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HEMODIALYSIS OVERVIEW Dialysis is a treatment for severe kidney failure (also called renal failure, stage 5 chronic kidney

disease, and end-stage renal disease). When the kidneys are no longer working effectively, waste products and fluid build up in the blood. Dialysis take over a portion of the function of the failing kidneys to remove the fluid and waste. Dialysis is typically needed when about 90 percent or more of kidney function is lost. This usually takes many months or years after kidney disease is first discovered. Early in the course of kidney disease, other treatments are used to help preserve kidney function and delay the need for replacement therapy. WHICH TYPE OF DIALYSIS IS BEST? Once dialysis becomes necessary, you (along with your physicians) should consider the advantages and disadvantages of the two types of dialysis:
• •

Hemodialysis (in-center or at home) Peritoneal dialysis (see "Patient information: Peritoneal dialysis")

The choice between hemodialysis and peritoneal dialysis is influenced by a number of issues such as availability, convenience, underlying medical problems, home situation, and age. This choice is best made by discussing the risks and benefits of each type of dialysis with a healthcare provider. PERITONEAL DIALYSIS CATHETER INSERTION Before peritoneal dialysis can begin, a catheter (thin tube) must be inserted in the abdomen to carry fluid into and out of the abdominal cavity. The catheter is made of a soft, flexible material (usually silicone) and has cuffs (like balloons) that inflate to hold the catheter in place. The end of the catheter inside the abdomen has multiple holes to allow fluid to flow in and out.

The catheter is placed on the left or right of the umbilicus (belly button); the patient may be given general or local anesthesia before the insertion procedure. (See "Placement and maintenance of the peritoneal dialysis catheter".) Although the catheter can be used right away, it is best to wait 10 to 14 days after placement before dialysis is performed; this allows the catheter site to heal. In some cases, a small volume of fluid can be exchanged during this time (see 'How does peritoneal dialysis work?' below). Your healthcare provider will provide more detailed instructions. PERITONEAL DIALYSIS CATHETER SITE CARE Care of the catheter and the skin around the catheter (called the catheter site) is important to keep the catheter functioning and also to minimize the risk of developing an infection. Care after insertion — After the catheter is inserted, the insertion site is usually covered with a gauze dressing and tape to prevent the catheter from moving and keep the area clean. The dressing is usually changed at the dialysis home training center seven to 10 days after placement. If a dressing change is needed before this time, it should be done by a specially trained peritoneal dialysis nurse using sterile techniques. The catheter should not be moved or handled excessively because this can increase the risk of infection. The area should be kept dry until it is well healed, usually for 10 to 14 days. This means that you should not take a shower or bath or go swimming during this time. A washcloth or sponge may be used to clean the body, although you should be careful to keep the catheter and dressing dry. While healing (two to three weeks), you will be asked to limit lifting and vigorous exercise.

Avoid constipation — It is important to avoid becoming constipated after the catheter is inserted. Straining to move the bowels can increase the risk of developing a hernia (a

not moving the bowels regularly can lead to problems with catheter function (slow drain time or difficulty draining the abdomen completely).) Long-term care — After the catheter site has healed (approximately two weeks after insertion).weakness in the abdominal muscle). Apply a prescription antibiotic cream to the skin around the catheter with a cotton-tip swab every time the dressing is changed. your healthcare provider may recommend a diet that is high in fiber. wash your hands with soap and water and put on clean gloves. should NOT be used unless directed by a healthcare provider. your dialysis nurse will instruct you on catheter exit site care. Other types of cleansers. Pat the skin around the site dry after cleaning. which helps prevent injury to the skin. A clean cloth or towel is suggested. Avoid using tapes or dressings that prevent air from reaching the skin. In addition. • • • • • • Before cleaning the area. such as hydrogen peroxide or alcohol. as well as a stool softener or laxative. The skin around the catheter site should be washed daily or every other day with antibacterial soap or an antiseptic (either povidone iodine or chlorhexidine). To avoid constipation. Hold the catheter still during cleaning. Do not pick at or remove crusts or scabs at the site. It will be important to keep the area clean to minimize the risk of skin infection as well as infection inside the abdomen (called peritonitis). (See"Patient information: Constipation in adults" and "Patient information: High fiber diet". The site should be covered with a sterile gauze dressing. The soap should be stored in the original bottle (not poured into another container). which should be changed every time the .

