Peritoneal dialysis (PD) is a type of dialysis that uses the

peritoneum The peritoneum is the serous membrane forming the lining of the abdominal cavity or coelom in amniotes and some invertebrates, such as annelids. It covers most of the intra-abdominal (or coelomic) organs, and is composed of a layer of mesotheli ...

in a person's

abdomen The abdomen (colloquially called the gut, belly, tummy, midriff, tucky, or stomach) is the front part of the torso between the thorax (chest) and pelvis in humans and in other vertebrates. The area occupied by the abdomen is called the abdominal ...

as the membrane through which fluid and dissolved substances are exchanged with the

blood Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood is com ...

. It is used to remove excess fluid, correct electrolyte problems, and remove toxins in those with

kidney failure Kidney failure, also known as renal failure or end-stage renal disease (ESRD), is a medical condition in which the kidneys can no longer adequately filter waste products from the blood, functioning at less than 15% of normal levels. Kidney fa ...

. Peritoneal dialysis has better outcomes than

hemodialysis Hemodialysis, American and British English spelling differences#ae and oe, also spelled haemodialysis, or simply ''"'dialysis'"'', is a process of filtering the blood of a person whose kidneys are not working normally. This type of Kidney dialys ...

during the first two years. Other benefits include greater flexibility and better tolerability in those with significant

heart disease Cardiovascular disease (CVD) is any disease involving the heart or blood vessels. CVDs constitute a class of diseases that includes: coronary artery diseases (e.g. angina pectoris, angina, myocardial infarction, heart attack), heart failure, ...

Side effects

Complications may include infections within the abdomen,

hernia A hernia (: hernias or herniae, from Latin, meaning 'rupture') is the abnormal exit of tissue or an organ (anatomy), organ, such as the bowel, through the wall of the cavity in which it normally resides. The term is also used for the normal Devel ...

s, high blood sugar, bleeding in the abdomen, and blockage of the catheter. Peritoneal dialysis is not possible in those with significant prior

abdominal surgery The term abdominal surgery broadly covers surgical procedures that involve opening the abdomen (laparotomy). Surgery of each abdominal organ is dealt with separately in connection with the description of that organ (see stomach, kidney, liver, e ...

inflammatory bowel disease Inflammatory bowel disease (IBD) is a group of inflammatory conditions of the colon and small intestine, with Crohn's disease and ulcerative colitis (UC) being the principal types. Crohn's disease affects the small intestine and large intestine ...

. It requires some degree of technical skill to be done properly.

Mechanism

In peritoneal dialysis, a specific solution is introduced and then removed through a permanent tube in the lower abdomen. This may occur either at regular intervals throughout the day known as continuous ambulatory peritoneal dialysis (CAPD), or at night with the assistance of a machine known as automated peritoneal dialysis (APD), or continuous cycling peritoneal dialysis (CCPD). The solution is typically made of

sodium chloride Sodium chloride , commonly known as Salt#Edible salt, edible salt, is an ionic compound with the chemical formula NaCl, representing a 1:1 ratio of sodium and chloride ions. It is transparent or translucent, brittle, hygroscopic, and occurs a ...

bicarbonate In inorganic chemistry, bicarbonate (IUPAC-recommended nomenclature: hydrogencarbonate) is an intermediate form in the deprotonation of carbonic acid. It is a polyatomic anion with the chemical formula . Bicarbonate serves a crucial bioche ...

, and an osmotic agent.

Glucose Glucose is a sugar with the Chemical formula#Molecular formula, molecular formula , which is often abbreviated as Glc. It is overall the most abundant monosaccharide, a subcategory of carbohydrates. It is mainly made by plants and most algae d ...

is the most commonly used osmotic agent and different concentrations of glucose in the dialysis fluid affect the

ultrafiltration Ultrafiltration (UF) is a variety of membrane filtration in which forces such as pressure or concentration gradients lead to a separation through a semipermeable membrane. Suspended solids and solutes of high molecular weight are retained in t ...

. Icodextrin is a high molecular weight glucose polymer developed as an alternative osmotic agent with slower absorption from the peritoneal cavity, facilitating better ultrafiltration. It is recommended for long dwells in patients with difficulties achieving or maintaining euvolemia.

