This class provides more information on PD. To navigate the class, use the left and right arrows at the bottom of the page or the blue boxes to the left to jump around the sections. At the end of the class you will have options to view other related classes.
Many prospective patients think that their only option for end-stage renal disease (ESRD) is dialysis in a center at least three times a week for an average of four hours a session. This however is not true and there are several other types of options available including peritoneal dialysis (PD), home hemodialysis and transplants. For more information on home hemodialysis options visit our class here [1].
Peritoneal Dialysis (PD) is a treatment that utilizes your peritoneum, a membrane lining your abdominal cavity, as a filter to remove wastes from your body. Your peritoneum does a similar job as the dialyzer on a dialysis machine during treatment or that your kidneys do every day. Waste products and fluid pass through the membrane into dialysate (dialysis fluid) and the fluid is drained with the waste products. Your peritoneum is what separates your blood from the dialysis fluid and allows the process to occur. Each time fluid is added to the abdomen and extra fluid and wastes are removed is called an exchange. PD has been used in the United States since the 1980’s and improvements continue to be made to ensure it is a safe and effective treatment (1). There are potential benefits and negatives to the treatment and those will be covered in the rest of the class. Upon completing this class, you should be able to make a more informed treatment decision.
1. National Kidney & Urologic Diseases Information Clearinghouse (NKUDIC). (2010), Treatment Methods for Kidney Failure: Peritoneal Dialysis. Retrieved from http://kidney.niddk.nih.gov/kudiseases/pubs/childkidneydiseases/overview [2].
Abdomen – the portion of your body between your chest and pelvis. Commonly referred to as the belly.
Catheter – rubber tubing that will serve as the access (entry and exit point) for PD.
Continuous ambulatory peritoneal dialysis (CAPD) - is where the blood is always being cleaned. It doesn’t require a machine and fluid is added and removed throughout the day.
Continuous cycling peritoneal dialysis (CCPD) - is a form of PD where a machine helps cycle the exchanges while you are sleeping.
Cycler – a device or machine that automatically performs PD exchanges.
Dialysate – the solution that helps your body remove excess waste during dialysis.
Diffusion – the mechanism that allows your body’s peritoneum to filter materials from higher to lower concentrations
Dwell time - the amount of time dialysis solution remains in the patient's abdominal cavity during a peritoneal dialysis exchange.
Exchange – the entire process of adding clean dialysate and removing old solution during PD.
Membrane – a thin layer of tissue that covers a surface.
Nocturnal – happening at night, in dialysis this is treatment that it done at night while sleeping.
Peritoneum – the membrane that lines your abdominal cavity that acts as your filter during PD.
Peritonitis – inflammation of the peritoneum caused by an infection and is a situation that requires medical attention.
Sterile techniques/practices – washing your hands and other surfaces using prescribed methods to help eliminate potential sources for infections.
Now that you know the basics of PD, you can learn the details of what makes it work. To prepare for PD therapy, you need to undergo a small surgical procedure to have a catheter inserted into your abdomen. The catheter is a small rubber tube that is placed into the wall of your abdomen and secured using Dacron cuffs. Generally two cuffs are used in adults and they help secure your catheter and prevent some forms of infections.1 The catheter is your entry and exit point for dialysate and for waste products.
Catheter placement:
The surgery itself can be done in several different ways.2 It can be done percutaneous, through a laparoscopic surgery or an open surgical route. The laparoscopic and open surgery techniques are preferred because there are additional risks such as bowel injury with the percutaneous method.
Laparoscopic surgery – is a minimally invasive technique when the operation is performed through a small incision. A laparoscope (type of small camera) is used to view the operation site and place the catheter.
Percutaneous surgery – involves a guidewire being placed inside of tube. The guidewire is then used to place the catheter into the correct spot and a tunnel is made under the skin to the exit site. This is also a less invasive technique, but could have complications due to the nature of the surgery.
Open surgery – is where a scalpel is used to but a tiny incision through your skin and muscle of your abdomen. The “open” area allows the surgeon to place the catheter and the wound is stitched around it. This is the largest incision, but most common surgery.
A similar surgery that takes place in the chest as compared to the abdomen is the use of a presternal catheter. During surgery the longer catheter is placed into the chest using two small incisions. The device has two rubber tubes connected by a metal connector. Since the chest skin is less likely to move and thinner than the abdomen, this could be a good option for children or heavier adults. Patients are also able to bathe with these as long as water levels aren’t up to the catheter.3
As with any surgery there can be complications including infections and bleeding. Working with your healthcare team to properly care for your catheter can greatly reduce complications. The most common types of issues involve catheter placement, infections and blockages.
