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Peritoneal Dialysis
LEADING ARTICLES
869
of peritoneal dialysis in 14 patients, of whom 9 were uraemic, 1 was in hepatic coma, and the remaining 4 had either salicylate or barbiturate poisoning without evidence of renal impairment. But, owing to the relatively slow rate of clearance, it is improbable that peritoneal dialysis will ever have much of a place in the treatment of intoxication with dialysable poisons. The increasing popularity of peritoneal dialysis in large centres is reflected in a report by BURNS et al.s of their experience at the Peter Bent Brigham Hospital. In 1959 only 3 peritoneal dialyses were performed, compared with 85 hxmodialyses; in 1961 the figure for peritoneal dialyses was 121, with 37 haemodialyses. BURNS et al. believe peritoneal dialysis to be of particular value in cases of acute renal failure with persistent hypotension, in postoperative anuria to allow the patient to be mobilised, and in intractable congestive heartfailure where diuretic responsiveness may occasionally be restored. The procedure is adopted in preference to the artificial kidney in cases of " surgical " acute renal failure where very frequent hxmodialyses would be indicated, and is not necessarily precluded by recent abdominal surgery. The need to provide dialysis facilities in addition to the artificial kidney has arisen largely from the everincreasing load on personnel and equipment due to earlier and more frequent dialysis in acute renal failure and to its application in chronic renal failure. In a review of the management of acute renal failure in a large number of patients, BALSL0V and J0RGENSEN 7 compare the results obtained when the indication for dialysis was taken as a blood-urea over 300 mg. per 100 ml. and/or hyperkalaemia with those where dialysis " was delayed until a state of " clinical uraemia had or the blood-urea had reached 400 developed mg. per 100 ml. or hyperkalaemia was present. They found no significant difference in mortality between the two groups, but the patients treated by earlier dialysis were easier to manage and had fewer complications. The use of dialysis in the treatment of chronic urxmia is a recent development. Peritoneal dialysis will probably be found of value in the management of those patients in whom repeated dialysis alone is contemplated and also of those for whom renal homotransplantation is to be attempted. BURNS et al. suggest that in the former group an indwelling peritoneal conduit be used to facilitate frequent reattachment of the dialysis tube. Where renal transplantation (particularly using a cadaver kidney) is planned, a long delay may be unavoidable before operation becomes feasible; and during’this time the patient’s condition may be controlled more safely by peritoneal dialysis than by repeated hxmodialyses. Peritoneal dialysis in the more chronic urxmias would help to spare equipment and personnel for haemodialysis in the treatment of acute renal failure with severe uraemia, hyperkalxmia, or acidosis and in the management of dangerous overdosage with dialysable ence
THE LONDON
LANCET 26
OCTOBER
Peritoneal
1963
Dialysis
PERITONEAL dialysis was first used in the treatment of renal failure in 1923; but, owing to the frequency of
subsequent peritoneal infection and retention of fluid, it was not widely adopted. The introduction of satisfactory methods of hxmodialysis in the 1950s resulted in almost complete disuse of the earlier technique except where the patient was too ill for transfer to a hospital equipped with an artificial kidney. In the past two or three years interest in the value of peritoneal dialysis has been revived, largely owing to improvements in technique, increasing awareness of the hazards of hxmodialysis (particularly in the elderly and very ill), and the great increase in demand for dialysis in the of both acute and chronic renal failure. In 1959 MAXWELL et al.1 described a method of intermittent peritoneal dialysis, based on that of GROLLMAN et al.,2 in which the dialysis fluid was introduced and drained by a single peritoneal catheter inserted via a trocar through the avascular midline linea alba. Drainage was much more effective than with the former continuous technique involving two tubes, and the risk of infection was reduced by the snug fit of the catheter iritroduced in this way as opposed to a surgical incision. The method gave a urea clearance about 25% of that of the Kolff twin-coil artificial kidney. A further practical problem-namely, the preparation and sterilisation of the dialysis fluid in the considerable volumes requiredhas been overcome, at least in the U.S.A., by the introduction of commercially prepared solutions. Three papers from Canada emphasise the value of peritoneal dialysis, particularly in the smaller hospital. PALMER et al.3 suggest that the main advantages are reduced demands for special equipment, trained per sonnel, and the large blood-supplies required for the artificial kidney. In their experience of peritoneal dialysis in 12 patients, this procedure was chosen in preference to hsemodialysis in 2 instances to avoid administration of anticoagulants. Although the clearance of urea was only about a quarter of that with the artificial kidney, dangerous hyperkalaemia could be corrected within a few hours. ELLIS et al.4 stress the importance of peritoneal dialysis in isolated hospitals where an artificial kidney is not available and transfer of patients would prejudice recovery. Moreover, once established, the procedure can be managed by nursing staff. In the third paper, COHEN5 describes his experi-
treatment
1.
Maxwell, M. H., Rockney, R. E., Kleeman, C. R., Twiss, M. R. J. Amer med. Ass. 1959, 170, 917. 2. Grollman, A., Turner, L. B., McLean, J. A. A.M.A. Arch. Intern Med. 1951, 87, 379. 3. Palmer, R. A., Maybee, T. K., Henry, E. W., Eden, J. Canad. med Ass. J. 1963, 88, 920. 4. Ellis, K. G., Lea, R. G., Drysdale, R. D. ibid. p. 928. 5. Cohen. H. ibid. p. 932.
poisons. Burns, R. O., Henderson, L. W., Hager, E. B., Merrill, J. P. New Engl. J. Med. 1962, 267, 1060. 7. Balsløv, J. T., Jørgensen, H. E. Amer. J. Med. 1963, 34, 753. 6.
