Peritoneal Dialysis Peritoneal Dialysis Kampol Pattanasombatsakul

Peritoneal Peritoneal Dialysis Dialysis

Kampol Kampol PattanasombatsakulPattanasombatsakul

Peritoneum: Peritoneum: 1-1.3 1-1.3 mm22

Visceral: Visceral: 90%90%

Parietal:Parietal: 10%10%

Peritoneal cavityPeritoneal cavity Potential spacePotential space

10-100 ml10-100 ml

Vascular supplyVascular supply

Peritoneal Peritoneal DialysisDialysis

จะเริ่��มอย่างไริ่จะเริ่��มอย่างไริ่

Prepare unit for PD Prepare unit for PD patientspatients Personal (Team)Personal (Team)

Nephrologist , SurgeonNephrologist , Surgeon Nurse , on call nurse Nurse , on call nurse OtherOther

EquipmentEquipment In unit : washing basin, dressing set, In unit : washing basin, dressing set,

catheter , connector , dialysis set , catheter , connector , dialysis set , At home : washing basin, storage , clean At home : washing basin, storage , clean

towel , weight towel , weight ManagementManagement

Education tools Education tools Data management , StatisticData management , Statistic First visit , hospitalization , First visit , hospitalization ,

Home Care therapy : Home Care therapy : benefit to Persons involved in dialysis benefit to Persons involved in dialysis

care teamcare team

Relatives

Co-worker

Rehabilitation

NutritionistSocial

workers

Technicians

Nurse & colleges

Nephrologist

Family physician

Patient

Prepare unit for PD Prepare unit for PD patientspatients Personal Personal




towel , weighttowel , weight ManagementManagement


Different PD Different PD catheterscatheters

Straight 1 cuff Straight 2 cuffs

Coiled Tenckhoff Coiled Tenckhoff catheterscatheters

Coiled 1 cuff Coiled 2 cuffs

Swan Neck Tenckhoff Swan Neck Tenckhoff catheterscatheters

Straight

Coiled

•Downwards directed exit site

•Permanent bend between 2 cuffs (180°)

•Right or left

Swan Neck MissouriSwan Neck Missouri

StraightCoiled

Bead placed IP, Flange extraP

Straight Tenckhoff Straight Tenckhoff catheterscatheters

Prepare unit for PD Prepare unit for PD patientspatients Personal Personal




towel , weight towel , weight ManagementManagement


Education toolEducation tool CKD, kidney functionCKD, kidney function Catheter care and aseptic Catheter care and aseptic

techniquetechnique Dialysis exchangeDialysis exchange Fluid and nutritional balanceFluid and nutritional balance RecordRecord ComplicationComplication MedicationMedication Follow upFollow up

Select the patientsSelect the patients

Not suitable for PDNot suitable for PD Skin disease over abdomenSkin disease over abdomen Serious abdominal surgery Serious abdominal surgery Malnourish : S. albuminMalnourish : S. albumin Large BSA > 2.0Large BSA > 2.0 Very low GFR < 2 ml/minVery low GFR < 2 ml/min Abdominal anatomical Abdominal anatomical

defectdefect ? COPD? COPD ? Diabetic? Diabetic

Theoretically not to choose PD Theoretically not to choose PD initially initially ––

BUT PD may be feasible with BUT PD may be feasible with added adjustmentsadded adjustments

Large body sizeLarge body size Diverticulosis / diverticulitisDiverticulosis / diverticulitis Severe backacheSevere backache NIPDNIPD HerniasHernias NIPDNIPD Multiple abdominal surgeryMultiple abdominal surgery Poor manual dexterityPoor manual dexterity BlindnessBlindness No complianceNo compliance

PD preferredPD preferred

Bleeding diathesis (no need of Bleeding diathesis (no need of heparinization)heparinization)

Diabetes (status of vessels, insulin i.p.)Diabetes (status of vessels, insulin i.p.) Chronic infections (prevention of the Chronic infections (prevention of the

nosocomial spread nosocomial spread –– hepatitis B, C, HIV) hepatitis B, C, HIV) Future transplantation (improved initial Future transplantation (improved initial

graft function rate) graft function rate) Multiple myeloma (improves the chances Multiple myeloma (improves the chances

of renal recovery, removes some light-of renal recovery, removes some light-chains proteins)chains proteins)

PD and HD equally PD and HD equally preferredpreferred

Polycystic kidney diseasePolycystic kidney disease Scleroderma, other conective Scleroderma, other conective

tissue diseases (tissue diseases (e.g. e.g. SLE)SLE) Patients living in nursing homesPatients living in nursing homes

Psychosocial situations in Psychosocial situations in which PD is more which PD is more

appropriate appropriate PD preferredPD preferred

Independent Independent LifeLife

Frequent travelsFrequent travels

Tendency towards PDTendency towards PD

Great need of Great need of independence independence

by the patient by the patient Need to maintain workNeed to maintain work Distance to the HD centerDistance to the HD center

Prepare the patientsPrepare the patients

Who choose method of renal Who choose method of renal replacement therapy ?replacement therapy ?

