Peritoneal dialysis
Presented by
Ray Agnello BSN, RN, CNN
Renal Educator
St. Joseph’s Medical Center
Objectives
To provide attendees with a summarized
review of peritoneal dialysis.
To highlight key points in the clinical care of
a PD patient.
Catheter placement
Care of catheter
Infectious complication
Non-infectious complications
Adequacy
Fluid balance assessment of the patient with PD
Peritoneal Dialysis
 Alternative
to hemodialysis
 Patient is taught to perform dialysis
exchanges in the home setting
 Focus is on patient autonomy and selfcare management
 Patient must be followed by a licensed
Peritoneal Dialysis unit
Peritoneal Membrane
Translucent
Vascular membrane
Two layers
Parietal (inner surface of abdominal wall)
Receives blood supply from the arteries of the abdominal
wall.
Visceral (covers abdominal viscera)
Covers the abdominal organs.
Blood is carried by the mesenteric and celiac arteries.
Most vascular layer where most of the dialysis occurs.
Envelope of space between layers called peritoneal
cavity.
Semi-permeable; acts as a filter.
Kelley (2004)
Anatomy and Physiology

Peritoneal Membrane
 Semi-permeable
 Bi-directional
 Membrane size – 1-2 m2
 Vascular wall, interstitium, mesothelium ,
and adjacent fluid films
 Closed in males
 Women – Ovaries and fallopian tubes open
into the peritoneal cavity
 Peritoneal cavity normally contains about
100 ml transudate
Kinetics of
Peritoneal Dialysis
 Diffusion
 Osmosis
 Ultrafiltration
 Drug
Transport
Diffusion
Tea Bag = Peritoneal Membrane
Water = PD Fluid
Tea Leaves = Waste
Scheme of semi-permeable membrane:
red = blood
blue = PD fluid
yellow = membrane
wikipedia.org/
Osmosis
The diffusion of pure solvent across a
membrane in response to a
concentration gradient, usually from
a solution of lesser to one of greater
solute concentration.
Miller-Keane 6th Edition
Osmotic Pressure of Dextrose Solution
1.5 %
Solution
2.5 %
Solution
4.25 %
Solution
The Peritoneal Dialysis
Process
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Definition-intra (within)
corporeal dialysis
Three phases to the
exchange process
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Drain
Fill
Dwell
How Does PD Work?
The semi-permeable peritoneal membrane
lines the abdominal cavity and covers the
abdominal viscera.
 The membrane allows (via diffusion) the
passage of toxins and electrolytes into the
dialysis solution.
 Ultra-filtration (removal of fluid) occurs via
osmosis.
 A “steady state” of toxin clearance and fluid
management is achieved due to daily
performance of dialysis.

Kelley (2004).
How Does PD Work?

Dialysis solution is infused and drained via
a catheter that is surgically placed in the
peritoneal cavity.

The action of draining and infusing dialysis
solution is called an exchange.

The frequency of exchanges and volume is
determined by the presence of residual
renal function and the individual
membrane characteristic.
Infusion or Fill
Baxter®
Drain
Baxter®
Peritoneal Dialysis
Dialysis
occurs during the dwell phase.
Diffusion:
Solutes cross from area of greater
concentration to lesser one.
- Depends on concentration gradient.
- Enough peritoneal surface area.
- Size of fill volume.
Ultra-filtration:
Water removal due to
osmotic gradient between the hyperosmolar
PD fluid and the capillary bed.
Kelley (2004).
Historical Perspectives
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Acute – Predominant use of PD prior to 1960s
1966 – Automated cycler
1967 – Tenckhoff catheter
1975 – CAPD
1978 – Polyvinyl bags manufactured
1980s – New catheter designs
1987 – PET and tidal PD – Twardowski
1990s – Alternative dialysate solutions,
updated system designs
Who Are the PD Patients ?

