Automated Peritoneal Dialysis {APD}

Ureter

Automated Peritoneal Dialysis

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Types of Dialysis

There are two main methods of dialysis that have become common in the treatment of ESRD patients. The first and most prevalent is known as hemodialysis. The second and less commonly utilized method is known as peritoneal dialysis. Though this website is concerned mainly with a method of peritoneal dialysis (hereafter referred to as "PD"), an overview and comparison will be given of hemodialysis as well but in less depth. What is most key about comparing the two treatments is their different impacts on patient life. Hemodialysis, though vastly more common than forms of PD, is actually ranked by most patients as the more disruptive and unpleasant of the two therapies, but due to a number of factors, many of which are historical or financial, PD is not the most common of the two therapies (the financial reasons are not typically so important from the patient's perspective but do come into play for the providers of care). The details of the two therapies are as follow:

Hemodialysis

In hemodialysis, patients must find the clinic nearest and most suited to them and come in three times a week to be dialyzed. The treatment works by mimicking the kidneys but outside of the body. First, the patient undergoes a minor surgery during which a fistula (blood circuit made surgically with a vein) is implanted between a vein and an artery to make a short blood access point that may be repeatedly punctured (alternatively, a Dacron or Teflon graft may be used but is considered by many to be inferior). After the fistula is in place, the patient can then begin treatments. What occurs is that the patient arrives and is seated in a chair or on a bed, and a needle is placed in the fistula in his or her arm. The blood then goes out through disposable tubing and through a machine. The machine is a pump that creates suction to pull the blood through its components by kneading the tube connected to the fistula. The blood then moves through a hemodialyzer.

o A hemodialyzer is a short plastic tube with many microtubules inside. On the inside of each of these microtubules, dialysate is run. On the outside, blood is run.

o Dialysate is a fluid composed like blood. Because its components (salt and sugar concentrations for instance) are the same as those essential to blood, and because they are in the same concentrations as in healthy blood, the dialysate fluid, which is free of toxins, provides a concentration gradient for the toxins but not for the molecules that must remain in the blood. In other words, the dialysate fluid is designed to attract the toxins while replacing the essential components in the blood for every amount that it accidentally takes.

As the blood flows by the clean dialysate fluid in the hemodialyzer, the toxins move out of the blood and into the dialysis fluid which is then discarded, much in the same way that urine is. Excess water in the body as well is drawn to the dialysate side of the circuit, and so that is removed as well.

The process takes 3-4 hours, the time of which is usually passed by doing any number of things including reading, watching TV, sleeping, or socializing. Many patients actually enjoy the social aspect particularly as they find a supportive group of people going through the same experience with them that they see on a regular basis. This is one of the strongest benefits to hemodialysis. The other strong selling point may also be the presence of a nurse administering the treatment and overseeing the process. Hemodialysis only requires that the patient show up whereas PD, for all its independence (which will be outlined below) may be viewed as intimidating for the level or responsibility of the patient who must administer their own treatments.

Disadvantages include the large quantities of time required out of the week for treatment and the higher peak value of toxins that occur when using hemodialysis (toxins get to a maximal point just before treatment is begun). Patients often report leaving dialysis clinics feeling greatly drained. They then feel better the next day, but as time goes on, they begin to feel worn down again as the toxins build back up. The cycle is described as being fairly rough.

Peritoneal Dialysis (PD)


http://australasia.renalinfo.com/relatedarticles/animation_related_hpdw.html

Inside of every person's abdominal cavity there lies a thin, moist sack known as the peritoneum inside of which is the intraperitoneal space. The membrane that bounds this space is heavily vascularized, meaning that it has an abundance of capillary blood vessels which are the very tiny, thin blood vessels where exchange of goods occurs between blood and cells. Though not much lies inside of the intraperitoneal space, the sac itself is easily expanded and may be filled with fluid.

The basic idea behind PD is that the intraperitoneal space, when filled with dialysate, does the same job that a hemodialyzer does, just more slowly. In PD a catheter, a small synthetic tube, is surgically implanted through the patient's abdomen as a direct outlet and inlet into the intraperitoneal space. In basic PD, this tube is used several times a day to exchange out old dialysate fluid for new dialysate fluid. In other words, the patient's intraperitoneal space begins functioning as though it were both kidneys and bladder, and the method of removing the urine becomes the catheter tube. Between exchanges, the fluid remains in the cavity.

PD does not require the same level of weekly trips to the dialysis clinic, and many companies that provide the equipment to do home PD will actually deliver dialysate bags to the patient's home. The process itself takes on average around 30 minutes per exchange and are typically done in a private place such as a living room or an office (if at work).

The main disadvantage to PD is the catheter tubing. Since access to the intraperitoneal space must be maintained, the catheter is, to some degree, a permanent open wound. Sterile techniques must be taught to the patients so that they do not introduce infection into their bodies when they do an exchange. Infection of the peritoneum is known as peritonitis and is the main disadvantage to PD (one case per 20-25 patient months). The secondary disadvantage is body image. PD patients must be careful that their catheter does not get hooked on anything but engage in all activities as normal, daily, exercise, or sexual. Self-consciousness can be an issue for some, though, at least initially, however for many it turns out not to be a bother.

CAPD VS APD

There are multiple types of PD. The first to be developed was CAPD, Continuous Ambulatory Peritoneal Dialysis. In this format, patients do exchanges throughout the day as described above. Typically, about 3-4 exchanges are made, one every 4-6 hours and an additional one overnight. This format requires timed exchanges during the day and the willpower to go through with them.

APD, Automated Peritoneal Dialysis, on the other hand, is a different format where a patient uses a machine at night to do the exchanges for them. This format does several exchanges of dialysate as the patient sleeps, thereby reducing patient technical burden and time sacrifice. Typically patients become used to being hooked up to their machine at night, and the machine itself is typically remarkably quiet. This format may also be viewed as being something closer to hemodialysis than the traditional CAPD as well since each unit of dialysate spends less time in the peritoneum thereby maximizing time efficiency. This works because concentration gradients are strongest at the beginning of equilibration. Going back to the field analogy. If you start the group out on one side of the field and tell them to start walking, more people will end up going to the vacant side of the field faster than if there was another, more diffuse group of people already on the vacant side. In the second case, the group already on the vacant side would bounce some of the members of the first group back towards the initial huddle. If you keep removing the more diffuse group, though, then one side stays vacant, and the exchange rate stays higher. Therefore, APD does overnight what CAPD does more gradually over the course of the day.

Equivalence of Therapies

Though the therapies differ by method, the current literature suggests that there is no demonstrable mortality or morbidity (causing other problems) difference from using one therapy format as opposed to another save for the differences cited above.

Upon being diagnosed, each patient should discuss in detail the advantages and disadvantages of choosing these different therapy formats

Automated Peritoneal Dialysis is the focus of this website because it is a technology that is underutilized but that has a great capacity for patient satisfaction while also featuring minimal impact on patient life. Since treatment is effected during sleep which is obligatory downtime, the patients' lives are less impeded by unwanted scheduling concerns while also benefiting from more of a uniform physiological state, the benefit being that they suffer fewer ups and downs.

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Patient with renal failure and raised intracranial pressure treated by automated peritoneal dialysis. At each cycle exchange, there was a marked reduction in the mean arterial blood pressure, despite resuscitation attempts with colloid and increasing pressure doses, resulting in a fall in cerebral perfusion pressure and eventual death from brain ischemia.

