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Saudi J Kidney Dis Transplant 1995;6(l):35-40
©1995 Saudi Center for Organ Transplantation
Practical Procedure
Continuous Ambulatory Peritoneal Dialysis (CAPD)
Nawaz AH Memon, Hassan Abu-Aisha
King Khalid University Hospital, Riyadh., Kingdom of Saudi Arabia.
Introduction
Continuous ambulatory peritoneal dialysis
(CAPD) was first described in 1976 by
Popovich et al. They called the procedure
"equilibrium peritoneal dialysis technique" (1).
Two liters of dialysate were infused
intraperitoneally and allowed to equilibrate for
5 hours while the patient continued his normal
activities. The dialysate was then drained and
fresh fluid was 'infused again. Five such
exchanges were carried out every day.
Subsequently, in 1978, further experience in a
larger number of patients was reported by the
same group, and the name of this method of
dialysis was changed to continuous
ambulatory peritoneal dialysis (CAPD) (2).
The procedure immediately gained acceptance
among nephrologists due to its simplicity and
the fact that it did not require expensive
machines and materials.
Initially, the dialysate was available only in
glass bottles. Oreopoulos' modification of
Reprint requests and correspondence to
Dr. Nawaz Ali Memon, MRCP
Department of Medicine
King Khalid University Hospital
P.O. Box 2925, Riyadh 11461
Kingdom of Saudi Arabia.
Saudi Journal
of Kidney Diseases
and Transplantation
CAPD using plastic bags made the technique
easier to perform and decreased the rather high
incidence of peritonitis (3). Long-term access
to the peritoneal cavity was made possible by
the Tenckhof's design of indwelling silicon
rubber catheter which had been widely
accepted earlier (4).
CAPD is more physiogical than hemodia-
lysis since there is a constant removal of waste
products thereby achieving steady chemistry.
There is sufficient removal of fluid resulting in
better salt and water balance. This makes
control of hypertension easier. Improved
erythropoiesis and better hematocrits are also
observed in patients on CAPD. These
advantages together with the relative absence
of dietary restriction and the ease of training
and management have made this modality of
treatment well accepted by patients and
physicians alike. However, peritonitis remains
a major problem. With increasing
improvement in the technique, the incidence of
peritonitis has declined remarkably and
technique survival has greatly improved.
Today, CAPD is the commonest form of
home dialysis throughout the world and
perhaps the only form of home dialysis
available in Saudi Arabia. The real long
term success of CAPD is yet to be seen.
However, it is increasingly evident that
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Table 1. Indications of CAPD Table 2. Contraindications of CAPD

Any patient with ESRD who prefers CAPD to HD.
Multiple abdominal surgeries affecting the
Diabetics with ESRD. There is an advantage peritoneum
of the possibility of adding insulin to the dialysate.
Hernias
Patients with failed vascular access.
Patients on immunosuppressive therapy
Patients with hemodynamic instability during HD.
Chronic abdominal wall infections e.g. colostomy,
Patients with recent myocardial infarction. ileostomy, nephrostomy

Patients with bleeding, in whom use of heparin Neurological deficits

during HD is contraindicated.
Crippling arthritis and backache
In young children where creating vascular access is
difficult. Psychosocial problems
ESRD = End-stage renal diseases,
HD = Hemodialysis, Severe hyperlipidaemia
CAPD = Continous ambulatory peritoneal dialysis

