Peritoneal Dialysis

Peritoneal dialysis (PD) cleans blood through the peritoneal membrane. Peritonitis and exit-site infection are the emergencies to recognize early.

Peritoneal dialysis (PD) is renal replacement therapy that works inside the peritoneal cavity. Dialysate dwells there, and the peritoneum is the membrane doing the work. Solute and water cross it. Then the used fluid drains out and fresh fluid goes in.

How It Works

• Diffusion: Urea, creatinine and potassium drift down their gradient. They move from blood into dialysate.
• Osmosis (ultrafiltration): Glucose or icodextrin in the dialysate pulls water out of the blood. The osmotic gradient does that work.
• Exchange cycle: Drain, fill, dwell. Waste and fluid come off over the length of the dwell.
• Access: The catheter is soft and cuffed. It sits in the peritoneal cavity and exits through the abdominal wall.

Where It Fits

For end-stage kidney disease, PD is one home option. In-center or home hemodialysis (HD) is the other route. The table below lays out the PD options.

Indications & Patient Selection

PD is a long-term option for end-stage kidney disease. Teams often choose it when:

• The patient, or a trained caregiver, can do sterile exchanges and wants therapy at home.
• The patient wants to skip in-center HD several times per week.
• Vascular access is limited, or it needs to be saved.
• Travel or transport makes in-center HD hard to reach.

Selection Considerations

• Capacity to perform or supervise exchanges: vision, dexterity and cognition
• A clean exchange area, supply storage and reliable power (for APD)
• Abdominal factors: hernia, prior major abdominal surgery, adhesions and body habitus
• Residual kidney function and comorbidities that affect fluid and glucose control

Absolute Contraindications

Nephrology decides where absolute ends and relative begins, and that line varies. The list below gives relative cautions for this page.

Relative Contraindications & Cautions

• Extensive adhesions or scarring that limit dialysate distribution
• Active intra-abdominal infection (peritonitis, diverticulitis) until resolved
• Large or unrepairable hernias, or a diaphragmatic defect not corrected surgically
• Severe protein loss or malnutrition that PD would worsen
• No safe way to perform sterile technique at home, and no support

Consider an Alternative

If PD won't work, HD is the fallback: Hemodialysis.

Team Roles During the Procedure

• Operator: performs the exchange under protocol (PD RN or nephrology)
• Monitor: watches vital signs, pain, dyspnea and effluent
• Medication clinician: gives antibiotics or insulin only as ordered
• Recorder: logs fill and drain volumes, times and effluent appearance

Pre-Dialysis Assessment

• Vitals: blood pressure, heart rate, respiratory rate, SpO₂ and temperature
• Weight: compare with the patient's dry weight; note gain or loss since the last exchange
• Abdomen: pain, distension, guarding, hernia and any leak at the catheter or scrotum
• Exit site and tunnel: redness, swelling, tenderness, drainage or crusting
• Effluent and volumes: last drain volume, clarity and net ultrafiltration
• Labs and symptoms: K⁺ and glucose per schedule; dyspnea, edema or confusion

Lower Abdomen Exit Site

1. Inspect the exit site and tunnel: look for redness, drainage, swelling, tenderness or crusting.
2. Confirm the exit path: the catheter should leave the skin pointing downward, away from the belt line and any hernia.
3. Report any cuff exposed at the skin: notify nephrology the same shift.
4. Secure the catheter: prevent traction on the exit site.

Pediatric

Pediatric surgery and nephrology decide placement and the exit site.

Upper Abdomen and Upper Chest Exit Sites

1. Confirm the site chosen by nephrology: note which catheter model is in place.
2. Check the loop and securement: the catheter must not pull on the exit site.
3. Inspect the exit site: use the same signs as the lower abdomen.
4. Keep the dressing dry and intact.

Pediatric

In children, each case is judged on its own. Pediatric surgery and nephrology make the call.

Equipment

Sizing

Each patient gets a prescribed dialysate strength and fill volume. The strengths sit in Key Numbers and Medications. This page gives no fill volume.

Patient Positioning & Preparation

Get the patient comfortable before the exchange. Bags and drain lines follow the system instructions, because gravity drives fill and drain. Clear clothing away from the exit site.

Doses are typical references. Verify them against local protocol and current drug labeling. For every patient, nephrology writes the dialysate prescription.

PD Prescription Elements

Phase 1: Prepare

1. Verify the order and solution: check the name, strength, expiry and clarity against the prescription.
2. Set up a clean work area: hand hygiene, mask per local protocol, and supplies laid out.
3. Inspect the catheter and exit site: check the dressing and look for redness, leaks or kinks.

Phase 2: Perform

4. Connect with aseptic technique: join the catheter to the transfer set using the closed system.
5. Drain: open the clamp to drain used dialysate; observe clarity, color, fibrin and volume.
6. Flush if the protocol requires: clear the line with a small volume of fresh dialysate.
7. Fill: infuse the prescribed volume. Stop and call the PD team for pain, dyspnea or leak.
8. Clamp and disconnect: close the lines and cap the transfer set per the system instructions.
9. Dwell: the patient continues daily activity for the prescribed dwell time.

