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Peritoneal dialysis

Peritoneal dialysis: what you need to know

Currently, in Australia, nearly 25 per cent of people on dialysis are using peritoneal dialysis (PD). About 40 per cent of new patients choose peritoneal dialysis as their first treatment or while they are waiting for a transplant.

There are two types of PD:

  • continuous ambulatory peritoneal dialysis (CAPD) - the day-time bags

  • automated peritoneal dialysis (APD) -  the overnight machine

Both use the same catheter (tube), which is placed in the abdomen (tummy). Special PD fluid is used to clean your blood. It is changed regularly. In between fluid changes, you can carry out your normal activities. Most people choose the overnight machine and have the dialysis while they sleep. You can find more information below.

Choosing the right option
You are ready to choose when you’ve learned everything that you need to know about each option. That means finding out the information that’s relevant and understandable to you.

My Kidneys, My Choice’ is a useful decision aid that will help you to make your choice. You can find a lot of helpful advice, including information about the decision-aid here.

Alternatively, our fact sheets and other helpful information can be found in our Resource Library.

Your Kidney Forum
You may also wish to visit our onsite forum to read about the experience of others on dialysis, ask a question or to post about your experience on dialysis. Visit Your Kidney Forum here.

Your life & PD

Your current lifestyle will be one of the main factors to consider when you make the decision about the type of treatment for your dialysis. If you have the treatment that fits best with your life then it will be easier to stay on track.

There are two forms of peritoneal dialysis

  • Continuous automated peritoneal dialysis (CAPD)
    The other form of PD is CAPD, where you manually use bags to do the dialysis instead of a machine. 
  • Automated peritoneal dialysis (APD)
    Using the automated cycler, known as automated peritoneal dialysis (APD), takes about 30 minutes to prepare and about 15 minutes to disconnect. The dialysis is all done overnight while you are sleeping. Some people need an extra bag exchange at teatime to remove extra fluid. 

The daily routine for PD can be flexible when you have special appointments or social events. Doing occasional bag exchanges early or late will not cause any long-term problems.

The length of time PD sessions take
Using the manual bags, known as continuous ambulatory peritoneal dialysis (CAPD), takes about 30 to 40 minutes and needs to be done four times a day. Of this time, ten minutes are spent connecting and disconnecting the bags and the remaining time is spent sitting down while the dialysis fluid goes in and out.

The usual times to do this are first thing in the morning, then around lunchtime, late afternoon and at bedtime. While the fluid goes in and out you can keep yourself occupied by doing things such as reading, watching TV or working on a laptop.

Where to do PD
The manual bags, CAPD, can be done anywhere you have a clean surface, a dust-free environment, and can wash your hands.

Many people do a CAPD lunchtime bag at work or at the homes of family members. People have changed their CAPD bags in their cars when travelling.

The APD machine can be used wherever you can plug it in and lie down. Bed is the preferred option.

Effect of PD on diet
Once you start PD you can usually eat and drink most things in moderation, but a healthy diet is recommended, including about four to six cups of fluid each day.

Everyone is different. Your dialysis healthcare team will check your blood results regularly and a dietitian will help you with any special needs for your diet.

Work and PD
You can work while on PD, but if you have a job that’s very physical or exposed to dust or dirt, you’ll need to take special care of the catheter.

Most people who work are on overnight APD, but at most workplaces you can do a CAPD bag exchange in the lunch break.

We have a useful resource for your employer about work and PD, which you can download here.

Swimming, sport and exercise
Once your PD catheter exit site has healed you can swim, but public pools are not recommended because of the risk of getting an infection. It’s preferable top swim in the ocean or a private pool that is well maintained. You can also take up or continue any other sport or exercise that you are physically capable of doing. You can see more about exercise and sport here.

Intimate relationships
You can continue intimate relationships while on PD. You’ll have the catheter to consider but this can be concealed by a bandage or dressing. 

Travel and holidays
Many people travel while on PD. If you’re doing APD you can travel with the bags or take the machine. For local travel in your car you just need to put the bags in the car.

Longer journeys and interstate travel require planning but your dialysis supply company can deliver the bags to your holiday destination. This includes when you’re travelling overseas, although for delivery to some countries there may be a cost involved.

