Dialysis was first described by Thomas Graham in 1854 1.

Graham worked as a chemist in Glasgow

University at around the same time as physician Richard Bright was describing the clinical features
and diagnosis of renal failure in Edinburgh.  Graham prepared a bell-shaped vessel shown below.

The wide open end of the bell was covered by a membrane created from an ox-bladder. He filled the
bell-shaped vessel with urine and suspended it inside a larger container, filled with distilled water. 
After several hours, the bell-shaped vessel was removed. The larger container was heated so that the
fluid inside boiled to dryness.  Graham showed that the residue in the larger container consisted
mainly of sodium chloride and urea, the principal components of urine. This proved that urea had
passed through the membrane. Graham termed this process dialysis and proposed, together with
Richard Bright, that this would form the basis of a treatment for renal failure. They predicted that it
would take around 60 years to develop the process sufficiently to be used in patients.

Click image to enlarge

Aside from being the first to describe the process of separating substances with a semi-permeable
membrane, Graham also was the first to separate colloids and crystalloids using a parchment
membrane2.  Graham realized that, for successful treatment of renal failure, toxins which accumulate
in renal failure would have to be removed. It would be necessary to understand the production rate of
these toxins in the patient and the rate at which they can cross the membrane.  So he made many
measurements of rates of transfer across the membrane for different solutes.  The science of dialysis
adequacy is based on a similar understanding of renal failure, uremic toxicity and membrane function.

The development of what eventually became a functional hemodialyzer was the cumulative effort of
several membrane pioneers.  Collodion membranes provided the first low flux dialyzers.  Fick was
perhaps the first to use collodion membranes to selectively separate small molecular weight solutes
(MW < 5000) from blood through the process of diffusion 3.  This was shortly followed by the
preparation of collodion tubes and the manufacturing process to control pore size and water
permeability4.

 
While significant research with artificial membranes, including dialysis of animal blood against saline
solution5and further characterization of membrane function and structure 6 was conducted between
1880 and 1913, it was not until 1914 that Abel et al. developed and tested the first efficient dialysis
system at Johns Hopkins University School of Medicine 7.  Their “vivi-diffusion” apparatus consisted of a
filtering device made of cellulose trinitrate (collodion) tubes and an attached burette containing hirudin
solution obtained from leech heads used as anticoagulant.  That same year, Hess and McGuigan
recommended high blood flows to avoid clotting or need for anticoagulation 8.

The first human hemodialysis was performed in a uremic patient by Haas in 1924 at the University of
Giessen in Germany9,10.  He used a tubular device made of collodion, cannulation of the radial and
carotid arteries and the portal vein and hirudin for anticoagulation.  Later that year he added a blood
pump.  In 1937, the first flat hemodialysis membrane made of cellophane was produced 11. 

Willem Kolff from the Netherlands, was one of the first investigators interested in the role of toxic
solutes in causing the uremic syndrome.  In 1940, while taking care of casualties after the German
invasion of the Netherlands, his interest in acute renal failure further increased and in 1943 he
introduced the rotating drum hemodialysis system using cellophane membranes and an immersion
bath and the first recovery of an acute renal failure patient treated with hemodialysis was
reported12,13.  This was the beginning of what was to become an important clinical reality: artificial
renal substitution therapy.

Significant improvements in dialyzer and equipment design occurred during the 1940’s and 50’s. Nils
Alwall developed a new system with a vertical stationary drum kidney and circulating dialysate around
the membrane14.  He was also responsible for applying hydrostatic pressure to achieve
ultrafiltration15.  Kolff in turn developed the coil dialyzer using a tubular membrane wrapped around a
solid core for use with a single pass dialysis fluid delivery system 16.  This was followed by the twin
dialyzer with twin blood pathways, the first disposable hemodialyzer.  In 1960, Kiil developed the plate
dialzyer that could be reassembled17.  The system consisted of multiple polypropylene boards
supporting flat cellulosic membranes.  This parallel flow kidney could be used without a blood pump
due to its low resistance.

