This is called a graft. Occasionally, an access is made by means of a narrow plastic tube, called a catheter, which is inserted into a large vein in your neck. This type of access may be temporary, but is sometimes used for long-term treatment. A type of hemodialysis called high-flux dialysis may take less time.
You can speak to your doctor to see if this is an appropriate treatment for you. In this type of dialysis, your blood is cleaned inside your body. The doctor will do surgery to place a plastic tube called a catheter into your abdomen belly to make an access.
During the treatment, your abdominal area called the peritoneal cavity is slowly filled with dialysate through the catheter. The blood stays in the arteries and veins that line your peritoneal cavity.
Extra fluid and waste products are drawn out of your blood and into the dialysate. There are two major kinds of peritoneal dialysis. You put a bag of dialysate about two quarts into your peritoneal cavity through the catheter.
The dialysate stays there for about four or five hours before it is drained back into the bag and thrown away. This is called an exchange.
You use a new bag of dialysate each time you do an exchange. While the dialysate is in your peritoneal cavity, you can go about your usual activities at work, at school or at home. This is similar to CAPD except that a number of cycles exchanges occur. Dialysis does some of the work of healthy kidneys, but it does not cure your kidney disease. You will need to have dialysis treatments for your whole life unless you are able to get a kidney transplant. The risk of infectious and non-infectious complications are no different than that observed in younger age groups.
Hence, chronological age is insufficient to deny a patient the choice in selecting their dialysis modality. Advancing age, however, is often associated with a decrease in manual dexterity, visual acuity, frailty, and cognition.
Elderly patients may be reluctant to impose the burden of home dialysis on their elderly partners, and in those patients who live alone, home dialysis may accentuate social isolation. Many times, family members are willing to provide support to allow the elderly to successfully perform peritoneal dialysis at home. Peritoneal dialysis offers several advantages over in-center hemodialysis to elderly patients. Peritoneal dialysis obviates the need for frequent travel to and from a health-care facility which may be as important to a care-giver as to the patient.
The life-plan of many elderly individuals may include recreational travel, which can be easier to accommodate with peritoneal dialysis. Creating and maintaining a vascular access and the need for anti-coagulation during the hemodialysis procedure are more likely to pose challenges for the elderly and should prompt consideration of peritoneal dialysis as an alternative.
Lastly, daily fluid and solute removal, which is inherent to PD, offers greater hemodynamic stability and is often better tolerated than thrice weekly in-center hemodialysis. The use of peritoneal dialysis in frail individuals, irrespective of age, can be facilitated by connection-assist devices and assisted therapy.
Such devices are available from both major manufacturers of peritoneal dialysis supplies and may be used for both continuous ambulatory CAPD and automated therapies APD. In most such reports, the risk for infectious complications in patients performing assisted peritoneal dialysis is no different than seen with unassisted therapy.
Assisted peritoneal dialysis is best performed using a cycler and the prescription can be designed such that a patient requires assistance only twice during any hour period at the time of connection to the cycler at night and disconnection in the morning. Thus, the availability of assistance may increase the confidence of selected individuals about their ability to undertake home dialysis and serve as a bridge to independent home care dialysis.
The effect of peritoneal dialysis on glycemic control, potential for weight gain, and patient longevity are important to consider. Glucose absorption from the peritoneal dialysate and increased nutrient intake after the amelioration of uremic anorexia with the start of dialysis treatment has the potential to influence glycemic control.
In most patients, this can be readily managed with appropriate adjustment of medical therapy. In a recent clinical trial, glucose-sparing peritoneal dialysis prescriptions that use icodextrin for the long dwell were associated with a significant improvement in glycemic control and dyslipidemia.
This strategy should be considered for selected patients. A recent study showed that significant weight gain in patients who begin treatment with peritoneal dialysis is no more frequent than those who start in-center hemodialysis and this consideration should not dissuade patients from considering the therapy either. Finally, care should be exercised before using survival data from observational studies in making decisions about dialysis modality for a given patient.
It remains unclear if differences in survival, between patients treated with different dialysis modalities are attributable to the therapy or to unmeasured differences in characteristics of patients who select the therapy. Thus, notwithstanding the purported challenges with peritoneal dialysis, most diabetics can choose the dialysis modality that fits best with their goals and expectations in life.
The ability of patients to tolerate instillation of peritoneal dialysate in the presence of enlarged kidneys, and reports suggesting a higher risk of hernias and diverticulitis, have raised some questions as to whether peritoneal dialysis is appropriate for treatment of end-stage renal disease in patients with polycystic kidney disease.
