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Booklet - Introduction to Peritoneal Dialysis

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The Renal Resource Centre is a national unit established to provide information and educational materials on kidney disease for patients and health professionals.

The primary objective of the Centre is to ensure that patients have easy access to such information, are well informed and can actively participate in their own health care.

The Renal Resource Centre is committed to providing education and service to the renal community.

RENAL RESOURCE CENTRE
2C Herbert St
St Leonards NSW 2065
Australia
Tel: 61 2 9462 9455 or 61 2 9462 9400
Freecall: 1800 257 189
Fax: 61 2 9462 9080
renalresource@nsccahs.health.nsw.gov.au
www.renalresource.com

Contents

Preface
Normal Kidney Function
Chronic Kidney Disease and Kidney Failure
Dialysis
Haemodialysis
Peritoneal Dialysis
Peritoneal Dialysis Advantages
Peritoneal Dialysis Disadvantages
Peritonitis
Methods of Peritoneal Dialysis
Continuous Ambulatory Peritoneal Dialysis (CAPD)
The Exchange Procedure
Automated Peritoneal Dialysis(APD)
Peritoneal Dialysis for Children
Peritoneal Dialysis & The Diabetic Patient
Peritoneal Dialysis Education
Going Home
Ongoing Care
Diet
Medications
Exercise
Relationships & Body Image
Pregnancy & Contraception
Holidays
Dialysis Supplies
A Final Note

PREFACE

This booklet has been written to provide prospective dialysis patients with some general information about kidney function and specific information about peritoneal dialysis . A companion booklet on haemodialysis is also available and it is recommended that you read both, especially if your renal physician has indicated that both treatments are medically suitable for you. Understanding why, when, where and how each form of dialysis is performed, will allow you to better consider which form of treatment will best suit you.

Like many thousands of Australians before you, facing the prospect of dialysis treatment is daunting. No doubt you have many questions and many fears about what it will entail and how it will change your life. Most of all, you probably wonder if it will keep you well enough to enjoy a long, full and active life. Rest assured that both peritoneal and haemodialysis are very effective forms of dialysis and that there are currently over 10,000 Australians receiving dialysis treatment. Furthermore, there are over 7,000 Australians living with kidney transplants.

After accepting the inevitable need for dialysis treatment, the next step is to decide which form of treatment will best suit you. There are two basic forms of dialysis - haemodialysis and peritoneal dialysis. Deciding which treatment is appropriate will depend on many factors. There may be medical reasons why your renal physician will recommend one over the other. In many cases, the choice will be entirely yours and will be influenced by several non-medical factors. The choice of treatment might be determined by your place of residence and the practicalities of attending for treatment. You may wish to consider your personal and family circumstances and how each form of dialysis will impact on those. It is always useful to consider how dialysis can be incorporated into your work, study, social life, leisure activities, business and holiday travel requirements.

Australia boasts some of the best results in the world in caring for people with kidney failure and is a world leader in home haemodialysis. These successful outcomes are a result of not just access to the best medical care and leading edge technology but are also influenced by the partnership developed between you and your renal team. Hopefully, by reading this booklet and also attending educational sessions about your treatment options, you will be well placed to participate in that partnership and so successfully manage your treatment, whatever form it may take.

In this booklet, we have attempted to anticipate your anxieties, fears, doubts and questions about peritoneal dialysis. However, a booklet cannot replace speaking with your physician and the staff of your renal unit. Knowing your individual circumstances, they are best positioned to guide you through the process of choosing the right treatment option.

With the prospect of future treatment and lifestyle changes ahead, try to take things slowly and don’t panic. What now seems overwhelming will soon be part of your routine. Read the information in this booklet carefully. We hope that it will help you to understand peritoneal dialysis and if and how it can benefit you. We wish you every success and good health.

Denise O'Shaughnessy
Senior Social Worker
Renal Resource Centre
March 2010


NORMAL KIDNEY FUNCTION

The kidneys are two of your vital organs and are located in the back of the abdominal cavity on either side of the spine, slightly above the small of the back. Each kidney is bean shaped, weighs approximately 150 grams and measures 11cm x 6cm (the size of a clenched fist).

