by Dr Andrew Stein and Prof Ram Gokal

 In Swinney’s 1966 UK survey of long term dialysis in the UK (Swinney, 1966), 7 of 140 were on “chronic peritoneal dialysis’. Presumably this was ‘IPD’ (intermittent PD) – several days of PD via  intermittent puncture every 10-14 days).

However Intermittent PD (IPD) was labour intensive, greedy of hospital beds, and limited in long term tolerability because of peritonitis and difficulties with repeated access. This meant that its place was mainly for short-term bridging. The technique remained in occasional use in a few UK units well into the 1980s.

Why did chronic PD not really take off in the 1960s? This was partly technical, the flexible catheters and bagged dialysate necessary to make community-based CAPD possible had not yet been developed; partly as it was very labour intensive to keep large numbers of patients on intermittent IPD; and partly because haemodialysis capacity was increasing. Also, at that time there were multiple approaches being used to deliver PD, with a paucity of published evidence. There were high technique failure rates so that HD back up was required.

These issues were coupled with the encouragement of conservative or supportive management (strict dietary and fluid restriction); resulting in the widely held perception that PD was not an appropriate long-term therapy. It was not until the late 70s when chronic PD re-emerged in the UK, due to the deelopment of CAPD.

CAPD (Continuous Ambulatory Peritoneal Dialysis)

CAPD was designed by nephrologist Jack Moncrief and biomedical engineer Robert Popovich (Moncrief, 1978) in Austin, Texas, in 1975. A particular enthusiast, Dimitrios Oreopoulos, had trained in Northern Ireland, and subsequently led the way in Toronto, with 70 patients on CAPD in 1976 (Oreopoulos, 1976). It entailed 4 daily exchanges – 3 during the day and one at night.

It is not certain which was the first UK unit to carry out CAPD. The Dutch nephrologist and PD expert, Ray Krediet – who was an honorary registrar at Guys in 1977-78, and is now joint editor of ‘Nolph and Gokal’s Textbook of Peritoneal Dialysis’ – thinks it was Newcastle, led by Ram Gokal, supervised by David Kerr. Ram Gokal stated in a 1980 paper “in January 1979 the technique (CAPD) was introduced in Newcastle as a definitive method of managing end-stage renal failure.” (Gokal, 1980).

But CAPD was also started in Glasgow at the Western Infirmary Glasgow, sometime in 1979. Shortly afterwards, Dr Brian Junor joined the unit as a consultant and CAPD was soon established at all three Glasgow units (the others being Glasgow Royal Infirmary and Stobhill Hospital). And John Feehally remembers his first day as a renal registrar in Leicester in January 1980 meeting two patients who had started CAPD in November 1979 (personal communication, 7.6.22).

CAPD in Newcastle 1979 onwards

Prof David Kerr (Royal Victoria Infirmary and University of Newcastle) and Mary McHugh (senior registrar at Freeman Hospital renal unit) were in Canada at the ISN meeting  in Montreal in 1978. They came back and were enthused about CAPD and wanted to introduce it into RVI. Mary McHugh’s work programme precluded her taking an effective  lead, and David Kerr said to Ram Gokal ’you take it over’ . Ram Gokal recalled having seen problems with stab PD for acute PD in Oxford and was not too enamoured with the prospect of taking on the programme! David Kerr insisted it was a challenge which would  benefit many because HD was so limited. So that was that. The programme started – Ram had to learn Tenckhoff insertion, and liase with Baxter. David Kerr was very supportive, and there was soon a good going programme – probably the first in UK See . The first CAPD patient was Gillian in Jan 1979 – probably therefore the first in the UK. She was young and articulate and became an advocate of CAPD at meetings. The chance for patients to travel (Baxter were able to have PD solutions awaiting the patient’s arrival at their destination) and there were innovative ways  of ‘hiding’ the empty bag once the fluid had been drained into the peritoneum.

 This publication (the first on PD from a UK renal unit) led Ram Gokal  to be invited to many meetings and congresses  travel (“have slides will travel” was the dictum)!

Ram was also involved in helping the paediatrician (Ed Eastham) and his team start CAPD in Newcastle in 1980 -probably the first programme in children in the UK.

