History of peritoneal dialysis (PD)
In this article we will describe the history of peritoneal dialysis (PD).
Prehistory
The term ‘peritoneum’ derives from the Greek peritonaion, meaning to ‘stretch around’ (see below). The first known recorded reference of the peritoneal cavity appears in the Ebers papyrus in 1550 BC. It is believed to have been copied from earlier texts, perhaps dating as far back as 3400 BC. The Ebers Papyrus is a 110-page scroll, which is about 20 meters long.
The Egyptians recognised that a sac surrounded the internal abdominal organs during their separation of the viscera from the rest of the corpse prior to embalmment. Galen and many other prominent physicians of antiquity observed the peritoneum in the open abdomen of injured gladiators. The early anatomists and surgeons described the extent of the peritoneal membrane, named its surfaces and attachments, but did not elaborate on its function or fine structure.
Early history (before 1923)
The initial concept of peritoneal dialysis may have evolved from a novel treatment developed by Christopher Warrick, an English surgeon in the early 1740s. Warrick presented his findings at a meeting of the Royal Society on February 16th 1743. Reverend Stephen Hales wrote about modifications to the procedure; speaking at the Royal Society on February 23rd 1743.Warrick was treating a 50-year-old woman who was suffering from severe ascites.
He decided to instill Bristol water and claret wine into the patient’s peritoneum through a leather pipe – the assumption being that the wine would have an antibacterial effect. The patient reacted so violently that the therapy was discontinued after three treatments. It is interesting to note, however, that she did recover from the ascites in a period of weeks, and, according to Warrick, in a short time she was able to walk seven miles in a day without difficulty.
The peritoneal membrane became of physiological interest to anatomists after the discovery of cells. Friedrich Daniel Von Recklinghaussen was the first to describe the gross and cellular anatomy of the peritoneum; giving the first scientific description of the peritoneum’s cellular composition.
In 1877, the German G. Wegner performed the first animal experiments to observe the metabolic transport processes occurring through the peritoneum. For example, he injected solutions of various contents and temperatures into rabbits and discovered that a concentrated sugar solution would lead to an increased amount of fluid in the abdominal cavity. This is how Wegner discovered the basis for using the peritoneum for fluid removal, or peritoneal ultrafiltration.
In 1894, two Englishmen, Starling and Tubby expanded these observations by studying the bidirectional transfer of molecules across the peritoneal and pleural membranes and demonstrated the rapid absorption of isotonic solutions and slow absorption of serum proteins. They discovered that fluid removal through the peritoneum occurred throughthe blood vessels in the peritoneal membrane.
In 1918, Desider Engel, working first in Prague and then in China, demonstrated that protein can pass through the peritoneal membrane. This significant finding was applied by later investigators in their efforts to show that peritoneal dialysis may be more efficient in removing large molecules. M. Rosenberg, in 1919, noted that the same fluid in the peritoneum contained the same amount of urea that is found in the blood, indicating that urea could, in fact, be removed using peritoneal dialysis.
By 1920, it had been recognised that, regardless of the infusate osmolality, the fluid was completely absorbed within 20 hours of infusion (Cunningham, 1920). These observations led to the administration ofIP fluids to infants with severe dehydration when the oral route was not possible (Blackfan, 1918). This may have been the first therapeutic use of the peritoneal membrane.
Also, in the late 19th century, Leathes established the physiological basisfor peritoneal dialysis (PD) with emphasis on the relationship between osmolality of the fluids and peritoneal ultrafiltration and absorption (Leathes, 1895); and the bidirectional flux of small molecules between the peritoneal cavity and the intravascular compartment.
Orlow (1895), Abbott, Clark, Putnam and others confirmed peritoneal membrane was permeabletosodium and other minerals. The concept of osmotic equilibrium between plasma and peritoneal fluid was established by Putnam in 1922; who concluded that mass transfer was driven by passive concentration gradients rather than active membrane transport.