You can see more about dialysis and travel here.

Costs associated with PD
PD supplies are free of charge and are delivered at no cost to your home, usually once a month. You’ll have to pay for medications, a set of scales and occasional supplies such as paper towels or gauze dressings that are not provided by your hospital.

Ask your dialysis healthcare team for more information about extras that you may need to purchase.

Required check-ups
The typical requirement is to go to the dialysis unit once a month for a check-up by your healthcare team.

Your kidney specialist will usually want to see you once every three months. No other trips to a hospital or clinics should be required in relation to your kidney disease.

Useful resources
’Introduction to PD’
This video introduces you to people on PD who talk about what it’s like to be on this form of dialysis. It provides a revealing account of the effects of PD on everyday life and how it can fit into your lifestyle. (Production of the video was supported by funding from the Federal Government through the Chronic Disease Prevention and Service Improvement Fund). You can watch this video here.

‘An Introduction to Home Dialysis’ 
This easy-to-read booklet focuses on all types of home dialysis and how they will fit into your life. You can download this booklet here.

‘Home Peritoneal Dialysis’
Our fact sheet provides a quick summary of important details about PD, with supporting photographs. Download the fact sheet here or you may prefer to read the simpler photosheet here.

Continuous ambulatory peritoneal dialysis (CAPD)

Continuous ambulatory peritoneal dialysis (CAPD)

Continuous ambulatory peritoneal dialysis (often just called ‘the bags’) is one type of peritoneal dialysis. It cleans your body, helps to control the water and replaces the work of the diseased kidneys.

CAPD is the most portable type of dialysis. It uses manual bags containing peritoneal dialysis fluid. It is done every day, via your peritoneal cavity, with bag changes four times a day. It can usually be learnt in about a week and does not require needles. The lady below is connected for her bag change.

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Your peritoneal cavity

The peritoneal cavity is the place in your lower abdomen (tummy), around your belly button, where you can put in the dialysis fluid to do your PD.

The peritoneal cavity has a lining called the peritoneum. There is one layer at the front under your skin and one on the inside around your organs. Usually a small amount of fluid sits in your peritoneal cavity, allowing you to move easily. The peritoneum usually protects your insides, especially the bowel and the bladder and the female reproductive organs. 

It is this space inside the peritoneal cavity where the peritoneal dialysis fluid goes. It can easily fit large amounts of fluid. To get the fluid in you need a catheter.

The peritoneal catheter

The catheter, also called the tube or Tenckhoff, is a soft tube about the thickness of a pencil and 30 to 40 centimetres long.

During a simple operation the catheter is placed into the peritoneal cavity, with about 10 to 15 centimetres being kept outside of the body.

The part of the tube in the peritoneal cavity has lots of tiny holes to allow the dialysis fluid to go in and out. The part under the skin has a cuff, a bit like Velcro, to keep it in place.

The part outside the body has a special connector on the end, to which a short extension tube is then attached. The special peritoneal dialysis fluid bags can be attached to the extension tube when dialysis is needed. The extension tube can be changed easily at the dialysis unit every six months. This is how the catheter looks between exchanges.

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The PD fluid bags

PD fluid is the fluid that’s put into the peritoneal dialysis cavity through the catheter.

It’s a pure fluid and is made to attract water and waste from your blood, through the peritoneum. Each PD bag has about two litres of fluid in it. To give you an idea how much fluid that is, pick up a two-litre carton of milk.

The amount of PD fluid fits easily into the peritoneal cavity in your abdomen, but may slightly increase your waistline size. At first the fluid may feel unusual but most people get used to it very quickly.

The PD bag change

You need to change the bag of fluid regularly, usually 4 times a day, a bit like having to go the toilet regularly.  Each change of bag is also known as an exchange or PD cycle. Each change involves:

  • connecting a new bag of fluid and a drain bag (5 to 10 minutes)
  • draining out the old fluid into the drain bag (15 to 20 minutes)
  • draining in the new fluid (10 minutes)
  • disconnecting the fluid and drain bag (2 minutes).

While the old fluid is draining out and the new fluid is running in, you can sit or lie down and either relax or do activities that don’t require you to move about.

