Although Peritoneal Dialysis (PD) is often considered the gentler of the dialysis options available, as with any procedure side effects can occur. It is important to understand the PD process and the potential side effects that you might experience.
PD uses the peritoneum – the inner lining of the abdomen – to filter waste products from your blood. If you have opted for PD, you will have a small PD catheter placed most commonly in the abdomen through your belly, but it can also be placed in the chest. Your nephrologist will recommend the appropriate PD access point and give you a dialysis prescription detailing which dialysis solutions you are to use and how often based on your specific needs.
The dialysis solution comes in multiple varieties with various levels of dextrose or icodextrin. These are what create the osmotic gradient that draws waste from the blood and into the dialysis solution to be removed. You will be able to easily identify the concentrations of dialysis solutions by the color-coded bags you are provided (e.g., yellow is 1.5% dextrose, green is 2.5% dextrose, red is 4.25% dextrose, and purple contains 7.5% icodextrin). Icodextrin inhibits reabsorption of fluid and is often used for those with diabetes that may be impacted by high levels of dextrose in traditional solutions.
The 3-step PD exchange process
Fill: First, via the PD catheter, you fill the abdominal cavity with the sterile dialysis solution that contains dextrose, salt, and other minerals.
Dwell: You cap the catheter and let the solution stay in your abdomen allowing the waste products to filter from your blood via the peritoneal membrane into the dialysis solution.
Drain: You drain the dialysis solution out of your body.
This process is called an exchange and is repeated multiple times each day with the dwell time lasting approximately 4-6 hours.
This can be done manually or with a PD cycler, a machine that automates this fluid exchange typically overnight while you sleep. Manual PD, also called ambulatory PD, is usually done by conducting four fluid exchanges daily by hand. Though PD is effective and less intrusive than other dialysis options, you should be aware of some common side effects of PD and their solutions, and the possibility that it may not be effective after a number of years.
Side Effects
Swelling or Edema
Some people may feel or notice swelling in the legs, wrists, ankles, scrotum, or other parts of their body. This is a sign that there is too much water in your body and is more common in people who manually do their PD compared to those who use continuous cycling PD overnight.
What action to take: If you notice edema, contact your nephrologist. They may switch you to a different dialysis solution or, for those on manual PD, may discuss switching to a PD cycler. The more frequent exchanges that occur during an overnight PD with a cycler limit the absorption of fluid and dextrose and may be why less swelling is seen in people who use a PD cycler for dialysis.
Constipation
One reason constipation occurs for those with chronic kidney disease is due to the necessary diet adjustments including limiting fruits and some vegetables that are high in potassium. Fruits and vegetables provide the necessary fiber for healthy bowel movements, but kidneys are responsible for removing excess potassium. For this reason, those with CKD often need to limit potassium intake. Though constipation is far more likely for those on hemodialysis, many people on PD still experience constipation.
For those on PD, constipation is more serious than discomfort. It can also impede the ability of PD fluid to drain through the PD catheter and straining increases the risk of hernia.
What action to take: To prevent constipation, try to consume as many fruits and vegetables as your diet will allow. If you need to limit potassium, select low-potassium options to maximize your intake of fruits and vegetables. Probiotics or probiotic-rich foods can also help. Fiber products like Metamucil or Citrucel® along with stool softeners are additional options for preventing constipation.
If these actions don't work, speak with your nephrologist about trying other options including MiraLAX®, or other brands of polyethylene glycol, stimulants such as Dulcolax™ or glycerin suppositories.
Other Gastrointestinal Side Effects
Some people undergoing PD report other gastrointestinal side effects such as acid reflux, abdominal hernias, or esophagitis. The symptoms of acid reflux, or heartburn, include a burning sensation in the chest, difficulty swallowing, and regurgitating sour or acidic fluid. Abdominal hernias are soft bulges in your stomach or other location that may or may not be visible. Hernias may cause pain while lifting or a dull ache. Esophagitis is inflammation in the lining of the esophagus – the tube that runs from your throat to your stomach. Esophagitis can make swallowing painful, cause chest pain, or lead to regurgitation of acid. It may be difficult to distinguish between heartburn and esophagitis as their symptoms are similar. Compared to those on hemodialysis, people on PD have higher rates of these gastrointestinal disorders.
What action to take: Discuss these symptoms with your nephrologist. They may prescribe you a proton-pump inhibitor to treat heartburn. Abdominal hernias can inhibit PD treatment. Hernia repair is likely necessary, so make sure to contact your nephrologist immediately.
High Blood Sugar
Traditional dialysis solutions used for PD contain dextrose which will elevate the blood sugar of those on dialysis. If you have diabetes, this can be dangerous.
What action to take: Talk to your nephrologist about options. Switching to icodextrin from dextrose-containing dialysis solutions may help. If using manual PD, switching to continuous cycling PD may help limit the absorption of dextrose.
Weight Gain
Weight gain may be due to the increased calories from the dextrose in the dialysis solution. It may also be due to other factors that have changed because of PD. If you are new to dialysis, your activity level and nutrition may have recently changed as a result.
What action to take: Discuss your weight gain concerns with your nephrologist to see if there is a need to change dialysis solutions. They may also be able to connect you with resources or suggest activities and foods that can help you manage your weight but that are also dialysis friendly.
Drain Pain
Many people using PD cyclers describe “drain pain”, especially during the first and/or last drain.
Some suggestions on how to alleviate drain pain from other people on PD include:
Altering the cycler height per cycler manual
Changing sleeping positions
Talking to your provider to adjust the prescription
Adjusting the catheter per dialysis clinic instructions
Avoiding constipation
Note: Do not use over-the-counter NSAIDs or other painkillers without the advice of your nephrologist and/or healthcare provider. For those with reduced kidney function, the use of NSAIDs or high-dose aspirin is not recommended.
