A brief history of the origin of peritoneal dialysis is given. The variations on the "intermittent" technique of peritoneal dialysis used on the Renal Unit, Cardiff Royal Infirmary are described. The ever-increasing importance of peritoneal dialysis as a therapeutic tool is outlined, and illustrative cases from personal experience at the CRI quoted. Additionally, possible complications of peritoneal dialysis are discussed, including peritonitis, abdominal discomfort, pulmonary problems, cardiac arrhythmias, losses of protein and amino-acids, overhydration and dehydration, hyperkalaemia and hypokalaemia, and hypocalcaemia. Further points of special clinical importance are indicated.peer-reviewe

Busuttil, Anthony

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40 PERITONEAL DIALYSIS ANTHONY A. BUSUTTIL * M.D. Department of Pathology, Royal University of Malta. According to S. T. Boen (1961), Weg-ner, in 1877, was the first to point out that the peritoneum could be considered as an inert, semi-permeable membrane per-meable to water, solutes and substances of a low mollecular weight. A. J. Hambur-ger concluded that the exchange of solutes and other diffusible products between the "rinsing fluid" in the peritoneal cavity and the blood depends upon the concentration gradients between the two fluid compart-ments. Experiments on healthy animals and on animals rendered uraemic went on for some time. In 1923, Gantner first published a report on the use of peritoneal lavage as a therapeutic measure in man; 1.5 litres of physiological saline were used as a dialysing solution in a case of bila-terally ureteric obstruction, due to a car-cinoma of the cervix uteri, with very pro-mising results. Two systems of peritoneal dialysis have been devised: the "intermittent" or "short-term", and thp. "continuous" systems. In the intermittent system a volume of fluid is introduced into the peritoneal cavity, left in for a variable time until an equi-librium of concentrations with the blood is established, and then is drained out. In * in receipt of a travel grant from the Royal University of Malta. the continuous method, the fluid is made to run through as an uninterrupted stream continuously rinsing the peritoneal cavity. The former method was used by Gantner in 1923, and later by Abbott and Shea in 1946, and by Grollman et al. in 1951. The continuous method was used by Wegner in 1877, and later by Rosenak and Siwon in 1926, by Wear, Sisk and Trinkle in 1939, and by Frank, Seligman and Fine (1946 and 1948); but it has largely been aban-doned because of the risk of infection and because of the large amounts of irrigation fluid needed. A modification of the intermittent method is in use in the Renal Unit of the Cardiff Royal Infirmary (CRI). The fluid, obtainable as No. 61 and No. 62 Dialaflex solutions (AlIen & Hanburys Ltd.), is available in clear, collapsible, plastic, litre containers. The No. 62 Dialaflex solution has a higher dextrose concentration which doubles its osmolarity thus making the removal of water from the patient's cir-culation possible when indicated. Two of either such packs, warmed to body tem-perature, are used for each dialysis cycle. 0.5g of potassium chloride can be added to each change when indicated and 500 i.u. heparin to each of the first four changes. The composition of each pack is shown in Table 1. TABLE 1 DIALAFLEX 6I DIALAFLEX62 111Eq / L g/L 1110S111 mEq/L g/L 11l0sm Sodium 140.4 140.4 140.4 140.4 Calcium 3.6 1.8 3.6 1.8 Magnesium 1.5 0.75 1.5 0.75 Total Chloride 100.8 100.8 100.8 100.8 Lactate 44.6 44.6 44.6 44.6 Dextrose 13.6 75.5 63.6 353.3 1.26 1.26 TOTAL 364.37 --- ---Sod. metabisul- 642.91 phate (antioxid) 0.52 0.52 Automated peritoneal dialysis making use of the Mark 1 cycling machine pro-duced by the Industrial Automation Divi-sion of Hawker Siddley Dynamics Ltd. of Coventry (Mallick, M. P. et aI., 1967), the "Cardiff" machine, is also used on some patients. The need for nursing supervision is reduced as is also