Choose PD as renal replacement therapy

Hemodialysis patient without access

Failed allograft (transplanted kidney)

Have CHF or CVD which exempts them
from hemodialysis

Often people without the benefit of CKD
education
PD Patient Selection
Inclusion criteria include patients who:
Choose the modality.
Want “control.”
Prefer home for dialysis.
Have residual renal function.
CVD, CHF.
Geriatric.
Pediatric.
Social support system.
Surgical Evaluation
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Abdominal wall weakness or hernia
Repair hernia preemptively or when
symptomatic
Previous abdominal surgeries
Likelihood of adhesions
Abdominal wall obesity
Surgical Evaluation
Catheter Insertion
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Some units advocate insertion 2 to 6
weeks prior to dialysis to optimize
healing.
Some units advocate insertion
months in advance (burying the
catheter).
In most situations, PD access is
elective.
Peri-Operative Routines
Anesthesia
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Local infiltration with sedation
Intravenous propofol with MAC
General anesthesia
Insertion Techniques
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Bedside-temporary catheters
Laparoscopic placement
Surgical dissection
Buried catheter technique
Insertion Techniques
Buried catheter:
 Entire catheter placed in
subcutaneous pocket for 4 to 6 weeks
or longer, allowing cuff to heal.
 Exit site is externalized in a separate
procedure.
 Reduced bacterial colonization (?).
 Do not have long-term outcomes yet.
Flanigan & Gokal (2005).
Pre-Catheter Insertion
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Patient education and consent signed
Examination of the patient’s abdomen
•
Avoid scars and fat folds
•
Avoid beltline
•
Mark the abdomen
Surgical prep
•
Empty bladder
•
Patient showers with disinfectant soap
•
Bowel prep
Steps to PD Catheter Access

Evaluation by nephrologist for PD
catheter placement and identified as
candidate.

Educated about catheter placement, and
pre- and post-operative care routines.

Referred to surgeon for evaluation that
includes determination of exit site,clinical
and anesthesia work-up, contraindications, completion of consent forms,
and scheduling of surgery.
Selection Continued
Exclusion Criteria
Patients who:
Have abdominal aortic aneurysm AAA
(size dependent)
Derm. disease of the abdominal wall
Morbid abdominal obesity
Altered mental status; poor coping styles
Solitary lifestyle
Patient states lack of interest in modality
Multiple abdominal surgeries – adhesions
Ostomies (increase risk of infection)
Recurrent hernias
Catheter History
•
Early catheters were glass cannulas
with straight or with mushroom ends.
•
1920s – Stainless steel coil with
rubber drain first used in NYC
(Rosenak)
•
1940s – Urinary catheters utilized
•
1950s – Nylon catheters at UCLA
•
1960s – Button catheters (Scribner,
Boen)
Catheter History
1964 –
Slicon rubber catheters (Palmer,
Quinton)
1965 – Tenckhoff intermittent catheter
1968 – Tenckhoff cuffed straight catheter
1970s – Single/double cuff coiled catheter
1980s – Swan neck configuration
2000s – T-shaped catheter (Ash)
The future..?
Catheters
Straight
(single or double cuff)
Coiled (single or double cuff )
Swan neck (single or double cuff)
Pre-sternal swan neck
Toronto Western
Missouri catheters
Disc catheters
Cuffs
 Single
 Double
 Elongated
 Bead/flange
configuration
Adaptors
 Plastic
 Titanium
PD Catheter Access Complication

Immediate/Early
Bloody effluent
Pain with infusion
Leak at exit site
Exit site infection
Migration of catheter tip
Poor fill or drain, with or without pain
Non-infectious cloudy effluent
(lymphatic leak or eosinophilic
peritonitis)
PD Catheter Access Complication
Later Issues
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Exit site leaks or subcutaneous leaks
Pleural communications
Excessive granulation tissue
Chronic site or tunnel infection
Cuff extrusion
Cracked, brittle catheter
Repetitive episodes of peritonitis
Bowel perforations
Post-Op
 Follow
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up appointment with surgeon
 Remove primary dressing in 5 to 7
days
 Replace dressing with DSD
Teach patient to secure catheter
Flush catheter during training sessions
Allow catheter to heal for 14 days or
longer if possible
Schedule training sessions
Post Operative Discharge Plan
Pain medication/prescription
Follow-up in PD unit within
48 to 72 hours of discharge
Dressing intact for 5 to 7 days
Reinforce dressing as needed
Dressing changed by PD nurse
Establish training schedule
Bowel regimen Prevent Constipation
No heavy lifting
Written instructions
Emergency phone numbers
Peritoneal Dialysis Therapies
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IPD (Intermittent Peritoneal
Dialysis)
CAPD (Continuous Ambulatory
Peritoneal Dialysis )
CCPD (Continuous Cycling
Peritoneal Dialysis) also known as
APD (Automated Peritoneal
Dialysis)
Training Sessions for the PD Patient
Assess readiness to learn
 Provide a quiet, relaxed atmosphere for
learning
 Identify patient’s learning style
 Individualized with respect to patient’s
expectations, cultural beliefs, and coping
abilities
 Length of training based on patient’s
clinical condition