869
of peritoneal dialysis in 14 patients, of whom 9 were uraemic, 1 was in hepatic coma, and the remaining 4 had either salicylate or barbiturate poisoning without evidence of renal impairment. But, owing to the relatively slow rate of clearance, it is improbable that peritoneal dialysis will ever have much of a place in the treatment of intoxication with dialysable poisons. The increasing popularity of peritoneal dialysis in large centres is reflected in a report by BURNS et al.s of their experience at the Peter Bent Brigham Hospital. In 1959 only 3 peritoneal dialyses were performed, compared with 85 hxmodialyses; in 1961 the figure for peritoneal dialyses was 121, with 37 haemodialyses. BURNS et al. believe peritoneal dialysis to be of particular value in cases of acute renal failure with persistent hypotension, in postoperative anuria to allow the patient to be mobilised, and in intractable congestive heartfailure where diuretic responsiveness may occasionally be restored. The procedure is adopted in preference to the artificial kidney in cases of " surgical " acute renal failure where very frequent hxmodialyses would be indicated, and is not necessarily precluded by recent abdominal surgery. The need to provide dialysis facilities in addition to the artificial kidney has arisen largely from the everincreasing load on personnel and equipment due to earlier and more frequent dialysis in acute renal failure and to its application in chronic renal failure. In a review of the management of acute renal failure in a large number of patients, BALSL0V and J0RGENSEN 7 compare the results obtained when the indication for dialysis was taken as a blood-urea over 300 mg. per 100 ml. and/or hyperkalaemia with those where dialysis " was delayed until a state of " clinical uraemia had or the blood-urea had reached 400 developed mg. per 100 ml. or hyperkalaemia was present. They found no significant difference in mortality between the two groups, but the patients treated by earlier dialysis were easier to manage and had fewer complications. The use of dialysis in the treatment of chronic urxmia is a recent development. Peritoneal dialysis will probably be found of value in the management of those patients in whom repeated dialysis alone is contemplated and also of those for whom renal homotransplantation is to be attempted. BURNS et al. suggest that in the former group an indwelling peritoneal conduit be used to facilitate frequent reattachment of the dialysis tube. Where renal transplantation (particularly using a cadaver kidney) is planned, a long delay may be unavoidable before operation becomes feasible; and during’this time the patient’s condition may be controlled more safely by peritoneal dialysis than by repeated hxmodialyses. Peritoneal dialysis in the more chronic urxmias would help to spare equipment and personnel for haemodialysis in the treatment of acute renal failure with severe uraemia, hyperkalxmia, or acidosis and in the management of dangerous overdosage with dialysable ence
THE LONDON
LANCET 26
OCTOBER
Peritoneal
1963
Dialysis
PERITONEAL dialysis was first used in the treatment of renal failure in 1923; but, owing to the frequency of
subsequent peritoneal infection and retention of fluid, it was not widely adopted. The introduction of satisfactory methods of hxmodialysis in the 1950s resulted in almost complete disuse of the earlier technique except where the patient was too ill for transfer to a hospital equipped with an artificial kidney. In the past two or three years interest in the value of peritoneal dialysis has been revived, largely owing to improvements in technique, increasing awareness of the hazards of hxmodialysis (particularly in the elderly and very ill), and the great increase in demand for dialysis in the of both acute and chronic renal failure. In 1959 MAXWELL et al.1 described a method of intermittent peritoneal dialysis, based on that of GROLLMAN et al.,2 in which the dialysis fluid was introduced and drained by a single peritoneal catheter inserted via a trocar through the avascular midline linea alba. Drainage was much more effective than with the former continuous technique involving two tubes, and the risk of infection was reduced by the snug fit of the catheter iritroduced in this way as opposed to a surgical incision. The method gave a urea clearance about 25% of that of the Kolff twin-coil artificial kidney. A further practical problem-namely, the preparation and sterilisation of the dialysis fluid in the considerable volumes requiredhas been overcome, at least in the U.S.A., by the introduction of commercially prepared solutions. Three papers from Canada emphasise the value of peritoneal dialysis, particularly in the smaller hospital. PALMER et al.3 suggest that the main advantages are reduced demands for special equipment, trained per sonnel, and the large blood-supplies required for the artificial kidney. In their experience of peritoneal dialysis in 12 patients, this procedure was chosen in preference to hsemodialysis in 2 instances to avoid administration of anticoagulants. Although the clearance of urea was only about a quarter of that with the artificial kidney, dangerous hyperkalaemia could be corrected within a few hours. ELLIS et al.4 stress the importance of peritoneal dialysis in isolated hospitals where an artificial kidney is not available and transfer of patients would prejudice recovery. Moreover, once established, the procedure can be managed by nursing staff. In the third paper, COHEN5 describes his experi-
treatment
1.
Maxwell, M. H., Rockney, R. E., Kleeman, C. R., Twiss, M. R. J. Amer med. Ass. 1959, 170, 917. 2. Grollman, A., Turner, L. B., McLean, J. A. A.M.A. Arch. Intern Med. 1951, 87, 379. 3. Palmer, R. A., Maybee, T. K., Henry, E. W., Eden, J. Canad. med Ass. J. 1963, 88, 920. 4. Ellis, K. G., Lea, R. G., Drysdale, R. D. ibid. p. 928. 5. Cohen. H. ibid. p. 932.
poisons. Burns, R. O., Henderson, L. W., Hager, E. B., Merrill, J. P. New Engl. J. Med. 1962, 267, 1060. 7. Balsløv, J. T., Jørgensen, H. E. Amer. J. Med. 1963, 34, 753. 6.