Bibliography

Pictures

  1. www.kidney.ab.ca/treatments/images/peritoneal.jpg
  2. www.renalresource.com/images/ipd08.jpg
  3. www.kidneyurology.org/Library/Kidney_Health/T..
  4. www.nature.com/.../ v56/n72s/images/4491261f2.gif
  5. http://images.google.com/images?um=1&hl=en&client=safari&rls=en- us&q=egg+%2B+dialysis+&btnG=Search+Images
  6. http://images.google.com/imgres?imgurl=http://www.indovacations.net/english/i mages/dialysis%2520and%2520kidney%2520transplant.jpg&imgrefurl=htt p://www.indovacations.net/english/medicare.htm&h=260&w=400&sz=77& hl=en&start=262&um=1&tbnid=MntNxh3v7BWPRM:&tbnh=81&tbnw=124 &prev=/images%3Fq%3Ddialysis%2Bnurses%26start%3D252%26ndsp% 3D21%26um%3D1%26hl%3Den%26client%3Dsafari%26rls%3Den- us%26sa%3DN
  7. com-med.ikalogic.com/.../1158616653Slide13.JPG
  8. www.bhrhospitals.nhs.uk/renal/images/renal1.gif
  9. www.freepatentsonline.com/7083719-0-large.jpg
  10. www.sclero.org/.../cycler-machine-full-204px.jpg
  11. www.nxstage.com/.../products/images/SL_back.jpg
  12. www.cartoonstock.com/.../cry/lowres/cryn41l.jpg
  13. www.scleroderma.org/.../kidney.jpg
  14. http://images.google.com/images?client=safari&rls=en- us&q=dialysis+patient&ie=UTF-8&oe=UTF-8&um=1&sa=N&tab=wi
  15. www.renalresource.com/images/ipd02.jpg
  16. http://images.google.com/images?q=dialysis+nurses&btnG=Search+Images&um=1&hl=en&client=safari&rls=en-us
  17. http://images.google.com/images?um=1&hl=en&client=safari&rls=en-us&q=dialysis+machine+&btnG=Search+Images
  18. http://kidney.niddk.nih.gov/kudiseases/pubs/peritoneal/images/Peritoneal.gif
  19. http://www.intelihealth.com/i/C/Cycler.gif
  20. http://www.leadershipmedica.com/sommari/2005/numero_04/medicina/quarteroni/
    articolo/foto/figura01.jpg
  21. http://www.dialysisoptions.org/images/pdPic02.jpg
  22. kentsimmons.uwinnipeg.ca/.../Kidney.jpg

Text sources

  1. http://www.davita.com/
  2. http://www.kidney.org/professionals/KDOQI/gfr_calculator.cfm
  3. http://www.kidney.org/professionals/KDOQI/gfr_calculator.cfm
  4. http://kidney.niddk.nih.gov/kudiseases/pubs/financialhelp/
  5. http://www.billpeckham.com/from_the_sharp_end_of_the/2008/02/dialysis-provid.html
  6. http://nephron.org/
  7. Ronco C, Amici G, Feriani , Virga G (eds): Automated Peritoneal Dialysis. Nephrol. Basel, Karger, 1999, vol 129, pp 1-14
  8. http://www.baxter.com/conditions/sub/renal_failure.html
  9. http://www.baxter.com/products/renal/peritoneal_dialysis/index.html
  10. http://renux.dmed.ed.ac.uk/edren/HistoryRRT.html
  11. http://www.ispd.org/history/genesis.php3

Diet:

Patients who chose APD instead of hemodialysis have a slightly different diet because the treatment is performed daily. Therefore, PD patients are less restricted in what they eat because the body does not buildup the same quantity of potassium, sodium and fluid. As with all dialysis patients, APD patients have a high protein requirement. However, PD patients in particular need a strong source of protein because protein is lost through the peritoneal membrane. Also PD patients are at a higher risk for infection that hemo patients and so protein is needed to keep the body strong. At the same time, though, Pd patients maintain normal to low potassium levels and so are encouraged to eat potassium rich foods such as tomatoes, orange juice and bananas. Phosphorous foods, on the other hand, need to be limited because phosphorous is not readily cleared by PD and may cause weak bones, heart problems, joint pain and skin ulcers if not managed via correct diet. All dialysis patients are required to monitor their sodium and fluid intake, however PD patients have the benefit of daily dialysis and so may have a more liberal diet in terms of sodium and fluid. Regardless, appropriate sodium and fluid intake must be determined by a patient's health care team. If a patient consumes too many salty foods the sodium will make the patient thirsty, which in turn causes increased fluid intake that results in swelling, shortness of breath and high blood pressure. Finally PD patients must remember that they are taking in additional calories through the dialysate. The solution contains dextrose, which is a type of sugar. In PD, the dialysate fills the peritoneum and sits for several hours until it is drained and exchanged with new solution. Mean while the body absorbs some of the glucose from the dialysate. Which can mean an additional caloric intake of about 500 per day. These extra calories add up and may cause a gain in solid weight. Hence dietitians may recommend that a patient eat slightly fewer calories to prevent excess weight gain.

So why is it important to watch what you eat?

A carefully considered diet will help PD patients feel good and will reduce the risk of potential health problems that are generally associated with kidney disease and subsequent dialysis. For example, Phosphorus is not cleared well through peritoneal dialysis and if this mineral builds to high levels in the bloodstream it can cause complications such as weak bones and heart problems and skin ulcers. Sodium increase causes your body to retain fluid, which raises blood pressure and causes discomfort and shortness of breath.

Your dietitian may recommend you eat fewer calories because of the dextrose that is present in the dialysate (the solution used in peritoneal dialysis). Your dietitian will coach you on an eating plan that will be in the right caloric range determined for your body type, health condition and level of activity so you can stay at a healthy weight. The diet will also contain nutrients to help one remain strong. While a patients diet may be modified as health conditions change, it is necessary that patients remain on a PD diet for the duration of their treatment. There is no specific way to make sure that a PD diet is effective; although, the patient should notice an improved appetite and energy level, better blood pressure and less swelling. Lab tests can also be used. Once a month, a doctor will test to see whether a patient is getting adequate protein by checking blood albumin level. Several times a year the doctor should order a peritoneal dialysis adequacy test to check the effectiveness of dialysis. This test includes normalized protein nitrogen appearance (nPNA), which also determines if a patient is eating enough protein.

A dietitian should also monitor health and conduct a nutrition assessment every year that looks for signs of nutrition problems, changes in weight and energy levels or any issues that are associated with diet. It is essential to remember that a patient's nutritional plan is customized to a patient's needs!

Unfortunately, diet is not a panacea. The PD diet cannot reverse kidney damage but it will help to promote effective treatment that keeps a patient feeling healthy.

Quick Tip: When eating vegetables make sure to "dialyze." This means that you soak certain vegetables, such as potatoes, to remove potassium. Peal and cut vegetables into small pieces, which you then soak in a large amount of water for 4 hours. Drain the water, add fresh water, and boil until vegetables are soft and tender.

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Recipes

1) How has dialysis evolved since you began to practice?

"Well, I have to say that I have been practicing since 1989, so that's quite awhile now and back in 1989 20%, maybe a little less. I'd say 15-20% of individuals in the united states with end stage renal disease were treated with pd. About 80% were treated with hemodialysis. Overtime, the last 13 to 18 years, the percentage of patients who are treated with pd has progressively decreased and currently that figure is around 11 or 12 %. In Rhode Islanders, actually, less than 5% are treated with peritoneal dialysis. The first major change is that the % of patients treated with peritoneal dialysis has decreased. In patients who are treated with peritoneal dialysis in the past a large number were on ambulatory dialysis were they would do the exchanges manually themselves without the use of automated machine and that has also changed and now although the number of patients on pd is smaller, virtually everybody is treated with some type of automated device. So those have been the two main demographic changes: smaller number of patients and then the shift in those patients treated with peritoneal dialysis to patients treated with automated rather than un-automated system." - Dr. Douglas Shemin

"It certainly has evolved quite a bit. The technical abilities of the machines that we use have evolved as you can imagine. There is to be done a lot of manual work with the dialysis machines but now we have a lot more software and they are much more efficient, so in that sense there has been a lot of progress. And then on top of that there ahs been a lot of progress just ion general medical care for our patients in terms of treating other problems like infections. There has been huge progress in general medical care since I have been practicing." - Dr. Jeffrey Clement

2) Why would you recommend hemo or ambulatory PD instead of automated peritoneal dialysis?