A new phase in clinical hemodialysis started with the introduction of the Quinton and Scribner AV
shunt in 196018.  They used silastic tubes fitted with Teflon tips into the radial artery and cephalic vein
in the wrist or the posterior tibial artery and saphenous vein at the angle as an arterio-venous shunt. 
The two tubes ended in expanded couplings to facilitate connection.  This shunt provided for the first
time continuous circulation of the blood when the patient was not attached to the machine, effectively
eliminating clotting and provided ready access for repeated long-term hemodialysis, opening the door
to chronic renal replacement therapy.
 

The next significant advance in vascular access occurred in the 1960’s when Cimino and Brescia first
described their native arterio-venous fistula for chronic vascular access 19.  These fistulas are generally
created by an end-to-side vein-to-artery anastomosis.  A mature native A-V fistula is by far the safest
and longest lasting vascular access for hemodialysis. 

The major developments over the past four decades related to improvements in membrane
biocompatibility and dialyzer design, volumetric control, sophisticated monitoring systems that provide
online clearances, isothermal dialysis, high flux membranes and convective modalities such as
hemofiltration and hemodiafiltration.

http://www.youtube.com/results?search_query=video+of+dialysis&aq=f

http://en.wikipedia.org/wiki/Peritoneal_dialysis

Basic Concepts. Dialysis is the process of removing waste products and water from the bloodstream. Necessary
elements include a semipermeable membrane, dialysate solution, and a surgically created access. Blood is separated
from dialysate solution by a semipermeable membrane. Because the dialysate solution contains physiologic amounts
of electrolytes and buffers, exposure to blood across the membrane allows diffusion to begin. Solutes dissolved in
the blood, such as blood urea nitrogen (BUN) and creatinine, cross the membrane from an area of greater to an area
of lesser concentration. Osmosis is the other process at work, whereby water moves across the membrane into the
dialysate, which by virtue of its composition has a lesser concentration of water molecules. (Levy, Morgan, &
Brown, 2001). Both HD and PD rely on these basic principles of osmosis and diffusion.

Membranes. Hemodialyzer membranes have characteristics that provide varying ultrafiltration (UF) and waste
clearance properties. In PD, the peritoneal membrane also has unique characteristics, which promote clearance and
UF. It measures from 1-2 square meters in adults, and many fine walled capillaries provide blood flow (White,
Korthius, & Granger, 1994). Though the object of both PD and HD is clearance and UF, the process by which they
occur differs.

Kidney failure affects hundreds of thousands in the United States alone. The failure of the kidneys can be contributed
to a variety of factors. Some of these include uncontrolled hypertension, diabetes, glomerulonephritus (an
inflammation of the kidney's filters.), systemic lupus, polycystic kidney disease, and drugs.

Dialysis is a scary scenario any way you look at, but people with kidney failure have no other options to undertake in
order to live, save for the miracle of receiving a transplant. As scary as dialysis may seem, it is a miracle of science in
it's own right, as it allows us to live on.
Okay, you've received the bad news, you will soon need to start dialysis, question is, which type are you going to
choose? Depending on your physical condition, you may or may not be given a choice. If you have the option of
choosing, weigh the pros and cons of each, and decide for yourself, which modality is best.

Hemodialysis uses a machine and an artificial kidney/ filter to remove the toxins and excess fluids. Peritoneal uses
the peritoneum (an area behind your abdomen), which has a natural filter, a semi-permeable membrane to remove
the toxins and excess fluids. Both treatments require your blood to be filtered and excess fluid to be removed. In
order for this to be achieved, you need to have an access made to enable the process. With hemodialysis you can
have a fistula/graft which is under the skin, although under the skin, it is a noticeable appearance. With peritoneal, a
catheter in your belly is used, with about 5 inches of the catheter being outside of your body.

Hemodialysis requires you to stick to a schedule and go to a facility to have your treatment, whereas peritoneal can
be done at home or elsewhere, at the time that's best for you.
Peritoneal dialysis gives you the freedom of travel with no pre-arranging of treatments in a facility where you are
vacationing.

Hemodialysis requires you to be stuck with 2 needles at each treatment.

Peritoneal dialysis puts you at a higher risk for infection.

Hemodialysis is done by the staff with little help from you. (you can be involved if you choose to).
Peritoneal is done by yourself requiring the changing of dialysate bags 4 times per day (can be tiring for some). You
will first need to be trained for a couple of weeks to learn how to do your peritoneal dialysis properly. A longer
overnight method is also an option, using a small machine.

