 Study Guide: Peritoneal Dialysis / Hemodialysis

Topic Outline
1. Definition

2. Purpose

3. Procedure

Learning Outcomes
After studying this unit, you will be able to:
1. Define terms associated with Peritoneal Dialysis/ Hemodialysis
2. Know purpose of Peritoneal Dialysis/ Hemodialysis.
3. Be familiarized with the steps in hemodialysis and peritoneal dialysis.

Introduction

Dialysis
Dialysis is used to remove fluid and uremic waste products from the body when the
kidneys cannot do so. It may also be used to treat patients with edema that does not
respond to treatment, hepatic coma, hyperkalemia, hypercalcemia , and uremia.
Dialysis is indicated when there is a high and rising level of serum potassium, fluid
overload, or impending pulmonary edema, increasing acidosis, pericarditis, and severe
confusion. It may also be used to remove certain medications or other toxins (poisoning or
medication overdose) from the blood. Chronic or maintenance dialysis is indicated in chronic
renal failure, known as end-stage renal disease (ESRD), in the following instances: the
presence of uremic signs and symptoms affecting all body systems (nausea and vomiting,
severe anorexia, increasing lethargy, mental confusion), hyperkalemia, fluid overload not
responsive to diuretics and fluid restriction, and a general lack of well-being.. Patients with
no renal function can be maintained by dialysis for years. Limitations on the patient’s ability
to work resulting from illness and dialysis usually impose a great financial burden on patients
and families. The decision to initiate dialysis should be reached only after thoughtful
discussion among the patient, family, physician, and others as appropriate. Many potentially
life-threatening issues are associated with the need for dialysis. The nurse can assist the
patient and family by answering their questions, clarifying the information provided, and
supporting their decision. The lifestyle changes that patients needing hemodialysis eventually
need to make are often overwhelming. Sometimes the news that a donor kidney is available
for transplantation can be so disruptive to the changes in lifestyle that were made to
accommodate hemodialysis that the patient may stall the process required for
transplantation or refuse the kidney when it becomes available, choosing instead to continue
with hemodialysis.

Definition KEY TERMS

HEMODIALYSIS
Hemodialysis is the most commonly used method of dialysis. It is used for patients
who are acutely ill and require short-term dialysis (days to weeks) and for patients with
ESRD who require long-term or permanent therapy. A dialyzer (once referred to as an
artificial kidney) serves as a synthetic semipermeable membrane, replacing the renal
glomeruli and tubules as the filter for the impaired kidneys. For patients with chronic renal
failure, hemodialysis prevents death, although it does not cure renal disease and does not
compensate for the loss of endocrine or metabolic activities of the kidneys. Patients receiving
hemodialysis must undergo treatment for the rest of their lives or until they undergo a
successful kidney transplant. Treatments usually occur three times a week for at least 3 to 4
hours per treatment (some patients undergo short-daily hemodialysis). Patients receive
chronic or maintenance dialysis when they require dialysis therapy for survival and control of
uremic symptoms. The trend in managing ESRD is to initiate treatment before the signs and
symptoms associated with uremia become severe