O
N
C
Warming the Solution
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Use warm, dry heat
At home – PD heating pad

NEVER MICROWAVE!!
Uneven heating of dextrose can create a
1st or 2nd degree burn to peritoneum
Leaching of plastics into dialysate can
create a chemical peritonitis
Patients At Risk for Inadequate
Dialysis
No residual renal function
 Low membrane permeability
 Large patients
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PD Equilibration Test
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First developed by Z. Twardowski at the
University of Missouri.
A 4-hour study that assesses membrane
transport characteristics.
Assessment of membrane function allows
for accurate prescription planning.
Usually completed within the first six
weeks of initiating PD.
Repeated per each unit’s protocol.
PD Equilibration Test continued
What does this tell us?
The results indicate the following
transport states:
High
High-average
Low-average
Low
KT/V Test
What is measured?
 24-hour collection of dialysate and
urine

Serum values of BUN and Creatinine

Frequency of test is determined by
each unit’s protocols and
interpretation of K/DOQI Guidelines
KT/V Test continued
What does it tell us?
 The adequacy of the current
prescription

Need for adjustments to insure
appropriate dialysis prescription
Infectious Complications
Exit Site Care
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Healthy exit site: Surrounding skin
natural, darkened, or light pink; no
drainage or crusting; visible sinus is
dry.
Goal: Prevent exit site infection and
identify problems early.
Frequency: Daily or 3 to 4 times
weekly; may be in conjunction with
showering.
Infection Prevention
Exit Site Care:
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No dressing needed for established catheter
exit site.
Keep catheter secured to abdomen with 2inch tape.
Daily showers with liquid soap.
Mupirocin (Bactroban®) at exit site of
known staph. carrier.
Inpatients – Dry dressing to protect site,
cleaned with soap and water. No occlusive
membrane dressings (Tegaderm®).
A healed and non-infected exit site is crucial
to longevity on Peritoneal Dialysis.
Exit Site Infection
Teach patient to identify and report immediately
to the PD Unit:
 Redness, tenderness, edema, presence of
exudate either at exit site or insertion site.
Treatment:
 Culture exudate if possible
 Specific antibiotic protocol
 Oral or IV/IP antibiotics depending on extent of
infection
 Saline soaks/dressing changes for care of local
cellulitis
Exit Site Infection

A chronic exit site infection can produce a
systemic inflammatory response.

Inflammation can lead to poor nutrition,
inadequate dialysis, and possible antibiotic
resistance. Vital role of dietitian.

Chronic exit site infections may result in
peritonitis.

Multiple infections can lead to removal and
replacement of catheter.

Consistent assessment and documentation
is needed to appropriately track infections.
Exit Site Infection
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Signs and Symptoms: Redness, swelling,
tenderness or pain, and purulent drainage.
Risk Factors: Poor catheter healing, sutures
at the exit site, trauma to the exit site, cuff
extrusion, and improper catheter care.
Diagnosis: Observation and culture.
Treatment: Antibiotics, IP, PO, or IV;
vigilant daily exit site care.
Responsible Organisms

Staphylococcus Aureus
Pseudomonas species
 Other gram-positive species
 Serratia species
 Other gram-negative organisms
 Fungi

Tunnel Infection
Signs and Symptoms
Erythema over the tunnel
Pain and tenderness
Drainage from exit site – No other signs of
an infection
Risk factors
Exit-site infection
Exit-site trauma
Leak
External cuff extrusion
Treatment – Antibiotic therapy to prevent
need for catheter removal
Prevention of Peritonitis

Basics of Aseptic Technique: 5-min. hand
scrub, face masks during exchanges,
warming of PD bags using dry heat,
aseptic technique for adding medicines.

Aseptic technique when making critical
connections to solution containers and the
patient’s transfer set.

