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Peritoneal Dialysis (PD)

Fluid and Solute Removal
PD Fluid
Treatment modes CAPD/APD
Treatment Strategy
Principles of PD
Dialysis fluid is introduced to the peritoneal cavity
through a catheter placed in the lower part of the
A thin membrane, called the peritoneum, lines the
walls of the peritoneal cavity and covers all the
organs contained in it.
In PD the peritoneum serves as the dialysis
membrane. The peritoneal cavity can often hold more
then 3 litres, but in clinical practice only 1.5 2.5L of
fluid are used.
This is an intra-corporeal blood purification as no
blood ever leaves the body of the patient.
Principles of PD

The abdominal cavity,
hold the large organs
of the digestive
system, is lined by the

In PD, special fluid is
instilled through a
permanent catheter in
the lower abdomen.
Principles of PD
An osmotic pressure
gradient is applied by the
addition to the dialysis fluid
of an osmotic agent which
will suck fluid from the
The concentration of this
osmotic agent is chosen to
give just the fluid removal
needed. In most cases
glucose is used to create the
osmotic pressure.
Fluid is removed by
ultrafiltration driven by an
osmotic pressure gradient.
(Eg. Yellow/Green/Red
Principles of PD
Solutes are transported
across the membrane by
The driving force is the
concentration gradient
between the PD fluid and
the blood.
Waste products present in
the blood per fusing the
peritoneum will diffuse
from the blood vessels
into the cleaner dialysis
Principles of PD
The dialysis fluid should be
instilled for 4 to 6 hours.
When the dialysis fluid is
drained from the
abdominal cavity, it
contains waste products
and excess fluid extracted
from the blood.
PD is most often applied
and effective as a
continuous therapy. In this
way it is a more
physiological treatment
then Haemodialysis (HD)
Principles PD / HD
The Peritoneum
The Peritoneum
The abdominal cavity and all
the organs contained in it are
lined by a thin smooth
membrane, the peritoneum.
It is a loose connective tissue
containing blood vessels and
If put under the microscope,
three layers can be identified
between the peritoneal cavity
and the blood stream.
The capillary wall / the
interstitium / the mesothelium
Each of these is a barrier to
the transport of fluid and
Fluid Removal
To understand how fluid
removal is achieved, we
need to understand how
osmosis works.
Osmosis is the process in
which water moves
through a semi
permeable membrane
from an area of high
water concentration (ie;
low solute concentration)
to an area of low water
concentration (ie; higher
solute concentration).
Fluid Removal
The osmotic agent normally used in PD fluid is glucose.
Not an ideal osmotic agent, as it is readily transported
across the peritoneum.
Large concentration glucose creates a temporary osmotic
gradient before being adsorbed into the blood.
The higher the glucose concentration, the larger the
osmotic pressure, resulting in a larger fluid removal.
If PD exchanges are missed or dwell more than 6-8 hours,
fluid may be gained by the patient rather then lost.
The Volume of dialysis solution administered is also
important for the total fluid removal, as it will take longer
for the concentration gradient to decline in a large volume
of fluid.
Fluid Removal
Transport capacity
for the fluid across
the Peritoneal
membrane varies
greatly between
Mainly the pore
area and the
capacity to
reabsorb fluid
which affect fluid
Solute Removal
The most important principle
for solute removal in PD is
diffusion, for which the
driving force is the
concentration gradient
between the blood and the
dialysis fluid.
Small solutes move quickly
through the membrane
creating an equilibrium
during the dwell period.
Larger solutes move slowly
across the peritoneum,
reaching equilibrium point
takes a long time.
Fluid Removal
Both solute and fluid removal in PD is
controlled by
1) glucose concentration
2) dwell time
3) volume
4) peritoneal membrane characteristics
PD Fluid
Components of PD fluid can be divided in into electrolytes,
buffer and osmotic agents.
The most abundant electrolyte in PD fluid is sodium. Its
hyponatremic, so it has a concentration lower than blood
to ensure sufficient removal of sodium.
Standard PD fluid contains no potassium.
