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| REVIEW ARTICLE |
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| Year : 2020 | Volume
: 38
| Issue : 1 | Page : 1-5 |
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History of peritoneal dialysis
Sabina Yusuf
Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| Date of Submission | 14-Apr-2020 |
| Date of Decision | 30-May-2020 |
| Date of Acceptance | 09-Jul-2020 |
| Date of Web Publication | 31-Dec-2020 |
Correspondence Address:
Dr. Sabina Yusuf
Department of Nephrology, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/IOPD.IOPD_2_20
>Peritoneal Dialysis is now an accepted mode of renal replacement therapy. The story of its development is a fascinating scientific journey of pioneers who have worked tirelessly to develop and extend the application of this technique which now plays such an important part in the treatment of patients with ESKD. This article reviews the milestones in the history of innovation of this life saving treatment in an attempt to understand to the hopes and ideas of our predecessors and build on them into the future to make peritoneal dialysis a more effective, safer, and inexpensive therapy for ESKD.
Keywords: Dialysis, history, peritoneal
How to cite this article:
Yusuf S. History of peritoneal dialysis. Indian J Perit Dial 2020;38:1-5 |
| History of Peritoneal Dialysis-I | |  |
Evolution of concept
As early as the nineteenth century investigators were aware that accumulation of toxic substances normally excreted in urine occurred in the blood in renal failure (known as Bright's disease then) and that their removal would be beneficial. However until then the therapy for uremic intoxication was extremely limited and consisted mainly of infusion therapy with NaCl, Ringer's and/or glucose solutions, repeated blood letting, sweating procedures as well as the combination of these.[1] In 1913 Abel and his colleagues developed vividiffusion system with semipermeable colloidum membranes for the blood rinsing of binephrectomised dogs.[2] Ten years later the physiologist Heinrich Necheles, University of Hamburg, reported in the Klinische Wochenschrift under the title “Uberdialysieren des stromenden Blutes am Lebenden (About the dialysis of flowing blood in living organisms) a considerable improvement of the dialyzer system. A tube system of sheep peritoneum served as membrane system whose surface area was increased to 4000 cm2 by means of sandwiching 10 dialysis membranes. The dialysis ystem was then introduced into the circulation by the use of arteries and venae femoralis.[3] Inspired by this publication Georg Haas of the university hospital in Giessen made his own dialysis system. It was characterised by a glass support for the collodium membrane and by a large dialysis surface area through parallel arrangement of 6 cylinders. Hirudin extracted from crushed leed heads was used as the anticoagulant. Use of hirudin led to severe haemorrhages in the intestinal tract and serosa of lungs in dogs.[4]
It was the era of these early animal experiments in the field of extracorporeal hemodialysis in 1923, when Georg Ganter suggested an alternative approach for the removal of uremic toxins from the blood. His opinion was based on personal observation in a patient in medical university hospital in Griefswald in 1919, in whom pleura was used as dialysis membrane. Although the patient died, Ganter was fascinated by the concept of using a natural membrane as dialysis membrane instead of extracorporeal hemodialysis which he viewed as “time consuming and difficult to implement at the bedside of the patient”. At that time considerable knowledge of the peritoneal cavity had been gained - the fundamental concepts of osmotic movement of water through the peritoneum described by Wegner in 1877 as well the exchange process of ions between the blood and peritoneal solution investigated by Orlow in 1895. Ganter started his experiments on peritoneal membrane in rabbits and guinea pigs which were rendered uremic by bilateral ureteral ligation. He would instill physiological salt solutions via implanted drainage tubes in the abdomen of these animals, drain it completely and then replace it by a fresh salt solution. In this way he was able to suppress their blood urea nitrogen levels and improve the uremia like state. He then applied this procedure to two patients – one with acute uremia due to bilateral ureteral obstruction from uterine carcinoma and another with diabetic coma. Finally in 1923 he published his work “Über die Beseitigung giftiger Stoffe aus dem Blute durch Dialyse” (“About the removal of toxins in the blood through dialysis”) in the MÜnchener Medizinische Wochenschrift (Munich Medical Weekly) and sought to promote the application of this procedure in humans. He was convinced of its simplicity and superiority over hemodialysis and mentioned “I do not believe it necessary to point out the advantages of this procedure over that proposed by Necheles.”[5] Although the procedure remained largely underestimated and hardly found any clinical application for another two decades, Ganters vision of the artificial kidney was a lasting monument for generations to come.