Peritoneal Dialysis
Peritoneal dialysis differs from Hemodialysis in that the blood is cleaned by a membrane inside the
body (the peritoneum), and not outside. Dialysis fluid, which is primarily composed of a glucose
solution and salts, is passed through a thin membrane that surrounds the exterior of organs in the
abdomen. 

There are two kinds of Peritoneal Dialysis. 

1. APD - Automated Peritoneal Dialysis, is a an automated method of Dialysis which runs while
you are sleeping. 8-12 liters of fluid will be exchanged during the course of a 8-10 hours sleep.
You will also need to be monitored frequently by nurses and clinics due to the strict rules and
guidelines which need to be met. 
2. CAPD - Continuous Ambulatory Peritoneal Dialysis, which cleans your body during the day.
You will need to exchange the fluids every few hours, which can take 40 minutes per session
(usually 4 times a day).

It was not too long ago that automated peritoneal dialysis (APD) was introduced as ahome dialysis
treatment optionfor people with chronic kidney disease (CKD). In 1970, the APD machine (also
known as a cycler) was released to a select few CKD patients who could perform peritoneal
dialysis using a machine at home. Peritoneal dialysis showed high demand in the 1980s and the
APD machine allowed many PD patients to free themselves from performing manual PD exchanges
during the day.

If you have considered peritoneal dialysis using a cycler but would like to know more about how it
works, this tour may help you better understand so that you can talk with your doctor about this
home dialysis treatment.

Automated peritoneal dialysis (APD) – how the machine works

Rather than performing manual peritoneal dialysis exchanges several times throughout the day, a
patient can do automated peritoneal dialysis while they sleep. Automated peritoneal dialysis is done
using a machine that fills your peritoneal cavity with fresh dialysis solution, also called PD fluid or PD
solution, and after a specified dwell time, drains the solution with waste out of your body and then
fills your peritoneal cavity with new dialysis solution. The average treatment time for automated
peritoneal dialysis is 9 hours at night while you sleep, but your doctor will prescribe what is best for
you.

APD equipment and supplies

Aside from the APD machine, there is required equipment and supplies that help you perform
peritoneal dialysis treatments:

Mask – You are required to wear a mask when you set up the APD machine and when you connect
and disconnect from the dialysis machine. The mask should be over your mouth and nose. Wash
your hands after you put your mask on so you do not contaminate your tube connections. Always
wearing your mask correctly and washing your hands are important for success. This will limit the
opportunities for bacteria to enter your body.

Large bags of PD fluid (PD solution) – Each PD fluid bag is filled with about 6 liters of PD fluid.
Two or three bags are generally used through the night. The PD fluid bags are hooked up to a
cassette in front of the cycler machine, which has a tube that is connected to the person’s peritoneal
catheter. The catheter leads into the abdomen (peritoneal cavity), and during each exchange some
of the fluid will flow from the bags into the abdomen and then later be drained out of the body. The
PD solution dwells inside the peritoneal cavity, collecting the wastes and extra fluid from the body
which is then drained out after each cycle is completed.

Drain bag – The drain bag is one of two options used to remove the PD fluid from the peritoneal
cavity. The drain bag is attached to a cassette that warms the fluid, sending it through tubes
connected to the cassette into a person’s peritoneal cavity. The bag is clear so that the person may
examine the waste and fluid that has been drained from the body. The used PD fluid should be
clear, like urine. If it is cloudy, that can be an early sign of infection. Peritoneal dialysis patients who
see this are recommended to call their PD nurse so they can receive treatment right away.

Drain line – The second option for draining PD solution is a drain line. The drain line can be from 12
to 24 feet long in order to reach the bathroom for disposal in either the toilet, sink or shower area.
Cassette and tubing – The various tubes used to perform APD are gathered into one area of the
cycler that keeps everything organized called the cassette or organizer. There are tubes that lead
from the cassette to each dialysis solution bag (there can be from one to four bags used for each
treatment depending on the patient’s prescription). The PD catheter is attached to a tube on the
cassette as well. There is another tube that attaches from the cassette to the drain bag or drain line.