the risk of infection since the machine is a closed system. The dialysing fluid used with the machine is prepared in 20 litre containers by diluting a concentrated electrolytic solution with sterile, pyrogen-free, distil-led water. Higher flow rates (as much as 4 L/hr) can be achieved; thus automated peritoneal dialysis is a more rapid and efficient procedure. The machine also al-lows for "pauses" of the fluid inside the peritoneal cavity. Technique If possible the procedure is first ex-plained to the patient in simple terms. After sedation and catheterisation (if re-quired), the patient is helped to lie flat in bed and the abdominal skin is shaved and cleaned carefully as before a major opera-tion. With full aseptic and antiseptic pre-cautions the puncture site is injected with lOcc of 2% lignocaine solution down to the level of the peritoneum. The cannula is threaded onto a stylet, and is then intro-duced through a small incision previously made. After piercing the peritoneum the stylet is withdrawn for 1 inch and the catheter is then advanced downwards towards the pelvic gutter. The cannula is usually introduced in the midline below the umbilicus; at times above the umbilicus or in one of the iliac fossae. The cannula used at the CRI is the one prepared by the McGraw Labora-tories of California, (Trade name: Trocath figure 1)). Having inserted the catheter as far as it will go downwards without causing discomfort to the patient, the stylet is removed and placed in a container of anti-septic solution for possible further later use in adjusting the position of the cathe-ter. The catheter is now connected via the connecting tube supplied with it (Fig. 1) 41 to the fluid bags through an administration set (the one used is Flexitron R. 61 pro-duced by Baxter Labs. of Illinois). Sterile disposable connecting tubing is attached to the other end of the Y-tube to drain the fluid out of the peritoneal cavity into a measuring cylinder. The catheter is now trimmed to about 1 inch above the level of the skin and a purse-string suture inserted round the point of entry of the cannula. The inflow and outflow paths are now tested making use of about 200cc of dialysing fluid; if all is satisfactory the dialysing solution is then introduced into the peritoneum (fig. 2). Some difficulties may be experienced during the introduction of the cannula. Oozing at the site of entry through the skin is usually well-controlled by pressure. In patients with multiple operative scars and in very obese patients it is relatively easy to introduce the cannula in the plane between the parietal peritoneum and the overlying adipose tissue; in such cases the entry of 1 he stylet is facilitated if the peri-toneum had been incised prior to the entry of the stylet. Perforation of the abdominal and pelvic viscera has been described in patients with a history of abdominal ope-42 rations, in puerperal patients and with a subinvoluted uterus, and in patients with severe ileus. Indications for P.D. 1. Uraemia with prominent neuro-muscular, gastro-intestinal and cardio-vascular changes due to acute or acute-on chronic renal insufficiency. In the 127 peritoneal dialysis performed at the CRI during the early part of 1967, 32.2% had disturbances of consciousness and 11.3% had other CNS disturbances, 52.4% had gastro-intestinal upsets, 10.5% had peri-carditis, 90.0% were anaemic and 9% had a bleeding tendency prior to the com-mencement of the dialyses. In cases of renal insufficiency, the need to dialyse depends more on the condition of the pa-tient, on the rate of rise of blood urea and other forms of deterioration of blood che-mistry, than on anyone single and specfic criterion (Merrill, 1965). However, in hyperkeratabolic renal insufficiency when the blood urea rises by more than 50mgm/100mljday peritoneal dialysis is not usually effective. 