While Ganter was experimenting in Germany, another pioneer, Tracy Jackson Putnam, was fascinated by the properties of peritoneal membrane and the possibility of its application to clinical problems. He was investigating the diffusion of substances from the blood into the peritoneal fluid in animal experiments with cats, dogs and rabbits and proved that crystalline solutes and water tend to diffuse through the peritoneum and capillary endothelium both from and to the blood- stream. In his paper submitted to American Physiological Society in 1922, “The living peritoneum as a dialysing membrane”, Dr Tracy Jackson Putnam mentioned “to explain the passage of small molecules but not large ones, in both directions through the peritoneum (plus the endothelium), we are forced to predicate the existence of a membrane, not necessarily endowed with “vital” powers, microscopically continuous, but physically pervious to particles of the size of a molecule of phenolsulphonephthalein or smaller. Such a membrane might be cellular or intercellular.”[6]
The adversities of world war II
The second world war brought the attention of the world to a highly incident fatal uremia in severely wounded men from battle fronts. It was recognised death from uremia could be prevented if retention products of acute renal damage could be excreted through an extra renal outlet. The technical difficulties associated with extracorporeal therapy provided by hemodialysis in those days were serious handicaps and efforts were channelised to search for alternative methods. A team of investigators from the Surgical Research Department, Beth Israel Hospital, and the Department of Surgery, Harvard University, working under contract with the Office of Scientific Research and Development, started investigating treatments for acute renal failure. This was the team of Howard Frank, Arnold Seligman and Jacob Fine. They performed continuous peritoneal irrigation in dogs using two catheters – one for inflow and the other for drainage - for 20 h daily for two days and 8–12 h daily thereafter. The irrigation fluid used was Ringer's solution, later changed to a Tyrode's solution, in their search for the best dialysis fluid.The optimal flow rate and volume of peritoneal irrigation fluid needed to obtain the maximum urea clearance was calculated. Comparison of blood urea clearance by peritoneal irrigation with clearance through the kidneys was done. They also experimented with irrigation of various parts of the gastrointestinal tract and pleural cavity and found that they were ineffective in removal of urea. The dogs survived for 3 to 10 days and none of them died of uremia. In 1945, they decided to treat a patient who presented to the emergency room at Beth Israel Hospital with acute renal failure from sulfathiazole administration. They applied the same technique of peritoneal irrigation that they had used in their experiments, and the patient recovered after seven days of treatment. They treated 18 more patients, out of which four survived.[7]
The foundation-from raft to bridge
In 1951 at the Southwestern Medical School in Texas, Arthur Grollman, carried out additional experiments and instead of continuous irrigation of peritoneal cavity, decided to leave the fluid in the abdomen for variable periods of time. He used a single needle for both instillation and drainage of peritoneal fluid in nephrectomised dogs and performed the exchange only twice a day. His kinetic studies showed that urea reached equilibrium in two hours after the peritoneal cavity of dogs was filled with one liter of fluid containing different concentrations of glucose. He also studied the volume of the fluid removed with various concentrations of glucose in the irrigation fluid. With his method of intermittent peritoneal lavage he was able to keep dogs alive for as long as 30-70 days which was several times that ever reported previously. He used this method to manage five patients with acute anuria. The irrigation fluid composition was modified based on patient's needs and intermittent exchanges of two hours duration were done daily for only 16-48 hours. He used a plastic access for the first time and described it as one “to which omentum does not attach itself”. Grollman and his colleagues concluded “a continuous lavage tends to result in channeling of the perfusion fluid and hence may actually prove less efficient than an adequate emptying of the peritoneal cavity intermittently by the procedure which we have described”.[8]
Defining the technique and potentialities
In 1959 Morton Maxwell described a simplified technique of peritoneal dialysis which was an adaptation of Grollman's intermittent peritoneal lavage. He found the extemporaneous preparation of lavage fluid from comercially available solutions “arduous and unsatisfactory”. In his classical paper published in JAMA in 1959, he mentioned that “since crystalloids diffuse in both directions across the peritoneal membrane, any biochemical abnormalities in the patient's serum will be partially corrected by the use of a solution containing “normal” concentrations of all the physiologically important electrolytes. To alter the solutions according to the individual patient's specific electrolyte pattern is hazardous in most hands and contributes little to the over-all clinical results”. He envisioned the concept of commercially prepared solutions, tubings, special catheters and a closed system of infusion and drainage [Figure 1] and [Figure 2]. In addition to acute renal failure he used peritoneal dialysis in treatment of barbiturate poisoning, intractable edema, hepatic coma and hypercalcemia and argued “In theory its use could be extended to intoxication with any diffusible poison and the treatment of any type of electrolyte abnormality”. Maxwell however noticed that most biochemical abnormalities reach their predialysis values within one to two weeks and believed that further refinements in technique could make it possible to treat patients with chronic uremia.[9] | Figure 1: Earliest commercially prepared dialysis solution. Reprinted from “Peritoneal Dialysis” by Maxwell et al.,[9]