The APD machine is programmed to drain the solution through the PD catheter to the drain tube (or
drain line). Once the draining is finished, new dialysis solution is released from a dialysis solution
bag to the peritoneal catheter that leads to the peritoneal cavity where the solution will dwell for a
certain time based on the patient's prescription. This process will repeat until the APD treatment is
completed for the night.

Documenting your APD treatment – Documenting your treatment is also important. This allows
your doctor and nurse to see how you are doing at home and help adjust your treatment to be just
right for you. There are different ways to do this depending on the dialysis system you use. Your
training nurse will help you understand what needs to be documented.

Automated peritoneal dialysis (APD) machines on the market

The peritoneal dialysis machines have been designed to be user-friendly and generally use similar
equipment and supplies to perform APD. Before you receive a cycler, you will go through peritoneal
dialysis training with a PD nurse. Here is a description of two automated peritoneal dialysis cyclers.

Baxter’s HOMECHOICE™ Automated PD System

Like many household electronic equipment, the Baxter HOMECHOICE™ plugs into a regular electric
outlet. The system will tell you on the display screen to “Press Go to Start.” Once you program your
prescription numbers into the machine, the HOMECHOICE will remember the information for each
time you use it. You may be prompted to type in your total fluid volume, therapy time and fill volume,
among other things. A patient can have one to four bags of dialysis solution attached to the machine
for the treatment in one night, depending on your prescription.

Baxter’s HOMECHOICE is 20 inches long, 13 inches high and 24 inches wide. It weighs 25 pounds.

Fresenius Medical Care NA – Newton IQ cycler

The Fresenius Newton IQ™ is also plugged into an electrical outlet. The machine requires the
patient or nurse to enter the patient’s entire prescription into the cycler for the first time. This
machine remains programmed for future use, until the prescription is changed and needs to be re-
entered. A patient may manually enter numbers such as number of fills, dwell time and drain time,
among other information. After the numbers are entered, the Newton IQ will ask about other
information, including if the PD solution bags need to be pre-warmed or if you would prefer the
instructions in English, Spanish or French.

Newton IQ sits 10 inches high and the machine is 22.5 inches long and 20 inches wide. This cycler
also weighs 25 pounds.

Both the Baxter HOMECHOICE and Fresenius Newton IQ cyclers have colorful buttons next to a
clear display screen that walks you through each step of preparation. Each machine comes with a
booklet or handout to help guide you through set up in case there is something you are unfamiliar
with on the display screen. It is recommended to call the manufacturer first, Baxter or Fresenius, in
case of major machine issues. It is best to call the manufacturer when the problem occurs so that
they can better assist you with trouble-shooting the problem. Both manufacturers have 24-hour per
day hotlines to help assist you with any cycler problems. Your PD health care team is also on hand
to help you with any questions.

Adjusting to the APD machine

Both APD machines are meant for nighttime use or during the day for people who work at night.
While you are asleep, the cycler helps you dialyze safely and efficiently. It may take time to adjust to
using the automated peritoneal dialysis machine.

Noise – APD machines do not make much noise. If they do, it’s just a slight humming sound. You
may be able to hear it while it is plugged in and turned on. Patients have said the noise is minimal
and not disruptive to falling asleep.

Alarms – Rarely do the alarms go off on the machine, but when they do, it is usually because you
may be sleeping in a position that is blocking the flow of dialysate. Many times, shifting to a different
position will alleviate this problem. The display screen indicates why the alarms are sounding so you
can correct the matter, turn off the alarms and resume dialyzing.

Emergencies – Emergencies can happen, which is why the APD machines are designed to alert
you if there is a problem. For example, if the electricity were to go out, the cycler automatically goes
into a shut down mode for up to two hours. If the electricity goes on before two hours are up, the
cycler will continue to dialyze from where it left off. You will have been trained on how to do manual
peritoneal dialysis exchanges in the event the electricity is off indefinitely or for an extended period.
Emergency scenarios will be discussed with your PD nurse in your PD training sessions.

Care partner optional – A person on automated peritoneal dialysis may opt to have a care partner,
but it is not usually necessary. The cycler is simple enough to set up and use so that a PD patient
does not need assistance from a care partner.

Getting up during the night – If there is a need to get up in the middle of the night during APD, you
can usually stay attached and dialyze, as the tube is relatively long. You can also detach from the
cycler and when you come back the APD machine will remember where you left off. Your PD
training nurse will give you instruction on how to perform this procedure safely.