Masks reduce the risk of contamination
with nasopharyngeal organisms.
Peritonitis
Portals of Entry
 Transluminal – Technique failure,
contamination
 Periluminal – Incomplete healing ,leaking
 Hematogenous – Bacteremia
 Transmurl – Through the bowel wall

ANNA Core Curriculum
Diagnosis of Peritonitis

Effective culture techniques:
 Minimum sample volume of 50-100
ml. Large samples reduce false
negative results.
 Dialysate must be mixed well by
inverting bag several times before
sampling.
 Sample port is disinfected before
sampling.
 Sample is obtained using aseptic
technique.
Peritonitis

Defined as the presence of WBC in the
effluent numbering 100 or greater.

Effluent appears cloudy and milky.

Patient may have fever, chills, abdominal
pain, nausea, vomiting, and diarrhea.

Some present initially with cloudy fluid as
the first sign and no symptoms.

Patient must be taught to contact their PD
nurse or nephrologist immediately for
cloudy effluent.
Peritonitis Presentation
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Signs and Symptoms: Fever, abdominal pain,
nausea and vomiting, diarrhea, and cloudy
effluent.
Incubation: 24-48 hours; if within 6 hours
suspect an enteric source.
Kinetic effects: Increased solute removal and
protein loss; increased glucose absorption
leading to a decreased osmotic gradient and
decreased ultrafiltration.
Prevention of Peritonitis

Careful individualized patient training

Adequate daily hygiene
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Meticulous hand washing

On-going retraining
Peritonitis

Treatment protocols

Patient may be treated in PD Unit or Emergency
Room depending on the severity of symptoms and
availability of resources.

Effluent is sent for cell count, C&S, and gram stain.

Fungal cultures should be included if patient is
immunosuppressed or has had frequent infections
requiring antibiotics.

PD Unit should have specific antibiotic protocols for
gram-positive and gram-negative coverage.
Peritonitis
Organisms
 Gram-Positive:
Staphylococcus epidermidis
Staphylococcus aureus
Streptococcus species
Enterococcus
Gram-Negative:
Pseudomonas
Klebsiella
Escherichia coli
Enterobacter
Fungal Organisms
PD Affects Drug Transport By:
Systemic drug removal via
effluent
 Drugs can be administered IP
 Dose related to urine output
and mechanism for elimination
of drug