2. Fluid overload especially if asso-ciated with intractable pulmonary oedema. In such cases Dialaflex Solution 62 is need-ed to remove the excess of fluid in the patient's circulation. The patient should be carefully weighed several times during the period of dialysis in order to assess its effectiveness. 3. Hyperkalaemia (Maxwell et aI., 1959), if it cannot be effectively controlled by glucose and insulin, cation exchange resin and the other more orthodox con-servative methods. 4. Certain intoxications a. acute barbiturate poisoning (Maxwell et aI., 1959) if con-servative therapeutic mea-sures have not proved effect-ive. b. salicylate intoxication. Peri-toneal dialysis has bem shown to be very effective in animals poisoned by salicyl-ates using a 5% albumen so-lution as the rising fluid (Et-teldorf et al. 1960). c. acute methyl alcohol poi-soning (Stinebaugh, 1960). Illustrative Cases 1. Mrs. P.W. 42 years, a chronic renal patient. First admission: July 1963, presenting with bilateral, staghorn, renal calculi, very severe pyelonephritis, oligu-ria and severe renal insufficiency. Since then, numerous hospital admissions for exacerbations of the pyelonephritis and deterioration of the renal insufficiency. Last admission: 3. 9. 67 with a ten-day history of generalised asthenia and ma-laise, frequency, nocturia and dysuria, no haematuria. No response to nitrofurantoin therapy. In the three days prior to admis-sion more pronounced urinary symptoms, oliguria, severe drowsiness, confusion, heavy hissing respiration, backache, nau-sea and vomiting. Examination on admis-sion: semicomatose, responding only to vio-lent stimulation with moaning and groan-ing. Kussmaul respiration. P: 100/min; BP 110/70; Temp. 35°C. Investigations: Hb: 7.2g%; PCV 25; WBC: 14,300 cells /c.mm; Bl. urea: 350 mg %; Na-++: 143mEq/L; K+: 6.6 mEq/L; HC03: 5 mEq/L; pH central venous blood: 7.17; pCOz: 13. The K+ level fell following the admi-nistration of glucose and insulin. -!L of 5% Sodium Bicarb. were also given i/v prior to the commencement of P.D. at 10.45 p.m. on 3. 9. 67. After the first twelve hours of P.D. TABLE II Date In lit. Out lit. Pre -urea Post urea Hrs. Changes Rate/Hr 3.9.67 2.100 1.720 350 200 1.25 1 1.68 4.9.67 35.700 34.680 200 III 24.00 17 1.49 5.9.67 33.600 35.650 III 95 19.50 16 1.72 71.400 72.050 44.75 34 43 ,,/ EL:r. MENa~.:'// ~ tYl.IMY.~!!:: _.Il_IA~~_RA_· · M __ []_F __ ApPA.RATU5 ... ~SR.P at D. 44 the patient's general condition was much better - less hyperpnoea and confusion, urinary output on the increase. Following the three days of P.D., state of health and renal function had returned to their for-mer satisfactory level. 2. Mr. R.R. 60 years, for the last two years suffered from episodes of L.I.F. pain, passage of blood and slim'e per rec-tum, and pyrexia. Diagnosed as diverticu-litis following investigation. In December, 1966 defunctioning transverse colostomy patient suffering from renal insufficiency due to a polycystic disease of the kidneys. Last admission to the Renal Unit CRI on 12. 8. 67 with severe ascites, severe pit-ting oedema of the lower limbs, genitalia, and sacral pad, and oliguria. Investigations: blood urea: 242mg %; Na+: 124 mEq/L; s.K+: 5.3 mEq/L; P.D. was indicated be-cause of the excessive water and salt re-tention. On introduction of the cannula 3.000 L of ascitic fluid were removed. Dialysis 1st 2nd In Out 48.410 25.720 Pre-urea Post urea Changes Hrs. Rate / Hr 1.81 1.58 46.200 21.000 242 168 22 10 25.5 13.3 168 146 was performed as symptoms of a colove-sical fistula had developed. During the last few months heavy bleeds per rectum every 5 to 6 weeks. On 17. 6. 67 admittance to a Cardiff hospital following a bleed; 11 pints of blood had to be transfused. Another 11 pints were again transfused following another bleed on 30. 7. 67. Four days following the last transfu-sion the patient developed jaundice, oli-guria (20 mll day) and a soaring blood urea. No response to ijv mannitol. Admit-ted to CRI: 6. 8. 