PERITONEAL DIALYSIS

Fig – Peritoneal dialysis

INTRODUCTION

Peritoneal dialysis (PD) is a treatment for kidney failure. A special sterile fluid is introduced
into the abdomen through a permanent tube that is placed in the peritoneal cavity. The fluid
circulates through abdomen to draw impurities from surrounding blood vessels in the
peritoneum, which is then drained from the body. PD can be carried out at home, at work, or
on trips, but requires careful supervision. PD gives patients more control. However, they need
to work closely with the health care team including the Nephrologists, dialysis nurse, dialysis
technician, dietician and social worker. The role of the PD patient and his/her family are very
important. By learning more about the treatment, patients can work with the health care team
to achieve the best possible results and lead an active life.

PHYSIOLOGY OF PERITONEAL DIALYSIS

 A PD catheter is inserted permanently at the abdomen to allow filling and draining of about
two litres of PD solution into and out of the peritoneum or abdominal cavity, which is
surrounded by the peritoneal membrane.
 The peritoneal membrane then filters waste and fluids from the blood into the solution.
 The PD solution is allowed to remain in the abdomen for four to six hours before it is drained
and replaced with fresh PD solution.
  The replacing of fresh PD solution with the used PD solution is called an exchange. Each
exchange takes about 30 minutes.
 PD patients perform an average of four exchanges per day. Different types of PD have
different schedules of daily exchanges.

TYPES OF PERITONEAL DIALYSIS

1. Continuous Ambulatory Peritoneal Dialysis (CAPD)
Unlike Haemodialysis, patients do not need a machine for CAPD. They need gravity to fill and
empty their abdomen. The doctor will prescribe the number of exchanges a patient needs,
typically three or four exchanges during the day and one evening exchange with a long
overnight dwell time while one sleeps.

 As the word “ambulatory” suggests, the patient can walk around with the dialysis solution in
the abdomen.

 The abdomen is cleaned in preparation for surgery, and a catheter is surgically inserted with
one end in the abdomen and the other protruding from the skin.
 Before each infusion the catheter must be cleaned, and flow into and out of the abdomen
tested. 2-3 liters of dialysis fluid is introduced into the abdomen over the next ten to fifteen
minutes.
 The total volume is referred to as a dwell while the fluid itself is referred to as dialysate. The
dwell can be as much as 3 liters, and medication can also be added to the fluid immediately
before infusion.
 The dwell remains in the abdomen and waste products diffuse across the peritoneum from the
underlying blood vessels.
 After a variable period of time depending on the treatment (usually 4–6 hours ), the fluid is
removed and replaced with fresh fluid. This can occur automatically while the patient is
sleeping (automated peritoneal dialysis, APD), or during the day by keeping two litres of fluid
in the abdomen at all times, exchanging the fluids four to six times per day (continuous
ambulatory peritoneal dialysis, CAPD).

 The fluid used typically contains sodium chloride, lactate or bicarbonate and a high percentage
of glucose to ensure hyperosmolarity.
 The amount of dialysis that occurs depends on the volume of the dwell, the regularity of the
exchange and the concentration of the fluid. APD cycles between 3 and 10 dwells per night,
while CAPD involves four dwells per day of 2-3 liters per dwell, with each remaining in the
abdomen for 4–8 hours. The viscera accounts for roughly four-fifths of the total surface area of
the membrane, but the parietal peritoneum is the most important of the two portions for PD.
 Two complementary models explain dialysis across the membrane - the three-pore model (in
which molecules are exchanged across membranes which sieve molecules, either proteins,
electrolytes or water, based on the size of the pores) and the distributed model (which
emphasizes the role of capillaries and the solution's ability to increase the number of active
capillaries involved in PD).
 The high concentration of glucose drives the filtration of fluid by osmosis (osmotic UF) from
the peritoneal capillaries to the peritoneal cavity. Glucose diffuses rather rapidly from the
dialysate to the blood (capillaries).
 After 4-6 h of the dwell, the glucose osmotic gradient usually becomes too low to allow for
further osmotic UF.
 Therefore, the dialysate will now be reabsorbed from the peritoneal cavity to the capillaries by
means of the plasma colloid osmotic pressure, which exceeds the colloid osmotic pressure in
the peritoneum by approximately 18-20 mmHg (cf. the Starling mechanism).
 Lymphatic absorption will also to some extent contribute to the reabsorption of fluid from the
peritoneal cavity to the plasma. Patients with high water permeability (UF-coefficient) of the
 peritoneal membrane can have an increased reabsorption rate of fluid from the peritoneum by
the end of the dwell.
 The ability to exchange small solutes and fluid in-between the peritoneum and the plasma can
be classified as high (fast), low (slow) or intermediate.
 High transporters tend to diffuse substances well (easily exchanging small molecules between
blood and the dialysis fluid, with somewhat improved results with frequent, short-duration
dwells such as with APD), while low transporters have a higher UF (due to the slower
reabsorption of glucose from the peritoneal cavity, which results in somewhat better results
with long-term, high-volume dwells), though in practice either type of transporter can
generally be managed through the appropriate use of either APD or CAPD.

