PERITONEAL DIALYSIS

Soni K.C
 Peritoneal dialysis
Peritoneal dialysis (PD) is a treatment for
patients with renal failure that uses the
patient's peritoneum in the abdomen as a
membrane across which fluids and
nitrogenous wastes are exchanged from
the blood.
Here, solute and fluid exchange occur
between peritoneal capillary blood and dialysis
solution in the peritoneal cavity via peritoneal
layer with the help of peritoneal catheter.
 Peritoneal dialysis
• PD involves repeated cycles of instilling
dilysate into the peritoneal cavity, allowing
time for substance exchange and then
removing the dilysate.

• It is useful for both AKI and ESRD and for fluid

and electrolyte imbalance.
Contd…
• Dialysis fluid is introduced to the peritoneal
cavity through a catheter placed in the lower
part of the abdomen.

• In PD, the peritoneum serves as the dialysis

membrane

• The peritoneal cavity can often hold more than

3 liters, but in clinical practice only 1.5 – 2.5L of
fluid are used

• This is an intra-corporeal blood purification

• Peritoneal dialysis may be the treatment of
choice for patients with renal failure who are
unable or unwilling to undergo hemodialysis
or renal transplantation.
 Contd…
• Patients who are susceptible to the rapid fluid,
electrolyte, and metabolic changes that occur
during hemodialysis experience fewer of these
problems with the slower rate of peritoneal
dialysis.

• Patients with DM or cardiovascular disease,

older patients, and those who may be at risk for
adverse effects of systemic heparin are likely
candidates for peritoneal dialysis.
 Peritoneal access
• Dialysis is done via peritoneum. For dialysis,
incision is made 3-5 cm below umbillicus
under GA/LA and PD catheter of about 12
inch is inserted.
• It requires
– Circulation of peritoneum
– PD catheter
– PD fluid
– Peritoneum
 Dialysis solution/dialysate
• Dialysis solutions are available in 1 or 2 lit plastic
bags with glucose concentrations of 1.5%, 2.5%
or 4.25%

• Electrolyte composition similar to plasma

 Composition of dialysate
• In commercially available peritoneal dialysates,
glucose serves as the osmotic agent that
enhances ultra filtration
• Available concentrations range from 1.5% to
4.25% dextrose

1.7% value 4.5%value

- Sodium(NA)-130 Mmol/L 141 Mmol/L
- Calcium 1.5Mmol/L 1.8 Mmol/L
- Magnicium 0.75Mmol/L 0.75 Mmol/L
- CL - 100mMOL/L 101 Mmol/L
- Hco3 (acetate)-35 actate-45
 PRINCIPLE
• Sterile dialysate fluid is introduced into the
peritoneal cavity through an abdominal
catheter

• Urea and creatinine, metabolic end products

normally excreted by the kidneys are cleared
from the blood by diffusion.
 Contd…
• Waste product move from an area of higher
concentration (the peritoneal blood supply) to an
area of lower concentration (the peritoneal
cavity) across a semi-permeable membrane (the
peritoneal membrane).

• Urea is cleared at a rate of 15 to 20 mL/min,

whereas creatinine is removed at a slower rate.
Contd…
• It usually takes 36 to 48 hours to achieve with
peritoneal dialysis what hemodialysis
accomplishes in 3 to 4hours.

• Ultrafiltration (water removal) occurs in

peritoneal dialysis through an osmotic gradient
created by using a dialysate fluid with a higher
glucose concentration.
Contd…
 Peritoneal Dialysis cycle
• PD cycle has 3 phases:
– Inflow (fill) Phase
– Dwell (equilibration) Phase
– Drain Phase

• Theses three phases called an exchange

 Contd…
• Inflow phase:
– A prescribed amount of solution usually 2 L
is infused over about 10 min
– Flow rate may decrease if patient has pain
– After finished infused solution, the inflow
clamp is closed before air enters the tubing
 Contd…
• Dwell phase:
– Diffusion and osmosis occur between
patient’s blood and peritoneal cavity
– The duration of the dwell time can last 20
to 30 minutes to 8 or more hours
depending on the method of PD
 Contd…
• Drain phase:
– Drain time takes 15 to 30 min and may be facilitated
by gently massaging the abdomen or changing
position

• The cycle starts again with the infusion of

another 2 L of solution
• For manual PD, a period of about 30-50 min is
required to complete an exchange
 INDICATIONs OF PD
Indication are same as HD but PD is more
preferable in :-
• In children and elderly patients, especially
diabetics
• CKD patients with cardiac compromise
• Exhaustion of AV fistula in ESRD patients
Contd…
• Hypertension , heart failure, and pulmonary
edema not responsive to usual treatment
regimens have been successfully treated with
peritoneal dialysis

