Haemodialysis vs Peritoneal Dialysis

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Renal replacement therapy (RRT) refers to life-supporting treatments for severe acute kidney injury (AKI) or end-stage kidney disease.1Β Types of RRT include haemodialysis, peritoneal dialysis, hemofiltration, haemodiafiltration, and kidney transplant.

This article will cover the similarities and differences between haemodialysis (HD) and peritoneal dialysis (PD). Further information on each can be found in their individual articles.

It should be noted that they are not the only types of RRT. For more details, refer to our articles on chronic kidney disease (CKD) and renal transplantation.

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Indications for RRT

Acute RRT

Important indications can be remembered using the mnemonic AEIOU:2,3,4

Chronic RRT

NICE recommends the initiation of chronic RRT when there is the presence of:1

  • Symptomatic uraemia (pericarditis/encephalopathy)
  • Biochemical measures (electrolyte or acid-base disturbances that are refractory to medical therapy) or uncontrollable fluid overload
  • Asymptomatic with an eGFR of 5-7 ml/min/1.73m2

Other indications outlined by Kidney Disease Improving Global Outcomes (KDIGO) include:4

  • Anorexia
  • Reduced energy level
  • Weight loss with no other potential explanation
  • Progressive deterioration in nutritional status that is refractory to interventions

Choice of dialysis modalities

All patients who are likely to require RRT should be offered a choice of RRT or conservative management (which involves supportive management and controlling symptoms but without RRT).1,4

NICE does not provide a straightforward recommendation in the initial choice of dialysis modality, apart from recommending PD as the first choice in patients two years or younger.1

The selection of dialysis modality should reflect shared decision-making between the clinician and patient after all available options are presented and explained to them.



In HD, access refers to a connection between the patient’s circulatory system and the dialysis machine. The two broad options for access are:

  • Arteriovenous (AV) access: most commonly through the formation of an AV fistula4,5Β 
  • Central venous catheter (CVC) access: generally either through a temporary dialysis catheter or a tunnelled haemodialysis catheter5,6Β 

AV access

The most common form of AV access is an AV fistula:4,5Β 

  • An artery is directly connected to a vein
  • Takes six to eight weeks to mature
  • Common fistula sites are radio-cephalic, brachio-cephalic and brachio-basilic
  • Precautions must be taken to prevent damage to the fistula: venepuncture, intravenous cannulation, and blood pressure measurement at the site of the fistula should be avoided
  • The preferred option if life expectancy is more than 1 year

CVC access

Temporary dialysis catheters:5,6Β 

  • Allow immediate use when emergency dialysis is needed in AKI
  • Common sites of insertion are the internal jugular, subclavian and femoral veins
  • High risk of infection, so should only be in situ for two weeks

Tunnelled haemodialysis catheters:5,6

  • Involve subcutaneous tunnelling of a large, double-lumen venous catheter inserted into a central vein
  • Often used while waiting for an AV fistula to mature
  • Lower risk of infection compared to temporary catheters
  • The preferred option if life expectancy is less than 1 year


The most common regimen for patients receiving HD is three sessions per week, for 12 hours total (i.e. fourΒ hours per session).7

The HD circuit consists of:5

  • A pump that removes blood from the patient
  • Anticoagulation of the blood with heparin
  • Pumping blood through the dialyser, where filtration takes placeΒ 
  • Dialysate: a solution of water, electrolytes, dextrose and a buffer
  • Filtered blood is returned to the patient, and dialysate discarded

Filtration occurs via passive diffusion across a semi-permeable membrane. The dialysate is continuously replaced to maintain the concentration gradient.

Blood cells and proteins are not lost; only water and low-molecular-weight solutes can pass through the membrane. However, this means it is not as efficient at removing larger solutes.

Haemodialysis vs haemofiltration

Haemofiltration is similar to standard HD, but it removes solutes via convection. This means that large molecules can be removed efficiently and it is preferred in critical care settings.5


The only absolute contraindications to long-term HD are:4

  • Absence of AV access
  • Haemodynamic instability


Complications of HD can be divided into intra-dialysis complications and long-term complications. A more comprehensive discussion of the complications can be found in the HD article.

Intra-dialysis complications8-10

  • Dialysis disequilibrium syndrome: acute cerebral oedema secondary to the rapid shifting of urea from the blood
  • Dialyser reactions: reaction between blood components and the semi-permeable membrane of the dialysis machine, may present with anaphylaxis-like symptoms
  • Acute intravascular haemolysis: can be from reactions to contaminants in the dialysate or from mechanical forces
  • Air embolism
  • Haemorrhage: from vascular access
  • Hypotension
  • Non-specific symptoms: headache, back pain, pruritis and muscle cramps are common11

Long-term complications8-10Β 

  • Cardiovascular disease (the leading cause of death)5,12-14
  • Bleeding: due to platelet dysfunction resulting from CKD and/or platelet contact with the dialysis membrane
  • Electrolyte disturbances: commonly hyperkalaemia, hyponatraemia, hypocalcaemia and hyperphosphataemia
  • Mineral bone disorders: associated with CKD
  • Loss of venous access: due to thrombosisΒ 
  • Catheter-related bacteraemia
  • Dialysis access-associated steal syndrome: limb ischaemia due to AV access shunting blood away from the limb

Peritoneal dialysis


In PD, access involves the placement of a catheter into the peritoneal cavity to allow the flow of dialysate solution.