After your catheter has healed, you will begin training. Training differs from office to office, but the basics remain the same. At training you will learn how to:
Once you have been trained and feel comfortable doing PD, you will be ready to do exchanges yourself. Here [3] is a great animation of the process.
For those of you that prefer text over a video, here are the steps of a CAPD exchange. (Please note this is a generalization and shouldn’t replace the steps given to you by your medical team).4,5
1. Wash your hands with proper antibacterial soap.
2. Clean the surface where you will place your supplies and check the expiration dates on your supplies.
3. Open up your bag of dialysate.
4. Wash your hands again after touching the dialysate bag.
5. Connect your protector to the dialysate’s opening to prevent infection.
6. Hang the fresh dialysate solution bag at your station above your head.
7. Connect your catheter line to the protected end of the dialysate bags.
8. Open the clamp to the drain bag and the old fluid will begin to drain into the empty bag.
9. Allow the fluid that is currently in your abdomen to drain out into the empty bag placed on a low surface or on the floor. This process takes about 20 minutes.
10. Turn the position on the transfer set to allow fresh dialysate to drain into your abdomen, which takes about 5 minutes.
11. After the fill portion has completed, turn the close the clamp.
12. Use the disconnection cap to close off the open end of the catheter.
13. The bag of collected old fluid can be disposed of in the toilet.
14. The bag itself can be collected in a medical waste container.
15. The dialysate that was added will need time to dwell or rest and will remain in your abdomen until your next exchange or overnight if this was your last exchange for the day.
16. The process will be repeated anywhere from 3-5 times a day as prescribed by your physician.
1. Ellsworth, Pamela. MD. FACS. Peritoneal Dialysis Catheter Insertion. Retrieved from http://emedicine.medscape.com/article/1829737-overview#a01 [4].
2. Twardowski ZJ., Prowant BF., Nicholas WK,. Nolph KD,. and Khanna R. Six-year experience with Swan neck presternal peritoneal dialysis catheter. Peritoneal Dialysis International. Nov-Dec; 18(6):598-602, 1998. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/9932658 [5].
3. Peritoneal Dialysis “Is it the right choice for me?”. 2002 Retrieved from http://www.med.umich.edu/intmed/nephrology/docs/pd_book_11_30_02.pdf [6].
4. The University of Connecticut Health Center. Procedure for: Peritoneal Dialysis: Acute, Stay-Safe CAPD exchange procedure. Revised May 2010. Retrieved from http://nursing.uchc.edu/nursing_standards/docs/Peritoneal%20Dialysis%20-%20Acute,%20Stay%20Safe%20CAPD%20Exchange%20Procedure.pdf [7].
There are two main types of PD therapy and although many choose to do the therapy at home, there are also in-center options and combination therapies.
Continuous cycling peritoneal dialysis (CCPD) is just how it sounds. It uses a machine called a cycler to continuously/automatically do your exchanges at night while you sleep. Generally three to five exchanges are done each night and you empty the drainage bag when you wake up in the morning. This program gives you more freedom because you aren’t hooked up to a machine during the day. Each nightly session lasts at least eight to ten hours. Some programs also have you start an exchange in the morning and the dialysate dwell lasts the entire day.
Benefits of CCPD:
Benefits of CAPD:
1.Piraino, Beth Bernardini, Judith Brown, Edwina et al., ISPD Position Statement on Reducing the Risks of Peritoneal Dialysis- Related Infections. Peritoneal Dialysis International. 2011 Vol 31 no.6, 614-630. Retrieved from http://www.pdiconnect.com/content/31/6/614.full [8].
For CAPD
Adequate clean space to do your exchanges – the room or area you choose shouldn’t have a lot of traffic in or out, shouldn’t have open windows and should if possible have enough room for your other PD supplies.
Normally delivered monthly, you will need space for around 30 boxes of supplies. Your supply company will help you, but you might need a helper to organize the boxes within your residence. The boxes are pretty heavy and do need to be kept in a dry space.
You will also need:
For CCPD
Similar equipment is needed for CCPD, but the main difference is the need for an automated cycling machine.
Machines currently available include:
Beyond the machine you will also need:
Benefits:
Drawbacks:
1. Rubin Haya R., Fink Nancy E., Plantigna Laura C., et al. Patient Ratings of Dialysis Care with Peritoneal Dialysis vs Hemodialysis. Journal of the American Medical Association. 2004; 291(6): 697-703. Retrieved from http://jama.jamanetwork.com/article.aspx?articleid=198181#qundefined [11].