• Diabetes client to reduce the risk of retinal

hemorrhage due to heparin used in HD and
because good blood glucose control can be
achieved by adding insulin to the dialysate
 CONTRAINDICATIONs OF PD
Absolute:-
• Insufficient abdominal space
• Untreatable Hydrothorax
• Pleuro – peritoneal fistula

Relative:-
• Recent abdominal surgery
• Previous episode of diverticulitis
• Colostomy
• Nephrostomy
Contd…
• Previous fungal or tubercular peritonitis
• Hydrocele
• Hernia
• Obesity
• Recurrent episode of peritonitis
• Respiratory disease
• Back problem increased weight of fluid may
increase back strain
 PROCEDURE
• The patient undergoing peritoneal dialysis
may be acutely ill, thus requiring short-term
treatment to correct severe disturbances in
fluid and electrolyte status, or may have end
stage renal disease and need to receive
ongoing treatments.
 INSERTING THE CATHETER
• Ideally, the peritoneal catheter is inserted in the operating room
to maintain surgical asepsis and minimize the risk of
contamination

• In some circumstances, catheter at the bedside under strict

asepsis

• A rigid stylet catheter is inserted for acute peritoneal dialysis use

only

• The skin is prepared with a local antiseptic to reduce risk of

contamination and infection.
 Contd…
• Anesthetizes the site with a local anesthetic agent

• Making a small incision in the lower abdomen, 3 to

5 cm below the umbilicus

• The catheter is threaded through the trocar and

positioned

• Secure the catheter with suture

• Apply antibacterial ointment and a sterile dressing

over the site.
• Before the start of PD, it is preferable to allow
a waiting period of 7 to 14 days for proper
sealing of the catheter and for tissue to grow
into the cuffs.
Contd…
The catheters have three sections:
(1) an intraperitoneal section, with numerous
openings and an open tip to let dialysate flow
freely

(2) a subcutaneous section that passes from the

peritoneal membrane and tunnels through
muscle and subcutaneous fat to the skin

3) An external section for connection to the

dialysate system
• Most of these catheters have two
cuffs, which are made of Dacron
polyester.

• The cuffs stabilize the catheter, limit

movement, prevent leaks, and
provide a barrier against
microorganisms.

• One cuff is placed just distal to the

peritoneum, and the other cuff is
placed subcutaneously.

• The subcutaneous tunnel (5 to 10

cm long) further protects against
bacterial infection
 Preparing the patient for Peritoneal Dialysis
Catheter Insertion
• Preparation of the patient and family for
peritoneal dialysis depends on:
- patient’s physical and psychological status
- level of alertness
- understanding of and familiarity with the procedure

• Explain the procedure to the patient and obtains

signed consent for it

• Baseline vital signs, weight, and serum electrolyte

levels are recorded
Contd…
• The patient is encouraged to empty the bladder and
bowel to reduce the risk of puncturing internal organs

• Assesses the patient’s anxiety about the procedure

and provides support and instruction

• If the peritoneal catheter is to be inserted in the

operating room, this is explained to the patient and
family
 PREPARING THE EQUIPMENT
• In addition to assembling the equipment for peritoneal
dialysis, consults with the physician to determine the
concentration of dialysate to be used and the
medications to be added to it

• Heparin may be added to prevent blood clotting and

resultant occlusion of the peritoneal catheter.

• Potassium chloride may be prescribed to prevent

hypokalemia if present

• Antibiotics may be added to treat peritonitis

 Contd…
• Insulin may be added for diabetic patients; a
larger-than-normal dose may be needed, however,
because about 10% of the insulin binds to the
dialysate container

• All medications are added immediately before the

solution is instilled

• Before medications are added, the dialysate is

warmed to body temperature to prevent patient
discomfort and abdominal pain and to dilate the
vessels of the peritoneum to increase urea
clearance
Contd…

• Solutions that are too cold cause pain and

vasoconstriction and reduce clearance
• Solutions that are too hot burn the peritoneum
• Dry heating is recommended (heating cabinet,
incubator, or heating pad)
• Aseptic technique is crucial
 PERFORMING THE EXCHANGE
• Peritoneal dialysis involves a series of
exchanges or cycles
• An exchange is defined as the infusion, dwell,
and drainage of the dialysate
• This cycle is repeated throughout the course
of the dialysis
• The dialysate is infused by gravity into the
peritoneal cavity
• A period of about 5 to 10 minutes is usually
required to infuse 2 L of fluid
 Contd…
• The prescribed dwell, or equilibration, time allows
diffusion and osmosis to occur

• Diffusion of small molecules, such as urea and

creatinine peaks in the first 5 to 10 minutes of the dwell
time

• At the end of the dwell time, the drainage portion of

the exchange begins

• The tube is unclamped and the solution drains from the

peritoneal cavity by gravity through a closed system

• Drainage is usually completed in 10 to 30 minutes

 Contd…
• The drainage fluid is normally colorless or straw-colored
and should not be cloudy.

