Table Of ContentThe Textbook of Peritoneal Dialysis
1st Edition
(Combining Continuous Ambulatory Peritoneal Dialysis, 2nd ed.
and Peritoneal Dialysis, 4th ed.)
The Textbook of
Peritoneal Dialysis
Edited by
Ram Gokal
Department of Renal Medicine, Manchester Royal Infirmary, Manchester, United Kingdom
and
Karl D. Nolph
Division of Nephrology, Department of Internal Medicine, School of Medicine, University of Missouri,
Health Sciences Center and Dalton Cardiovascular Research Center, Columbia, Missouri,
United States of America
w
Springer Science+Business Media, B.V.
Library of Congress Cataloging-in-Publication Data
The Textbook of peritonea l dialysis / edited by Ram Goka1 & Karl D.
No I ph. — 1st ed.
p. ca.
Includes Index.
ISBN 978-94-010-4349-6 ISBN 978-94-011-0814-0 (eBook)
DOI 10.1007/978-94-011-0814-0
1. Peritoneal dialysis. I. Cokal, R . II. Nolph, Karl D.
[DM_M: ,1. Peritoneal Ola lysis. 2. Peritoneal—physiology.
3. Per1toneu»—drug effects. WJ 378 T356 1994]
RC901.7.P48T46 1994
617.4*61059—dc20
DNLM/DLC
for Library of Congress 93-40474
ISBN 978-94-010-4349-6
Printed an acid-free paper
All Rights Reserved
© 1994 Springer Science+Business Media Dordrecht
Originally published by Kluwer Academic Publishers in 1994
Soft cover reprint of the hardcover 1st edition 1994
No part of the material protected by this copyright notice may be reproduced or utilized in any form or by any means,
electronic or mechanical, including photocopying, recording or by any information storage and retrieval system,
without written permission from the copyright owner.
Table of Contents
Foreword vii
B. H. Scribner
Preface ix
R. Gokal and K. D. Nolph
List of Contributors xi
1. Historical developments and overview of peritoneal dialysis
Ram Gokal and Karl D. Nolph
2. Ultrastructure and pathology of the peritoneum in peritoneal dialysis 17
James W. Dobbie
3. The peritoneal microcirculation in peritoneal dialysis 45
Randall White, Ronald Korthius and D. Neil Granger
4. Peritoneal physiology-transport of solutes 69
Bengt Rippe and Raymond Theodorus Krediet
5. Peritoneal lymphatics 115
Robert A. Mactier and Ramesh Khanna
6. Ultrafiltration in peritoneal dialysis 135
John K. Leypoldt and Chandra D. Mistry
7. Pharmacologic alterations of peritoneal transport rates and pharmacokinetics of the peritoneum 161
Przemyslaw Hirszel, Norbert Lameire and Marc Bogaert
8. CAPD systems and solutions 233
Mariano Feriani, Giuseppe LaGreca, Frank L. Kriger and James F. Winchester
9. Peritoneal dialysis access and exit site care 271
Zbylut J. Twardowski and Ramesh Khanna
10. Placement, repair, and removal of chronic peritoneal catheters 315
Stephen R. Ash and W. Kirt Nichols
11. Organization of the peritoneal dialysis program - the nurses' role 335
L. Uttley and B. Prowant
12. Continuous ambulatory peritoneal dialysis 357
J. W. Moncrief, R. P. Popovich, N. V. Dombros, G. E. Digenis and D. G. Oreopoulos
v
vi TABLE OF CONTENTS
13. Automated peritoneal dialysis 399
Jose A. Diaz-Buxo and Wadi N. Suki
14. Adequacy of peritoneal dialysis 419
Prakash Keshaviah
15. Nutritional requirements of peritoneal dialysis patients 443
Bengt Lindholm and Jonas Bergstrom
16. Peritonitis 473
William F. Keane and Stephen I. Vas
17. Host defence and effects of solutions on peritoneal cells 503
Gerald A. Coles, Sharon L. Lewis and John D. Williams
18. Calcium, phosphate and renal osteodystrophy 529
Alastair J. Hutchison and Ram Gokal
19. Noninfectious complications of peritoneal dialysis 555
Joanne M. Bargman
20. Peritoneal dialysis in children 591
Steven R. Alexander, J. Williamson Balfe and Elizabeth Harvey
21. Peritoneal dialysis in diabetic end-stage renal disease 639
Ramesh Khanna
22. Peritoneal dialysis in the elderly patient 661
Allen R. Nissenson
23. Quality of life 679
Ram Gokal
24. Outcome of peritoneal dialysis: comparative studies 699
Rosario Maiorca and Giovanni C. Cancarini
25. Registry results 735
Karl D. Nolph
26. The use of peritoneal dialysis in special situations 751
Sarah S. Prichard and Joanne M. Bargman
27. Intraperitoneal chemotherapy 769
Michael F. Flessner and Robert L. Dedrick
Index 791
Foreword
In May 1992 a landmark article entitled "Survival be withdrawn slowly at the initiation of dialysis
as an Index of Adequacy of Dialysis" was published therapy as the extracellular space is normalized by
by Charra et al. [1]. Although it was based only on aggressive ultrafiltration.