Click here to view |
 | Figure 2: Equipment for peritoneal dialysis. Two liters of electrolyte solution are shown, with administration tubing attached to special catheter. Also shown is Duke trocar set, consisting of straight trocar with sharp and blunt stylets and scalpel with no. 11 Bard-Parker blade. Reprinted from “Peritoneal Dialysis” by Maxwell et al.,[9]
Click here to view |
A medical breakthrough
In the early 1950s there were a large number of casualties from the Korean war and most deaths were attributed to high concentration of potassium resulting from acute renal failure. A team of doctors including Dr Paul Doolan was formed to take the rotating drum kidney to Korea for battlefield dialysis. Dr Doolan had reviewed the work of Seligman, Frank and Fine and had known Dr Jacob Fine. He wanted to investigate the use of peritoneal dialysis and so he adopted the Grollman technique, modified the catheter for easy insertion and began dialysing patients. He infused a volume varying from 2-3 liters and extended the dwell time to 4 hours. Doolan was able to perform more than 50 lavages and found the technique safe and effective. Richard Rubin, who was serving in Navy, became familiar with peritoneal dialysis after working for a short time with Paul Doolan at the Oak Knoll Naval Hospital in 1959. In late 1959, he was asked to see a patient with renal failure as a complication of recent childbirth. He initiated peritoneal dialysis in her. She responded well to the initial dialysis but after a week her condition deteriorated. She was dialyzed again and her condition improved dramatically. Thereafter she was admitted weekly for “periodic” peritoneal dialysis, using a Murphy-Doolan catheter which was clamped and left in place after each dialysis treatment and she was found to respond well to this regimen. After seven months, the patient asked that the treatment be discontinued and she died soon after. Rubin wrote a paper and submitted it to the New England Journal of Medicine. The paper was rejected as a single example of chronic peritoneal dialysis was judged not to be significant enough. However the stage for chronic peritoneal dialysis was set with this landmark discovery.[10],[11]
When the rubber meets the road
A group of doctors at University of Washington, Seattle, including working on this new fundamental concept of peritoneal dialysis in chronic uremic patients developed an automatic peritoneal dialysis for a home dialysis program in 1964 using a roller pump, head tank and a small cycling machine. Their first patient was a 32 year old female with endstage pyelonephritis. She was initially dialysed in the hospital by once weekly peritoneal dialysis for 6 weeks during which she and her husband were trained for dialysis at home. Then in May 1964 the dialysis eqiuipment was moved to patient's home. Since reports on use of indwelling peritoneal catheters were discouraging at that time, repeated puncture technique for dialysis had to be used in which the physician, Henry Tenckhoff, used to insert a new catheter each time for dialysis, into the lower abdomen at alternating sites. Dialysis was carried out once weekly. About 60 L of dialysate were exchanged over 20-22 hours with each dialysis. At the end of each dialysis patient removed the catheter and approximated the wound edges with sterile bandaids. Although good longterm results were obtained in this patient, there were multiple episodes of bleeding from the abdominal wall and the patient required 12 blood transfusions for replacement of blood loss over a period of one year.[12]
In his paper on peritoneal dialysis in 1964, CF Gutch mentioned “Our approach has been lacking in mechanical sophistication”.[13] His work on catheters led him to the development soft permanent catheters made of silastic tubing which were “more comfortable, with “no plugging or obstruction” and associated with decreased protein loss in the fluid. He reported the use of such silicon catheters for as long as 17 months and preferred to dialyse patients daily rather than twice or thrice weekly.[14] Following this, in 1964 Palmer from The Vancouver General Hospital, British Columbia and Quinton, who was already successful in manufacturing silicone rubber shunts for hemodialysis (W.E. Quinton Instrument Co., Seattle, Washington, USA), developed a catheter, which is the prototype for currently used coiled catheters. It was made of silicone rubber with a colied intraperitoneal part , numerous perforations in the distal 23 cm and a triflange step in the middle for locating in the deep fascia and the peritoneum.[15] Although the results were very encouraging, peritonitis episodes, pericatheter leaks, and tunnel infections were still common.