• Bloody drainage may be seen in the first few exchanges

after insertion of a new catheter but should not occur
after that time

• The entire exchange (infusion, dwell time, and drainage)

takes 1 to 4 hours, depending on the prescribed dwell
time

• The number of cycles or exchanges and their frequency

are prescribed based on the patient’s physical status
Contd…
• The removal of excess water during peritoneal
dialysis is achieved by using a hypertonic
dialysate with a high dextrose concentration
that creates an osmotic gradient.

• The higher the dextrose concentration, the

greater the osmotic gradient and the more
water removed

• Selection of the appropriate solution is based

on the patient’s fluid status
 Different approaches of PD:
Peritoneal dialysis can be performed using
several different approaches:
– Intermittent Peritoneal Dialysis (IPD)
– Continuous Ambulatory Peritoneal Dialysis
(CAPD)
– Automated Peritoneal Dialysis (APD)
 Intermittent Peritoneal Dialysis
• It permits a more gradual change in the patient’s
fluid volume status and in waste product removal.

• Therefore, it may be the treatment of choice for the

thermodynamically unstable patient.

• Exchange times range from 30 minutes to 2 hours.

• A common routine is hourly exchanges consisting of

a 10-minute infusion, a 30-minute dwell time, and a
20-minute drain time
 Continuous Ambulatory Peritoneal
Dialysis(CAPD)
• CAPD is a form of dialysis used for many
patients with ESRD

• CAPD is performed at home by the patient or

a trained caregiver, who is usually a family
member

• The procedure allows the patient reasonable

freedom and control of daily activities
CAPD contd…
• The patient performs exchanges four or five times
a day, 24 hours a day, 7 days a week, at intervals
scheduled throughout the day

• After infusing the dialysate into the peritoneal

cavity through the catheter (over about 10
minutes), the patient can fold the bag and tuck it
underneath the clothing during the dwell time.

• This provides the patient with some freedom and

reduces the number of connections and
disconnections necessary at the catheter end of
the tubing, thereby reducing the risk of
contamination and peritonitis.
CAPD Contd…
• At the end of the dwell time, the dialysate is
drained from the peritoneal cavity by unfolding
the empty bag, opening the clamp, and placing the
bag lower than the abdomen near the floor.

• This allows the peritoneal fluid to drain out by

gravity.

• When drainage ends, the patient repeats the

procedure by spiking a new bag containing
dialysate and infusing the solution into the
peritoneal cavity
 Automated PD
• An automated device called a cycler is used to
deliver the dialysate for APD
• A machine performs the exchanges overnight while patient
sleep.

• It uses an automated device to do multiple nighttime exchanges,

sometimes with a daytime dwell.

• One or two day time manual exchanges may also be prescribed

to ensure adequate dialysis
• Automated cycler times and controls the fill, dwell
and drain phases

• The machine cycles four or more exchange per night

with 1 to 2 hrs per exchange

• Alarms and monitors system to make safe for the

patient to dialyze when sleeping

• Machine disconnect from pt in the morning and

usually leaves fluid in abdomen during day
 Advantages
• Immediate initiation in almost any hospital
• Less complicated than hemodialysis
• Portable system
• Fewer dietary restrictions
• Relatively short training time
• No needles puncture required
• Minimal cardio-vascular stress
• Greater life style flexibility
• Enhanced psycho-social adjustment
 Disadvantages
• Needs training to patient/ care taker
• Possibility of infection
• Catheter related exit-site, tunnel infection
• Bacterial or chemical Peritonitis
• Three or Four exchanges per day (no day off)
• Protein loss
• Glucose absorption
• Storage space needed for supplies
• Self image problems with catheter placement
 Care of peritoneal access
• Check the site for infection
• Dressing with sterile technique
• Perform treatment in a clean area
• Prevent from getting wet
• Donot pull out or twist catheter
 COMPLICATIONs OF PD
- Subcutaneous infiltration
- Intraperitoneal bleeding
- Perforation of hollow viscous
- Peritonitis
- Fluid overload
- Hyperglycemia
- Hernias
- Malnutrition
- Low back pain and anorexia from fluid in the abdomen
- Pulmonary complications
- Carbohydrate and lipid abnormalities
 CATHETER RELATED COMPLICATION
1. Leakage
2. Dislodgement of catheter tip
3. Subcutaneous tunnel infection
4. Exit wound infection
5. Obstruction may be due to malposition, adherence of
the catheter tip to the omentum or infection
6. Bladder perforation can also occur if the bladder has
not been emptied before catheter insertion
7. Bleeding is common during the first few exchanges
after a new catheter insertion
THANK YOU
 NURSING MANAGEMENT
Assessment
• Assesses the patient’s and family’s understanding
of CAPD and their use of safe technique in
performing CAPD.
• Assessments include checking for changes
related to:
- renal disease
- complications such as peritonitis
- treatment related problems such as heart failure,
inadequate drainage, and weight gain or loss
Contd…
• Assesses the patient’s and family’s progress in
coping with the procedure
• Observe for:
- Fluid volume status
- Calculation of dialysate input and output
- Colour of dialysate
- Assess patient’s comfort
- Monitor vital status
 Intervention
• Monitor fluid volume status
• Follow fluid restriction
• Take measure to relieve nausea and vomiting
• Keep semi flower position or in comfortable
position
• Explain about the purpose of dialysis and
approximate time it take until completion.
Managing discomfort and pain
• Antihistamine agents, such as diphenhydramine
hydrochloride (Benadryl), are commonly used,
and analgesic medications may be prescribed