Principles of Hemodialysis
The objectives of hemodialysis are to extract toxic nitrogenous substances from the
blood and to remove excess water. In hemodialysis, the blood, laden with toxins and
nitrogenous wastes, is diverted from the patient to a machine, a dialyzer, in which the blood
is cleansed and then returned to the patient. Diffusion, osmosis, and ultrafiltration are
the principles on which hemodialysis is based. The toxins and wastes in the blood are
removed by diffusion—that is, they move from an area of higher concentration in the blood
to an area of lower concentration in the dialysate. The dialysate is a solution made up of all
the important electrolytes in their ideal extracellular concentrations. The electrolyte level in
the patient’s blood can be brought under control by properly adjusting the dialysate bath. an
area of lower solute concentration (the dialysate bath)Excess water is removed from the
blood by osmosis, in which water moves from an area of lower solute concentration (the
dialysate bath) to an area of higher solute concentration (the blood). Ultrafiltration is
defined as water moving under high pressure to an area of lower pressure. This process is
much more efficient at water removal than osmosis. Ultrafiltration is accomplished by
applying negative pressure or a suctioning force to the dialysis membrane. Because patients
with renal disease usually cannot excrete water, this force is necessary to remove fluid to
achieve fluid balance.
Complications of Hemodialysis
Although hemodialysis can prolong life indefinitely, it does not alter the natural course
of the underlying kidney disease, nor does it completely replace kidney function. The patient
is subject to a number of problems and complications. One leading cause of death among
patients undergoing maintenance hemodialysis is atherosclerotic cardiovascular
disease. Disturbances of lipid metabolism (hypertriglyceridemia) appear to be accentuated
by hemodialysis. Heart failure, coronary heart disease and anginal pain, stroke, and
peripheral vascular insufficiency may occur and may incapacitate the patient. Anemia and
fatigue contribute to diminished physical and emotional well-being, lack of energy and drive,
and loss of interest, although the use of erythropoietin (Epogen) before the start of dialysis
has been shown to have a significant effect on hematocrit values for the first 19 months
after starting dialysis. Increased dialyzer clotting may occur, which is prevented by adjusting
heparin doses, and dialyzer solute clearances may decrease slightly . Gastric ulcers and other
gastrointestinal problems occur from the physiologic stress of chronic illness, medication, and
related problems. Disturbed calcium metabolism leads to renal osteodystrophy that produces
bone pain and fractures. Other problems include fluid overload associated with heart failure,
malnutrition, infection, neuropathy, and pruritus. Up to 85% of people undergoing
hemodialysis experience major sleep problems that further complicate their overall health
status. Recent studies suggest that early-morning or late-afternoon dialysis may be a risk
factor for developing sleep abnormalities. Researchers suggest such interventions as
changing the temperature of the dialysate bath to prevent temperature elevation and limiting
napping during dialysis as strategies to reduce sleep problems in individuals receiving
hemodialysis.
Other complications of dialysis treatment may include the following:
• Hypotension may occur during the treatment as fluid is removed. Nausea and
vomiting, diaphoresis, tachycardia, and dizziness are common signs of hypotension.
• Painful muscle cramping may occur, usually late in dialysis as fluid and electrolytes
rapidly leave the extracellular space.
• Dysrhythmias may result from electrolyte and pH changes or from removal of
antiarrhythmic medications during dialysis.
• Air embolism is rare but can occur if air enters the vascular system.
• Chest pain may occur in patients with anemia or arteriosclerotic heart disease.
• Dialysis disequilibrium results from cerebral fluid shifts. Signs and symptoms include
headache, nausea and vomiting, restlessness, decreased level of consciousness, and
seizures. It is more likely to occur in acute renal failure or when blood urea nitrogen levels
are very high (exceeding 150 mg/dL)

Vascular Access
Access to the patient’s vascular system must be established to allow blood to
be removed, cleansed, and returned to the patient’s vascular system at rates between
200 and 800 mL/minute. Several types of access are available.

SUBCLAVIAN, INTERNAL, JUGULAR, AND FEMORAL CATHETERS

Immediate access to the patient’s circulation for acute hemodialysis is
achieved by inserting a double-lumen or multilumen catheter into the subclavian,
internal jugular, or femoral vein. Although this method of vascular access involves
some risk (eg, hematoma, pneumothorax, infection, thrombosis of the subclavian
vein, and inadequate flow), it can be used for several weeks. The catheters are
removed when no longer needed, because the patient’s condition has improved or
another type of access has been established. Double-lumen, cuffed catheters may
also be surgically inserted into the subclavian vein of patients requiring a central
venous catheter for dialysis.
 FISTULA
A more permanent access, known as a fistula, is created surgically (usually in
the forearm) by joining (anastomosing) an artery to a vein, either side to side or end
to side (Fig. 44-6). Needles are inserted into the vessel to obtain blood flow adequate
to pass through the dialyzer. The arterial segment of the fistula is used for arterial
flow and the venous segment for reinfusion of the dialyzed blood. The fistula takes 4
to 6 weeks to mature before it is ready for use. This gives time for healing and for the
venous segment of the fistula to dilate to accommodate two large-bore (14- or 16-
gauge) needles. The patient is encouraged to perform exercises to increase the size of
these vessels (ie, squeezing a rubber ball for forearm fistulas) and thereby to
accommodate the large-bore needles used in hemodialysis.