When the old fluid is drained out of your body, it contains the wastes and unwanted water.

How PD cleans the blood

Here’s a scientific explanation of how the PD process cleans the blood, using osmosis and diffusion.

Osmosis is when the water moves across a membrane (the peritoneal membrane) from an area where there is excess water (blood) to an area with less water concentration (dialysis fluid).

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The dialysis fluid is concentrated because it has a lot of glucose in it, which attracts the water. Different bags have different levels of glucose. The water removal can be changed by altering the bags.

Diffusion is when electrolytes (waste products) move across a membrane (the peritoneal membrane) from an area of high concentration (blood) to an area of low concentration (dialysis fluid).

Urea, creatinine, potassium and phosphate are among the electrolytes that travel from the blood to the dialysis fluid. Bicarbonate is an electrolyte that travels from the dialysis fluid into the blood where it is needed.

Useful video links
Here are links to some informative videos you may find helpful.

‘How does CAPD work?’
This video provides descriptions of how CAPD works by a patient as well as a dialysis nurse. A simple animation helps explain what happens during dialysis. You can watch this video here.

‘How Does Peritoneal Dialysis Work’
This short video from the USA features health professionals explaining how PD works. You can watch this video here.

‘CAPD – Patient Video’
This short home video was made by a woman in the UK who manages her own PD. You can watch this video here.

‘Matt’s story’
Matthew is blind but he has maintained his independence by learning to do CAPD. He shares his inspiring story about how he continues his passion for car racing despite needing dialysis. You can watch this video here.

Automated peritoneal dialysis (APD)

Automated peritoneal dialysis (APD)
APD is the other type of peritoneal dialysis. It uses the same peritoneal catheter and the same peritoneal cavity as CAPD. The blood is cleansed in the same way.

APD is also known as Continuous Cyclic Peritoneal Dialysis (CCPD). Other terms you’ll get to hear often are ‘the machine’ or ‘the cycler’. They all mean the same thing.

The use of APD has been increasing in Australia and there are now more people using APD than CAPD.

The difference between the two methods is that with APD a machine is programed to control how much fluid goes in and out and how often this happens.

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Firstly, the machine is prepared with lines and these are connected to about 10 to15 litres of fluid, usually in bags containing five or six litres. The end of the line from the machine is connected to the catheter at bedtime and remains connected all night, for eight hours on average.

The fluid that comes out may go into a large drain bag or, if it is close enough, straight down the drain using a drain line.

The machine is programmed to control the fluid movement, using a series of clamps and pumps. It controls when the fluid should drain out and when new fluid should be put in.

As everyone needs different amounts of dialysis, the machine will be set up to suit your individual requirements.

Animations demonstrating APD
This series of four animations illustrate the process of doing APD, produced by the Home Dialysis First Project at Monash Health in Victoria. You need Adobe Flash Player installed to view.

Prepare and prime the machine

Getting ready for bed

Exchanges through the night

Good morning and disconnect

The amount of dialysis
You get as much dialysis as you do on CAPD. On average, five to eight exchanges (cycles) of about two litres each go in and out of the peritoneal cavity overnight.

When the last cycle occurs, many people have fluid put in, which will continue the dialysis during the day. Some people have a ‘dry’ day with no dialysis fluid in the peritoneum. Some people need lots of dialysis and may do an extra bag change at dinner time to improve their dialysis.

Interruptions to sleep
Most people take a few days to adjust to sleeping while connected to the machine. There are lights on the machine but they can be dimmed down for sleep. It’s very quiet but not silent.

Occasionally an alarm can go off, particularly if you lie on the tube at night. The alarm will sound to let you know that you need to move so the fluid can continue going in and out.

Coming off the machine overnight
You can occasionally come off the machine overnight, but it does increase the risk of infection. If you need to get up and down through the night then APD might not be for you. If this is a concern for you, discuss it with your dialysis healthcare team.

Cost of running the machine
The machine uses electricity at the rate of a normal light globe, which is about 0.1 kilowatt-hours (kWh). In most states there are reimbursement schemes that cover electricity costs.

You can see more about the schemes and other financial support here.

When the machine is not working or you’re travelling
If the APD machine is not working or you are travelling, you can use manual CAPD bags. Most dialysis units will provide training in the use of CAPD bags, just in case you need them.

