sodium-water removal, hemodynamic tolerance, RKF and prognosis	Net UF number alone
Cirrhosis/ascites	Effective arterial volume, ascites, infection, nutrition, leaks/hernias, transplant plan	Historical contraindication
Multimorbidity	Competing goals, polypharmacy, treatment burden and limited reserve	More dialysis is always better

BEDSIDE TRANSLATION The first adaptation is usually not a new bag strength. It is a better definition of what is limiting success.

2. The universal framework: GOAL → CONSTRAINT → SUPPORT → PRESCRIPTION → VERIFY

A useful difficult-prescription review starts with the patient goal and then separates four kinds of constraint: task capability, anatomy, physiology and system support. This prevents a correct technical prescription from becoming an unusable treatment plan. ISPD goal-directed care explicitly broadens “adequacy” beyond small-solute clearance to symptoms, volume, nutrition, residual kidney function, quality of life and treatment burden. [1,2,19]

Table 16.3 — Constraint domains and their redesign levers.

Constraint domain	Examples	Redesign lever
Task capability	Cannot lift bags, connect, read labels, respond to alarms	Assistance, APD, simplified routine, adaptive equipment
Cognition	Forgets sequence, contamination risk, delirium	Care-partner/staff delivery, teach-back, reduced complexity
Anatomy	Pannus, hernia risk, difficult exit-site visibility	Preoperative seated marking, extended catheter, pressure strategy
Physiology	Fast transport, low UF, hypotension, residual urine	Dwell architecture, icodextrin long dwell, diuretics if responsive, fill-volume adaptation
Metabolic	Hyperglycemia, obesity, glucose load	Glucose-sparing where volume-safe; diabetes treatment review
System	No transport, storage limits, caregiver fatigue, staff availability	Home support, assisted program, supply redesign, backup plan
Goals/prognosis	High treatment burden, limited prognosis, comfort focus	Incremental/palliative approach, planned transition, supportive care

3. Older adults and frailty: measure reserve, not age

Older adults on PD are heterogeneous. Frailty, cognition, mobility, nutrition, sensory impairment and multimorbidity are more useful than age alone for identifying vulnerability. Contemporary reviews recommend frailty screening followed by comprehensive geriatric assessment when indicated, particularly at PD initiation and when function changes. Outcomes that matter may include home time, symptom burden, independence and avoidance of hospitalization rather than survival alone. [3,4,20]

Table 16.4 — Geriatric PD assessment.

Domain	Question	Prescription/program consequence
Frailty	Is physiologic reserve low or declining?	Avoid unnecessary treatment burden; plan assistance and rehabilitation
Cognition	Can steps be learned, remembered and troubleshot?	Care-partner/staff task transfer; simplify regimen
Mobility/falls	Can the patient move safely around tubing/cycler at night?	Home setup, line management, APD placement, falls plan
Vision/hearing	Can labels, connections and alarms be perceived?	Adaptive equipment, assistance, standardized routine
Nutrition	Is there PEW/sarcopenia?	Cross-reference Chapter 15; avoid over-restriction
Symptoms	Which symptoms are dialysis-responsive?	Target prescription to symptom benefit
Goals	What does the patient want dialysis to preserve?	Define acceptable burden and transition threshold

PROGNOSIS RULE For a frail older adult, a numerically “stronger” prescription that reduces home time, worsens sleep, increases falls or overwhelms caregivers may be lower-quality dialysis.

4. Assisted PD: capability is task-specific and support can be dynamic

Figure 16.2 — Assisted PD replaces unsafe tasks while preserving autonomy. Assistance may be partial or complete, temporary or long-term, and provided by family, professional caregivers or trained staff depending on the health system.

Assisted PD makes home treatment possible when self-care capacity is limited. In a multicenter cohort of incident PD patients aged 50 years or older, frailty, functional dependence and cognitive impairment were common, and 62% received assistance one month after starting PD. Contemporary European reviews and programs in Canada and the United States show that assisted PD can be implemented using different workforce models. A 2025 US multicenter staff-assisted program used short-term assistance largely for physical, cognitive and psychosocial barriers; most supported patients were subsequently discharged on PD without ongoing staff assistance. These data support feasibility, but they do not prove universal superiority over other modalities. [5–9]

Table 16.5 — Assisted PD: match assistance to the failed task.

Unsafe or burdensome task	Possible support	Reassessment
Cycler setup	Care partner or trained staff	Can patient later assume part/all setup?
Connections/disconnections	Assisted exchanges	Technique safety and contamination events
Exit-site care	Care partner/staff	Site visibility, infection, caregiver competency
Bag lifting/storage	Delivery/setup assistance	Home ergonomics and injury risk
Alarm troubleshooting	Remote/care-partner support	Alarm frequency and sleep burden
Medication/recording	Simplified written/digital routine	Accuracy and cognitive change
All PD tasks	Full assisted PD	Goals, caregiver burden, program sustainability

ASSISTANCE RULE Do not label the whole patient “incapable” because one task is unsafe. Map tasks individually and replace only what needs replacing.