hemodialysis results, I believe it has important Despite the fact that hypertension was first impli
implications for peritoneal dialysis as well. cated back in 1978 by Haire and Sherrard [6] as a
The importance of this article is that their high risk factor for premature mortality among the
patient survival data are superior to any previously dialysis population, I believe that far too little
reported. The authors clearly recognized the pitfalls attention is paid to its control in the day to day
inherent in comparing survival data among various administration of renal replacement therapy. (I use
series. They employed sophisticated statistical the term renal replacement therapy to include the
methods to reduce these pitfalls to a minimum and pre-dialysis management of the patient, as well a
were careful to draw conclusions only when the treatment by both dialysis and transplantation).
survival data were clearly superior to data reported Also, I agree with Charra's suggestion that the def
by others for a similar sub-group of patients. inition of adequacy of dialysis should be expanded
Using old fashioned Kiil dialysis, each of the to include adequate control of blood pressure [4].
445 patients received 24 hours of long slow dialysis I believe that many of the points discussed above
a week. Since the average KTN was 1.67, under have important implications for the future of peri
dialysis, which has been shown to adversely effect toneal dialysis. Since this mode of therapy has only
mortality [2], was eliminated as a variable in this been in widespread use for a little over a decade, it
study. Similarly, the adverse effects of protein will be some time before long term survival can be
malnutrition [3] were eliminated as a variable since used to judge adequacy. Nevertheless, it is impor
protein intake was generous as indicated by an tant to begin now to initiate the proper studies
average protein catabolic rate of 1.43 grams/kglday including patient registries that will one day
and an average serum albumin of 4.1 gramsllOO ml. delineate what effect if any the time spent being
Thus the authors were able to concentrate on the maintained on peritoneal dialysis has on patient
two other controllable variables that can effect survival [7].
patient survival namely smoking and hypertension, In the meantime it is essential to monitor care
and to conclude that their superior survival rate was fully in each patient on peritoneal dialysis the four
due entirely to adequate control of blood pressure. controllable variables known to affect patient
This conclusion was made even more explicit in survival. These are: the dose of peritoneal dialysis,
a recent editorial by Charra [4]. He also offered adequate protein intake, avoidance of smoking and
further documentation to the principle, long adhered control of blood pressure.
to by our group [5], that the only way to control As to the first two variables, dose of peritoneal
blood pressure among dialysis patients is to nor dialysis and protein intake, it is important to
malize the volume of the extracellular space while develop similar methods to follow them [7], and to
phasing out antihypertensive medications. Dialysis express the results in terms that the patient himself
patients are resistant to antihypertensive medica can readily understand.
tions unless the extracellular space is normalized. Referring to the above discussion by Charra
At the same time, because they cause vascular regarding blood pressure control, it seems to me that
instability during ultrafiltration, these drugs make CAPD should offer the ideal mode of dialytic
it virtually impossible to gain control of blood therapy to control blood pressure without drugs,
pressure by using ultrafiltration to normalize the since removal of extracellular fluid is both constant
size of the extracellular space. These drugs should and easily adjusted as compared to hemodialysis
R. Goka/ & K.D. No/ph (eds.J, The Textbook of Peritoneal Dialysis, vii-viii.
© 1994 Kluwer Academic Publishers.
viii FOREWORD
with its inherent wide swings in extracellular 2. Held JH, Levin NW, Bovbjerg RR, Pauly MV,
volume. A recent publication presents data consis Diamond LH. Mortality and duration of dialysis treat
ment. JAMA 1991; 265: 871-5.
tent with this idea [8].
3. Lowrie EG, Lew NL. Death risk in hemodialysis
In line with Charra's opinion [4] that control of
patients: the predictive value of commonly measured
blood pressure is the variable most often neglected variables and an evaluation of death rate differences
in the care of patients on renal replacement between facilities. Am J Kidney Dis 1990; 15:
therapy, the subject of blood pressure control 458-82.