History and culture

The solution used for peritoneal dialysis is on the

World Health Organization's List of Essential Medicines The WHO Model List of Essential Medicines (aka Essential Medicines List or EML), published by the World Health Organization (WHO), contains the medications considered to be most effective and safe to meet the most important needs in a health s ...

. As of 2009, peritoneal dialysis was available in 12 of 53 African countries.

Medical uses

Peritoneal dialysis is a method of

renal replacement therapy Renal replacement therapy (RRT) is therapy that replaces the normal blood-filtering function of the kidneys. It is used when the kidneys are not working well, which is called kidney failure and includes acute kidney injury and chronic kidney dis ...

for those needing maintenance therapy for late stage

chronic kidney disease Chronic kidney disease (CKD) is a type of long-term kidney disease, defined by the sustained presence of abnormal kidney function and/or abnormal kidney structure. To meet criteria for CKD, the abnormalities must be present for at least three mo ...

and is an alternative to the most common method

Complications

PD-related peritonitis

A common cause of

peritonitis Peritonitis is inflammation of the localized or generalized peritoneum, the lining of the inner wall of the abdomen and covering of the abdominal organs. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. One pa ...

is touch contamination, e.g. insertion of catheter by un-sanitized hands, which potentially introduces bacteria to the abdomen; other causes include catheter complication, transplantation of bowel bacteria, and systemic infections. Most common type of PD-peritonitis infection (80%) are from bacterial sources. Infection rates are highly variable by region and within centers with estimated rates between 0.06–1.66 episodes per patient year. With recent technical advances peritonitis incidence has decreased over time. Antibiotics are needed if the source of infection is bacterial; there is no clear advantage for other frequently used treatments such as routine peritoneal lavage or use of

urokinase Urokinase, also known as urokinase-type plasminogen activator (uPA), is a serine protease present in humans and other animals. The human urokinase protein was discovered, but not named, by McFarlane and Pilling in 1947. Urokinase was originally ...

. The use of preventative nasal mupirocin is of unclear effect with respect to peritonitis. Of the three types of connection and fluid exchange systems (standard, twin-bag and y-set; the latter two involving two bags and only one connection to the catheter, the y-set uses a single y-shaped connection between the bags involving emptying, flushing out then filling the peritoneum through the same connection) the twin-bag and y-set systems were found superior to conventional systems at preventing peritonitis. The fluid used for dialysis uses

glucose Glucose is a sugar with the Chemical formula#Molecular formula, molecular formula , which is often abbreviated as Glc. It is overall the most abundant monosaccharide, a subcategory of carbohydrates. It is mainly made by plants and most algae d ...

as a primary osmotic agent. According to a 2020 review published in the ''American Journal of Nephrology'', some studies suggest that the use of glucose increases the risk of

, possibly as a result of impaired host defenses, vascular disease, or damage to the peritoneal membrane. The

acid An acid is a molecule or ion capable of either donating a proton (i.e. Hydron, hydrogen cation, H+), known as a Brønsted–Lowry acid–base theory, Brønsted–Lowry acid, or forming a covalent bond with an electron pair, known as a Lewis ...

ity, high concentration and presence of lactate and products of the degradation of glucose in the solution (particularly the latter) may contribute to these health issues. Solutions that are neutral, use

instead of lactate and have few glucose degradation products may offer more health benefits though this has not yet been studied. The mortality rate of peritoneal dialysis related peritonitis is estimated to be 3-10%, with approximately 50% of cases resulting in hospitalization. Peritoneal fluid studies with a white blood cell count greater than 100 per μL and greater than 50% neutrophils strongly suggest peritonitis, with a definitive diagnosis based on culture of microorganisms from the peritoneal fluid. In order to avoid delaying treatment, a cloudy fluid in the dialysate fluid can be assumed to be due to peritonitis unless an alternative cause is identified. Peritonitis in those undergoing PD is usually due to gram positive bacteria. Intraperitoneal antibiotics are preferred to

intravenous Intravenous therapy (abbreviated as IV therapy) is a medical technique that administers fluids, medications and nutrients directly into a person's vein. The intravenous route of administration is commonly used for rehydration or to provide nutr ...

as they have a greater effect at the area of infection, unless

sepsis Sepsis is a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage of sepsis is followed by suppression of the immune system. Common signs and s ...

is present, in which case intravenous antibiotics are indicated. The peritoneal dialysis catheter may have to be removed if the infection does not resolve with antibiotics, and it is recommended that the PD catheter be removed in all cases of fungal peritonitis.