5. Training when cognition or function is limited: competency, not attendance, is the endpoint

The 2025 ISPD training position paper emphasizes preparation, individualized teaching, appropriate nurse-trainer competency, return demonstration and post-training support. In patients with cognitive or physical limitations, the trained unit may be the patient–care-partner dyad rather than the patient alone. Training intensity and repetition should be determined by demonstrated competency, not by a fixed number of days. [10]

Table 16.6 — Training adaptations for reduced capacity.

Barrier	Training adaptation	Safety check
Mild cognitive impairment	Short repeated sessions, consistent sequence, visual prompts	Teach-back and return demonstration
Low literacy	Pictorial/stepwise materials; minimal jargon	Demonstration rather than written test alone
Visual impairment	Large labels, tactile organization, assistance	Correct solution/connection identification
Dexterity/arthritis	Connection aids, APD, care-partner support	Aseptic technique without excessive hand strain
Hearing impairment	Visual alarm cues/care-partner plan	Alarm recognition and response
Fluctuating cognition	Care-partner-led treatment; delirium trigger plan	No unsupervised exchanges during unsafe periods

6. Diabetes: dialysate glucose is both therapy and metabolic exposure

Figure 16.3 — Diabetes and obesity require simultaneous metabolic and dialysis reasoning. Reducing glucose exposure is useful only if sodium-water control and treatment delivery remain effective.

Glucose-based PD solutions can worsen hyperglycemia, glycemic variability, weight gain and dyslipidemia. At the same time, glucose is the osmotic agent that may be maintaining ultrafiltration. Therefore, the safe goal is not “remove glucose from the prescription”; it is to minimize unnecessary glucose exposure while preserving volume and sodium control. Icodextrin can reduce glucose exposure for the long dwell and may improve long-dwell ultrafiltration in appropriate patients, but a glucose-sparing prescription must be judged by both metabolic and volume outcomes. [11,12,21]

Table 16.7 — Diabetes: problem → mechanism → response.

Problem	Mechanism	Response direction
Hyperglycemia after stronger bags	Absorbed dialysate glucose	Review osmotic need; reduce unnecessary high-glucose exposure; adjust diabetes therapy
Wide glucose variability	Exchange-related glucose absorption + reduced kidney clearance of drugs/insulin	Use SMBG/CGM when needed; coordinate with diabetes team
Volume overload after glucose-sparing	Insufficient osmotic UF / sodium removal	Do not accept metabolic improvement at cost of congestion
Recurrent hypoglycemia	Reduced insulin/drug clearance, variable intake or regimen change	Review insulin/agents and monitoring; avoid rigid targets
Vision/dexterity impairment	Diabetes complications impair technique	Assisted PD/adaptive training
Foot/vascular disease	Mobility and access burden	Home therapy may reduce travel but requires functional plan

7. Glycemic monitoring in PD: HbA1c is useful but less reliable in dialysis

KDIGO 2022 recommends HbA1c for glycemic monitoring in diabetes and CKD but explicitly notes reduced accuracy and precision in advanced CKD, particularly in dialysis. CGM-derived glucose management indicators or direct SMBG/CGM can help when HbA1c conflicts with measured glucose or symptoms. Importantly, KDIGO’s numeric HbA1c target range of <6.5% to <8.0% applies to patients with CKD not treated with dialysis; it should not be copied into PD as a universal dialysis target. Individualization is essential. [13]

Table 16.8 — Glycemic tools in PD.

Tool	What it adds	Limitation / caution
HbA1c	Longer-term trend	Lower reliability in dialysis; affected by anemia/ESA/RBC turnover
SMBG	Immediate treatment decisions	Sampling burden; may miss nocturnal/exchange-related patterns
CGM	Time-in-range, variability, hypoglycemia pattern	Cost/access; interpret with clinical context
Dialysate prescription log	Explains glucose exposure changes	Not a glucose measurement
Weight/volume trend	Detects trade-off from glucose-sparing	Fluid and adipose changes may coexist

ICODextrin SAFETY Patients using icodextrin must use glucose-monitoring methods that are compatible with icodextrin metabolites. Maltose can cause falsely elevated readings on certain nonspecific glucose meters and lead to dangerous insulin administration. Follow current product/device compatibility information. [22,23]

8. Obesity: a technical planning problem, not a blanket contraindication

Contemporary evidence does not support obesity as an automatic contraindication to PD. A 2026 review emphasizes catheter and exit-site customization, adjusted interpretation of small-solute clearance, incremental prescribing where appropriate and glucose-sparing long-dwell strategies. A 2026 meta-analysis of 18 nonrandomized studies found heterogeneous associations: underweight status carried mortality risk, obesity was associated with higher peritonitis risk in pooled analyses, while transfer to HD and technique failure were not clearly different across BMI groups. These are associations, not reasons for automatic modality exclusion. [14,15]

Table 16.9 — Obesity: concern → planning response.