Who will take care the patients?Who will take care the patients? Uremic symptomsUremic symptoms Volume balanceVolume balance ComplianceCompliance Socioeconomic and hygiene statusSocioeconomic and hygiene status

CAPD for a new patientCAPD for a new patient

Patient educationPatient education Patient training program Patient training program Catheter placementCatheter placement Break – in period & training Break – in period & training

timetime Peritoneal testingPeritoneal testing Mode of DialysisMode of Dialysis

Patient EducationPatient Education

๑๑..ไตวาย่เริ่��อริ่�ง และ ไตวาย่ริ่ะย่ะสุ�ดท้�าย่ไตวาย่เริ่��อริ่�ง และ ไตวาย่ริ่ะย่ะสุ�ดท้�าย่๒๒ . . การิ่ควบค�มอาหาริ่ น้ำ"�า และ การิ่ริ่�บการิ่ควบค�มอาหาริ่ น้ำ"�า และ การิ่ริ่�บ

ปริ่ะท้าน้ำย่าปริ่ะท้าน้ำย่า๓๓ . . อาการิ่และอาการิ่แสุดงตางๆอาการิ่และอาการิ่แสุดงตางๆ๔๔ . . ภาวะแท้ริ่กซ้�อน้ำ และ ความผิ�ดปกต�ท้*�พบภาวะแท้ริ่กซ้�อน้ำ และ ความผิ�ดปกต�ท้*�พบ

ได�ได�๕๕ . . ความสุ"าค�ญของการิ่บ"าบ�ดไตท้ดแท้น้ำความสุ"าค�ญของการิ่บ"าบ�ดไตท้ดแท้น้ำ

Patient training programPatient training program

Hand washHand wash Basic sterile Basic sterile

techniquetechnique Exchange procedureExchange procedure การิ่ท้"าแผิล การิ่ท้"าแผิล ( exit site ( exit site

care )care ) การิ่ฉี*ดย่าเข�าถุ�งน้ำ"�าย่าการิ่ฉี*ดย่าเข�าถุ�งน้ำ"�าย่า การิ่เก1บน้ำ"�าย่าสุงตริ่วจการิ่เก1บน้ำ"�าย่าสุงตริ่วจ

Catheter placementCatheter placement Pre operative preparationPre operative preparation

Ideal location should be mark by teamIdeal location should be mark by team Free of constipationFree of constipation Controversy : nose culture for S. aureus nasal Controversy : nose culture for S. aureus nasal

carrier, if positive , 5-day course intranasal carrier, if positive , 5-day course intranasal mupirocin will be used.mupirocin will be used.

OperativeOperative Prophylaxis ABOProphylaxis ABO (evidence): 1 (evidence): 1stst generation generation

cephalosporin ( randomized control : vancomycin 1 cephalosporin ( randomized control : vancomycin 1 gm iv, single dose is superior than cephalosporin ) gm iv, single dose is superior than cephalosporin ) ( odd ratio 11.5 : 6.45 : 1)( odd ratio 11.5 : 6.45 : 1)

Using Double cuff with superficial cuff should be Using Double cuff with superficial cuff should be 2-2-3 cm3 cm. from the exit site. from the exit site

Downward direct tunnel Downward direct tunnel Swan neck catheter ( not confirm )Swan neck catheter ( not confirm ) Avoid trauma and hematoma during catheter Avoid trauma and hematoma during catheter

placementplacement Suture increase riskSuture increase risk of infection and are of infection and are

contraindicatecontraindicate

Peritoneal Dialysis-Related InfectionsPeritoneal Dialysis-Related InfectionsRecommendations : 2005 update Recommendations : 2005 update

PDI 2005: 25(2) ; 107-131PDI 2005: 25(2) ; 107-131

Peritoneal catheterPeritoneal catheterExit site

Cuffs

Post operative carePost operative care

Pain managementPain management AntibioticAntibiotic Break in period : rinse peritoneumBreak in period : rinse peritoneum ? Dialysis need ? Dialysis need

