Patient information: Peritoneal dialysis (Beyond the Basics)

OVERVIEW

Peritoneal dialysis (PD) is a procedure that can be used by people whose kidneys are no longer working effectively. The procedure is performed at home and works to remove excess fluid and waste products from the blood.

This topic discusses peritoneal dialysis. Other treatments for chronic kidney disease are discussed separately. (See "Patient information: Dialysis or kidney transplantation — which is right for me? (Beyond the Basics)" and "Patient information: Hemodialysis (Beyond the Basics)" and "Patient information: Chronic kidney disease (Beyond the Basics)".)

WHEN WILL I NEED DIALYSIS?

As the kidneys lose their ability to function, fluid, minerals, and waste products that are normally eliminated in the urine begin to build up in the blood. When these problems reach a critical stage, excess fluid and waste must be removed with kidney (renal) replacement therapy.

There are two types of dialysis: hemodialysis and peritoneal dialysis. Kidney transplantation may be an option for some patients, although dialysis is the most commonly used treatment. The "best" type of dialysis depends upon your abilities, underlying medical illnesses and personal needs. These issues are discussed separately. (See "Patient information: Dialysis or kidney transplantation — which is right for me? (Beyond the Basics)".)

It usually takes many months or years after kidney disease is first discovered before dialysis is necessary. However, some patients have a rapid decline in kidney function and occasionally severe kidney failure is discovered for the first time in people who were not previously known to have kidney disease. (See "Patient information: Chronic kidney disease (Beyond the Basics)".)

You and your doctor will decide together when to begin dialysis after considering a number of factors, including your kidney function (as measured by blood and urine tests), overall health, and personal preferences.

Advance planning — People with kidney disease should discuss the possible need for dialysis early in their treatment course. Advance planning allows the physician to choose a therapy that will best meet the patient's lifestyle and needs. In addition, advance planning allows the physician time to plan for the placement of a peritoneal dialysis catheter in the abdomen.

After the catheter is placed, the patient and family will be trained by the staff at the home dialysis unit on how to set up the equipment and become familiar with the procedures used in peritoneal dialysis. During most of this "training", the patient will actually be doing dialysis.

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 (which are like Velcro) that skin tissue grows into 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 exit site is typically placed on the left or right of the umbilicus (belly button) although occasionally the catheter exit site may be placed higher up on the abdominal wall or over your sternum. Reasons for this would vary from patient to patient and should be discussed with your doctor; 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 weakness in the abdominal muscle). In addition, not moving the bowels regularly can lead to problems with catheter function (slow drain time or difficulty draining the abdomen completely).

To avoid constipation, your healthcare provider may recommend a diet that is high in fiber, as well as a stool softener or laxative. (See "Patient information: Constipation in adults (Beyond the Basics)" and "Patient information: High-fiber diet (Beyond the Basics)".)

Long-term care — After the catheter site has healed (approximately two weeks after insertion), your dialysis nurse will instruct you on catheter exit site care. 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).

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). The soap should be stored in the original bottle (not poured into another container). Other types of cleansers, such as hydrogen peroxide or alcohol, should NOT be used unless directed by a healthcare provider.

• Before cleaning the area, wash your hands with soap and water and put on clean gloves.
• Hold the catheter still during cleaning, which helps prevent injury to the skin.
• Do not pick at or remove crusts or scabs at the site.
• Pat the skin around the site dry after cleaning. A clean cloth or towel is suggested.
• Apply a prescription antibiotic cream to the skin around the catheter with a cotton-tip swab every time the dressing is changed.
• Avoid using tapes or dressings that prevent air from reaching the skin. The site should be covered with a sterile gauze dressing, which should be changed every time the site is cleaned. The catheter should be anchored to the skin with tape or a specially designed adhesive.

With appropriate catheter placement and exit site care, most PD catheters are problem free and work for many years. If the catheter no longer works or is needed, a minor surgical procedure is required to remove it.

Appearance — After the first two weeks, the skin around the catheter should not be red or painful. The skin should feel soft. There may be a small amount of thick yellow mucus discharge around the catheter. A crust or scab may form every few days.

If the skin is reddened, painful, firm, or there is pus-like discharge around the catheter, there may be an infection. (See 'Peritoneal dialysis complications' below.)

Care after injury to the catheter site — If there is an injury to the catheter site, such as an accidental pull on the catheter, or if the catheter is moved excessively, a short course of oral antibiotics may be recommended to prevent infection from developing inside the abdomen (peritonitis). Most dialysis units recommend that you call if you injure the catheter site to determine if further evaluation or treatment is needed.

HOW DOES PERITONEAL DIALYSIS WORK?