Prior to starting APD, many people do CAPD for about six weeks to let their peritoneum settle down and get used to the dialysis and the fluid control. You need to make choices that suit you.

Machine types
APD machines are made by various companies and, like different models of TVs, they do the same thing in slightly different ways. The most commonly used APD machines in Australia are the Baxter Homechoice and the Fresenius Sleep-safe.

Your dialysis healthcare team can advise which of the available machines best suits you.

Useful video links
Here are links to two informative videos you may find helpful.

‘How does APD work?’
This is a home video showing how to use the Baxter HomeChoice APD machine. Please note the technique used may be different to that taught by your dialysis healthcare team. You can watch this video here.

‘How does automated PD work?’
This video provides a description of how APD works by a patient as well as a dialysis nurse. A simple animation helps explain what happens during dialysis. You can watch this video here.

Getting started

Getting started on PD
Here’s some vital information about steps to be taken and decisions to be made when you’re starting on PD.

Choosing when and where to insert the PD catheter
You will be referred to a surgeon and the first step is to plan the surgery together. Ideally, the catheter (tube) will be inserted about a month before you need dialysis.

Prior to the operation, you and your PD nurse will decide where the tube and connector will come out of your abdomen. It’s important that the tube is in a comfortable place and you can easily see it to do your dressings. Usually it will be just below the belly button, to the left or the right.

Another option is a pre-sternal tube, which is tunnelled and exits the body in the middle of the chest. This is also known as a bath-tube.

How the PD catheter is inserted
Most surgeons use a technique where a tiny hole is cut in your abdomen to allow the catheter to be inserted. This is known as a laparoscopy.

About 10 to 15 centimetres of the tube will be outside your body. The point where it exits the body is known as the exit site.

The operation is relatively short. Most people only need to stay overnight in the hospital, but this varies depending on your general health and your surgeon’s advice.

‘Burying’ the catheter
If the tube is not required for a while, the surgeon may ‘bury’ the tube. At a later date a quick procedure will bring it out ready for use.

Burying allows the inside of the body to heal and reduces the risk of infection around the catheter exit site.

Pain after the surgery
As with any surgery there will be some short-term discomfort, which will be managed with mild painkillers.

If you have long-term pain, or pain develops later across your abdomen, let your dialysis healthcare team know immediately in case there’s an infection that requires treatment.

Taking care of the catheter exit site
The first six weeks are critical in the healing of the exit site. Good care will help ensure healing for the long term.

The general recommendation is that that the catheter is not disturbed for at least one week. The site is then dressed for four to six weeks until healing is complete. The dressings must be kept dry. During this time, special cuffs on the catheter inside your body act like anchor points and prevent the catheter from falling out.

Once the site has healed you can shower every day and put a dressing on the exit site as shown by your healthcare team. Some people choose to have no dressings and just secure the tube with a piece of tape.

The exit site can become infected, particularly if you don’t look after it. You should be prescribed an ointment to help prevent infections. The ointment may also be applied to the nose, which can be a site for infections.

If an infection occurs, you may need to have antibiotics and keep the exit site dry until the infection is healed. 

Looking after the catheter until dialysis begins
In the early days, if the catheter is not being used or if there’s blood in it, your healthcare team may run a small amount of PD fluid in and out of the tube to check it’s working properly.

This is often also done when you are ready for training; however, it’s not essential and hospital practice will vary. Otherwise, keep the catheter protected. Ask your dialysis healthcare team about catheter belts, which are designed to protect the tube.

The right time to start dialysis
After the catheter has been inserted you will continue to have blood tests and your general health will be monitored.

The time to start dialysis will be a decision that you and your healthcare tram make together. Often the catheter is rested for at least two weeks before dialysis begins.

Useful resources

‘Getting Started’
This video provides a brief snapshot of what to expect when you have chosen PD - watch it here.


Training for PD

Time for Peritoneal Dialysis (PD) training

Starting training
To learn PD you need to go to a specialised training clinic. This may be in your hospital or a community setting. Often home training is attached to a dialysis unit.

The PD nurses at the clinic are specialists in this treatment and, as well as helping you to learn, will support you at home and can become an extended part of your family.