although you should not feel pain. dialysis fluid (called dialysate) is infused into the abdominal cavity (called the peritoneal cavity) through a catheter. or if the catheter is moved excessively. there may be an infection. firm. . most PD catheters are problem free and work for many years. The lining of the abdomen (the peritoneum) acts as a membrane to allow excess fluids and waste products to pass from the bloodstream into the dialysate. A crust or scab may form every few days. HOW DOES PERITONEAL DIALYSIS WORK? In peritoneal dialysis. a short course of oral antibiotics may be recommended to prevent infection from developing inside the abdomen (peritonitis). When the abdomen is full of dialysate. you may have a feeling of fullness or bloating. If the catheter no longer works or is needed. a minor surgical procedure is required to remove it. or there is pus-like discharge around the catheter. The catheter should be anchored to the skin with tape or a specially designed adhesive. Most patients have no abnormal sensations. painful. With appropriate catheter placement and exit site care. such as an accidental pull on the catheter. this is called a dwell. Most dialysis units recommend that you call if you injure the catheter site to determine if further evaluation or treatment is needed. The skin should feel soft. The fluid is held (dwells) within the abdomen for a prescribed period of time.) Care after injury to the catheter site — If there is an injury to the catheter site. (See 'Peritoneal dialysis complications' below. If the skin is reddened. Appearance — After the first two weeks.site is cleaned. the skin around the catheter should not be red or painful. There may be a small amount of thick yellow mucus discharge around the catheter.

.When the dwell is completed. family. (See 'Which type is right for me?' below. In developed countries such as the United States. The process may be done manually four to five times during the day by infusing the fluid into the abdomen and later allowing it to run out by gravity. The process of emptying and filling for each exchange takes 30 to 40 minutes when done manually. there may be a long daytime dwell.) • • Continuous ambulatory peritoneal dialysis (CAPD) involves multiple exchanges during the day (usually three) with an overnight dwell. the "used" dialysate can then be drained out of the abdomen (called an exchange) into a sterile container or into a shower or bathtub. which is usually eliminated in the urine. A machine is not needed and the person can walk around while the fluid is in the abdomen. Occasionally. CCPD is performed more commonly than CAPD. Which type is right for me? — Patients are often allowed to choose between CAPD and CCPD based upon lifestyle or personal issues. and occasionally a manual daytime exchange. The "right" type of peritoneal dialysis depends upon an individual's situation. dialysate is infused and is drained upon awakening. The peritoneal cavity is then filled again with fresh dialysate. At bedtime. Types — Several different types of peritoneal dialysis schedules are possible. and social activities than CAPD. This used fluid contains the excess fluid and waste from the blood. a machine (called a minicycler) will be needed to perform an exchange one or more times while sleeping. Continuous cycler peritoneal dialysis (CCPD) is an automated form of therapy in which a machine performs exchanges while the patient sleeps. CCPD allows significantly more uninterrupted time for work. The exchange may also be done using a machine (called a cycler).

) PERITONEAL DIALYSIS COMPLICATIONS One of the most serious complications of peritoneal dialysis is infection. or tenderness of the skin around the catheter Pus-like drainage from the area Peritonitis — Peritonitis is the term used to describe an infection of the abdominal cavity. or type of dialysate after beginning treatment. These infections can usually be treated at home and resolve completely. based upon how the body responds. (See"Adequacy of peritoneal dialysis". dwell time. a weakness in the abdominal muscle. Another potential but less serious complication of peritoneal dialysis is the development of a hernia. number of exchanges. Periodic blood and urine tests.) Left untreated. peritonitis can become a life-threatening infection.4ºF or 38ºC) Nausea or diarrhea . are used to fine tune PD treatment. firmness.There may be changes in treatment type. which can develop in the skin around the catheter or inside the abdominal cavity (called peritonitis). which may be mild to severe Cloudy used dialysate fluid Fever (temperature greater than 100. Catheter site infection — The signs of catheter site infection include: • • Redness. as well as tests of the used dialysate. Signs of peritonitis may include one or more of the following: • • • • Abdominal pain. (See "Diagnosis of peritonitis in peritoneal dialysis". People who use peritoneal dialysis are at increased risk of peritonitis because bacteria can enter the abdomen through or around the peritoneal dialysis catheter.