In peritoneal dialysis, dialysis fluid (called dialysate) is infused into the abdominal cavity (called the peritoneal cavity) through a catheter. The fluid is held (dwells) within the abdomen for a prescribed period of time; this is called a dwell. 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.

At times when the abdomen is full of dialysate, you may have a feeling of fullness or bloating, although you should not feel pain. However, most patients have no abnormal sensations and despite the fluid in the abdomen, most people do not look different.

When the dwell is completed, the "used" dialysate can then be drained out of the abdomen (called an exchange) into a sterile container or into a shower or bathtub. This used fluid contains the excess fluid and waste from the blood, which is usually eliminated in the urine. The peritoneal cavity is then filled again with fresh dialysate.

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. The exchange may also be done using a machine (called a cycler). In this case the fluid exchanges are done automatically while the patient sleeps.

Types — Several different types of peritoneal dialysis schedules are possible. The "right" type of peritoneal dialysis depends upon an individual's situation. (See 'Which type is right for me?' below.)

• Continuous ambulatory peritoneal dialysis (CAPD) involves multiple exchanges during the day (usually three) with an overnight dwell. A machine is not needed and the person can walk around while the fluid is in the abdomen. At bedtime, dialysate is infused and is drained upon awakening. Occasionally, a machine (called a cycler) will be needed to perform an exchange one or more times while sleeping.
• Continuous cycler peritoneal dialysis (CCPD) is an automated form of Peritoneal Dialysis (APD) in which a machine performs exchanges while the patient sleeps; there may be a long daytime dwell, and occasionally a manual daytime exchange. In developed countries such as the United States, CCPD is performed more commonly than CAPD.

Which type is right for me? — Patients are often allowed to choose between CAPD and CCPD or APD based upon lifestyle or personal issues. CCPD or APD allows significantly more uninterrupted time for work, family, and social activities than CAPD.

There may be changes in treatment type, dwell time, number of exchanges, or type of dialysate after beginning treatment, based upon how the body responds. Periodic blood and urine tests, as well as tests of the used dialysate, are used to fine tune PD treatment. (See "Adequacy of peritoneal dialysis".)

PERITONEAL DIALYSIS COMPLICATIONS

One of the most serious complications of peritoneal dialysis is infection, which can develop in the skin around the catheter or inside the abdominal cavity (called peritonitis). Another potential but less serious complication of peritoneal dialysis is the development of a hernia, a weakness in the abdominal muscle.

Catheter site infection — The signs of catheter site infection include:

• Redness, firmness, 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. People who use peritoneal dialysis are at risk of peritonitis because bacteria can enter the abdomen through or around the peritoneal dialysis catheter. These infections can usually be treated at home and resolve completely. (See "Clinical manifestations and diagnosis of peritonitis in peritoneal dialysis".)

Left untreated, peritonitis can become a life-threatening infection. Signs of peritonitis may include one or more of the following:

• Abdominal pain, which may be mild to severe
• Cloudy used dialysate fluid
• Fever (temperature greater than 100.4ºF or 38ºC)
• Nausea or diarrhea

Treatment of infection — If there are any signs of infection, you need to be seen by a healthcare provider and begin treatment as soon as possible. The type of treatment used depends upon the severity and location of the infection. Peritoneal dialysis is usually continued as the infection is being treated.

• Catheter site infections are often treated with an antibiotic cream and/or oral antibiotics, as well as more frequent skin cleaning. Most mild infections resolve with treatment within one to two weeks. If the infection does not resolve, the catheter may need to be removed and replaced. (See "Tunnel and peritoneal catheter exit site infections in continuous peritoneal dialysis".)
• Peritonitis usually requires treatment with antibiotics, which are commonly given with the dialysate (eg, intraperitoneal dosing). A change in the dwell time and/or dialysis prescription is sometimes needed temporarily. Less commonly, the peritoneal dialysis catheter must be removed and the person will be transitioned to hemodialysis. (See "Microbiology and therapy of peritonitis in continuous peritoneal dialysis".)

Hernia — Hernia is the medical term for a weakness in the abdominal muscle. People who use peritoneal dialysis are at risk of developing a hernia for several reasons, 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. Hernias can develop near the belly button (umbilical hernia), in the groin (inguinal hernia), or near the catheter site (incisional hernia).

Signs of a hernia include painless swelling or new lump in the groin or abdomen. If you develop signs of a hernia, contact your healthcare provider but continue to perform peritoneal dialysis regularly. Treatment of a hernia generally involves surgery. (See "Abdominal hernias in continuous peritoneal dialysis".)