Volume shifts

The volume of dialysate removed as well as patient's weight are monitored. If more than 500ml of fluid are retained or a liter of fluid is lost across three consecutive treatments, the patient's physician is generally notified. Excessive loss of fluid can result in

hypovolemic shock Hypovolemic shock is a form of Shock (circulatory), shock caused by severe hypovolemia (insufficient blood volume or extracellular fluid in the body). It can be caused by severe dehydration or blood loss. Hypovolemic shock is a medical emergency ...

hypotension Hypotension, also known as low blood pressure, is a cardiovascular condition characterized by abnormally reduced blood pressure. Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps out blood and is ...

while excessive fluid retention can result in

hypertension Hypertension, also known as high blood pressure, is a Chronic condition, long-term Disease, medical condition in which the blood pressure in the artery, arteries is persistently elevated. High blood pressure usually does not cause symptoms i ...

and

edema Edema (American English), also spelled oedema (British English), and also known as fluid retention, swelling, dropsy and hydropsy, is the build-up of fluid in the body's tissue (biology), tissue. Most commonly, the legs or arms are affected. S ...

. Also monitored is the color of the fluid removed: normally it is pink-tinged for the initial four cycles and clear or pale yellow afterward. The presence of pink or bloody effluent suggests bleeding inside the abdomen while feces indicates a perforated bowel and cloudy fluid suggests infection. The patient may also experience pain or discomfort if the dialysate is too acidic, too cold or introduced too quickly, while diffuse pain with cloudy discharge may indicate an infection. Severe pain in the

rectum The rectum (: rectums or recta) is the final straight portion of the large intestine in humans and some other mammals, and the gut in others. Before expulsion through the anus or cloaca, the rectum stores the feces temporarily. The adult ...

perineum The perineum (: perineums or perinea) in placentalia, placental mammals is the space between the anus and the genitals. The human perineum is between the anus and scrotum in the male or between the anus and vulva in the female. The perineum is ...

can be the result of an improperly placed catheter. The dwell can also increase pressure on the diaphragm causing impaired breathing, and

constipation Constipation is a bowel dysfunction that makes bowel movements infrequent or hard to pass. The Human feces, stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the ...

can interfere with the ability of fluid to flow through the catheter.

Chronic complications

Long term use of PD is rarely associated with fibrosis of the peritoneum. A potentially fatal complication estimated to occur in roughly 2.5% of patients is encapsulating peritoneal sclerosis, in which the bowels become obstructed due to the growth of a thick layer of

fibrin Fibrin (also called Factor Ia) is a fibrous protein, fibrous, non-globular protein involved in the Coagulation, clotting of blood. It is formed by the action of the protease thrombin on fibrinogen, which causes it to polymerization, polymerize. ...

within the peritoneum.

Other

Other complications include

low back pain Low back pain or wiktionary:lumbago#Etymology, lumbago is a common musculoskeletal disorders, disorder involving the muscles, nerves, and bones of the back, in between the lower edge of the ribs and the lower fold of the buttocks. Pain can var ...

and

or leaking fluid due to high pressure within the abdomen.

Hypertriglyceridemia Hypertriglyceridemia is the presence of high amounts of triglycerides in the blood. Triglycerides are the most abundant fatty molecule in most organisms. Hypertriglyceridemia occurs in various physiologic conditions and in various diseases, and ...

and

obesity Obesity is a medical condition, considered by multiple organizations to be a disease, in which excess Adipose tissue, body fat has accumulated to such an extent that it can potentially have negative effects on health. People are classifi ...

are also concerns due to the large volume of glucose in the fluid, which can add 5001,200

calorie The calorie is a unit of energy that originated from the caloric theory of heat. The large calorie, food calorie, dietary calorie, kilocalorie, or kilogram calorie is defined as the amount of heat needed to raise the temperature of one liter o ...

s to the diet per day.

