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Renal Resource Centre 37 Darling Point Poad, Darling Point, NSW 2027 AUSTRALIA Telephone: 61 2 9362 3995 9362 3121 Facsimile: 61 2 9362 4354 Freecall: 1800 257 189 Click here for our location map |
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 |
| 37 Darling Point Road |
| Darling Point NSW 2027 |
| Australia |
| Tel: 61 2 9362 3995 or 61 2 9362 3121 |
| Freecall: 1800 257 189 |
| Fax: 61 2 9362 4354 |
| renalresource@nsccahs.health.nsw.gov.au |
| www.renalresource.com |
Preface
Normal Kidney Function
Kidney Failure
Dialysis
Haemodialysis
Peritoneal Dialysis
Peritoneal Dialysis Advantages
Peritoneal Dialysis Disadvantages
Peritonitis
Methods of Peritoneal Dialysis
Continuous Ambulatory Peritoneal Dialysis (CAPD)
Automated Peritoneal Dialysis
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
Kidney Disease affects many thousands of Australians each year and in most cases, the need for dialysis treatment will not be necessary. Experienced health professionals have prepared this booklet specifically for those who will require dialysis treatment. This can be a difficult time and it is our aim to provide you with accurate and easy to read information. Dialysis treatment takes two major forms: Haemodialysis and Peritoneal Dialysis. This booklet examines peritoneal dialysis in detail.
Your choice of treatment may already have been decided or you may still be weighing up the pros and cons of each method. Your doctor may recommend one form of dialysis in favour of another, based on many factors. Your participation in discussing this can only be possible if you understand how each treatment works and how it will fit in with your lifestyle. You may need to consider your personal and family circumstances, your home and work environment, leisure activities, holiday routines, time available for training, as well as many other intangible reactions to each method of dialysis. Unless you understand how and why each treatment works, you will be unable to plan an active role in your treatment. At all times, remember that your kidney failure is treatable and that your enjoyment of life will relate directly to the interest, care and responsibility you take in your dialysis.
In this booklet, we have attempted to anticipate your anxieties, fears, doubts and questions about peritoneal dialysis. Let us assure you that many people throughout Australia and the world have gone before you with exactly those feelings. If they managed ... and they did, so can you!
With each year we learn more about dialysis and continue to perfect the techniques and equipment involved. This booklet will give you a comprehensive picture of peritoneal dialysis treatment today. We hope that the information it contains will assist you at this time.
| Denise O'Shaughnessy |
| Senior Social Worker |
| Renal Resource Centre |
| May 2008 |
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 3 main hormones:
(1) ERYTHROPOIETIN: : Stimulates the bone marrow to produce red blood cells. A decrease in red blood cell production may lead to the condition anaemia.
(2) RENIN: Assists to control blood pressure.
(3) ACTIVE VITAMIN D: Stimulates the absorption of calcium from the blood into the bones to keep them strong.
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.
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 failure or renal failure may be acute or chronic.
Acute renal failure 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 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 tissue has been damaged. Even if the problem is discovered before this (by blood or urine tests) it often cannot be cured and the aim of early treatment (diet and medication) is to slow the progression towards End Stage Renal Failure.
End Stage Renal Failure occurs when the kidneys can no longer function adequately and survival depends on either dialysis or transplantation. You are probably at, or approaching this stage of kidney disease and your present treatment (medications, dietary and fluid restrictions) is aimed at easing the load on your damaged kidneys and preventing waste products and fluid from accumulating in your body.
You will require dialysis when these symptoms are no longer effectively controlled by your present treatment.
Dialysis is the process of cleansing or filtering the blood.
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 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, 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 done in the right schedule 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. People can and do change from one treatment to another as their needs or health changes.
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.
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 frequently haemodialysis at home may mean some of these restrictions can be reduced.
Peritoneal dialysis is the oldest form of dialysis. It was first used in 1923. Today over 160,000 patients worldwide utilise this form of dialysis. Currently in Australasia about 22% of all dialysis patients and 69% of all home dialysis patients are treated by peritoneal dialysis.
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 his or her 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.
The following are the advantages of peritoneal dialysis:
The following are the disadvantages of peritoneal dialysis:
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.
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.
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.
There are two methods of peritoneal dialysis:
1. Continuous Ambulatory Peritoneal Dialysis (CAPD).
2. Automated - Peritoneal Dialysis (APD)
In Australia in 2006, CAPD was used to treat 11% of all dialysis patients and APD was used to treat 11% of all dialysis patients. So the method of peritoneal dialysis used in Australia is split 50/50 between CAPD and APD.
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.
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, craft work, 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.
In APD the exchanges are performed automatically by a peritoneal dialysi's 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.
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.
APD is generally performed over night while you sleep.
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 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. Extraneal 7.5% Solution uses starch derived glucose as the osmotic agent. This allows for improved control of blood glucose levels.
It is important that your Endocrinologist continues to manage your diabetes.
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.
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.
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 CENTRE VISITS
Each month you will be required to attend the Peritoneal Dialysis Centre. 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 wish to 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 with your doctor any difficulties you may have.
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.
Once stable on peritoneal dialysis, your medication requirements may change. This will be decided by your Renal Physician.
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 wellbeing.
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.
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 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.
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 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.
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.
We hope that after reading this booklet, you have a clearer understanding of peritoneal dialysis. You may be feeling overwhelmed by the details of treatment and be wondering how you will incorporate dialysis into your daily routine. Let us assure you that everyone feels uncertain and apprehensive at first but soon learns to master the techniques involved.
Although your kidneys are no longer working properly, peritoneal dialysis, together with your diet, fluid and medication requirements, can restore you to good health. Just as we are all encouraged to maintain our health through some form of regular exercise, so too must you! Not only will this keep you fit, it will strengthen your muscles and help prevent you from gaining excess body weight.
This booklet has been designed to give you a basic overview of peritoneal dialysis. You may still have some questions that have not been answered in sufficient detail. If this is the case, please discuss these questions with your Renal Physician, Nurse or Social Worker. Remember, you are not alone in this. The staff of your renal unit understand that you may have special concerns. They are there to help you successfully manage your treatment so that you may lead an active and fulfilling life. Just as many others before you have achieved this, so can you!
RENAL RESOURCE CENTRE, 2008
37 Darling Point Road, Darling Point NSW 2027
Telephone: 61 2 9362 3995 or 61 2 9362 3121 Freecall: 1800 257 189
Fax: 61 2 9362 4354
Web: www.renalresource.com
Publications of the Renal Resource Centre are endorsed by
The Australian and New Zealand Society of Nephrology and Transplant Australia
Renal Resource Centre