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   What is Peritoneal Dialysis (PD)?
    Can anyone do PD?
    Are there different types of PD?
    How will I know if PD is working well?
    What problems can happen on PD?
    How long can people remain on PD?
    Will I be able to lead a normal life on PD?
    What medicines will I need to take?
    Will I need to be on a special diet or fluid restriction?
    What’s it really like? Patient experiences of PD
    Key Points
Peritoneal dialysis and hospital haemodialysis are both treatments for kidney failure. Throughout the UK the number of people on each treatment is about equal. People often ask, “which type of dialysis is the best?”. The answer is neither – different treatments suit different people.
On PD you manage your own care, compared to hospital haemodialysis, and this gives you independence and flexibility. On PD you tend to spend around 1-2 hours each day draining dialysis fluid in and out of your tummy, and the rest of the time you get on with your life while the dialysis happens inside your body. For haemodialysis you need to be connected to a machine which cleans your blood. This takes around 3-5 hours, 2-3 times each week.
Expect changes to be made in your PD or haemodialysis prescription. Regular check ups are performed to make sure your blood results stay as close to the target levels as possible.
Everyone is different, and their body will react according to the lifestyle and circumstances of that individual. There are solutions to problems, and people who care and can give information, help and support.
What is Peritoneal Dialysis?

Peritoneal dialysis (PD) is one of the two types of dialysis (removal of waste and excess water from the blood) that is used to treat people with kidney failure. In PD, the process of dialysis takes place inside the body. The abdomen (tummy) has a lining called the peritoneal membrane, which can be used as a filter to remove excess waste and water. A tube (catheter) is inserted into the abdomen during an operation. Special dialysis fluid is drained into the abdomen. Excess waste and water pass from the blood into the fluid and after a few hours the fluid is drained out. GoTo what is PD info
Can anyone do PD?
PD is a suitable treatment for most people with end stage renal failure (ESRF). People who have had several major abdominal operations may not be able to have PD. People who are blind or have problems with their fingers such as arthritis can usually do PD, with the help of a special system and devices. PD requires a lot of commitment from kidney patients and their families. People on PD are usually responsible for their own dialysis, in their own homes. For this reason, PD may not be suitable for some people who have no support at home. Elderly people, living in Nursing Homes can sometimes get help to carry out their PD.
Are there different types of PD?
There are two main types of PD. The most commonly used type is known as Continuous Ambulatory Peritoneal Dialysis (CAPD). In this form of PD, patients have fluid in their abdomen 24 hours a day. At the end of each period of dialysis, they have to change the dialysis fluid themselves. The other type is known as Automated Peritoneal Dialysis (APD). ‘Automated’ means that a machine changes the dialysis fluid for the person, usually at night. 
How will I know if PD is working well?
Most people, who have been on PD for a few weeks, start to feel quite well again. When you first start PD you may still be passing urine and this will help clear some waste and fluid from your body. Over the first two years on PD your urine output may decline, and your PD prescription may need to be changed. Symptoms such as feeling weak and tired, nausea and lack of appetite may be a sign that you are not receiving enough dialysis. A number of different blood and PD fluid tests can be carried out to assess how well your dialysis is working. 
What problems can happen on PD?
PD is not always entirely trouble free. Generally speaking one third of people experience no problems on PD, a third have occasional problems, and a third have repeated problems and feel PD is a disaster! Problems with PD tend to fall into 4 categories:
    Psychological problems
    Infections
    Problems with the PD tube, such as drainage problems
    Physical problems such as pain, itching, or cramps
How long can people remain on PD?
Once a person’s kidneys have failed, they will need dialysis indefinitely. Some people may go on to have a kidney transplant, or may change from PD to haemodialysis. Others have been successfully treated with PD for over 10 years. The availability of new PD fluids and a wide range of prescriptions on CAPD and APD will mean that more people who choose to stay on PD can do so. 
Will I be able to lead a normal life on PD?

Many people on PD do all or most of the things that they did before they started on PD. Important aspects of life; (family life, work, holidays, sport and exercise, and sexual relationships), are limited in some ways, though often less of a problem on PD than people might expect. Some people cope more easily than others do with life on PD. 
Will I need to take medications on PD?

Everyone on PD will need to take prescribed medications. The most common types of medicines are those used to help;
    Prevent constipation
    Reduce bone disease
    Prevent anaemia (low blood count)
    Control blood pressure
Will I need to be on a special diet or fluid restriction?
Many people on PD are able to enjoy a normal diet without too many restrictions, but may need to moderate certain types of food. This is because PD can only ever replace a small amount of the work done by healthy kidneys. People on PD may have a poor appetite because of the dialysis fluid in their abdomen, which can make them feel bloated, or if they are not having enough dialysis. People are often asked to restrict the amount of fluid that they drink particularly when they start to pass less urine than they used to.
The Author cannot accept responsibility for information provided. The above is for guidance only. Patients are advised to seek further information from their own doctor.

