What Is Kidney Failure?

The kidneys do several important jobs in the body, including helping to control your blood pressure and make red blood cells, and removing waste products and extra water from your body to make urine. In chronic kidney disease (CKD), the kidneys no longer work as well as they should and are unable to remove waste products from your blood. As a result, too much fluid and waste products remain in the body, which can cause health problems such as heart disease, stroke and anemia. Although CKD can be a mild condition with no or few symptoms, around 1 in 50 patients can progress to a very serious form of CKD known as kidney failure, where kidney function drops to below 15% of normal.

How Is Kidney Failure Treated?

When the kidneys stop working, kidney replacement therapy in the form of dialysis or kidney transplant are needed so that the person can survive. Kidney failure treated in this way is called end-stage renal disease. If you have a kidney transplant, a healthy kidney from a donor is placed in your body to filter your blood. In contrast, dialysis is a procedure by which the blood is “cleaned”. There are two types of dialysis. In hemodialysis (HD), your blood leaves your body, goes through a filter in a machine and is returned to your body. HD is usually delivered in a healthcare setting. In contrast, peritoneal dialysis (PD) uses the lining of your abdomen, the peritoneum, to filter the waste and extra fluid from your body. A key difference between the two is that, once you have been trained, PD can be done at home, at work or while travelling without the help of another person. Home HD is possible, but you need the help of a partner and it is not available in all regions.

How Does Peritoneal Dialysis Work?

Before a patient can begin to use PD, they need an operation to insert a catheter, usually near the bellybutton. The catheter will carry the dialysate into and out of their abdomen. The patient then usually waits up to 1 month before starting PD to give the catheter site time to heal, and is trained how to use the equipment. Once PD begins, in each session, a cleansing fluid (called “dialysate”) flows through the catheter into part of the abdomen and stays there for a fixed period of time (called the “dwell time”), usually 4–6 hours. The dialysate contains dextrose, which helps to filter waste and extra fluid from tiny blood vessels in the peritoneum. At the end of the dwell time, the dialysate drains into a sterile collecting bag, taking the waste products and extra fluid with it. There are two main ways of conducting PD: continuous ambulatory PD, which uses gravity to move the fluid through the catheter and into and out of the abdomen, and continuous cycling PD, which uses a machine to perform multiple exchanges while you sleep at night. Your medical team will help you identify which PD method is best for you.

What Are the Advantages and Disadvantages of Peritoneal Dialysis?

Compared with in-center HD, the benefits of PD include:

• greater lifestyle flexibility and independence, which can be especially important if you have to travel long distances to a dialysis unit;
• a less restricted diet than if you receive HD, because PD is done more continuously than HD, so there is less build-up of potassium, sodium and fluid;
• and the possibility of longer lasting residual kidney function.

However, PD might not be suitable for you if you have extensive surgical scarring in your abdomen, a hernia, limited ability to care for yourself or caregiving support, or inflammatory bowel disease or diverticulitis. It is also likely that people using PD will eventually have a decline in kidney function that will require HD or a kidney transplant.

How Has the COVID-19 Pandemic Affected the Treatment of People with Kidney Failure?

Patients with kidney failure, especially those receiving dialysis, are more susceptible to infections like COVID-19 than the general population and are at greater risk of severe disease or death when infected, partly because they are more likely to have other conditions that have been linked to severe COVID-19 (such as cardiovascular disease, diabetes, and cerebrovascular disease). Many patients experienced difficulties accessing HD during lockdowns, and those that could travel to a dialysis unit risked exposing themselves, their family and healthcare staff to COVID-19 infection. As a result, patients and healthcare providers have been encouraged to consider PD as a preferred option for kidney replacement therapy because home-based treatment prevents chains of transmission through in-center dialysis units, reduces the risk of exposure through travel, and helps to preserve hospital resources being stretched by this and possible future pandemics.

What Has Been the Effect of Increased Use of Peritoneal Dialysis during the Pandemic?

Evidence suggests that increased use of PD during the pandemic has had a beneficial effect. Survival and efficacy rates for patients undergoing PD are similar to those undergoing HD, and observational data from multiple countries have identified lower rates of COVID-19 infection in patients undergoing PD than those receiving in-center HD. In addition, fewer healthcare staff can support a larger number of patients through ongoing interaction using telehealth, although careful monitoring is required to ensure any negative effects are identified.

Take-Home Message for Patients

PD is currently underutilized, thought to be in part because of patient hesitancy, less frequent interaction with nephrologists and perceived lower levels of clinical oversight. However, if available, PD is an important treatment option that can protect patients with kidney failure from exposure to infection and may be worth their consideration in consultation with their clinical team.

Note: The authors of this paper make a declaration about grants, research support, consulting fees, lecture fees, etc. received from pharmaceutical companies. It is normal for authors to declare this in case it might be perceived as a conflict of interest. For more detail, see the Conflict of Interest Statement at the end of the paper.