Concern	Mechanism	Planning direction
Exit site hidden under pannus	Poor visibility and self-care	Mark while sitting/standing; consider extended/presternal configuration
Higher intraperitoneal pressure	Leak/hernia/reflux discomfort	Individualize fill volume and posture; cross-reference Chapter 12
Kt/V denominator	Adipose tissue contains less water than lean tissue	Avoid scaling V directly to total body weight; use clinically appropriate body-water assumptions
Glucose calories	Weight/metabolic burden	Minimize unnecessary hypertonic glucose; use long-dwell strategy appropriately
Infection risk	Skin folds/exit-site care may complicate hygiene	Visible exit site, fixation and prevention bundle
Transplant pathway	Center-specific BMI criteria may apply	Do not confuse transplant eligibility with PD feasibility

DO NOT AUTOMATE BMI is not a prescription. Translate body habitus into exit-site geometry, pressure tolerance, body-water estimation, metabolic exposure and patient goals.

9. Difficult access in obesity and altered body habitus

The 2019 ISPD access guideline supports individualized catheter selection and exit-site planning based on body habitus, scars, stomas, belt line and the patient’s ability to see and care for the site. Extended or presternal catheter configurations can move the exit site to a visible, accessible area when standard lower-abdominal positioning is unsuitable. The key test is functional: can the patient or care partner inspect and care for the exit site reliably? [16]

Table 16.10 — Exit-site planning in large or complex body habitus.

Planning question	Why it matters	Direction
Can the patient see the site while seated?	Self-care and early infection recognition	Move site if visibility is poor
Is site under pannus/belt line?	Moisture, friction, traction	Alternative exit-site trajectory
Prior scars/hernia/ostomy?	Mechanical/infection interactions	Surgical/access-team planning
Can catheter be immobilized?	Reduces traction injury	Secure external segment
Will fill volume worsen pressure symptoms?	Leak/hernia/reflux risk	Individualized pressure-aware prescription

10. Heart failure: the target is decongestion, not a heroic UF number

Figure 16.4 — Heart failure and cirrhosis share a need for gentle continuous volume management, but the safety threats differ. Success requires symptom and congestion improvement without hypotension, nutrition decline or technique complications.

PD can provide slow, continuous ultrafiltration and sodium removal, which may be attractive in refractory congestion or hemodynamic intolerance of intermittent extracorporeal ultrafiltration. A 2023 systematic review/meta-analysis of 20 observational before-and-after studies (769 patients) reported improvements in NYHA class and hospitalization burden, but the certainty of evidence was very low and randomized comparative evidence is lacking. PD should therefore be presented as a supported decongestion strategy in selected patients, not as proven superior heart-failure therapy. [17,24]

Table 16.11 — Heart failure: what to monitor.

Domain	Question	Why it matters
Congestion	Edema, orthopnea, JVP, lung findings, weight trend?	Defines therapeutic target
Sodium intake	Is thirst/weight gain driven by intake?	UF cannot compensate indefinitely for high sodium
Residual urine	How much diuretic-responsive output remains?	Continuous native sodium/water removal is valuable
Blood pressure	Can the patient tolerate decongestion?	Avoid organ hypoperfusion and RKF loss
PD UF	Is long-dwell/overall UF adequate?	Prescription lever but not outcome alone
Hospitalizations	Are congestion admissions falling?	Patient-important outcome
Nutrition/cachexia	Is decongestion worsening intake/lean mass?	Advanced HF may shift goals

EVIDENCE CALIBRATION Observational improvement after starting PD does not prove that PD is superior to optimized medical therapy, extracorporeal UF or HD. Use the evidence to support feasibility and symptom-oriented decongestion—not a mortality claim.

11. Heart-failure prescription reasoning: protect RKF and sodium balance

For heart failure, the useful prescription is the least burdensome pattern that provides reliable sodium-water removal. If residual urine remains, diuretics can support volume control; PD then supplements rather than replaces native output. Long-dwell icodextrin may be helpful when sustained UF is required and glucose long-dwell UF is poor. Recurrent hypotension, loss of RKF, refractory dyspnea despite apparent UF or rapid nutritional decline should trigger diagnostic reassessment rather than simply intensifying osmotic therapy. Cross-reference Chapters 8 and 9. [1,17,21]

Table 16.12 — Heart-failure failure modes.

Finding	Think	Next step
High UF but persistent edema	Sodium intake, right-sided HF, low urine, poor sodium removal	Reassess sodium balance and cardiac phenotype
Hypotension after stronger osmotic prescription	Over-removal / low effective arterial volume	Reduce intensity; protect perfusion/RKF
Falling urine output	RKF loss or overdiuresis/hypoperfusion	Search reversible causes; recalculate total removal
Dyspnea without edema	Pleural disease, anemia, lung disease, low output	Do not assume volume; targeted evaluation
Repeated admissions despite PD	Wrong phenotype, membrane limitation, progression of HF	Multidisciplinary review and transition/goals discussion

12. Cirrhosis and ascites: PD can be feasible in selected patients

Cirrhosis with ascites has historically been viewed as unfavorable for PD because of infection, protein loss, leaks, hernias and malnutrition. Contemporary evidence is more nuanced. A 2025 systematic review/meta-analysis of 13 studies (15,089 patients) found no significant mortality difference between PD and HD among patients with cirrhosis; PD patients with cirrhosis had a modestly higher pooled peritonitis risk than PD patients without cirrhosis, while estimates for hernia and transfer to HD were imprecise. Observational data therefore support PD as a viable option in selected patients, especially when intermittent HD is limited by hemodynamic instability. [18,25]

Table 16.13 — Cirrhosis/ascites: benefit–risk map.

