Home Dialysis Therapies: Peritoneal Dialysis and Home HemoDialysis

The home dialysis therapies rotation combines exposure to peritoneal dialysis and home hemodialysis. The Peritoneal Dialysis Clinic follows approximately 300 peritoneal dialysis (PD) patients with more than 1000 clinic visits per year. This unit incorporates the use of CAPD and CCPD. The home hemodialysis unit currently follows approximately 100 patients.

The home therapies experience will include:

  1. Peritoneal dialysis
    During each month-long home therapies rotation, the nephrology resident will see all patients in the PD clinics held 3-4 half days a week (Monday, Wednesday, and Thursdays either morning or afternoon) with the staff nephrologist assigned to the PD unit for the month. They will see all new patients starting PD during the month and together with the staff be responsible for their management, including writing the initial PD prescription. The trainee will attend the unit daily to review all patient blood work and problem solve with the peritoneal dialysis nursing staff in consultation with the staff nephrologist.
  2. Home hemodialysis
    The trainee will attend a weekly half-day clinic in the home hemodialysis unit during the rotation. The resident will review all patients attending clinic, including new assessments and prevalent patients requiring follow up. The trainee will be available to address patient issues raised by the unit RNs during the week.

The trainee will also obtain experience in peritoneal dialysis and extended hours hemodialysis via patient encounters on inpatient services and lectures scheduled during the core lecture series.


Upon completion of this rotation:

  1. The resident will have an understanding of the evaluation and selection of patients for peritoneal dialysis.
  2. The resident will demonstrate knowledge of the principles of peritoneal dialysis:
    • understand the principles of ultrafiltration, diffusion, and convective solute transport
    • understand peritoneal membrane physiology, including the relationship to dextrose concentration, dwell time, and clinical outcomes
    • describe how the peritoneal equilibration test is performed and how the results are applied to the clinical situation to assist in the choice of modality and dialysis prescription
  3. The resident will understand concepts of adequacy of peritoneal dialysis including:
    • the importance of residual renal function and management strategies to maintain residual renal function
    • the importance and clinical assessment of volume control and its management
    • the importance and clinical assessment of nutritional status and its management
    • the measurement of dialysis adequacy, including Kt/V and creatinine clearance
    • current guidelines for adequate dialysis
  4. The resident will demonstrate knowledge of the mechanical aspects of peritoneal dialysis:
    • describe the indications, technique, limitations, and prescriptions for the peritoneal dialysis options (CAPD and CCPD )
    • describe how the various procedures available are performed and taught to the patient
    • prescribe the appropriate dialysis (number of exchanges, volume/exchange, length of dwell time, dialysis dextrose and calcium concentration) for each clinical situation.
    • discuss the constituents of commercial dialysis solutions and the effects (short and long-term) on peritoneal membrane function
  5. The resident will demonstrate knowledge of the peritoneal dialysis catheter
    • describe the different types of dialysis catheters available and the standard insertion techniques - the resident is not required to demonstrate proficiency in the actual insertion of the catheters
    • manage patients with a newly placed catheter, including the options of delay of dialysis, low volumes, cycler dialysis, or temporary hemodialysis
    • describe the indications for catheter removal
  6. The resident will be able to describe the pathophysiology and management of the following complications of peritoneal dialysis:
    • exit site and tunnel infections
    • peritonitis
    • leaks
    • hernias
    • inadequate drain
    • ultrafiltration failure
    • sclerosing peritonitis
    • altered bowel function
    • obesity and cachexia
  7. The resident will be able to describe the pathophysiology and management of long-term complications of peritoneal dialysis including: renal osteodystrophy, hypertension, lipid abnormalities, anemia, cardiac dysfunction and hypercalcemia
  8. The resident will know the outcome of peritoneal dialysis, including the rates of mortality and technique failure
  9. The resident will understand the management of diabetic patients on peritoneal dialysis, including insulin management
  10. Describe the indications, potential benefits and associated risks and prescription of extended hours/home hemodialysis
  11. Understand costs associated with the different dialysis modalities
  12. The resident will understand the impact of home dialysis therapies upon the individual and their family and be able to determine the functional status of the patient with respect to the capability of performing home therapies. They should be able to discuss social, ethical, and legal issues around the appropriate initiation and withdrawal of home therapies
  13. Demonstrate knowledge of the criteria for transplant candidacy and where appropriate address referral status
  14. To promote recognition of the broader determinants of health, including an appreciation for the importance of social and physical environment
  15. Demonstrate an approach to issues around barriers to adherence to dialysis, medications, and diet
  16. Demonstrate clear communication with patient and family and provide appropriate education regarding issues identified and treatment plans
  17. Document and notify nursing regarding changes to dialysis prescription and medications
  18. Communicate with family physicians and other specialists through up-to-date case summaries
  19. To promote understanding of the role played by families, volunteers, other health professionals, and other support services in outpatient peritoneal dialysis and home hemodialysis care
  20. Achieve effective treatment appreciating the infrastructure of local nurses physicians and available community resources
  21. To work effectively as a member of the outpatient multi-disciplinary team, providing leadership where appropriate
  22. Consult where appropriate regarding non-dialysis related issues
  23. To improve awareness of health economic issues in ambulatory care:
    • application of evaluative science to diagnostic and treatment modalities
    • cost benefit analysis of treatment in the ambulatory vs. hospital setting
    • decision making re: optimal venues for care
  24. To acquaint residents with the types of investigational and interventional procedures which can appropriately be carried out in ambulatory care settings
  25. Manage time effectively: provide regular telephone rounds with dialysis staff and address nursing and patient concerns
  26. Coordinate continuity clinic (general nephrology/transplant) schedule with home therapy clinic schedule in advance of rotation
  27. Complete the peritoneal dialysis workbook during the 4-week rotation, demonstrating an understanding of the core literature provided
  28. Demonstrate an understanding of current literature where relevant to the medical expert objectives outlined above
  29. Address any concerns from nursing and allied health that may occur in-between regularly scheduled rounds
  30. Conducts outpatient clinic patient encounters in an empathetic and courteous manner
  31. Timely review of any concerns with the attending nephrologist
  32. Complete case summaries within a week of clinic date to ensure timely correspondence with family practitioner