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Title: Peritoneal dialysis becomes a treatment for endstage renal disease
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Peritoneal dialysis becomes a treatment for endstage renal disease

Many small improvements

Peritoneal dialysis (PD) for endstage renal failure was first given as intermittent intensive treatments (IPD) given continuously for 1-2 days once weekly. Patients would generally have a new rigid PD catheter inserted each week under local anaesthetic, be treated for up to 48h, then receive no dialysis for 5 days. Its first use this way is attributed to Richard Ruben in 1959, but the shortage of haemodialysis (HD) facilities led to it being widely used, despite its many problems, in the 1960s and 1970s. Even in the early 1980s some patients were being treated by intermittent puncture IPD in the UK.
Photo (Copyright reserved): Nora Kehoe with a newly implanted PD catheter, London 1987. It's the Maxwell system of 1959 with plastic fluid bags.

However the success of PD as a lasting treatment required better catheters that could be left in long term, and a reduction in the risk of introducing infection during fluid exchanges.
In 1959 Fred Boen published an impressive thesis in Amsterdam which helped to understand the capabilities of PD. The following year he went to Belding Scribner’s unit in Seattle to attempt to set up a chronic PD programme. An automated infusion and drainage system was developed, but maintaining peritoneal access without infection remained a key obstacle. For a time he tried home visits to insert a new PD catheter under local anaesthetic each week, an experience reported at the same time as the very first experiments were taking place with the even more revolutionary concept of home haemodialysis.

Henry Tenckhoff joined the Seattle group in 1963 and developed both home fluid production machines and the silicone Tenckhoff catheter, a modification of a design by Russell Palmer which was made by Wayne Quinton who had developed the Quinton haemodialysis catheter (references at the foot of the unsung story of early PD). Harold McDonald added a Dacron cuff, and Tenckhoff added the second one.
Dimitrios Oreopoulos encountered PD while training in Belfast in 1966, and in 1969 took on the 4-bed chronic IPD programme in Toronto. Coupling the Tenckhoff catheter with a cycling device made by Norman Lasker, who was sending patients home with these devices in Philadelphia, Oreopoulos developed a home IPD programme which had expanded to over 70 by 1974. Moncrieff and Popovich developed the continuous ambulatory (CAPD) technique in response to a patient with no vascular access in 1975, and Oreopoulos investigated this further in his patients in 1977, converting most to CAPD.

Further improvements in peritonitis rate were needed and the first commercial 2 litre bags and improved connection systems from Baxter in 1978 and 1979 made CAPD more generally possible.

When CAPD was introduced widely in the UK during the 1980s, haemodialysis places were very limited, and CAPD was seen as a way of broadening access to dialysis, for example by accepting patients with diseases such as diabetes who would otherwise have been excluded. The slow growth of HD capacity in the UK led to its PD programme burgeoning in the 1980s, so that by 1990 the UK had more patients on PD than on HD. 18 years later the total number of PD patients was about the same, but by now this was only 10% of endstage patients were on PD, with 43% on HD and 47% transplanted (UK Renal Registry).

Experience with CAPD proved that PD could work for years as a feasible treatment. Debate about its relative place as a longterm treatment will no doubt continue.

Further info:

International Society of Peritoneal Dialysis. The history of peritoneal dialysis. Only published online, and no longer available, unfortunately.
Boen ST. Peritoneal dialysis – a clinical study of factors governing its effectiveness. PhD thesis 1959 University of Amsterdam
Boen ST et al. Periodic peritoneal dialysis using repeated puncture technique and automatic cycling machine. Trans Am Soc Artif Intern Organs 1964 10:409-14
J. Stewart Cameron 2002. A History of the Treatment of Renal Failure by Dialysis (OUP)
Sources for a fuller history of PD at the foot of the The unsung story of early PD

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