Consider HD first Consider HD first HospitalizationHospitalization Training review , catheter exchange Training review , catheter exchange

system system

Immediate post operative Immediate post operative statestate

Perioperative painPerioperative pain Bloody effluentBloody effluent Dialysate leakageDialysate leakage DisplacementDisplacement Perioperative Perioperative

peritonitisperitonitis Temporary obstructionTemporary obstruction Cuff extrusionCuff extrusion

Perioperative painPerioperative pain Wound pain Wound pain Catheter related pain – reaction , Catheter related pain – reaction ,

locationlocation In flow painIn flow pain – dialysate related– dialysate related ManagementManagement

Adequate analgesic during operation and Adequate analgesic during operation and post operative periodpost operative period

Pseudo ascites during catheter insertionPseudo ascites during catheter insertion No guide-wire / smooth catheter insertionNo guide-wire / smooth catheter insertion Slow infusion / low volumeSlow infusion / low volume Non osmotic dialysate solutionNon osmotic dialysate solution Warm dialysate Warm dialysate

Immediate post operative stateImmediate post operative state

Bloody EffluentBloody Effluent Bleeding complication during surgical Bleeding complication during surgical

procedureprocedure Bleeding tendency in end stage renal diseaseBleeding tendency in end stage renal disease ThrombocytopeniaThrombocytopenia ManagementManagement

Rinse peritoneal cavity until clearRinse peritoneal cavity until clear Add heparin 500-1000 unit / L in last bag Add heparin 500-1000 unit / L in last bag

dialysatedialysate Correction of bleeding tendencyCorrection of bleeding tendency Peritoneal restingPeritoneal resting Prevention Prevention


Dialysate leakageDialysate leakage Leakage via insertion point, exit siteLeakage via insertion point, exit site Commonly found in midline insertion, Commonly found in midline insertion,

acute PD catheteracute PD catheter How to test – only dipstick for glucoseHow to test – only dipstick for glucose ManagementManagement

Prevention – catheter fixation first 2-3 Prevention – catheter fixation first 2-3 days , soak both cuffs with NSSdays , soak both cuffs with NSS

Decrease intraabdominal pressure – using Decrease intraabdominal pressure – using low volume , avoid constipationlow volume , avoid constipation

Temporary hemodialysisTemporary hemodialysis Late catheter useLate catheter use


DisplacementDisplacement Upward displacement of catheter , non Upward displacement of catheter , non

in appropiated positionin appropiated position How to diagnose – plain abdomenHow to diagnose – plain abdomen ManagementManagement

Prevention – constipationPrevention – constipation During catheter insertion – pain During catheter insertion – pain

management , deep cuff fixation , management , deep cuff fixation , subcutaneous tract subcutaneous tract

Laxtive along with early ambulationLaxtive along with early ambulation Guide wire manipulationGuide wire manipulation Re-explorationRe-exploration


Perioperative peritonitisPerioperative peritonitis Early peritonitisEarly peritonitis Cause – infection , reactionCause – infection , reaction( plasticizer, air , ( plasticizer, air ,

fluid component ) fluid component ) How to diagnose – cell count & How to diagnose – cell count &

differential differential ( PMN , Eosinophil ) ( PMN , Eosinophil )

ManagementManagement Prevention – antibiotic prophylaxisPrevention – antibiotic prophylaxis Sterile techniqueSterile technique Wound dressing Wound dressing Antibiotic , prefere i.v. for infectionAntibiotic , prefere i.v. for infection Symptomatic treatment for reaction / Symptomatic treatment for reaction /

allergy – usually resolve in 2 weeksallergy – usually resolve in 2 weeks


Temporary obstructionTemporary obstruction Inflow obstruction – fibrin , clotInflow obstruction – fibrin , clot Outflow obstruction ( one way valve ) – Outflow obstruction ( one way valve ) –

omentum occlusion , catheter clinking, omentum occlusion , catheter clinking, displacementdisplacement

Complete obstructionComplete obstruction ManagementManagement

Prevention –gently catheter insertion without guide Prevention –gently catheter insertion without guide wire , control bleeding before insertion , catheter wire , control bleeding before insertion , catheter testing immediate insertion , pseudoascites testing immediate insertion , pseudoascites

NSS flush , intraluminal fibrinolytic agents, heparin NSS flush , intraluminal fibrinolytic agents, heparin locked catheter, brush , guidewire manipulationlocked catheter, brush , guidewire manipulation

NSS 100 ml + heparin 1000 u intraperitoneally , NSS 100 ml + heparin 1000 u intraperitoneally , peritoneum restingperitoneum resting