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The most common types of medicines that patients on PD need to take are:
    Phosphate binders to reduce bone disease
    Iron, and Erythropoietin to reduce anaemia (low blood count)
    Anti-hypertensive medicines to control high blood pressure
    Laxatives to prevent constipation

Phosphate binders
When the kidneys are working properly they get rid of excess phosphate from the body. Phosphate, which is found in dairy products, nuts and meat, is needed to keep bones healthy. If phosphate levels become too high in kidney failure this can damage bones and blood vessels. Medications taken before meals can bind with phosphate in the food you eat so that the phosphate is not absorbed into the body and the level in the blood becomes lower. There are several different types of phosphate binder medication, your doctor and renal dietitian will be able to discuss which one might suit you best. GoTo kidney medications

Iron and Erythropoietin
Healthy kidneys produce a substance called Erythropoietin (known as EPO for short). EPO is used in the bone marrow to help produce red blood cells. Red blood cells carry oxygen around the body and, if the level is low, it is called anaemia. There are several different types of synthetic EPO, called Erythropoeisis Stimulating Agents (ESA). An ESA is injected into the body (using a small needle) and helps produce red blood cells. People on ESA will use up Iron quickly making red blood cells, and they may need an iron supplement. This can be given by tablet (eg Ferrous sulphate or Pregaday) or by injection. 

Anti-hypertensive medicines
High blood pressure (hypertension) is fairly common in people with kidney problems. Blood pressure is affected by the amount of fluid in the body as well as the width of the vessels (arteries) that the blood flows through. It is therefore important for people on PD to control the level of fluid in their blood. This is done by balancing what fluid goes in with what comes out. Often one or more medications are needed to control blood pressure. 

Laxatives
Constipation causes drainage problems on PD and it is therefore important to avoid becoming constipated. Lactulose is a liquid, which can be taken daily to prevent constipation: it works by softening the faeces in the bowel. Senokot (senna) can also be used daily to prevent constipation: it works by stimulating the bowel to move. Both drugs can cause stomach cramps in some people. It is important to let the pharmacist know that you are on dialysis if you are buying other laxatives, as some are not suitable for people with kidney failure.

People with kidney failure will often need to take many drugs to help keep them healthy. This page lists some of the drugs that are commonly taken and a few side effects. Also see the page about blood pressure and water tablets.

ALFACALCIDOL is a Vitamin D capsule. It is given to increase your blood calcium level and keep it normal. It is usually taken once a day in the morning. Side effects can include feeling sick. If this happens try taking it with food. Liquid drops are also available if you have trouble swallowing, or prefer to avoid capsules that contain gelatin, for example if you are a strict vegetarian.

ASPIRIN is a tablet given to help to thin your blood to stop your dialysis lines or fistula from becoming blocked. It is normally taken once a day in the morning. Aspirin may irritate your stomach or cause indigestion; this can be reduced by taking the tablet with food and dissolving it in water before swallowing.
ANTIHISTAMINES

There are many different types of anti-histamines. These include:

    Chlorphenamine (“Piriton”)
    Hydroxyzine
    Cetirizine
    Loratadine
    Fexofenadine
Anti-histamines are used to reduce itching that can happen as chemicals build up in your body. There are several types available. Some anti-histamines can cause drowsiness, if you feel drowsy do not drive or operate machinery.
Chlorphenamine (“Piriton”) and some other antihistamines can be bought from your local pharmacy. Take care not to take twice the recommended dose ie do not take antihistamines from your doctor and those you have bought.
FERROUS SULPHATE is an iron tablet which can be taken to try and reduce anaemia. It is often taken three times a day. If you are taking phosphate binders or some antibiotics (check with the pharmacist) you should try and split the doses by one hour. Side effects can include constipation, diarrhoea or feeling sick. If this happens try taking the tablets with food. You may notice your stools or urine becoming a darker colour; this is normal and nothing to worry about.
LACTULOSE and SENNA are given to relieve constipation. Senna is usually taken in the evening, lactulose can be taken twice a day. They may take a day or so to be effective. Side effects can include belching and stomach cramps.
RANITIDINE helps to reduce the amount of acid in your stomach, to prevent acid indigestion or problems with stomach ulcers. It is usually taken once or twice a day. Possible side effects can include tiredness, headaches and dizziness.
LANSOPRAZOLE and OMEPRAZOLE reduce the amount of acid in your stomach, to prevent acid indigestion or problems with stomach ulcers. Lansoprazole should be taken first thing in the morning before breakfast, Omeprazole can be taken in the morning or evening. Side effects include diarrhoea, feeling sick.
SIMVASTATIN or ATORVASTATIN help to reduce cholesterol levels. The tablets should be taken at bedtime. Possible side effects include headache, feeling sick and muscle pain or muscle weakness. If you suffer from muscle pain you should tell your doctor.
Possible Problems & Disadvantages of Peritoneal Dialysis
Peritoneal dialysis (PD) is not always trouble-free. Patients may experience both psychological and physical problems, discussed below.
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.
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.
Fluid overload
Fluid overload occurs when there is too much fluid in the body. It is characterized 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 hemodialysis patients.
Dehydration
Dehydration occurs when there is too little fluid in the body. It can be caused by excess fluid loss due to diarrhea or sweating. It is characterized by dizziness, feeling sick, or a sudden decrease in weight. Dehydration is far less common than fluid overload in dialysis patients.
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.
Dialysis centers can give advice on how to minimize or avoid discomfort.
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:
    Constipation. Dialysis patients tend to be constipated due to dietary and fluid restrictions, and medications. 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.
    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. 
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 hemodialysis 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 hemodialysis may be required.
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 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 hemodialysis 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.
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 hemodialysis 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.
Peritonitis
Peritonitis is an infection of the peritoneum, usually caused by bacteria entering through or around the catheter. This can happen when patients touch the open ends of the connections between the bag of dialysis fluid and the catheter. Sometimes, contamination around the catheter at the exit site can lead to peritonitis.
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 recognize. 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 have several episodes of peritonitis that might require the PD catheter be replaced. Repeated episodes of peritonitis may damage the peritoneum.
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.
Effectiveness of the peritoneum
In a small number of patients, the peritoneum may cease to be effective as a dialysis membrane. There are a number of possible causes for this, including repeated infections or the effect of the dextrose in the dialysis fluid.
In this case a peritoneal dialysis may need to be supplemented with hemodialysis, and later transferred permanently to hemodialysis.
"At the beginning, I thought the tube was slightly nauseating, and it took a little time to get used to having such a direct opening into my insides. In order to make the tube less frightening, both to myself and to those about me, I was happy to talk about it, where it was inserted, and to show it to anyone who asked what it looked like." - Anita, a CAPD patient