Each kidney is composed of millions of minute filters which remove waste products and excess fluid from the blood.

The major function of the kidneys is to control the fluid and chemical balance of the body. In addition, the kidneys produce and regulate three main hormones:

Erythropoietin: Stimulates the bone marrow to produce red blood cells. A decrease in red blood cell production may lead to the condition anaemia.

Renin: Assists to control blood pressure.

Active Vitamin D: Stimulates the absorption of calcium from the blood into the bones to keep them strong.

Normal kidney anatomy

The kidneys help maintain the chemical and fluid balance of the body. The kidneys are located in the back of the abdominal cavity, on either side of the backbone, slightly above the small of the back.

CHRONIC KIDNEY DISEASE AND KIDNEY FAILURE

When the kidneys cease to function normally, resulting in a build up of waste products (toxins) and fluid in the body, the kidneys are said to be “failing”. Kidney or renal failure may be acute or chronic.

Acute Kidney Injury

Acute kidney injury may occur following severe blood loss, serious kidney infection and various types of kidney disease. The kidneys suddenly cease to function but usually recover with treatment.

Chronic Kidney Disease

Chronic renal failure means that kidney tissue has been destroyed gradually over a long period of time - usually months or years. Many people are unaware of the problem until more than 70% of kidney function has been lost. The aim of early detection of kidney disease and treatment (diet and medication) is to prevent or slow down progression of the disease. However, in some cases, the progression to end stage renal failure, when dialysis or transplantation is necessary, is not preventable.

The most common causes of end stage renal failure in Australian today are diabetes mellitus, glomerulonephritis, hypertension and polycystic kidney disease.

End Stage Kidney Disease

End stage renal failure occurs when the kidneys can no longer function adequately and survival depends on either dialysis or transplantation. You have probably reached or are approaching this stage of kidney disease and your present treatment is aimed at easing the load on your damaged kidneys and minimising the accumulation of waste products in your body.

Causes Of Chronic Kidney Disease

Symptoms you may be experiencing at the moment

You will require dialysis when these symptoms are no longer effectively controlled by your present treatment. Following the commencement of dialysis, you will notice a marked improvement in your health, as many of these symptoms are minimised or completely resolved.

The Functions of the Kidneys

Kidney functions

DIALYSIS

Dialysis is the process of cleansing or filtering the blood and removing excess fluids.

The filter used to cleanse the blood in dialysis treatment is a semi-permeable membrane, i.e. a thin material with holes large enough to let small particles (up to a particular size) through but small enough to retain large particles.

The body’s excess water and waste products filter from the blood across the membrane and are washed away by the dialysis solution. Large particles, such as blood cells and proteins, stay behind in the blood where they continue to do their work.

There are two methods of dialysis treatment:
Haemodialysis and Peritoneal Dialysis.

Both haemodialysis and peritoneal dialysis work equally well when treatment is undertaken as prescribed and when people take good care of themselves. If you are medically a candidate for either type of dialysis treatment, it is best to select a treatment based on your lifestyle, daily schedule, activities and personal preference. Many factors such as age, where you live, medical condition and support system will influence the decision. If you find that the treatment chosen as your first option does not really suit you, it may be possible to change to another form of dialysis. You are not necessarily permanently committed to one form of dialysis. It is also sometimes medically necessary to change over from one form of dialysis to another. You may wish to discuss the likelihood of this with your renal physician.

Dialysis

A semi-permeable membrane is used to filter the blood during dialysis. The membrane has tiny holes that will let small particles (like waste products) and excess water through but keep large particles (like blood cells) back.

HAEMODIALYSIS

In haemodialysis, the blood is circulated and cleansed outside the body.

The blood is withdrawn through a needle inserted in a blood vessel in the arm or leg. The needle is attached by plastic tubing to a haemodialysis machine. The machine pumps the blood out of the body and through an “artificial kidney” containing a synthetic semi-permeable membrane. Only a small amount of blood (200 - 220 ml) is out of the body at any one time.