2. Automated Peritoneal Dialysis (APD)

An alternative to CAPD is Automated Peritoneal Dialysis (APD) where a machine called a
cycler will change the dialysate solution during the night, usually while patients are asleep.
This means that patients have to be attached to the machine for 8-10 hours.

BENEFITS OF PERITONEAL DIALYSIS

1. Painless and No Needling
 Unlike HD, no vascular access or needling is required for PD, hence PD is a painless
procedure.
 Vascular access-related complications are one of the common causes of hospitalisation in
haemodialysis patients.

2. Home-based Therapy
 Patients carry out treatment themselves in the comfort of their own homes.
 No need to travel to the dialysis centre for treatment and not restricted to dialysis centre’s
schedule.
 More flexibility to better fit dialysis into their lifestyle.
 Patients take charge their own treatment plan and advice given by the PD care team.

3. Gentler and works more like the natural kidney

 PD mimics the function of real kidneys more as the constant presence of the PD solution in the
abdominal cavity allows waste products and excess water from the blood to be removed
continuously.
 The non-intermittent nature of PD makes it a gentler treatment. Patients have lesser food
restrictions and experience lesser side effects.

4. PD Community Support Programme

 This is a service provided free by The National Kidney Foundation as part of its Peritoneal
Dialysis Community Support Programme.
 The NKF PD Home visit is conducted by a team of nurses who are experienced and trained in
PD.

METHOD

DIALYSIS PROCESS

Hookup Infusion Diffusion (fresh)

Diffusion (waste) Drainage

COMPLICATIONS

Excessive loss of fluid can result in hypovolemic shock or hypotension .

 Excessive fluid retention can result in hypertension and edema. Also monitored is the color of
the fluid removed: normally it is pink-tinged for the initial four cycles and clear or pale yellow
afterward.
The presence of pink or bloody effluent suggests bleeding inside the abdomen while feces
indicate a perforated bowel and cloudy fluid suggests infection.
The acidity, high concentration and presence of lactate and products of the degradation of
glucose in the solution (particularly the latter) may contribute to these health issues.
Solutions that are neutral, use bicarbonate instead of lactate and have few glucose degradation
products may offer more health benefits though this has not yet been studied.

ADVANTAGES OF PERITONEAL DIALYSIS

 Peritoneal dialysis (PD) offers the freedom of doing dialysis at home or work rather than
spending time in a dialysis center.
 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.

DISADVANTAGES OF PERITONEAL DIALYSIS

 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.
 PD supplies must be kept at home so storage space must be available.
 A clean environment is necessary to perform exchanges.
PROBLEMS WITH PERITONEAL DIALYSIS

Peritoneal dialysis (PD) is not always trouble-free. Patients may experience both psychological
and physical problems, discussed below:

(a) Responsibility

Some kidney patients get tired of the responsibility of doing their peritoneal dialysis every day.
If this is a problem, talk to your peritoneal dialysis nurse who may be able to help you
incorporate more flexibility into your routine.

(b) Body image

Some peritoneal dialysis patients find it difficult to accept a permanent PD catheter. They
worry that the catheter may affect their sexual activity and their relationship with their partner.
Peritoneal dialysis nurses can help with tips on how to disguise the PD catheter.
Peritoneal dialysis tends to stretch the abdomen, giving it a rounded appearance.
Keeping fit and doing exercises to strengthen the abdominal muscles will help counteract this.
PD nurses can give advice on suitable exercises.

