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Peritoneal Dialysis - Past, Present and Future - (full conference transcript)

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Jaqueline Campbell

I'd like to thank the committee for asking me to speak today, and I'm here to tell you a little bit about the history of peritoneal dialysis, it's a lesser known replacement therapy, about where we are now with it, and finally to speculate about what will be happening in the next few years.

I thought that I might start off with what peritoneal dialysis is, because some of you may not know. Peritoneal dialysis is a natural dialysis; it is almost natural dialysis, though no dialysis is natural, but it utilises one of the bodies' natural membranes, your peritoneum, which is a large sac that holds all your organs in place, even your new kidney (see Diagram to the left). We infuse fluid through a surgically inserted catheter, then to the peritoneum, and whilst the fluid is inside the peritoneum cavity, dialysis takes place. Now this happens by osmosis and diffusion, natural processes. The fluid stays there for a while, whilst you go about your normal daily routine, I'm sure there's quite a few that are dialysing right now as I am talking. After a few hours, the fluids are exchanged for a new fluid, and the process begins again. There are two types of peritoneal dialysis, there's APD, which is Automated Peritoneal Dialysis, and there's CAPD, which is Continuous Ambulatory Peritoneal Dialysis. Now CAPD is the one that most people know because it has been around the longest, and it's four exchanges in the day. So in the course of 24 hours, you'll change that fluid four times. APD happens via machine and the exchanges are concentrated overnight, whilst you're sleeping.

So that's what peritoneal dialysis is, in a nutshell, but how did it begin? Peritoneal itself was first mentioned in 3.000 BC by the ancient Egyptians. Now they tried to treat renal impairment by purgative of beer. Next, Christopher Warwick in 1740 tried to treat a patient with a collection of fluid in their abdomen with Bristol water and claret wine. Are you beginning to get the pattern? I have to just clarify that the only alcohol we use nowadays is the stuff we use to clean our hands. The Bristol water and claret wine was used as lavage, that had limited success for a short while but it was not until 1923 that George Ganter used the peritoneum successfully to treat a patient suffering from renal failure following childbirth. Unfortunately after the initial success, he got the blood results back to normal and he stopped, he didn't realise that this would have to be an ongoing process until she either fully recovered her kidney function, or for the rest of her life. But he did make a precedent for modern PD.

Next; the major step was in 1936, in the USA. A group of doctors used PD on a patient suffering from repeat renal failure. This time they realised that the process had to continue, and they were successful. During the time of war and conflict, new challenges arise from the need to treat large groups of patients under restrictive circumstances. WW2, Vietnam and the Korean wars, all provided a springboard for the development of dialysis that was portable and could be used in the front line. The development of peritoneal dialysis fluid and plastic bags then came into vogue. Before that they used 40 litre or 20 litre drums, which you really couldn't get into the battlefield.

So until then, PD was considered to be acute treatment, it was still only seen as the stepping-stone until haemodialysis or until the kidneys recovered function. But in 1975, Jack Moncrief, who was a doctor in Texas, and Robert Popovich, an engineer, and it took an engineer to suss it out in the very end for us, moved to CAPD. Popovich came up with the concept of leaving the fluid in for a while, because before that it was always washed out, and it didn't quite get the results, so he came up with the dwell time concept, which then began to work, and then by 1976, Dimitrios Oreopolis had established the first proper PD programme in Toronto Western Hospital (in Canada). He was inspired by the time he spent in Belfast as a resident. So we kind of claim a bit of UK kudos there as well. The PD programme was bred from the tightening of hospital resources, and also from patients who wanted a less life consuming therapy. They were finding they were spending far too much time in hospital, so it's all a bit familiar. You can tell it's been a long slow slog to get to where we are today, and most of the gap years, having been filled in with various technique and system modifications, for example there have been many different types of access.

First of all we had leather tubing (see table to the left), which doesn't sound to bad, we had rubber tubing, and then for some bizarre reason we had metal tubing, can you imagine that?. It was probably because it wasn't an ambulatory process and the patient was bedbound at the time, so kind of got away with it. We then progressed to two catheters, and then with the advent of plastic, things took off.