The haemodialysis machine keeps the blood moving through the artificial kidney while wastes and fluid are being filtered out. It then returns the cleansed blood to the body through a second needle in the same blood vessel.

Those who need long-term haemodialysis treatment, use the haemodialysis machine for 4 to 6 hours at a time at least three times a week. Some people have a machine at home and dialyse alone or with the help of a partner. They may dialyse more frequently and for longer hours overnight or during the day. Others have their treatment as outpatients at a community or hospital dialysis centre.

Because the artificial kidney is not as efficient at filtering the blood as real kidneys, haemodialysis patients usually follow a special diet to limit their intake of salt, potassium and fluids. Longer and more frequent haemodialysis at home may mean some of these restrictions can be reduced.

PERITONEAL DIALYSIS

Peritoneal dialysis is the oldest form of dialysis. It was first used in 1923. In Australia in 2007, 22% of all dialysis patients were treated by peritoneal dialysis (ANZDATA, 2008).

In contrast to haemodialysis, peritoneal dialysis works inside the body using the body’s own natural PERITONEAL MEMBRANE as the semi-permeable membrane through which the blood can be filtered. The peritoneal membrane (peritoneum) lines the peritoneal or abdominal cavity and covers the organs that are contained within (stomach, liver, spleen, intestines).

During a special procedure requiring a short hospital admission, a soft thin tube called a peritoneal catheter is inserted through the wall of the abdominal cavity. The catheter provides an opening through which dialysis solution can be instilled into the peritoneal cavity. Once this solution is fully instilled, the bag which contained the solution is disconnected. The peritoneal cavity can then be used as a reservoir for the dialysis solution. The average adult can comfortably hold 2-3 litres of dialysis solution in the peritoneal cavity.

Although this appears to be a large amount of fluid to hold in the abdomen, no discomfort should be experienced. The fluid disperses between the two layers of the peritoneum, causing minimal increase in waist measurement. You may initially be aware of its presence, but this will decrease over time.

Waste products pass from the bloodstream across the peritoneal membrane and into the dialysis solution. The used dialysis solution is drained from the peritoneal cavity and replaced with fresh solution at regular intervals.

The peritoneal catheter is your “access” for dialysis and therefore it will be permanent. The point at which the peritoneal catheter exits your abdomen is called the exit site.

It is important that the exit site is kept clean and free of infection. To ensure this, you will be required to examine and cleanse your exit site daily. Your exit site care becomes an extension of your normal showering routine. It is essential that the catheter is well immobilised. You will be taught how to care for your exit site as part of your peritoneal dialysis education.

FILL DRAIN
fill and drain
Peritoneal Dialysis works inside the body. Dialysis solution flows through a tube into the abdominal cavity where it collects waste products from the blood. Periodically, the used dialysis solution is drained from the abdominal cavity, carrying away waste products and excess water from the blood.

PERITONEAL DIALYSIS

Advantages

The following are the advantages of peritoneal dialysis:

Disadvantages

The following are the disadvantages of peritoneal dialysis:

PERITONEAL DIALYSIS DISADVANTAGES

The following are the disadvantages of peritoneal dialysis:

PERITONITIS

Peritonitis is an infection of the peritoneal membrane. It is the major complication of peritoneal dialysis. The introduction of germs into the peritoneal cavity causes peritonitis and usually occurs when there has been a breakdown in the exchange procedure and peritoneal dialysis associated techniques. Every precaution should be taken to prevent peritonitis.

Signs and Symptoms

Treatment

As for all types of infections, antibiotics play the major role in peritonitis treatment. The antibiotics required to eradicate the peritoneal infection will be given via your peritoneal dialysis solution. The duration of antibiotic treatment will be dependent upon the type of germ and extent of infection. You will be closely monitored by your doctor during an episode of peritonitis.

For treatment of peritonitis to be effective it must commence as soon as possible.

Peritonitis is preventable!

Your peritoneal dialysis education is directed towards the prevention of peritonitis through the use of disconnect systems for delivering your dialysis solution. By adhering to your learned procedures, peritonitis can be avoided.