APD patient benefits

Many patients appreciate that using the automated peritoneal dialysis machine during the night
helps free up their day. The APD cycler option has given many patients the ability to travel, since it is
portable. Many people are able to work outside their home without having to perform manual
peritoneal dialysis several times a day, although it is possible to do manual peritoneal exchanges at
work. Some patients performing automated peritoneal dialysis also report feeling better and get
better results on their lab tests.
Summary
You have a choice when it comes to home dialysis and it is good to explore your options. Talk to
your doctor if you are interested in learning more about automated peritoneal dialysis or other home
dialysis treatments.

Continuous Ambulatory Peritoneal Dialysis (CAPD)

CAPD is performed manually. It can be done almost anywhere. CAPD stands for:

 Continuous - CAPD is a continuous process. The blood is being cleaned as

long as fresh dialysis fluid is exchanged for old fluid in the peritoneal cavity.
With CAPD, dialysis takes place 24 hours a day, 7 days a week.
 Ambulatory - To ambulate means to walk. CAPD patients are not attached
to a machine for treatment, but move around freely and even dialyze while
sleeping.
 Peritoneal - The peritoneum is the membrane in the abdomen that is used
as the dialysis membrane. The peritoneal membrane acts as a filter,
removing waste and excess fluid from the blood. The wastes and excess fluid
cross the membrane into the dialysis solution. They are removed from the
body when the dialysis solution is drained into a drainage bag.
 Dialysis - The blood inside the body is filtered and cleansed of wastes and
excess water.

How does a CAPD exchange work?

An exchange of dialysis fluid in CAPD is simple. You will be able to do it yourself
once you have been trained by a specialised CAPD nurse. This training usually takes
one to two weeks, either at a training center or at home.

The basic steps are:

1.Connect the peritoneal dialysis catheter to a disposable tubing and bag set of
dialysate fluid and an empty drain bag.
2.Drain the fluid from your peritoneal cavity into the drain bag.
3.Drain fresh fluid into your peritoneal cavity by clamping the drain bag,
opening the inflow of the new dialysate bag, and letting the fluid fill your
peritoneal cavity.
4.When the new fill bag is empty, clamp the bag and disconnect.
5.Discard the used solution and disposable tubing set.
6.Go about your activities with the solution in your peritoneal cavity until the
next exchange (about 4 to 6 hours).

An exchange takes about 30 minutes. Most CAPD patients need to do between

three and five exchanges a day.
 

How does APD work?

 1.When the patient goes to bed, they connect their PD catheter to the APD
machine, and switch on the machine.
2.The APD machine carries out exchanges automatically overnight while the
patient is asleep. The machine carefully measures the amount of fluid that
goes into the peritoneal cavity and the amount that comes out. This usually
continues for between 8 to 10 hours with a last fill that will remain through
the day.
3.In the morning, the patient disconnects from the machine.

APD is a simple procedure. The machines are easy to operate and have built-in
safety devices. They are about the size of a small suitcase and are portable. They
can be used wherever there is a supply of electricity.
 

At the renal unit, a training nurse will help you learn how to perform your CAPD or
APD treatment safely. At home most patients, or someone they live with, do the
treatments. Patients return to the renal unit for regular check-ups.

Patients on either kind of peritoneal dialysis are relatively independent and can
manage their own care at home. Continuous dialysis means dialysis is happening
24 hours a day and 7 days a week, with no days off. This means that the dialysis is
effective, provides good control of blood pressure, and offers more choices of diet
and fluid intake than does hemodialysis. PD patients are usually comfortable and
pain free. Most adults hold 2 to 3 liters of fluid in their abdomen without being
aware of it. No needles are used for PD. Although PD patients do not have to travel
to a renal unit for treatment sessions, it is important to maintain the dialysis
schedule of 3-5 exchanges each day prescribed by your doctor.

Travel for business or pleasure can be arranged easily with a little planning.

PD requires the insertion of a permanent catheter, which poses some risk of

infection.
Storage space is needed at home for PD supplies. The bags of dialysis fluid come in
boxes of 4 or 5, so a month's supply can be as many as 40 boxes. These must be
stored in a clean, dry area.

May 1, 2006