(c) Fluid overload

Fluid overload occurs when there is too much fluid in the body. It is characterised by a sudden
increase in body weight, swollen ankles, and/or shortness of breath. Generally dialysis patients
need to restrict their fluid intake to prevent fluid overload. Peritoneal dialysis patients,
however, have more flexible fluid allowances than haemodialysis patients.

(d) Dehydration
Dehydration occurs when there is too little fluid in the body. It can be caused by excess fluid
loss due to diarrhoea or sweating. It is characterised by dizziness, feeling sick, or a sudden
decrease in weight. Dehydration is far less common than fluid overload in dialysis patients.

(e) Discomfort
Some PD patients find that having the dialysis fluid in their abdomen is uncomfortable. They
feel full or bloated. Others suffer from backache or experience shoulder pain, especially when
draining in or out. Very rarely, some patients experience discomfort when fresh fluid is drained
 in. Renal units can give advice on how to minimize or avoid discomfort.

(f) Poor drainage

One of the most common problems with peritoneal dialysis, especially among new patients, is
poor drainage of the dialysis fluid. The most common causes are:

1. Constipation - The pressure of the peritoneal dialysis fluid in the abdomen can cause
movement of the bowel to slow down, increasing the likelihood of constipation. Constipation
can cause the bowels to press against the catheter and interrupt drainage. It can also displace
the catheter inside the peritoneal cavity. To avoid constipation, peritoneal dialysis patients may
need to change their diet. In some cases, the patient's doctor may prescribe a laxative.

2. Catheter displacement - Sometimes the PD catheter moves into the wrong position. It may
"float" back into the right place naturally. If not, a minor operation or manipulation under X-
ray may be required to correct its position.

(g)Leaks
In some patients, the peritoneal dialysis fluid leaks out around the catheter exit site. If this
occurs, it may be necessary to decrease the volume of fluid in each exchange or stop peritoneal
dialysis temporarily and have haemodialysis for a short period of time until the leak has
resolved. Occasionally, it may be necessary to place a new catheter at a different site. In some
people, fluid leaks into the genitals and causes swelling. In men, this is called scrotal leak. If
this occurs, peritoneal dialysis must be temporarily stopped until the leak has healed and a
period of temporary haemodialysis may be required.

(h) Exit-site infections

An infected exit site is inflamed, red, sore, and discharges pus. It can be treated with
antibiotics. Occasionally, the infection spreads inward, following the catheter tube along the
"tunnel" through the abdominal wall. This type of infection is called a tunnel infection. If this
occurs, it may be necessary to remove the catheter and put a new one in. A temporary period of
haemodialysis may be required.
Prevention of infections is extremely important. Patients need to follow the procedures covered
during the initial PD training in order to care for their exit site. Good hygiene, and keeping the
catheter taped down on the skin to protect the catheter, can significantly reduce the chances of
getting an infection.

(i) Hernia
A hernia is the protrusion of an organ (most commonly the bowel) through muscle wall,
causing swelling. Sometimes a hernia may be undetected at the time a peritoneal catheter is put
in. This may become a problem later as the constant pressure of dialysis fluid on the hernia
may cause it to become bigger and painful. Surgery may be required to correct the problem. In
some cases haemodialysis may be needed for a short time to allow healing after the operation.
Alternatively, small volume PD exchanges may be recommended. Until patients have healed
completely, they should not lift heavy objects.

(j) Peritonitis
Peritonitis is an infection of the peritoneum, usually caused by bacteria entering through the
catheter. This can happen when patients touch the open ends of the connections between the
bag of dialysis fluid and the catheter. Sometimes, even though everything is kept clean, an
infection can get into the abdomen from the outside.
The chances of getting peritonitis are greatly reduced by following correct dialysis exchange
procedures. Peritonitis infections are not that common. On average, patients can expect to get
less than one attack of peritonitis every year. Some patients never get one.
Peritonitis is easy to recognise. Dialysis fluid is normally clear. Peritonitis makes it cloudy.
Some patients also experience abdominal pain and fever.
Adding antibiotics to fresh dialysis fluid is the method of treatment. Some patients are shown
how to do this at home.
Occasionally, a patient may get several attacks of peritonitis in a row. When this happens, the
PD catheter may need to be replaced and the abdomen 'rested' by not using peritoneal dialysis
for 4 to 6 weeks. During this time, the patient usually needs to have haemodialysis until PD is
resumed.
Repeated attacks of peritonitis may damage the peritoneum and reduce the efficiency of the
dialysis. If this happens, the patient will have to change to haemodialysis for long-term
treatment.