METHODS OF PERITONEAL DIALYSIS

There are two methods of peritoneal dialysis:

1. Continuous Ambulatory Peritoneal Dialysis (CAPD).

2. Automated - Peritoneal Dialysis (APD)

In Australia in 2007, CAPD was used to treat 10% of all dialysis patients and APD was used to treat 12% of all dialysis patients. So the method of peritoneal dialysis used in Australia is split almost 50/50 between CAPD and APD.

CONTINUOUS AMBULATORY PERITONEAL DIALYSIS (CAPD)

CAPD utilises the peritoneal membrane to filter the blood on a continuous basis. Dialysis solution is introduced into the peritoneal cavity on an average of four times a day. This means that dialysis solution is constantly within the peritoneal cavity. Around 2-3 litres of dialysis solution is instilled into the peritoneal cavity via a simple exchange procedure. In children the volumes are much smaller and tailored to the size of the child.

CAPD

THE EXCHANGE PROCEDURE

This involves draining dialysis solution, which contains waste products and excess fluid, from the peritoneal cavity and instilling fresh dialysis solution back into the peritoneal cavity, so that the cleansing process may begin again.

The exchange procedure is undertaken wherever there is privacy and a clean, well-lit environment: home, office, bathroom. The environment should be clean and free from drafts and dust.

The single most important consideration in CAPD is asepsis i.e. maintaining very clean conditions during all procedures. Whilst the exchange procedure is a simple technique to learn, it must be done with great care every time. This is because there is always a risk of infection.

There are exchange assist devices specifically designed for those who require assistance performing their exchanges, e.g. patients with visual problems, arthritis or tremor.

The exchange device assists to maintain asepsis of the exchange procedure and most importantly, your independence.

Prior to learning CAPD, the nursing staff will meet with you and assess which delivery method is best suited for you and whether you will require an exchange device.

A typical daily CAPD routine might be to perform exchanges at the following times: 7am (upon waking), 1pm (lunch time), 5pm (after work) and 10pm (before bed). Although this routine is flexible and may be adjusted to suit your lifestyle, it is important that a minimum of three hours between exchanges occurs to allow sufficient time for waste products and fluid removal.

Connecting and disconnecting the CAPD system takes only a few minutes. Allowing for draining, the whole procedure takes approximately 30 minutes. Most people use this time for reading or watching television.

During the course of your PD therapy, your prescription for dialysis may change. Changes in your prescription may include the amount of fluid instilled and the length of time it remains in your peritoneal cavity. Your prescription will be adjusted by your doctor according to blood results.

AUTOMATED PERITONEAL DIALYSIS (APD)

In APD the exchanges are performed automatically by a peritoneal dialysis machine (cycler).

Your peritoneal catheter is connected to the cycler each night before going to sleep. While you sleep, the cycler will perform four or more solution exchanges. Upon waking, simple disconnection from the cycler permits freedom from dialysis for the rest of the day.

APD may appeal to patients of all ages with busy lifestyles who want or need to free up their daytime hours. This option can be discussed with your renal physician and renal nurses.

In APD, “a cycler” machine controls the dialysis process during the night, while you sleep. APD is especially appealing to patients with busy lifestyles who want to free up their daytime hours.

PERITONEAL DIALYSIS FOR CHILDREN

Peritoneal dialysis is often the preferred treatment for children. With effective dialysis, good phosphate-calciurn-PTH control and the use of growth hormone, children on both peritoneal dialysis and haemodialysis have an equal opportunity for growth. The choice between PD and HD is purely based on the individual needs, the environmental and social aspects of the individual’s lifestyle, the treating centre’s preference, availability of the service and the physical condition of the patient.

Most children are able to use a cycler machine overnight, leaving their daytime hours free.

The volume of dialysis solution generally depends on the weight of the child, i.e 50mls of dialysis solution per kilogram of body weight.

Infants may only require 0.5 litre (50Omls), while teenagers may need 1.5-2 litres of dialysis solution.

Children on peritoneal dialysis are able to enjoy a relatively uninterrupted and active lifestyle, participating in varied sports.

