The history of peritoneal dialysis: Early years at Toronto Western Hospital

Early investigators of the permeability of the peritoneum and other experimental data, provided convincing evidence that the peritoneal membrane is permeable in both directions.1-3 Although peritoneal dialysis as a treatment began much earlier than hemodialysis, it fell into disrepute because of the many complications associated with it and the difficulties with access to the peritoneal cavity.4 In the late 1940s, Fine and colleagues reported successful peritoneal irrigation in a patient with severe anuria, who survived after four days of continuous peritoneal lavage.5 This was indeed a landmark in the history of treatment of uremia using the peritoneal cavity. In the late 1960s, intermittent peritoneal dialysis (PD; provided once or twice a week in hospital) was practiced worldwide, but mainly in three centers: Seattle under Henry Tenckhoff; Montpelier, France under Charles Mion; and in Toronto.6 In all these centers PD was provided mainly to patients who could not be dialyzed with hemodialysis (HD). Patients would come to the hospital one or two days a week and start on PD with a new stylet catheter inserted into their abdomen each time. As soon as a patient on chronic HD would die, one of those patients, who had survived the longest on PD, would be rewarded by being moved to HD. Initially the composition of the fluids used in PD varied considerably from normal saline to 5% dextrose. In their literature review, Odell and colleagues7 found that dialysis fluid with high sodium concentrations were used and that hyperchloremic acidosis was a frequent side effect. Morton Maxwell is primarily responsible for the composition of fluid currently used, with minor modifications.8 In the late 1950s and early 1960s, intermittent PD became a safe and standardized procedure. Further advances were primarily related to catheter improvements that made long-term therapy possible. Norman Deane introduced the prosthesis that bears his name and that between dialyses kept patent the tract between the skin and the peritoneal cavity (Figure 1). Because this prosthesis was not commercially available, we had to "manufacture" it, by cutting the stylet catheter in three parts and using the two non-perforated parts after sealing their ends with the heat of an electric plate (Figure 2). A sample of the Deane's prostheses that keeps the track between the skin and the peritoneal cavity patent between dialyses. Dr. Oreopoulos "manufacturing" a Deane's prostheses from pieces of the stylet catheter. This prosthesis represented a great improvement in the care of these patients. No longer did we need to insert a new catheter each week with the attending risk of perforation. Instead the patient would come to the unit twice a week and a stylet catheter was slipped through the permanent track after removal of the Deane's prosthesis. A large number of patients (up to 40) were maintained on chronic intermittent PD for long periods, some up to two years using this technique.9 In the early 1960s, various devices were tried to achieve easy and frequent access to the peritoneal cavity. The reports were discouraging.10 It was not until Tenckhoff designed an indwelling silicone rubber catheter that had two Dacron cuffs that intermittent PD became accepted as a long-term therapy for renal failure.11 Basically, the original Tenckhoff catheter was a modification of the curled Palmer catheter.12 Subsequent modifications were introduced to reduce the various complications—such as dislocation from the minor pelvis, obstruction, fluid leaks, and catheter infections. To this day the original Tenckhoff catheter is the main catheter used for chronic peritoneal access. In 1962, Norman Lasker first thought of and developed the chronic PD cycler (Figure 3).13 This cycler used a fourpronged connector joined to four 2L glass containers of PD solution. Through this set of tubings, 2 liters of fluid would flow by gravity to a bag in a heater and from there by gravity to the patient; from the patient the effluent would drain to a bag where its weight was measured, and from there it was drained into a large container. The first peritoneal dialysis cycler designed and developed by Lasker. A system of clamps on the tubules directed the fluid from the containers to the heater and from the heater weight scale. In a second step, the clamps would allow the fluid to run from the heater and from the scale to the waste bag. Once we had some experience with it, we started using the cycler for home dialysis after training the patients on its operation. This was the first attempt in our hospital to do home PD (10 hours x 4 nights a week) on a large scale. Soon we had between 50 and 60 patients on home PD using this cycler. While Lasker was developing this automated cycler, Physio Control Company in Seattle (with the assistance of Tenckhoff) developed an automated machine that would produce sterile and deionized fluid by passing it through a reverse-osmosis membrane. During dialysis this sterile fluid was mixed with a concentrated solution of 19 parts to 1 and was then infused into the patient after being passed through various monitors that ensured its appropriate mixing and temperature. Approximately one-third of our patients were using this machine while two-thirds used the simpler cycler. Despite this experience with chronic intermittent PD, the patients did not do well, especially after they became anuric; at that time we did not recognize the importance of residual kidney function. We were devastated when an article from Tenckhoff's unit14 expressed a pessimistic view of chronic PD, declaring