Less commonly. The type of treatment used depends upon the severity and location of the infection. as well as more frequent skin cleaning. Most mild infections resolve with treatment within one to two weeks. People who use peritoneal dialysis are at risk of developing a hernia for several reasons. Hernias can develop near the belly button (umbilical hernia). (See "Microbiology and therapy of peritonitis in continuous peritoneal dialysis". which are commonly given with the dialysate (eg. you need to be seen by a healthcare provider and begin treatment as soon as possible. intraperitoneal dosing).Treatment of infection — If there are any signs of infection. Peritoneal dialysis is usually continued as the infection is being treated. the peritoneal dialysis catheter must be removed and the person will be transitioned to hemodialysis. Signs of a hernia include painless swelling or new lump in the groin or abdomen. (See "Tunnel and peritoneal catheter exit site infections in continuous peritoneal dialysis". in the groin (inguinal hernia). including the increased stress on the muscles of the abdomen (as a result of the weight of the dialysate) and the opening in the abdominal muscle created by the peritoneal dialysis catheter. or near the catheter site (incisional hernia). If you develop signs of a hernia.) Peritonitis usually requires treatment with antibiotics. A change in the dwell time and/or dialysis prescription is sometimes needed temporarily. • • Catheter site infections are often treated with an antibiotic cream and/or oral antibiotics. contact your healthcare provider but continue to perform peritoneal dialysis . the catheter may need to be removed and replaced. If the infection does not resolve.) Hernia — Hernia is the medical term for a weakness in the abdominal muscle.

lower quality protein is found in some vegetables and grains. nuts. dried beans. but not excessive. • . cheese. The body absorbs some of this dextrose during the dwell. People who use peritoneal dialysis lose protein with every exchange. and monitoring the amount of fluids consumed. are often required to make changes to their diet. In general. liver. and eggs. A dietitian can provide specific recommendations about how much and what type of protein is needed. Protein is found in meat. which usually means that they must eat an increased amount of protein in the diet. • Diet — People who undergo dialysis. It is sometimes necessary to switch from one form of treatment to another as circumstances change. amount of protein and certain minerals.) LIVING WITH PERITONEAL DIALYSIS Chronic kidney disease is a lifelong condition that requires lifelong treatment. (See "Abdominal hernias in continuous peritoneal dialysis". chicken. (See "Patient information: Low sodium diet". a type of sugar. Dietary changes help to ensure that the body has an adequate. both hemodialysis and peritoneal dialysis. with other options including hemodialysis and kidney transplantation. and chocolate) and sodium. milk. people who use peritoneal dialysis have a less restricted diet compared to those who use incenter hemodialysis. Treatment of a hernia generally involves surgery. fish. • Other changes in diet may include reducing the amount of foods eaten that contain phosphorus (found in dairy products. Peritoneal dialysis is one option for lifelong treatment.regularly.) Weight gain — Weight gain can be a problem for people undergoing peritoneal dialysis because the dialysate contains a high concentration of dextrose.

(See 'Where to get more information' below. It is important to perform every exchange and dwell exactly as recommended. potentially interfering with other activities.• • • which can lead to weight gain. Patient support groups and websites can provide reassurance and tips for dressing. Most patients begin dialysis when their kidneys have lost 85%-90% of their ability. Time requirements — Peritoneal dialysis requires time and dedication. . although you should discuss your activities with your physicians. people using peritoneal dialysis should limit physical activities when their peritoneal cavity is full (has a large volume dwell). If the demands of peritoneal dialysis feel overwhelming. it may be necessary to cut back on responsibilities. which requires the person to perform several exchanges during the daytime. Body image — The abdomen will enlarge and may cause you to feel bloated when it is filled with fluid. and can even shorten the person's life. or if you're having trouble performing all the necessary treatments. This is especially true with CAPD. It is still possible to exercise and participate in sports. talk to a healthcare provider __________-- Definition Dialysis is a treatment that takes over the job of the kidneys when they fail .) Activities and peritoneal dialysis — In general. You may need a larger size of clothing. and some people have a hard time accepting the change in their appearance. A dietitian can provide guidance on how to minimize weight gain by monitoring the number of calories eaten. Skipping a treatment or performing a dwell for shorter or longer than recommended increases the risk of illness and the chances of being hospitalized. Although it is possible to work and be active while using peritoneal dialysis.