In 1968, Tenckhoff and H. Schechter from the University of Washington, Seattle, Washington, USA, published the results of their studies on a new catheter. Their catheter was an improved version of the Palmer catheter. An intraabdominal flange was replaced by a Dacron felt cuff, a subcutaneous tunnel was shortened and a second, external cuff was used to decrease the length of the catheter sinus tract. The external cuff was not protruding through the skin, but was located just below the skin surface. Ultimately, the coiled intraperitoneal portion was replaced by a straight segment resembling the Gutch catheter. The intraperitoneal segment was open ended and the size of the side holes was optimized to 0.5 mm to prevent tissue suction [Figure 3]. A shorter subcutaneous tunnel and a straight intraperitoneal segment facilitated catheter implantation at the bedside. To avoid excessive bleeding, the catheter was inserted through the midline.[16] Reports on the use of this catheter were excellent with duration for as long as 14 months. A detailed description on the implantation and care of his catheter was provided by Tenckhoff eight years later. | Figure 3: Tenckhoff peritoneal catheter. Reprinted from “The Permanent Tenckhoff catheter for chronic peritoneal dialysis” by Devine et al., CMA J 1975;113
Click here to view |
| References | | |
| 1. | |
| 2. | Abel JJ, Rowntree LG, Turner BB. On the removal of diffusible substances from the circulating blood of living animals by dialysis. J Pharmacol Exp Ther 1914;5:275-316.  |
| 3. | Necheles H. Uber dialysieren des stromenden blutes am lebenden (On dialysis of the circulating blood in vivo). Klin Wochenschr 1923;2:1257. |
| 4. | Moeller C, Köhling H. Die apparative Blut-Dialyse (“Künstliche Niere”)Uberblick und Eigene Erfahrungen. (The apparatus blood dialysis (“artificial kidney”) overview and own experiences). Klin Wochenschr 1956;34:569-77. |
| 5. | Teschner M, Heidland A, Klassen A, Sebekova K, Bahner U. Georg ganter – A pioneer of peritoneal dialysis and his tragic academic demise at the hand of the Nazi regime. J Nephrol 2004;17:457-60. |
| 6. | Putnam TJ. The living peritoneum as a dialyzing membrane. Am J Physiol Leg Content 1923;63:548-65. |
| 7. | Seligman AM, Frank HA, Fine J. Treatment of experimental uremia by means of peritoneal irrigation 1. J Clin Invest 1946;25:211-9. |
| 8. | Grollman A, Turner LB, McLean JA. Intermittent peritoneal lavage in nephrectomized dogs and its application to the human being. AMA Arch Intern Med 1951;87:379-90. |
| 9. | Maxwell MH, Rockney RE, Kleeman CR, Twiss MR. Peritoneal dialysis. 1. Technique and applications. J Am Med Assoc 1959;170:917-24. |
| 10. | Doolan PD, Murphy WP Jr., Wiggins RA, Carter NW, Cooper WC, Watten RH, et al. An evaluation of intermittent peritoneal lavage. Am J Med 1959;26:831-44. |
| 11. | Negoi D, Nolph KD. History of peritoneal dialysis. In: Khanna R, Krediet RT, editors. Nolph and Gokal's Textbook of Peritoneal Dialysis. Boston, MA: Springer US; 2009. p. 1-18. |
| 12. | Tenckhoff H, Shilipetar G, Boen ST. One yearʼs experience with home peritoneal dialysis. ASAIO J 1965;11:11-7. |
| 13. | Gutch CF. Peritoneal dialysis. Trans Am Soc Artif Intern Organs 1964;10:406-8. |
| 14. | Gutch CF, Stevens SC. Silastic catheter for peritoneal dialysis. Trans Am Soc Artif Intern Organs 1966;12:106-7. |
| 15. | Twardowski ZJ. History of peritoneal access development. Int J Artif Organs 2006;29:2-40. |
| 16. | Tenckhoff H, Schechter H. A bacteriologically safe peritoneal access device. Trans Am Soc Artif Intern Organs 1968;14:181-7. |
[Figure 1], [Figure 2], [Figure 3]
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