GRAFT
An arteriovenous graft can be created by subcutaneously interposing a biologic,
semibiologic, or synthetic graft material between an artery and vein (see Fig. 44-6). The
most commonly used synthetic graft material is expanded polytetrafluoroethylene (PTFE).
Usually, a graft is created when the patient’s vessels are not suitable for a fistula. Patients
with compromised vascular systems (eg, from diabetes) often need to have a graft to
undergo hemodialysis. Grafts are usually placed in the forearm, upper arm, or upper
thigh. Infection and thrombosis are the most common complications of arteriovenous grafts
PERITONEAL DIALYSIS
The goals of peritoneal dialysis are to remove toxic substances and metabolic wastes
and to re-establish normal fluid and electrolyte balance. Peritoneal dialysis may be the
treatment of choice for patients with renal failure who are unable or unwilling to undergo
hemodialysis or renal transplantation. Patients who are susceptible to the rapid fluid,
electrolyte, and metabolic changes that occur during hemodialysis experience fewer of these
problems with the slower rate of peritoneal dialysis. Therefore, patients with diabetes or
cardiovascular disease, many older patients, and those who may be at risk for adverse
effects of systemic heparin are likely candidates for peritoneal dialysis. Additionally, sever
hypertension, heart failure, and pulmonary edema not responsive to usual treatment
regimens have been successfully treated with peritoneal dialysis. Peritoneal dialysis can be
performed using several different approaches: acute, intermittent peritoneal dialysis;
continuous ambulatory peritoneal dialysis (CAPD); and continuous cyclic
peritoneal dialysis (CCPD). These three methods are discussed later in this chapter. As
with other forms of treatment, the decision to begin peritoneal dialysis is made by the
patient and family in consultation with the physician. Although specific patient populations do
benefit from peritoneal dialysis, it is not as efficient as hemodialysis. Because cardiovascular
disease is the cause of death in half of all patients with ESRD, the adequacy of dialysis must
be defined, in part, by its potential to reduce cardiovascular disease. Blood pressure, volume,
left ventricular hypertrophy, and dyslipidemias are the major causes of morbidity and
mortality in patients undergoing peritoneal dialysis .
Underlying Principles
In peritoneal dialysis, the peritoneum, a serous membrane that covers the abdominal
organs and lines the abdominal wall, serves as the semipermeable membrane. The surface
of the peritoneum constitutes a body surface area of about 22,000 cm2. Sterile dialysate
fluid is introduced into the peritoneal cavity through an abdominal catheter at intervals. Urea
and creatinine, metabolic end products normally excreted by the kidneys, are cleared from
the blood by diffusion and osmosis as waste products move from an area of higher
concentration (the peritoneal blood supply) to an area of lower concentration (the peritoneal
cavity) across a semipermeable membrane (the peritoneal membrane). Urea is cleared at a
rate of 15 to 20 mL/min, whereas creatinine is removed at a slower rate. It usually takes 36
to 48 hours to achieve with peritoneal dialysis what hemodialysis accomplishes in 6 to 8
hours. Ultrafiltration (water removal) occurs in peritoneal dialysis through an osmotic
gradient created by using a dialysate fluid with a higher glucose concentration.
 Procedure
The patient undergoing peritoneal dialysis may be acutely ill, thus requiring short-term
treatment to correct severe disturbances in fluid and electrolyte status, or may have chronic
renal failure and need to receive ongoing treatments.
Preparing the Patient
The nurse’s preparation of the patient and family for peritoneal dialysis depends on the
patient’s physical and psychological status, level of alertness, previous experience with
dialysis, and understanding of and familiarity with the procedure. The nurse explains the
procedure to the patient and obtains signed consent for it. Baseline vital signs, weight, and
serum electrolyte levels are recorded. The patient is encouraged to empty the bladder and
bowel to reduce the risk of puncturing internal organs. The nurse also assesses the patient’s
anxiety about the procedure and provides support and instruction. Broad-spectrum antibiotic
agents may be administered to prevent infection. If the peritoneal catheter is to be inserted
in the operating room, this is explained to the patient and family.
Preparing the Equipment
In addition to assembling the equipment for peritoneal dialysis, the nurse consults with
the physician to determine the concentration of dialysate to be used and the medications to
be added to it. Heparin may be added to prevent blood clotting and resultant occlusion of
the peritoneal catheter. Potassium chloride may be prescribed to prevent hypokalemia.
Antibiotics may be added to treat peritonitis. Insulin may be added for diabetic patients; a
larger-than-normal dose may be needed, however, because about 10% of the insulin binds
to the dialysate container. All medications are added immediately before the solution is
instilled. Aseptic technique is crucial. Before medications are added, the dialysate is warmed
to body temperature to prevent patient discomfort and abdominal pain and to dilate the
vessels of the peritoneum to increase urea clearance. Solutions that are too cold cause pain
and vasoconstriction and reduce clearance. Solutions that are too hot burn the peritoneum.
Dry heating is recommended (heating cabinet, incubator, or heating pad). Microwave heating
of the fluid is not recommended because of the danger of burning the peritoneum.
Immediately before initiating dialysis, the nurse assembles the administration set and tubing.
The tubing is filled with the prepared dialysate to reduce the amount of air entering the
catheter and peritoneal cavity, which could increase abdominal discomfort and interfere with
instillation and drainage of the fluid.
 Inserting the Catheter
Ideally, the peritoneal catheter is inserted in the operating room to maintain surgical
asepsis and minimize the risk of contamination. In some circumstances, however, the
physician inserts the catheter at the bedside under strict asepsis
A rigid stylet catheter is inserted for acute peritoneal dialysis use only. Before the
procedure, the skin is prepared with a local antiseptic to reduce skin bacteria and the risk of
contamination and infection. The physician anesthetizes the site with a local anesthetic agent
before making a small incision or stab wound in the lower abdomen, 3 to 5 cm below the
umbilicus. Because this area is relatively free from large blood vessels, little bleeding occurs.
A trocar is used to puncture the peritoneum as the patient tightens the abdominal muscles
by raising the head. The catheter is threaded through the trocar and positioned. Previously
prepared dialysate is infused into the peritoneal cavity, pushing the omentum (peritoneal
lining extending from the abdominal organs) away from the catheter. The physician may
then secure the catheter with a purse-string suture and apply antibacterial ointment and a
sterile dressing over the site. Catheters for long-term use (Tenckhoff, Swan, Cruz) are
usually made of silicone and are radiopaque to permit visualization on x-ray. These catheters
have three sections: (1) an intraperitoneal section, with numerous openings and an open tip
to let dialysate flow freely; (2) a subcutaneous section that passes from the peritoneal
membrane and tunnels through muscle and subcutaneous fat to the skin; and (3) an
external section for connection to the dialysate system. Most of these catheters have two
cuffs, which are made of Dacron polyester. The cuffs stabilize the catheter, limit movement,
prevent leaks, and provide a barrier against microorganisms. One cuff is placed just distal to
the peritoneum, and the other cuff is placed subcutaneously. The subcutaneous tunnel (5 to
10 cm long) further protects against bacterial infection

