Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Peritonitis in Peritoneal Dialysis

Peritoneal dialysis (PD) is the modality of kidney replacement therapy in about 15% of the dialysis population worldwide. Despite the advances in technology and antibiotic therapy, peritonitis remains a major cause of technique failure and morbidity in PD patients. Although only 4% of peritonitis episodes are a direct cause of mortality, peritonitis is a contributing factor to death in 16% of PD patients. Furthermore, peritonitis accounts…

Peritoneal Catheter Exit Site and Tunnel Infections

Introduction Peritoneal dialysis (PD)–related infections, including peritonitis, exit site infections, and tunnel infections, remain an important cause of morbidity and technique failure. While peritonitis is usually the most frequent and morbid event among the infectious complications, exit site and tunnel infections are relevant and concerning complications of PD. This chapter will focus on the risk factors for their occurrence, as well as optimal strategies for their…

Peritoneal Access Devices, Placement Techniques, and Maintenance

The success of peritoneal dialysis (PD) as kidney replacement therapy for end-stage kidney disease and acute kidney injury relies upon a functional access to the peritoneal space for exchange of water and solutes. This access represents a controlled cutaneoperitoneal fistula comprised of a catheter device that bridges the abdominal wall through which fluid exchanges occur. Knowledge of best practices in catheter placement and maintenance can optimize…

Volume Management With Peritoneal Dialysis

Introduction Among patients receiving kidney replacement therapy, it is well established that persistent volume overload is associated with higher mortality. In peritoneal dialysis (PD) patients specifically, the Initiative of Patient Outcomes in Peritoneal Dialysis (IPOD-PD) study is a large prospective observational study of 1092 incident PD patients across 32 countries that assessed hydration and nutrition status at dialysis start and every 3 months with bioimpedance analysis…

Solute Management With Peritoneal Dialysis

Introduction One of the primary purposes of peritoneal dialysis (PD) is to clear solutes that are normally removed by the kidney. In this chapter, we will discuss the determinants of solute clearance, how to measure and evaluate it, and how to adjust the prescription to increase solute clearance. You’re Reading a Preview Become a Clinical Tree membership for Full access and enjoy Unlimited articles Become membership…

Peritoneal Dialysis Solutions

Introduction Peritoneal dialysis (PD) is a form of home-based kidney replacement therapy (KRT) used to treat patients suffering from kidney failure. Small solute and fluid removal are achieved using diffusion and convection across the peritoneal membrane, enabled by PD solutions. Understanding the principles behind PD solution compositions and their mechanisms of action is central to ensuring safe and effective prescribing of PD to optimize patient outcomes.…

Peritoneal Dialysis Cyclers and Other Mechanical Devices

Peritoneal dialysis (PD) cyclers were initially designed for intermittent PD to perform many frequent and short dialysis exchanges within a hospital setting. Following the introduction of continuous cycling PD (CCPD) and variations thereof, the cycler underwent modifications that allowed a broad variety of prescriptions and laid the foundation for its success as a home therapy device. Further improvements in the performance, safety, and convenience of modern…

Determination of Continuous Ambulatory Peritoneal Dialysis and Automated Peritoneal Dialysis Prescriptions

Dialysis Adequacy for Patients Receiving Peritoneal Dialysis A major goal of dialysis therapy is to restore patients to their previous quality of life. For most patients, the objective is to eliminate uremic symptoms, such as poor appetite and fatigue. This is accomplished by prescribing a dialysis treatment of sufficient intensity to remove uremic toxins. There are numerous solutes that accumulate in kidney failure; ascribing the uremic…

Infectious Complications From Vascular Access

Overview of Vascular Access Infections In 2017, in the United States, there were more than 468,000 prevalent and 108,000 incident hemodialysis patients. Provision of hemodialysis requires direct access to a large vein to enable venous blood to be pumped through the circuit, including the hemodialysis filter, which is then returned back to the patient via a conduit into the draining vein. Available options for vascular access…

Noninfectious Complications From Vascular Access

Noninfectious complications of hemodialysis vascular access are associated with higher morbidity and can be life-threatening. The resulting interruption in the dialysis schedule with inadequate hemodialysis therapy decreased sense of well-being, and overall poor quality of life can lead to frustration amongst patients and their caregivers. Two commonly used long-term hemodialysis vascular accesses are arteriovenous fistula (AVF) and arteriovenous graft (AVG). AVF is preferred over AVG for…