"Well, that's a good question actually. The first thing to start out by saying is that what I tell patients there is no and there never has been or will be a random device controlled trial in which patients are perspectively randomized to one form of therapy or another. so the information that we have about the treatment in patients that I have seen with end stage renal disease is all observational or anecdotal so right now we cant very well say which treatment is best. In the observational treatment that are there however, it appears that there is a mortality, that there is probably not a significant difference between therapies within the first year. The treatments are pretty even. As a matter of fact pd may even be a little bit better. But in virtually every observational trial, and again these are observational trials not randomized trials, there seems to be a mortality advantage, a lower mortality in patients who are treated with hemodialysis compared to peritoneal dialysis. So that's a little bit more support for hemodialysis - number one. Number two, hemodialysis basically . . . the point of dialysis is to do two things basically. Remove solutes, uremic waste solutes, byproducts of metabolism. That's one thing you do, and then the other thing you do is get rid of salt and water too. Now in hemodialysis both of those occur at the same time and you can increase the intensity of both solute removal and water or fluid removal that is by increasing the intensity of dialysis. You can make it longer; you can use large membrane, ect. And that in hemodialysis. In peritoneal dialysis it's a little tricky, however because what happens is, is than in peritoneal dialysis fluid enter the peritoneum cavity and it sits there and the longer fluid is associated with peritoneal capillaries, the greater the degree of diffusion of solutes that occurs. So after putting the fluid in, it sits there for 4 hours and you get some solute out. If it sits there for 6 hours you'll get even more solute out because there is more diffusion that occurs. The problem, though, is the longer the fluid stays in contact with the peritoneal capillaries, the smaller the amount of salt and water that is removed because salt and water is moved by an osmotic gradient not diffusion so the ability to get rid of salt and water directly relates to the difference in osmolality between the peritoneal fluids which have high osmolarity of glucose and the patient's fluid which is high in sodium for example. So a little bit the problem with pd is that its difficult to simultaneously increase removal of solutes and increase removal of salt and water and that makes it a challenge. And finally here have been some suggested goals in terms of how much solute to remove per patient per day or per weak in order to achieve what we call adequate dialysis. Ant that amount of solute is dependant on the patient needs. A larger individual obviously needs more solute removed. In very large individuals, which unfortunately there are many due to high rate of obesity, it is harder to remove solute on peritoneal dialysis. So these reason, although not terribly difficult, make pd a challenge for patients with E.S.R.D. And the finally, it may be harder if the patient is too late. Many patients are relatively adverse to a therapy where they have to play such a major role. Many patients prefer to have the therapy done for them and that makes it al little more difficult to prescribe of to patients if you will, so those are most of the reasons." - Dr. Douglas Shemin

"The patients have similar outcomes. They have similar morbidity and mortality rates. Its mostly a patient preference thing. Some patients prefer the peritoneal dialysis as opposed to the hemodialysis. They prefer the flexibility that it gives to them to do the treatment at home, by themselves, with the supervision of the doctor or nurse. So its mostly a life style preference. I find that some people who need to work chose APD because it gives them better control of their schedule." - Dr. Jeffrey Clement

3) If a patient is on APD, how does it alter your interaction with the patient or the role you play in the course of treatment?

"I don't think it alters the interaction, except a lot of times the patients have better satisfaction or more control of their own schedule and they prefer that, but I don't think the treatment type alters our interaction. " - Dr. Jeffrey Clement

4) Are patients reliable in terms of self-treatment? If not how do you deal with it?

"Well, its sort of a challenge but it's a self-selected group that uses pd. The pd patients are already interested in doing a lot of things themselves anyway. They are trying to do it because they don't want to go to a clinic three times a week; they are trying to do it because they like the idea of some autonomy. So already they are individuals who are interested in managing their health a bit more. And interesting this has nothing to do with things you may think about. It has nothing to do with standard of living or educational status. There are just as many people with 8th grade educations who live in slums in south providence who are very interesting in taking care of themselves and who are actually much more interested than people who may be educated or who may even have health care backgrounds. So in general it's a basic population that tends to be very proactive for their health care anyway. Usually, what a happens is that something interferes with their ability to do pd. Its usually some event that makes it more difficult to self treat so what happens is they become compliant or may lose interest. For example they become sick, have a stroke, something happens, one of their caregivers or a spouse becomes ill or dies, some catastrophe happens in their life that makes them less able to participate in their care. In my experience, its not so much that they lose interest in doing the procedure." - Dr. Douglas Shemin

5) In terms of running your practice, how does APD factor in? Does it make it harder or easier or is there no effect?

"For patients with peritoneal dialysis I schedule monthly visits with me, with the doctor, but there is significant interaction with our dedicated peritoneal nurses who often see the patient on a weekly basis. Where as the hemodialysis patients I will probably see once every one or two weeks. Where as for pd patients its once per month and general if there is a peritoneum problem that comes up. And that the same for any time of PD, automated or ambulatory. " - Dr. Jeffrey Clement

6) If the ultimate goal is transplant would you recommend APD over hemo or other forms of PD? Why or why not?

"Again it comes down to patient preference. In terms of ultimate goal of transplant, the treatments remains the same. " - Dr. Jeffrey Clement

7) Do you find APD to be as successful as hemo? And do demographics such as age race and gender influence your treatment suggestions? For example, do you people do better on APD than the elderly or vice versa?

"From a medical point of view it doesn't make a big difference in terms of patient outcomes in terms of which type of dialysis they get, whether they get pd or whether they get hemo-dialysis. So a lot of times it turns out to be patient preference. But there are some practical differences that do go into it a little bit. So one thing is that most of the pd is done by the patients themselves at home so even when they use these automated devices like the cyclers which relieve them of a lot of the responsibility of actually doing the pd, its still a lot more complicated for them than hemo-dialysis where they just go to a center and sit in a chair and the nurse or technician actually does the treatment. One issue is, are the patients really up to doing this themselves? So they need to be motivated and be able to learn the technique and want to do it. To take more responsibility for their own care, which some people are really willing to do. So that one factor. So because of that, they tend to be a younger, healthier group. People who want to be a little more autonomous, to have more person treatment, that don't want to be tied to be going to a dialysis unit three times a week. But isn't not really from a medical point of view that they need to be younger. It just patient selection for other reasons that kinds of drives them. Another factor that a bit of an issue is that in general pd is a little less efficient than hemo-dialysis and so it has to do with how much dialysis people need and providing enough to keep them well. Its very easy with hemodialysis to provide a lot of treatment in a relatively short amount of time. It a little more difficult with peritoneal dialysis. So some times, for example, if you have very large people, man or woman, and more often then not it turns out to be very big men, where there is a lot of muscle mass it may be a littler harder to do enough dialysis with pd. But that's not usually the limiting factor. Usually it can be done from a technical point of view but sometimes it can play a role in chosen treatment." - Dr. Lance Dworkin

8) During your residency or your time as a physician, how were you trained to use APD and how does your training influence your treatment suggestions? In other words, why one over the other?