Some people are trained in their own home. If you think this would be better for you, ask your PD nurses if a home service is available. Sometimes a specialist trainer from a PD supply company can also provide training in your home.

Learning to do PD
Doing your PD alone at home only happens once training is complete and you and the training team are satisfied you have the skills.

On average, training takes a week for CAPD and an extra three to five days for APD. You can make a request for family members or support persons to be involved.

Videos, booklets, information sheets, demonstrations and practice are some of the ways the training team support your learning.

Not only will you get to know all about PD but you’ll also learn how to solve problems that may arise, and how to live a healthy lifestyle while on PD.

Most people begin with CAPD.

If you’re planning to do APD and you can wait to start this type of dialysis, the additional machine training takes one or two days and usually occurs after about six weeks, once you’ve got used to PD. 

Useful resources
More information is available in an easy-to-read booklet ‘Introduction to Peritoneal Dialysis' which can be downloaded here.

You can watch a video about training and peritoneal dialysis here.

For people who have later stages of kidney disease we recommend you:

  • visit our ‘Treatment for kidney disease’ section of this website here
  • order and purchase our ‘Living with Kidney Failure: Your Extensive guide' handbook here.
  • download any of our many free fact sheets from our  Resource Library.

Problem solving

Problem solving while on PD
As you’d expect, treatment for chronic kidney disease will not run smoothly all of the time.

When problems occur, there’s no substitute for advice from your dialysis healthcare team. You will receive training in how to deal with issues and advice about when to call your training clinic or hospital for assistance.

Here we describe some of the medical problems that may occur. This information can also help you decide which type of treatment suits you best and also shows how important it is to manage your dialysis as you are taught.

Peritonitis is an infection in the peritoneal cavity. With people on haemodialysis in Australia, this occurs on average once every two years, but please be aware many people never get peritonitis.

The infection occurs when bacteria (bugs) get into the peritoneal cavity, usually through the catheter. It can be prevented by washing your hands, looking after your catheter and doing your bag changes how you are taught.

If you get peritonitis you will feel unwell and have cloudy bags, stomach pain and maybe fever.

It’s very important that you call your dialysis healthcare team and go to hospital immediately in order to be treated with antibiotics. Quick treatment usually leads to a quick recovery.

Around eight in ten infections are cured by the antibiotics, but some may lead to loss of the PD catheter, temporarily or permanently. 

Blocked PD catheter
Sometimes the fluid will not flow in and out through the catheter as quickly as usual, or not at all. This is known as a blocked catheter.

The problem is most commonly caused by constipation, or a piece of fibrin (clotting material from your body) in the tube, or a poorly positioned catheter.

You will know you have a problem if the PD fluid will not flow in or out, or flows very slowly, or you cannot get all the fluid out.

Usually a blocked catheter is easily fixed but sometimes the tube will need to be replaced.

Constipation is when your bowels are not opening regularly and easily. People on PD and with chronic kidney disease and diabetes are more at risk. It can be caused by not eating enough foods with roughage or having a sluggish bowel.

Signs you’re getting constipated can include the PD fluid flowing very slowly, a gain in your weight, and your abdomen feeling swollen.

The problem can be prevented by eating a healthy diet, exercising, and using prescribed medicines. Many people on PD take a mild laxative such as lactulose daily. You may need to contact your dialysis healthcare team or a dietitian for advice.

Your PD should be okay once the constipation is resolved.

Exit site infection
This is an infection around the site where the PD catheter comes out of your abdomen. It’s caused by bacteria (bugs) getting into the exit site, which can happen if the exit site is left wet after your shower.

You can prevent infection by looking after your exit site as you’ve been taught and by using a prescribed ointment. The ointment may also be applied to the nose, which can be a site for infections.

If your exit site is infected it will be sore, red, discharging or swollen. To fix the infection you will need to see your doctor or PD nurses, keep the exit site dry and treat it with antibiotics or an ointment as prescribed.

In most cases, especially if treated quickly, the exit site will heal; however, if it doesn’t, temporary tube removal may be necessary. 

Useful video
‘Challenges on PD’
This video addresses some of the challenges you may experience when on PD, and how you can deal with them. You can watch this video here.

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