Membrane changes

Sclerosing, Encapsulating Peritonitis
 A thick fibrous layer of tissue
encapsulates the bowel
 Membrane becomes thick and opaque
 Onset gradual or rapid
 Presentation
 Decreased ultrafiltration and solute
clearances
 Recurrent abdominal pain
 Intermittent nausea and vomiting
 Partial and/or complete bowel
obstruction
 Intervention – Emergency laparotomy
Clinical Management Issues
for the PD Patient
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Catheter insertion and healing of exit site
Prevention of infection
Blood pressure control and fluid
management
Nutrition evaluation and interventions
Systems assessment
Medication evaluation
Anemia/Ca/Phos./PTH management
PET and initial Kt/V
Coping with stress of chronic illness
Transplantation
Current Issues in Peritoneal Dialysis
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Revision of K/DOQI
Co-morbidities
Role of sodium
Volume Control
Blood pressure control
Utilization of Icodextrin
Role of inflammation
Integrated dialysis care
Improving fellow education
CKD education for patients and families
ADEMEX study-adequacy
European APD Outcome Study (2003)
Underutilization of Peritoneal Dialysis
Questions ?
References
Ash [Author: Need full reference]
Flanigan, M. & Gokal,R. (2005). Peritoneal catheters and exit site
practices toward optimum peritoneal access: A review of
current developments. Peritoneal Dialysis International, 25,
132-139.
Kelley, K. (2004) How peritoneal dialysis works. Nephrology
Nursing Journal, 31(5), 481-491.
Palmer & Quinton {Author: Need full reference]
Rosenak [Author: Need full reference]
Scribner & Boen [Author: Need full reference]
Additional Readings
Abu-Alfa, A. (2003) The Ademex Study: Expanding the Boundaries of peritoneal dialysis
adequacy beyond small solute clearances. Dialysis and Transplantation, 32(3), 115-124.
American Nephrology Nurses’ Association (ANNA). (YEAR?). Chronic kidney disease – What
every nurse should know. Partnering for quality care. Retrieved May 31, 2007, from
www.annalink.com
American Nephrology Nurses’ Association (ANNA). (2006). Peritoneal dialysis. (2006) In
Molzahn, A.E., & Butera, E. (Eds.). contemporary nephrology nursing: Principles and
practice (2nd ed.) (pp. 629-687). Pitman, NJ: Author.
American Nephrology Nurses’ Association (ANNA) Peritoneal Dialysis Special Interest Group.
(2003). Peritoneal dialysis nurse resource guide. Nephrology Nursing Journal, 30(5), 535.
American Nephrology Nurses’ Association (ANNA) Peritoneal Dialysis Special Interest Group.
(2004). A monograph on peritoneal dialysis. Nephrology Nursing Journal, 31(5).
American Nephrology Nursing Association (ANNA) Peritoneal Dialysis Special Interest Group.
(2005) The Peritoneal equilibration test. Nephrology Nursing Journal, 32(4), 452-453.
Bargman, J. (1995). Preventing hernias and leaks in long-term patients on peritoneal dialysis.
Seminars in Dialysis., 8(6), 370-372.
Additional Readings
Babcock, D.E., & Miller, M.A. (1994). Client education: Theory and practice. St. Louis, MO:
Mosby.
Bargman, J. (2000). Non-infectious complications of peritoneal dialysis. In R.Gokal, R.Khanna,
R.Krediet, & K. Nolph (Eds.), Textbook of peritonealdialysis (2nd ed.) (pp. 609-646).
London: Kluwer Academic Publishers.
Bernardini, J. (2004). Peritoneal dialysis: Myths, barriers, and achieving optimum outcomes.
Nephrology Nursing Journal, 31(5), 494-498.
Bernardini, J., Bender, F., Florio,T., Sloand, J., Palmmontalbano, L., Fried, L., et al. (2005).
Randomized, double-blind trial of antibiotic exit site cream for prevention of exit site
infection in peritoneal dialysis patients. Journal of American Society of Nephrologists.
16(2), 539-545.
Burkart, J. (2003). The Ademex Study and its implications for peritoneal dialysis adequacy.
Seminars in Dialysis, 16(1), 1-4.
Burrows-Hudson, S.
(2005) Chronic kidney disease: An overview. American Journal of
Nursing, 105(2), 40-49.
Crawford-Bonadio, T., & Diaz-Buxo, J. (2004) Comparison of peritoneal dialysis solutions.
Nephrology Nursing Journal, 31(5), 500-513.
Additional Readings
Dana, C. (2004). What is missing in making PD a success? Nephrology News and
Issues, 18(9), 25-28.
Davies, S.J., Woodrow, G., Donovan, K., Plum, J., Williams, P., Johansson, A.C., et
al (2003) Icodextrin improves the fluid status of peritoneal dialysis patients:
Results of a double-blind randomized controlled trial. Journal of American
Society of Nephrology, 14(9), 2338-2344.
DeHaan, B. (2003) Why peritoneal dialysis should be the first treatment option.
Dialysis & Transplantation, 32(3), 160-164.
Diffusion. www2.merriam-webster.com/mwmednl. Accessed 8/23/2007