Kidney Patient Guide
    Introduction
    What patients say
    Physical aspects
    Treatment
        The role of medication
        Bone disease
        What is acidosis?
        Dialysis
            Treating kidney failure through dialysis
            Which kind of dialysis?
            Haemodialysis
            An Introduction to peritoneal dialysis
                How Peritoneal dialysis works animation
                CAPD
                APD
            How will dialysis affect your life?
            Training for dialysis
            Adequacy of dialysis
        Transplants
        Your relationship with the renal team
        what's happening in renal research?
    Emotional effects
    Diet
    Financial implications
    Holidays
    Carers, family and friends
    Support groups

 The treatment of kidney failure
An Introduction to peritoneal dialysis
With this method, instead of being cleaned by an artificial membrane outside the body, the blood is cleaned inside the body, through the Peritoneum. This is the thin membrane that surrounds the outside of the organs in the abdomen.
The peritoneum allows waste products to pass through it and is very rich in small blood vessels. By running a dialysis fluid into the peritoneal cavity, through a tube called a Tenckhoff Catheter - and then out again - waste can be filtered from the blood.
There are two types of peritoneal dialysis:
CAPD - which stands for Continuous Ambulatory Peritoneal Dialysis - happens throughout the day, at home or at work, while the person goes about his or her daily life. Between 1.5 and 3 litres of fluid is run in four times a day, exchanging for the fluid from the previous exchange. This takes about 30-40 minutes.
APD - Automated Peritoneal Dialysis - in which the dialysate solution is changed by a machine, at night, while you are asleep. The machine will exchange 8-12 litres over 8-10 hours and then leave 1-2 litres to dwell during the day.
You will be trained by the PD nurses - the techniques need to be done correctly and in a clean manner - but are designed to be done at home perhaps with the help of a partner. Although you are at home, you will be contacted frequently by the nurses and will come to the out-patient clinic every few weeks.
What is the Peritoneal Dialysis Fluid?
    Peritoneal dialysis fluid is a sugar (glucose) solution containing other salts. Bags come in 3 strengths (1.36%, 2.27% and 3.86% or light, medium and heavy) - the "heavier" the bag (ie.3.86%), more water will be removed from the body.
    If you have a lot of fluid in the body, you would use heavy bags to remove fluid. If you are dehydrated, you would use some light bags so that the dialysis does not remove fluid.
    The sugar solution can be a problem for diabetic patients and changes in therapy may be needed. New solutions are being developed - Protein or starch.
How good is peritoneal dialysis?
    Peritoneal dialysis can provide good, efficient dialysis but needs to be monitored carefully. It needs to be performed daily with breaks only because of unusual circumstances.
    The nurses and doctors will measure how effectively the dialysis is being performed and change the volume and strength of the fluids.
    If good dialysis cannot be achieved it is important to think about a change - from CAPD to APD or to haemodialysis.
What are the problems with peritoneal dialysis?
    There can be problems with fluid leaks in the groin or around the catheter when dialysis starts. These problems can be managed easily.
    Infections are the major risk - either in the exit site or most importantly in the tummy itself, peritonitis. This shows as tummy pain, a fever and a cloudy fluid bag. It is important to ring the kidney unit immediately if a cloudy bag develops. Peritonitis is treated with antibiotics added to the bags and may need admission to hospital for a few days. Rarely, the infection may be so bad that the catheter has to be removed.
    In the long term, there can be a thickening of the peritoneal membrane so that it does not work efficiently. The dialysis fluid may need to be changed or switched to haemodialysis.
Having a Tenckhoff catheter
The Tenckhoff Catheter provides permanent long-term access to the peritoneal cavity. It is a thin, non-irritating, flexible tube. One end of this tube rests in the peritoneal cavity, while the other extends from the body by about 4 inches, so that it can be attached to the dialysis fluid. This end is sealed off when fluid is not being run in or out of the abdomen.
The catheter can be put in place either under sedation, with a local anaesthetic (patients describe it as an uncomfortable procedure rather than painful). Or it can be done as a minor surgical operation under general anaesthetic. Once in place, however, it will not be used for 2 weeks, to allow healing.
The treatment of kidney failure
Treating kidney failure through dialysis
If the kidneys fail, it is possible to replace their function using dialysis, an artificial way of getting rid of toxins.
How a patient is feeling and blood tests determine when it is necessary to begin dialysis. Some patients do not need to start until some time - occasionally years - after diagnosis. But even if this is the case, they need to know in advance about the different options available, because they should have a choice about which method of dialysis they use.
There are two different kinds of dialysis - haemodialysis, where the blood is cleaned outside the body via a machine, and Peritoneal dialysis, where the cleaning is done inside the body. Occasionally, there may be medical reasons to prefer one sort of dialysis to another - this is something to discuss with your doctor.