"Practice patterns and physician preferences also certainly have an impact on this and also probably the relative availability of hemodialysis has an impact on this. So it certainly is the case as you go around this country and if you compare how E.S.R.D is treated in different countries, the percentage of patients that are on hemo versus PD is very different. If you go from community to community, or within a community from doctor to doctor and certainly from country to country. So in this country in most places the vast majority are on hemo. The number of patients on pd is much lower. Physicians are more used to taking care of patients on hemo now days unless the physician is particularly enthusiastic about it. It is interesting, if you go to a country like Canada which really isn't that different from the United States in terms of what people are like or the types of disease that they have that cause kidney failure or even the type of medical education that patients get and you look at they types of treatment, there is a difference. In Canada 50% are on PD whereas in this country its probably less than 5%. One of the factors responsible for that is that there just aren't so many hemo units in Canada as there are in the U.S. Here, for the most part, hemodialysis is a for-profit business where big companies that manufacture the equipment actually own and operate the units. So there is some economic incentive it, I think, that sometimes causes one to treat people with hemo. In Canada, where everything is paid for by the government, they just don't have as many units so patients with ESRD may not be able to get a slot in the unit. Here in the United States, in most communities there are far many more slots for hemo than there are patients. Its certainly true in Rhode Island, where there are twice as many slots as there are patients. So if you are a dialysis patient and you want hemo you can very easily find a place that can do it for you. Whereas if you are in Canada, you might not have that option so there is more incentive to go on PD. There are a lot of factors for one treatment over the other: there are economic factors, factors of health insurance, social factors availability factors that all influence the type of treatment used." - Dr. Lance Dworkin

9) Have you ever dealt with cases in which the adverse of effects of APD on the peritoneum cause major health concerns? If so what would be a few?

"There have definitely been cases over the years. In fact, we have had to stop peritoneal dialysis and switch it to hemodialysis because the peritoneum was not working as they years went by or due to peritonitis, so yes, I have definitely seen that in several cases. At the same time, I have had other cases in which the patients have been successfully treated by peritoneal dialysis for many years. As a matter of fact I did just switch a patient who had been on peritoneal dialysis for several years to hemodialysis because her peritoneum was not working that well anymore due to treatment effects. " - Dr. Jeffrey Clement

10) What do you feel about the equipment used to do APD? What's good and what needs improvement?

"The equipment is easy to use. The way pd works is it uses the peritoneal cavity, an internal body cavity. What you do is insert a dialysis catheter into the space and the patient connects the tube to a machine which makes exchanges. There are a lot of bags of dialysis fluid that are hung on the machine which automatically runs in a certain volume of fluid, usually about 2 liters. It lets it sit for a a while and drains it out and then repeats the procedure multiple times during the night while the patient is sleeping. What the patient has to do is start up the machine and hang up big bags of fluid and make connections by basically spearing tubes into bags and then make the connection between the tube the runs from the machine to the tube that runs into the abdomen. Its not really that complicated. Its something that people can be easily trained to do and so its not that difficult. One of the critical aspects of it is that it has to be sterile because otherwise you can introduce bacteria into the fluid, which can produce infections in the peritoneal cavity, which is one of the more common complications that people get when they are undergoing PD. But its not that difficult. Usually any body who is a reasonably careful person, you don't need a college educated person or anything like that, can do it. The programs are set up so that there are nurses who train patients and who can observe them until they understand what they are supposed to do." - Dr. Lance Dworkin

11) What drugs do you most often prescribe to go along with APD and what do one of 2 of them do?

"A lot of the PD drug treatments are similar to hemo. A lot of the drugs these patients are on are designed to treat the complications of renal failure that really aren't addressed by dialysis. So dialysis provides some of the things that people with kidney failure need. So it's a way of removing some of the fluid that accumulate in the body, of removing some of the solutes and wastes that build up in body that the kidney would normally excrete. But other things that are not removed so well or conditions that are not treated perfectly still require drugs. For instance one problem of people with kidney disease is a problem with calcium and phosphorus metabolism and then the production of one of the hormones in the body, parathyroid hormone, which regulates the concentration of calcium in the blood. So in end stage renal disease people have problems excreting the phosphorous that you get from eating proteins. That's something that is not removed adequately by dialysis. So people take medications to prevent the phosphorous in the diet from being absorbed. They take medications to supplement the amount of calcium in the body and they also often take vitamin b which is really a kind of a hormone that is involved in regulating calcium and phosphorous metabolism that the kidney makes, which is not produced in adequate quantities in patients with ESRD. So those are a few of the medication. Another hormone that the kidney normally makes is erythropoietin, which stimulates the production of red blood cells. So what happens in kidney failure is that production of the hormone go down and most of the patients become anemic, they have a low blood count, and they need to take erythropoietin as a drug to replace what kidney would normally do. Pretty much almost all end stage renal disease patients are on that regardless of the type of dialysis treatment. There are other types of problems: most people with chronic kidney disease have high blood pressure and they need to take medications to control blood pressure. The most common cause of ESRD in the united states is diabetes. About 40-50% of all dialysis patients are diabetic so they may need to take medications to treat diabetes. So the average patient actually ends up on a lot of medications in addition to needing dialysis. It not unusual to have people on 5,6,7,8,9,10 prescription medications in addition to their dialysis treatments in order to treat associated conditions. And there aren't huge differences in most of these things between people on hemodialysis or CAPD. They are mostly similar." - Dr. Lance Dworkin

Side Effects of PD

Weight Gain

During dwell time, the peritoneum can allow glucose to pass to the blood vessels where it is absorbed into the body. Because glucose is a sugar, weight gain and a rise in sugar levels can occur.

Bloating

Patients carry fluid in their abdomen during the day, which can cause bloating in the abdominal area. Sometimes the abdomen may appear distended and patients may feel discomfort

Risk of Infection

The PD catheter is a passageway through which germs can enter the body. The catheter, a soft, straw-like tube is positioned both inside and outside of the body to allow dialysis solution into and out of the abdominal cavity The skin surrounding the catheter site is at particular risk for infection. Patients must maintain excellent hygiene to limit exposure to infection. Washing hands before and after handling the catheter and using a local antibiotic cream reduces the risk of infections. Wearing a face mask will prevent germs from the nose and mouth from having contact with the catheter. The skin surrounding the catheter should be inspected for any signs of infection. Activities such as as swimming or soaking in a tub should be avoided because they increase the risk of infection. Peritonitis can cause fever, nausea, vomiting and stomach pain.

Hernias

The muscles of the abdominal wall protect the internal organs. Insertion of a catheter can weaken these muscles and the pressure from the dialysis solution in the peritoneum pushes against these weak muscles during exchanges. This pressure can cause a tear, and organs from the abdominal cavity can push through the opening.

Nutrition

Some PD patients find eating uncomfortable, because of the full feeling from the dialysis solution in their stomach area.  This can lead to malnutrition.

PD is well-tolerated by most people and serious side effects are rare.

6

Other questions:

Does dialysis hurt? The treatment itself does not hurt. In hemodialysis the needles may cause pain along with painful muscle cramps. In peritoneal dialysis (PD), abdominal pain can be a sign of an infection called peritonitis. Some people on PD with a cycler machine sometimes experience pain at the end of a drain cycle.

Feeling better? While some people notice an almost immediate result, others notice a difference after a few months.

The best sign that you are receiving appropriate dialysis is that you feel well and look healthy Patients should also have a good appetite.

Consult a doctor if . . .

In PD, dialysis dose can be raised fairly easily by either using larger bags during exchanges or by doing exchanges more frequently.