LIVING WITH PERITONEAL DIALYSIS

Chronic kidney disease is a lifelong condition that requires lifelong treatment. Peritoneal dialysis is one option for lifelong treatment, with other options including hemodialysis and kidney transplantation. It is sometimes necessary to switch from one form of treatment to another as circumstances change.

• Diet — People who undergo dialysis, both hemodialysis and peritoneal dialysis, are often required to make changes to their diet. In general, people who use peritoneal dialysis have a less restricted diet compared to those who use in-center hemodialysis. Dietary changes help to ensure that the body has an adequate, but not excessive, amount of protein and certain minerals.
  
  People who use peritoneal dialysis lose protein with every exchange, which usually means that they must eat an increased amount of protein in the diet. Protein is found in meat, milk, chicken, fish, and eggs; lower quality protein is found in some vegetables and grains. A dietitian can provide specific recommendations about how much and what type of protein is needed.
• Other changes in diet may include reducing the amount of foods eaten that contain phosphorus (found in dairy products, cheese, dried beans, liver, nuts, and chocolate) and sodium, and monitoring the amount of fluids consumed. (See "Patient information: Low sodium diet (Beyond the Basics)".)
• Weight gain — Weight gain can be a problem for people undergoing peritoneal dialysis because the dialysate contains a high concentration of dextrose, a type of sugar. The body absorbs some of this dextrose during the dwell, which can lead to weight gain. A dietitian can provide guidance on how to minimize weight gain by monitoring the number of calories eaten.
• Body image — The abdomen will enlarge slightly and may cause you to feel bloated when it is filled with fluid. You may need a larger size of clothing, and some people have a hard time accepting the change in their appearance. Patient support groups and websites can provide reassurance and tips for dressing. (See 'Where to get more information' below.)
• Activities and peritoneal dialysis — In general, people using peritoneal dialysis should limit physical activities when their peritoneal cavity is full (has a large volume dwell). It is still possible to exercise and participate in sports, although you should discuss your activities with your physicians.
• Time requirements — Peritoneal dialysis requires time and dedication, potentially interfering with other activities. This is especially true with CAPD, which requires the person to perform several exchanges during the daytime. Although it is possible to work and be active while using peritoneal dialysis, it may be necessary to cut back on responsibilities.

It is important to perform every exchange and dwell exactly as recommended. Skipping a treatment or performing a dwell for shorter or longer than recommended may increase the risk of illness and the chances of being hospitalized, and can even shorten the person's life.

If the demands of peritoneal dialysis feel overwhelming, or if you're having trouble performing all the necessary treatments, talk to a healthcare provider.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Peritoneal dialysis (The Basics)
Patient information: Chronic kidney disease (The Basics)
Patient information: Choosing between dialysis and kidney transplant (The Basics)
Patient information: Dialysis and diet (The Basics)
Patient information: Kidney transplant (The Basics)
Patient information: Planning for a kidney transplant (The Basics)
Patient information: Acute kidney failure (The Basics)
Patient information: Glomerular disease (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Dialysis or kidney transplantation — which is right for me? (Beyond the Basics)
Patient information: Hemodialysis (Beyond the Basics)
Patient information: Chronic kidney disease (Beyond the Basics)
Patient information: Constipation in adults (Beyond the Basics)
Patient information: High-fiber diet (Beyond the Basics)
Patient information: Low sodium diet (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Adequacy of peritoneal dialysis
Choosing a modality for chronic peritoneal dialysis
Clinical manifestations and diagnosis of peritonitis in peritoneal dialysis
Fungal peritonitis in continuous peritoneal dialysis
Indications for initiation of dialysis in chronic kidney disease
Medical management of the dialysis patient undergoing surgery
Microbiology and therapy of peritonitis in continuous peritoneal dialysis
Modalities for the diagnosis of abdominal and thoracic cavity defects in peritoneal dialysis patients
Noninfectious complications of continuous peritoneal dialysis
Noninfectious complications of peritoneal dialysis catheters
Pathophysiology and prevention of peritonitis in peritoneal dialysis
Placement and maintenance of the peritoneal dialysis catheter
Problems with solute clearance and ultrafiltration in continuous peritoneal dialysis
Tunnel and peritoneal catheter exit site infections in continuous peritoneal dialysis
Abdominal hernias in continuous peritoneal dialysis

The following organizations also provide reliable health information.

• National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

• National Institute of Diabetes and Digestive and Kidney Diseases

     (www.niddk.nih.gov)

• National Kidney Foundation

     (www.kidney.org)

• American Kidney Fund

     (www.akfinc.org)

• American Association of Kidney Patients

     (www.aakp.org)

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