Patient selection for automated peritoneal dialysis: for whom, when?

The use of the various forms of automated peritoneal dialysis (APD) has increased considerably in the past few years. This increase has in part been driven by technology, through improved cycler design. Other contributing factors include better adjustment of APD to patient lifestyle, the flexibility that APD offers to patients, and the increased ability of APD to achieve adequacy and ultrafiltration targets. For high transporters and for patients unable to perform peritoneal dialysis (PD) on their own (for example, pediatric and elderly patients), APD is considered the most suitable PD modality. Furthermore, APD has been associated with improved compliance, lower intraperitoneal pressure, and lower incidences of peritonitis. On the other hand, concerns have been raised regarding increased complexity and cost, a more rapid decline in residual renal function, inadequate sodium removal, and disturbed sleep. Automated PD is an alternative to continuous ambulatory PD when a higher dialysis dose is needed, and it could be a reliable alternative for unplanned or urgent dialysis start. Other than beneficial results in high transporters, the medical advantages of APD remain controversial. Individual patient choice therefore remains the main indication for the application of APD, which should be made available to all patients starting PD.