If you are reading this and wondering what peritoneal dialysis is, you have stepped into a very small, but very relevant room. “I know what dialysis is, but not sure what peritoneal means”. If you know what dialysis is, then you know that it is a treatment that people with kidney failure (non-working kidneys) must have on a regular basis to stay alive. Chances are if you are still reading this, you are either working in the industry, know someone on dialysis, or may have chronic kidney disease (CKD). Whichever the reason, this blog seeks to provide information on some of the pros (benefits) and cons (complications) of considering the switch to Peritoneal Dialysis (PD) as well as ways to enhance your health and quality of life on PD.
A few facts
The dialysis community is still small among those living with CKD. The number of people on dialysis however has been growing exponentially over the past 10 years. There are now close to 800,000 people in the U.S. and 2 million worldwide living with end-stage kidney disease (ESKD) requiring dialysis. In 2018, 12.5% of patients on dialysis performed it at home, most of whom were on peritoneal dialysis.
What is Peritoneal Dialysis?
Peritoneal dialysis is an alternative way for people living with kidney failure to receive dialysis while at home instead of having to go to a clinic for treatment. Peritoneal dialysis involves removing waste products from the blood when the kidneys are no longer working.
In this process, a sugar-based dialysate solution called dextrose flows into the lining of the abdomen called the periosteum. The dextrose enters the peritoneum through a tube (catheter) and dwells (stays) there for the prescribed length of time known as “dwell time”. The peritoneum is used as a filter to remove waste products and excess fluid from the blood.
The dialysis prescription is individually determined and includes the following factors:
- Body weight and distribution
- How well the peritoneum filters waste is determined by the peritoneal equilibration test (PET)
- Amount of dialysis solution
- Number of daily exchanges
- Length of dwell time
- Concentration of dextrose
Peritoneal Dialysis Catheter Insertion
Before starting peritoneal dialysis, a plastic tube (catheter) is surgically or laparoscopically placed in the abdomen. Placement of the catheter is determined by the surgeon which can be based on the size of the patient along with other structural dynamics and the comfort level of the nephrologist in managing.
The peritoneal dialysis catheter is usually placed about 2 weeks before it can be used for dialyzing to allow time for healing and monitoring. There are however instances in which a peritoneal dialysis catheter is inserted in the hospital and used immediately for emergent dialysis.
Peritoneal Dialysis Complications
There are some peritoneal dialysis complications that can occur shortly after the catheter is placed. The most common causes of peritoneal dialysis catheter failure are catheter tip migration and constipation. Other common but less frequent causes are clotting of the catheter, omental wrap, and adhesions.
Peritoneal dialysis complications that tend to occur later on (over 30 days of placement) include exit-site infection, tunnel infection, peritonitis, cuff protrusion, outflow failure, and dialysate leaks or hernias.
Managing constipation is one of the complications that require patient education when a patient first starts peritoneal dialysis.
Constipation, one of the peritoneal dialysis complications, is managed prophylactically with stool softeners and/or laxatives. The renal dietitian also counsels peritoneal dialysis patients on how they can include high-fiber foods in possibly probiotics to best prevent constipation as well as maintain a healthy gut.
How does Peritoneal Dialysis work?
Sterile cleansing fluid is then put into the peritoneal cavity through the catheter. The fluid remains for at least one hour to allow for filtering of the blood before it is then drained. This process is repeated until both extra fluid (that would normally be flushed out of the body by the kidneys), as well as waste products, are removed.
Types of Peritoneal Dialysis - CAPD vs CCPD
There are two kinds: Continuous Ambulatory Peritoneal Dialysis (CAPD) and Continuous Cyclical Peritoneal Dialysis (CCPD). They each have their pros and cons. (See below).
Continuous Ambulatory Peritoneal Dialysis (CAPD)
CAPD (illustration shown below) is a type of PD that requires the patient to perform dialysis exchanges during the day manually by hanging a dialysate bag and allowing gravity to move the dialysate fluid in and out of the abdomen. The fluid remains in the peritoneal cavity for at least an hour. This time is known as the “dwell time”.
People using CAPD can expect to do anywhere between 3 and 5 exchanges during the day and one long exchange overnight. CAPD allows people to carry on with their normal lives during the dwell time. Exchanges can be done at home or any sterile place.
Continuous Cyclical Peritoneal Dialysis (CCPD)
CCPD (illustration shown below) is a form of PD done mostly at night while sleeping. People using CCPD will have multiple exchanges performed by a machine about the size of an average printer.
Using this modality allows dialysis patients to possibly work during the day, thereby maintaining their preferred lifestyle. It also allows greater flexibility and the ability to spend time with family and friends during the day.
Some benefits of being on Peritoneal Dialysis
- Ease of travel
- More time at home with family
- Higher energy level to exercise
- Fear of blood? No blood transfer involved
- Limited exposure to community-acquired infections
- Fewer restrictions on diet (often no fluid restriction)
- Ability to work during the day
- Gentle on your heart if there is a history of heart problems
- Feeling of control over your health
- Can still go swimming if in the private pool or the ocean (must use waterproof colostomy cover)
Some downsides if you are on Peritoneal Dialysis
Other than the peritoneal dialysis complications discussed above, there are some downsides that you must be aware:
No tub baths
If you like taking baths while submerged in water, you may not be able to continue to do so with peritoneal dialysis. An exception is if the dialysis catheter is placed high up enough to avoid being in the water.