Potential advantage	Potential risk	Clinical safeguard
Gentle continuous treatment	Chronic hypotension / low effective arterial volume	Slow adjustments; close BP/perfusion monitoring
Regular ascites drainage	Protein loss / malnutrition	Nutrition surveillance; avoid assuming albumin decline is “just PD”
Avoids vascular access anticoagulation burden	Peritonitis / SBP diagnostic overlap	Low threshold for effluent studies and infection assessment
Home therapy	Leaks/hernias from abdominal pressure	Pressure-aware fill strategy; surgical review when needed
Stable decongestion	Electrolyte/volume instability	Frequent early reassessment
Bridge within transplant pathway	Complex liver-kidney candidacy	Coordinate hepatology/transplant team

13. Ascites changes the starting and monitoring logic

There is no single evidence-based universal fill-volume schedule for cirrhosis/ascites. Expert practice generally favors individualized, progressive intraperitoneal volumes and careful drainage rather than abrupt high-pressure therapy, with close monitoring for leaks, hernias, hypotension, abdominal discomfort and nutrition decline. The ascites itself can make the initial drained volume large; do not interpret every high drain as PD-generated UF. [18,25]

Table 16.14 — Cirrhosis/ascites monitoring.

Parameter	Interpretation	Action direction
Pre/post-exchange weight and symptoms	Net volume trajectory	Avoid rapid depletion
Blood pressure/perfusion	Effective arterial volume tolerance	Reduce intensity if symptomatic hypotension
Serum albumin/nutrition trajectory	Risk marker + intake/loss/inflammation	Cross-reference Chapter 15
Effluent symptoms/cell count when indicated	Peritonitis vs noninfectious ascitic process	Follow Chapter 10 diagnostic pathway
Abdominal wall/hernia	Pressure complication	Cross-reference Chapter 12
Transplant status	Changes long-term modality objective	Coordinate liver/kidney team

ASCITES RULE The question is not “Can cirrhosis receive PD?” It is whether a selected patient can achieve stable decongestion and home treatment without unacceptable infection, pressure, nutrition or hemodynamic cost.

14. Reduced physical or cognitive capacity: redesign the workflow before changing modality

Physical and cognitive barriers are often workflow problems. A patient may be unable to carry bags but perfectly able to connect; able to run a cycler but unable to manage exit-site care; or cognitively intact but unable to read small labels. The assessment should therefore be task-by-task. New cognitive impairment while on PD is particularly important because it can convert a previously safe routine into contamination or dosing risk. [5–10]

Table 16.15 — Task-level capability map.

Task	Capability test	If unsafe
Hand hygiene/asepsis	Can patient perform sequence consistently?	Care partner/staff assistance
Solution identification	Can patient read/recognize correct bag?	Large labels/standardized plan/assistance
Connection technique	Can hands perform connection without contamination?	Assistive device or helper
Cycler programming	Can patient select correct program and respond to alarms?	Preset program + helper/remote support
Exit-site care	Can site be seen/reached and treated?	Care partner/staff; access redesign if needed
Record symptoms/weights	Can trend data be captured reliably?	Simplified log or digital support
Emergency response	Does patient know when/how to call?	Written escalation plan + care partner

15. Multimorbidity and limited reserve: simplify when complexity stops adding value

In multimorbidity, adding exchanges can improve a clearance metric while worsening sleep, fatigue, caregiver load, glucose exposure or treatment completion. The ISPD goal-directed framework supports shared decisions about incremental or less burdensome prescriptions when clinical goals are met, and re-escalation when symptoms, volume or biochemistry deteriorate. For palliative or limited-prognosis patients, PD may be used primarily to manage symptoms and maintain home time rather than to maximize numerical dialysis targets. [1–3,19]

Table 16.16 — When simplification is reasonable.

Situation	What can be simplified	What must remain safe
Substantial RKF + stable clinical state	Exchange number/total burden where appropriate	Symptoms, volume, biochemistry and agreed clearance framework
Frailty + treatment fatigue	Connections, regimen complexity, monitoring burden	Asepsis, medication safety, fluid control
Cognitive decline	Patient-performed tasks	Reliable assisted delivery
Palliative goals	Intensity aimed at numbers alone	Symptom relief and avoidance of distressing complications
Caregiver burnout	Unpaid task load	Continuity via professional assistance or modality transition

BURDEN RULE A prescription that the patient or caregiver cannot reliably complete is not “adequate” because it looks strong on paper.

16. Difficult prescription matrix: match the lever to the constraint

Table 16.17 — Population → dominant target → useful levers → common error.