4. Charra B. Does empirical long slow dialysis result
received almost no mention in an otherwise excel
in better survival? Proc ASAIO (in press).
lent scientific meeting which compared overall
5. Scribner BH. Kidney Int (editorial) 1992; 41: 1286.
results of hemodialysis and peritoneal dialysis [9]. 6. Haire HM, Sherrard DJ, Scardapane D, Curtis FK,
BrunzeIl JD. Smoking hypertension and mortality in
Belding H. Scribner M.D. a maintenance dialysis population. Cardiovasc Med
1978; 3: 1163-7.
Seattle, Washington
7. Keshaviah P. Urea kinetic and middle molecule
March, 1993
approaches to assessing adequacy of hemodialysis
and CAPD. Kidney Int 1993; 43 (suppI40): S28-38.
References 8. Saldanha LF. Weiler E, Gonick HC. Effect of con
tinuous ambulatory peritoneal dialysis on blood
1. Charra B, Calemard E, Ruffet M, Chazot C, Terrat pressure control. Am J Kidney Dis 1993; 21: 184-8.
JC, Vanel T, Laurent G. Survival as an index of 9. Nolph KD, Henderson LW. Options in renal therapy.
adequacy of dialysis. Kidney Int 1992; 41: 1286-91. Kidney Int Supplement 40, Feb 1993.
Preface
Textbook of Peritoneal Dialysis
In 1986, the first edition of Continuous Ambulatory and even physicists are involved in studies to better
Peritoneal Dialysis, edited by R. Gokal, was understand peritoneal dialysis. The complexities of
published. In 1989, the third edition of Peritoneal peritoneal dialysis and the peritoneal membrane are
Dialysis, edited by K. D. Nolph, was published. becoming apparent. Studies of peritoneal dialysis
Rather than edit new editions of each of these books increase understanding of the anatomy and physi
separately, we have decided to combine our efforts ology of biological membranes and the factors
to edit this single book which is called The Textbook influencing the paths for movement of solutes
of Peritoneal Dialysis. across the microcirculation and related structures.
Peritoneal dialysis represents an internal tech Peritoneal dialysis provides a "window" to the
nique for blood purification. In this dialyzer, the visceral microcirculation in animals and in humans.
blood path, the membrane and the dialysate Peritoneal dialysis may be useful to treat
compartment are provided by nature. Interest in and problems other than renal failure. Beneficial effects
utilization of peritoneal dialysis has been stimulated in the treatment of dysproteinemia, psoriases,
by the developments of chronic peritoneal catheters, hypothermia and metabolic problems have been
automated cycling equipment, manipulations of reported. The intraperitoneal administration of
transport, experiences with continuous ambulatory chemotherapeutic agents draws upon and con
peritoneal dialysis, experiences with peritoneal tributes to our understanding of peritoneal dialysis.
dialysis using cyclers, decreases in peritonitis rates This book contains a chapter dealing with the
with new connection approaches and better defini concepts of intraperitoneal chemotherapy.
tions of adequate peritoneal dialysis. New advances The editors feel fortunate to have been involved
in our understanding of the physiology of peritoneal in peritoneal dialysis research and development for
dialysis (including the role of peritoneal lymphatics) over 50 years of combined experience. New ideas
and peritoneal dialysis kinetics are examples of the and new developments have been an almost daily
dynamic nature of the field. occurrence. Yet, our understanding of this dialysis
Publications related to peritoneal dialysis usually system is still in its infancy. The authors of the
exceed 400 annually. Peritoneal Dialysis Interna chapters in this book have been actively investi
tional, the official journal of the International gating and writing about their respective topics for
Society for Peritoneal Dialysis, is a journal solely many years. Most are individuals with whom we
devoted to peritoneal dialysis experiences and have had the good fortune to have had frequent
development. The Sixth Congress of the Interna contacts. Many coauthors of chapters have some
tional Society for Peritoneal Dialysis was held in what different opinions, and yet, they have made an
Thessaloniki, Greece, in 1992. The next meeting effort to combine their thoughts in a single chapter.
of this international society will be held in As in our previous books, each chapter is an
Stockholm, Sweden, in 1995. The 13th Annual extensive review of a given topic. We have not
Peritoneal Dialysis Conference was held in San edited out all overlap between chapters since we
Diego, California, in 1993 and attracted 2,500 feel the reader benefits by exposure to slightly
participants from 40 countries. At this time, more different perspectives of complex material, and this
than 70,000 patients are estimated to be maintained allows each author to deal with all issues that relate
on chronic peritoneal dialysis worldwide. to his respective topics.
