The role of tidal peritoneal dialysis in modern practice: A European perspective

Tidal peritoneal dialysis (TPD) has been introduced to optimize adequacy of peritoneal dialysis (PD). Early studies reported similar or even better small solute clearances with TPD than those achieved with continuous ambulatory peritoneal dialysis or continuous cyclic peritoneal dialysis. However, in many studies treatment volumes were much higher during TPD compared with other PD modalities. Based on current evidence, TPD provides no advantage of increased small solute clearances, middle molecule clearances, or peritoneal ultrafiltration as compared to non-tidal automated peritoneal dialysis (APD) when dialysate flow is kept constant. However, TPD reduces drainage pain and nightly alarms during cycler treatment. Tidal volume should be kept as high as possible in these patients, especially in those with low average peritoneal transport rates. Based on theoretical considerations and little evidence, TPD could provide better clearances than conventional APD when a very high dialysate flow (>or=5 l/h) is used. Such dialysate flow rates are not routinely prescribed in home APD patients. However, they may be interesting for in-center PD patients. One randomized crossover trial reported higher small solute clearances with TPD compared to non-tidal APD in patients with acute renal failure. TPD is also the preferred treatment modality in patients with ascites as it allows a controlled outflow of fluid from the peritoneal cavity. Newer treatment modalities, for example, continuous flow PD, may be interesting alternatives in an effort to increase efficacy of PD in the future. However, because such treatment regimens are expensive and elaborate they have not been established for routine use until now.