2. Chertow GM., Levin NW., Beck GJ., et al. In-Center hemodialysis six times per week versus three times per week. New England Journal of Medicine. 2011 Jan 6;364(1):93. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21091062 [12].
3. Lafrance Jean-Philippe, Rahme Elham, Iqbal Sameena, et al. Association of Dialsis Modality with Risk for Infection-Related Hospitalization: A propensity Score-Matched Cohort Analysis. Clinical Journal of the American Society of Nephrology. 2012. Published online at http://cjasn.asnjournals.org/content/early/2012/08/15/CJN.00440112.full [13].
4. Dasgupta Mrinal K., Management of Patients with Type 2 Diabetes on Peritoneal Dialysis. Advances in Peritoneal Dialysis. 2005 Vol 21. Retrieved from http://www.advancesinpd.com/adv05/Adv20053d-1.pdf [14].
5. Mahale AS., Katyal A., Khanna R., Complication of peritoneal dialysis related to increased intra-abdominal pressure. Advances in Peritoneal Dialysis. 2003; 19:130-5. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/14763049 [15].
6. Stenvinkel Peter, Lindholm Bengt, Lonnqvist Fredrik., Increases in serum leptin levels during peritoneal dialysis are associated with inflammation and a decrease in lean body mass. Journal of the American Society of Nephrology. 2000 Vol 11:7 1303-1309. Retrieved from http://jasn.asnjournals.org/content/11/7/1303.full [16].
One of the most common problems with PD is the risk of peritonitis. This is when your peritoneum, that natural lining in your stomach, gets infected. This might happen if germs get into your belly through your catheter.
Bad infections can keep you from being able to do the PD treatments you need. To help prevent an infection:
Prevention of fungal peritonitis
The majority of fungal peritonitis cases are preceded by courses of antibiotics – patients with prolonged or repeated courses of antibiotics are at increased risk of fungal peritonitis.
Cost
There are several options to pay for your dialysis treatments including insurance through your employer or other private health plan, Medicare, Medicaid and through military health programs.
The Medicare program was designed to be available to anyone who was born in the US, a permanent and legal resident for 5 years, or the spouse of an individual who paid Medicare taxes for at least 10 years. People with end stage renal disease (ESRD) or those who needed a kidney transplant regardless of age (as long as they met the residency requirements) qualify for Medicare.
Some individuals are considered dual eligible and receive Medicare coverage for acute services, and Medicaid covers Medicare premiums and some additional costs. Eligibility requirements for Medicaid vary by state.
Also, if you have health insurance through an employer, you have the ability to maintain this coverage for 30 months before Medicare becomes the primary payer through the Medicare Secondary Payer (MSP) policy. This can help keep costs lower, give broader coverage and provide continuity of care.
For more information on Medicare and Medicaid visit our class here [17].
Medicare Part B will cover:
In 2012 the yearly deductible was $140 dollars. After you pay your deductible you pay 20% coinsurance.(1)
This means that once you pay your yearly deductible, you pay 20% of the costs. So, a $100 dollar bill means you owe $20 dollars. Medicare pays for PD at the same rates as in-center dialysis.
A major benefit to choosing PD or another form of home dialysis is the immediate coverage ability. Those that aren’t eligible for Medicare before the diagnosis of ESRD have a 90 day coverage gap if they choose in-center dialysis. If you choose PD or other home therapies, Medicare can be activated immediately or retroactively to cover costs.
1. Centers for Medicare and Medicaid Services. Medicare Coverage of Kidney Dialysis and Kidney Transplant Services. Retrieved from http://www.medicare.gov/Pubs/pdf/10128.pdf [18].
One of the largest advantages of PD is the increased ability to travel. Since you are in more control of your treatments and schedule, you have increased flexibility to take a vacation. The first step to planning a trip is talking to your healthcare team. They can help you determine what supplies you need, how much you will need, connect you with resources at your destination and better understand how to help should you run into trouble.
The next step is determining if you are going to travel with your dialysate solution or have it shipped to your destination. If you choose to have it shipped to your destination you will need to give at least 2 weeks’ notice to your supplier and notify your hotel to expect your packages and ensure you have a room that will hold your supplies.
Next, it is important to grab all of your necessary supplies including all of the tools needed to do an exchange including items such as masks and disinfectant. If you are flying, you are allowed to bring your supplies on the plane. It is recommended that you bring enough equipment for at least two days’ worth of essentials. This will cover you in case your bags are misplaced.
If you are using a cycler to do CAPD, talk to your doctor about giving you a letter showing that it is an essential medical device. Additionally don’t check this as baggage as they are expensive machines to replace. You should also connect with your doctor to write a similar note to cover any other materials that are essential to do an exchange.