CAPD has become a first choice initial method silicone rubber catheter with one or two
of renal replacement therapy (RRT) for many Dacron cuffs and Tenckhoff's curled catheter
patients. with two cuffs are the ones most widely used
The common indications and (Figure 1).
contraindications of CAPD are given in Tables 1 Patients should be prepared as per the routine
and 2 respectively. followed for a surgical procedure. It is useful
to follow a check list (Table 3). One should
Procedure remember that it is imperative to explain the
Peritoneal Access procedure to the patient in detail.
Permanent peritoneal access is the lifeline
for success of CAPD. There are several Method of Catheter Implantation
types of peritoneal catheters available. Complete aseptic technique during catheter
However, straight Tenckhoff's indwelling insertion is crucial. Peritoneal catheter could
either be implanted at the bedside or by a
surgeon in the operating room. The latter
method is preferred as it will allow direct
vision and placement of catheter intraperito
neally properly directed towards the pelvis.
This method also makes the immediate,
potentially serious complications like rupture
of a viscous or injury to major blood vessels
unlikely. The procedure can be done under
Figure 1. Top: Straight Tenckhoff catheter Bottom: local or general anesthesia. The catheter
Tenckhoffs curled catheter insertion is usually through a midline incision
Segment A-B: Pelvic segment 3-4 cms below the umbilicus. Lately, catheters
Segment B-C: In subcutaneous tunnel have been implanted under laparoscopic
Segment C-D: External segment
guidance.
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Table 3. Checklist for the preparation of patients for
CAPD
1. Take consent
2. Check whether the patient is listed in the
operating room
3. Ensure nil orally for 6-8 hours before the
procedure
4. Clean and shave the skin of abdomen
5. Administer light sedation in restless
patients
6. Empty the bladder
7. Bath with soap and water on previous day
8. Empty rectum with enema in the morning
9. Prophylactic antibiotic one hour before
procedure in the form of:
a) Cefazoline, 1 gm i.v. stat
b) Gentamicin, 1.7 mg/kg body weight
i.v. stat
There are three segments for the catheter
(Figure 1).
i) The first segment is from the tip to the
first Dacron cuff. This part is with side
holes and is implanted in the pelvis.
The first Dacron cuff lies between the
peritoneum and the rectus sheath,
ii) The second segment is from the first
Dacron cuff to the second cuff. This
segment is usually buried in a
subcutaneous tunnel in one of the
abdominal quadrants, usually the right
quadrant. The second Dacron cuff is
placed 2 cms deep to the skin exit-site,
iii) The third segment of the catheter is the
part beyond the second Dacron cuff.
This lies outside the body and is
connected to the dialysate connection.
Table 4. Composition of standard dialysate for CAPD
Dextrose concentration - 1.5%
pH - 5.2
Sodium - 132 mmol/L
Calcium - 1.75 mmol/L
Magnesium - 0.75 mmol/L
Chloride - 102 mmol/L
Potassium – nil
Lactate - 35 mmol/L
Osmolality - 347 mosm/kg
Catheter patency should be checked in the
operating room itself by connecting the
dialysate and administering two to three
exchanges. Some surgeons infuse two to three
liters of dialysate while the patient is still on
the operation table to check the integrity of the
catheter seal.
Post-catheter Insertion Care
i) Immediately after the patient is
received in the ward, give six quick
exchanges without dwell time till color
of the fluid clears. Add heparin 500-
1000 I.U./liter of dialysate to prevent
formation of fibrin clots. Initially,
infuse only 250-500 ml of dialysate at
a time.
ii) This is to be followed by hourly
exchanges. Thereafter, the form of
exchanges is decided by the team on
individual basis. In order to prevent
leakage of dialysate and to allow heal-
ing, ideally the catheter should be
capped and the exchanges should be
resumed only after 7-10 days.
iii) A surgical dressing is placed at the
catheter entry site and is changed after
one week. The subsequent dressings
are done daily
iv) The exit-site of the catheter and the
skin surrounding the catheter is
cleansed and covered with povidone
iodine and several layers of dry gauze.
Such a dressing is to be done daily.
v) Sutures are removed after two weeks.
Dialysate Solution
There are several dialysate solutions
available commercially in various
concentrations and in plastic bags. The
most commonly used formula is given in
Table 4.
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Table 5. Early complications of CAPD

Complication Cause Action to be taken
Leakage of dialysate Poor surgical technique Stop PD, give rest for about one
week and resume PD with small
volume exchanges.
Poor drainage Fibrin clot or omental capture of Do flat plate x-ray abdomen
catheter (AP/Lat) to visualize catheter

Heparin flush (10000 units of

heparin per liter of dialysate) and
allow dwell time of 6-12 hrs

Administer streptokinase if no
contraindication

May need catheter replacement

Catheter tip migration
Poor inflow
Poor inflow and outflow
Abdominal distension and pain
Poor drainage, turbid effluent,
abdominal pain and fever.
Faulty position If confirmed on flat plate x-ray of
abdomen, give laxatives and
mobilize the patient. Peristalsis
may bring catheter in position.
Catheter kink or clot May need catheter replacement
Omental capture of catheter May need catheter replacement
Rapid infusion of dialysate and Infuse dialysate slowly
stretching Ensure that dialtysate temperature
is not too cold or too warm
Peritonitis Treatment of peritonitis