Patients on APD are able to control their schedules which allows them to control their schedules, keep a job and maintain health insurance. These patients must:

ESRD: An Introduction

22

End Stage Renal Disease (ESRD) is a functional name for progressive and chronic deterioration of kidney function brought on most commonly by diabetes, hypertension, or autoimmune attack (glomerulonephritis) that occurs in roughly 1 individual in every 3000 per year (For more on the causes of ESRD, see the section below). The disease is divided into five stages of progressively worse kidney functioning at the beginning of which a patient may be asymptomatic (stage 1) despite declining function of his kidneys. By stages four and five, though, symptoms become severe, and the condition is fatal if proper treatment is not administered.

To understand the problems presented by ESRD, it is useful to think of the body as a fine machine. In fact, it is not only fine, it is a hugely complicated machine that may be viewed as an integration of functional systems each with a very specific and important purpose, and as such, these systems exist to rely on one another as a larger whole. The kidneys perform several functions vital to this integrated whole but the most important of which is the cleaning of the blood to remove wastes. The body produces byproducts of its functioning that must be expelled in order to maintain a state of equilibrium known as homeostasis. When a person eats, (s)he takes in metabolites. This fuel is what allows the body to move (like gasoline in a car) or to repair itself or even to send messages from the appendages to the brain (information like temperature). A person's body uses its food intake as best it can and then discards what cannot be used or what no longer serves a purpose. Much of these byproducts end up in the blood.


http://www.kidney.org.au/flash/dialysis_animation/dial.html

Blood, for its part, is a complicated fluid full of different components vital to the body's functioning. It is useful to think of the blood vessels as the highway system inside of a person and the blood itself as the cargo that must be carried along these roads in order to maintain life. If a cell in a toe needs food or oxygen, the blood is what carries these things to it. The blood not only serves this function but another as well, though. It is also responsible for carrying away the waste products from the cells, but where do these go?

Much of the body's waste ends up being filtered out of the blood by the kidneys, which may be thought of as a complex system of filters and pipes that regulate the body's excretion. When the body has too much water, the kidneys are instructed to filter some out (1.5 Liters per day on average), and when the body has too much salt, the kidneys are what remove the excess. As for metabolite waste, about 20 grams of urea, a molecule that largely comes from the metabolism of protein, is removed as well. Urea is typically measured in BUN (blood urea nitrogen), a quantity that is, by definition, half of the urea content (20 grams of urea is 10 grams of BUN). What happens when this functioning declines or stops altogether, though?

Uremia is a term that refers to the effects of increased levels of toxins in the blood. When the filtration rate of the kidneys drops below 50%, patients begin to experience loss of appetite and lethargy. As functioning tapers off even further, these symptoms become more severe and may also include nausea, vomiting, decreased cognitive functioning, coma, and eventually death. The last symptoms occur mostly as the patient moves into stage five of ESRD.

The cause of these symptoms is increased concentrations of toxins built up in the blood without removal, which interferes with the cellular processes vital to life. In order to function properly, homeostasis must be maintained because the concentration gradients themselves are important.

A useful example of why this is true is to imagine yourself as a cell. If you are a cell, and you need food which is going to be delivered by somebody, and it cannot be brought to you because there are too many obstacles in the way, then you run the risk of going hungry and dying. The same is true with a cell and its ability to metabolize food. If the concentration gradient becomes unfavorable (meaning that if anything becomes an obstacle due to there being too many of it in the way), then proper functioning ceases. This principle is why homeostasis is essential to maintaining life.

So what happens to ESRD patients? The answer is dialysis, a general name for any of several processes by which the blood is cleaned by a biotechnology that functions in the place of the kidneys. Though the methods of treating the blood differ, the treatments themselves all rely on a very basic scientific principle, diffusion.

Diffusion is the physical principle used by the kidneys to treat blood. Simply put, it is the principle that high concentrations of a molecule tend to move to areas of low concentration. Anyone who has ever seen food dye dropped into a glass of water knows that eventually the die will spread out until it is uniform in the glass. This state of uniformity is known as equilibrium. A thought experiment is useful to envision why this is true. Think of yourself standing on a football field with many blindfolded people, all of whom have been instructed to walk. Chances are that they will not move inward so that they all end up walking into one tightly packed huddle. Due to random chance, many of them will end up walking in different directions, and if they should run into one another, they will bounce off and end up switching directions so that they spread out more evenly. Molecules behave in this way. Temperature is a measure of the violence of molecules jiggling (walking), and as they meet one another, they ricochet off in other directions. Thus, diffusion occurs (this also explains in part why the body must maintain a temperature of 98.6 degrees Fahrenheit).

7

Technical Definitions of ESRD

GFR is the most common way to measure kidney functioning. GFR stands for Glomerular Filtration Rate. The glomerulus is a functional part of a nephron which is, itself, one of the many microtubules in the kidney where the sorting out of waste products from regular blood content is performed. There are more than a million nephrons in each kidney. The GFR is determined by measuring urine content of two primary molecules which have been determined as good estimations of filtration. These are urea and creatinine.

Clearance is a proportion of how much of a given molecule appears in the urine (is cleared out of the blood) relative to the actual concentration of this substance in the blood. GFR is a measurement of clearance. It is interesting to note that clearance naturally declines in individuals who are healthy (without Renal (kidney) disease) by about 10% (of the remaining value) every decade after the age of 30.

Stages 1-3: Ranges from a GFR of greater than 90 mL/ min/1.73 meters squared down to 30 mL/ min/ 1.73 meters squared. At less than 25 mL/min, toxins begin to be noticeable in blood chemistry tests

Stage 4: GFR of 29 down to 15 mL/min/1.73 meters squared

Stage 5: Less than 15 mL/min/1.73 meters squared of GFR. This is kidney failure. Patients become overtly symptomatic and require dialysis treatment.

8

How does automated peritoneal dialysis work?

9

It is actually uses a very simple mechanism that has not changed in decades.

The earliest peritoneal dialysis was done using a container of dialysate that was transferred to the patient via direct line, a catheter inserted into the peritoneal lining. The container was kept above the level of the patient, so gravity could do all the work. When the container was empty, it would be moved to the floor so that gravity could help with drainage.

While effective, this method required constant supervision and a nurse to move or change the container every 35 to 40 minutes.

In 1962, Boen et al. developed an automatic cycling machine. It used electric circuits and timers to open and close valves leading to both the dialysate and the drainage bottle. It did not require the presence of a technician the whole time.

It begins with a bottle of unsterilized dialysate, which is then sterilized and put under pressure so that it can be forced into the patient's peritoneal cavity. A vacuum then removes the spent dialysate from the patient and it is carried into a spent dialysate tank, where some of it is discarded and the rest is added to unsterilized fresh dialysate, and the cycle begins again. The cycler was inexpensive and fairly easy to use, making it an advantageous source of dialysis.

Here is a simplified drawing of the cycler:

APD cyclers have only been modified since then. Pressure monitors can accurately regulate the system and optimum intraperitoneal volume can be maintained. Now, memory cards can be used to incorporate the patients prescription and history to further prevent error. The system has also become interactive and easier for patients to use.

