By Dr. Mark Shapiro
When chronic kidney disease (CKD) progresses to the point where kidneys are no longer able to function, it is called end stage renal disease (ESRD), kidney failure or renal failure. When the kidneys stop working, toxins and fluid build up in the body and cannot be released. To stay alive, people with kidney failure will need to have dialysis treatments or a transplant to take over the job their kidneys can no longer do. One type of dialysis is a form of home dialysis called peritoneal dialysis (PD). Not all people with end stage renal disease are able to choose peritoneal dialysis. Your doctor will help you determine if you are a good candidate for PD and, if not, will prescribe the treatment option that is best for you.
Peritoneal dialysis uses the peritoneal cavity in the abdomen. Many people are familiar with hemodialysis, which takes blood out of the body, runs it through an artificial kidney that removes toxins and extra fluid, and then returns the cleaned blood back into the body. With PD, instead of cleaning the blood outside of the body, a membrane inside the abdomen, called the peritoneum, acts as a filter to remove toxins and fluid in place of the kidneys. A dialysis fluid, called dialysate, is placed into the peritoneal cavity to help pull toxins and fluid across the semipermeable membrane of the peritoneum. After a time, the dialysate is removed and replaced with fresh dialysate, so the process of removing toxins and fluids can be repeated.
To perform peritoneal dialysis, a patient must first have a catheter placed in their abdomen to allow the fluid to enter and drain. The catheter is a small, flexible tube about the thickness of a pencil. It is inserted off to the side, below the belly button, and goes into the abdominal space called the peritoneal cavity. The catheter is placed into the body in the operating room by a surgeon or trained nephrologist, which is usually an outpatient procedure. The catheter remains permanently in the abdomen, and is taped down on the outside of the body so that it doesn’t interfere with everyday activities like work, exercise, recreation, showering or sexual activity.
After the catheter is in place and healed, the patient will visit the peritoneal dialysis nurse and begin learning how to perform PD. There are several training sessions over a one- to two-week period. Family members are encouraged to participate in training and provide support, although it is not necessary to have a partner to perform PD. In addition to learning how to do peritoneal dialysis, information is given about diet, fluid management, good hygiene and medication management.
A dietitian and social worker will meet with the patient and be involved in some of the teaching sessions. Patients watch videos, read instruction manuals and actually perform fluid exchanges—during which they drain the dialysate from the peritoneal cavity and then replace it with fresh dialysate—until both the nurse and patient feel that the patient is ready to begin performing the treatments at home without the nurse. Learning about PD and how to perform it is pretty easy for most people. Even small children are able to perform PD. People with certain handicaps, such as learning disabilities, blindness and amputations have been taught to successfully perform home dialysis with PD.
Home treatments usually begin two to three weeks after the catheter has been placed and training has been completed.
When someone chooses to do peritoneal dialysis at home, they will consult with their doctor about which type of PD they will perform:
Most patients will start off doing continuous ambulatory peritoneal dialysis (CAPD). CAPD involves between two and five daily fluid exchanges that are done manually—without the use of a machine. The fluid exchange includes draining the dialysis solution from the abdomen, then filling it with fresh solution and letting the solution dwell in the abdomen for a period of time. To do an exchange, the patient takes a bag of dialysate, which is a solution of water, minerals to keep the body in balance and dextrose (sugar), attaches it to the PD catheter, and fills it into the abdomen. Several hours later, the PD catheter is attached to an empty bag and the solution is drained out. A new bag of dialysate is then filled into the abdomen, to be drained out again in three to four hours.
Each drain and fill exchange takes about 15 to 20 minutes, and can be done in a clean area at home or at work. People who have significant function left in their kidneys can sometimes do well with only two to three exchanges per day. However, most patients need four to five exchanges per day in order to stay well.
Home dialysis with PD can also be performed using an automated machine known as a cycler. Most patients chose to do their PD with a cycler machine because it allows dialysis to be done at night and frees up the day for work, school or other activities.
In automated PD, larger bags of the dialysis solution are hung next to the bed, connected to the cycler machine and then attached to the PD catheter. The cycler is programmed to perform three to five fluid exchanges while the person sleeps in bed, usually over an 8- to 10-hour time period. Most patients get used to sleeping while on a cycler rather quickly and have few problems. In the morning, patients detach from the machine and put a small cap onto the end of their tubing. Some people will leave fluid in their abdomen to dwell during the course of the day, and then drain it out when they attach to the cycler machine that evening. Other people can leave their abdomen empty during the day. Depending on dialysis needs, some people may have to do a manual PD exchange during the day in addition to the cycler exchanges at night.
PD offers the freedom of doing dialysis at home or work rather than spending time in a dialysis center. PD allows a person to have more control over their schedule. It is easier for someone on PD to work, attend school or travel. When traveling the dialysis solution can be delivered to the traveler’s destination.
People on PD usually visit the dialysis clinic only once or twice each month.
Because peritoneal dialysis is done each day, people on PD have fewer dietary limitations than those on hemodialysis who only go to dialysis three times a week.
Peritoneal dialysis is an excellent dialysis choice for many people despite some of the drawbacks of the therapy. Because the dialysis solution is made up of dextrose, or sugar, there can be some weight gain and problems with glucose control. If you have diabetes or are obese, ask your doctor if PD would be a good choice for you.
Since PD is done using the abdomen, PD may not be an option if you’ve had previous abdominal operations.
Some people feel that the abdominal catheter and fluid in the belly are unattractive.
Infection of the catheter site isn’t common, but can happen. Your doctor will provide you with instructions on how to keep your catheter site clean to help prevent infections. There is also a risk of peritonitis—an infection in the abdomen—which can be painful, and in serious cases may require a stay in the hospital.
PD supplies must be kept at home so storage space must be available.
A clean environment is necessary to perform exchanges.
Ask your doctor about peritoneal dialysis. Usually the decision to choose PD is made by the patient with the help of his or her nephrologist (doctor who specializes in kidney care). You can meet with a chronic kidney disease educator, who can provide you with extensive education. The Kidney Smart℠ educators can provide information about PD and hemodialysis. Call 1-888-MY-KIDNEY (1-888-695-4363), to find out more. You may schedule a visit to a peritoneal dialysis center. To arrange your tour at a DaVita® peritoneal dialysis center, please call DaVita Guest Services at 1-800-244-0582.
Several websites offer PD information and support, including:
Dr. Shapiro is a nephrologist who practices in Escondido, CA. He did his undergraduate training at University of California, Los Angeles, obtained his medical degree at the University of Pittsburgh, and completed his residency training and nephrology fellowship at the University of California, San Diego.
Dr. Shapiro is an Assistant Professor of Medicine at University of California, San Diego, but also maintains an active private nephrology practice in the San Diego area. His primary area of medical interest is in peritoneal dialysis (PD). Dr. Shapiro was a medical advisor for PD within Gambro Healthcare, Inc., but more recently was named the national peritoneal dialysis medical advisor within DaVita Inc. In addition, he serves on the Physician Advisory Council and the Pharmacy and Therapeutics Committee within DaVita.
Dr. Shapiro is married and has two sons. He enjoys kayaking, fishing and most other outdoor sports.
This site is for informational purposes only and is not intended to be a substitute for medical advice from a physician.
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