 The outcome in the programme over the first 24 months in 32 patients was:

 

The advantages and disadvantages of CAPD were  becoming apparent:

 

 CAPD across the UK

Many UK units began to use CAPD 1979 from onwards. CAPD offered the incentive of reduced demand for in-centre HD slots, which were extremely limited at the time; coupled with a shorter training period, which could be provided at home. Initially, patients were admitted for 2-3 weeks for PD training. By the 1990s, this was done as day-case patients for up to 5 days. This is largely the case today. Patients performing their own PD reduced dialysis costs, a key reason for this modality being taken up so avidly in the NHS. Few if any significant comparator trials were conducted but there was anecdotal evidence of improved nutritional status and haemoglobin compared with patients on HD. Another benefit was the freedom for patients to take holidays more easily.

 

PD patients from MRI on a day trip with family members

Severe peritonitis remained problematic. But, in 1981, evidence from the flush-before-fill trial (Maiorca, 1983) led to improvements in peritonitis rates. Alongside the benefits mentioned, this lead to acceleration in uptake of the technique.

CAPD in Manchester  

The early work to establish a CAPD programme at Manchester Royal Infirmary (MRI)at was initiated  by Netar Mallick, and led by Bob Coward (senior registrar and later nephrologist in Preston).  The move of Ram Gokal   from Newcastle, with his established PD experience, to become a consultant at MRI  in 1980  provided the stimulus to MRI becoming a leading UK PD centre.  Before thenm in-patient HD facilities were sparse and the programme had been geared to home HD and transplantation, which was restricted because of the limited number of patients suitable for transplant.

This changed with the advent of CAPD and its rapid growth. Coupled with the increased intake on the dialysis programme, there was a need for proper infrastructure, particularly a strong multi-disciplinary staff team – especially highly trained and experienced nursing staff – Linda Uttley, Judy Moon were key at the start at MRI. They were involved in the teaching of staff, research, home visiting nurses, pre-dialysis education and training.  It was necessary to verify that CAPD was indeed a good initial therapy, including prior to transplant.   This led to publication of the ‘seven centres study’, in which the relative benefits of CAPD compared to  HD in survival terms in all age groups were demonstrated (Gokal, 1987).

(See below for more about the work of the MRI unit  under Contributions of Individual Units)

 The 1980s: Rationing of Therapy:

PD became increasingly popular in the UK throughout the 1980s for a variety of reasons most notably the reduced requirement for capital investment in building and equipment compared to HD. This  favoured high PD uptake with slower increases in HD until the turn of the century, when PD rates started to fall. The low acceptance rate onto RRT was indeed a ‘hot topic’ and several nephrologists were quite ‘vocal’ about the situation. In 1983, a meeting was organised by Chisholm Ogg and Frank Parsons to publicise this and very well attended by nephrologists as well as the press. Well, guess what? The Falklands war broke out the same day and any chance to highlight the problem was gone!! The papers had a one-inch report on an inside page.

Around this time there was a great deal of discussion about the low number of patients receiving RRT in the UK compared with European countries. (see 1980s on: meeting Demand) Lack of resources often meant that fewer patients were considered ‘suitable’ for treatment, a scenario that caused many patients a great deal of distress, which was shared by renal physicians.

International comparisons of PD and HD were In a study that compared Europe to the USA and Australia in 1981, it was noted that the UK was ‘leading the world’ in numbers of units performing PD (Nolph, 1983). At that time, over 80% of units were carrying out PD, compared to a European (EDTA Registry data) average of just  over 30%. This was despite a negative impression of CAPD by some leading UK physicians, owing to the wide range of patients undertaking this therapy. Many thought it was only popular as we had little choice, with limited space for HD. It was becoming clearer that   maintaining patients on PD ‘too long’ was detrimental and it was important to have a integrated RRT programme – of course that demanded a higher maintenance HD capacity which   was limited in many units.

From outside  , the view of the UK was more positive. According to Bengt Lindholm (Karolinska, Sweden): “In the 1980s, UK was very much the beacon of light in the PD world and UK had the largest PD population in Europe” (personal communication, 2.6.22).

The CAPD programme often acquired patients unsuitable for transplantation, or for in-centre HD owing to lack of space, age, or complications of HD. Some units preferentially used CAPD for diabetic patients, and their diabetes-related complications  were leading to worse outcomes for PD cohorts.