Concentrated dialysate with 2.5% or 4.25%
Dextrose and resultant higher osmolality (488
mosm/kg) is more suitable if excess fluid
removal is desired. The standard solutions do
not contain potassium. In patients with
hypokalemia, potassium can be added to the
dialysate.
Technique of CAPD
In most adult patients, four exchanges of two
liters of dialysate are carried out in 24 hours,
seven days a week, while the patient continues
with his/her usual activities. The exchanges are
performed roughly six hours apart but can be
tailored according to the needs of the patient.
Observing sterile technique, two liters of
dialysate are infused. The transfer set and the
plastic bag, upon becoming empty, are folded
and carried under the clothes. At the end of the
pre-determined dwell time (around 6 hours)
the empty bag is put on a clean drape placed
on the floor and the control of the transfer set
is released while the patient sits or reclines on
the bed. The peritoneal dialysate effluent flows
into the plastic bag by gravity. Complete
drainage is ensured. The control is closed and
again, while observing strict aseptic technique,
the dialysate effluent bag is disconnected, a
fresh bag is connected and fluid infused. It
may be noticed that the connection site is the
most vulnerable site for entry of micro-
organisms. Therefore, strict aseptic technique
is mandatory and povidone iodine or other
antiseptic solutions should be used during the
connection and disconnection procedures.
The administration set is changed every
month. This is yet another vulnerable point
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Table 6. Late complications of CAPD
Hemoperitoneum
Hernias
Genital edema
Hydrothorax
Cardiorespiratory decompensation
Chyloperitoneum
Sclerosing peritonitis
Loss of ultrafiltration
of entry for microbes and again povidone
iodine or other antiseptic solutions should be
used.
Patients Training
Commitment of the nephrologist and nursing
team to meticulous sterile technique, regular
catheter management and patient training is
absolutely essential for a successful CAPD
program. CAPD training can be imparted
either in the hospital or on outpatient basis.
Although good hospital backup and expert
management is ideal, many centers have found
that specialized nurses can handle both the out-
patient as well as in-patient management. On
an average, a patient can be trained in one
week after the peritoneal access is successfully
achieved.
Modifications of Continuous PD
There are several modifications of
continuous PD. These modifications have
given a chance for the patients to select one
that suits them on individual basis.
Continuous Cycling Peritoneal Dialysis
This technique requires a special machine
and the procedure is carried out every night.
Upon retiring at night the PD catheter is
connected to the cycler. The machine is
programmed to deliver three exchanges of two
liters of dialysate as three hour cycles. After
the last exchange, two liters of dialysate are
infused and the patient is disconnected and
catheters capped. The dialysate remains in the
peritoneal cavity during the day time.
Semi-continuous Semi-ambulatory PD
This procedure can be performed in two
ways.
a) Eight rapid exchanges of one liter of
dialysate are carried out at night
followed by a two liter exchange. One
two liter exchange is carried out during
the day time.
b) Four rapid exchanges of one liter are
carried out during day time ending in a
two liter long cycle exchange. Another
two liter long cycle exchange is done
at night.
Intermittent Peritoneal Dialysis (IPD)
Dialysis sessions are done periodically
several times per week in various ways as per
the choice of the physician. There are three
main types:
a) Series of two liter exchanges with an
average inflow time of 10 minutes and
dwell time of 30 minutes. The fluid is
then drained which takes about 20
minutes.
b) Rapid IPD i.e., 2 liter exchanges with
no dwell time.
c) Rapid IPD i.e., 2 liter exchanges with
short dwell time.
d) Rapid IPD i.e., 2 liter exchanges with
restricted drain time.
All these modalities are inferior methods to
CAPD and are not encouraged.
Complications of CAPD
There are many potential complications of
CAPD due either to the procedure itself or
those that occur soon after peritoneal access
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is achieved or later in the course of treatment.
In well trained hands, the complications
related to implantation of catheter are rare.
Bleeding due to injury to vessels, bowel
perforation or urinary bladder perforation have
all been described but if the procedure is done
by surgeons in the operating room under direct
vision, these complications are rare. The early
complications that occur following initiation of
CAPD and the action to be taken in each case
are given in Table 5. The late complications
that could occur are listed in Table 6.
With improvements in the technique, the
incidence of peritonitis has declined
remarkably. As technique survival of CAPD
has improved, rarer irreversible complications,
which may limit the real long term success like
sclerosing peritonitis and progressive calcific
peritonitis are being recognized.
Recent Advances in CAPD
New technical developments that have been
made include use of bacterial filters in
dialysate infusion lines (5), use of the heat
sterilization or ultraviolet light for connections
(6) and the discontinuation of carrying empty
bags during dwell time (7). In order to
decrease catheter migration and malposition-
ing, and to decrease the incidence of exit-site
and tunnel infections, -various modified
catheters are available. Examples are
Tenckhoffs straight and curled catheters type I
and II, Toronto-Western catheters type I and
II, Swan neck catheters, Swan neck 2
Missouri, Toronto and Tenckhoff catheters
and column disc catheters. However, the
Tenckhoff straight or curled catheter with two
Dacron cuffs is the most commonly used one
(8). Mesothelial cell transplantation, low
calcium solutions and urea kinetic modeling
are also important new areas of interest with
potential to improve therapy (9).
Conclusion
CAPD is a simple and effective method of
RRT and is the commonest form of home
dialysis. It allows freedom to the patient,
imposes no dietary restrictions, achieves
effective control of blood pressure and good
biochemical, water and electrolyte as well as
acid base control.
Acknowledgment
We would like to thank Ms. Bennie Campos
for her most valuable secretarial assistance.
References
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al. The definition of a noval portable-
wearable equilibrium technique. Abstract.
Am Soc Artif Intern Organs 1976;64.
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Continuous ambulatory peritoneal
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Clayton S, de Veber GA. A simple and
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Satellite Symposium on CAPD. Kyoto,
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