Method

Best practices for peritoneal dialysis state that before peritoneal dialysis should be implemented, the person's understanding of the process and support systems should be assessed, with education on how to care for the catheter and to address any gaps in understanding that may exist. The person should receive ongoing monitoring to ensure adequate dialysis, and be regularly assessed for complications. Finally, they should be educated on the importance of infection control and an appropriate medical regimen established with their cooperation. File:DP branchement.svg, Hookup File:DP infusion.svg, Infusion File:DP stase.svg, Diffusion (fresh) File:DP fin stase.svg, Diffusion (waste) File:DP drainage.svg, Drainage Blausen 0160 CAPD

The abdomen is cleaned in preparation for surgery and a

catheter In medicine, a catheter ( ) is a thin tubing (material), tube made from medical grade materials serving a broad range of functions. Catheters are medical devices that can be inserted in the body to treat diseases or perform a surgical procedure. ...

is surgically inserted with one end in the abdomen and the other protruding from the skin. Catheters can also be inserted without a general anaesthetic by a physician using a needle, known as a medical insertion. Both methods have similar safety profiles. Before each infusion the catheter must be cleaned, and flow into and out of the abdomen tested. 2-3 liters of dialysis fluid is introduced into the abdomen over the next ten to fifteen minutes. The total volume is referred to as a ''dwell'' while the fluid itself is referred to as dialysate. The dwell can be as much as 3 liters, and medication can also be added to the fluid immediately before infusion. The dwell remains in the abdomen and waste products diffuse across the peritoneum from the underlying blood vessels. After a variable period of time depending on the treatment (usually 4–6 hours ), the fluid is removed and replaced with fresh fluid. This can occur automatically while the patient is sleeping (automated peritoneal dialysis, APD), or during the day by keeping two litres of fluid in the abdomen at all times, exchanging the fluids four to six times per day (continuous ambulatory peritoneal dialysis, CAPD). The fluid used typically contains

, lactate or

and a high percentage of

to ensure hyperosmolarity. The amount of dialysis that occurs depends on the volume of the dwell, the regularity of the exchange and the concentration of the fluid. APD cycles between 3 and 10 dwells per night, while CAPD involves four dwells per day of 2-3 liters per dwell, with each remaining in the abdomen for 4–8 hours. The viscera accounts for roughly four-fifths of the total surface area of the membrane, but the parietal peritoneum is the most important of the two portions for PD. Two complementary models explain dialysis across the membrane — the three-pore model (in which molecules are exchanged across membranes which sieve molecules, either

protein Proteins are large biomolecules and macromolecules that comprise one or more long chains of amino acid residue (biochemistry), residues. Proteins perform a vast array of functions within organisms, including Enzyme catalysis, catalysing metab ...

s, electrolytes or water, based on the size of the pores) and the distributed model (which emphasizes the role of

capillaries A capillary is a small blood vessel, from 5 to 10 micrometres in diameter, and is part of the microcirculation system. Capillaries are microvessels and the smallest blood vessels in the body. They are composed of only the tunica intima (the in ...

and the solution's ability to increase the number of active capillaries involved in PD). The high concentration of glucose drives the filtration of fluid by osmosis (osmotic UF) from the peritoneal capillaries to the peritoneal cavity. Glucose diffuses rather rapidly from the dialysate to the blood (capillaries). After 4-6 h of the dwell, the glucose osmotic gradient usually becomes too low to allow for further osmotic UF. Therefore, the dialysate will now be reabsorbed from the peritoneal cavity to the capillaries by means of the plasma colloid osmotic pressure, which exceeds the colloid osmotic pressure in the peritoneum by approximately 18-20 mmHg (cf. the Starling mechanism). Lymphatic absorption will also to some extent contribute to the reabsorption of fluid from the peritoneal cavity to the plasma. Patients with a high water permeability (UF-coefficient) of the peritoneal membrane can have an increased reabsorption rate of fluid from the peritoneum by the end of the dwell. The ability to exchange small solutes and fluid in-between the peritoneum and the plasma can be classified as high (fast), low (slow) or intermediate. High transporters tend to diffuse substances well (easily exchanging small molecules between blood and the dialysis fluid, with somewhat improved results with frequent, short-duration dwells such as with APD), while low transporters have a higher UF (due to the slower reabsorption of glucose from the peritoneal cavity, which results in somewhat better results with long-term, high-volume dwells), though in practice either type of transporter can generally be managed through the appropriate use of either APD or CAPD. Though there are several different shapes and sizes of catheters that can be used, different insertion sites, number of cuffs in the catheter and immobilization, there is no evidence to show any advantages in terms of morbidity, mortality or number of infections, though the quality of information is not yet sufficient to allow for firm conclusions. A peritoneal equilibration test may be done to assess a person for peritoneal dialysis by determining the characteristics of the peritoneal membrane mass transport characteristics.

