PERITONEA
L
DIALYSIS
Peritoneal Dialysis
a way to remove waste
products from your blood
when kidneys can no longer
do the job
blood vessels in your
abdominal lining
(peritoneum) fill in for your
kidneys, with the help of a
fluid (dialysate) washed in
and out of the peritoneal
space
Contraindications:
•hypercatabolism
peritoneal dialysis cannot adequately clear uremic toxins
•poor condition of the peritoneal membrane because of
adhesions or scarring
•obesity
•history of ruptured diverticula
•recurrent episodes of peritonitis
•back problems
the increased weight of fluid may increase back strain
•extensive abdominal surgery
Peritoneal dialysis may be the better option if:
•You can't tolerate the rapid changes of fluid balance associated with
hemodialysis
•You want to minimize the disruption of your daily activities and
work or travel more easily.
Peritoneal dialysis might not work for you if:
•You have extensive surgical scars in your abdomen
•You have a limited ability to care for yourself or lack caregiving
support at home
•You have inflammatory bowel disease or frequent bouts of
diverticulitis
complications of peritoneal dialysis:
•Infections
•Weight gain
•Weakening of the abdominal muscles (hernia)
•Peritonitis
•Fluid overload
•Amyloidosis
•Pain
•Hypotension
•Overhydration
•Hyperglycemia
•Respiratory difficulty
•Infections
most common problem
can also develop at the site
where the tube (catheter) is
inserted
•Weight gain
client may take in several hundred calories each day by
absorbing some dialysate (dextrose)
the extra calories can also lead to high blood sugar if
you have diabetes
•Weakening of the abdominal muscles (hernia)
holding fluid in your abdomen for long periods may
strain your belly muscles.
•Peritonitis
is the major concern
meticulous aseptic technique must
be maintained during handling of the
catheter, tubing, and dialysate
solution
bacteria may enter the peritoneal
cavity through contaminated dialysis
fluid, a contaminated catheter lumen
the catheter insertion site
Clinical evidence of peritonitis
includes fever, rebound abdominal
tenderness, nausea, malaise and
cloudy dialysate output
If peritonitis develops, antibiotics
may be added
•Fluid overload
the body may
absorb too much fluid
when holding the
dialysis fluid for long
periods
this can heart
failure or fluid
accumulation and
swelling in your
lungs (pulmonary
edema)
•Amyloidosis
proteins in blood are
deposited on joints and
tendons, causing pain, stiffness
and fluid in the joints
common in people who have
been on dialysis for more than
five years
•Pain
rapid instillation
incorrect dialvsate temperature
dialysate accumulation under the
diaphragm
excessive suction during outflow
some pain is expected in the early
stages but should disappear after 1
to 2 weeks
Low back pain may develop with
continuous dialysis procedures
•Hypotension
too rapid removal of fluid
•Overhydration
from insufficient fluid removal
may manifest as heart failure and pulmonary edema
•Hyperglycemia
May occur in diabetic clients as a result of absorption
of glucose from the dialysate
•Respiratory difficulty
•may occur during dwell time because of pressure on the
diaphragm
Process
• the dialysate flows through the catheter into your abdomen
•the solution stays in your abdomen depending on the dwell time
•the peritoneum acts as a
membrane that allows waste,
chemicals and extra fluid to pass
from your blood into the dialysis
solution
•the solution contains a sugar that
draws wastes and extra fluid
through the tiny blood vessels in
your peritoneum into your
abdomen
•when the dwell time is over, the
solution is drained into a sterile
collection bag (exchange)
Types of Peritoneal Dialysis:
•Continuous ambulatory peritoneal dialysis
(CAPD)
•Continuous cycling peritoneal dialysis
(CCPD)
•Intermittent Peritoneal Dialysis
•Nocturnal Intermittent Peritoneal Dialysis
(NIPD)
•Continuous ambulatory 1.5 to 3 L of dialysate is
peritoneal dialysis (CAPD) instilled into the abdomen
client fills the abdomen with
dialysis solution and later
drains the fluid
gravity moves the fluid
through the tube and into and
out of your belly
may need three to four
exchanges during the day and
one with a longer dwell (8
hours) time during sleep
client is free to go about
normal activities while the
dialysis solution dwells in the
abdomen between exchanges
•Continuous cycling
peritoneal dialysis (CCPD)