that 40 hours of intermittent PD a week was not adequate and that patients on this treatment did not do as well as those on chronic HD. In retrospect, we do not know why we or other centers never considered increasing the four nights of dialysis per week to every night/week, thus achieving improved results with nightly intermittent PD. In 1978, in their first article published in the Annals of Internal Medicine,15 Robert Popovich and colleagues described their experience with a new technique, called continuous ambulatory peritoneal dialysis (CAPD). Despite their outstanding results, they had a high peritonitis rate (1 episode every 3–4 patient months) mainly because they were using dialysis solutions in glass containers—the only containers that were available in the United States at that time. This meant they had to connect and disconnect the tubing to the glass containers via a spike 5 times a day, contributing to the high rate of peritonitis. Initially the concept of peritoneal dialysis as a continuous therapy was called the "portable/wearable equilibrium dialysis technique." Popovich, Jack Moncrief and their group described the theoretical mass transfer characteristics for this procedure.16 As they recorded, in the early days the main advantages were good steady-state biochemical control and more liberal dietary and fluid intakes than with hemodialysis. However, until 1973 peritoneal dialysis solutions were only available in 1L or 2L glass containers (Figure 4). A patient on manual chronic peritoneal dialysis using dialysis solutions in glass containers. Baxter Canada was the first branch of that company to produce peritoneal dialysis solutions in plastic bags, which were much easier to handle than glass containers. The introduction of dialysis solutions in plastic bags in Canada was a major contribution in the subsequent development of the Toronto Western Hospital Technique for CAPD described below. Although with CAPD the continuous presence of fluid in the peritoneal cavity achieved excellent results, we did not try it in our patients because we were unwilling to risk increased peritonitis rates. However, these peritonitis rates improved after we introduced the new technique for CAPD using plastic bags. In September 1977 one of our patients, who previously had been on intermittent PD using, in the beginning, the reverse-osmosis machines and subsequently the cycler, became grossly under dialyzed, with a serum creatinine of 24 mg/dL. She was severely confused, and had suffered a fall with extensive bruising. Because the patient was so ill, we gave her a trial of continuous PD despite the risk of peritonitis. However, instead of glass containers we used plastic bags that did not have to be disconnected between exchanges. Figure 5 shows the typed-up version of the verbal order for this technique, as I gave it to a nurse. The order by Dr. Oreopoulos describing the steps of the Toronto Western Hospital Technique for CAPD. After three days on this form of continuous PD the patient made a dramatic recovery. She was alert and mentally clear. Her serum creatinine decreased from 24 mg/dL to 14.5 mg/dL and she started on a free diet and free fluids. Her serum potassium came down and her phosphorous was controlled without more aluminum binders. She was dialyzed continuously for 6 days a week and, because of her previous experience with PD at home, it was easy to train her on the new technique. She was discharged home, becoming the first patient on CAPD using this technique, which became known as the Toronto Western Hospital Technique for CAPD,17 or the Spike Technique for CAPD. The steps of this technique were first presented in January 1978 at the Annual Contractors' Conference in Bethesda, Maryland. At that time we had more than 50 patients on home intermittent PD using either the Lasker cycler (most of them) or the reverse osmosis machine. All of these patients already had considerable experience with connection and disconnection using the spike on a plastic bag. Because we were so impressed with the results of CAPD in the first patient, we made a deal with these patients to try the new technique for a week and, if they were not satisfied, they would go back to the cycler. To everyone's surprise, all of these patients preferred to stay on CAPD with the new technique. Within a few months we had almost 50 patients on CAPD, the largest such program in the world. In January 1978, when Dr. Ben Burton, then director of the Artificial Kidney and Chronic Uremia Program of the NIH, invited Dr. Oreopoulos to describe this new technique at the Annual Contractors' Conference, he gave him only a fiveminute slot to present this new technique, since he was not one of the contractors. Among those present were Drs. Popovich, Moncrief, and Karl Nolph, who were most impressed with the technique. Subsequently, in 1978, Dr. Oreopoulos presented the results of this new technique under the title "A simple and safe technique for CAPD" to a larger number of physicians at the Annual Meeting of the American Society for Artificial Organs.17 Dr. Burton, recognizing the importance of this new technique, helped the Toronto Western Hospital team get a large three-year contract from the Artificial Kidney and Chronic Uremia Program of the NIH. With this support and with the equally generous support of the Physicians Service Incorporated Foundation of Ontario, we carried out important observations on a large number of patients at the Toronto Western Hospital that established the simplicity and usefulness of CAPD. During the first few months we thought that patients on CAPD using this new technique would never develop