Many companies sell peritoneal dialysis supplies, competing to distribute equipment that is:

Some companies that sell devices specifically for peritoneal dialysis internationally are:

The supplies that must be in constant supply for an APD patient include:

10 11 12

Sources: Ronco C, Amici G, Feriani , Virga G (eds): Automated Peritoneal Dialysis. Contrib Nephrol. Basel, Karger, 1999, vol 129, pp 1-14

Formulae Associated with Automated Peritoneal Dialysis:

G (Urea Generation Rate) = (.11 x DPI (Dietary Protein Intake) - .12) = mg/min

DPI (Dietary Protein Intake) = 1 mg per kilogram of body weight per day

Clearance = (CD x VD) / (CB x T)

CD / CB = D / P Urea D/P=1 at 6 Hours Creatinine D/P=.75 at 6 Hours VD=entered by subject in ml T= entered by subject in min

CB = G / (KR + KD) = Concentration in Blood in mg/ml KR = Residual Renal Clearance ml/min = 0 ml/min for ESRD Patients KD = Clearance of Dialysate ml/min

Since CD / CB = D / P = 1 then CD = CB

Urea Removal = CD x VD = grams

VERY LARGE file - 18 frame continuous animation of the kidney dialysis process - showing only urea and other small molecules passing through the dialysis membrane - see if you can spot the join!

http://biotopics.co.uk/human2/andial.html

Caloric Intake Calculations:

Assume a 2.5% solution of glucose you would have approx. 2.5g/100ml (2.5g/100ml) x VD= g of glucose 60% is absorbed Grams Glucose x .6 = Grams absorbed Calories= (4.1kcal/g) x Grams Absorbed = kcals

Urine Production Decrease per Month:

There is approx a 10% decrease in urine production per month in end stage renal patients producing 500ml/day. Concentration Final=C Initial x (.90) Months

The following are Calculators for GFR and Clearnance:

GFR: http://www.kidney.org/professionals/KDOQI/gfr_calculator.cfm
Clearnce: http://www.kidney.org/professionals/KDOQI/gfr_calculator.cfm 13

Other Websites:

Some interesting case studies:

http://www.blackwell-synergy.com/doi/pdf/10.1046/j.1525-139X.2002.00095.x

Title: Utilization of PD Modalities: Evolution
Authors: Vijaya Venkataraman and Karl Nolph
From: Automated Peritoneal Dialysis Symposium

http://www.springerlink.com/content/td059ybcggm6wm9c/fulltext.pdf

Title: Icodextrin re-absorption varies with age in children on automated peritoneal dialysis
Authors: Allison Dart · Janusz Feber · Hubert Wong · Guido Filler
Received: 7 July 2004 / Revised: 12 November 2004 / Accepted: 12 November 2004 / Published online: 18 February 2005

http://www.nature.com/ki/journal/v70/n9/full/5001808a.html

Title: Adequacy of automated peritoneal dialysis with and without manual daytime exchange: A randomized controlled trial
Authors: D Demetriou1, A Habicht1, M Schillinger2, W H Hörl1 and A Vychyti
Kidney International (2006) 70, 1649–1655. doi:10.1038/sj.ki.5001808; published online 6 September 2006

Paying for your End-Stage Renal Disease Treatment

image

The stresses associated with deciding which ESRD treatment option will best suit your physical, temporal and lifestyle constraints are stressful enough without having to worry about the big question. How I am going to pay for everything?

Rest assured that your ESRD treatment will not leave you destitute and financially ruined in the United States due to a legislature signed into law by congress in 1972 concerning ESRD treatment. By this law, your ESRD treatment costs will be taken care of by Medicare up to 80% of total cost and in some cases the additional 20% can be paid for by Medicaid or your own private insurance.

The following are basic eligibility requirements for Medicare coverage of your ESRD.

  1. You have been diagnosed by a physician as having ESRD and require dialysis.
  2. You have been selected for a kidney transplant for ESRD.

The following are also required financial requirements.

  1. You must have either paid into social security through legally working under a valid social security number.
  2. You may have worked as a federal, military or railroad employee.
  3. You must be receiving social security or retirement benefits.

Note: Each case has its own set of circumstances and you should be in contact with a social worker or VA administrator (if you are a veteran). Only a proper official can determine whether you qualify for Medicare or VA benefits for you ESRD treatment. If you are a retired military member you should be completely covered by Tricare and will incur absolutely no cost to you or your family.

What does Medicare pay for and what are differences between Part A and Part B?

You can sign up for Medicare with a CMS-43 form (Application for Health Insurance Under Medicare for Individual with Chronic Renal Disease). Your local Social Security office and some dialysis clinics have this form.
When the time for dialysis comes, you will be asked to fill out and sign a CMS-2728 form that tells Social Security that you started dialysis. If you start home dialysis training in your first 3 months of dialysis, Medicare will start paying on the 1st day of the month you started dialysis. Otherwise, there is a 3-month waiting period before Medicare will start.

  1. Part A pays for hospital care, including transplant. Part A is free if you have worked enough time and paid into the Social Security and Medicare trust funds. If you are 65 or older and have not worked enough, you can pay a premium to get Medicare Part A.
  2. Part B pays for doctors and outpatient care, like dialysis. There is a monthly premium for Part B. Social Security takes the premium out of your monthly Social Security checks. If you don't get a Social Security check, you will get a bill every 3 months to pay Medicare Part B premiums. Remember you must pay your premiums to keep your Medicare benefits.

What if I have Private Insurance?

If you have a health plan, it will pay first and Medicare will pay second for 30 months from when you could have Medicare (the "coordination of benefits" period). When you start home training and home dialysis during this 30 month period, your health plan pays first and Medicare pays second. So, if your health plan does not pay the whole charge, your clinic can bill Medicare for the balance. After 30 months, Medicare will pay first and your health plan will pay second.

Be sure that your clinic or any home dialysis supply companies you choose to work with accept Medicare assignment. This means they will bill Medicare for you and they agree not to bill you for any cost that is over Medicare's allowed charge.

How are training and supplies paid for?

Medicare will pay for up to 15 days of training for either CAPD or APD, and most people learn how to do them in a week or two. In some cases, Medicare will pay for more days if your doctor provides a good reason (e.g., you are handicapped)
Medicare covers PD supplies such as:

  1. A PD machine
  2. Manual blood pressure cuff and stethoscope
  3. Dialysate heater
  4. Dialysate solution
  5. Tubing
  6. Supplies such as gloves, syringes, tape
  7. A start-up kit that includes such things as a scale, thermometer, scissors, clamps, etc., if it's charged as part of your dialysis equipment
  8. For further information, the following sites are of good reference.

Past, present and future – a timeline!

Year

Discovery

1913

Abel, Rowntree, and Turner devised an apparatus for the dialysis of blood.

1943

Kolff and Berk developed the first clinically successful hemodialyzer.

1948

Skeggs-Leonards developed the parallel plate dialyzer, utilizing countercurrent flow of blood and dialyzing fluid.

1956

Travenol developed the first twin-coil disposable dialyzer unit.

1956

Hollow fiber kidneys were developed in the United States.

1956

Gambro began production of disposable parallel plate dialyzers in Europe.

1960

Kiil developed a simpler countercurrent flow method with parallel flow.

source

http://www.shodor.org/Master/biomed/physio/dialysis/hemodialysis/fivea.htm

14

Thomas Graham, Chairman of Chemistry at University College, London, first discovered the idea of selective diffusion or "Dialysis." meaning "loosening from something else" in Greek.

Early stage dialyzers consisted of cellulose tubing wrapped around a small drum that was then partially emersed in a bath of dialysate that dialysate consisted of a saline solution.

The the drum was hand cranked, and the blood was propelled through the cellulose tubing

Today, dialyzers employ motors to pump the blood and dialysate. Maintaining pressure of the blood in the veins is the job of microprocessors. Transducers maintain a constant pressure across the body and dialyzer. The blood and dialysate flow through plastic composite tubing. The dialysate is a mixture of sodium chloride, sodium bicarbonate or sodium acetate, calcium chloride, potassium chloride, and magnesium chloride.