67 jaundiced and com-pletely disorientated. Investigations:: Urine: dark brown in colour, with a depo-sit of RBCs and pus cells. Blood urea: 320 mg%; Na 139 mEq/L; K 4.9 mEq/L; RC03: 15 mEq/L; Rb: 16.7 g/l (113%); PCV: 51%; RBCs: 5.1 millions/cub mm; Retics: 4%; Platelets: 115,000; WBCs: 16,000 cells/cub mm (96% polymorphs); s. total proteins: 5.6 g/L; s. alb: 3.0 g/L; raised gamma globulin fraction; s. alk. phos: 7.9K.A. units%; total s. bilirubin: 3.1 (direct 2.4), thymol turb: 1 unit; blood group: 0 Rh; CDE/cde Anti-Kell bodies present (saline, albumen, enzymes, iCT); Direct Coombs: negative. P.D. started on 6. 8. 67 and stopped on 10. 9. 67 (uncomplicated despite the colostomy). Blood urea then had fallen to a normal level and renal function had re-turned to normal with a urinary output of more than 1 L per 24 hours. 3. Mr. R.Y. 58 years, a chronic renal In these two dialyses spread over two days 6.93 L (besides 3.3 L of ascitic fluid) were removed. Contra-indications No absolute contra-indications are known. Age is no barrier; peritoneal dia-lyses has been performed successfully on an infant 3 days of age. Pregnancy may give rise to technical difficulties; peritoneal dialysis can, however, be performed very satisfactorily in the immediate puerperium. In severe peritonitis, some hold that peri-toneal dialyses is absolutely contra-indi-cated; others however maintain that the flow of dialysing solution with added anti-biotics helps to clear up the infection. Recent surgical operation, as well as, re-cent intra-abdominal injury, may be a bar to operational dialysis. In my brief expe-rience I have seen peritoneal dialyses being performed with its usual satisfac-tory results, on a patient with a colostomy, active diverticulitis and an established colo-vesical fistula. Complications of P.D. Some complications of peritoneal dia-lysis have been described but they are the exception rather than the rule (Doolan, 1959). 1. Peritonitis with the later forma-tion of adhesions. The risk is light - in only 17 out of the 127 CRI dialyses being quoted did infection of the peritoneum supervene during the dialysis. Only 1 of these patients had clinical peritonitis al-though the cultures of the effluent fluid, routinely made, were positive. Regular bacteriological examinations of the peri-toneal outflow and the appropriate use of effective antibiotics both systematically and into the dialysing solutions lowers further the incidence. 2. Pain or abdominal discomfort. This usually occurs after a prolongBd dialysis and is ingravescent. Pain can be referred to the lower part of the chest-wall and to the shoulder-tip, and is exacer-bated by moving, coughing and deep breathing. Its occurrence is related to the volume of dialysing fluid introduced into the peritoneal cavity. Pain only oc-curred in 13 of the dialyses and more com-monly during the introduction of fluid. 3. Pulmonary complications (Ber-lyne et aI., 1966). The chest complications of peritoneal dialyses that have been des-cribed are pneumonia, atelactasis, purulent bronchitis and pleural effusion. These pro-bably arise from partial collapse of the lower pulmonary lobes due to elevation of the diaphragm caused by overdistension of the peritoneal cavity by the dialysing solution. It has, however, been thought that anatomical communications between the pleural and the peritoneal cavities might allow dialysing fluid to pass into the chest. The uraemic patient is prone to chest infection because of his immunity insompetence and the likelihood of aspi-ration of bronchial secretion due to inhi-bition of coughing by pain and distur-bances of consciousness. It has, however been shown (M. Poppen and U. von Sydow, 1966), that these complications are great-ly reduced by prophylactic breathing exer-cises started concomitantly with the dia-lysis. At the CRI breathing exercises are encouraged by an expert physiotherapist, routinely, in all patients undergoing dia-lysis; the incidence of chest complications is negligible. 