Evolution of PD

The first patient treated with PD was reported by Ganter in 1923. The patient was a female with ureteral obstruction that was due to uterine carcinoma1. This experience was followed by scattered reports with variable outcomes using the continuous perfusion technique2,3.

In 1938, Rhoads used intermittent dialysis (IPD) to treat two nephrotic patients using dwell times of 50 minutes and total dialysate volumes of 6 – 11 L4. In 1951, Grollman and colleagues used intermittent peritoneal lavage in uremic dogs and reported on its applicability to humans5,6. Such applications elucidated the need for a sterile setting, dietary restrictions and nutritional supplementation. As a means to do overnight unattended dialysis at home and overcome peritonitis, Boen developed the “intermittent paracenthesis method” in 19627. This involved an automated dialysate delivery system. A catheter was placed in the abdomen for each successive dialysis; the old one was removed when the dialysis session was done. This automated PD device could perform multiple 2-L exchanges over a 10-hour period. It was able to minimize the time required for clamping and opening of fluid lines, while concomitantly reducing peritonitis rates. In 1966, Lasker designed a simpler, smaller cycler that could provide exchanges with relatively short dwell times of 30 minutes at prescribed intervals8. This allowed PD to be carried out at the patient’s home. Also during the 1960s, Harold McDonald developed a technique for teaching patients how to do peritoneal dialysis by themselves, at home or in the clinic. He also evaluated the use of different types of silicone catheters for long-term use. However, it was Russell Palmer who developed the first silicone rubber catheter with a unique, coiled design in 19649. Also in 1964, Boen published the first textbook on PD for use in clinical medicine. He stressed the importance of PD in the treatment of acute renal failure (ARF) and expounded on the basic physiology, indications and complications of this technique10.

Despite the advancement of PD and an increase in PD awareness, the utilization of this technique remained low. This may have been due to the success of hemodialysis (HD) as a chronic renal replacement therapy and the complexity of the equipment being used for home PD. Although Boen’s system was cumbersome and laborious, it was still being used. As a treatment option, intermittent PD (IPD) had been in use for some time; however, it was not the modality of choice. Many investigators reported favorable survival rates in patients on IPD for 4 to 8 years11,12; 83% of patients survived after two years. Despite these data, the overall results were not very encouraging. Researchers identified a preponderance of malnutrition, decreased hematocrit, recurrent metabolic acidosis and poor control of hydration. Clinical deterioration was accompanied by a reduction in residual renal function (RRF). IPD use has now been relegated to supplemental status, due to the limited small molecule clearance, inferior middle molecule clearance and poor clinical outcomes. Based on these and other experiences, Henry Tenckhoff realized that patients required more dialysis than was currently being prescribed in order to control their uremia. He developed a system that could be installed and effectively used by the patient at home13. Although a good system, there were peritoneal access-related issues. To overcome these obstacles, Tenckhoff modified Palmer’s catheter by shortening it and adding dacron cuffs. He also adjusted the trocar to optimize insertion14. Tenckhoff’s straight and curled catheters became the gold standard for PD access.

A novel concept termed equilibration dialysis soon transformed PD into a popular, effective and acceptable form of renal substitution therapy15. As proposed by Popovich and colleagues, the equilibration peritoneal system allowed for the continuous presence of dialysate in the peritoneal cavity, except during periods of drainage and infusion of new dialysate. This method of continuous dialysis countered the deficiencies of IPD and allowed better clearances of small molecules. Its simplicity and freedom allowed patients to learn how to use it at home, leading to its consideration as an alternative to hemodialysis. The first application of this technique by Moncrief and Popovich was referred to a continuous ambulatory PD or CAPD; and the name has remained to this day.

A major breakthrough in CAPD came with the introduction of plastic containment bags for the dialysate. This allowed the plastic bag to be rolled up and attached to the patient’s body until the end of the prescribed cycle. This provided the patient greater freedom of movement.

Continuous cycling PD (CCPD) was introduced during the late 1970s. Jose Diaz Buxo was one of the first pioneers developing this treatment modality clinically and working together with industry on the first CCPD cyler16. This modality may be thought of as a reversal of CAPD. In this modality, multiple exchanges are performed during the night using variable volumes over a 10-hour period. In the morning, a predetermined amount of fluid is left in the peritoneal cavity for the duration of the day, until the next nocturnal session. An additional exchange can be added to the daytime dwell – a modification which is known as PD Plus.

In summary, the introduction of a safe and permanent catheter by Tenckhoff in 1968, the availability of commercial dialysate and the development of automated systems in the 1960s resulted in a resurgence of PD. In 1979 less than 5000 patients worldwide were on PD, however by 2008, there were 26,517 patients were on peritoneal dialysis in the US alone17.

References:

  1. Ganter G. Ueber die Beseitigung giftiger Stoffe aus dem Blute durch Dialyse. Munch Med Wochschr 70:1478, 1923
  2. Heusser H, Werder H. Untersuchungen über Peritonealdialyse. Bruns Beiträge z klin Chir 141:38, 1927
  3. Balázs J, Rosenak S. Zur Behandlung der Sublimatanurie durch peritoneale Dialyse. Wien Med Wchnschr 47:851, 1934
  4. Rhoads JE. Peritoneal lavage in the treatment of renal insufficiency. Am J Med Sci 196:642, 1938
  5. Grollman A, Turner LB, Levitch M, et al. Hemodynamics of bilaterally nephrectomized dogs subjected to intermittent peritoneal lavage. Am J Physiol 165:167, 1951
  6. Grollman A, Turner LB, McLean JA. Intermittent peritoneal lavage in nephrectomized dogs and its application to the human being. Arch Intern Med 87:379, 1951
  7. Boen ST. Peritoneal Dialysis in Clinical Medicine. Springfield, Illinois, Charles C. Thomas, 1964
  8. Lasker N, McCaukey EP, Passarotti CT. Chronic peritoneal dialysis. ASAIO Trans 12:94-105, 1966
  9. Palmer R, Quinton W, Gray J. Prolong peritoneal dialysis chronic renal failure. Lancel 1:700-702, 1964
  10. Boen ST. Peritoneal Dialysis in Clinical Medicine. Springfield, Illinois, Charles C. Thomas, 1964
  11. Diaz-Buxo JA, Walker PJ, Chandler JT, Burgess WP, Farmer CD. Experience with intermittent peritoneal dialysis and continuous cyclic peritoneal dialysis. Am J Kidney Dis 4(3):242-8, 1984.
  12. Teckhoff H. Adantages and shortcomings of peritoneal dialysis in the management of chronic renal failure Semin Uronephrol 1: 107, 1977
  13. Tenckhoff H, Shilepetar G, Van Paaschen WH, Swanson E. A home peritoneal dialysis delivery system. ASAIO Trans 15:103, 1966
  14. Tenckhoff H, Schechter H. A bacteriologically safe peritoneal access device. Trans Am Soc Artif Intern Organs 14:181-186, 1968
  15. Popovich RP, Moncrief JW, Decherd JF, et al. The definition of a novel portable/wearable equilibrium peritoneal dialysis technique. Trans Am Soc Artif Intern Organs 5:64, 1976 (Abstract)
  16. Diaz-Buxo JA, Farmer CD, Walker PJ, Chandler JT, Holt KL. Continuous cyclic peritoneal dialysis: a preliminary report. Artif Organs. 1981 May;5(2):157-61.
  17. USRDS 2010. http://www.usrds.org/ Accessed July 11, 2011

P/N 101857-01 Rev A 08/2014