The most commonly used catheter is the Tenckhoff catheterΒ and this can be implanted surgically (open or laparoscopic) or via a percutaneous procedure.15, 16,17

It is recommended to create access around two weeks before starting dialysis to prevent leakage.1Β 


The two most common regimes for PD patients are:

  • Continuous ambulatory peritoneal dialysis (CAPD)
  • Automated peritoneal dialysis (APD)

Both can be carried out at home, and patients require PD daily. Patients cannot remain on PD indefinitely and will usually need to change to HD at some point unless they receive a kidney transplant.18

In PD the patient’s peritoneal membrane acts as the interface between the blood and dialysate. It acts as a semi-permeable membrane which solutes can diffuse across down their concentration gradients. Excess water is also removed from the blood through the creation of a net positive osmotic gradient.


  • Dialysate is infused into the peritoneal cavity
  • The patient is disconnected from the system and can carry out normal activities
  • Dialysate remains in the peritoneal cavity for four to six hours and filtration occurs
  • The patient is reconnected to the system to drain the used dialysate
  • This is repeated around four times a day


  • Dialysate is infused into the peritoneal cavity via a dialysis machine
  • The patient remains connected to the machine, often while sleeping
  • Dialysis remains in the peritoneal cavity and filtration occurs
  • The dialysate is drained and replaced automatically by the machine
  • The machine completes this cycle three to five times a night and takes around eight to ten hours total


Absolute contraindications to PD are when catheter access or use of the peritoneal membrane is not feasible:4,16,20

  • Inflammatory abdominal diseases: Crohn’s disease, ulcerative colitis, current clostridium difficile infection
  • End-stage liver disease with ascites
  • Unrepaired hernias
  • Presence of stomas or feeding tubes
  • Presence of abdominal adhesions
  • Non-functional peritoneal membrane


The complications of PD can be divided into four main groups. A more comprehensive discussion of these can be found in the PD article.

Catheter-related complications17

  • Catheter obstruction
  • Catheter mispositioning
  • Bowel perforation
  • Infection: which may progress to bacterial peritonitis
  • Peritoneal leak

Membrane-related complications

  • Peritonitis: generally secondary to contamination with skin commensal bacteria during exchange or a catheter-related infection, requires prompt assessment and management with intra-peritoneal antibiotics21,22, the leading cause of needing to transfer to HD23
  • Peritoneal fibrosis: occurs with long-term PD and can cause membrane failure, a common cause of needing to transfer to HD24
  • Sclerosing encapsulating peritonitis (SEP): recurrent episodes of small bowel obstruction due to adhesions and strictures25

Metabolic complications

  • Cardiovascular disease26,27
  • Fluid overload26,27
  • Hyperglycaemia and insulin resistance: due to high glucose concentrations in dialysate5
  • Hypokalaemia26

Fluid dwelling-related complications

  • Hernias: due to chronically raised intra-abdominal pressure21
  • Abdominal pain21

Summary table

Table 1. Table summarising haemodialysis and peritoneal dialysis.

Β  Haemodialysis Peritoneal dialysis


Acute/chronic RTT Chronic RRT (preferred dialysis modality in home-based dialysis)
Access AV fistula/AV graft/central venous catheter Peritoneal catheter
Timing Four hours per day, three times weekly Daily exchange (no dialysis-free days)


  • Intra-dialytic hypotension
  • Dialysis disequilibrium syndrome
  • Cardiovascular diseases
  • Peritonitis
  • Membrane failure
  • Metabolic complications


  • Four dialysis-free days a week
  • Nocturnal haemodialysis allows a more regular work or school routine
  • More mobility and flexibility
  • Less fluid and diet restrictions
  • Better preservation of residual renal function


  • Strict diet and fluid restriction
  • Strict schedule
  • Frequent travel to dialysis unit
  • Done everyday
  • PD catheter to be left in situ permanently
  • Cannot be used indefinitely


Dr Roberta Callus

Consultant Nephrologist


Dr Jess Speller


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  3. Baker JB, Navarro Y, Sisroe TA, Everett C. Indications for Urgent and Emergent Hemodialysis. Annals of Vascular Surgery 2024 Jan;98:39-40.
  4. Chan CT, et al. Dialysis initiation, modality choice, access, and prescription: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney International 2019 Jul;96(1):37-47.
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  22. Li PKT, et al. ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment. Sage Journals 2022 Mar;42(2).
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  24. Terri M, et al. Mechanisms of Peritoneal Fibrosis: Focus on Immune Cells-Peritoneal Stoma Interactions. Frontiers in Immunology 2021 Mar;12:607204.
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