Performing the Exchange

Peritoneal dialysis involves a series of exchanges or cycles. An exchange is defined as
the infusion, dwell, and drainage of the dialysate. This cycle is repeated throughout the
course of the dialysis. The dialysate is infused by gravity into the peritoneal cavity. A period
of about 5 to 10 minutes is usually required to infuse 2 L of fluid. The prescribed dwell, or
equilibration, time allows diffusion and osmosis to occur. Diffusion of small molecules,
such as urea and creatinine, peaks in the first 5 to 10 minutes of the dwell time. At the end
of the dwell time, the drainage portion of the exchange begins. The tube is unclamped and
the solution drains from the peritoneal cavity by gravity through a closed system. Drainage is
usually completed in 10 to 30 minutes. The drainage fluid is normally colorless or straw-
colored and should not be cloudy. Bloody drainage may be seen in the first few exchanges
after insertion of a new catheter but should not occur after that time. The entire exchange
(infusion, dwell time, and drainage) takes 1 to 4 hours, depending on the prescribed dwell
time. The number of cycles or exchanges and their frequency are prescribed based on the
patient’s physical status and acuity of illness. The removal of excess water during peritoneal
dialysis is achieved by using a hypertonic dialysate with a high dextrose concentration that
creates an osmotic gradient. Dextrose solutions of 1.5%, 2.5%, and 4.25% are
available in several volumes, from 500 mL to 3,000 mL, allowing the dialysate selection to fit
the patient’s tolerance, size, and physiologic needs. The higher the dextrose concentration,
the greater the osmotic gradient and the more water removed. Selection of the appropriate
solution is based on the patient’s fluid status.