Ultimately, CAPD was shown to be equivalent in comparable patients (Burton, 1987), with specific advantages in particular patient groups, most of all in children. It became apparent, however, that time on CAPD was finite, believed to be around 10 years at that time; owing to membrane failure, recurrent peritonitis, or to the previously unforeseen complication of sclerosing encapsulating peritonitis.

Two UK based studies contributing to our understanding of PD occurred in the 1980s. Firstly, in 1984, it was found that the haemoglobin concentration rose in the early months of PD, and remained above those in haemodialysis patients (Saltissi, 1984) – though this was observational data, with no RCT comparing the two dialysis techniques. Secondly, in 1989, it was discovered that carriers of Staph aureus on their skin and in their noses, were much more likely to get peritonitis; so that the search for, and treatment of, bacterial carriage was worthwhile (Davies, 1989).

Throughout the 1980s there was incremental improvements in PD outcomes as a series of innovations were incorporated into routine care

 

Studies of health-related quality of life outcomes began to show outcome for CAPD compared to HD:

The  wider advantages of PD were also becoming apparent:

 

Automated Peritoneal Dialysis (APD)

Originally CAPD was prescribed as 3 cycles at night and one during the day when a cycler was developed by Baxter and initially became known as CCPD – continuous cyclic peritoneal dialysis. It suffered from the long dwell being of 12-14 hours and the need for hypertonic glucose to prevent reabsorption of fluid. APD in due course became the term used for all PD regimens which used a mechanical cycler to perform exchanges.  APD regimens became more complex but tailored to meet patients’ requirements and dialysis goals. APD became more mainstream and results improved. Evidence began to emerge that APD offered improved technique survival compared to CAPD.

 

 The 1990s: Satellites and Suitability

In 1991 the average annual acceptance rate for patients commencing RRT was 67 patients pmp, which was below the estimated need of 80 new cases pmp under the age of 80 years at that time. There was considerable geographical variation in provision and acceptance rates but, year on year, the acceptance rates rose. Increasing numbers of diabetic and elderly patients were receiving dialysis in line with evidence that the views of nephrologists about suitability were changing (Parry, 1996).

Many nephrologists cited the risk of encapsulating peritoneal sclerosis as a reason for not undertaking PD. But most patients commencing PD, received a transplant, switched to HD, or died before entering the timeframe where encapsulating peritoneal sclerosis was more likely (Brown, 2009). With its significantly shorter training period and fewer home modifications required, PD also had clear advantages over home HD (HHD). Assisted PD is also now a well recognised   therapeutic option suitable for frail patients.

Despite high use of PD in the UK in the 1990s, there was little discussion of PD at Renal Association meetings; perhaps demonstrating a lack of enthusiasm from the UK renal community in general. In fact, the first invited lecture at the RA was the 1995 Osman Lecture as by Gerry Coles (Cardiff) entitled “CAPD – a critique”. Since then, only two other guest lectures have focused on PD: Ram Gokal in 2004 (Chandos Lecture), and Edwina Brown in 2019 (de Wardener Lecture). And the RA has still never had a president whose primary interest is PD.

 PD or HD – a continuing debate

Many studies in the 1980s and 1990s compared patient and technique survival for CAPD and HD:

 n

In the UK there have been  remarkable variations in percentage of patients on PD  shown in the UK Renal Registry annual reports.  John Feehally discussed this in his 2007 report after visiting all the UK units (Feehally, 2007) .

“There is virtual universal agreement that PD was an over-used modality in much of the UK throughout the 1980s and 1990s. In many units the wide use of PD became a mechanism to ensure treatment for people in the face of significant limitations in hospital and satellite HD facilities. In most places PD programmes have gradually shrunk and numbers have typically reached a plateau or continued to fall very slowly over the last five years. However opinion still varies significantly among nephrologists and nurses about the optimum size of a PD programme.

The mainstream view is that about 20-25% of dialysis patients would appropriately be on some form of PD, and these patients would usually be early in their dialysis career, when there is still worthwhile residual renal function. However units which assured me they provided free choice of dialysis modality nevertheless had PD programmes varying between 5% and 30% of the total dialysis population. I have no doubt that this reflects the specific opinion of unit leaders, both nephrologists and nurses, and I was struck in the number of places that forceful leadership can maintain and increase the size of a PD programme, as well as restrict it.