In 1902, Klapp first observed that heat applied to the anterior abdominal wall could accelerate the exchange of substances between the IP cavity and the blood compartment. This observation was a precursor of the concept of augmentation dialysis. In 1921, twenty years later, Clark confirmed these findings by using IP infusions of warm solutions and suggested that vasodilatation was responsible for the accelerated rate of exchange.
The initial uraemic models consisted of rabbits and guinea pigs subjected to ureteral ligation. Intraperitoneal exchanges lasting 2 to 4 hours were utilised. Although there was moderate absorption of the dialysate, due to its hypotonicity relative to uraemic plasma, definite clinical improvement was noted in the animals after dialysis.
Later history (1923-1951)
Wegner, in 1877, was the first to report experiments with peritoneal lavage. But George Ganter, in 1923, published the first trials of peritoneal dialysis for uraemia (Ganter, 1923). He ligated the ureters of rabbits and guinea pigs, and instilled saline solution in the peritoneal cavity. Subsequently, in 1923, he treated the first ever patient with peritoneal dialysis. She was a female with ureteral obstruction due to uterine carcinoma. The PD solution containing saline.
He published only one paper entitled “On the elimination of toxic substances from the blood by dialysis” in humans and animals. Ganter studied at Freiberg, Munich, Greiswald and Wurzburg where his work on peritoneal dialysis was done, and he became Professor of Internal Medicine at Rostoc. As an opponent of the Nazi regime he was deposed from his academic role in 1937.
This experience was followed by scattered reports with variable outcomes using the continuous perfusion technique (Heusser 1927, Balázs 1934). Heusser added glucose to the PD solution to improve ultrafiltration. This was to become the standard osmotic agent in PD fluid decades later.
The next significant event in the development of peritoneal dialysis occurred at the Wisconsin General Hospital in 1936. A group headed by Wear, Sisk, and Trinkle (Wear, 1938) used peritoneal dialysis also on a patient who was suffering from urinary obstructive disease. They were able to maintain the patient on continuous dialysis until the obstruction was resolved, demonstrating for the first time that a patient could be safely treated with continued peritoneal dialysis.
In 1938, Rhoads used intermittent dialysis (IPD) to treat two nephrotic patients. Rhoads added lactate to the PD fluid to correct acidosis. Again, this was to become the standard buffer in PD fluid decades later.
PSM Kop was an associate of Willem Kolff’s in Holland during the mid-1940’s. It was Kolff’s work with haemodialysis that kept alive an intense interest and belief in the value of dialysis treatment among numerous researchers. Kop, however, turned his attention to peritoneal dialysis. Kop created an integrated system that used gravity as the means to instill the dialysis solution into the patient’s peritoneal cavity.
The system used components that could be easily sterilised: porcelain containers to hold the solution, latex rubber tubing to carry the solution peritoneal down to the patient, and a large glass catheter to instill the solution into the patient’s peritoneal dialysis delivery system. Kop’s group treated 21 patients and met success with ten of these treatments.
Arnold Seligman, Jacob Fine, and Howard Frank developed a system, similar to that used by Kop, but which addressed several technical issues: such as optimal flow rates and modification of the solution to suit patient needs. To prevent peritoneal bacterial contamination, they used large bottles of solution that were sterilised; and they used dialysis system which used two catheters to minimise any potential obstruction during the outflow phase of the procedure (see below).
In 1946, the Seligman group used their system to treat a patient who was suffering from acute renal failure induced by an overdose of sulfa drugs. The patient’s successful recovery is one of the primary milestones in the development of peritoneal dialysis.
There were several other reports of the use of PD in patients with acute renal failure in 1946 (Reid, UK; Tanret, Paris). By 1950, more than 100 patients had been treated with PD, of which approximately two thirds had acute renal failure (Odel, 1950). The next serious contributions to the clinical use of PD were the recognition of the need for frequent intermittent dialysis, the maintenance of a sterile setting and the concomitant use of a CKD programme consisting of dietary restrictions and nutritional supplements.