Population	Dominant target	Useful levers	Common error
Older/frail	Home time, symptoms, safety	Assistance, simplification, APD/CAPD selection, RKF preservation	Treating age as contraindication
Diabetes	Volume + glycemic stability	Limit unnecessary glucose, icodextrin long dwell, CGM/SMBG when needed	Improving HbA1c while worsening congestion
Obesity	Access visibility + pressure + metabolic burden	Extended catheter, seated marking, pressure-aware fills, appropriate V estimation	Scaling prescription to total body weight alone
Heart failure	Gentle sodium-water removal	Diuretics if responsive, dwell/UF strategy, icodextrin when appropriate	Chasing UF number despite hypotension
Cirrhosis/ascites	Stable volume without hemodynamic/nutritional harm	Progressive low-pressure adaptation, infection/nutrition monitoring	Automatic PD exclusion
Multimorbidity	Benefit-to-burden ratio	Incremental/palliative design, assistance, transition plan	Adding treatment without patient-important benefit

17. Reassessment: special populations are dynamic, not fixed labels

Frailty can worsen or improve; caregivers become unavailable; residual kidney function falls; diabetes control changes after prescription changes; obesity may improve or worsen; heart failure and cirrhosis progress. Therefore, every difficult prescription needs a planned reassessment trigger. A once-safe home plan can become unsafe without any change in the membrane. [1,3,4,10]

Table 16.18 — Re-decision triggers.

Trigger	Why it matters	Required review
New delirium/cognitive decline	Technique and medication safety	Competency + assistance
Fall or functional decline	Cycler/tubing and self-care risk	Home/geriatric assessment
Caregiver illness/burnout	Supportability failure	Respite/staff assistance/transition
Falling urine output	Prescription adequacy changes	Chapter 7/8 reassessment
Repeated glucose escalation	Metabolic + membrane burden	Volume/sodium and prescription review
New hernia/leak	Pressure intolerance	Chapter 12 pathway
Recurrent admission despite PD	Treatment target not met	Phenotype reset + goals discussion
Change in transplant/prognosis goals	Different time horizon	Shared decision-making and modality plan

18. Major clinical algorithms

Flowchart 16.1 — Older, frail or cognitively impaired patient. Capability is assessed task-by-task; assistance and simplification are considered before concluding that PD is unsuitable.

Flowchart 16.2 — Diabetes/obesity prescription redesign. Glycemic, volume and access problems are separated so one improvement does not conceal another failure.

$Flowchart 16.3 — Heart failure/refractory congestion.$

Flowchart 16.3 — Heart failure/refractory congestion. Decongestion is judged by symptoms, admissions, sodium-water balance, RKF and tolerability—not net UF alone.

Flowchart 16.4 — Cirrhosis/ascites. PD feasibility depends on hemodynamics, nutrition, infection risk, abdominal-wall tolerance and the broader liver–kidney plan.

19. Retention tables: pattern recognition

Table 16.19 — If you see this, think this first.

Finding	First hypothesis	Immediate action
Older patient misses steps but wants home therapy	Task/cognitive support gap	Competency assessment + assisted PD plan
Caregiver suddenly overwhelmed	Support failure, not membrane failure	Respite/professional assistance/backup modality
HbA1c improves after glucose-sparing but edema worsens	UF/sodium trade-off	Reassess volume and osmotic prescription
Obese patient cannot see exit site	Access geometry problem	Access-team review; alternative exit site
High Kt/V requirement seems impossible in obesity	V-estimation/body-water issue plus true dose need	Check collection and denominator assumptions before escalation
HF patient has high UF but recurrent admissions	Wrong decongestion phenotype / sodium problem	Reassess cardiac + sodium + RKF context
Cirrhosis patient tolerates HD poorly	Hemodynamic fragility	Consider PD feasibility rather than excluding automatically
Cirrhosis patient loses albumin after PD start	Losses, inflammation, intake, dilution	Full nutrition/infection/volume assessment
New cognitive impairment on established PD	Technique safety changed	Retraining/assistance immediately

Table 16.20 — What not to confuse.

Do not confuse	With	Correction
Chronological age	Frailty	Assess reserve/function directly
Needs assistance	PD contraindication	Assisted PD may solve task barrier
Low HbA1c	Safe glycemia	Dialysis HbA1c may be unreliable; hypoglycemia matters
Glucose-sparing	Better PD automatically	Volume control must remain adequate
High BMI	High urea distribution volume	Adipose water content is lower; interpret V carefully
PD for HF	Proven mortality therapy	Evidence is observational/very low certainty
Ascites	Absolute contraindication	Selected patients can receive PD
More exchanges	Higher-quality care	Burden and completion determine delivered therapy

20. Clinical pearls

1. The best “special-population” prescription begins with the dominant constraint, not the diagnostic label.

2. Frailty and cognition are dynamic; reassess after hospitalization, falls or functional change.

3. Assisted PD is a delivery model—not evidence that the patient has failed self-care.

4. Training ends with demonstrated competency, not a predetermined number of training days.

5. In diabetes, every glucose bag is both an osmotic prescription and a metabolic exposure.

6. KDIGO’s numeric HbA1c target recommendation does not apply to dialysis patients; HbA1c is less reliable on dialysis.

7. Glucose-sparing that causes congestion is not a successful prescription.

8. Obesity is primarily an access/pressure/body-composition problem, not a PD prohibition.

9. If the exit site cannot be seen or reached, redesign it before expecting perfect self-care.

10. In heart failure, judge success by congestion, symptoms and hospital burden—not UF volume alone.

11. Cirrhosis/ascites requires nutrition and infection surveillance from day one.

12. High initial drain volumes in ascites do not equal dialysis-generated ultrafiltration.

13. Caregiver capacity is a clinical variable and should be monitored like residual kidney function.

14. Planned transition is adaptation to changing physiology or life circumstances—not treatment failure.

21. Common pitfalls — and the correction

Table 16.21 — High-frequency errors in special-population PD.