The great majority of pre-dialysis preparation and counselling in our units is led by senior nurses; in conversation with them I was typically assured that the patient was given absolutely free choice and neutral information, although I formed a clear view that this is not the case and that like it or not patient ‘choice’ is heavily modified by professional advice.

At one extreme there do still appear to be a small number of renal unit leaders who are close to sharing the view (to paraphrase the famous critique of Stanley Shaldon) that PD is ‘a second rate treatment for second rate patients prescribed by second rate doctors’. However such opinions are in a very small minority.”

 The 2000s and onwards

There is continuing evidence of a lack of interest in PD by many in the renal community extending into the 21st century. In February 2008 there was a Witness Seminar at the Wellcome Trust entitled the ‘History of Dialysis in the UK: c. 1950–1980’ (ed Crowther, 2008). None of the 32 experts (mainly senior consultant nephrologists) invited to the event had an interest in PD. In fact, CAPD was not mentioned until page 46 of the transcript, and then not in a positive way. One delegate said “CAPD is extremely expensive, especially if it is done badly”. After that, PD hardly gets a mention at all.

The National Institute for Health and Care Excellence (NICE) showed more interest and published a PD guideline in July 2011 (NICE CG125, 2011). It provided guidance in England and Wales on supporting informed choice for people needing RRT, and the role of assisted automated PD in an integrated dialysis programme.

It also examined the effectiveness of interventions to support and improve shared decision-making for dialysis, factors that influence the choice of dialysis, the clinical and cost-effectiveness of PD in the community – compared with hospital or satellite HD or HHD .

It also examined the support needs of patients and carers commencing PD and when to switch to or from PD. The document was further complemented by findings in  2010 from the BOLDE study. This demonstrated that older patients have at least the same quality of life (or better), on PD compared to HD (Brown, 2010).

The NICE CG125 PD guideline was replaced, in 2018, by one on RRT and conservative care (NICE NG107, 2018).

 Contributions of Individual Units

We report here the units which are considered to be those that pioneered PD in the UK, and contributed most to its research and development.

But we can only post what you tell us about. Please contact us if you think more should be said about other units, we want to hear about them.

Manchester 

Although the development of CAPD at MRI is associated with Ram Gokal, there was an interest in PD  from the mid-60s, Geoffrey Berlyne, in 1964, described PD-associated protein loss, one of the complications of the technique (Berlyne, 1964). And Netar Mallick, head of the unit when Gokal was appointed) had been interested in  PD, and indeed had designed a PD cycling machine as a registrar in Cardiff in the early 1960s.

The renal unit at MRI included the transplant ward, the HD unit, and training facilities for home HD and CAPD, all in close vicinity. Specialised nurses were available for all modalities but they worked in close collaboration with the other members of the nursing staff of the renal unit.

Sister Linda Uttley  was the CAPD head nurse for many years. In this environment, an abundance of clinical research studies were performed, some of which directly impacted various aspects of patient care.

L to R: Judy Moon, Manchester CAPD patient who was an orchestral violinist, Linda Uttley, Ram Gokal.

In Manchester, we contrived to set up a programme that was aimed at patient well-being and a positive outcome. At its peak there were around 150 PD patients managed at home – yes a large programme indeed which  needed a carefully co-ordinated approach.  Key factors were: facilities, multidisciplinary team, plan for managing patients, home training, liaison with Baxter and Fresenius, home assessment, dietetics, audit, finance. For the medical staff an important lesson was:

From the time Ram Gokal arrived at MRI, he led a major effort not only to establish a clinical CAPD programme but to develop a related strong research base. Research areas in PD at the MRI have included:

• CAPD outcomes (Chandra Mistry, Alastair Hutchison)
• PD solutions (icodextrin, low calcium, bicarbonate, amino-acids – Chandra Mistry, Alistair Hutchinson)
• Adequacy of dialysis including the debate about Kt/V (John Harty)
• Renal bone disease (Alastair Hutchinson, Mike Picton)
• SIRS (Study of Implementation of Renal Standards) (Anu Trehan)
• Cardiovascular assessment in PD (Anand Vardhan)

All those named completed an MD or PhD thesis.

Icodextrin.  Perhaps the most seminal work at MRI was from 1983 onwards the investigation and clinical introduction of icodextrin as an alternative to high glucose concentrations which were the early norm as an osmotic agent to drive ultrafiltration. This work was led by Chandra Mistry (who went on to consultant posts in Merthyr Tydfil and then Peterborough) and Ram Gokal See under Great British Research for a full description of this work.

