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Introduction
Current treatment options for patients with severe chronic kidney failure are dialysis and kidney transplantation. Dialysis is a treatment that removes substances such as water, salts, and waste products (from the body’s normal metabolism), which build up in patients with failing kidneys. There are two forms of dialysis. One is called hemodialysis (HD), where the blood is cleaned outside the body and then returned to the body. This treatment, done in a hospital, or a dialysis clinic, is normally done 3 times a week, where each session takes about 4 hours. In HD, a machine and a filter are required, as well as a system to get the blood out of the body, as well as returning the cleaned blood to the patient. In most patients, this so called access to the blood, is done by inserting two needles into blood vessels on the forearm. A few centers around the world can train patients for self- HD. In regard to transplantation, the new kidney can come from either a deceased person or a living donor.
Fun fact: in 1972, a law was passed that medical care had to cover dialysis and kidney transplants.
What is peritoneal dialysis (PD) and how does it work?
The other form of dialysis is called peritoneal dialysis (PD). More than 150,000 patients are currently receiving this lifesaving treatment around the world.
In PD, a dialysis fluid is entered into the patient’s abdominal (= peritoneal) cavity (the “belly”), which is covered by a thin membrane, containing many small blood vessels. This membrane, called the peritoneum, is like a big bag that keeps the stomach, intestines, liver, and other organs in place. The dialysis fluid will make water, salts, and the waste products move from the blood into the fluid (also called solution). This process is called dialysis, and means that the peritoneum works as a dialysis filter. As the fluid gets saturated after a while, the solution must be exchanged regularly (see below).
The solutions
The fluids contain either sugar (glucose), amino acids, which are building blocks for proteins, or a compound called icodextrin, to remove the water. The sugar solution is the one most commonly used. The glucose “strength” (1.5%, 2.5% or 4.25%) of the solution determines how much water is removed from the blood; the higher the concentration, the greater the water removal. The amino acid solution is used to improve a patient’s nutritional condition (as the amino acids are taken up by the body, i.e. they move from the solution to the blood), and/ or to reduce the uptake of glucose from the solution. The benefits of the icodextrin fluid is that it removes more water than the glucose solution for longer exchange intervals, and that it is glucose- free, which is advantageous both for the peritoneum and the body as a whole.
There are two types of glucose solutions. The main difference is the pH, and the type of substance added to reduce the acidity of the blood, which is common in patients with kidney disease.
How can the solution be exchanged?
A small plastic tube, called a catheter, which has been placed through the abdominal wall in a small operation done before starting PD, is used to let the fluid go in to, and out from, the abdomen. The place where the catheter comes out is called the “exit site”. The catheter can normally be used for many years if so needed. In most cases two liters of fluid is entered each time, and is exchanged 4 times per day. In the beginning the patient may feel some discomfort when the solution goes in, but this normally disappears after a while. The bags are delivered to the patient’s home at regular intervals.
Preparation for the exchange
The recommended procedure varies somewhat between centers, but in most cases the patient wears a disposable surgical mask, and scrubs the hands for 3 minutes using soap and water. The solution should be warmed to body temperature before use, for example by using a heating pad or a heating plate. Many centers will provide the patients with an appropriate heating device to be used at home.
Two methods for the solution exchange/ types of PD
There are two types of PD: CAPD and APD. The difference is that in CAPD the exchanges are done manually, and in APD automatically by a small machine.
CAPD means: Continuous Ambulatory Peritoneal Dialysis
C- continuous: dialysis solution is always inside the “belly” cleansing the blood in a continuous manner.
A- ambulatory: ambulatory means that between exchanges, one can move about freely and continue normal activities like going for a drive, walking, golfing, studying or sleeping. In CAPD the solution exchanges are done manually at home, normally with 4 exchanges daily, seven days a week, by the patient him/herself.
P- peritoneal: this type of dialysis makes use of the peritoneal membrane that covers the peritoneal cavity in order to cleanse the blood of waste products and water.
D- dialysis: dialysis is the process of removing all wastes and excess water from the blood, in PD using the peritoneal membrane as a filter.
Steps in CAPD are
Step 1) Attach the new bag
Step 2) Drain: this means letting the solution go from the peritoneal cavity (by gravity) to the so-called drain bag, which takes 15-20 minutes
Step 3) Flush: this is when the system is ‘flushed’ with unused solution for approximately 10 seconds. This ensures your system is made clear of bacteria that may have entered the system when the new bag was connected
Step 4) Fill: this means filling the new solution into the peritoneal cavity. This normally takes less than 10 minutes
Step 5) Dwell time: this is when the dialysis solution is inside the peritoneal cavity
APD means: Automated Peritoneal Dialysis
A- Automated: automated means that the fluid exchanges are done automatically by a machine. In APD, the treatment is done at home at night while sleeping. Most patients are prescribed a continuous (see above) treatment, but in some cases it may be possible to have no dialysis during the day, which means no fluid in “the belly” at daytime.
The steps in APD are
Step 1) Start the machine
Step 2) Connect the new bags
Step 3) Connect to machine
Step 4) The fluid exchanges are done by the machine during the night
Step 5) Disconnect from the machine
Travel
Travel is possible with both CAPD and APD, as the bags can be delivered to the visiting areas. In APD the small size of the machine (such as HomeChoice, manufactured by Baxter) makes it easy to travel despite the PD treatment.
Disposing of the drained fluid
Patients can empty the bags containing the drained fluid into the toilet.
Advantages and disadvantages of peritoneal dialysis
Advantages
A. Compared to HD
* Treatment at home, which means no travel to a HD unit 3 times a week.
* Self control of the therapy
* No needles required
* Facilitates employment
* Easy travel
* Better preservation of the remaining kidney function, which is very important because it helps removing the water and the waste products. This reduces the need for a high dose of dialysis, and also improves patients’ survival and their quality of life.
* Lower doses of medication needed to treat anemia
* Lower risk for hepatitis B and C (liver infections caused by virus)
* Better results after kidney transplantation
* The removal of water is more gentle
B. General
* Easy to learn (3-5 days)
* High level of patient satisfaction and well-being
Disadvantages
* Peritonitis is an infection in the peritoneal cavity. This is in most cases caused by bacteria entering the fluid pass at a solution exchange procedure. The risk for such an infection is nowadays low (on average one episode every 3-5 years) due to improvements in the design of the products used. Also, following the instructions about how to exchange the fluids will further reduce the risk. Usually, a patient with peritonitis has fever, abdominal pain and a cloudy appearance of drained dialysis fluid. Peritonitis is treated, and normally cured, by using antibiotics. Sometimes a change of the catheter or a change of dialysis therapy (temporarily or permanently) may be necessary.
* Exit site infection is an infection of the “exit site” (=where the catheter comes out through the skin) and normally caused by bacteria. Common signs of such an infection are redness and secretion at the exit site. Antibiotics are given to cure the infection. There are also simple ways to prevent the occurrence of exit site infection, such as changing clothes daily, and always wash and dry hands before touching the catheter and exit site.
* Membrane function With time on PD, the peritoneal membrane may change its capability to remove enough water and wastes, which can require a need to change the prescription. In some cases, mainly after many years of PD (more than 5 years), this may not be sufficient, and a change to HD may be needed.
Summary
PD is a home- based therapy and widely used around the world. In general, it is easy, convenient, safe and effective for most patients with failing kidneys.
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