Pitfall	Why it fails	Correction
“Too old for PD”	Age poorly captures function or preference	Assess frailty, cognition, home and goals
Training only the patient despite unsafe tasks	Creates contamination and burnout risk	Train the actual patient–care-partner unit
Using HbA1c as the sole diabetes metric	Lower reliability in dialysis; misses variability/hypoglycemia	Use direct glucose data when needed
Reducing dialysate glucose without checking volume	Can trade metabolic gain for congestion	Reassess UF/sodium/weight/BP
Placing exit site under pannus	Makes self-care difficult	Seated preoperative marking/extended catheter
Prescribing to total body weight in obesity	Overstates V and can drive excessive burden	Use appropriate body-water assumptions + clinical goals
Calling PD “heart-failure treatment” with high-certainty language	Evidence is observational and biased	Describe decongestion benefit with evidence calibration
Excluding cirrhosis automatically	Ignores contemporary feasibility evidence	Individualized liver–kidney risk-benefit review
Ignoring caregiver burnout	Support collapse causes technique failure	Reassess caregiver burden and provide backup
Adding exchanges after every abnormal number	May worsen burden and noncompletion	Name mechanism and patient-important goal first

22. Mini-cases: decisions, not trivia

Case 1 — Frailty without cognitive impairment An 82-year-old with ESKD, slow gait and weak grip wants home dialysis to avoid three weekly hospital trips. Cognition is intact, but she cannot lift bags and has arthritis in both hands. BEST NEXT STEP The limiting variable is task function, not understanding or preference. Map which tasks are unsafe, consider APD/assisted setup and train the patient–care-partner unit rather than excluding PD.

Case 2 — New cognitive decline A previously independent PD patient develops recurrent contamination events after a hospitalization. Family reports new memory problems. BEST NEXT STEP Treat this as a change in technique safety. Reassess cognition and competency now; move unsafe tasks to assisted delivery while investigating reversible delirium/cognitive causes.

Case 3 — Diabetes trade-off A diabetic APD patient is switched to a glucose-sparing long-dwell strategy. CGM improves, but weight and edema rise over two weeks. BEST NEXT STEP The metabolic outcome improved while volume control failed. Reassess long-dwell UF, sodium intake, RKF and the complete osmotic prescription rather than declaring success from CGM alone.

Case 4 — Obesity and hidden exit site A patient with severe central obesity can perform all PD steps but cannot see a standard lower-abdominal exit site while sitting. BEST NEXT STEP This is an access-design problem. Re-mark the exit site in the functional position and consider an extended/presternal configuration rather than rejecting PD.

Case 5 — Heart failure and high UF A patient with advanced HF on PD reports 1.2 L daily UF but has recurrent right-sided congestion and hospital admissions. BEST NEXT STEP Net UF is not the endpoint. Reassess sodium intake/removal, residual urine, right-heart physiology, membrane function and whether the cardiac disease has progressed beyond what the current plan can control.

Case 6 — Cirrhosis with hemodynamic intolerance of HD A patient with cirrhosis, recurrent ascites and kidney failure develops severe intradialytic hypotension on HD. BEST NEXT STEP PD is not automatically contraindicated. Assess infection, nutrition, abdominal wall, transplant pathway and home feasibility; if appropriate, use a carefully titrated low-pressure PD strategy with close monitoring.

Case 7 — Caregiver burnout A daughter has performed all exchanges for a frail parent for a year and now says she cannot continue. Clinical PD parameters are stable. BEST NEXT STEP This is technique-threatening support failure. Discuss respite/staff-assisted PD where available and a backup modality plan rather than increasing family pressure.

Case 8 — Multimorbidity and burden A frail patient with limited prognosis is clinically euvolemic and comfortable but spends most waking time performing exchanges to maintain a high clearance number. BEST NEXT STEP Revisit goals and the delivered clinical benefit. A less burdensome goal-directed prescription may be more appropriate if symptoms, volume and biochemistry remain acceptable.

23. Active recall

MUST MEMORIZE

Table 16.22 — Core facts.