peritonitis, so every-one was disappointed when the third patient in our program did. Eventually, we were able to decrease the peritonitis rates with this new technique from one every three or four months with the glass containers to one every 11 to 12 months—an acceptable level. This was the beginning of the expansion of CAPD throughout the world. Because of the outstanding results obtained in Toronto, Dr. Burton tried to expedite the introduction of PD dialysate in plastic bags in the United States. Early on, Baxter had submitted an application to the Food and Drug Administration (FDA) for approval of PD dialysis solution in plastic bags, but this was not actively pursued. Citing our findings, and under considerable pressure from nephrology teams including those in Austin (Texas; Columbia (Mo.), and at the NIH, the dialysate bags were approved for use in the United States by the end of 1978. The Toronto Western Hospital team included outstanding individuals, such as the late Gabor Zellerman, a medical engineer who worked on the development of peritoneal catheters; the late Stephen Vas, who established the microbiological principles in the diagnosis and treatment of peritonitis; Ramesh Khanna, who worked with us in the early years, and subsequently joined Dr. Nolph in the Nephrology Division at the University of Missouri in Columbia; Nicholas Dombros, who did important work on the nutrition aspects of these patients; Joanne Bargman, who made important contributions in the study of complications of CAPD; and Peter Blake who worked with us for three years analyzing our experience with the adequacy of dialysis; and many others. This medical team was supported by an outstanding group of nurses, initially under the leadership of Sheila Clayton and later Sharron Izatt, who still leads this team. Finally, an important element in the promotion of PD worldwide was the founding and development of the Peritoneal Dialysis Bulletin that subsequently became the official journal of the International Society for Peritoneal Dialysis (ISPD), under its new title, Peritoneal Dialysis International. Umberto Buoncristiani, a prominent Italian nephrologist from Perugia, visited our unit to learn about our technique and, upon his return to Italy, tried the technique but could not get good peritonitis rates. Instead he proposed his own technique, the Y-set, that decreased the peritonitis rate to 1 episode every 36 patient months.18 He and his colleagues published their results of a prospective controlled study in Lancet confirming their initial experience. Still it took five years for us and other North Americans to accept this development (it seemed too good to be true), but eventually, after a prospective controlled trial, with the collaboration of Dr. David Churchill, we confirmed that even in North America the use of the Y-set technique gives peritonitis rates as low as 1 episode every 30 to 35 patient months.19 Now the double-bag disposable system has become the technique of choice for PD. Patients on CAPD usually loose 4 to 8 g of proteins per day and 2.0 to 2.5 g of amino acid to the peritoneal membrane.20 It has been demonstrated that the infusion of a solution containing amino acids (2 L of 1.1%) during one exchange results in an average amino acid absorption of 17.6 g/day, that is twice as large as the dialysate losses of amino acids and proteins (on average 9.2 g/day).20 Treatment with intraperitoneal amino acid solution results in a positive nitrogen balance, a significant increase in net protein anabolism, and more normal fasting plasma amino acid pattern, and significant increases in serum total protein and transferring.21 For patients on continuous cycler-assisted PD (CCPD), the amino acid solutions may be used for the long dwell and to achieve adequate ultrafiltration with these solutions; they may also be combined with glucose or a glucose polymer.22 Traditionally, the initial choice of dialysis for patients with end-stage renal disease (ESRD) has been in-center HD or PD. Home dialysis modalities (both PD and HD) improve rehabilitation and quality of life, prolong survival, and are more cost efficient than in-center HD.23 In 1997, the Canadian Society of Nephrology recommended that "home (and self-care) dialysis modalities, which generally are more cost effective, should be encouraged by renal-care providers." Based on this and the information described above, we propose a different approach for a new ESRD patient requiring dialysis. If the patient has a potential living-related donor, a pre-emptive transplantation should be encouraged. If this is not possible, however, we should present patients with the advantages of home dialysis and, instead of asking them to choose between PD and HD, they should be offered the option to choose between dialysis at home (PD or HD) or in-hospital HD. When a patient chooses to be dialyzed at home, this can be done with either an automated peritoneal dialysis (APD), CAPD, or home HD. Based on this approach at the University Health Network, out of 153 new patients seen at the pre-dialysis clinic between 2001 and 2007 who were presented with the various renal replacement options and who made a free choice, 59 chose in-hospital HD, 15 chose home HD, and 79 chose home PD (unpublished data). Therefore, we propose a change in our approach to the choice of the initial form of dialysis for new patients with ESRD. This should be presented with the advantages of dialysis at home and instead of asking them to choose between PD or HD, they should be offered the option to choose between dialysis at home (PD or HD) or in-hospital.

Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.