Here is a resource that shares additional information on creating your own travel toolbox [19].
Last but not least, enjoy yourself and have a great vacation. The planning that you do early will make all the difference.
Your local ESRD Network will have resources and clicking on the map will bring you to local information.
http://www.esrdnetworks.org/ [20]
The National Kidney and Urologic Diseases Information Clearinghouse also have a lot of great information about PD.
http://kidney.niddk.nih.gov/kudiseases/pubs/peritoneal/ [21]
Home Dialyzers United has a buddy program that can help you connect to current PD patients.
http://homedialyzorsunited.org/hdu-buddies/ [22]
The National Kidney Foundation has a bunch of background information.
http://www.kidney.org/atoz/content/peritoneal.cfm [23]
Fresenius Medical Care has information on PD and more specifically on their line of cyclers and products.
http://www.fmcna.com/fmcna/HomeTherapies/home-therapies.html [10]
Baxter also has good background information and a listing of their products and cyclers.
http://www.fmcna.com/fmcna/HomeTherapies/home-therapies.html [10]
Home Dialysis Central not only breaks down PD therapies, but also has information on other home therapies.
DaVita’s site is another good place to search for basic information on PD. Their site also has a listing of videos.
http://www.davita.com/treatment-options/home-peritoneal-dialysis [25]
Congratulations on finishing the class! Please choose another class from the list below to continue your journey.
Another type of dialysis is called peritoneal dialysis (PD). Peritoneal dialysis uses the lining or membrane of the abdominal cavity as a filter to remove fluids and toxins from the blood. A surgeon places a special tube called a PD catheter into the abdomen. Care must be taken to prevent infection with any type of dialysis access. Peritoneal dialysis is done at home every day.
There are 2 types of PD: Continuous Ambulatory Peritoneal Dialysis (CAPD) and Continuous Cycling Peritoneal Dialysis (CCPD). Another name for CCPD is Automated Peritoneal Dialysis (APD).
In CAPD, exchanges are done using gravity. Dialysis fluid flows from prepackaged fluid bags into the peritoneal cavity through the catheter. The solution usually stays in the abdomen for 4 to 6 hours where it absorbs waste products and extra fluids and then drained. This is called an exchange. Most people do 4 to 5 exchanges per day.
In CCPD or APD, a machine called a cycler, is used to perform the exchanges, and the process is typically done at night while you sleep.
For more information on peritoneal dialysis, check out the class here [26].
Links
[1] http://dpcedcenter.org/classroom/home-hemodialysis
[2] http://kidney.niddk.nih.gov/kudiseases/pubs/childkidneydiseases/overview
[3] http://www.kidneypatientguide.org.uk/pdanim.php
[4] http://emedicine.medscape.com/article/1829737-overview#a01
[5] http://www.ncbi.nlm.nih.gov/pubmed/9932658
[6] http://www.med.umich.edu/intmed/nephrology/docs/pd_book_11_30_02.pdf
[7] http://nursing.uchc.edu/nursing_standards/docs/Peritoneal%20Dialysis%20-%20Acute,%20Stay%20Safe%20CAPD%20Exchange%20Procedure.pdf
[8] http://www.pdiconnect.com/content/31/6/614.full
[9] http://www.baxter.com/patients_and_caregivers/products/homechoice.html
[10] http://www.fmcna.com/fmcna/HomeTherapies/home-therapies.html
[11] http://jama.jamanetwork.com/article.aspx?articleid=198181#qundefined
[12] http://www.ncbi.nlm.nih.gov/pubmed/21091062
[13] http://cjasn.asnjournals.org/content/early/2012/08/15/CJN.00440112.full
[14] http://www.advancesinpd.com/adv05/Adv20053d-1.pdf
[15] http://www.ncbi.nlm.nih.gov/pubmed/14763049
[16] http://jasn.asnjournals.org/content/11/7/1303.full
[17] http://dpcedcenter.org/classroom/medicare-and-part-d-donut-hole/medicare-101
[18] http://www.medicare.gov/Pubs/pdf/10128.pdf
[19] https://www.annanurse.org/download/reference/practice/pdToolbox.pdf#page=12
[20] http://www.esrdnetworks.org/
[21] http://kidney.niddk.nih.gov/kudiseases/pubs/peritoneal/
[22] http://homedialyzorsunited.org/hdu-buddies/
[23] http://www.kidney.org/atoz/content/peritoneal.cfm
[24] http://homedialysis.org/
[25] http://www.davita.com/treatment-options/home-peritoneal-dialysis
[26] http://dpcedcenter.org/classroom/peritoneal-dialysis