peritoneal-dialysis | Singapore General Hospital

Your kidneys are responsible for removing waste products and excess water that your body produces everyday. However, when you develop chronic kidney disease (CKD), the kidneys are no longer able to do these for the body. In fact, over time, you may start to experience symptoms including (not but limited to) shortness of breath, fits, and abnormal heart rhythm which could affect your quality of life.

One solution that your doctor may prescribe is peritoneal dialysis, a treatment which replaces what your body would usually do to maintain a healthy balance.

In this article, we're going to guide you through peritoneal dialysis and demonstrate how you & your caregiver can manage the treatment & lifestyle changes.

How does Peritoneal Dialysis Work?

This is a form of dialysis which is performed daily by yourself (or your caregiver) in the comforts of your own home.

Prior to starting Peritoneal Dialysis (PD) you will undergo a minor operation where a PD catheter (tube) will be inserted into your abdomen. When performing PD, a cleansing fluid (dialysis fluid) will be introduced via the catheter into your peritoneal cavity. The lining of the peritoneal cavity, i.e. the peritoneal membrane acts as a

filter to remove your body's waste products and excess water.

We'll illustrate this with a tea bag:

Similar to a tea bag, waste products in the body moves through the peritoneal membrane to mix with the dialysate (see diagram on the right). After a period of time, the dialysate is removed from your abdomen via the same catheter and discarded.

There are 2 types of peritoneal dialysis. Namely...

1. Continuous Ambulatory Peritoneal Dialysis (CAPD)

CAPD is a form of kidney dialysis where a patient's abdominal cavity is filled with dialysis fluid manually exchanged several times a day, allowing waste and excess fluids to pass into the fluid and then be drained out.

2. Automated Peritoneal Dialysis (APD)

A type of peritoneal dialysis that employs a machine called a cycler to automatically perform multiple exchanges of dialysis fluid while the patient sleeps, simplifying the process and enhancing convenience.

Meet the Peritoneal Dialysis team

While a patient and a caregiver may take the lead on the treatment, the PD team is always on standby to lend a helping hand:

How we can help

A PD nurse will teach you over 3 - 5 days how to perform PD. At the end of training, you and your caregiver will be able to:

Perform PD exchange competently
Look after your PD catheter and its exit site
Keep a treatment record of your daily PD exchanges
Recognise and manage possible complications like infection, a poorly functioning catheter, PD machine alarms and fluid overload
Understand the importance of maintaining a healthy diet and adequate nutrition
Understand the need for medications
Know how to store and order your dialysis supplies
Understand the need for certain investigations (Peritoneal Equilibration Testing and adequacy testing)

How to Perform Peritoneal Dialysis

Now that you understand CKD, PD, and the PD team, let's talk about how you or your caregiver can perform PD in the comfort of your home.

What you'll need

A clean environment in which to perform the exchange
Hand cleaning supplies like hand sanitiser
A surgical mask
A PD catheter
A catheter extension
A disinfection cap for the end of the catheter extension
Dressing for exit site care
Dialysis solution contained within its sterile bag
A drainage bag
A PD machine (if performing APD) and a power source

Introduction to the PD catheter

At this point, we need to elaborate a little more on the PD catheter.

A soft plastic catheter will be inserted into your abdomen 2 - 4 weeks before you start PD.

Part of the catheter lies within the abdomen and exits the skin via a small hole called the exit site. Your catheter will be attached to a catheter extension set which is changed every 6 months to reduce the risk of infection. The

end of the catheter extension is covered with a new sterile cap every time it is removed.

Our staff will teach you how to care for your catheter and exit site. Read on and refer to the steps below where required.

Procedure

Follow these 4 simple steps:

You will usually require 3 - 4 manual exchanges, or a single connection to the PD machine for 8 - 10 hours a night. Check with your doctor about your dialysis prescription and how often you should perform the procedure.

Do the above in a conducive environment that is well-lit and free from draft, distractions, and pets. Ensure your hands are sanitised and do not wear hands accessories or nail varnish.

