Peritoneal Dialysis

Dialysis is a procedure that replaces some of the work healthy kidneys do. It is done when you lose about 85–90% of your kidney function, and sometimes earlier if your symptoms may be improved by dialysis. During dialysis, wastes, salt, and extra water are removed from the blood and the level of certain chemicals in the blood (such as potassium) is maintained. Peritoneal dialysis is a type of dialysis in which the thin lining of the abdomen (peritoneum) and a fluid called dialysate are used to do these tasks.

ExitCare ImageBefore beginning peritoneal dialysis you will have surgery to place a thin, plastic tube (catheter) in your abdomen. The catheter will be small, soft, and easy to conceal. It will be used to transfer a fluid called dialysate to and from your abdomen during each session. The surgery is usually done at least 2 weeks before you begin dialysis.

HOW DOES PERITONEAL DIALYSIS WORK?

At the start of a session, your abdomen is filled with dialysate. Dialysate contains a sugar that pulls wastes, salt, and extra water from the blood. These substances pass through the peritoneum and into the dialysate over the course of several hours. At the end of the session the dialysate is drained from the body. The abdomen is then refilled with dialysate and the procedure is repeated. The process of draining and filling the abdomen with dialysate is called an exchange. The time the dialysate is in your body between exchanges is called a dwell. The dwell depends on the number of exchanges needed, the type of dialysate used, and the characteristics of the peritoneum. It usually varies from 1.5–3 hours.

Peritoneal dialysis is done during the day or at night while you are sleeping. Peritoneal dialysis that is done during the day is called continuous ambulatory peritoneal dialysis (CAPD). In CAPD, exchanges are performed up to 5 times a day. Each exchange takes about 30–40 minutes. You may go about your day normally between exchanges. Peritoneal dialysis that is done at night while you are sleeping is called continuous cycling peritoneal dialysis (CCPD). In CCPD, a machine called a cycler performs exchanges while you are sleeping. Sometimes a combination of CAPD and CCPD is needed.

RISKS AND COMPLICATIONS

Generally, peritoneal dialysis is a safe procedure. However, as with any procedure, complications can occur. Possible complications include:

  • Infection in the peritoneum. This is the most common complication of peritoneal dialysis.

  • Infection around the site of catheter insertion.

  • Weakened abdominal muscles. This may lead to a hernia, which can in turn have complications if left untreated.

PREPARING FOR AN EXCHANGE

  • Close doors and windows and turn off any fans before performing an exchange. Make sure you are in a space without drafts or air currents. Doing these things reduces your risk of infection.

  • Wear a mask to cover your nose and mouth. Do this before you wash your hands and handle equipment. Keep the mask on during each exchange.

  • Wash your hands thoroughly before each exchange. Use a gel or foam.

  • Make sure your catheter and its cap are sterile. If you are using a cycler, make sure the device that attaches the dialysate bag and tubing to the catheter (adapter) is also sterile. 

  • Make sure the area of your body around the catheter is sterile.

  • Check your blood pressure if directed by your health care provider. Your blood pressure reading may help determine what type of dialysate to use.

  • Examine the dialysate:

  • Make sure the bag is the right size and contains the correct mixture. Size information is on the label.  

  • Gently squeeze the bag to make sure there are no leaks.  

  • Look at the color of the dialysate. The dialysate should be clear. You should be able to see any writing on the side of the bag clearly through the solution. Do not use a cloudy solution.

  • Check the expiration date. The expiration date is on the label. If it is past the expiration date, throw the bag away. 

  • Warm the dialysate using a dry heating pad. Leave the dialysate in the bag with the cover on while doing this. Do not use a microwave or hot water to warm the dialysate.

  • If you are using a cycler, make sure it is set up and programmed correctly.

HOW TO PERFORM AN EXCHANGE

The following steps illustrate how exchanges are commonly performed. The actual way in which an exchange should be performed varies depending on the equipment used and other factors. Always perform exchanges in exactly the way that your health care provider has trained you to. Remember to always wash your hands before touching any tubing. This is extremely important in preventing infection.

CAPD

  1. Hang your bag of dialysate above the level of your abdomen on the IV pole.

  2. Place a drain bag below your abdomen.

  3. Pull out the ring of y-shaped tubing that connects both bags.

  4. Uncap the tube that is connected to your catheter (transfer set) and immediately attach it to the y-shaped tubing of the dialysate and drain bags.

  5. Twist open the clamp on the transfer set. This will cause the fluid in your abdomen to drain through the tube that goes to the drain bag (drain line). It usually takes about 20 minutes for all of the fluid to drain.

  6. Once the fluid has finished draining, twist lock the clamp of the transfer set.  Then clamp the drain line.

  7. Break the seal (frangible) on the tubing that is connected to the dialysate bag (fill line) and then unclamp the drain line. Air bubbles will flow into the drain line. Make sure your transfer set is still locked so that no air gets into the abdomen.