An introduction to haemodialysis (HD)
An introduction to peritoneal dialysis (PD)
Which kind of dialysis? Making an informed choice
Training for dialysis
How will dialysis affect your life?
Taking a holiday on dialysis
The greatest advantage is that you feel so much better after two or three weeks of dialysis. The technology and jargon of dialysis soon becomes familiar. (M.J.P.)
Peritoneal dialysis (PD) is a treatment for patients with severe chronic kidney disease. The process uses the patient's peritoneum in the abdomen as a membrane across which fluids and dissolved substances (electrolytes, urea, glucose, albumin and other small molecules) are exchanged from the blood. Fluid is introduced through a permanent tube in the abdomen and flushed out either every night while the patient sleeps (automatic peritoneal dialysis) or via regular exchanges throughout the day (continuous ambulatory peritoneal dialysis). PD is used as an alternative to hemodialysis though it is far less commonly used in many countries, such as the United States. It has comparable risks but is significantly less costly in most part of the world, with the primary advantage being the ability to undertake treatment without visiting a medical facility. The primary complication of PD is infection due to the presence of a permanent tube in the abdomen.
    Best practices for peritoneal dialysis state that before peritoneal dialysis should be implemented, the patient's understanding of the process and support systems should be assessed, with education on how to care for the catheter and to address any gaps in understanding that may exist. The patient should receive ongoing monitoring to ensure adequate dialysis, and be regularly assessed for complications. Finally, the patient should be educated on the importance of infection control and an appropriate medical regimen established with their cooperation.[1]
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 area must be cleaned, and flow into and out of the abdomen tested. A large volume of fluid is introduced to the abdomen over the next ten to fifteen minutes.[2] The total volume is referred to as a dwell[3] while the fluid itself is referred to as dialysate. The dwell can be as much as 2.5 litres, and medication can also be added to the fluid immediately before infusion.[2] 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[2]), 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).[3][4]
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 2-2.5 litres 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 more 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 filter molecules, either proteins, electrolytes or water, based on the size of the pore) 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 exchange of fluid from the blood with glucose from the peritoneum. The solute flows from the peritoneal cavity to the organs, and thence into the lymphatic system. Individuals differ in the amount of fluid absorbed through the lymphatic vessels, though it is not understood why. The ability to exchange fluids between the peritoneum and blood supply can be classified as high, low or intermediate. High transporters tend to diffuse substances well (easily exchanging small molecules between blood and the dialysis fluid, with somewhat improved results frequent, short-duration dwells such as with APD) while low transporters filter fluids better (transporting fluids across the membrane into the blood more quickly with somewhat better results with long-term, high-volume dwells such) though in practice either type of transporter can generally be managed through the appropriate use of either APD or CAPD.[5]
Though there are several different shapes and sizes of catheters that can be used, different insertion sites, number of cuffs in the catheter and immobilization, there is no evidence to show any advantages in terms of morbidity, mortality or number of infections, though the quality of information is not yet sufficient to allow for firm conclusions.[6]
Complications
The volume of dialysate removed and weight of the patient are normally monitored; if more than 500ml of fluid are retained or a litre of fluid is lost across three consecutive treatments, the patient's physician is generally notified. Excessive loss of fluid can result in hypovolemic shock or hypotension while 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 afterwards. The presence of pink or bloody effluent suggests bleeding inside the abdomen while feces indicates a perforated bowel and cloudy fluid suggests infection. The patient may also experience pain or discomfort if the dialysate is too acidic, too cold or introduced too quickly, while diffuse pain with cloudy discharge may indicate an infection. Severe pain in the rectum or perineum can be the result of an improperly placed catheter. The dwell can also increase pressure on the diaphragm causing impaired breathing, and constipation can interfere with the ability of fluid to flow through the catheter.[2]
A potentially fatal complication estimated to occur in roughly 2.5% of patients is encapsulating peritoneal sclerosis, in which the bowels become obstructed due to the growth of a thick layer of fibrin within the peritoneum.[7]
