Peritoneal Dialysis Solutions (Monograph)

Drug class: Irrigating Solutions
VA class: IR200
CAS number: 71-50-1

Introduction

Peritoneal dialysis solutions are sterile solutions that produce osmotic and electrolytic gradients across the semipermeable peritoneal membrane.

Uses for Peritoneal Dialysis Solutions

Peritoneal dialysis is generally not intended for use as single therapy but only as an adjunct in the usual therapy of patients for whom dialysis is considered appropriate. The solutions are used during peritoneal dialysis for the removal of excess metabolites, for the management of serum electrolyte and/or fluid imbalances, and for the removal of toxic substances following acute overdosage. Peritoneal dialysis may be appropriate in patients with acute or chronic renal failure when usual therapy is determined to be inadequate. Peritoneal dialysis is used in the management of intractable edema, hepatic coma, hypercalcemia, hyperkalemia, azotemia, or uremia. Peritoneal dialysis also may be used as an alternative to hemodialysis in the management of shock or circulatory collapse when the patient’s artery-to-vein flow is inadequate. Peritoneal dialysis may also be used as an adjunct to hemodialysis in some patients. Peritoneal dialysis has been used in the treatment of acute overdosage with dialyzable toxic substances when usual measures are inadequate or when such substances are known to be potentially nephrotoxic and/or cause acute renal dysfunction or failure; however, other methods of detoxification may be more effective than peritoneal dialysis for overdosage with many substances.

Peritoneal dialysis solutions containing 1.5% dextrose may be used for the management of acute renal failure (including renal failure for which the cause has not yet been determined), uncontrolled hyperkalemia, or oliguria in the presence of a rapid catabolic rate, overhydration, or worsening of a patient’s clinical condition in spite of appropriate therapy.

Peritoneal dialysis solutions containing decreased sodium concentrations (e.g., 131 mEq/L) are used to prevent postdialysis hypernatremia in hypertonic or short dialysis exchanges where fluid removal exceeds solute removal or in patients with severe hypernatremia.

Peritoneal dialysis solutions containing acetate are used for dialysis therapy in patients with impaired lactate metabolism, including patients with hepatic dysfunction or impaired tissue perfusion. Solutions containing acetate are also used for dialysis therapy in patients with severe acidosis because of the higher concentrations of bicarbonate precursors in acetate-containing solutions compared with lactate-containing solutions (i.e., 45 versus 35 mEq/L).

Peritoneal dialysis solutions containing decreased magnesium concentrations (i.e., 0.5 mEq/L) are used for dialysis therapy in patients with hypermagnesemia or in patients in whom increased oral magnesium intake is desirable. Solutions containing decreased magnesium concentrations contain increased concentrations of lactate (40 mEq/L), the bicarbonate precursor, because of the decreased bicarbonate concentrations that frequently occur in patients with hypermagnesemia.

Pharmacology

Peritoneal dialysis, although it requires minor surgical technique, is a relatively simple method for removing substances from the body by instilling a solution into the peritoneal cavity and then draining the solution from the cavity after an appropriate dwell period. Peritoneal dialysis involves the principles of osmosis and diffusion across the semipermeable peritoneal membrane and includes the osmotic and chemical equilibration of the fluid within the peritoneal cavity with that of the extracellular compartment. The semipermeable peritoneal membrane restricts the movement of formed elements (e.g., erythrocytes) and large molecules (e.g., protein) but allows for the movement of small molecules (e.g., water, urea, electrolytes) in both directions across the membrane according to concentrations on each side of the membrane, with net movement occurring in the direction of the concentration gradient. Intraperitoneal instillation of dialysis solutions containing physiologic concentrations of electrolytes allows for the movement of water and toxic substances and/or metabolites across the membrane in the direction of the concentration gradient, resulting in removal of these substances from the body following drainage of the solution from the peritoneal cavity (outflow); alteration of electrolyte concentrations in extracellular fluid also may result.

The electrolyte concentration of peritoneal dialysis solutions is similar to that of plasma; however, commercially available solutions generally do not contain potassium since the solutions frequently are used for removing potassium in patients with hyperkalemia, although potassium may be added to the dialysis solution and used cautiously when necessary. Peritoneal dialysis solutions also contain sufficient dextrose to produce a final solution that is hyperosmolar to plasma, resulting in an osmotic gradient that facilitates the removal of fluid from the extracellular compartment into the peritoneal cavity. Although the peritoneal membrane is permeable to dextrose, fluid moves into the peritoneal cavity containing the hyperosmolar solution since water and electrolytes diffuse across the membrane more rapidly than do the larger dextrose molecules. Osmolarity adjustment with dextrose prevents overhydration following the introduction of protein-free dialysis solutions into the peritoneal cavity and permits for hydration if dehydration is present.

For further information on chemistry and stability, pharmacology, uses, cautions, and dosage and administration of peritoneal dialysis solutions, specialized references on peritoneal dialysis and the manufacturers’ labeling should be consulted.

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

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