(j) Back strain

 The extra weight of dialysis can cause back strain if your abdominal muscles are weak. A few
simple exercises will strengthen both these muscles and those of your back.

PROCEDURES

 Before peritoneal dialysis begins, patients have a catheter surgically inserted into their
peritoneal cavity.

 The catheter is usually placed 1.2–2 in (3–5 cm) below the umbilicus.
 When dialysis is ready to begin, a bag of fluid (dialysate) containing sterile water, normal
plasma, electrolytes, and glucose is infused into the abdominal cavity. The volume of dialysate
used can range from1.5–3 qt (1.5–3 l), and the concentration of electrolytes and glucose is
altered according to what the physician prescribes.
 The dialysate is left in the abdominal cavity for anywhere from one hour to 10 hours,
depending on the type of dialysis.
 The period of time that the dialysate is left in the abdominal cavity is called the dwell time. At
the end of the prescribed dwell time, the dialysate is drained out of the abdominal cavity
through the catheter.
 The drained dialysate takes waste products with it. This process of instilling a bag of dialysate,
dwell time, and emptying the dialysate is called an exchange.
 The amount and timing of exchanges performed by patients depends on the type of
dialysis, the recommendation of the physician, and the lifestyle of the patient.
 Peritoneal dialysis works based on the principles of osmotic pressure and diffusion. Osmotic
pressure is the moving of fluid toward the solution with a higher solute
concentration. Diffusion is the passing of particles from an area of high concentration to an
area of lower concentration. The dialysate infused into the abdominal cavity is prepared with
specific concentrations of electrolytes and glucose that will draw the waste products and excess
fluid across the peritoneal membrane using diffusion and osmotic pressure. The pores in the
peritoneal membrane are large enough to allow the waste to pass through into the abdominal
cavity, but small enough that blood cells and other protein molecules are unable to pass
through.
 NURSES RESPONSIBILITY

1. PREDIALYSIS CARE
 Document vital signs including temperature, orthostatic blood pressures (lying, sitting, and
standing), apical pulse, respirations, and lung sounds. These baseline data help assess fluid
volume status and tolerance of the dialysis procedure. Hypertension, abnormal heart or lung
sounds, or dyspnea may indicate excess fluid volume. Poor respiratory function may affect the
ability to tolerate peritoneal dialysis. Temperature measurement is vital, because infection is
the most common complication of peritoneal dialysis.
 Weigh daily or between dialysis runs as indicated. Weight is an accurate indicator of fluid
volume status.
 Note BUN, serum electrolyte, creatinine, pH, and hematocrit levels prior to peritoneal dialysis
and periodically during the procedure. These values are used to assess the efficacy of
treatment.
 Measure and record abdominal girth. Increasing abdominal girth may indicate retained
dialysate, excess fluid volume, or early peritonitis.
 Maintain fluid and dietary restrictions as ordered. Fluid and diet restrictions help reduce
hypervolemia and control azotemia.
 Have the client empty the bladder prior to catheter insertion. Emptying the bladder reduces the
risk of inadvertent puncture.
 Warm the prescribed dialysate solution to body temperature (98.6° F or 37° C) using a warm
water bath or heating pad on low setting. Dialysate is warmed to prevent hypothermia.
 Explain all procedures and expected sensations. Knowledge helps reduce anxiety and elicit
cooperation.