Improvised dialysis

Peritoneal dialysis can be improvised in conditions such as combat surgery or disaster relief using surgical catheters and dialysate made from routinely available medical solutions to provide temporary renal replacement for people with no other options.

Epidemiology

As of 2017, hemodialysis is the most widely available renal replacement modality found in 96% of countries whereas peritoneal dialysis (PD) is only available in 75% of countries. In 2016, the proportion of people receiving peritoneal dialysis (PD) was estimated at 11% with wide differences between different countries and regions. In Hong Kong and

Mexico Mexico, officially the United Mexican States, is a country in North America. It is the northernmost country in Latin America, and borders the United States to the north, and Guatemala and Belize to the southeast; while having maritime boundar ...

, PD is more common than the world average, with Mexico conducting most of its dialysis through PD, while

Japan Japan is an island country in East Asia. Located in the Pacific Ocean off the northeast coast of the Asia, Asian mainland, it is bordered on the west by the Sea of Japan and extends from the Sea of Okhotsk in the north to the East China Sea ...

and

Germany Germany, officially the Federal Republic of Germany, is a country in Central Europe. It lies between the Baltic Sea and the North Sea to the north and the Alps to the south. Its sixteen States of Germany, constituent states have a total popu ...

have rates lower than the world average. Peritoneal dialysis first models, patients requiring renal replacement therapy are placed on PD first, and financial incentives for using PD are associated with increase uptake of PD in multiple countries.

East and Southeast Asia

Hong Kong has the highest rate of PD use worldwide at 71.9% in 2014, while in Mainland China had 20% in 2014, 23% in Thailand during 2012, and 10-20% in Vietnam during 2011. Hong Kong had a PD-first model since 1985, Thailand began a PD-first model since 2008 which increased their levels of PD from <10%.

Americas

The prevalence of PD in 2013 was 9.7% in the United States and 16.3% in Canada. The lower PD rates in the US are due to the higher availability of large corporate-owned hemodialysis centers. There have been recent increases in PD uptake in the US due to changes to Medicare reimbursement, such as

bundled payment Bundled payment is the reimbursement of health care providers (such as hospitals and physicians) "on the basis of expected costs for defined episodes of care." It has been described as "a middle ground" between fee-for-service reimbursement (in whi ...

s for dialysis; this incentivizes the use of PD, which is a less-costly modality for dialysis. Overall, prevalence of PD use was 24.6% in Latin America during 2011. Within Latin America, hemodialysis has a higher growth rate in use compared to PD from 1994 to 2010. In 2010, the most prevalent use of PD was in Mexico (55.9%) and El Salvador (67.6%). Between 2000–2010, Colombia's PD rate dropped from 54% to 31.3%.

History

Peritoneal dialysis was first carried out in the 1920s; however, long-term use did not come into medical practice until the 1960s. The timeline was * 1923 – Georg Ganter performs the first peritoneal dialysis in a

guinea pig The guinea pig or domestic guinea pig (''Cavia porcellus''), also known as the cavy or domestic cavy ( ), is a species of rodent belonging to the genus ''Cavia'', family Caviidae. Animal fancy, Breeders tend to use the name "cavy" for the ani ...

and attempts the procedure in humans, without success. Hypertonic saline was used as the dialysate. * 1927 – Heinrich Heusser and Hermann Werder were the first to treat 3 patients with continuous flow PD using two catheters. They demonstrated a decrease in the levels of blood urea, but did not succeed clinically. * 1946 – Howard Frank, Arnold Seligman, and Jacob Fine of Beth Israel Hospital in

Boston Boston is the capital and most populous city in the Commonwealth (U.S. state), Commonwealth of Massachusetts in the United States. The city serves as the cultural and Financial centre, financial center of New England, a region of the Northeas ...