A more detailed timeline from http://renux.dmed.ed.ac.uk/edren/HistoryRRT.html

Milestones in the development of modern haemodialysis

1861

The process of dialysis was first described by Thomas Graham (Glasgow) More

1913

Artificial kidney developed - John Abel (Baltimore) More

1924

First human dialysis - George Haas (Giessen) More

1943

Rotating drum dialyzer - Kolff and Berk (Kampen) - the first practical dialyser More

1946

Coil dialyzers - George Murray (Canada), Nils Alwall (Sweden; more)

1946-7

First dialyses in Britain - Bywaters and Joekes (Hammersmith); Darmady (Portsmouth)

1948

Kolff-Brigham machine. As used in the Korean war for acute renal failure

1955

Twin coil dialyzer - Watschinger and Kolff More

1956-7

Dialysis recommenced in the UK in Leeds (Parsons), London (Shackman) and RAF Halton (Jackson) Report from Edinburgh on these centres in 1958

1960

Kiil dialyzer (Oslo) Picture

1960

Scribner shunt (Seattle) More

1960

Clyde Shields (d1971), Harvey Gentry (d1987) commenced haemodialysis in Seattle - the first long-term dialysis patients Read a contemporary account

1961

Dialysis using a domestic washing machine (later leading to the Maytag program in Cleveland; Nose, Japan) More

1964

Home dialysis introduced by Shaldon (London), Scribner (Seattle), Merrill (Boston) More

1965

Hepatitis outbreaks in the UK More - hepatitis in Edinburgh, 1969

1966

Internal AV fistula developed - Brescia, Cimino (New York) More

1972

Aluminium toxicity More

1975

Haemofiltration introduced (Henderson, Quellhorst)

1977

Continuous arteriovenous haemofiltration described

1981

Dialysis-related amyloidosis described

1986

Recombinant erythropoietin introduced

Milestones in the development of peritoneal dialysis

1744

Peritoneal lavage undertaken by the Rev. Stephen Hales

1877

Experimental studies of the peritoneum

1923

First human peritoneal dialysis - Ganter

1946

Treatment of acute renal failure by PD - Frank, Seligman, Fine (Boston); Reid (UK); Tanret (Paris); Kop (Netherlands) More

1959

Intermittent PD - Ruben and Doolan (Oakland, CA)

1964

Repeated puncture method introduced More

1965

Stylet catheter (Trocath) introduced

1968

Tenckhoff catheter introduced

1976

CAPD describe - Moncrieff and Popovich (Austin, Texas) More

1981

CCPD

Milestones in kidney transplantation

1933

First human renal transplant (unsuccessful) - Voronoy More

1936

Histocompatibility antigens described in mice - Snell

1944

Accelerated rejection of a second transplant described in rabbits - Medawar

1954

First successful human renal transplant, between identical twins - Murray and Merril (Boston) More

1962

First successful cadaver transplant and first use of azathioprine - Murray and Calne More

1962

Second use of azathioprine - Edinburgh's third renal transplant More

1965

Tissue typing using white blood cells - van Rood/ van Leeuwen, Terasaki

1976

UK brain death guidelines facilitate retrieval from heart-beating cadaveric donors

1983

Cyclosporine licensed as new immunosuppressive drug

PD in particular

(Source: http://www.ispd.org/history/genesis.php3)

The past

The Present

The Future

Going onto any form of dialysis can be stressful and will alter a patient's daily life. The treatment does not only affect the patient, though. Caregivers for young and older patients also experience a wide range of emotions. Both patients and care providers must be well educated in terms of their treatments so that they can better deal with the emotional aspects of renal failure.

Quality of life on dialysis image

Quality of life is subjective. When faced with chronic kidney disease and life on dialysis, many people fear each day, because they realize that life will eventually come to an end. Dialyses patients must continually remember just what it is that makes life worth living and they must live between treatments instead of from one treatment to the next.

To gage an understanding of quality of life a patient can ask the following questions:

15

It is important to remember that dialysis is a lifestyle change that takes some getting used to. New patients, regardless of what type of treatment but particularly hemo patients will feel physically tired and will need to adjust their lifestyles to incorporate treatments. However, as treatments progress blood should be cleaner, anemia should be treated and patients should have more energy and should begin to feel better.

Schedules and treatment success (both mental and physical)

While hemo patients generally go to a center for four hours, 3 times per week, PD patients require daily treatments. APD patients, generally have the most flexibility in their schedules because treatment is usually performed at night while the patient is sleeping. It is absolutely essential that patients do not skip or shorten treatments unless otherwise told to do so by their doctor. Scheduling appointments with the doctor and speaking up when need be are key ingredients to a successful treatment. Working with a dietitian, being active and remembering to take prescribed medication is key!

Correct diet and exercise also have a mental benefit. Dietitians can help with food plans and doctors and social workers can provide information about exercise opportunities. Patients who are educated about kidney disease, treatments and what to expect are generally better prepared to face obstacles and can make better treatment choices.

Remember: Patients will need to plan their week around peritoneal dialysis schedules. Patients may have to take time off work or school before starting peritoneal dialysis and when the treatments begin. When a patient's health has stabilized he or she should be able to return to normal daily activities. Of course, this depends on energy levels and some adjustments in work or activities may need to be made.

Just a thought: travel! image

old lady21

Traveling is easy on peritoneal dialysis and exchanges can be performed almost anywhere as long as it is clean. Patients need to arrange transportation for supplies, including dressings and the cycler. Supplies can be carried as luggage, checked with luggage or shipped ahead. Some companies will deliver supplies to the intended destination. For more information patients should consult their healthcare team and local Kidney Foundation office, which can provide information concerning travel costs and arrangements.

Social Workers' Suggestions for an active mind and spirit:

Resources:

Interviews:

16

Risks Associated With APD

Serious side-effects and risks associated with Automated Peritoneal Dialysis are rare, but they are of use to consider. Most are very minor and can be managed easily.

APD Fluid:

While each individual patient may have different responses, it may be advantageous to customize the dwell time of the solution used in peritoneal dialysis.

APD involves mechanically automated changes of the solution three to five times per night. The number of times can be adjusted depending on your need. In the morning, you will perform one exchange that usually lasts the entire day. However, some risks that may be associated with this treatment are excessive dwell time in the peritoneum and inefficient waste removal. Although it is natural for some dextrose in the solution to be absorbed in the body, too much may lead to increased fluid uptake. To resolve this problem, another exchange mid-day may be necessary, preventing immoderate dextrose and fluid uptake, while providing fresh solution for proper waste removal.

Thus, your doctor can customize your treatment by increasing/decreasing the number of exchanges per day, increasing/decreasing volume of dialysis solution, or by adding a mid-day exchange.

19

APD Catheter:

In preparation for Automated Peritoneal Dialysis, a soft catheter will need to be placed in your abdomen to transport the fluid. This surgery can be performed under local or general anesthesia, which may involve certain risks. The surgery involves cutting small slits in the skin and underlying tissue, including the peritoneum. After a short period (usually a couple weeks), scar tissue will form.

The risks associated with anesthesia are uncommon, but they vary depending on your age, health, and personal response to anesthesia. Certain pre-existing health conditions, such as heart or nervous system problems, may pose an added risk to anesthesia. These concerns should be addressed by your doctor. Local anesthesia can cause great risk due to its toxicity at high doses. Appropriate medical care should be on hand to deal with such problems. General anesthesia may involve inserting an endotracheal tube to prevent aspiration of stomach fluids into the lungs. This may cause some respiratory problems or muscle spasms, high blood pressure, and increased heart rate. Other risks may include heart attack and stroke. However, death due to solely to anesthesia and not other surgical complications is very rare. In addition, "awareness" during anesthesia, or incomplete unconsciousness, is very rare and much is done to monitor and prevent this from occurring.

Infection of the catheter is the most common problem and risk associated with APD. It is of greatest concern to keep the catheter free from bacteria. There has been some advancement in catheter design to avoid bacterial infection, however infection is still a problem. There are certain preventative precautions that should be observed. If not, complications such as peritonitis (infection of the peritoneum) can occur and make APD treatment no longer possible.

