Tour of Automated Peritoneal Dialysis (APD) Machines

It was not too long ago that automated peritoneal dialysis (APD) was introduced as a home dialysis treatment option for people with chronic kidney disease (CKD). In 1970, the APD machine (also known as a cycler) was released to a select few CKD patients who could perform peritoneal dialysis (PD) using a machine at home. Peritoneal dialysis showed high demand in the 1980s and the APD machine allowed many PD patients to free themselves from performing manual PD exchanges during the day.

If you have considered peritoneal dialysis using a cycler but would like to know more about how it works, this tour may help you better understand so that you can talk with your doctor about this home dialysis treatment.

Automated peritoneal dialysis (APD) – how the machine works

Rather than performing manual peritoneal dialysis exchanges several times throughout the day, a patient can do automated peritoneal dialysis while they sleep. Automated peritoneal dialysis is done using a machine that fills your peritoneal cavity with fresh dialysis solution, also called PD fluid or PD solution, and after a specified dwell time, drains the solution with waste out of your body and then fills your peritoneal cavity with new dialysis solution. The average treatment time for automated peritoneal dialysis is 9 hours at night while you sleep, but your doctor will prescribe what is best for you.

APD equipment and supplies

Aside from the APD machine, there is required equipment and supplies that help you perform peritoneal dialysis treatments:

• Mask – You are required to wear a mask when you set up the APD machine and when you connect and disconnect from the dialysis machine. The mask should be over your mouth and nose. Wash your hands after you put your mask on so you do not contaminate your tube connections. Always wearing your mask correctly and washing your hands are important for success. This will limit the opportunities for bacteria to enter your body.
• Large bags of PD fluid (PD solution) – Each PD fluid bag is filled with about 6 liters of PD fluid. Two or three bags are generally used through the night. The PD fluid bags are hooked up to a cassette in front of the cycler machine, which has a tube that is connected to the person’s peritoneal catheter. The catheter leads into the abdomen (peritoneal cavity), and during each exchange some of the fluid will flow from the bags into the abdomen and then later be drained out of the body. The PD solution dwells inside the peritoneal cavity, collecting the wastes and extra fluid from the body which is then drained out after each cycle is completed.
•  Drain bag – The drain bag is one of two options used to remove the PD fluid from the peritoneal cavity. The drain bag is attached to a cassette that warms the fluid, sending it through tubes connected to the cassette into a person’s peritoneal cavity. The bag is clear so that the person may examine the waste and fluid that has been drained from the body. The used PD fluid should be clear, like urine. If it is cloudy, that can be an early sign of infection. Peritoneal dialysis patients who see this are recommended to call their PD nurse so they can receive treatment right away.
• Drain line – The second option for draining PD solution is a drain line. The drain line can be from 12 to 24 feet long in order to reach the bathroom for disposal in either the toilet, sink or shower area.
• Cassette and tubing – The various tubes used to perform APD are gathered into one area of the cycler that keeps everything organized called the cassette or organizer. There are tubes that lead from the cassette to each dialysis solution bag (there can be from one to four bags used for each treatment depending on the patient’s prescription). The PD catheter is attached to a tube on the cassette as well. There is another tube that attaches from the cassette to the drain bag or drain line.

  The APD machine is programmed to drain the solution through the PD catheter to the drain tube (or drain line). Once the draining is finished, new dialysis solution is released from a dialysis solution bag to the peritoneal catheter that leads to the peritoneal cavity where the solution will dwell for a certain time based on the patient's prescription. This process will repeat until the APD treatment is completed for the night.

• Documenting your APD treatment – Documenting your treatment is also important. This allows your doctor and nurse to see how you are doing at home and help adjust your treatment to be just right for you. There are different ways to do this depending on the dialysis system you use. Your training nurse will help you understand what needs to be documented.

Automated peritoneal dialysis (APD) machines on the market

The peritoneal dialysis machines have been designed to be user-friendly and generally use similar equipment and supplies to perform APD. Before you receive a cycler, you will go through peritoneal dialysis training with a PD nurse. Here is a description of two automated peritoneal dialysis cyclers.