Prompt	Answer
First question in special-population PD?	What must PD accomplish, and what constraint threatens success?
Frailty vs age?	Frailty/function—not chronological age—should drive adaptation.
Assisted PD?	Another person performs some or all PD tasks the patient cannot safely perform.
Training endpoint?	Demonstrated competency of the actual treatment unit (patient and/or care partner).
HbA1c in dialysis?	Useful trend but less reliable; direct glucose data may be needed.
KDIGO HbA1c <6.5–<8% target in PD?	No; that numeric recommendation is for CKD not treated with dialysis.
Diabetes prescription rule?	Balance glucose exposure against UF/sodium-volume control.
Obesity contraindication?	No; translate obesity into access, pressure, body-water and metabolic planning.
Heart-failure PD evidence?	Observational/very-low-certainty; may improve congestion/hospital burden in selected patients.
Cirrhosis/ascites contraindication?	No absolute exclusion; selected patients may receive PD with close monitoring.
Key cirrhosis risks?	Hypotension, infection, protein/nutrition loss, leak/hernia and liver prognosis.
Caregiver capacity?	A dynamic clinical variable requiring reassessment.
Best transition?	Planned before safety or sustainability collapses.

USE AS REFERENCE

Exact diabetes medication selection and insulin dose adjustment in dialysis.
CGM device performance and target metrics for an individual patient.
Icodextrin product/device glucose-monitor compatibility.
Extended/presternal catheter selection and operative technique.
Heart-failure pharmacotherapy and device therapy.
Cirrhosis-specific ascites management, SBP prophylaxis and transplant criteria.
Local staff-assisted PD eligibility, staffing and reimbursement rules.
Formal frailty/CGA instruments used by the local geriatric-nephrology pathway.
Palliative-dialysis and supportive-care protocols.

24. Flashcards: spaced repetition

1. Q: What governs special-population PD? A: Goal → constraint → support → prescription → verify.

2. Q: Does old age exclude PD? A: No—assess frailty, cognition, function, home and goals.

3. Q: What is assisted PD? A: PD in which another person performs some or all unsafe/unmanageable tasks.

4. Q: Why map tasks separately? A: A patient may be unable to do one task but safe and independent with others.

5. Q: What is the training endpoint? A: Return-demonstrated competency, not time spent training.

6. Q: Main diabetes PD trade-off? A: Glucose burden versus osmotic UF/sodium control.

7. Q: Why can HbA1c mislead on dialysis? A: Anemia, ESA and altered RBC turnover reduce reliability.

8. Q: What if HbA1c conflicts with symptoms/glucose? A: Use SMBG/CGM/GMI as appropriate.

9. Q: KDIGO dialysis HbA1c numeric target? A: No universal dialysis-specific numeric target from the <6.5–<8% recommendation.

10. Q: Obesity and PD? A: Technical planning problem, not blanket contraindication.

11. Q: Obese patient cannot see exit site? A: Redesign exit-site location/consider extended catheter.

12. Q: Why avoid total-weight Kt/V scaling in obesity? A: Adipose tissue contains less water; V may be overestimated.

13. Q: HF PD target? A: Gentle sustained sodium-water removal with symptom and admission improvement.

14. Q: Quality of HF evidence? A: Very low; mainly observational before–after studies.

15. Q: Cirrhosis and PD? A: Feasible in selected patients; monitor infection, hypotension, nutrition and mechanical complications.

16. Q: High drain in ascites equals UF? A: No—pre-existing ascites contributes to drain volume.

17. Q: Caregiver burnout means? A: Support-system failure requiring assistance or transition planning.

18. Q: When simplify PD? A: When added treatment burden is not producing patient-important benefit and safety goals remain met.

19. Q: What triggers re-decision? A: Change in function, cognition, support, RKF, complications, prognosis or goals.

20. Q: Planned transition means? A: Adaptation—not failure.

25. Rapid differential / troubleshooting

Table 16.23 — Special-population troubleshooting from problem to action.

Problem	Differential / mechanism	First actions
Repeated contamination in older adult	Cognition, vision, dexterity, fatigue, caregiver gap	Observe technique; screen cognition/function; assist unsafe tasks
Cycler alarms + falls risk	Tubing route, nocturia, mobility, catheter flow	Home setup + catheter troubleshooting + assistance
Hyperglycemia after PD change	Higher glucose exposure, infection/stress, medication mismatch	Review bags + direct glucose data + diabetes therapy
Edema after glucose-sparing	Long-dwell UF/sodium failure, RKF loss, high sodium intake	Volume assessment; restore adequate osmotic strategy
Obese patient low Kt/V but clinically well	Collection error, V estimation, true dose shortfall	Verify collection and denominator; assess RKF/clinical goals
Obese patient recurrent ESI	Hidden/moist exit site, traction, hygiene barrier	Inspect location; access/exit-site redesign; Chapter 11 prevention
HF patient hypotensive with strong UF	Over-removal, low output, medication effect	Reduce removal intensity; assess perfusion/RKF/cardiac status
HF patient congested despite high UF	Sodium excess, right-heart disease, low urine, membrane issues	Sodium/RKF/cardiac/membrane review
Cirrhosis patient cloudy effluent	PD peritonitis, SBP/enteric process, noninfectious ascitic inflammation	Chapter 10 effluent pathway + hepatology context
Cirrhosis patient albumin falls	Inflammation, protein losses, poor intake, dilution	Infection/volume/nutrition assessment
Caregiver unable to continue	Burnout, illness, social change	Assisted PD/respite/backup modality
Multimorbid patient noncompleting regimen	Treatment burden, cognition, symptoms, depression, logistics	Simplify/assist; revisit goals rather than blame

26. Final revision sheet

CORE CONCEPT Special-population PD succeeds when the therapy is redesigned around the dominant constraint. Age, diabetes, obesity, heart failure and cirrhosis are not prescriptions or automatic contraindications; they are signals to reassess capability, anatomy, physiology, support and goals.