Phase 3: Confirm & Secure

10. Secure the catheter: prevent traction on the exit site and keep the dressing dry.
11. Document: record fill and drain volumes, times, effluent appearance and tolerance.
12. Dispose and perform hand hygiene: remove used supplies per local protocol.

Alternative Technique: Automated PD (APD)

The cycler runs the exchanges overnight. Set up the disposable set and solutions per the device instructions. Connect the catheter aseptically before the cycler starts. Pain, poor drainage or cloudy effluent? Stop the cycler and call the PD team.

Primary Confirmation

Did the exchange work? Look at two things: clear effluent, and the net ultrafiltration you expected.

Secondary Confirmation

• Drain volume close to the fill volume plus expected ultrafiltration
• Free drain and free fill with no pain or dyspnea
• Dry exit site with no leak at the catheter or scrotum
• Weight trend in line with the prescription

The 0–3 exit-site score is a traditional scoring system, and a national PD cohort study evaluated it (see References). It grades how the site looks. It is not the ISPD definition of exit-site infection. That definition rests on purulent drainage (see the ISPD 2023 catheter-infection recommendations in References).

Ongoing Monitoring

• Every exchange: effluent appearance, volumes and patient tolerance
• Every shift (inpatient): vital signs, abdomen and exit site
• Daily or per program: weight and fluid balance
• Per schedule: electrolytes, glucose, bicarbonate, calcium, phosphate, albumin and blood counts

Pediatrics

• For acute kidney injury in children, PD is a suitable renal replacement option (ISPD pediatric AKI guideline, 2021).
• Pediatric nephrology sets fill volume and dwell by body size. This page gives no fixed mL/kg fill volume.
• The FDA label, section 8.4, says icodextrin safety and effectiveness in children are not established.
• Pediatric surgery and nephrology decide catheter placement and the exit site.
• Check vital signs against age-based norms: pediatric vital signs.
• Weight-based drug references: weight-based dosing.

Older Adults

• Poor vision or cognition can delay the spotting of cloudy effluent. Train a caregiver.
• Hyperglycemia and volume overload are common in this group. Check for both.

Obesity

• Extra abdominal bulk raises the hernia risk. It can also limit how well the catheter works.
• Upper-site ExxTended catheters are one option. Nephrology decides.

Pregnancy

• A growing abdomen changes dwell comfort and catheter position. Nephrology and obstetrics plan the prescription together.

Physiologically Difficult

• Under ISPD 2022, hypokalemia is a modifiable peritonitis risk factor. Check K⁺ and correct it per protocol.
• Histamine-2 receptor antagonists and domestic pets also count as modifiable peritonitis risk factors under ISPD 2022.

Immediate Aftercare

• Confirm the catheter is clamped, capped and secured after each exchange.
• Check the exit site and dressing before the patient leaves the area.
• Confirm the patient has solution, supplies and the PD team phone number.

Ongoing Maintenance

• Exit-site care daily: cleanse with the program's solution and keep the site dry.
• Topical antibiotic: ISPD 2023 downgraded routine topical antibiotic use. Apply it only per program protocol.
• Baths and pools: Avoid soaking unless someone has specifically cleared it.

Transport Considerations

• Keep the catheter clamped, capped and secured during every move.
• Do not drain or fill en route without medical direction.
• Reassess after each move: pain, dyspnea, leak and exit-site position.
• Send the solution bag, supplies and the PD record with the patient.

Pearls

• Cloudy effluent plus pain: Call it peritonitis until proven otherwise.
• Purulence defines exit-site infection: ISPD's diagnostic sign is purulent drainage.
• Modifiable risks: Keep pets out of the exchange area. Check potassium. Review acid suppression.
• Icodextrin meters: GDH-PQQ, GDO and some GDH-FAD meters read falsely high for up to 2 weeks after icodextrin (label). Use a glucose-specific method.

Common Pitfalls

• Routine ointment: Topical antibiotic on every exit site, by reflex → apply it only per program protocol. ISPD 2023 downgraded routine use.
• Cloudy bag blamed on the solution: Treat it as infection → stop, send cell count and culture, and notify.
• Catheter used for IV or blood draw: That brings in infection → the PD catheter is for dialysis only.
• Waiting for results to treat: Waiting costs time → once cultures are sent, start empiric antibiotics per protocol.

Skill Maintenance

• Run the exchange on a simulator, or work through a checklist, at least annually or per program.
• After every peritonitis case, debrief. Look for missed signs and calls that came late.
• Walk each new PD nurse through the cloudy-effluent action plan.

Patient & Family Teaching

• Aseptic technique: Hand hygiene, a mask and a clean workspace. Keep pets and drafts away.
• Recognize cloudy effluent or abdominal pain: Cloudy effluent or belly pain means calling the PD team at once.
• Recognize exit-site redness, pain or drainage: Redness, pain or drainage at the exit site means calling the PD team that same day.
• Daily exit-site care: Cleanse and dress per program, every day. Keep the site dry.
• Fluid overload: Shortness of breath, swelling or rapid weight gain points to fluid overload. Call the PD team.
• Dialysis and diet: Nephrology sets the fluid, salt and potassium limits.
• Emergency plan: Plan for power outages (APD) and for where supplies are stored.