Itchy Skin
Itchy and/or dry skin may be caused by reduced fluid intake for those on dialysis. Elevated phosphorus may also be to blame; phosphate binders can manage phosphorus levels. Inadequate removal of waste products may also result in itchy skin.
What action to take: Check with your nephrologist to see what adjustments to your dialysis prescription can be made. Altering your dialysis regimen (e.g., dwell time, frequency, etc.) may remedy itchy skin and provide more adequate dialysis. Importantly, don't scratch your skin, it can make it worse and damage your skin leading to infection. Check with your dialysis team to see what recommendations they have for you in terms of cleaning and moisturizing your skin.
Sleep Issues
When you first start nighttime continuous cycler PD, it may take a few nights to get used to the cycler running and the anxiety associated with treatment. You may also experience sleep issues such as night sweats and sleep disorders including restless leg syndrome, sleep-disordered breathing, and periodic limb movements during sleep.
What action to take: The importance of sleep can not be underestimated, if you aren’t able to get sleep during the night, particularly with the continuous cycler, taking naps during the day can help you catch up a certain amount of the sleep you missed.
6 tips to get better sleep:
Regularity: Keep consistent sleep and wake times to improve the quantity & quality of your sleep. 7-9 hours of sleep is recommended.
Temperature: Keep it cool. Your body needs to drop its temperature by 2-3 degrees Fahrenheit to initiate and stay asleep. Aim for 65°F/18°C.
Darkness: In the last hour before bed, dim the lights in your home, avoid electronic devices, and wear an eye mask or use blackout shades.
Alcohol/Caffeine: Avoid caffeinated drinks in the afternoon and the evening, it disrupts your sleep.
Have a wind-down routine: Find what works for you to relax before bed and then stick to this routine.
Have trouble sleeping? If you can't sleep within 20-25 min, don't stay in bed, get up and move around a bit if possible, go to a separate dark or dimly lit room or a chair in the bedroom and do something else: read a book, stretch, or write in a journal. Just make sure to avoid screens during this time.
If sleep issues persist, speak with your nephrology team to see what other recommendations they have.
Burning Sensation
Some people experience a burning sensation when the fluid first enters the abdominal cavity.
What action to take: If you experience this, contact your nephrologist, the addition of sodium bicarbonate or lidocaine to the bags of dialysis solution should alleviate this sensation but your nephrologist will provide you with the best plan to help with this.
Peritonitis
Peritonitis is an infection of the peritoneum (the inner lining of the abdomen). This can be caused by accidental contamination of the dialysis fluid. The best way to avoid peritonitis is to follow all the instructions and training regarding the handling of the fluids including hand washing, use of protective equipment such as face masks, and sterile technique.
What action to take: If you believe you have inadvertently contaminated your fluid, contact your PD nurse or nephrologist immediately. Swift treatment with antibiotics can avoid infection.
Peritonitis symptoms include:
Cloudy dialysis fluid
Abdominal pain
Fever
Nausea and/or vomiting
If you experience this, call your nephrologist as soon as possible. Treatment involves several weeks of antibiotics, but the sooner treatment begins, the better.
Ultimately, sharing your symptoms and challenges with your nephrology team will allow them to help identify the best way to minimize the side effects you are experiencing.
References/Resources:
Gastrointestinal Disorders in Peritoneal Dialysis Patients. Kosmadakis G et al. Am J Nephrol. 2018;48:319-325. doi: 10.1159/000494145
Patient-reported gastrointestinal symptoms in patients with peritoneal dialysis: the prevalence, influence factors and association with quality of life. Yi C et al. BMC Nephrol. 2022 Mar 9;23(1):99. doi: 10.1186/s12882-022-02723-9.
Proton Pump Inhibitors in Kidney Disease. Lazarus, B et al. CJASN Oct 2018, 13 (10) 1458-1459; DOI: 10.2215/CJN.10110818
Hernias and PD. Home Dialysis Central
Icodextrin Versus Glucose Solutions for the Once-Daily Long Dwell in Peritoneal Dialysis: An Enriched Systematic Review and Meta-analysis of Randomized Controlled Trials. Goosen, K et al. Am J Kidney Dis. 2020 Jun;75(6):830-846. doi: 10.1053/j.ajkd.2019.10.004.
Icodextrin increases technique survival rate in peritoneal dialysis patients with diabetic nephropathy by improving body fluid management: a randomized controlled trial. Takatori, Y et al. Clin J Am Soc Nephrol. 2011;6(6):1337-1344. doi:10.2215/CJN.10041110
Fluid Overload in a Dialysis Patient. National Kidney Foundation (NKF)
Constipation on Dialysis. Home Dialysis Central
Taking Care of Your PD Catheter. National Kidney Foundation (NKF)
View from the Bed: How to Cope with PD Cycler Pain. Home Dialysis Central
Pain Medicines. National Kidney Foundation (NKF)
Dialysis: Dry, Itchy Skin. National Kidney Foundation (NKF)
Objective and subjective sleep disorders in automated peritoneal dialysis. Roumelioti, ME et al. Can J Kidney Health Dis. 2016;3:6. Published 2016 Feb 17. doi:10.1186/s40697-016-0093-x
Sleep Quality and Its Correlates in the First Year of Dialysis. Unruh, M et al. CJASN July 2006, 1 (4) 802-810; DOI: https://doi.org/10.2215/CJN.00710206
Peritoneal Dialysis – Safe, and Perhaps Easier than You Think. The American Association of Kidney Patients (AAKP)
Sleep is your superpower. TED Talk. April 2019 & Why we sleep (book). Matthew Walker, Ph.D. Center for Human Sleep Science
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