Additionally, check that the dialysis fluid solution is suitable by looking out for:

Correct dialysis fluid concentration
Expiry date and volume
Intact medical port protector
No leakage
No abnormal discoloration

Immediate steps to manage the catheter

After the PD catheter is inserted, dialysis will begin after a period of rest. PD nurses will assist you with wound care.

However, there are some rules you should take note of as early post-operative care is vital to establish and maintain the function of the catheter:

Keep the surgical wound dry for at least 14 days
Immobilise the catheter
Check that the exit site of the catheter is not rubbing against your belt line
Ensure daily bowel movement
Avoid strenuous exercise for the first 2 weeks

Daily PD catheter care

Follow these 6 steps in a well-lit room with all necessary equipment ready.

Wear mask and clean your hands
Remove dressing
Clean exit site
Apply antibiotic cream around the exit site
Apply new dressing
Immobilise catheter

A healthy exit site is skin coloured with no tenderness or discharge. Should there be any redness or pain, please alert our team.

Discard the dialysate into the toilet bowl. Do not reuse used equipment.

Long-term care for your PD catheter

After your surgical wound has healed, it is important to maintain care of your PD catheter and the exit site. Follow these rules:

Maintain good general hygiene
Keep the dressing clean and dry
Immobilise the catheter as close as possible to the exit site
Place the catheter exit site away from the belt line
Ensure daily bowel movement
Avoid using chemical substances to clean the exit site
Avoid using any ointments, talcum powder, or cream
Do not swim or take a bath in a bathtub
Do not use scissors near the catheter

A functioning catheter should allow good flow of dialysate in and out of the peritoneal cavity. Usually, it takes 10 minutes for 2 litres of dialysis fluid to completely fill the peritoneal cavity and up to 20 minutes to drain. Prolonged in-flow or out-flow may suggest catheter dysfunction. If you are doing APD, catheter dysfunction may present with alarms during the dialysis. If any of this happens, please contact your PD nurse.

Dieting for Peritoneal Dialysis Patients

A crucial element of long-term care for CKD and PD is abiding by a dialysis-friendly diet. Follow these simple rules:

1. Reduce sodium intake

Excessive sodium results in fluid overload and poor blood pressure control.

Go for fresh foods whenever possible and limit sodium seasoning when cooking. Enhance the taste of your foods by using other flavourful ingredients such as herbs, spices, lemon, garlic, ginger, onion, fresh chili and vinegar. Or use a salt substitute which contains less sodium than table salt.

If you have to choose processed foods, look out for these words on food labels such as “low sodium”, “sodium free”, “unsalted”, and “no added salt”. Inspect the nutrition labels as well.

When eating out, ask for foods to be prepared with less salt and sauces whenever possible.

2. Restrict fluid intake

Restricting fluid intake helps to reduce fluid build-up and achieve better blood pressure control. Fluids include all beverages and foods that are liquid at room temperature. These include:

That is not to say that dehydration is the way to go. Instead, drink fluids in moderation and do not go overboard with your fluid intake.

Here are some other tips to keep your fluid intake in check:

Use measuring cups to accurately measure your fluid intake
Fill up a jug/bottle of water and use this to keep track of your fluid intake
Spread out your fluid allowance throughout the day
Drink from smaller cups.
Rinse your mouth with water but do not swallow
Suck on an ice cube slowly as it is better at quenching thirst.
Suck on sweets or lemon slices to stimulate saliva production
Limit sodium intake

3. Control phosphate intake

Phosphate may accumulate in the blood when your kidneys do not work properly. High blood phosphate levels can draw calcium out of your bones, making them weak and brittle. This can also result in calcium deposition in your blood vessels, lungs, eyes, and heart.

A good way to keep your phosphate levels in check is to limit your phosphate intake. Here are some examples of foods that are rich in phosphate:

Additives in processed foods found in processed meat
Dried shrimp which you can find in sambal belachan, laksa, mee reubus, and more
Anchovies (ikan bilis) in nasi lemak
Meat, fish bones, and offal (internal organs) in soups and broths
Beverages that are:

Cola-based
Malt or coca-based
Creamer-based
Rich in evaporated or condensed milk

Coconut-containing products such as nasi lemak rice and coconut slushies

Generally, choosing fresh foods & flavourings, managing your phosphate intake when cooking & eating out, and swapping phosphate-rich ingredients with alternatives are a great way to control your diet.