high blood pressure . such as potassium. sodium.Dialysis will continue for the rest of their lives (or until they receive a kidney transplant). Dialysis is not a cure for ESRD. or other kidney problems. ESRD is caused by conditions such as diabetes. kidney cancer . Risk Factors for Complications During the Procedure Hemodialysis • Heart problems Peritoneal dialysis • • • • Adhesions or significant abdominal scar tissue Infection of the peritoneum (lining of the abdominal cavity) Abdominal hernia Diverticulitis . It helps you feel better and live longer. and chloride It may also be done to quickly remove toxins from the bloodstream. or neck Peritoneal dialysis—abdomen Reasons for Procedure The main functions of dialysis are to: • • • Remove waste and excess fluid from the blood to prevent build-up Control blood pressure Keep a safe level of chemicals in the body. This can occur in cases of poisoning or drug overdose. This is called end-stage renal disease (ESRD) . leg. There are two types of dialysis: • • Hemodialysis Peritoneal dialysis Parts of the Body Involved • • Hemodialysis—veins in the arm. drug use.

An access site called a fistula or shunt may be surgically created in one of your veins. the physician places a small. Hemodialysis . A portion of the tube remains outside the body for use in the process. Each treatment lasts from two to four hours. They are never used if the treatment is temporary. It is usually done three times a week. or neck. Fistulas may need as long as 2 to 3 months to fully heal before they can be used. soft tube (approximately 24 inches long) in the abdomen. leg. Hemodialysis is usually done at a dialysis center or hospital.• Abdominal defects What to Expect Prior to Procedure Hemodialysis • • • Weight. This tube will remain there permanently. Anesthesia For hemodialysis: topical anesthetic Description of the Procedure Hemodialysis Blood is filtered through an artificial kidney machine. They are typically created many months before dialysis is begun. called a dialyzer. blood pressure. The blood travels from the body to the machine through tubes inserted into a vein in your arm. It is important to keep this access clean and dry to prevent infection. It may be done at home with assistance. and temperature are taken Topical anesthetic (a pain numbing medicine) is applied to the arm for needle insertion Heparin (a medication that prevents blood clotting) is given Peritoneal Dialysis Before the first treatment.

No machine is needed. This way your blood is always being cleaned. Intermittent peritoneal dialysis (IPD)—uses the same type of machine as CCPD. It remains there for 3-6 hours and is drained. Peritoneal Dialysis . In this type of treatment it is used to filter blood instead of a machine. New dialysate can then be added to repeat the process. Peritoneal Dialysis The abdominal lining is called the peritoneal membrane. The abdomen is refilled with fresh solution. A bag of dialysate is infused into the abdomen through a catheter. It often takes longer than CCPD. A port in the abdomen may be needed for long-term treatment. and chemicals pass from the tiny blood vessels in the peritoneal membrane into the dialysate. A cleansing solution. This requires assistance and is usually done at a hospital or center. wastes. called a dialysate.© 2009 Nucleus Medical Art. is inserted into your abdomen. It is done at night while sleeping. It is then drained after several hours. Continuous cyclical peritoneal dialysis (CCPD)—is done by machine. There are three types of peritoneal dialysis: • • • Continuous ambulatory peritoneal dialysis (CAPD)—is the most common type of peritoneal dialysis. Fluid. Inc.

After Procedure Your blood pressure will be monitored.© 2009 Nucleus Medical Art. and chloride Dialysis method used The approximate time and frequency of each method: Type Length of procedure Frequency of procedure 3 times/week Hemodialysis 2-4 hours CAPD CCPD IPD 3-6 hours. potassium. Inc. How Long Will It Take? The time needed for dialysis depends on a few factors: • • • • • • How much kidney function remains How much fluid weight gain has occurred since the last treatment Amount of waste in the body Body size Level of minerals in your body such as sodium. plus 30 minutes to drain 4 times/day 9-12 hours 12 + hours Every night 36-42 hours/week Will It Hurt? .