a machine called an
automated cycler performs
three to five exchanges at night
during sleep
the cycler automatically fills
the abdomen with dialysis
solution, allows it to dwell
there, and then drains it to a
sterile drainage bag
gives more flexibility during
the day, but client must remain
attached to the machine for 10
to 12 hours at night
•Intermittent Peritoneal Dialysis
performed for 10 to 14 hours, three to four times a week
the same peritoneal cycling machine is used as in
continuous cyclic peritoneal dialysis
•Nocturnal Intermittent Peritoneal Dialysis (NIPD)
is like CCPD
only the number of overnight exchanges is greater (six or more)
exchange is not performed during the day
is usually reserved for patients whose peritoneum is able to
transport waste products very rapidly or for patients who still have
substantial remaining kidney function
Factors Affecting Peritoneal Dialysis:
•Size of the client
•peritoneum waste filter time (peritoneal transport rate)
•Amount of dialysis solution (fill volume)
•number of daily exchanges
•dwell times
•concentration of sugar (dextrose) in the dialysis solution
Tests to determine adequacy of dose:
•Peritoneal equilibration test
(PET)
measures how much sugar
has been absorbed from a
bag of used dialysis solution
how much of two waste
products (urea and
creatinine) have entered
into the solution during a
four-hour exchange
•Clearance test
samples of used dialysis solution and a blood sample are collected
to compare the amount of urea in the used solution with the amount
in the blood
if you still produce urine, your doctor may take a urine sample at
the same time to measure its urea concentration
DIALYSIS
ACCESS
SITES
Peritoneal dialysis access
•a minor operation, performed using a
local or a general anesthetic
•the doctor inserts a soft plastic tube
into the abdomen
•called a peritoneal dialysis catheter
(PD catheter)
• acts as a permanent pathway into the
peritoneal cavity
•is about 30 cm (12 inches) long, and
about as wide as a pencil
•about15 cm (6 inches) of the tube
remains outside your body
•this allows the disposable dialysis
bags to be attached
•the place where the catheter comes out
of the body is called the exit site
•is usually placed just below and
slightly to the side of the belly button
•the catheter exit site is usually covered
with a dressing and the catheter is taped
to the skin to avoid pulling on the exit
site
•the peritoneal-dialysis nurse will teach
you a simple routine for cleaning and
looking after the exit site
•proper care of the exit site is important
in order to avoid infection
Hemodialysis access
•also called vascular access
•is an entranceway into your
bloodstream that lies beneath
your skin and is easy to use
•the access is usually in your
arm or leg and allows blood to
be removed and returned
quickly, efficiently, and safely
during dialysis
Types of Access:
•fistula
•graft
•catheter
Fistula
•best choice for hemodialysis
•preferred because it usually lasts longer and
has fewer problems like clotting and
infections
•should be placed several months before
takes one to four months to “mature” or
enlarge before it can be used
•Minor surgery is needed to create a fistula
•preferred locations: wrist, elbow
•made by connecting a vein to a nearby
artery, usually in your arm
•creates a large blood vessel that has a fast
flow of blood
•usually last for many years
PROS CONS
Lasts longer Needs to mature one to
four months before it can be
Not prone to infection used
Provides excellent blood Needles are inserted to
flow once it is ready to use connect to the dialysis
machine.
Less likely to develop
blood clots and become
blocked
You can take showers
once the access heals after
surgery
Graft
•second choice for an access
•minor surgery is done using an artificial tube between a vein and a
nearby artery
•usually put inside the bend of your arm or in your upper arm.
•sometimes grafts may be placed in your leg or chest wall
•need to be in place at least two weeks after surgery before they can
be used
PROS CONS
Provides excellent blood Lasts less time than a
flow once it is ready to use fistula
You can take showers once More prone to infection
the access heals after surgery than a fistula
Needs at least two weeks
before it can be used
Clotting can be a problem
that may require surgery or
other treatment to correct.
Needles are inserted to
connect to the dialysis
machine.
