The more commonly known hemodialysis is considered to be too harsh for babies. Peritoneal dialysis is preferred as it does not cause the rapid and harsh fluid and electrolyte shifting. A tube is placed into the abdominal region. It is called peritoneal dialysis tube (PDT).

The end of the tube goes into the peritoneum, which is the cavity that houses the digestive organs such as the stomach and the intestines. The peritoneal dialysis fluid is called dialysate. When the dialysate enters the peritoneum via the PDT, it is actually the peritoneal lining that perfoms the dialysis.

There will be numerous cycles of the dialysis, with fresh dialysate going in and staying in the peritoneum for a prescribed amount of time and then the dialysate will be allowed to drain out, taking the wastes of the body along with it. Then the process is repeated for the prescribed amounts of times.

Peritoneal dialysis can be performed while the kidney's are still in the body. This is not ideal for a long period of time, as the kidney's will still allow protiens to escape through the glomeruli filters. So, after the PDT and surrounding tissues have healed and dialysis has been proven to work by seeing if the PDT is patent and how much the peritoneum can hold, the kidneys will usually be removed. This will now change the diagnosis of having CNS to being a dialysis patient.

My William's kidneys were removed. The name of this surgery is bilateral nephrectomy. Many have asked why just one kidney could not have remained. The answer is because the proteins would continue to escape, as both sides were affected with CNS. It is probable that with acquired nephrotic syndome, if only one kidney were affected, then just that affected kidney could be removed and dialysis and transplant might not be necessary.

After Williams kidneys were removed and he was still on pain medications, the dialysis team came to perform the first dialysis. Most of the team were specialized in pediatric dialysis (this was a state of the art hospital in Houston). I can't help but smile at the memory of one of the nurses that kept covering him with the diaper so that he would not have an accident on them. I mentioned that the doctors specifically stated that the inguinal hernia repair sites were to be watched during the first real dialysis to make sure that they held and with him covered with his diaper, they would not be able to monitor this and there was no reason to worry about him having an accident, as he no longer had his kidneys. She looked rather sheepish *hee hee*

The number of times the cycles must be repeated are determined by how much dialysate the peritoneum can hold, and most first time dialysis attempts must not be able to hold much, especially with babies. So he had to have numerous cycles and was hooked up most of the day at first. They put in a bit more each time and over time, he was only hooked up about 8 hrs a night. With the smaller amount of time, and the promise that he would have care by parent 24 hours a day, he was transferred to his private room, I was thrilled for this way I would be able to actually sleep there at the hospital and spend more time with him. After settling into the new unit for about a week (for the new nurses to get used to his higher than normal acuity level), our dialysis by parent training was started.

To train parents in peritoneal dialysis usually takes a week or so, but they had never trained parents that were both nurses. Our training was completed in about 1 1/2 days and the remainder of the time was spent observing to make sure that we had it down as perfectly as possible and also trouble-shooting and how to respond to problems.

As ideal as peritoneal diaysis is when compared to hemodialysis, the peritoneal version is usually short lived. If peritonitis (infection of the peritoneal cavity) occurs bad enough to cause even the slightest damage to the peritoneal lining, then the patient will have to be converted over to hemodialysis. Hopefully, the patient will be old enough not to be affected in adverse ways by hemodialysis. My friend's son was the youngest that we know of to do well on hemodialysis and I am going to get her to write an article for this page about that, and about her son's transplant of her kidney to him, since I was unable to give my kidney to my son and can't write as much due to lack of experience in this subject.

Back to peritonitis, since the body's been invaded by an unnatural PDT, this raises the chances of infection starting up in the surrounding skin and tissues of the tube, the inside of the tube itself can carry the infection into the peritoneum. The training covered aseptic technique (which was more sterile than any sterile procedure I have ever seen or done!). Without going into great detail, I will try to cover the basics of the aseptic techniques that were used.

• Sterile gloves were not used, if nothing comes in actual contact with any of the actual dialysis equipment and dialysate and tubing, then it is fine not to use sterile gloves. Masks were required though. They had cultured many of the patients in the past that had come down with peritonitis and found in many cases that the bacteria was airborn, hence the use of masks.

  All windows and air vents in the ceilings and walls also had to be covered to make sure that there was not a draft during the setup. Doors were not allowed to be opened during setup either. This was difficult to enforce even with big caution signs placed on the door at the hospital. We ended up placing a heavy chair up against the door and when personel would try to enter, they couldn't open the door very well with the chair placed up against it and this would give us the chance to yell through the door to please read the sign and no one was allowed in until set up was completed.

• Alcohol was used to initially disinfect the covers of drugs that were to be placed into the dialysate and the sites where the drugs were injected. Then, after the initial cleansing with alcohol, the very same sites had to have betadine swabs placed over them and let them stay on them for the predermined time (I don't recall the time, but it seemed like forever). After the betadine had set long enough, then the drugs could be pulled and injected into the dialysate. Then the dialysate could be punctured by the dialysis tubing (much like IV tubing, only larger). After the tubing had been primed (this means to get the dialysate in all the area's of the tubing with as little air bubbles as possible), the next step could occur.

• The next step was to prepare the site on the abdomen, where the PDT was in place. After the dressing had been removed, then the skin surrounding the PDT had to be cleansed with betadine and then the betadine had to be removed with alcohol. The cleansing is very similiar to subclavian IV site dressing changes and cleansing if any of you have ever witnessed this. One starts up against the tube and then make circles increasing in size towards the outer parts while changing out the betadine swab as one gets more towards the outer areas. This prevents the germs of the skin from the outer parts from creeping in to the tube area. This is repeated with the alcohol. After everything had dried, then the new dressing could be placed.

  If the baby or child is asleep during this, it makes it much easier, as the child will not try to touch the area's that need to be kept aseptic. If the child does touch the aseptic area's of their abdomen, or any of the tubing, then the contaminated parts have to be cleansed again, starting from scratch of whatever was contaminated

• Now the primed dialysate tubing can be connected to the PDT, after proper cleansing of the end of the PDT. This involves placing a little cover cap that has betadine inside of it over the end of the PTD for the required amount of time. We would place the betadine caps over the end of the PDT during the dressing change to save time. If everything has been done correctly without any touching of anything except for with the betadine, then the tubing can be attached to the PDT.

• Now the gloves and masks can be revoved, the doors can be opened, and the coverings to the vents can be removed. We all were pretty hot by this time and usually took a moment to cool ourselves off and get a drink before programming the peritoneal dialysis machine. But aseptic time was over, until the next day.