  8. Count to 5 and then clamp the drain line.

  9. Twist the transfer set clamp to open it and allow the dialysate to flow into your abdomen. This should take about 10 minutes.

  10. Once the fill is complete, twist the transfer set clamp to lock it and then clamp the tubing of the fill line.

  11. Detach the tubing from the catheter and immediately cap the catheter transfer set. Secure the transfer set to your abdomen wall using tape as instructed.

  12. Inspect the drainage. The fluid may look like urine, but it should be clear.

  13. Weigh the drain bag and record the volume drained.

  14. Check your blood pressure, temperature, and pulse if it is the first exchange of the day.

  15. Allow the solution to stay in the abdomen for as long as directed by your health care provider. While the solution is in your abdomen, you may go about your day.

If your body cannot go all night without an exchange, a cycler may be used to perform exchanges while you sleep. The cycler is similar to the one used during CCPD but is smaller. Using a cycler allows you to sleep without having to get up and do an exchange.

CCPD

  1. When you are ready for bed, put the dialysate bags onto the cycler. Put on exactly the number of bags that your health care provider said to use.  

  2. Cyclers have a small cartridge (cassette) with tubing that attaches to each dialysate bag and the tube that goes to the patient (patient line). Depending on the number of dialysate bags you are to use, all the tubes on the cassette may need to be connected to separate dialysate bags. If you use fewer bags than there are tubes on the cassette, the extra lines will need to be clamped.

  3. Insert the cassette with the attached tubing into the front of the cycler.

  4. Make sure that the drain line extends to the toilet. The tip of the drain line should not touch the water in the toilet bowl.

  5. Pull the ring on the tubing from the dialysate bag on the heating pad of the cycler and attach it to the first tube of the cassette. Then break the frangible on the tubing of this dialysate bag.

  6. Repeat this process with all the bags you need to use.

  7. Start the cycler. This will prepare (prime) the cycler and tubing by filling it with dialysate and getting rid of all the air in the tubes.

  8. Once all lines are primed, the cycler will instruct you to connect yourself.

  9. Remove the pull ring from the patient line with one hand.

  10. Uncap your transfer set and attach it to the patient line.

  11. Twist open the clamp on the transfer set.

  12. Press "GO" on the cycler and it will begin the draining and filling process. The cycler may do 3–5 exchanges overnight, depending on what your health care provider recommended.

  13. In the morning, record all volumes and times shown on the cycler.

  14. Press "GO" on the cycler, which will then instruct you to close all clamps.

  15. Close your transfer set twist clamp and then clamp all the tubes that go to the cycler.

  16. When indicated by the cycler, disconnect the patient line from the transfer set and immediately re-cap your transfer set.

  17. Secure the transfer set to your abdomen wall using tape as instructed.

  18. Check your blood pressure, temperature, and pulse.

The solution that is in your abdomen in the morning will stay there during the day.

If the body cannot go all day without an exchange, you may need to perform an exchange during the day. Follow the steps under CAPD if an extra exchange is needed. 

HOME CARE INSTRUCTIONS

  • Follow diet instructions as directed by your health care provider.

  • Avoid becoming constipated. Constipation prevents dialysate from draining effectively after a dwell. To prevent constipation, make sure you are eating fiber-rich foods and avoiding foods that cause constipation. Increasing your physical activity and going to the restroom when you feel you need to instead of holding it in can also prevent constipation. If your health care provider recommends drugs to prevent constipation such as laxatives, use them only as directed.

  • Always keep the dialysate bags and other supplies in a cool, clean, and dry place.

  • Keep a strict schedule. Dialysis must be done every day. Do not skip a day or an exchange. Make sure to make time for each exchange.

  • Weigh yourself every day. Sudden weight gain may be a sign of a problem.

  • Take medicines as directed by your health care provider.

SEEK MEDICAL CARE IF:

  • You have a fever or chills.

  • You feel sick to your stomach (nauseous) or throw up (vomit).

  • You have diarrhea.

  • You have any problems with an exchange.  

  • Your blood pressure increases.

  • You suddenly gain weight or feel short of breath.

  • The catheter seems loose or feels like it is coming out.  

  • The fluid that has drained from your abdomen is pinkish or reddish. However, women having their menstrual period do not need to seek medical care if the fluid is only a little pink or red.

  • There are white strands in the dialysate that are large enough to get stuck in your tubing or catheter.

SEEK IMMEDIATE MEDICAL CARE IF:

  • The area around the catheter swells or becomes red, tender, or painful.

  • There is pus coming from the catheter site.

  • The fluid that has drained from your abdomen is cloudy.

  • You feel abdominal pain or discomfort.