4. Cardiac arrhythmias. Such ar-rhythmias are probably due to movement of water and electrolytes between the cells and the extracellular fluid. Adequate con-45 trol of the electrolytic status of the pa-tient is therefore essential during perito-neal dialysis. In only 6 dialyses from the CRI series quoted did cardiac irregulari-ties develop. 5. Losses of protein and amino-acids. This has proved to be the most important complication of peritoneal dialysis. It has been noted and studied by a number of workers; Frethien and Selvaag in 1948, Boen 1961 and Burns et al. in 1962. Losses of amino-acids have also recently been proved by Berlyne et al. (1967). Figures for protein losses vary from no protein loss to losses of 0.2-8.0 gjL. The total loss of protein may be large, thus in a dialysis of 30 cycles ,of one litre exchange con-taining 5 g of protein per litre, the loss would be that of 150 g of protein during the one dialysis. As well as albumen va-rious plasma globulin fractions are lost, in particular gamma globulin in large amounts, leading to further deterioration in the immunological competence of the patient with renal insufficiency (Berlyne et aI., 1967). 6. Overhydration and dehydration. Regular estimations of arterial blood pres-sure, careful observations of the jugular venous pressure, and thorough, repeated, physical examinations of the patient should serve as an adequate safeguard against this complication. It is also impor-tant that the patient be weighed accurately at frequent intervals. The tonicity of the dialising fluid should be regulated in the light of these observations by the use of 1.36% and 6.36% concentrations of glu-cose in the dialysing solutions. 7. Hyperkalaemia and Hypokalaemia. Regular estimations of the serum potas-sium and electrocardiograms should help prevent these complications. 8. Hypocalcaemia. The irrigation so-lution should contain at least 3 mEqjL of calcium otherwise hypocalcaemia may re-sult. The Dialaflex solutions used contain adequate amounts of Ca++. Briefly the success of peritoneal dia-lysis depends on meticulous control and monitoring by both the medical and the 46 nursing staff. The following are some points of special clinical importance: 1. Blood pressure reading (one hour-ly or two hourly B.P. Chart) 2. Pulse (note especially rate and rhythm) 3. Auscultation of the heart (ar-rhythmias, gallop rhythm) 4. Auscultation of the lung fields (Basal crepitations) 5. Central venous pressure observa-tions 6. Very efficient fluid balance charts 7. Careful weighing of the patient. Summary A brief history of the ongm of peri-toneal dialysis has been given. The varia-tions on the "intermittent" technique of peritoneal dialysis used on the Renal Unit, Cardiff Royal Infirmary have been des-cribed. The ever-increasing importance of peritoneal dialysis as a therapeutic tool has been outlined, and illustrative cases from personal experience at the CRI quoted. Possible complications of peri-toneal lavage have been discussed. Acknowledgements I wish to thank Professor H. Scarbo-rough and Dr. G. Coles for all their inter-est and help and Professor G. P. Xuereb for his advice and criticism. References ABBOTT, A.M. and SHEA, C.L. (1946). Amer. J. lIled. Sci. 312. BERLYNE, G.M et al. (1966). Lancet, ii, 75. BERLYNE, G.M et al. (1967). Lancet, i, 738. BERLYNE, G.M et al. (1967). Lancet, i, 1337. BOEN, S.T. (1961). Peritoneal Dialysis in Clinical Medicine. DooLAN, P.D. (1959). Amer. J. Med. 26, 831. ETTELDORF, J.N. et al. (1960). J. Ped. 56, 1. FRANK, H.A., SELIGMAN, A.M. and FINE, J. (1946). J. Amer. med. Ass., I30, 703. FRANK, H.A., SELIGMAN, A.M. and FINE, J. (1946). ]. Clin. Investig., 25, 211. MALLICK, M.P. et al. (1967). Lancet, i, 1303. MAxwELL, L.H. et al. (1959). J. Amer. med. Ass. I70' 91 7. MERRILL, J.P. (1965). The Treatment of Renal Failure, 2nd edit. POPPEN, M. and VON SYDOW, U. (1966). Lancet, ii, 753. STINEBAUGH, B.J. (1960). Arch. Int. Med. I05, 613. WEAR, S. et al. (1938). J. Urol., 39, 53· 

Peritoneal dialysis

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Peritoneal dialysis

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