1. Baxter’s HOMECHOICE™ Automated PD System -

   Like many household electronic equipment, the Baxter HOMECHOICE™ plugs into a regular electric outlet. The system will tell you on the display screen to “Press Go to Start.” Once you program your prescription numbers into the machine, the HOMECHOICE will remember the information for each time you use it. You may be prompted to type in your total fluid volume, therapy time and fill volume, among other things. A patient can have one to four bags of dialysis solution attached to the machine for the treatment in one night, depending on your prescription.

   Baxter’s HOMECHOICE is 20 inches long, 13 inches high and 24 inches wide. It weighs 25 pounds.

2. Fresenius Medical Care NA – Newton IQ cycler - The Fresenius Newton IQ™ is also plugged into an electrical outlet. The machine requires the patient or nurse to enter the patient’s entire prescription into the cycler for the first time. This machine remains programmed for future use, until the prescription is changed and needs to be re-entered. A patient may manually enter numbers such as number of fills, dwell time and drain time, among other information. After the numbers are entered, the Newton IQ will ask about other information, including if the PD solution bags need to be pre-warmed or if you would prefer the instructions in English, Spanish or French.

   Newton IQ sits 10 inches high and the machine is 22.5 inches long and 20 inches wide. This cycler also weighs 25 pounds.

Both the Baxter HOMECHOICE and Fresenius Newton IQ cyclers have colorful buttons next to a clear display screen that walks you through each step of preparation. Each machine comes with a booklet or handout to help guide you through set up in case there is something you are unfamiliar with on the display screen. It is recommended to call the manufacturer first, Baxter or Fresenius, in case of major machine issues. It is best to call the manufacturer when the problem occurs so that they can better assist you with trouble-shooting the problem. Both manufacturers have 24-hour per day hotlines to help assist you with any cycler problems. Your PD healthcare team is also on hand to help you with any questions.

Adjusting to the APD machine

Both APD machines are meant for nighttime use or during the day for people who work at night. While you are asleep, the cycler helps you dialyze safely and efficiently. It may take time to adjust to using the automated peritoneal dialysis machine.

• Noise – APD machines do not make much noise. If they do, it’s just a slight humming sound. You may be able to hear it while it is plugged in and turned on. Patients have said the noise is minimal and not disruptive to falling asleep.

• Alarms – Rarely do the alarms go off on the machine, but when they do, it is usually because you may be sleeping in a position that is blocking the flow of dialysate. Many times, shifting to a different position will alleviate this problem. The display screen indicates why the alarms are sounding so you can correct the matter, turn off the alarms and resume dialyzing.

• Emergencies – Emergencies can happen, which is why the APD machines are designed to alert you if there is a problem. For example, if the electricity were to go out, the cycler automatically goes into a shut down mode for up to two hours. If the electricity goes on before two hours are up, the cycler will continue to dialyze from where it left off. You will have been trained on how to do manual peritoneal dialysis exchanges in the event the electricity is off indefinitely or for an extended period. Emergency scenarios will be discussed with your PD nurse in your PD training sessions.

• Care partner optional – A person on automated peritoneal dialysis may opt to have a care partner, but it is not usually necessary. The cycler is simple enough to set up and use so that a PD patient does not need assistance from a care partner.

• Getting up during the night – If there is a need to get up in the middle of the night during APD, you can usually stay attached and dialyze, as the tube is relatively long. You can also detach from the cycler and when you come back the APD machine will remember where you left off. Your PD training nurse will give you instruction on how to perform this procedure safely.

APD patient benefits

Many patients appreciate that using the automated peritoneal dialysis machine during the night helps free up their day. The APD cycler option has given many patients the ability to travel, since it is portable. Many people are able to work outside their home without having to perform manual peritoneal dialysis several times a day, although it is possible to do manual peritoneal exchanges at work. Some patients performing automated peritoneal dialysis also report feeling better and get better results on their lab tests.

Summary

You have a choice when it comes to home dialysis and it is good to explore your options. Talk to your doctor if you are interested in learning more about automated peritoneal dialysis or other home dialysis treatments.