Now the first indwelling permanent catheter was in 1959, and you might wonder why it took so long to get that, but before that, doctors went to the patient's house, inserted the catheter, he went twice a week, and the patient then stayed on peritoneal dialysis bedbound, for 48 to 72 hours. Now thank goodness Tenckhoff then invented this permanent catheter in 1962, and incidentally that is the one we still use (see photograph below/right, with an xray, to the left, showing the Tenckoff in situ and, to the right, a patient with the catheter exiting the abdomen) today.

The delivery systems - but don't get them confused with your boxes being delivered to your door - we're talking about the method in which we instil the fluid. There's been little change in the way the peritoneal dialysis has been administered over the past few years, and really it's the same procedure as Oreopolis's programme in the 1970's. The procedure still involves instilling the solution through the catheter, however, we have seen various devices to help us transfer the fluid. The biggest advance had been the disconnect system, where you only have the catheter left and you aren't carrying the bag around all day. And the twin bag system, where the fluid comes in a full bag that drains in, and an empty bag for you to drain out. However the biggest move nowadays is towards CAPD and although Automated Peritoneal Dialysis has been around there is a little wonder that it hasn't been largely subscribed to before.

[A picture of a Koff dialysis machine (see phtograph to the left; Koff machine is on the left; PackX machine is on the right) was shown on the screen and Jackie goes on to discribe it]

This is gravity fed peritoneal dialysis system, which was used in Holland in the 1940's. More recently was the PackX, now some of you may know of this machine, and that was only decommissioned earlier this year. So APD today is a much-changed system, we now have machines that are portable (see photograph below/right of modern APD machine with patient dialysing at night), which allow you to go on holiday and have freedom of choice and they are safe to use. Using the machine to do overnight dialysis allows you the freedom for the rest of the day. Whist you are able to make optimum use of the peritoneum with less abdominal pressure being exerted, you also have ease of set up, less connections and therefore less chance of infection.

By starting off CAPD with Bristol water and claret wine, back in 1740, Warwick opened up a whole can of worms! Many types of solutions have been used over the years with differing results. Indigo, calamine, and Methaline Blue have all been used before 1920, when Cunningham discovered that glucose gave the best results. Since then it has been used as the best dialysis solution to date, however there have been moves to deal with the complications which commonly arise in PD with the development of solutions. These solutions can help treat malnutrition, and ultrafiltration failure. This is when the peritoneum can no longer pull off fluid. To these problems are added peritonitis, which is an infection of the peritoneum, and membrane failure, when the peritoneum eventually just packs in. These are the main problems with patients having to stop PD and transfer on to haemodialysis.

Peritonitis is best fought with common sense and good systems, but the state of the art fluids we now have are called biocompatible, and they hopefully will help preserve the peritoneal membrane for longer, meaning that you can stay on the therapy of choice for a much longer time. These fluids try to emulate the natural peritoneal environment and are becoming more refined all the time.

The downside of peritoneal dialysis now, and there are probably few people that will agree that there is a downside to peritoneal dialysis, but there is. Unfortunately it's not suitable for all patients. People who have undergone major abdominal surgery, have a stoma, or suffer from chronic severe back pain might not be considered suitable for this type of therapy because of the weight of the fluid. Also because it is a self-care therapy, you have to be motivated to do the exchanges yourself, and of course there's a procedure to learn, however this isn't always as difficult as it often seems. Infection is synonymous with peritoneal dialysis, and it's a horror. But as I mentioned, peritonitis rates have lessened recently, and with improved systems and keeping to the correct procedure, with hand washing and all that sort of thing, then it does minimise the risk.

PD is a nurse-led therapy, now is this a downside or not? What I mean by a nurse-led therapy is that the nurses in peritoneal dialysis are the experts, the doctors tend to take a bit of a back seat and let the nurses get on with it. And that frees up their time to care for the patients in hospital and it means that you also have an expert resource in your nurse there. Now that's an excellent set up in that your always going to have your nurse on the end of the phone, but the reason it's a downside, and I'm sure Maddy will go into this as well, is that when people go in for their pre dialysis options in clinic or whatever, the doctor might come across as being more positive towards haemodialysis because he doesn't know as much about peritoneal dialysis. And that always makes PD seem to be a bit of a lesser therapy. Perhaps the most important downside of peritoneal dialysis, because it's not really very exciting, it's never on the TV because there's nothing to see. As you know, some of you will be dialysing here as I speak, and it's not really very exciting watching you lot out there, so that's why it's not on the TV and nobody knows about it.