In general. weak. Patients who have peritoneal dialysis may have slightly fewer dietary restrictions than hemodialysis patients. This will help to keep overall health and optimize the treatment. There are some special considerations: Dietary Guidelines Certain dietary guidelines should be followed. These include. resulting in weakened bones Average Hospital Stay None Postoperative Care Once the procedure is complete and blood pressure is stable. There may be some temporary discomfort with the insertion of the needle or tube. but are not limited to . Possible Complications • • • • • • • • • • • • Anemia Drop in blood pressure during dialysis Muscle cramps Nausea. Talk to your doctor about your specific dietary needs. sweaty. This is due to the more frequent filter schedule. and/or dizzy Peritonitis (infection of the peritoneum). You will not feel the blood exchange. which causes fever and stomach pain (peritoneal dialysis only) Growth problems in children Inflammation of the heart sac (pericarditis) Neurologic problems Disruption of calcium and phosphorus balance. vomiting Headaches Infection Feeling hot. Medications Your doctor may give various types of medication. dialysis procedures do not cause pain. you are free to continue daily activities.

and chemical and hormonal exchanges that are critical to survival. under your navel (belly button). kidneys. or left side. stomach and bowel). called a PD catheter. The holes are too small to allow large molecules to pass through therefore blood and dialysate will never mix.• • • • • • Blood pressure medications Calcium supplements or multivitamins Phosphorus binders—to lower phosphorus levels in the blood Diuretics—to remove excess fluid Stool softeners or laxatives—to prevent or treat constipation. other hospitals may insert them under local anaesthetic. including fever and chills Redness. excessive bleeding. the remaining 6 inches are tunnelled through tissue to exit either on the right. cleaning of the blood. thus allowing waste products and fluid from the blood to pass through it. soft plastic tube. The membrane has many tiny holes and acts as a filter. . or discharge at the catheter or tube insertion site Blood or cloudiness in the peritoneal dialysis fluid Nausea or vomiting Abdominal pain Dizziness or weakness What is peritoneal dialysis? Peritoneal dialysis uses the peritoneum. PD catheters are inserted in theatre under general anaesthetic at Arrowe Park Hospital. which is important for production of red blood cells Outcome Dialysis helps maintain blood pressure. increasing pain. warmth. Many major organs are contained within this cavity (liver. 6 inches are placed inside the peritoneum. Call Your Doctor If Any of the Following Occurs • • • • • • Signs of infection. The catheter is approximately 12 inches long in total. a natural membrane that lines the cavity of the abdomen. Peritoneal Dialysis is performed daily at home. which can be caused by decreased fluid intake Iron supplements—to increase iron intake. How does the dialysis fluid get into the peritoneum? Dialysis fluid (dialysate) flows into the peritoneal cavity through a small. swelling.

. The PD Nurse will explain how to care for your catheter. You should be able to go home the day after the operation.The catheter that is inside the peritoneum has lots of small holes at the end of it. this allows time for the catheter to "settle in" and for the wound to heal. and will arrange your follow-up care. this is to aid the in-flow and out-flow of fluid through the peritoneal cavity. It is best to allow at least 4 weeks after the operation before you start to use your catheter.

this process means that molecules will pass from the stronger solution (blood) into the weaker solution (dialysate).How does PD work? PD dialysis fluid is made up of a glucose solution. The fluid in the blood is pulled across the peritoneal membrane to ‘dilute’ the glucose using the process called osmosis. different concentrations of glucose are provided in order to help with the removal of excess fluid in the blood. . Waste products are removed from the blood through the process called diffusion. In order to increase the amount of fluid removed a higher concentration of glucose would be used.

specialised PD fluids available. your individual prescription will be based on your specific needs. your PD nurses and your consultant. following discussions with you. What are the treatment choices on PD? We offer a choice of peritoneal dialysis: CAPD -Continuous Ambulatory Peritoneal Dialysis APD .There are a range of different.Automated Peritoneal Dialysis .