This book is meant to provide an overview of the We hope that this book will serve as a reference
state of the art of peritoneal dialysis. Many clini text for all those with more than a casual interest
cians are making extensive commitments to peri in peritoneal dialysis.
toneal dialysis. Nephrologists, anatomists, physi
August 1993 Ram Gokal
ologists, pharmacologists, biomedical engineers,
Karl D. Nolph
R. Gokal & K.D. Nolph (eds.), The Textbook of Peritoneal Dialysis, ix.
List of Contributors
Stephen R. Alexander Gerald A. Coles
University of Texas Institute of Nephrology
Health Science Center Cardiff Royal Infirmary
Dept. of Clinical Pediatric Nephrology Newport Road
523 Harry Hines Blvd. Cardiff, Wales CF21SZ
Dallas, TX 75235-9063 United Kingdom
U.S.A.
Robert Dedrick
Stephen R. Ash 1633 Warner Ave.
Ash Medical Systems, Inc. McLean, VA 22101
2701 B. Kent Avenue U.S.A.
West Lafayette, IN 47906
U.S.A. Jose A. Diaz-Buxo
Metrolina Kidney Center
J. Williamson Balfe 928 Baxter Street
The Hospital for Sick Children Charlotte, NC 28204
555 University Avenue U.S.A.
Toronto, Ontario M5G 1X 8
Canada George E. Digenis
48 Dekelia Street
Joanne M. Bargman Aharnes, Attika
Division of Nephrology Greece 13671
Dept. of Medicine, ECW 7·034
Toronto Western Hospital James W. Dobbie
399 Bathurst St. Baxter R&D Europe, S.C.
Toronto, Ontario M5T 2S8 Pare Industriel
Canada Rue du Progres, 7
1400 Nivelles
Jonas L. Bergstrom Belgium
Department of Renal Medicine
K 56, Huddinge University Hospital Nicholas V. Dombros
Karolinska Institute Karolov Diehl 13
S-141 86 Huddinge 54623 Thessaloniki
Sweden Greece
Marc Bogaert Mariano Ferriani
Heymans Institute of Pharmacology Department of Nephrology
University of Gent Medical School St. Bortolo Hospital
Gent, Belgium 36100 Vicenza
Italy
Giovanni C. Cancarini
Department of Nephrology - Spedali Civili
Pizzo Ospedale, 1
Brescia
Italy 25125
R. Gokal & K.D. Nolph (eds.), The Textbook of Peritoneal Dialysis, xi-xiv.
Xli LIST OF CONTRIBUTORS
Michael F. Flessner William F. Keane
Box 675, Nephrology Unit Professor of Medicine
Department of Medicine University of Minnesota School of Medicine
University of Rochester Hennepin County Medical Center
601 Elmwood Ave. 701 Park Avenue
Rochester, NY 14642 Minneapolis, MN 55415
U.S.A. U.S.A.
Ram Gokal Prakash Keshaviah
Department of Renal Medicine Baxter Clinical Engineering Laboratory
Manchester Royallnfrimary 825 S. 8th Street - Suite 722
Oxford Road Minneapolis, MN 55404
Manchester, England M13 9WL U.S.A.
United Kingdom
Ramesh Khanna
D. Neil Granger Division of Nephrology
Dept. of Physiology and Biophysics MA 436 Health Sciences Center
Louisiana State University Medical Center University of Missouri
1501 Kings Highway Columbia, MO 65212
P.O. Box 33932 U.S.A.
Shreveport, LA 71130-3932
U.S.A. Ronald Korthius
Dept. of Physiology and Biophysics
Elizabeth Harvey Louisiana State University Medical Center
The Hospital for Sick Children 1501 Kings Highway
555 University Avenue P.O. Box 33932
Toronto, Ontario M5G 1X 8 Shreveport, LA 71130-3932
Canada U.S.A.
Przemyslaw Hirszel Raymond T. Krediet
Professor of Medicine Renal Unit
Department of Medicine Academic Medical Center
Nephrology Division Meibergdreef 9
Uniformed Services University Amsterdam 1105 AZ
of the Health Sciences The Netherlands
4301 Jones Bridge Road
Bethesda, MD 20814 Frank L. Kriger
U.S.A. Division of Nephrology
Georgetown University School of Medicine
Alistair J. Hutchison 3800 Reservoir Road, N.W.
Dept. of Renal Medicine Washington, DC 20007-2113
Manchester Royal Infirmary U.S.A.
Oxford Road
Manchester, England M13 9WL Giuseppe LaGreca
United Kingdom Department of Nephrology
St. Bartolo Hospital
Via Rodolfi
36100 Vicenza
Italy