So, what can we expect from peritoneal dialysis today? We've got solutions, we've got biocompatible solutions, and we've got APD, we can hope to stay on PD for a longer time in general. What else can we expect? As I mentioned earlier, the peritonitis rates have improved, and on average we can expect peritonitis once every 18 months on therapy, that doesn't mean to say that if you're on therapy you aren't going to get peritonitis after 18 months. Some people get it more often; some people get it less often. It's on average there will be an episode of peritonitis per person every 18 months in your unit or less. Treatment nowadays is much more flexible. It allows more freedom, and it's more appealing to a wider group of patients than ever it did before. Systems are more sophisticated, and you can get all the back-up that you could ever want. All this means is that patients who choose PD can now expect to stay on the therapy for a longer period of time than they could have, say maybe five years ago.

So on current trends, where is PD today? Recent studies have shown peritoneal dialysis to be the treatment of choice for patients who wish a kidney transplant, due to the reduction in the long-term changes in the body associated with any treatment of renal failure, and it does help maintain your residual renal function a bit longer so your body kind of appreciates this, staying a little bit healthier. It has long been thought of as a treatment of choice for diabetics and for children. It's a long slow continuous process and it also preserves your haemodialysis access and minimises long-term complications. So you can see if a child is going to need dialysis, we want to preserve their access for as long as possible. Nowadays the most forward thinking of physicians are moving away from the number crunching, and targets that they used to aim for. We used to say you had to have a creatinine clearance of 60, it didn't matter how you felt but there's lots of recent studies proving that more holistic approach looking at how your actually feeling and listening to what your saying about how your treatment is going are better markers for dialysis adequacy. So we don't now adhere so rigidly to the numbers. Lifestyle is a big thing for PD; it is the most flexible in an adaptable treatment.

I mentioned earlier that it was flexible but I would just like to have a word about Tony Ward. Last year, Tony Ward, who is a mountaineer from the Lake District, climbed Mount Blanc with his wife Bridget. He did a CAPD exchange at 4002 metres, now that doesn't really mean a lot to me because I know it's high but he needed to be really fit and committed to do that. This year, as if it wasn't enough, Tony and his wife cycled from John O Groats to Lands End, and it's quite some commitment. This time they stayed in a camper van and he did his APD overnight in the camper van.

Now a lot of people would say Tony's mad, and people have, the reason I know this is because I actually told him he was mad as well, but the message he is trying to get across is probably the message that every one of you in this room have, is that his life before dialysis was climbing mountains. Whether your life before dialysis is climbing mountains or going up to the shops for your messages, you should be able to achieve that lifestyle again. Maybe take it a bit slower, it might take a bit more training or whatever, but you have to make your dialysis work for you. Dialysis to live, not live to dialyse. I'm sure you all work by that philosophy here.

So what can the future have in store for us? Distance monitoring from units, now I should say, this is happening with APD machines. What we can do now is tap into your APD machine through your phone line. You know what is happening, it is not like Big Brother or anything like that. All your information can be downloaded from your phone line into the machine. It is already happening in some places, and the benefits to you are that you have more rapid and efficient troubleshooting. If you have a problem with your dialysis all the information is there and can be sorted out quicker and easier. Less routine hospital visits for you. You are going to see more machines that are more compact, even easier to use and more accessible for everyone, and these machines will allow your treatment to be more flexible. APD will last longer and your peritoneum will be better cared for. These are things which are all happening as we speak, but there are other things going on that we do not know about yet, and you just have to rest assured that everyone is working to make things even better for you.

We have come a long way in a relatively short time. I think there is an exciting time ahead in peritoneal dialysis, with again the need of freeing hospital resources. It is a cheaper and some might say an alternative to hospital dialysis, but most importantly for patients wanting to take control of their life and fitting it around them. So with all the research and development on the way, and also with the evidence being produced that is likely to be a better first line therapy, I personally believe that peritoneal dialysis will undergo a resurgence and return to vogue in the next few years.

Thank you for your time.

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