Table 16.24 — One-minute revision.

Domain	Must remember
Older/frail	Screen function/cognition; use CGA where indicated; prioritize home time, symptoms and burden
Assisted PD	Replace unsafe tasks; assistance can be partial, temporary or long-term
Training	Individualize; prove competency; train care partner when they deliver therapy
Diabetes	Glucose is both osmotic agent and metabolic exposure; monitor both glycemia and volume
HbA1c	Less reliable in dialysis; KDIGO numeric target range does not apply to dialysis
Obesity	Not a contraindication; plan exit site, catheter, pressure, V estimation and metabolic burden
Heart failure	Gentle decongestion may help; evidence remains very low certainty
Cirrhosis/ascites	Feasible in selected patients; monitor hypotension, infection, nutrition, leaks/hernias
Multimorbidity	Simplify when burden exceeds added patient-important benefit
Support	Caregiver/system capacity is dynamic
Transition	Plan before safety or sustainability fails

TEN TAKE-HOME RULES 1) Start with goals, not labels. 2) Assess capability task-by-task. 3) Frailty is more informative than age. 4) Assisted PD can preserve home therapy. 5) Training requires demonstrated competency. 6) Diabetes management must preserve volume control. 7) Obesity is a technical planning problem, not a PD veto. 8) Heart-failure PD evidence is supportive but low certainty. 9) Cirrhosis/ascites can be treated with PD in selected patients. 10) Reassess support and goals whenever health or life circumstances change.

Table 16.25 — One-minute bedside synthesis.

If you see…	Think…	Do now…
Frail but motivated patient	Supportable home therapy may exist	Task map + frailty/CGA + assistance plan
Cognitive decline	Technique safety changed	Reassess competency; transfer unsafe tasks
Diabetes + worsening glucose	Dialysate glucose may contribute	Review glucose load + direct glucose monitoring + meds
Glucose-sparing + edema	Volume trade-off	Reassess UF/sodium/RKF
Obesity + hidden exit site	Access design failure	Reposition/extended catheter planning
HF + recurrent congestion	Decongestion target unmet	Sodium/RKF/UF/cardiac reassessment
Cirrhosis + HD hypotension	PD may be viable	Individualized liver–kidney PD assessment
Caregiver burnout	Support failure	Respite/assisted PD/transition plan
High treatment burden, stable clinical state	Possible over-prescription for current goals	Shared goal-directed simplification review

FINAL MENTAL MODEL GOAL → CONSTRAINT → TASK CAPABILITY → SUPPORT → PHYSIOLOGY → PRESCRIPTION → BURDEN/SAFETY → VERIFY → RE-DECIDE.

Rapid oral viva

Explain why frailty is more useful than chronological age for PD adaptation.
Define assisted PD and give examples of partial assistance.
Explain how the 2025 ISPD training position paper changes training for a patient with cognitive impairment.
Explain why KDIGO’s HbA1c target range should not be copied directly into dialysis.
Build a diabetes prescription that balances glycemic burden and volume control.
Explain why obesity is not a PD contraindication and how exit-site planning changes.
Describe the evidence for PD in refractory heart failure and its limitations.
Build a risk–benefit assessment for PD in cirrhosis with ascites.
Explain when a difficult PD prescription should be simplified rather than intensified.
Describe the triggers for assisted PD escalation or planned modality transition.

SAFETY BOUNDARY This chapter teaches adaptation and clinical reasoning. Exact diabetes drug/insulin dosing, CGM targets, icodextrin-compatible glucometer selection, heart-failure drug/device management, cirrhosis/SBP prophylaxis, transplant candidacy, catheter operative technique, assisted-PD staffing rules and palliative-dialysis protocols require current local specialist guidance and product/system information.

27. Selected authoritative references

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12. Vuković M, et al. Glycemic Control in Patients with Diabetes on Peritoneal Dialysis: From Glucose Sparing Approach to Glucose Monitoring. 2025. PMID: 40430224; PMCID:PMC12113379.

13. Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group. KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. Kidney Int. 2022;102(5S):S1–S127.

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25. Brenner & Rector’s The Kidney. 12th ed. Elsevier; 2024. Chapters on peritoneal dialysis, older adults, kidney supportive care and interventional nephrology.

SOURCE NOTE Guideline status and contemporary special-population evidence were checked 3 September 2026. KDIGO has a 2026 diabetes guideline draft under public review, but the finalized standard used in this chapter remains KDIGO 2022. No universal frailty score, assisted-PD staffing model, obesity BMI cutoff, heart-failure UF target, cirrhosis fill-volume schedule or dialysis-specific HbA1c target is imposed here because current evidence does not support one universal rule. Local product labels, diabetes/cardiology/hepatology protocols, access expertise, assisted-PD resources and patient goals govern operational details.