report the first successful use of peritoneal dialysis in clinical practice, in a 51-year-old man with acute renal failure caused by sulfathiazole poisoning. * 1959 – Paul Doolan and Richard Ruben of

Naval Hospital Oakland Naval Hospital Oakland, also known as Oak Knoll Naval Hospital, was a United States Navy, U.S. naval hospital located in Oakland, California that opened during World War II (1942) and closed in 1996 as part of the 1993 Base Realignment and Closur ...

first use peritoneal dialysis to treat end-stage renal disease, in a 33-year-old woman named Willie Mae Stewart. After 6 months of intermittent dialysis, she declines further treatment due to complications and dies in June 1960. * 1964–1965 – Henry Tenckhoff, G. Shilipetar and Fred Boen of the

University of Washington The University of Washington (UW and informally U-Dub or U Dub) is a public research university in Seattle, Washington, United States. Founded in 1861, the University of Washington is one of the oldest universities on the West Coast of the Uni ...

report the first case of home peritoneal dialysis, with long-term success despite technical difficulties and a burdensome process. * 1968 – Henry Tenckhoff creates the Tenckhoff catheter, avoiding the need to replace the catheter in the abdomen at every treatment.

Comparison to hemodialysis

Compared to hemodialysis, peritoneal dialysis (PD) has several potential advantages: it allows greater lifestyle flexibility for patients, may preserve residual kidney function to a greater extent, and produces fewer changes in blood pressure due to the continuous nature of fluid removal, thus making it more suitable for patients with cardiorenal syndrome or cardiac instability. Also,

phosphate Phosphates are the naturally occurring form of the element phosphorus. In chemistry, a phosphate is an anion, salt, functional group or ester derived from a phosphoric acid. It most commonly means orthophosphate, a derivative of orthop ...

compounds are better removed on PD, but large amounts of

albumin Albumin is a family of globular proteins, the most common of which are the serum albumins. All of the proteins of the albumin family are water- soluble, moderately soluble in concentrated salt solutions, and experience heat denaturation. Alb ...

are removed which requires constant monitoring of nutritional status. PD also has potential disadvantages, including a higher risk of

dyslipidemia Dyslipidemia is a metabolic disorder characterized by abnormally high or low amounts of any or all lipids (e.g. fats, triglycerides, cholesterol, phospholipids) or lipoproteins in the blood. Dyslipidemia is a risk factor for the development of ...

, a tendency to exacerbate

hyperglycemia Hyperglycemia is a condition where unusually high amount of glucose is present in blood. It is defined as blood glucose level exceeding 6.9 mmol/L (125 mg/dL) after fasting for 8 hours or 10 mmol/L (180 mg/dL) 2 hours after eating. Blood gluc ...

(due to the exogenous glucose load) and additional responsibilities for patients and families. The costs of PD are generally lower than those of HD in most parts of the world; this cost advantage is most apparent in high-income countries. There is insufficient research to adequately compare the risks and benefits between CAPD and APD; a

Cochrane Review Cochrane is a British international charitable organisation formed to synthesize medical research findings to facilitate evidence-based choices about health interventions involving health professionals, patients and policy makers. It includes ...

of three small

clinical trial Clinical trials are prospective biomedical or behavioral research studies on human subject research, human participants designed to answer specific questions about biomedical or behavioral interventions, including new treatments (such as novel v ...

s found no difference in clinically important outcomes (i.e.

morbidity A disease is a particular abnormal condition that adversely affects the structure or function of all or part of an organism and is not immediately due to any external injury. Diseases are often known to be medical conditions that are asso ...

or mortality) for patients with end stage renal disease, nor was there any advantage in preserving the functionality of the kidneys. The results suggested APD may have psychosocial advantages for younger patients and those who are employed or pursuing an education.

Society and culture

Economics

The cost of dialysis treatment is related to how wealthy the country is. In the United States peritoneal dialysis costs the government about $53,400 per person per year.

References

External links

* {{DEFAULTSORT:Peritoneal Dialysis Digestive system procedures Medical treatments Renal dialysis World Health Organization essential medicines Wikipedia medicine articles ready to translate de:Dialyse#Peritonealdialyse