Peritoneal Dialysis for Children

PERITONEAL DIALYSIS & THE DIABETIC PATIENT

Peritoneal dialysis is often recommended for diabetic patients. Anticoagulant therapy (Heparin) used in haemodialysis can accelerate the vascular changes associated with Diabetes Mellitus.

New dialysis solutions have been developed, which are especially suitable for people with diabetes. This allows for improved control of blood glucose levels.

It is important that your endocrinologist continues to manage your diabetes.

PERITONEAL DIALYSIS EDUCATION

Your peritoneal dialysis education is undertaken at a peritoneal dialysis education centre. Most people complete the dialysis education programme in less than two weeks as an outpatient. No one need return home until they feel completely confident. If you are well, you may be discharged from hospital and continue your dialysis education each day as an outpatient.

Continuous Ambulatory
Peritoneal Dialysis (CAPD) Education

Continuous Ambulatory Peritoneal Dialysis (CAPD) Education

GOING HOME

On completion of your dialysis education, the peritoneal dialysis nurse may accompany you home. This is to give you confidence in performing the exchange at home.

Following the initial visit, you will be visited from time to time by the peritoneal dialysis staff to see how you are progressing.

In the case of country patients, the peritoneal dialysis staff may contact the local community nurse to provide assistance, when required.

ONGOING CARE

Line Changes

The line attached to your catheter is changed every six months. This is usually done by the peritoneal dialysis nurse using aseptic techniques.

It is important that the line is changed regularly as the plastic materials may become worn with time and harbour germs.

Peritoneal Dialysis Clinic Visits

Each one to two months you will be required to attend the peritoneal dialysis clinic. During these visits a line change may be performed, blood may be taken to check blood chemistry and your general well-being will be assessed. This is a good time to talk with the peritoneal dialysis nurse regarding any problems you may have.

Seeing Your Renal Physician

Your renal physician will see you regularly. Timing this with your peritoneal dialysis centre visit is a good idea. The doctor will review your progress and make any necessary adjustments to your dialysis treatment. Take this opportunity to discuss any difficulties you may be experiencing.

DIET

Peritoneal dialysis allows you to have a more liberal diet. This will be a welcome change after the dietary restrictions necessary before beginning dialysis.

However, it is essential that you have a well balanced diet. You need to eat much more protein (meat, fish, dairy products etc.) to replace protein which is lost in the peritoneal dialysis solution.

You will be seen by the dietitian, who will advise you on your individual dietary requirements.

MEDICATIONS

Medications are a very important part of your treatment. Once stable on peritoneal dialysis, your medication requirements may change. Your renal physician will advise on these.

EXERCISE

People on peritoneal dialysis may gain weight easily. This is caused by:
i) improved appetite
ii) the glucose content of the dialysis solution which gives the body extra kilojoules /calories.
iii) eating too many sweet or fatty foods.

A regular, gentle exercise program is encouraged to prevent obesity, tone up the muscles and add to general well-being.

You should continue to play your favourite sports.

You may still be able to swim in clean private pools and clean, uncrowded ocean beaches should present no problems. However, check with your renal team first.

Following a swim or active sport, peritoneal catheter exit site care should be undertaken.

RELATIONSHIPS AND BODY IMAGE

You may be concerned at first about the presence of the catheter. Will the catheter be noticeable? The staff will show you how to secure the catheter so that it’s not noticeable. Meeting other patients similar in age and lifestyle be of great help in learning to adjust.

At times you may feel depressed and think that your family and friends don’t understand. It is important to share your feelings and concerns with those close to you, whilst also realising that they too may be affected by your illness and its treatment. The quality of your relationships depends on communication.

Do talk with the staff if you are experiencing difficulties in your relationships. Particularly when you are first on dialysis, many personal and family adjustments need to be made and it is helpful to talk with someone outside your immediate situation.

Kidney failure can affect your sexual desires or activity. The causes are varied and the changes in sexual interest will occur at different times for different people and will vary in intensity.