2. INTRADIALYSIS CARE
 Use strict aseptic technique during the dialysis procedure and when caring for the peritoneal
catheter. Peritonitis is a common complication of peritoneal dialysis; sterile technique reduces
the risk.
 Add prescribed medications to the dialysate; prime the tubing with solution and connect it to
the peritoneal catheter, taping connections securely and avoiding kinks. This allows dialysate
to flow freely into the abdominal cavity and prevents leaking or contamination.
 Instill dialysate into the abdominal cavity over a period of approximately 10 minutes. Clamp
tubing and allow the dialysate to remain in the abdomen for the prescribed dwell time. Keep
 drainage tubing clamped at all times during instillation and dwell time. Dialysate should flow
freely into the abdomen if the peritoneal catheter is patent. Dialysis, the exchange of solutes
and water between the blood and dialysate, occurs across the peritoneal membrane during the
dwell time.
 During instillation and dwell time, observe closely for signs of respiratory distress, such as
dyspnea, tachypnea, or crackles. Place in Fowler’s or semi-Fowler’s position and slow the rate
of instillation slightly to relieve respiratory distress if it develops. Respiratory compromise
may result from overly rapid filling or overfilling of the abdomen or from a diaphragmatic
defect that allows fluid to enter the thoracic cavity.
 After prescribed dwell time, open drainage tubing clamps and allow dialysate to drain by
gravity into a sterile container. Note the clarity, color, and odor of returned dialysate. Blood or
feces in the dialysate may indicate organ or bowel perforation; Cloudy or malodorous dialysate
may indicate an infection.
 Accurately record amount and type of dialysate instilled (including any added medications),
dwell time, and amount and character of the drainage. When more dialysate drains than has
been instilled, excess fluid has been lost (output). If less dialysate is returned than has been
instilled, a fluid gain has occurred (intake).
 Monitor BUN, serum electrolyte, and creatinine levels. These values are used to assess the
effectiveness of dialysis.
 Troubleshoot for possible problems during dialysis.
 Slow dialysate instillation. Increase the height of the container and reposition the client. Check
tubing and catheter for kinks. Check abdominal dressing for wetness, indicating leakage
around the catheter. Slow dialysate flow may be related to a partially obstructed tube or
catheter.
 Excess dwell time. Prolonged dwell time may lead to water depletion or hyperglycemia.
 Poor dialysate drainage. Lower the drainage container, reposition, check for tubing kinks.
Check abdominal dressing. Tubing or catheter obstruction can also interfere with dialysate
drainage.

3. POSTDIALYSIS CARE
 Assess vital signs, including temperature. Comparison of pre and post dialysis vital signs helps
identify beneficial and adverse effects of the procedure.
 Time meals to correspond with dialysis outflow. Scheduling meals while the abdomen is
empty of dialysate enhances intake and reduces nausea.
 Teach the client and family about the procedure. The client may elect to use peritoneal dialysis
at home to manage end stage renal disease and prevent uremia.

PRACTICE ALERT

Frequently assess breath and heart sounds, neck veins for distention, and back and extremities
for edema. Adventitious breath sounds (crackles), abnormal heart sounds such as an S3 or S4
gallop, distended neck veins,and peripheral edema may indicate hypervolemia, heart failure, or
pulmonary edema.
CONCLUSION:

Peritoneal dialysis may be a feasible and safe alternative to HD in patients who need to
start dialysis urgently without established dialysis access, with an acceptable complications
rates, as well as patient and technique survival.
 BIBLIOGRAPHY

Book reference:

1. Brunner and Sudderth. Medical and Surgical Nursing. 11th ed. wolters publications:2005
2. Lewis, Medical and Surgical Nursing .6th ed. Mosby publication .2000.
3. Sr. Alicen Mathias “Father Muller Manual of nursing procedure, Emmess medical publicher.

Net references:

 [Link]/tests-procedures/peritoneal-dialysis/home/ovc-20202856
 [Link] › Health Information › Kidney Disease › Kidney Failure
 [Link]
 [Link]
 [Link]
INDEX

SL NO. CONTENT PAGE NO.

1 INTRODUCTION 1

2 PHYSIOLOGY OF PERITONEAL DIALYSIS 1

3 TYPES OF PERITONEAL DIALYSIS 1-4

4 BENEFITS OF PERITONEAL DIALYSIS 4

5 METHODS 5

6 COMPLICATIONS 5

7 ADVANTAGES OF PERITONEAL DIALYSIS 6

8 DISADVANTAGES OF PERITONEAL DIALYSIS 6

9 PROBLEMS WITH PERITONEAL DIALYSIS 6-9

10 PROCEDURES 9-10

11 NURSES RESPONSIBILITY 10-12

12 PRACTICE ALERT 13

13 CONCLUSION 13

14 BIBLIOGRAPHY 14