The fluid used for dialysis uses glucose as a primary osmotic agent, but this may lead to peritonitis, the decline of kidney and peritoneal membrane function and other negative health outcomes. The acidity, high concentration and presence of lactate and products of the degredation 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.[8]
Risks and benefits
PD is less efficient at removing wastes from the body than hemodialysis, and the presence of the tube presents a risk of peritonitis due to the potential to introduce bacteria to the abdomen;[3] peritonitis is best treated through the direct infusion of antibiotics into the peritoneum with no advantage for other frequently used treatments such as routine peritoneal lavage or use of urokinase.[9] The tube site can also become infected; the use of prophylactic nasal mupirocin can reduce the number of tube site infections, but does not help with peritonitis.[10] Infections can be as frequent as once every 15 months (0.8 episodes per patient year). Compared to hemodialysis, PD allows greater patient mobility, produces fewer swings in symptoms due to its continuous nature, and phosphate compounds are better removed, but large amounts of albumin are removed which requires constant monitoring of nutritional status. The costs and benefits of hemodialysis and PD are roughly the same - PD equipment is cheaper but the costs associated with peritonitis are higher.[4] There is insufficient research to adequately compare the risks and benefits between CAPD and APD; a Cochrane Review of three small clinical trials found no difference in clinically important outcomes (i.e. morbidity or mortality) for patients with end stage renal disease, nor was there any advantage in preserving the functionality of the kidneys. The results suggested APD may have psychosocial advantages for younger patients and those who are employed or pursuing an education.[11]
Other complications include hypotension (due to excess fluid exchange and sodium removal), low back pain and hernia or leaking fluid due to high pressure within the abdomen. PD may also be used for patients with cardiac instability as it does not result in rapid and significant alterations to body fluids, and for patients with insulin-dependent diabetes mellitus due to the inability to control blood sugar levels through the catheter. Hypertriglyceridemia and obesity are also concerns due to the large volume of glucose in the fluid, which can add as many as 1200 calories to the diet per day.[12] Of the three types of connection and fluid exchange systems (standard, twin-bag and y-set; the latter two involving two bags and only one connection to the catheter, the y-set uses a single y-shaped connection between the bags involving emptying, flushing out then filling the peritoneum through the same connection) the twin-bag and y-set systems were found superior to conventional systems at preventing peritoniti
s.[13]
Frequency
In a 2004 worldwide survey of patients in end stage renal disease, approximately 11% were receiving PD, compared to the much more common hemodialysis. In the United Kingdom, South Korea and Mexico PD was more common than the world average, with Mexico conducting most of its dialysis (75%) through PD, while Japan and Germany had rates lower than the world average.[14]
Improvised dialysis
Peritoneal dialysis can be improvised in conditions such as combat surgery or disaster relief using surgical catheters and dialysate made from routinely available medical solutions to provide temporary renal replacement for patients with no other options.[15]
Gastrostomy (Percutaneous endoscopic gastrostomy) · Gastrectomy (Billroth I, Billroth II, Roux-en-Y) · Bariatric surgery (Gastric bypass surgery, Adjustable gastric band, Sleeve gastrectomy, Vertical banded gastroplasty surgery) · Gastroenterostomy · Hill repair · Nissen fundoplication · Gastropexy · Pyloromyotomy
Endoscopy: Esophagogastroduodenoscopy
Upper gastrointestinal series · Barium swallow
Lower GI tract
Small bowel
Bariatric surgery (Duodenal switch, Jejunoileal bypass) · Jejunostomy · Ileostomy · Partial ileal bypass surgery
Large bowel
Colectomy · Colostomy · Appendicectomy · Hartmann's operation · Colonic polypectomy
Rectum
Lower anterior resection · Abdominoperineal resection
Anal canal
Rubber band ligation · Anal sphincterotomy · Lateral internal sphincterotomy · Transanal hemorrhoidal dearterialization · Anorectal manometry
Medical imaging
Endoscopy: Colonoscopy · Proctoscopy · Sigmoidoscopy · Enteroscopy · Anoscopy · Capsule endoscopy
Transrectal ultrasonography · Abdominal ultrasonography · Enteroclysis · Small bowel follow-through · Lower gastrointestinal series · Virtual colonoscopy · Defecating proctogram · Double-contrast barium enema
Stool tests
Fecal pH test · Stool guaiac test · Fecal fat test
Accessory
Liver
Hepatectomy · Liver transplantation · Artificial extracorporeal liver support (Liver dialysis, Bioartificial liver devices) · Liver biopsy
Gallbladder, bile duct
Cholecystostomy · ERCP · Cholecystectomy · Hepatoportoenterostomy
Medical imaging: Cholangiography (PTC, IV, MRCP) · Cholecystography · Cholescintigraphy
Pancreas
Pancreatectomy · Pancreaticoduodenectomy · Pancreas transplantation · Puestow procedure · Frey's procedure
Abdominopelvic
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Categories:
    Medical treatments
    Renal dialysis
    Nephrology Dialysis Transplantation
Initial survival advantage of peritoneal dialysis relative to haemodialysis
Background. The influence of dialysis modality on prognosis is controversial. In the absence of randomized trials, epidemiological investigations present the best method for studying the problem.