It is important to follow all instructions given to you by your doctor and health care providers to prevent infection. Some of these may include:

If you experience any problems with your catheter or have symptoms of infection, including nausea, vomiting, diarrhea, fever, pain (especially around catheter), or notice an unusual color of fluid, report to your health care official immediately to resolve the problem.

APD and Kidney function:

The kidneys function in many important roles of hormone and chemical balance. Loss of function may cause problems such as anemia (low red blood cell count), which explains fatigue and some heart problems. Erythropoietin (EPO), a hormone produced by the kidneys that helps in red blood cell production, may not be produced in an adequate amount by a diseased kidney. Commercial EPO can be given to patients on dialysis to counteract this deficiency.

Itchiness of skin (Pruritus) may be experienced by those on peritoneal dialysis, due to toxins in the blood that are not adequately removed. There is no one effective cure, but caring for dry skin is important. In some cases it is related to increased parathyroid hormone. As a result, some have their parathyroid glands removed. Others may improve with EPO, antihistamines, UV light treatment, or various creams.

Bone disease can also occur, due to lack of calcium and phosphorous in the blood. This is especially serious in growing children and older patients, who are at a high risk of osteoporosis. This risk can be monitored by your doctor and can be addressed through proper diet, medication, and exercise.

Some patients on APD treatment may suffer from insomnia and even apnea (breaks in breathing). This can greatly affect the quality of life, as it leaves many drowsy during the day, and causes headaches and depression. Aching or restless legs can also affect a good night's rest. Your health care team may suggest exercise during the day, losing weight, changing sleeping position, a nose-air mask (nasal continuous positive airway pressure, CPAP), or medication.

APD and You:

As you have read above, much success of APD depends on you. You must be constantly alert to any changes or complications in the catheter, solution, etc. Your taking preventative measures, too, will also aid in the success of APD. By maintaining a proper diet, you can improve your APD and overall health. Follow the suggestions of your dietician. If you feel depressed, talk to your health care providers, and they can assist you in dealing with depression. One of the greatest problems and risks can be compliance – when a patient does not follow the instructions given by the doctor and health care team. By skipping any treatments or exchanges, this puts you at risk of hospitalization and death. Please recognize the great responsibility of APD and follow all procedures and precautions.

Sources:

http://kidney.niddk.nih.gov/kudiseases/pubs/peritoneal/
http://www.webmd.com/pain-management/tc/anesthesia-risks-and-complications
http://kidney.niddk.nih.gov/kudiseases/pubs/anemia/index.htm
http://kidney.niddk.nih.gov/kudiseases/pubs/renalosteodystrophy/index.htm

Here is a patient's PD story:

By ladams posted in Home hemodialysis, Patient Stories with No Comments March 3, 2008

"My name is Ann David, and I am 77 years old. I have been on home peritoneal dialysis for one year. I live with my husband and have two daughters who live in the same subdivision as us.

Deciding whether to do dialysis at home or to do dialysis at a clinic was a tough decision. Reading the material, I was overwhelmed with the information about doing dialysis at home. The amount of supplies, the machine, making sure things are sterile, learning how to run the machine, hooking myself up, it all seemed so complicated. Then, there were the questions. What do you do if there is a power failure or if the machine malfunctions? Where do we store everything? Can we make this work? With the help of my family, we decided to make it a family project and try doing dialysis at home.

The first hurdle I encountered was getting the catheter put in. I had breast cancer 43 years ago. I've had two mastectomies and several abdominal surgeries. There was a possibility that I had too much scare tissue for it even to be possible to have the catheter inserted. I went to Columbia, MO, and Dr. Nichols did the procedure without any problems. First hurdle cleared.

Next came the classes and learning how things would work. My daughters and I went to DaVita Lake St. Louis. Lisa Wilson is my nurse. The girls took notes as we learned how to do dialysis manually. We'd talk about the things we learned and review handouts. Lisa had all of us doing all parts of the dialysis in the office, and eventually, we felt better about what we were about to encounter at home.

After doing manual dialysis for a while at home, it didn't seem that overwhelming. We had a schedule, and things went pretty smoothly. Now it was time to learn how to operate the machine. We went back for more classes and practice sessions. Soon it was time to begin at home.

I'd like to say that the first night was a piece of cake, but it wasn't. The machine started beeping in the middle of the night. We were scared that we messed up. We called the 24-hour help line, and they walked us through some steps. We found out that we did everything okay. We did manual treatments that next day, and in less than 24 hours, the machine company had a new machine out to us.

You probably think that at this point, I was ready to give up and go to the clinic. That is just the opposite of what happened. This problem was a good thing for us. We were no longer afraid of anything going wrong. We found out how nice and helpful the people were on the 24-hour helpline. We didn't have to worry about messing up because help was just a phone call away. This experience gave us the confidence and courage that other problems wouldn't be that hard to solve.

During the winter, there was an ice storm, and we were without power for three days. Once again, we were put to the test. When the power first went off in the middle of the night, I disconnected myself, found an extra blanket, and went back to bed, knowing Lisa or one of the nurses on call would advise me what to do in the morning. The next morning, we still did not have power, so I was told to do manual dialysis. This was a little more complicated since we had to find a way to heat the solution and get enough light to see what we were doing. The family all helped, and we made it through the ice storm.

Enough about the mechanics of home dialysis, how has this affected my life? Before dialysis, I had little energy, had lost my appetite and spent most of my time sitting in my recliner and sleeping in front of the television. I stopped doing most of my crafts, didn't do much shopping and limited activities outside the house. When we would go to the doctor's appointments, that was about all I could do that day. It would wear me out. I didn't even want to stop for lunch outside the house.

Once I started dialysis, all of that slowly changed. Now, I am back doing my crafts. I have energy again, and people can't believe how much better I look physically. Don't believe me? Last Monday, I had a doctor's appointment. After that, my daughters and I went to lunch. Then we went shopping. We went to four stores all located in different areas. Five hours later, we finally came home, and I spent my evening crocheting. On Tuesday, I went to my church's seniors' meeting and luncheon. Then, on Wednesday, I spent the day quilting. My family says I'm always on the go now, and they think it is great.

Home dialysis has given me my life back. I am grateful for all the help and support of my family and the great staff at DaVita. I am so glad I didn't give in to my concerns and gave home dialysis a try. I would recommend it to anyone."

Questions for Consideration

Some suggested questions to ask fellow patients ...

  1. How has APD bettered your treatment? Daily life?
  2. What did you feel when you were told you needed dialysis?
  3. Why did you choose APD over hemo or PD or vice versa?
  4. How easy is the equipment to use?
  5. If you could make one improvement to the equipment what would it be?
  6. Have you ever experienced any adverse effects?
  7. What is the hardest part of APD?
  8. What piece of advice would you give a person recently diagnosed with kidney disease?
  9. Does APD affect your quality of sleep?
  10. What is your APD schedule?
  11. Describe your treatment? For example give us a walk through of one treatment?
  12. If you travel does your machine travel with you?
  13. How has APD impacted your social/ economic life?

Treatments

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Videos

http://davita.feedroom.com/

The kidney is an interactive menu
About Us:
Christopher Baker, Hans Dietrich, David Eichhorn, Kriya Gishen, and Robin Zelman all Brown University students taking Biology 108, Organ Replacement with Professor Michael Lysaght. For more information regarding Automated Peritoneal dialysis please feel free to contact us at Christopher_Baker(at)brown(dot)edu, Hans_Dietrich(at)brown.edu, David_ Eichhorn(at)brown(dot)edu, Kriya_Gishen(at)brown(dot)edu, and Robin_Zelman(at)brown(dot)edu