Catheters
•used for a temporary access
•they are sometimes used for a short time in people who get a fistula and need to start
dialysis before the fistula is ready
•are made of soft plastic tubing
•there are two parts, one for removing your blood and the other for returning the
cleaned blood to your body
•placed only when you need to start dialysis
•are put in a large vein, usually in your neck but sometimes in your upper chest
•have more problems (like clotting and infections)
than fistulas or grafts
•may not have enough blood flow for good dialysis treatment
PROS CONS
Can be used right away Usually a temporary access
No needles are needed to Most prone to infection
connect to machine
May not have the blood flow
needed for enough dialysis
May develop blood clots that
block the flow of blood through
your catheter
You need to wear a protective
cover for your catheter to take a
shower
Can cause narrowing of major
blood vessels
What can I do to keep my new access site working
properly in the weeks after the surgery?
•Keep the incision dry for at least 2 days after the procedure and
do not soak or scrub the incision until it has healed.
•Avoid lifting more than about 15 pounds or other activities that
stress the access area, such as digging.
•Report pain, swelling, or bleeding immediately to your
physician, especially if these symptoms are becoming worse.
Some pain or swelling is common and not worrisome if
decreasing, but you should tell your physician if you have
bleeding or a fever higher than 101 degrees Fahrenheit.
•You may feel some coolness or numbness in the hand with the
fistula. These sensations usually go away in a few weeks as your
circulation compensates for the fistula. However, if these
sensations are severe or don’t disappear, tell your physician as
soon as possible, because the fistula may be causing too much
blood to flow away from your hand, a condition physicians call a
“steal.”
• You should perform exercises to grow and strengthen your
fistula, after the pain from the surgery decreases, to make dialysis
faster and easier. Your physician may recommend squeezing a
soft object with the hand in the arm with the fistula.
•Grafts mature more quickly than fistulas. They sometimes can
be ready in 2 to 3 weeks, but many physicians recommend
waiting about 4 to 6 weeks before using a graft.
• Grafts are more likely than fistulas to become infected. Grafts
usually last about 1 to 2 years, which is less than fistulas.
• Fistulas can often last up to 3 to 7 years. If you care properly
for your graft, however, you can help it last for many years.
• Sometimes portals can take weeks or even months until they
are ready for dialysis use. Until the portal is ready, you may
have to use a catheter for dialysis.
Complications:
•Infection
•Clotting or poor blood flow in
your access
•Bleeding from Your Access
Decreased Circulation in Your
Access Arm
Infection
Warning Signs:
Redness, swelling, soreness and/or a feeling of warmth around your
access site; fever, chills, and/or achy feeling.
Steps to Take:
•Call your doctor or dialysis care team at once.
•You’ll need to take antibiotic medicine prescribed by your doctor.
Clotting or poor blood flow in
your access
Warning Signs:
Absence of the vibration (thrill) or sound (bruit) at your fistula or graft site; swelling of
your arm; lower skin temperature on the access site; a decrease in your delivered dose
of dialysis; changes in other lab values.
Steps to Take:
•Call your doctor or dialysis center.
•Keep a record of your Kt/V or URR and other labs. Speak to your dialysis care team
when there are changes.
Bleeding from Your Access
Warning Signs:
Bleeding from a fistula or graft that lasts more than 20 minutes after your dialysis
treatment is over. Any bleeding from a catheter site or catheter tube.
Steps to Take:
•For bleeding from a fistula or graft, gently press your access with a clean gauze pad to
stop the blood; if bleeding lasts more than 20 minutes, call your doctor or dialysis
center at once.
•For bleeding from a catheter site or tube, call your doctor or dialysis center at once, or
go to the emergency room at your local hospital.
Decreased Circulation in Your
Access Arm
Warning Signs:
Feelings of numbness, tingling, coldness or weakness in your arm; blue fingers or
sores at the tips of your fingers.
Steps to Take:
•Call your doctor or dialysis center right away (this must be treated at once to
prevent nerve damage in your access arm).
What can I do to keep my access site working
properly?
• Check several times each day to make sure the access is functioning
• Monitor any bleeding after dialysis. If the graft seems to bleed longer
than usual from the needle sites, you should notify your dialysis center
staff
• Do not carry heavy items with the arm that has the access
• Do not sleep on that arm
• Do not wear any clothing or jewelry that binds that arm
• Do not let anyone draw blood or measure blood pressure from that arm
• Do not allow injections to be given into the fistula or graft
• Keep the site of the fistula or graft clean
• After dialysis, monitor the access for signs of infection, such as swelling
• Do not use any creams and lotions over the site of the fistula or graft