Methods. 4568 haemodialysis (HD) and 2443 peritoneal dialysis (PD) records in 4921 dialysis patients treated between 1990 and 1999 were retrieved from the Danish Terminal Uremia register in order to determine the influence of dialysis form on prognosis. The register is national, comprehensive, and incident.
Results. Factors reducing survival included age, cardiovascular disease, malignancy, lung disease, diabetes, alcoholism, haematological disease, but not sex or hypertension. Transplant non‐candidacy was associated with an adjusted relative risk of 4.7 (CI 4.0–5.6). PD mortality relative to HD (after correction for comorbidity and transplant candidacy) was 0.65 (CI 0.59–0.72, P<0.001) on an ‘as treated’ and ‘history’ analysis and 0.86 (CI 0.78–0.95, P<0.01) on an intention‐to‐treat (ITT) analysis. The difference was confined to the first 2 years of dialysis. Change in dialysis modality was associated with increased mortality, and change from PD to HD with an accelerated mortality for the first 6 months. This was presumably due to the transfer of sick PD patients, but did not explain the difference. The relative advantage of PD was lower for diabetic patients, where it was not significant on ITT analysis. Dialysis prognosis improved by 14% during the period, with similar results for HD and PD patients. PD patients who were subsequently transplanted had a significantly shorter time to onset of graft function (3.5 vs 5.1 days, P<0.05).
Conclusions. These results show a survival advantage for PD during the first 2 years of dialysis treatment. This may be due to unregistered differences in comorbidity at the start of treatment, or may be causal, possibly due to better preservation of residual renal function. The study lends credence to the ‘integrative care’ approach to uraemia, where patients are started on PD and transferred to HD when PD related mortality increases.
Key words