CAPD outcomes.The establishment of a prospective multicentre study on a comparison between CAPD and HD in seven large PD units in the UK was one of the important initiatives of the Manchester group (Gokal, 1987). No significant difference in mortality was found between HD and PD patients but technique survival was better in HD patients. This study can be considered the first in a large number of subsequent prospective or registry analyses, all showing similar or superior survival for patients on PD.   There was also a study of an Oxford/Manchester cohort (Auer J, Gokal R, Stout JP, Hillier VF, Kincey J, Simon LG, et al. The Oxford/Manchester study of dialysis patients. Scand J Urol Nephrol 1990; 131(Suppl):31–7.)

Adequacy of dialysis.  In the 1990s much emphasis was put on the presumed value of the dialysis dose, expressed as Kt/V urea, for the survival of CAPD patients. The removal of urea by PD in stable patients reflects their protein intake. The latter can be expressed as the normalised protein equivalent of nitrogen (appearance) rate (nPNR). This provides an indication of protein intake. The presence of malnutrition is not uncommon in CAPD patients, mostly due to underlying conditions and complications. Yet, a hypothesis was promoted very strongly that increasing Kt/V urea would lead to better protein intake and thereby to improvements in nutritional status. This hypothesis was challenged by the Manchester group. John Harty showed that the relationship between Kt/V urea and nPNR was due to mathematical coupling: both have the dialysate urea excretion in the numerator of the equation. Furthermore, a randomised controlled trial showed that increasing Kt/V urea did not lead to a significant increase in nPNR or food intake (Harty, 1995). These clinical data rejected the oversimplification that more dialysis leads to more protein intake and a better nutritional status.

Renal Bone disease. While in Newcastle, Ram Gokal had already become interested in uraemic bone disease in CAPD patients. This line of clinical research was continued in Manchester by Alastair Hutchison. The Manchester team was focused on adynamic bone disease (Hutchison, 1994), and its  prevention by lowering the dialysate calcium and magnesium concentrations (Hutchison, 1992). And later on, the use of lanthanum carbonate as a non-calcium phosphorus binder (Hutchison, 2005).

Other topics studied included: quality of life and lifestyle  (Gokal R. Quality of life in patients undergoing renal replacement therapy. Kidney Int 1993; 43(Suppl 40):S23–7; Stout J. How does dialysis affect the lifestyle of renal patients? A comparative study between CAPD and HD. EDTNA J 1988; 9:11–12.) and sexual dysfunction (Uttley L. Treatment of sexual dysfunction. Perit Dial Int 1996; 16(Suppl 1):S402–5). Anational registry for encapsulating peritoneal sclerosis was started (Angela Summers).

The influence of the Manchester unit was widespread. In addition to clinical investigations, the   group has also been very much involved in the promotion of CAPD and in providing educational activities.

Both Linda Uttley and Ram Gokal were Council members of the ISPD. Ram Gokal was ISPD president from 1998 until 2001. His focus was on educational activities for developing countries. This led to the ISPD scholarship program, allowing nephrologists from these countries to spend 6-8 weeks in well-established PD units all over the world.

Until the mid-1980s there was only one  book on PD (edited by Karl Nolph in 1981).

Ram Gokal then edited   ‘Continuous Ambulatory Peritoneal Dialysis’, first published in 1986. Because of overlap between the two books, they were combined into ‘The Textbook of Peritoneal Dialysis’, the first edition of which was published in 1994. The fourth edition of this book (2022)  is now-called ‘Nolph and Gokal’s Textbook of Peritoneal Dialysis’ (eds Khanna, Krediet). It embeds the place of the Manchester Renal Unit in the history of peritoneal dialysis.

 Leeds

Leeds were early adopters of peritoneal dialysis as a treatment option for end-stage kidney disease, with a strong focus on the benefits of PD on patient quality of life. They were early advocates of offering automated peritoneal dialysis on the basis of patient choice and lifestyle benefits, at a time when availability of APD was constrained by funding issues. Introduction of the use of icodextrin in patients on APD with evaluation by body composition assessment with bioimpedance provided early evidence for the effectiveness of this combination in management of hydration in PD patients.