Guidewire manipulation , reinsertionGuidewire manipulation , reinsertion


Before starting PD Before starting PD

Make sure dialysis exchange and Make sure dialysis exchange and septic techniqueseptic technique

Select type of dialysis solutionSelect type of dialysis solution Do we need PET?Do we need PET? Select mode of dialysis Select mode of dialysis Select dialysis doseSelect dialysis dose

Volume : Guideline Volume : Guideline

• Acute dialysis• small volume : 1000 ml• - increase 1500 2000 ml in

supine position• Chronic dialysis

• - volume 2 0 0 0 3 0 0 0 ml

Peritoneal dialysis solutionPeritoneal dialysis solution Buffer compositions Buffer compositions

- 35 40Lactate mEq/L - 35 40Lactate mEq/L - Bicarbonate 25 39 mEq/L - Bicarbonate 25 39 mEq/L

Osmotic compositions Osmotic compositions Glucose ( Dextrose ) : 1.36% , 2.25% , 3.8 Glucose ( Dextrose ) : 1.36% , 2.25% , 3.8

6% glucose 6% glucose

1.5% , 2.5% , 4.25% 1.5% , 2.5% , 4.25%dextrosedextrose

ElectrolytesElectrolytes - Sodium : 132 134 mEq/L dialysate - Sodium : 132 134 mEq/L dialysate - :0.5 1.0 / - :0.5 1.0 / - :02 .0 / - :02 .0 / - - :2.0 3.5 / ( 1.0 1.75 / ) - - :2.0 3.5 / ( 1.0 1.75 / )

PD solution : Calcium PD solution : Calcium

• 2.0 - 3.5 mEq/L ( 1.0 - 1.75 mmol/L )

• Precaution of low calcium dialysate• Negative calcium balance• induce severe hyperparathyroidism

•Indication for low calcium dialysate ( 2.0 mEq/L )• hypercalcemia • serum phosphate > 3.0 mEq/L with oral calcium• serum phosphate < 3.0 mEq/L with hyperparathyroidism with oral vitamin D• hypoparathyroidism

Ectopic CalcificationEctopic Calcification

despite better P control, PD patients may despite better P control, PD patients may be at increased risk for vascular be at increased risk for vascular calcification because of low turnover bonecalcification because of low turnover bone

vascular medial calcification associated vascular medial calcification associated with arterial stiffening and increased with arterial stiffening and increased afterloadafterload

vascular intimal calcification associated vascular intimal calcification associated with luminal narrowing and occlusive with luminal narrowing and occlusive diseasedisease

Fate of Ingested Calcium – Fate of Ingested Calcium – Normal or Increased Bone Normal or Increased Bone

TurnoverTurnover

Oral Ca Gut absorption

Bone uptake

Visceral Calc’n

Vascular Calc’n

Fate of Ingested Calcium – Fate of Ingested Calcium – Low Bone TurnoverLow Bone Turnover

Oral Ca Gut absorption

Bone uptake

Visceral CalcVisceral Calc’’nn

Vascular Calc’n

Intimal Intimal CalcificationCalcification

tends to correlate with tends to correlate with plaque areaplaque area

may be responsible for may be responsible for occlusive vascular occlusive vascular diseasedisease

Medial Medial CalcificationCalcification

produces stiff produces stiff arteriesarteries

may be may be responsible for responsible for LVH and CHFLVH and CHF

How to diagnosed adynamic bone How to diagnosed adynamic bone disease disease

in dialysis patients?in dialysis patients? Bone markerBone marker

Bone turnover Bone turnover Parathyroid hormoneParathyroid hormone (<150 (<150 pg.ml)pg.ml)

Resorption Resorption Tartarate resistant acid phosphatase Tartarate resistant acid phosphatase ( TRAP)( TRAP)

Pyridinoline and deoxypyridinoline Pyridinoline and deoxypyridinoline ( PYD,DPD)( PYD,DPD)

Procollagen type I cross linked C-terminal Procollagen type I cross linked C-terminal telopeptide ( ICTP)telopeptide ( ICTP)

Formation : Formation : Total alkaline phosphatase ( TAP)Total alkaline phosphatase ( TAP)

Bone alkaline phosphatase Bone alkaline phosphatase ( BAP) < 27 U/L( BAP) < 27 U/L

Osteoclacin ( OC) < 14 ng/mlOsteoclacin ( OC) < 14 ng/mlProcollagen type I carboxy Procollagen type I carboxy

terminal terminal propeptide ( PICP)propeptide ( PICP)

Bone biopsyBone biopsy




Standard PET Standard PET Standard PET Standard PET - 812Upright , drain the overnight ( hr) - 812Upright , drain the overnight ( hr)