Complications of Peritoneal Dialysis

Peritoneal dialysis is not without complications. Most are minor, but several, if
unattended, can have serious consequences.
Peritonitis
Peritonitis (inflammation of the peritoneum) is the most common and most serious
complication of peritoneal dialysis. The organism responsible for peritoneal dialysis-related
peritonitis is an important factor in clinical outcome and the basis of treatment guidelines.
There has been a significant decrease in the rate of cases of peritonitis, from 1.37
episodes/patient-year in 1991 to 0.55 episodes/patient-year in 1998. Staphylococcus aureus
and Staphylococcus epidermidisremain the most common Gram-positive organisms
responsible for peritonitis, although the rates of each have decreased. Pseudomonas
aeruginosa, E. coli, and Klebsiella species are the most common causes of Gram-negative
peritonitis. Resistance to antibacterial agents (ie, ciprofloxacin, methicillin) used in their
treatment increased dramatically from 1991 to 1998. Peritonitis is characterized by cloudy
dialysate drainage, diffuse abdominal pain, and rebound tenderness. Hypotension and other
signs of shock may occur if S. aureus is the responsible organism. The patient with
peritonitis may be treated as an inpatient or outpatient (most common), depending on the
severity of the infection and the patient’s clinical status. Initially, one to three rapid
exchanges with a 1.5% dextrose solution without added medications are completed to wash
out mediators of inflammation and to reduce abdominal pain. Drainage fluid is examined for
cell count, and Gram’s stain and culture are used to identify the organism and guide
treatment. Antibiotic agents (aminoglycosides or cephalosporins) are usually added to
subsequent exchanges until the Gram’s stain or culture results are available for appropriate
antibiotic determination. Intraperitoneal administration of antibiotics is as effective as
intravenous administration. Antibiotic therapy continues for 10 to 14 days. Careful
calculation of the antibiotic dosage helps prevent nephrotoxicity and further compromise of
renal function. Heparin (500 to 1,000 U/L) may be added to the dialysate to
prevent fibrin clot formation; oral administration of low-dose warfarin
(Coumadin) is also effective in decreasing coagulation factors and preventing
thrombosis without increasing the risk of bleeding. Peritonitis that is unresolved after 4 days
of appropriate therapy necessitates catheter removal. The patient is maintained on
hemodialysis for about 1 month before a new catheter is inserted. In patients with
fungal peritonitis, the peritoneal catheter must be removed if there is no response to therapy
in 4 to 7 days. Tunnel infections and fecal peritonitis also necessitate catheter removal.
Systemic antibiotics should continue for 5 to 7 days after catheter removal. Regardless of
which organism causes peritonitis, the patient with peritonitis loses large amounts of protein
through the peritoneum. Acute malnutrition and delayed healing may result. Therefore,
attention must be given to detecting and promptly treating the infections.
Leakage
Leakage of dialysate through the catheter site may occur immediately after the
catheter is inserted. Usually, the leak stops spontaneously if dialysis is withheld for several
days to give the incision and exit site time to heal. During this time, it is important to re duce
factors that might delay healing, such as undue abdominal muscle activity and straining
during bowel movement. Leakage through the exit site or into the abdominal wall can occur
for months or years after catheter placement. In many cases, leakage can be avoided by
using small volumes (100 to 200 mL) of dialysate, gradually increasing the volume up to
2,000 mL.
BLEEDING
A bloody effluent (drainage) may be observed occasionally, especially in young,
menstruating women. (The hypertonic fluid pulls blood from the uterus, through the opening
in the fallopian tubes, and into the peritoneal cavity.) Bleeding is common during the first
few exchanges after a new catheter insertion because some blood exists in the abdominal
