Peritoneal dialysis

Dialysis is the procedure of removing waste products from blood when the kidneys do not function properly. The two types of dialysis include Hemodialysis and peritoneal dialysis. Peritoneal dialysis (PD) cleans the blood in the body itself without any external device when the kidneys fail to clean the waste products from the body. The peritoneum is the inner lining of the abdomen or the belly. In PD, the peritoneum is used to filter the blood and clear the waste products from the body. 

The technique of PD:

PD cleans the body of the waste products using the peritoneum as the filter. A tube is placed in the body by a cut. Sterile cleansing fluid containing water, salt, and other additives is sent into the abdomen through this tube to filter the blood from a bag. This solution is called the dialysate. This solution filters the waste products from the blood vessels in the abdomen. The solution is present in the body for about 4-6 hours. This period is called the dwell time. After filtration of the blood, the fluid is drained through the catheter into the bag. The repeated process of sending the dialysate into the peritoneum to filter the blood and discard the filtered products collected in the blood is called the exchange. This is the basic principle of PD. 

Continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD) are the two types of PD. Both these procedures can be done at home or the workplace in a clean area or even when traveling. The main difference between the two types of PD is the time and the way of exchange of the solutions. CAPD is done by hand at any time while APD is done by a machine at night

• CAPD is the dialysis procedure where a person can continuously move while the exchange goes on. CAPD can be self-done without using any machines. Each exchange occurs for about 30-40 minutes and one can continue their activities of daily living while the exchanges happen. These exchanges have to be done about 4 times a day. 
• APD is done by a cycler at night. A machine called the cycler does the exchange process about 3-5 times at night. There will be a fresh solution in the belly after exchanges at night. This procedure is also called continuous cycler-assisted PD. 

Indications: 

PD is indicated in individuals with kidney diseases. It is the treatment of choice for those with end-stage kidney disease. It is also indicated in 

• Individuals who cannot bear hemodialysis due to needle anxiety
• Individuals who cannot get proper blood vessel access for hemodialysis
• Individuals with blood vessel disease called peripheral vascular disease or bleeding disorders 
• Individuals with heart conditions like congestive heart failure, prosthetic valvular disease, or poorly functioning heart. 
• Very young children between ages 0-5 years
• Metabolic disorders like diabetes
• Long-standing infections

Contraindications:

PD is not indicated in long-standing and uncorrected abdominal wall hernias, adhesions of the abdominal walls, digestive system disorders, and when there is a medical device called the pleuro-peritoneal shunt. 

Advantages: 

PD has many advantages

• It is a safe, and effective procedure for removing waste from the body
• It is more convenient and gives the freedom of doing it in any clean place. 
• It does not need to place any needles in the blood vessel. 
• It has the advantage of keeping the kidneys functioning even when they are damaged
• It has relatively fewer side effects than hemodialysis 

Before starting the PD:

Before starting the PD, one has to undergo surgery to place a catheter in the abdomen. After blood tests and physical examination, catheter placement is planned. Catheter placement should be done at least 3 weeks before starting the first exchange. Catheter placement can be done through the skin, by open surgery, or laparoscopically. This can be done under local anesthesia or general anesthesia based on the technique of catheter placement. 

A cut is made under general anesthesia below the belly button and the catheter is sent through this cut into the peritoneal cavity. The cut is closed by sutures and it is tested by using saline to check for any leakages. PD catheters are available in various shapes consisting of a flexible silicone tube with an open end and any side holes. Two cuffs are present in the tube to hold the catheter in place and to ward off infection. 

During PD:

After the catheter placement, one has to wait at least 15 to 20 days for healing of the catheter site. After the site heals exchange process can be carried out based on the type of PD chosen like CAPD or APD. The type of PD depends on the patient’s choice and their medical condition. An individual or the caretaker has to be well-trained in the technique of PD. 

The success of PD:

The PD is influenced by many factors like the size of the individual, the lining of the abdomen, the quantity of the dialysis solution used, the number of exchanges, dwell time lengths, and the amount of sugars in the dialysate. A peritoneal equilibration test can be done to find the efficacy of the procedure by comparing the blood and the dialysis solution. A clearance test can also be done to check the sample of blood and the dialysis fluid for urea. Based on the result one can alter the number of exchanges, change the amount of dialysate, or use a dialysate with a high concentration of dextrose. 

Risks and complications: 

The most important complication associated with the procedure is the risk of infection of the peritoneum called peritonitis. This can be reduced by following the hand-washing protocol, and keeping the entry port of the catheter clean. Using sugars in the dialysate can lead to the body absorbing the sugars. This leads to weight gain and altered sugar levels in the body. Hernia development occurs as a complication of PD due to long-standing fluids in the body that can weaken the abdominal muscles. 

Conclusion: 

Peritoneal dialysis offers the freedom of doing dialysis at home or in a comfortable place to the patient. Proper training can help individuals to do PD without error to increase their quality of life and survival rates. 

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