Central Venous Access for Hemodialysis

The Role of Central Venous Access In the United States, more than 5 million central venous catheters (CVCs) are placed every year, translating to more than 15 million days of treatment with CVCs for different purposes. CVCs are useful tools to administer medications and fluids, and to collect blood samples and exert a pivotal role in the setting of hemodialysis (HD) treatments in patients affected by…

Cannulation of Arteriovenous Vascular Access: Science and Art

Introduction The delivery of hemodialysis (HD) therapy for a patient with an arteriovenous (AV) vascular access is dependent on successful vascular access cannulations. A typical in-center HD patient requires routine cannulation for 156 treatments per year. Despite the high frequency of cannulation, limited randomized controlled trials (RCTs) provide the scientific aspect. The art of cannulation is the skill part of the procedure. Nephrologists oversee the overall…

Vascular Access

Introduction It is well established that dialysis cannot be provided without access; while this should not be taken for granted, such access can be achieved in a majority of cases. In contrast, the attainment and maintenance of a single reliable , long-lasting dialysis access with minimal complications continue to be challenging. Achievement of such access is associated with optimal patient clinical outcomes, superior quality of life,…

Home Preparation and Installation for Home Hemodialysis

Introduction Home hemodialysis has been available as a modality of kidney replacement therapy since the 1960s. The interest in home hemodialysis has been increasing over the past years because of its flexibility and benefits (which will be further discussed in the following section). Historically, home hemodialysis accounted for about 40% of the dialysis population in the United States in the 1970s and decreased in popularity in…

Wearable and Implantable Renal Replacement Therapy

Introduction Dialysis is the semi-selective removal of solutes from a solution by diffusion across a semipermeable membrane. It was first used in vitro by Thomas Graham in 1861 to separate ions from macromolecules in a colloidal solution. Early in the 20th century, John Jacob Abel isolated epinephrine, insulin, and other hormones from the blood of living dogs using dialysis, which he termed “vividiffusion.” Kolff is generally…

Hemofiltration and Hemodiafiltration

Introduction Conventional hemodialysis (HD) is based on diffusive transport of solutes across a semipermeable membrane and is effective in removing water-soluble small-molecular-weight (MW) solutes and electrolytes. The removal of solutes with larger molecular sizes, such as phosphate and β 2 -microglobulin, however, is limited by diffusive resistance. Because insufficient removal of these larger uremic toxins may contribute to the high cardiovascular mortality risk observed in these…

Common Clinical Problems in Hemodialysis

Introduction Hemodialysis (HD) treatments are performed millions of times per year and offer a life-saving and life-sustaining therapy. Technological advances in the delivery of HD have occurred over the past 70 years and these have been supplemented with enhanced patient monitoring and the development of protocols and procedures that govern the operation of HD facilities. Despite these advances, complications of HD still occur, and clinicians must…

Methods of Hemodialysis Anticoagulation

Introduction During intermittent hemodialysis and continuous kidney replacement therapies (CRRTs), blood is continuously flowing between the patient’s vascular access and the dialyzer. This extracorporeal circuit exposes blood to surfaces with variable degrees of thrombogenicity. Clotting of the circuit, specifically the microfibers of the dialyzer, is associated with decreased dialysis clearance. Furthermore, the inability to return blood from a clotted circuit to the patient results in approximately…

Safety Monitors in Hemodialysis

Hemodialysis monitors include machines, devices, protocols, and personnel. The major goal is to ensure patient safety during the hemodialysis procedure. All tasks that check, observe, keep track of, and control the hemodialysis treatment is monitoring procedures. These important tasks are too often lightly dismissed. This chapter focuses on the fluid delivery system and extracorporeal circuit, their respective monitoring devices, functions, locations, performance standards, and management. Monitoring…

Dialysate Composition

Introduction Patients with end-stage kidney disease (ESKD) depend on dialysis to maintain fluid and electrolyte balance. In hemodialysis, solutes diffuse between blood and dialysate such that, over the course of the procedure, plasma composition is restored toward normal values. The makeup of the dialysate is of paramount importance in accomplishing this goal. Individualizing the dialysate composition is of critical importance in improving tolerance to the procedure,…