cavity from the procedure. In many cases, no cause can be found for the bleeding, although
catheter displacement from the pelvis has occasionally been associated with bleeding. Some
patients have had bloody effluent after an enema or from minor trauma. Invariably, bleeding
stops in 1 to 2 days and requires no specific intervention. More frequent exchanges during
this time may be necessary to prevent blood clots from obstructing the catheter.
LONG-TERM COMPLICATIONS
Hypertriglyceridemia is common in patients undergoing long-term peritoneal dialysis,
suggesting that this therapy may accelerate atherogenesis. Despite this, the use of
cardioprotective medications is relatively low, and many patients have suboptimal blood
pressure control. Given the high burden of disease in these patients, beta-blockers and
angiotensin-converting enzyme inhibitors should be used to control hypertension or protect
the heart; the use of aspirin and statins should be considered. Other complications that may
occur with long-term peritoneal dialysis include abdominal hernias (incisional, inguinal,
diaphragmatic, and umbilical), probably resulting from continuously increased intra-
abdominal pressure. The persistently elevated intra-abdominal pressure also aggravates
symptoms of hiatal hernia and hemorrhoids. Low back pain and anorexia from fluid in the
abdomen and a constant sweet taste related to glucose absorption may also occur.
Acute Intermittent Peritoneal Dialysis
Indications for acute intermittent peritoneal dialysis, a variation of peritoneal
dialysis, include uremic signs and symptoms (nausea, vomiting, fatigue, altered mental
status), fluid overload, acidosis, and hyperkalemia. Although peritoneal dialysis is not
as efficient as hemodialysis in removing solute and fluid, it permits a more gradual
change in the patient’s fluid volume status and in waste product removal. Therefore, it
may be the treatment of choice for the hemodynamically unstable patient. It can be
carried out manually (the nurse warms, spikes, and hangs each container of dialysate)
or by a cycler machine. Exchange times range from 30 minutes to 2 hours. A common
routine is hourly exchanges consisting of a 10-minute infusion, a 30-minute dwell
time, and a 20-minute drain time
Old peritoneal dialysis modality involving thrice weekly therapy in a hospital
(ncbi.nlm.nih.gov/pmc/articles).
Continuous Ambulatory Peritoneal Dialysis CAPD
A form of dialysis used for many patients with ESRD. CAPD is performed at
home by the patient or a trained caregiver, who is usually a family member; the
procedure allows the patient reasonable freedom and control of daily activities.
Although CAPD is not suitable for all patients with end-stage renal disease
(ESRD), it is a viable therapy for those who can perform self-care and exchanges and
who can fit therapy into their own routines. Often, patients report having more energy
and feeling healthier once they begin CAPD. Nurses can be instrumental in helping
patients with ESRD find the dialysis therapy that best suits their lifestyle. Those
considering CAPD need to investigate the advantages and disadvantages along with
the indications and contraindications for this form of therapy.
Continuous Cyclic Peritoneal Dialysis CCPD
Combines overnight intermittent peritoneal dialysis with a prolonged dwell time
during the day. The peritoneal catheter is connected to a cycler machine every
evening, and the patient receives three to five 2-L exchanges during the night. In the
morning, the patient caps off the catheter after infusing 1 to 2 L of fresh dialysate.
This dialysate remains in the abdominal cavity until the tubing is reattached to the
cycler machine at bedtime. Because the machine is very quiet, the patient can sleep.
Moreover, the extralong tubing allows the patient to move and turn normally during
sleep. CCPD has a lower infection rate than other forms of peritoneal dialysis because
there are fewer opportunities for contamination with bag changes and tubing
disconnections. It also allows the patient to be free from exchanges throughout the
day, making it possible to work more freely and carry out activities of daily living.

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