While hernias may be more common, they are readily treatable and peritoneal dialysis can be performed peri-operatively. Hence, a diagnosis of polycystic kidney disease generally should have no bearing on selection of dialysis modality. In patients with systemic sclerosis, concern has been sometimes raised that peritoneal fibrosis may preclude successful performance of peritoneal dialysis.
Scleroderma is a rare disease and the published clinical experience in the form of case-reports and case-series show that peritoneal dialysis can be successfully performed in these patients. Several observational studies have demonstrated that patients with previous cardiovascular disease treated with peritoneal dialysis have a higher mortality risk than those treated with hemodialysis.
The risk is more pronounced in older individuals. However, studies also indicate that the magnitude of risk elevation in such patients treated with peritoneal dialysis has diminished over time. Peritoneal dialysis offers continuous ultrafiltration allowing for greater hemodynamic stability. Furthermore, since the peritoneal dialysate contains no potassium, hyperkalemia is virtually never a problem in patients treated with peritoneal dialysis making it safer to initiate or maintain cardio-protective drugs like angiotensin-converting-enzyme inhibitors, angiotensin receptor blockers, or aldosterone antagonists.
On the other hand, the nature of therapy places a greater burden on the healthcare team to educate the patient on how to quickly adjust the dialysis prescription in response to day-to-day changes in salt and water intake. It also highlights the importance of ensuring that prescriptions are designed such that they mitigate the metabolic effects of peritoneal dialysis like dyslipidemia and to preferentially use glucose-sparing regimens in such patients.
These considerations could inform decision-making about the most appropriate dialysis modality for any given patient. A history of previous abdominal surgery in and of itself is not a contra-indication for peritoneal dialysis but does increase the likelihood that the patient has intra-peritoneal adhesions.
Nonetheless, what can be learned from the medical record is ultimately limited to what clinicians chose to document and provides only limited insight into the patient perspective or experience. Third, because documentation was not uniform across clinicians and patients, we could not reliably determine whether particular themes were present or absent in each case to measure counts.
Themes identified were also complex and could not be precisely rendered into dichotomous variables. Hence, we could not estimate their prevalence or infer their generalizability. Fourth, we selected to present only dominant themes; thus, findings reported here are not exhaustive of all themes relevant to decisions to forgo dialysis.
Finally, because follow-up for our study ended in , it is possible that our results do not reflect contemporary practices. We believe this is unlikely because the incidence of maintenance dialysis in the United States has not changed appreciably in more recent years, 42 and conservative care programs of the kind found in other developed countries remain in their infancy in the United States.
This study of a national cohort of patients with advanced CKD not treated with dialysis provides an important window on decision making regarding dialysis in a large US health system. Our findings describe an all-or-nothing approach to care for patients with advanced CKD in which dialysis serves as a powerful default with few perceived alternatives. Collectively, these findings call for stronger efforts to develop more patient-centered models of care for patients with advanced CKD with the capacity to proactively support those who do not wish to pursue dialysis.
Corresponding Author: Susan P. Published Online: January 22, Author Contributions: Dr Wong had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Critical revision of the manuscript for important intellectual content: All authors. No other disclosures were reported. Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position or policy of the Department of Veterans Affairs.
They received salary support for their work. Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy Continue. Download PDF Comment. Table 1. View Large Download. Table 2. Table 3. Table 4. Treatment intensity at the end of life in older adults receiving long-term dialysis. Arch Intern Med. Healthcare intensity at initiation of chronic dialysis among older adults.
J Am Soc Nephrol. J Gen Intern Med. Comparison of life participation activities among adults treated by hemodialysis, peritoneal dialysis, and kidney transplantation: a systematic review. Am J Kidney Dis.
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Timing of initiation of maintenance dialysis: a qualitative analysis of the electronic medical records of a national cohort of patients from the Department of Veterans Affairs. Old age, life extension, and the character of medical choice. Patient and health care professional decision-making to commence and withdraw from renal dialysis: a systematic review of qualitative research.
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Use of text search to effectively identify lifetime prevalence of suicide attempts among veterans. Krippendorff K. Techniques to identify themes. Field Methods. Sign up now. My year-old husband has been on kidney dialysis for a year. He's not a good candidate for a kidney transplant. How will we know when dialysis is no longer working and should be discontinued? Answer From Robert Albright, D.
Show references Koncicki HM, et al. Withdrawal from and withholding of dialysis. Accessed Oct. Davison SN, et al. Withdrawal of dialysis: Decision making Journal of Palliative Medicine. Treatment methods for kidney failure: Hemodialysis. Hemodialysis dose and adequacy.
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