4. Increase your protein intake

Protein may be lost during dialysis so be sure to fuel your diet with them. Some examples of high-quality protein are:

Preventing Infections

Whether you are taking the lead on the treatment or engaging a caregiver, it is tantamount to take preventive care against infections by keeping everything that comes into contact with the peritoneal cavity as clean and sanitised as possible. These include:

The work surface where you place the sterile dialysate bags
The entry ports of the bags
The catheter extension
All medications and needles used to add medications
to the dialysate bags
The dialysis fluid and its bag
The internal parts of the equipment
The sterile cap

There are 3 main types of infections; let's take a closer look at them below:

1. Exit site infection

An exit site infection is a complication that occurs when germs infect the skin around the catheter.

A tunnel tract infection is an infection of the tunnel under the skin where the catheter lies. These may occur due to improper care of your exit site.

You will know that you have an exit site or tunnel tract infection if you develop:

Pain around the exit site or on applying any pressure on the catheter
Redness around the exit site
Swelling around the exit site or of the tunnel
Discharge of pus or bloody fluid from the exit site

2. Peritonitis

This is a serious complication of PD and occurs when germs enter the peritoneal cavity and may be fatal. It is curable, but requires immediate medical attention.

The germs can enter the peritoneal cavity due to:

Improper practices when performing the PD exchange (inadequate hand washing or accidentally contaminating
something that was supposed to be sterile)
Infection of the exit site
Improper use of the face mask
Any break or leak in the PD system

Peritonitis is diagnosed by:

Cloudy-drained PD fluid
Abdominal pain, vomiting, diarrhoea
Fever

If any of the symptoms occur, taking immediate action is imperative. Notify your PD nurse as soon as possible.

These are just 2 of the possible risks associated with PD. Download a full guide to Peritoneal Dialysis at the foot of this article to learn more about these risks.

Frequently Asked Questions about Peritoneal Dialysis

1. Why is it important to perform daily dialysis?

Daily dialysis helps remove waste and excess fluids from the body, maintaining electrolyte balance and overall health in cases of kidney dysfunction. With adequate dialysis, you will notice less swelling, and an improved sense of well-being with higher levels of energy and enhanced appetite.

2. What happens if I miss a session of peritoneal dialysis?

Missing a peritoneal dialysis session can lead to accumulation of toxins and fluids in the body, causing potential health risks. Ensure you attend your sessions faithfully and regularly.

3. Can I continue to work while on peritoneal dialysis?

Many individuals on peritoneal dialysis can continue working, but it depends on individual circumstances and treatment demands. Speak to your employer about your condition and seek their understanding.

4. Can I continue with my favourite sports?

Regular exercise has many benefits for PD patients and you should continue exercising. Patients can perform most exercises except for swimming. You must just remember to clean and dry your exit site after completing each exercise activity.

5. Will I still be able to enjoy evenings out with family and friends?

With proper planning and consideration for treatment needs, social activities can still be enjoyed while on peritoneal dialysis. Speak to your doctor about managing your treatment.

6. How will my sex life be impacted?

Various reasons such as anaemia or hormonal disturbances may cause both men and women affected by kidney failure to experience difficulty with sexual activities. After starting dialysis, there may be an improvement in these difficulties but due to other factors such as stress, anxiety or altered body image, patients may still find it difficult to continue with sexual activities.

Please highlight any issues you may be having with your medical team or social workers so that appropriate interventions can be made.

7. Will I be able to continue to travel overseas?

Good news, you'll be able to continue leisure travel! However, traveling overseas on peritoneal dialysis requires planning ahead for supplies, medical support, and adjustments to treatment routines. Speak to your doctors about your plans and get their feedback about how to perform PD while you are abroad.

Read more about administering PD, managing lifestyle changes, and risks associated with PD by downloading the booklets below in your preferred language:

Peritoneal dialysis.pdf