There is a long track record in Leeds of research activity in the field of peritoneal dialysis. A lot of early work related to the importance of nutritional abnormalities and investigation of biochemical abnormalities in kidney disease and peritoneal dialysis.

Subsequent work related to measurement of body composition in patients with chronic kidney disease in collaboration with the Centre for Bone and Body Composition Research at the University of Leeds. Work involved evaluation of a wide range of technologies of body composition in the patient group, ranging from complex gold-standard research tools to potentially clinically applicable modalities such as bioimpedance (Woodrow G et al.  Effects of icodextrin in automated peritoneal dialysis on blood pressure and bioelectrical impedance analysis. Nephrology Dialysis Transplantation 2000; 15: 862-866.)

The techniques were used to investigate abnormalities of body composition in dialysis patients, with particular emphasis on hydration and nutrition/wasting as well as determining their applicability as clinical assessment and monitoring tools.

Northern Ireland

At a meeting of the International Society of Nephrology, in Geneva, in 1961, Prof Mollie McGeown (the founder of the renal service in Northern Ireland) met Paul Doolan, an American naval doctor, who gave her some advice about PD; and arranged to send her supplies of a cannula that he had designed and was using with success. In 1963, Prof McGeown experimented with PD in acute renal failure but considered it to be inferior to haemodialysis.

However, by 1967, necessity led to its introduction, not only for acute cases, but also as support for patients with chronic renal failure. They were dialysed in hospital, with two 24-hour IPD sessions a week for each patient, in an annexe of one of the medical wards in the Royal Victoria Hospital. Although less efficient than haemodialysis, PD was easier to understand, technically simpler, and cheaper. Initially however there were considerable risks, particularly prior to Henry Tenckhoff’s development of a reliable access device. Before that, fluid leaks and infections were frequent. These, along with inadvertent bowel perforations, were sometimes fatal.

With the opening of a purpose built Renal and Transplant Unit in the Belfast City Hospital in 1968, and a growing band of trained nurses, PD became more accessible. Twice-weekly overnight sessions were to remain the rule for many years. However, the introduction of early automated devices, such as the ‘PacX’ machine, began to make the experience a little better, for both patient and nurse.

CAPD had an obvious appeal, particularly for patients who lived a long way from the unit. And in 1986, an outpatient training programme for CAPD began. There were also advantages for children, who now had the prospect of maintaining normal home life and schooling.

Professor Dimitrios Oreopoulos was an important international figure in PD and much of the credit for turning CAPD into a truly effective therapy belongs to him. Dimitrios, a graduate of Athens University, Greece, had gained a doctorate at Queens University Belfast in the 1960s; where he had trained in nephrology under Prof Mollie McGeown, and had been a member of her pioneering team.

In due course there was a transition to automated PD, freeing patients from the need to do daytime exchanges. Then in 2011 a pilot service began to train health workers to help with the dialysis. This ‘assisted PD’ became a huge success, allowing frailer and more comorbid patients, previously excluded from home dialysis, to access this modality.

 Cardiff – led by Gerry Coles, John Williams and Nick Topley – has focused on peritoneal membrane physiology (Davies, 2011).

Publications also included a practical PD manual: Coles GA, ed. Manual of Peritoneal Dialysis: Practical Procedures for Medical and Nursing Staff. Kluwer Academic Publishers Group; 1988.Ed Gerry Coles (1st Edition, 1988)

Charing Cross later the West London Renal Centre – led by Edwina Brown – has focused on PD in the elderly and supportive care (Brown, 2011).

Publications include:

Survival of Functionally Anuric Patients on Automated Peritoneal Dialysis: The European APD Outcome Study (Brown, 2003)

Quality of Life and Physical Function in Older Patients on Dialysis: A Comparison of Assisted Peritoneal Dialysis with Hemodialysis (Iyasere, 2016)

Derby   – led Chris McIntyre (before he moved to Canada)  focused on the haemodynamic effects of PD

Sheffield – led by Martin Wilkie

Stoke – led by Simon Davies and Mark Lambie

 We welcome information from all units about their contributions to the development and expansion of PD.

The role of Nursing and Allied Health Professionals

Nursing  The introduction of PD led to further increases in clinical responsibility and autonomy in clinical decision making by nurse members of the multidisicplinary team.  Patient training for PD was nurse-led from the beginning, and in many units nurses also took the lead in pre-dialysis education about PD,  in dealing with acute PD complications, in PD clinics, and through home visits. A good PD nurse needed to be multiskilled!