Limited community
Longer time to dialyze
Image Perception
Need space
Childbirth
Weight loss may be necessary
Precautions to be taken to avoid peritoneal dialysis complications
There are certain protective measures for patients with Peritoneal dialysis to prevent infections and ensure the dialysis treatment does not have any interruptions. The nurse and healthcare team educate on proper handling and operating equipment as well as the best way to store supplies.
These treatments must be performed in a sterile environment, preferably with no pets with access to the treatment room. Infection control precautions are most important to limit the risk of exit site infections and peritonitis.
Peritonitis infections (as one of the complications) should be prevented at all costs as it increases the risk of losing peritoneal permeability, thereby losing the ability to use Peritoneal dialysis as a means of dialysis. In fact, peritonitis is the number one reason why patients must move from Peritoneal to traditional hemodialysis performed at a clinic.
Restrictions to avoid complications
Although Peritoneal dialysis offers much flexibility, there are some restrictions and limitations. We listed some of the downsides when considering this as a dialysis modality.
Some restrictions include:
- If you decide to work, lifting anything heavy (over 20 lbs) can increase the risk of a hernia. Peritoneal dialysis patients are already at an increased risk for hernia due to the dialysis fluid weight carried.
- Some dietary restrictions include those on Phosphorus and carbohydrate. In some cases, if a patient is not getting enough dialysis, there may be a need for restrictions on Potassium and sodium.
- It is generally safer to not have pets to avoid serious infection, however, it may be possible to keep a sterilized room.
- Peritoneal dialysis patients can still swim for leisure enjoyment but cannot swim in public swimming pools or lakes.
- Travel is possible; however, Peritoneal dialysis patients must see their healthcare team in person at least once a month to have labs drawn and a physical exam. Therefore, a patient generally cannot travel for more than 30 days to avoid being involuntarily discharged from care.
Peritoneal Dialysis vs Hemodialysis
The majority (90%) of people in the United States on dialysis use Hemodialysis. In some countries, however, Peritoneal dialysis has much higher rates. For example, Canada, Mexico, Guatemala, and Thailand all use Peritoneal dialysis at rates ranging from 25-59%. Mexico and Thailand have a “peritoneal dialysis – first” policy where ESKD patients are required to have this initiated first with few rare expectations.
These policies have resulted in 59% of patients in Mexico and 45% in Guatemala using Peritoneal dialysis.
Hemodialysis, by contrast, requires a patient to travel to a dialysis provider at least 3 days per week. Each treatment lasts about 4 hours sitting in a dialysis chair. A common complaint from Hemodialysis patients is the feeling of fatigue after treatments which may prevent or limit quality time with family.
It is still possible to travel while on Hemodialysis, however, coordination of care is necessary to plan ahead of time to be placed at an appropriate clinic.
Possibly the most important distinction between Hemodialysis vs Peritoneal dialysis is that Hemodialysis provides a total of 12 hours per week (on average) of dialyzing as opposed to 70-84 hours per week with Peritoneal dialysis. The more dialysis, the better overall health outcomes, and possibly longer life expectancy.
People who are most appropriate for Peritoneal Dialysis are those who have not had a significant history of abdominal surgeries and illnesses such as colectomy, colon cancer, and other gastrointestinal disorders such as Crohn’s disease.
Despite these possible deterrents and complications to using this form of dialysis, many people use and are thriving on Peritoneal dialysis. Although one of the attractions is the ability to work during the day and dialyze at night, ideally people on Peritoneal dialysis are not working more than a few days a week. This allows time to create a life balance.
When deciding on the best way to dialyze and to avoid peritoneal dialysis complications, there are many factors to consider. Your healthcare team can help you make the decision that is best for you. Regardless of whether you choose home or in-center (clinic) dialysis, the most important thing to remember is that the methods that provide the longest and most frequent dialysis, are the ones proven to have the best overall outcomes.
References
- https:// niddk.nih.gov/health-information/health-statistics/kidney-disease
- https:// cdrg.org/chronic-diseases/nephrology/?gclid=CjwKCAjwoMSWBhAdEiwAVJ2ndvCTUABZ8oVRdf1oHvg6Kmx3fuezK8bL1cv892gY1CkaJhL-LQYqExoCWaAQAvD_BwE
- https://cdrg.org/etc-hub/?gclid=CjwKCAjwoMSWBhAdEiwAVJ2ndnr_rjwEQetdklX0-sC-ldacLHa9WgWqGYzOdoyOXetKA4VVm9OSRBoCZs4QAvD_BwE
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4803502/
- https://homedialysis.org/home-dialysis-basics/peritoneal-dialysis gclid=CjwKCAjwoMSWBhAdEiwAVJ2ndmuTqOi59Qm4LIBk1rqJyXxvAWRwEckS8IxPItOsIqnNtmtjk_edUBoCt7wQAvD_BwE
- https://ncbi.nlm.nih.gov/pmc/articles/PMC4421142/
- https://asnjournals.org/content/2/4/604
Cheryl Robinson
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