Women may notice a decline in their sexual interest and some may stop menstruating. Men may have difficulty in achieving or maintaining an erection and their fertility may also be reduced. If you experience these changes, talk it over with your partner so that it is clear that those changes are related to your illness and treatment. This may be difficult at first, but by talking through these changes and your feelings with your partner, you will find that together you can work towards resolving them and continue to enjoy a satisfactory relationship. As your sense of well-being improves, you may notice an improvement in your sexual desires. If difficulties persist, your renal physician can refer you to the appropriate specialist or counsellor.

You may at first be embarrassed about your peritoneal dialysis catheter and it is best to be honest about this with your partner. Sexual activity is perfectly safe but you must first feel comfortable with the changes in your body. Just give yourself a little time to adjust.

PREGNANCY AND CONTRACEPTION

Although women who dialyse have conceived, the chances of the pregnancy reaching full term with a normal sized baby are low. Men who are on dialysis can father children, so if pregnancy is not desired, you should discuss the most appropriate form of contraception with your doctor. It is advised that pregnancy be postponed until at least two years after transplantation.

Being open and honest with your partner about your thoughts and feelings will ensure that you can strengthen your relationship and resolve any difficulties as they occur.

HOLIDAYS

Holidays provide important breaks from your usual environment and routine and are essential for both you and your family.

Peritoneal dialysis will not prevent you from travelling. The dialysis staff can assist to plan your holidays and arrange for your dialysis supplies to be transported with you or delivered to your holiday location.

As well as travelling in Australia, it is possible to travel overseas. Forward planning is essential. The cost of dialysis supplies overseas will depend upon your destination. If you plan to travel, discuss this with your renal team. Check overseas health insurance arrangements thoroughly, in case hospital admission is required.

DIALYSIS SUPPLIES

You may be required to supply some items to assist you to perform dialysis. This should be discussed with your renal unit as some of these items may be found in your home already.

All disposable equipment necessary for your peritoneal dialysis is supplied through a healthcare contractor and delivered to your home address.

Before you go home, the peritoneal dialysis nurse organises your initial dialysis order to be delivered to your home.

Dialysis supplies will be delivered on a monthly basis. We therefore ask you always to bear in mind that your supplies are very valuable resources and need to be stored carefully and never damaged or wasted. You will be required to assist in the ordering process by giving an accurate stocktake of your supplies. You will be contacted monthly for this information. If you are unable to attend to this yourself, another family member or friend may assist.

A FINAL NOTE

We hope that after reading this booklet, you now have a basic understanding of peritoneal dialysis, how it compares to haemodialysis (the alternative method of dialysis) and how it may fit into your lifestyle. To some degree, its impact and suitability will depend on your pre-existing health, age, attitude, commitments and activities and the support of those around you.

It is natural at first to feel overwhelmed and apprehensive about the future and how dialysis will affect your life. Eventually, dialysis will become part of your routine and combined with your prescribed medications, diet and fluid intake, be an effective replacement of kidney function. Your renal physician and the staff at your renal unit will help you to make the best possible treatment choice. Information and counselling will be offered as a routine part of your preparation for dialysis and on-going treatment.

If you are already suffering from some other major or complex health problem and are frail, chronically unwell or in pain, you may be facing a dilemma about whether dialysis is the right choice for you. In such circumstances, it is perfectly understandable to consider declining dialysis. Discuss any reservations you or you family may have with your renal physician, who can advise on the treatment that best matches your special situation.

Take the opportunity to talk with your family about the information you have gathered from this booklet. This will help you to be well prepared for further discussions with your health care team about your treatment choice. The knowledge and understanding you have acquired will help you to regain a sense of control, when life may seem out of control. Being well informed will also help you to participate more fully in decisions about your immediate and future care and contributes to improved long-term health.


AMGEN Logo

This publication has been supported by an educational grant from Amgen.

RENAL RESOURCE CENTRE, 2010
2C Herbert St, St Leonards NSW 2065
Telephone: (02) 9462 9455 or (02) 9462 9400
Facsimile: (02) 9462 9080
Toll Free: 1800 257 189
email: renalresource@nsccahs.health.nsw.gov.au
Web: www.renalresource.com

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Publications of the Renal Resource Centre are endorsed by
The Australian and New Zealand Society of Nephrology and Transplant Australia

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