Later history (1951-1959): Grollman and Maxwell
Progress with peritoneal dialysis slowed until 1951, when Arthur Grollman et al, working at the Southwestern Medical School in Dallas, reported their classic work on the use of IPD in uraemic dogs and its application to humans. In 1952, he published a book on the subject. In his book, Grollman described the use system, using a 1-litre container with a cap that connected to a piece of plastic tubing.
The tubing was then attached to a flexible polyethylene catheter. The catheter was revolutionary; first, because it was flexible in design; and, second, because by making very small holes in the distal end, he was able to keep the patient’s body tissue from impeding the drainage. The result was better inflow and outflow of the fluid.
Grollman suggested that the fluid be instilled by gravity and that it should dwell for 30 minutes, at which time it would be drained out into the same container. He suggested that the technique be repeated on an hourly basis until the patient’s biochemistry returned to normal. Grollman’s book is a classic in that it describes the intermittent method of peritoneal dialysis that we use today.
Morton Maxwell had been involved with acute haemodialysis at Wadsworth VA Hospital in Los Angeles during the latter part of 1950’s. He felt that the haemodialysis system was too difficult for the average practitioner to handle. He reviewed the work of Seligman, Fine and Frank as well as Grollman and decided that he would attempt to put together a system to treat acute renal failure.
Maxwell was looking for a simple system that would be easy to set up and use by a variety of medical personnel. He wanted to prevent infection so the system was designed to require as few connections and disconnections as possible. He convinced a local manufacturers (Baxter Corporation and Cutter Laboratories) to manufacture dialysate in a glass container, plastic tubing set and a polyethylene multihole catheter.
The technique was quite simple: instill two liters of solution into the peritoneum, let it dwell for thirty minutes and then drain the fluid into the original bottles. This procedure was continued until the patient’s biochemistry was normal (Maxwell, 1959).
Maxwell performed a number of successful peritoneal dialyses using this method. Dialysis was no longer relegated only to those hospitals that had haemodialysis equipment; it could now be performed in any hospital where the supplies were available and the procedure was understood. It became known as the ‘Maxwell Technique’ for those who would perform peritoneal dialysis later.
Also, in 1959, Ruben and Doolan introduced intermittent PD, i.e. inserting a new catheter whenever dialysis was required. This was the first time a patient could be maintained on PD in the long-term. Their multihole catheter was soft and made of PVC.
Later history (1959-1976)
In 1964 Boen developed an automated device to do peritoneal dialysis at home. It utilised a 40-litre bottle that was filled and sterilised at the University of Washington. The bottles were delivered to the patient’s home and returned to the hospital after use. This is the Automated Cycling Machine:
This technqiue used the ‘repeated puncture’ method for access. This required that a physician go to the patient’s home and surgically place a 14F trocar in the patient’s abdomen. The patient’s helper would be trained to remove the trocar after the peritoneal dialysis treatment. Also in 1964, Boen published his textbook of PD for use in clinical medicine.
He emphasised its importance in the treatment of acute kidney injury (AKI), and further contributed to the basic physiology, indications, and complications of this technique. The success of hemodialysis (HD) as chronic renal replacement therapy and its fast proliferation kept PD dormant for some time.
In 1965, Weston and Roberts, introduced a new simple method of introducing a rigid PD catheter: the stylet peritoneal access catheter (Trocath). Russell Palmer, in Vancouver, first introduced a silicone semi-permanent indwelling peritoneal tube that he developed with Wayne Quinton; providing continuous access into the peritoneum for first time.
It was first used in September, 1963 in a patient, a nurse, who subsequently went home to dialyse in January 1964. It was not until 1967 that the Seattle team, under the leadership of Henry Tenckhoff, modified and improved Palmer’s tube; and was able to send patients home unassisted as Palmer had done. In the 1960-70s, there was renewed interest in PD because of these advances, the availability of commercial dialysate, and the development of automated systems.