Gokal, R., Khanna, R., Krediet, R., & Nolph, K. (2000) Textbook of peritoneal
dialysis (2nd ed.). London: Kluwer Academic Publishers.
Gokal, R. (2002). What is the evidence that PD is underutilized as an ESRD
therapy. Seminars in Dialysis, 15(3), 149-150.
Heaf, J. (2004). Underutilization of peritoneal dialysis. Journal of the American
Medical Society, 291(6), 740-742.
Knowles, M.S. (1990). The adult leaner. A neglected species (4th ed.). Houston:
Gulf Publishing.
Additional Readings
Luongo, M., & Kennedy, S. (2004) Interviewing prospective patients for peritoneal dialysis: A
five-step approach Nephrology Nursing Journal, 31(5), 513-520.
Maaz, D. (2004). Troubleshooting non-infectious peritoneal dialysis issues. Nephrology Nursing
Journal, 31(5), 521-532.
Miller, D., MacDonald, D., Kolnack, K., & Simek, T. (2004). Challenges for nephrology nurses
in the management of children with chronic kidney disease. Nephrology Nursing Journal,
31(3), 287-294.
Mujais, S., Nolph, K., Gokal, R., Blake, P, Burkart, J., Coles, G., et al. (2000). Evaluation and
management of ultrafiltration problems in peritoneal dialysis. Peritoneal Dialysis
International, 20(Suppl 4), S5-S21.
Oreopoulos, D.G., Lobbedez, T., & Gupta, S. (2004) Peritoneal dialysis: Where is it now and
where is it going? International Journal of Artificial Organs, 27(2), 88-94.
Paniagua, R., Amato, D., Vonesh, E., Correa-Rotter, R., Ramos, A., Moran, J., et al. (2002).
Effects of increased peritoneal clearances on mortality rates in peritoneal dialysis:
ADEMEX, a prospective, randomized controlled trial. Journal of American Society of
Nephrology, 13(5), 1307-1320.
Piraino, B. (2005) Peritoneal Dialysis-Related inrections recommendations:2005 Update.
Peritoneal Dialysis International. Vol 25(2) 107-131
Prasad, N., & Gupta,A. (2005) Fungal peritonitis in peritoneal dialysis patients. Peritoneal
Dialysis International, 25(3), 207-222.
Additional Readings
Pritchard, S. (2005). Will peritoneal dialysis be left behind? Seminars in Dialysis, 18(3), 167-170.
Prowant, B. (2001) Peritoneal dialysis. In L.E. Lancaster (Ed.), ANNA core curriculum for nurses (4th ed.) (pp.
331-375) Pitman, NJ: American Nephrology Nurses’ Association (ANNA).
Prowant, B., & Twardowski, Z. (1996) Recommendations for exit care. Peritoneal Dialysis International,
16(Suppl. 3), S94-S99.
Ramon, G. (1998). Hydrothorax in peritoneal dialysis. Peritoneal Dialysis International, 18(1), 5-10.
Robinson, K. (2001). Does pre-ESRD education make a difference? The patient’s perspective. Dialysis &
Transplantation, 30(9), 571-574.
Rubin, H.R., Fink, N.E., Plantinga, L.C., Sadler, J.H., Kliger, A.S., & Powe, N.R. (2004) Patient ratings of
dialysis care with peritoneal dialysis vs.hemodialysis. Journal of the American Medical Society, 291(6),
697-703.
Salzer, W. (2005). Antimicrobial-resistant gram positive bacteria in PD peritonitis and the newer antibiotics
used to treat them. Peritoneal Dialysis International, 25(4), 313-319.
Schatell, D., Ellstrom-Calder, A., Alt, P.S., & Garland, J.S. (2003). Survey of CKD patients reveals significant
gaps in knowledge about kidney disease. Nephrology News & Issues, 17(6), 17-19.
Sturdivant, R., & McArthur, J. (2004). Eosinophilic peritonitis associated with atopy. Dialysis &
Transplantation, 33(2), 97-104.
Twardowski, Z.J., & Nichols, W.K. (2001). Peritoneal dialysis access and exit-site care including
surgical aspects. Textbook of peritoneal dialysis (2nd ed.). London: Kluwer Academic Publishers.
Twardowski, Z. (1987). Peritoneal equilibration test. Peritoneal Dialysis Bulletin, 7, 138-147.
Additional Readings
Van Dijk, C., Ledesma, S., & Teitelbaum, I. (2005). Patient characteristics
associated with defects of the peritoneal cavity boundary. Peritoneal Dialysis
International, 25(40), 367-373.
Von Biesen, W. (2002). Peritoneal dialysis in anuric patients: Concerns and
cautions. Seminars in Dialysis, 15(5), 305-310.
Von Biesen, W. et al. (2004). Improving salt balance in peritoneal dialysis patients.
Peritoneal Dialysis International, 25(Suppl 3), S73-S75.
Wingard, R. (2005). Patient education and the nursing process: Meeting the
patient’s needs. Nephrology Nursing Journal, 31(3), 211-214.
Wolfson, M. (2002). A randomized controlled trial to evaluate the efficacy and
safety of icodextrin in peritoneal dialysis. American Journal of Kidney
Diseases, 40(5), 1055-1065.
Zorzanello, M. Fleming,W., & Prowant, B. (2004). Use of tissue plasminogen
activator in peritoneal dialysis catheters:a literature review and one center’s
experience. Nephrology Nursing Journal, 31(5), 534-537.