History of PD
Peritoneal dialysis has its roots in the early civilizations, when the existence of the peritoneum was recognized. The term peritoneum derives from the Greek peritonaion, meaning to stretch around. The first known recorded reference of the peritoneal cavity appears in the Ebers papyrus in 1550 BC1.
The Egyptians recognized that a sac surrounded the internal abdominal organs during their separation of the viscera from the rest of the corpse prior to embalmment. Galen and many other prominent physicians of antiquity observed the peritoneum in the open abdomen of injured gladiators. The early anatomists and surgeons described the extent of the peritoneal membrane, named its surfaces and attachments, but did not elaborate on its function or fine structure.
The peritoneal membrane became of physiological interest to anatomists after the discovery of cells. Von Recklinghaussen was the first to describe the gross and cellular anatomy of the peritoneum in 18622,3. Wegner described the effects of changes in body temperature occurring after intraperitoneal (ip) infusion of solutions with various temperatures4. He also reported the effects of concentrated dextrose or glycerin solutions on the volume of outflow obtained in the peritoneal effluent; this was perhaps the first evidence of osmotic ultrafiltration (UF). Starling and Tubby expanded these observations by studying the bidirectional transfer of molecules across the peritoneal and pleural membranes and demonstrated the rapid absorption of isotonic solutions and slow absorption of serum5. Prior to 1850, treatment of patients with renal failure was crude and limited to applying heat, immersing the patient in warm baths, bloodletting and administering diaphoretic mixtures with nitric acid and alcohol6. In 1854, Graham described a process, termed “Osmotic Force”, where colloids and crystalloids could be separated. Based on this principle, Graham developed the “hoop” type dialyzer and suggested that animal tissue could provide a semipermeable membrane across which molecules could selectively diffuse7.
Early Peritoneal Dialysis Solutions
The first therapeutic infusion of fluid into the peritoneal cavity recorded in the literature was performed by Warrick8 in 1744 and involved the infusion of red wine for the treatment of ascites. In 1877, Wegner4 reported the increase of effluent volume after infusing saline solution or glycerin into the peritoneal cavity; this may have been the first report of diffusion across the peritoneal membrane.
During the first quarter of the 20th century, the physiologic basis for peritoneal dialysis (PD) was established. The relationship between osmolality of the fluids and peritoneal ultrafiltration, absorption and the bidirectional flux of small molecules between the peritoneal cavity and the intravascular compartment was emphasized8, 9. By 1920, it had been recognized that, regardless of the infusate osmolality, the fluid was completely absorbed within 20 hours of infusion 10-12. These observations led to the administration of intraperitoneal (ip) fluids to infants with severe dehydration when the oral route was not possible13,14. This may have been the first successful therapeutic use of the peritoneal membrane. Orlow, Clark, Putnam, and others demonstrated that the peritoneal membrane was permeable to sodium and other minerals15-19. Importantly, Putnam elucidated that an osmotic equilibrium exists between the peritoneal fluid and the plasma, and that mass transfer occurred by a passive process16. Klapp first observed that applying heat to the anterior abdominal wall accelerated the exchange of substances between the peritoneal cavity and the blood18. Clark later confirmed these finding using ip infusions of warm solutions. He suggested that vasodilatation was responsible for the accelerated rate of exchange19.
It was Ganter20, however, who was the first to use peritoneal lavage to treat renal failure in a patient with obstructive uropathy and in uremic animal models using physiological saline in 1923. In his uremic models, intraperitoneal exchanges of physiologic saline lasting 2 to 4 hours were utilized. Although there was moderate absorption of the dialysate due to its hypotonicity relative to uremic plasma, definite clinical improvement was noted in the animals after dialysis. As the evolution of PD solutions continued, Heusser21 sought to improve UF and added dextrose to the infusate in 1927, and Rhoads22 added lactate as a source of bicarbonate in 1938. In 1969, Boen used a peritoneal dialysate formulation containing acetate (35 mEq/L), sodium (130 – 140 mEq/L) and glucose (1.5 – 5 g/dL). This approach then became the standard practice for many years until acetate was replaced by lactate23.
- Cunningham RS. The physiology of the serous membranes. Physiol Rev 6:242,1926
- von Recklinghaussen FT. Die Lymphgefässe und ihre Beziehung zum Bindegewebe. Berlin, Germany: Hirshwald; 1862
- von Recklinghaussen FT. Zur fettresorption. Virchows Arch 26:172, 1863
- Wegner G. Chirurgische Bermekungen über die Peritonealhöle, mit besonderer Berucksichtigung der Ovariotomie. Arch Klin Chir 20:51, 1877
- Starling EH, Tubby AH. The influence of mechanical factors on lymph production. J Physiol (London) 16:140, 1894
- MacBride PT. The Development of Hemodialysis and Peritoneal Dialysis. In: Clinical Dialysis Nissenson AR, Fine RN eds, 4th Ed, McGraw Hill Publishers, pp 2-25, 2005
- Graham T. Osmotic Force. Philos Trans Soc Lond 144:177-228, 1854
- Schechter AJ, Cary MK, Carpentieri AL, et al. Changes in composition of fluids injected into the peritoneal cavity. Am J Dis Child 46:1015, 1933
- Leathes JB, Starling EH. On the absorption of salt solutions from the pleural cavities. J Physiol 18:106, 1895
- Warrick C. Improvement on the practice of tapping by which that application instead of relief of symptoms, becomes an absolute cure for ascites. Philos trans R Soc Lond 438:1744-1745, 1744
- Cunningham RS. Studies on absorption from serous cavities, III. Am J Physiol 53:488, 1920
- Hamburger HJ. Ueber die Regelung der osmotischen Spannkraft von Flüssigkeiten in Bauch-und Pericardialhöhle. Archiv f Phys du Bois-Reymond 281, 1895
- Blackfan KD, Maxcy KF. The intraperitoneal injection of saline solution. Am J Dis Child 15:19, 1918
- Weinberg M. Die Anwendung der intraperitonealen Infusion beim wasserverarmten Saügling. Ztschr f Kinderheilkunde 29:15, 1921
- Orlow WN. Einige Versuche über die Resorption in der Bauchhöle. Arch f Phys Pflüger 59:170, 1895
- Putnam TJ. The living peritoneum as a dialyzing membrane. Am J Physiol 63:548, 1922
- Abbott WE, Shea P. The treatment of temporary renal insufficiency by peritoneal lavage. Am J Med Sci 211:312, 1946
- Klapp R. Ueber Bauchfelresorption. Mitt Grenzgeb der Med u Chir 10:254, 1902
- Clark AJ. Absorption from the peritoneal cavity. J Pharmacol 16:415, 1921
- Ganter G. Ueber die Beseitigung giftiger Stoffe aus dem Blute durch Dialyse. Munch Med Wochschr 70:1478, 1923
- Heusser H, Werder H. Untersuchungen über Peritonealdialyse. Bruns Beitäge Klin Chir 141:138, 1927
- 22. Rhoads JE. Peritoneal lavage in the treatment of renal insufficiency. Am J Med Sci 196:642,1938
- Boen ST. Peritoneal dialysis. Thesis. Amsterdam, The Netherlands, University of Amsterdam, 1959
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