20over min. 20over min. RRRR RRRR RR RRRR ,2.0 ,2.5 % 10 . RRRR RRRR RR RRRR ,2.0 ,2.5 % 10 . every every

400 ml or 2 min.400 ml or 2 min. R RRR RRRR R RRRRRRR RR RR RR RRRRRRRRR R () 2,200 ,, 10 , R RRR RRRR R RRRRRRR RR RR RR RRRRRRRRR R () 2,200 ,, 10 ,

190reinfuse ml 190reinfuse ml 2Collect blood at hr. 2Collect blood at hr. RRR RRRRR R RRR RRRR R RRRRRRR RRRRRR R4. , , RRR RRRRR R RRR RRRR R RRRRRRR RRRRRR R4. , ,

nd collect sample nd collect sample

Peritoneal Equilibration Test

Solute clearanceUltrafiltration




CAPDCAPD (continuous (continuous

ambulatory PD)ambulatory PD)

NIPD NIPD ( nocturnal ( nocturnal

intermittent PD)intermittent PD)

CCPDCCPD ( continuous ( continuous cyclical PD)cyclical PD)

DAPD DAPD ( day time ( day time

ambulatory PD)ambulatory PD)

CAPD prescriptionCAPD prescription

Adequacy recommendationAdequacy recommendationAdequacy recommendationAdequacy recommendation

Method Weekly Kt/VCreatinine clearance( L/wk/1.73sq.m.)

CAPD 20> . 6>0NIPD 22> . 66

CCPD 2163

Calculation of renal creatinine clearance for 24 hours:Calculation of renal creatinine clearance for 24 hours: Total urinary creatinine removal divided by serum creatinine levelTotal urinary creatinine removal divided by serum creatinine level

U/Pcreatinine x urine volumeU/Pcreatinine x urine volume Standardized by body surface areaStandardized by body surface area

Calculation of peritoneal clearance (Urea/Creatinine) Calculation of peritoneal clearance (Urea/Creatinine) for 24 hoursfor 24 hours Total peritoneal removal divided by serum levelTotal peritoneal removal divided by serum level

D/P x total dialysate volumeD/P x total dialysate volume Standardized by body surface area (creatinine)-Standardized by body surface area (creatinine)-

Peritoneal creatinine clearancePeritoneal creatinine clearance Standardized by body water content (urea): Standardized by body water content (urea): Kt/VureaKt/Vurea

Adequacy recommendationAdequacy recommendationAdequacy recommendationAdequacy recommendation

At least Kt/V > 1.7 in CAPD ;

At least Kt/V 1.7 & CCr 45 L/wk/1.73 sq.m for APD

Krt/V 2.0 = GFR ปริ่ะมาณ 9.38 – 12.43 ml/min

Estimate GFR = - 0.4462 + ( 4.9179 * Krt/V ) ;

หริ่�อ Krt/V = 0.09 + estimate GFR /4.9179




PD prescriptionPD prescription

Determine RRF

High RRF Low RRF, urine vol

Start with NIPD, may be with 3 x 2L

Start with CAPD, 4 x 2L unless very small size

Inadequate UF/clearance

NIPD with 4 x 2 L,Or 5 x 2L

Inadequate UFHigh transport

High transportHigh transport 高转运高转运

Low transportLow transport Inadequate clearance

Yet adequate UF

Increase volume / frequency, day dwell

CCPD/NIPD +mid-day exchange

Inadequate Clearance

Increase dwell vol/mid-day ex.CCPD?? PD+HD

Complication in CAPDComplication in CAPD

Immediate complication – first 6 monthsImmediate complication – first 6 months Immediate post operative periodImmediate post operative period

Early complication – up to 24 monthsEarly complication – up to 24 months Late complication – more than 24 monthsLate complication – more than 24 months




Early period complication Early period complication in CAPD in CAPD

Catheter displacement / obstructionCatheter displacement / obstruction Cuff extrusion Cuff extrusion Catheter infectionCatheter infection

PeritonitisPeritonitis Exit site infectionExit site infection

Blood pressure and volume controlBlood pressure and volume control Metabolic , Electrolytes and Metabolic , Electrolytes and

Nutritional compliactionNutritional compliaction




Late complication in Late complication in CAPD CAPD

Catheter problem & infectionCatheter problem & infection Prolong increase intraabdominal Prolong increase intraabdominal

pressurepressure Peritoneal changePeritoneal change Cardiovascular complicationCardiovascular complication

THANK YOUTHANK YOU

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Peritoneal Dialysis Peritoneal Dialysis Kampol Pattanasombatsakul