    epidemiology
    haemodialysis
    peritoneal dialysis
    renal transplantation survival
Introduction
The relative merits of peritoneal dialysis (PD) and haemodialysis (HD) in the preservation of life of patients with terminal renal failure is still controversial. As randomized trials are probably impossible to perform, conclusions must be drawn from registry data. These data should preferably be recent, large, incident, and be adjusted for available comorbidity data. Two recent large studies [1,2] have suggested a survival advantage for PD during the first 2 years of dialysis. The existence of a national Danish registry describing incident active treatment for terminal uraemia enables further information to be gathered on this important subject. We performed an epidemiological study of all patients treated in Denmark between 1990 and 1999 in order to investigate the effect of dialysis modality on prognosis.
Patients and methods
Patients
The Danish Society of Nephrology Terminal Uremia Register (TUR) contains data concerning every patient in Denmark receiving active treatment for terminal uraemia, and forms the basis of the Danish EDTA register. The register contains the patient age, sex and renal diagnosis using standard EDTA terminology, and the start‐date, end‐date and location of every active treatment. Active treatment is classified as transplantation, HD, CAPD, continuous cycling PD (CCPD, generally synonymous with use of the night cycler), or intermittent PD (H‐IPD, a hospital‐based therapy consisting of 20 l thrice weekly or 60 l once a week). The register became comprehensive on January 1, 1990, and full treatment data on all patients under treatment on that day are available. Active treatment of diabetic patients and patients aged 70–80 years increased substantially during the period of observation. All dialysis treatments starting from January 1, 1990 to December 31, 1999 were included in the study.
Methods
Data from the TUR was combined with data from two other registers. (i) The National Patient Register (LPR) contains all national hospital admission data since 1977: date of admission, date of discharge, and WHO ICD discharge diagnoses. The first occurrence of the following chronic diseases was noted: malignancy excluding myeloma, multiple myeloma, thyroid disease, diabetes mellitus types 1 and 2, diabetic retinopathy, diabetes with multiple complications, blood dyscrasias, psykosis, neurosis, alcoholism, neurological disorders, hypertension, myocardial infarction, ischaemic heart disease, cerebrovascular disease, peripheral vascular disease, chronic obstructive lung disease (COLD) (including emphysema), cirrhosis. (ii) The Scandiatransplant register contains the data of all patients entering the waiting list for transplant and all patients receiving a renal transplant. The date of final removal from the waiting list was noted, patients being assumed to be transplant candidates prior to this date.
The registers were combined using the individual national identity number, which is unique, and common to the three registers.
Statistical analysis
Variables were compared using Student's t‐test, logarithmic transformation being performed where indicated. Categorical variables were compared using χ2 analysis. Survival analysis was performed using Kaplan–Meier and Cox proportional hazards analysis. The primary analysis was performed ‘career’‐wise (as treated). Each dialysis ‘career’ was treated individually, with each ‘career’ being censored for change of therapy or loss to follow‐up (LTF). For certain analyses the ‘history’ and intention to treat (ITT) methods were used. The history method is similar to the ‘as treated’ method, but includes only first dialysis ‘careers’, censored for change of therapy or LTF. The ITT method includes only first ‘careers’, censored for transplantation or LTF, but not change of dialysis modality. For the ‘history’ and ITT analyses, only patients beginning their first dialysis ‘careers’ after January 1, 1990 were included, defined as ‘complete patients’. Diagnoses were included as comorbid risk factors if they were present before the start of the dialysis ‘career’ (‘as treated’ analysis) or start of first dialysis ‘career’ (‘history’ and ITT analyses). Switches from one PD modality to another were ignored, apart from the PD modality analysis as such. The Statistica (Tulsa, AZ, USA) statistical package was used. The confidence interval was defined as twice the standard error of the mean.
Results
A total of 4921 patients were included. There were 4568 HD ‘careers’ and 2443 PD ‘careers’ registered. There were 4490 ‘complete’ patients, with 4020 HD and 2208 PD ‘careers’. The initial ‘career’ was HD in 3281 patients and PD in 1640 patients (complete 2956 and 1534). Patient characteristics are shown in Table 1. PD patients had a generally more favourable comorbidity profile than HD patients: they were slightly younger, had less cancer, cerebrovascular disease, blood dyscrasia, alcoholism, COLD, and were more likely to be transplant candidates. However, significantly more were diabetics and had diabetic complications. The relative risks (RRs) for individual variables, adjusted for age and sex are shown in Table 1. All variables with significant RRs were also significant on a proportional hazards analysis. Primary renal diseases were associated with a lower mortality, while diabetic and renovascular nephropathy had a poorer prognosis.
A total of 2184 patients died during the period of observation. The cause of death is shown in Table 2. There was no significant difference in cause of death between HD and PD, but a trend to a higher relative cardiac mortality for PD patients was noted.
A proportional hazards analysis was performed to investigate the relative influence of PD and HD on mortality and is shown in Table 3. PD had a 35% better prognosis using ‘as treated’ and ‘history’ analyses, and a 14% better prognosis using ITT analysis. The survival of non‐diabetic PD patients was 90% during the first year, and of diabetic patients, 87%. This improved prognosis was confined to the first 2 years of the first dialysis ‘career’ (Table 3 Figures 1 and 2). The difference was less marked for older patients and diabetics, where it was not significant on an ITT analysis, but for no group could a detrimental effect of PD be demonstrated.
Change of dialysis modality was associated with an excess mortality (RR 1.11 per change of modality (CI 1.06–1.18, P<0.001)), independent of comorbidity and age. 465 patients aged 20–70 years changing from initial PD to HD, and 378 changing from HD to PD were compared with 2027 and 1286 patients, matched for age and diabetes, starting on HD and PD, respectively (Figure 2). There was a significantly increased mortality of second ‘career’ compared with first for both modalities. HD patients had an accelerated mortality during the first 6 months of the second dialysis ‘career’ amounting to 37.2±4.6 (SEM) %/year. These patients were sicker on transfer with a 9 and 3% (HD and PD patients, respectively) increased prevalence of atherosclerosis.
PD prevalence in the 13 major dialysis centres varied between 28 and 48%, there being no effect of PD prevalence on prognosis. HD patients treated at large centres had a poorer prognosis of 11%/100 ‘careers’/year (CI 2–26, P<0.02), while PD patients had a 25%/100 ‘careers’/year (CI 62–89, P<0.01) better prognosis.