Modern history (1976-)
In 1976, Robert Popovich and Jack Moncrief (in Austin, Texas) published an abstract describing the principles of continuous ambulatory PD (CAPD). Two years later, this team published their first results of the use of continuous ambulatory PD (CAPD) (Popovich, 1978). In 1978 Dimitrios Oeopolous, in Toronto, introduced PVC bags, rather than glass bottles, to contain the dialysate. In 1979, In order to reduce peritonitis rates, Karl Nolph, in Missouri, introduced the light titanium connector.
This advance caused enormous growth in utilisation of the PD technique. The number of dialysis units in Europe providing CAPD had increased to almost 160 by 1979 (Jacobs, 1981). In this paper, the first clinical results were published – but the results were rather discouraging. In 1979, the combined 2-year patient and technique survival in 1728 patients was only 32%.
In 1980, Oreopoulos started a journal titled Peritoneal Dialysis Bulletin – which was later changed to Peritoneal Dialysis International – aimed at spreading knowledge about PD worldwide. And the first national conference on CAPD was organised in 1981 in Kansas City (Nolph, 1981). In 1981, Umberto Buoncristiani introduced the ‘flush before fill’ Y-system. Also in 1981, Diaz-Buxo further developed an automated form of peritoneal dialysis (CCPD, continuous cycling peritoneal dialysis).
In the years that followed, that conference was transformed into an international meeting, currently called the Annual Dialysis Conference. Proceedings of these meetings are published as Advances in Peritoneal Dialysis. The first International Course on PD was organised in Vicenza in 1982 by LaGreca and colleagues. Since then, the Course has been repeated every three years. The proceedings of the Course were originally published as books, then later as supplements of Peritoneal Dialysis International, and currently in Contributions to Nephrology.
In 1984, the International Society for Peritoneal Dialysis was founded. The objectives of the ISPD were to stimulate good-quality PD worldwide by organising a congress (originally to be held every thee years), by developing guidelines, by publishing Peritoneal Dialysis International, and by establishing training scholarships.
In 1987, Twardowski developed the PET (peritoneal equilibration test) (Twardowski, 1987). This was the first standardised method to quantify individual peritoneal membrane characteristics and to compare the individual results with larger populations. It requires the collection of peritoneal effluent samples at time intervals over four hours using a standard protocol and a mid-point blood sample.
The CANUSA study was published in 1996 (Churchill, 1996). This prospective cohort study in incident PD patients from dialysis units in Canada and the United States investigated associations between higher renal and peritoneal small-solute transport values (such as Kt/Vurea and creatinine clearance) and patient survival. But it, nor anyother subsequent study, has been able to show an effect of peritoneal solute clearances on survival. In 2002, the use of double-bag systems was shown to further reduceperitonitis rates (Li, 2002),
The interest in APD, the introduction of new modalities of automated PD, advances in connectology and other technological improvements are responsible for the further growth of PD. The quest for the optimal prescription and dose of dialysis remain an important subject of investigation.
Summary
We have described the history of peritoneal dialysis (PD). We hope you have found it interesting.
Other resources
There are several good histories of the development of PD.
Palmer (1980)
Mcbride (1980?)
ISPD (1987)
Krediet (2007)
Oreopoulos (2008).
Etymology
Peritoneal
1540s, from Late Latin peritonaeum (c.420), from Greek peritonaion (‘abdominal membrane’), lit.’part stretched over’, from neut. of peritonaios (‘stretched over’) from peri- (‘around’)+ teinein (‘to stretch’)
Dialysis
1580-90. Via Latin, from Greek dialysis = ‘dissolution, separation’ (of the disbanding of troops, a divorce etc), from dialyein = ‘dissolve, separate’, from διά (diá, ‘inter’ ‘through’) and λύειν (lýein, ‘loosen). Used originally in logic and grammar. First used in chemistry sensein 1861, and in medicine in 1914
Last Reviewed on 9 April 2024