Today, there is a tendency to use normcalcemic PD fluid as
many patients receive extra calcium from phosphate-
binding drugs.
The buffer normally used in PD is lactate. Lactate is
metabolised to form bicarbonate, the most important
buffer in the blood.
PD Fluid
The major osmotic agent used today is glucose.
As the rate of fluid transport is related to the osmotic strength of
the PD solution, the ultrafiltration can be controlled by an
appropriate glucose concentration. Normal range of
concentrations include 1.5%, 2.3% & 4.25%.
Glucose is not ideal, as it is rapidly absorbed from the PD fluid.
This may lead to problems with fluid removal, patient gains
calories and can lose there appetite. Resulting in overweight and
malnourishment. Disturbances of the carbohydrate and lipid
metabolism may also occur.
Research to find alternative osmotic agents has resulted in new
products which are still not widely used. Amino acids are an
interesting alternative as they provide nutritional supplement.
High molecular weight glucose polymer (extraneal/icodextrin)
provide sustained ultrafiltration for long overnight dwells.
Treatment Modes CAPD/APD
Whatever method is used it is
of the highest importance that
the treatment is performed
with great hygienic care as
the introduction of bacteria in
to the abdomen can lead to
Continuous Ambulatory
Peritoneal Dialysis, CAPD is
most widely used; know as
the manual method where
each exchange is taken care
of by the patient.
Typically regime 4 bags x
2L/day. This means that the
patient performs 4 bags
during the day.
Treatment Modes CAPD/APD
To increase the efficiency of
PD and help the patient with
the exchanges, a machine can
be used, known as Automated
Peritoneal Dialysis of APD.
Advantages of APD v CAPD
are 1) higher clearance of
solutes, as higher volumes
can be used 2) better fluid
removal, as shorter dwell time
can be used 3) more freedom
during the daytime as no
exchanges need to be made.
Drawbacks of APD are that of
a higher cost and portability.
The most common in PD and also one of the major problem with
the therapy in general, is PERITONITIS.
The normal cause of inflammation is bacterial infection. Bacteria
from the patients skin, equipment or from an unclean
environment can be flushed into the abdominal cavity by the
instilled PD fluid.
The exit site of the catheter is also an infection route. In rare
cases bacteria may enter from the intestines.
During an episode of peritonitis many events take place in the
affected tissue which may change the transport characteristics of
the peritoneum (eg formation clots or adhesions)
Repeated episodes eventually damage the peritoneum and force
the patient to choose another treatment (HD).
PD leaks, Hernias are another complications; partly a result of
the increased abdominal pressure. APD can be a suitable option
(lying down) as these patients are not CAPD candidates with the
added abdominal pressure.
Patient technique survival is better for HD; ie, patients can
usually be treated with HD for a longer period of time.
Reoccurring episodes of peritonitis together with loss of residual
function are the major causes for patients transferred from PD to
Treatment Strategy
Many factors are considered and assessed to ascertain the best
effective treatment for each individual
Personal needs and preferences are of great importance, to suit
Some prefer nightly treatments and are comfortable operating a
PD is often chosen as a temporary treatment of transplant
candidates, waiting for a suitable kidney.
PD is often the best choice for pediatric patients; as the continued
blood purification is probably the reason why children grow
better than HD.
Cardiovascular problems and blood access problems can be
impossible to treat on HD; PD is an alternative.
The peritoneal membrane characteristics, ie. The transport
properties of the peritoneum can vary widely among patients. A
small person may have a large peritoneal surface area with many
pores available for transport. However, a large person who needs
much more dialysis, may have only a small peritoneum.
Ged PD Coordinator
Thanks for your time this morning and
have a great day!!!!!
Peritoneal Dialysis
Information and pictures in this
presentation has been collaborated in
conjunction with;
Fresenius Medical Care
Baxter Health Care