H‐IPD was mainly used as an introductory treatment to CAPD, only 18% of H‐IPD ‘careers’ being long term (>3 months). CCPD prevalence increased from 3 to 16% during the period, while long‐term H‐IPD fell from 14 to 0%. CCPD and CAPD had the same prognosis (Figure 3), while H‐IPD had a significantly increased mortality (age and sex‐adjusted RR 1.69, CI 1.22–2.35, P<0.01) relative to CAPD.
Patients treated between 1996 and 1999 had an overall 22% better adjusted prognosis (P<0.001) than previous cohorts, which was similar on ‘history’ and ITT analysis. This was, however, related to an excess of PD patients with short, and correspondingly favourable, ‘careers’. If only the first 2 years of dialysis were included, the cohort had a 14% (CI 0–26, P=0.05) better prognosis; this was similar both for PD (16%) and HD (13%) patients.
1397 patients (877 HD, 520 PD) were subsequently transplanted. There was no difference in incidence of delayed graft function (HD 41%, PD 38%) or permanent graft non‐function (7 vs 5%), but 5‐ and 10‐day delayed function was significantly higher after HD than PD (26 vs 19%, P<0.01; 17 vs 11%, P<0.01) and time to onset of function was significantly longer (5.1±9.7 vs 3.5±7.0 days, P<0.05). No significant influence on graft survival was seen (5‐year graft survival 67 vs 72%).
As randomized studies of different dialysis modalities are almost impossible to perform, conclusions about their relative merits must rely on epidemiological data, with corrections being made for different case mix. This method is not infallible, with a number of statistical problems recently reviewed by Schaubel et al. [3]. Conventional morbidity variables may miss subtle differences in somatic and psychological health. There may be insufficient allowance for comorbidity, particularly in the present study where comorbidity was registered as in‐patient diagnoses only. Thus, 26% of patients in this material had registered cardiovascular disease compared with 46% in the study by Fenton et al. [2]; the true figure, based on echocardiographic studies is probably even higher [4]. Our model, however, has the advantage that it includes transplant candidate status, a powerful predictor of mortality in that transplant non‐candidates were five times more likely to die than age‐ and sex‐matched candidates. The population studied was nation‐wide and comprehensive and all dialysis data was incident. Other well‐known risk factors included in this model were age, cancer, myeloma, diabetes, diabetic complications, renovascular disease, cardiac disease, cerebrovascular disease, peripheral atherosclerosis, and COLD. Alcoholism and blood dyscrasias were also risk factors. The RR for cancer excluding myeloma was surprisingly low at 1.23; presumably, patients with disseminated malignant disease are less likely to be selected for active treatment of terminal uraemia. Another surprising finding was that hypertension was not an adverse factor. This is, however, in accordance with other recent epidemiological studies of dialysis patients [5], the implication being that systolic dysfunction with consequent hypotension and poor prognosis, is common in the dialysis population.
The present study shows a substantial advantage of PD over HD during the first 1–2 years of dialysis, after which results were approximately similar, except for diabetic patients where the advantage for PD patients was reversed after 2.5 years. Several studies have investigated the effect of dialysis modality. Most found no significant difference, although many of these studies do not have the statistical strength to detect a difference. Some [1,2,6,7] found a better prognosis for PD, others a poorer prognosis [8–10]. Our findings are very similar to the findings of Fenton et al. [2], using Canadian data, and Collins et al. using USA data [1], although the survival advantage in the Collins study was shorter. The advantage was, as found by others [1,2,11] lower for diabetics, where it was insignificant on ITT analysis. In contrast to others [1,11], we did not, however, find a detrimental effect of PD in this subgroup. The advantage was lower for older patients on ‘as treated’ and ‘history’ analysis, but not ITT analysis.
These data lend support to the hypothesis that, except for elderly diabetic patients, PD has a therapeutic advantage in the first 2 years of treatment of terminal renal failure, but, as stated above, do not exclude the possibility that the difference is due to unregistered selection bias. If the relationship is causal, one possible explanation is the fact that residual renal function (RRF), a major determinant of survival in PD, is better preserved in PD than HD [12,13]. Support for this possibility can be seen in Figure 2 where the initial low mortality on PD was not seen during second PD ‘careers’, where RRF presumably is minimal. Emergency referrals have a poorer prognosis than planned dialysis ‘careers’ [14]. It is probable that these patients are preferentially referred to HD, but it is unlikely that this is the explanation as censoring the data for early death does not remove the difference. Another possible explanation is that PD patients who die after transfer to HD due to increasing morbidity will be registered as HD deaths. This does indeed seem to be the case in this study: patients suffered an accelerated mortality for up to 6 months after transfer to HD (switches from HD to PD and repeated modality changes were also associated with increased mortality). Other reports have shown similarly increased mortality and morbidity after transfer, though Van Biesen et al. [15] found unchanged mortality. Patients in this study were probably being maintained on their original modality for too long, and the findings emphasize the need for timely modality transfer when dialysis related morbidity is observed. The relative advantage of PD was therefore reduced on the ITT analysis, but was still significant. This study, therefore, lends support to the ‘integrative care’ approach to dialysis therapy [15–17], where it is postulated that optimal outcomes will be achieved by an initial PD ‘career’ followed by transfer to HD when PD related morbidity increases.
The relative prognosis of PD became progressively poorer over time [1,2]. This may be due to loss of RRF, with consequent underdialysis of PD patients (who are often critically dependent on RRF), or to increased mortality related to PD complications, such as recurrent peritonitis and damage to the peritoneal membrane. The period under study was characterized by increasing attention to dialysis quantification (from virtually non‐existent to near‐universal). H‐IPD, with theoretical maximum clearances of 2–3 ml/min is clearly an inadequate therapy, resulting in excess mortality. The treatment is now obsolete, except as a short‐term introduction to other forms of PD. Increasing quantification may be one of the causes of a significant 14% improvement in prognosis during this period, similar for both dialysis modalities. Further improvements in long‐term HD and PD prognosis may be achieved in the future by the use of more biocompatible membranes and dialysis solutions.
As found by others [18,19], PD patients experienced a more rapid onset of graft function after transplantation than HD patients. The most likely cause of this is that PD patients will be better hydrated prior to transplantation. Pedantic attention to preoperative hydration may reduce this difference [20].
In contrast to Fenton's study [2], no beneficial effect of large centre size was seen. Large centres had a higher HD and a lower PD mortality, suggesting a preferential referral of high‐risk patients to HD at these centres. Dialysis treatment appears to be uniform in Denmark.


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