• Keep the skin clean and well moisturized using

bath oils, super fatted soap, and creams or lotions
helps to promote comfort and reduce itching

• Teach the patient to keep the nails trimmed to

avoid scratching and excoriation and to rub lotion
into the skin instead of scratching also promotes
comfort
Controlling electrolyte levels and diet
• Electrolyte alterations are common, and
potassium changes can be life threatening
• Serum laboratory values are assessed daily
• Dietary intake must also be monitored
• Recognize and counsel frustrations related to
dietary restrictions
• Hypoalbuminemia is an indicator of
malnutrition in patients undergoing long-term
or maintenance dialysis.
 Administering medications
• The medications prescribed for any dialysis
patient must be closely monitored to avoid those
that are toxic to the kidneys and may threaten
remaining renal function
• All medications must be monitored, and
alterations in dosages may be necessary to
prevent either toxic effects on the kidney or over
dosage because of impaired renal excretion
• Care must be taken to evaluate all problems and
symptoms that the patient reports without
automatically attributing them to renal failure or
to dialysis therapy
 Caring for the catheter site
• Patients receiving CAPD usually know how to
care for the catheter Site

• Daily or three-or-four-times-weekly routine

catheter site care is typically performed
during showering or bathing

• The exit site should not be submerged in bath

water
Contd…
• The most common cleaning method is soap
and water; liquid soap is recommended.

• During care, the nurse and patient need to

make sure that the catheter remains secure
to avoid tension and trauma.

• The patient may wear a gauze or

semitransparent dressing over the exit site.
 Monitoring blood pressure
• Hypertension in renal failure is common
• Many dialysis patients receive some form of
antihypertensive therapy and require intense
teaching about its purpose and adverse effects.
• Antihypertensive agents must be withheld on
dialysis days to avoid hypotension due to the
combined effect of the dialysis and the
medication
• Maintaining strict volume control via absolute
dietary salt restrictions
 Providing psychological support

• Evaluate Patients undergoing dialysis for

their status, the treatment modality, their
satisfaction with life, and the impact of these
factors on their families and support systems
• Provide opportunities for these patients to
express their feelings and reactions and to
explore options
• Involve them in the decision making process
 Preventing infection
• Patients with ESRD commonly have low white
blood cell counts (and decreased phagocytic
ability), low red blood cell counts (anemia),
and impaired platelet function.
• High risk for infection and potential for
bleeding after even minor trauma
• Preventing and controlling infection are
essential
• Infection of the vascular access site and
pneumonia are common.
 Patient Education
• The use of CAPD as a long-term treatment
depends on prevention of recurring
peritonitis.
– Use strict aseptic technique when performing bag
exchanges.
– Perform bag exchanges in clean
– Wash hands before touching bag
– Inspect bag, tubing for defects and leaks
Contd…
• Some weight gain may accompany CAPD the
dialysate fluid contains a significant amount of
dextrose, which adds calories to daily intake

• Report signs and symptoms of peritonitis

cloudy peritoneal fluid, abdominal pain or
tenderness, malaise, fever
 Reference
1. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing
Lippincott ,12th edition vol-2 p-1289
2. Black J.M &Hawks J.H. “Medical Surgical Nursing Clinical
Management For Positive Outcome”, division of Reed
Elsevier India pvt ltd 8th edition ,vol -1 p-823
3. Lippincott , “manual of nursing practice of the adult “ 8th
Edition ,Jaypee brother pgno.727
4.Devidson’s “principle and practice of mrdicine” 20th
edition.pg.no 419.
5. National kidney foundation. (2011). Treating kidney failure
with hemodialysis. Available at www.kidneyorg.com
6. Sultania P,et.al.,( 2009) Adequacy of hemodialysis in
Nepalese patients under going maintenance hemodialysis
availabe at www.nks.com