fluid balance and general health. dwell for the programmed time and then drain the fluid out. BP. The dialysis fluid is left in place for 4 . and then refill with fresh fluid for the dialysis process to begin again. depending on individual requirements. the cycles will continue for the set time programmed into the machine. on holiday or in the car! Automated peritoneal dialysis (APD) APD is machine-assisted dialysis. Summary of peritoneal dialysis Patients on either type of peritoneal dialysis are relatively independent and can manage their own care at home. When you go to bed you will connect up to the machine and the dialysis will be performed while you sleep.4 times daily. they are not required to attend hospital at any other time unless they require further review. allow the fluid to drain out of you into the drain bag. usually performed at home overnight every night. When your exchange is due you will connect a bag of dialysate and drainage bag to your catheter.6 hours. during this time you will be disconnected and free to carry on with your everyday life. until bedtime when you will need to connect up again. PD patients are reviewed monthly for routine bloods.30 minutes. . CAPD is flexible and can be adjusted to suit your individual needs.Continuous ambulatory peritoneal dialysis (CAPD) CAPD is a manual form of peritoneal dialysis carried out 3 . Peritoneal dialysis regimes are prescribed by the PD nurse responsible for the patient. this is the time that dialysis is taking place. The machines are simple and safe to operate once the PD nurses have taught you how. The dialysis fluid is drained into the peritoneal cavity via the PD catheter and left to 'dwell'. The whole procedure should take approximately 20 . it can be performed in any clean place . The machine is programmed to fill the peritoneal cavity with dialysis fluid. Peritoneal dialysis is performed every day. APD can be performed wherever there is a supply of electricity for example when you are on holiday.at work. Fluid and dietary restrictions on PD are generally less restrictive than on haemodialysis. provides good control of blood pressure and fluid balance. weight. Each dialysis session will last 8-10 hours. all regimes are individual to each patient based on their blood results and any symptoms they may have. In the morning you will disconnect from the machine and carry on with your normal routine. in a caravan for instance. which means that the dialysis is effective.

PD allows greater patient mobility. Risks and benefits PD is less efficient at removing wastes from the body than hemodialysis.[8] The tube site can also become infected. but does not help with peritonitis. their family and the members of the hospital team.[9] Infections can be as frequent as once every 15 months (0. ensure your dialysis is most effective. Patients are requested to give a minimum of 8 weeks notice when planning a holiday. training and on-going support needed to enable you to remain as independent as possible. and promote the best quality of treatment and care available to you and your family. We aim to provide the information. Compared to hemodialysis.[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. Home Haemodialysis (HHD) Home Therapies (including PD and HHD) requires a partnership between the patient. in conjunction with a specialised travel club. the use of prophylactic nasal mupirocin can reduce the number of tube site infections. produces fewer swings in symptoms due to its continuous nature. Patients receiving PD will require storage space for approximately 3040 boxes. and the presence of the tube presents a risk of peritonitis due to the potential to introduce bacteria to the abdomen. the PD unit may be able to provide a shed for the patient to store their supplies. but large amounts ofalbumin are removed which requires constant monitoring of nutritional status.8 episodes per patient year).Patients receiving PD may travel to most countries. If storage is a problem. and phosphate compounds are better removed.PD equipment is cheaper but . The costs and benefits of hemodialysis and PD are roughly the same . The PD Nurse can arrange your dialysis requirements on holiday. All the required dialysate will be delivered by the dialysis company to the patients’ destination before they arrive.

the costs associated with peritonitis are higher. morbidity or mortality) for patients with end stage renal disease. a Cochrane Review of three small clinical trials found no difference in clinically important outcomes (i.[12] S . The results suggested APD may have psychosocial advantages for younger patients and those who are employed or pursuing an education. Hypertriglyceridemia and obesity are also concerns due to the large volume of glucose in the fluid. 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 peritonitis. low back pain and hernia or leaking fluid due to high pressure within the abdomen.e. the y-set uses a single y-shaped connection between the bags involving emptying.[11] Of the three types of connection and fluid exchange systems (standard. which can add as many as 1200 calories to the diet per day. twin-bag and y-set.[4] There is insufficient research to adequately compare the risks and benefits between CAPD and APD. PD may also be used for patients with cardiac instability as it does not result in rapid and significant alterations to body fluids.[10] Other complications include hypotension (due to excess fluid exchange and sodium removal). and for patients with insulin-dependent diabetes mellitus due to the inability to control blood sugar levels through the catheter. nor was there any advantage in preserving the functionality of the kidneys. the latter two involving two bags and only one connection to the catheter.