Dietetics

Dieticians also play an important role in the  PD team. Their contributions include:

• To assess, monitor and maintain the nutritional status of patients
• To educate/counsel patients & families why and how they may make changes to their diet at various stages of CKD
• To educate staff about the importance of good nutrition in CKD

 

The Role of Industry in the Growth of PD in the UK

From the beginning of CAPD there were two companies offering PD consumables – Baxter and Fresenius. The systems they offered were not compatible – bags, locks and lines had to be used as a single system. A patient was therefore either ‘on Fresenius’ or ‘on Baxter’. Units negotiated hard to obtains favourable supplies contracts; some became ‘Fresenius’ units or ‘Baxter’ units, others had some patients on both systems.

Fresenius reached its zenith in the early 1990s when it held the exclusive licence for icodextrin, which was gaining dominance as a non-glycaemic osmotic agent. But Fresenius never held more than about a quarter of the UK market.

Once Baxter obtained the icodextrin licence in 1996, the influence of Fresenius declined, and it soon stopped providing PD supplies, leaving Baxter with a UK-wide monopoly.

In 1994 Baxter introduced HomeChoice, a cycling machine which grew in popularity as APD became a more mainstream approach to PD.

Baxter has contributed to PD education   for professionals, e.g the PD Academy.  And also digital education and support systems for patients including Sharesource, an APD system for keeping PD patients remotely connected with their healthcare providers, and My Kidney Journey, a patient-centred educational app.

 

Further reading

·      Much relevant information can be found in ‘PD in the United Kingdom – past, present & future. Peritoneal Dialysis International 2011; Vol 31 (Suppl 2).

• Cameron, JS. A History of the Treatment of Renal Failure by Dialysis. Oxford : Oxford University Press, 2002 (Cameron, 2002).
• Crowther et al. History of Dialysis in the UK: c. 1950–1980. The transcript of a Witness Seminar held by the Wellcome Trust Centre. For the History of Medicine at UCL, London, on 26 February 2008. Edited by S M Crowther, L A Reynolds and E M Tansey (Crowther, 2008).
• Gokal R, ed. Continuous Ambulatory Peritoneal Dialysis. Churchill Livingstone; 1986.
• Gokal R, Nolph K. Historical developments and overview of peritoneal dialysis. The Textbook of Peritoneal Dialysis pp 1–15 (Gokal, 1994).
• Gokal R, Nolph K, eds. The Textbook of Peritoneal Dialysis. 1st ed. Dordrecht: Kluwer Academic Publishers; 1994.
• Hopewell J. The Early History of the Treatment of Renal Failure by Haemodialysis and Transplantation in the UK. British Transplantation Society (Hopewell).
• Khanna R, Krediet RT, eds. Nolph and Gokal’s Textbook of Peritoneal Dialysis. 3rd ed. New York: Springer; 2009 (4th edition in Nov 2022).
• McBride P. Taking the First Steps in the Development of Peritoneal Dialysis. PDI. Vol 2, Issue 2, 1981 (Mcbride, 1981).
• Miller, Ashton (1908-92), known as ‘Jerry’
• Miller, Ashton. Peritoneal Dialysis. Brit J Urol. 1962 Dec: 34(4): 465-469 (Miller, 1962).
• Miller, Ashton. Acute Renal Failure in Surgery Conditions: Peritoneal Dialysis. Proc R Soc Med. 1966 Jan;  59(1): 40-42 (Miller, 1966).
• Misra M, Phadke GM. Historical Milestones in Peritoneal Dialysis. Contrib Nephrol. Basel, Karger, 2019, vol 197, pp 1–8 (Misra, 2019).
• Reid R, Darmady EM, Bywaters EGL, Joekes AM. Discussion on advances in the treatment of uraemia. Proc R Soc Med. 1948 Jul; 41(7): 409-26 (Reid, 1948). This is an interesting article in the Section of Urology, with the papers  delivered on January 22, 1948. Ronnie Reid, a urologist in Bristol presented on PD. Michael Darmady, Eric Bywaters, and ‘Jo’ Joakes   on haemodialysis. The abstract is written in English, French, Greek & Spanish!

Last Updated on May 22, 2023 by John Feehally