40 seyrafian peritoneal dialysis

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  • 1. PERITONEAL DIALYSIS Presentation and modalities Shiva Seyrafian MD Isfahan University of Medical Sciences
  • 2. Background
    • Worldwide, 12% of dialysis patients are maintained on PD
    • This varies greatly between countries
    • >50% on PD in New zealand, Hong Kong, and Mexico
    • <8% on PD in Japan ,Germany and Taiwan
    PERITONEAL DIALYSIS
  • 3. Modality Selection
    • Most patients (>80%) can do either modality and the decision is not a primarily medical one although some factors may favor one modality over the other to some degree
    • Modality selection should take into account medical issues, patient’s social circumstances, wishes of patient but also overall economic circumstances in which the dialysis program operates
    PERITONEAL DIALYSIS
  • 4. Organizing a peritoneal dialysis program PERITONEAL DIALYSIS
  • 5. Introduction:
    • PD is a very simple technique when compared to hemodialysis.
    • Set a program : needs _ a doctor _ a nurse _ a patient
    • Assure a successful one :well- planned
    PERITONEAL DIALYSIS
  • 6. Some absolute and relative indications to PD
    • Absolute indications :
    • Poor cardiac function
    • Peripheral vascular disease
    • Relative indications :
    • Free life style
    • Want to take care themselves
    • Long distance to hemodialysis center
    PERITONEAL DIALYSIS
  • 7. Teaching plans and materials
    • Demonstration is essential :
    • _by a nurse
    • _by an experienced patient
    • _via video
    • Practice on a mannequine
    • Practice on himself/herself
    • Recheck the procedure
    • Update for new knowledge
    PERITONEAL DIALYSIS
  • 8. Equipment requirement in PD training
    • Comfortable chair
    • Water sink
    • Weighing scales
    • Drip stand/hook
    • Books, booklets ,charts ,posters
    • Television and video/VCD/DVD
    • Automate PD machine
    • Shelving for consumable
    PERITONEAL DIALYSIS
  • 9. Multi-discipline care team
    • The team typically includes
    • Doctors
    • Nurses
    • Dietitians
    • Social workers
    • Often include a surgeon, a cardiologist, a psychologist, a psychiatrist, a physiotherapist etc.
    PERITONEAL DIALYSIS
  • 10. Contraindications to PD
    • Inability to make connections and lack of family member or other person willing or able to help (dementia ,stroke ,arthritis , blindness, debilitation etc)
    • Previous complicated abdominal surgery with adhesions, ostomies etc
    • Lack of space to store PD solutions
    PERITONEAL DIALYSIS
  • 11. Contraindications to HD
    • lack of vascular access-usually some years on HD
    • Cardiovascular instability in HD with recurrent large weight gains ,fluid overload, symptomatic hypotension, angina etc
    • Long distance from HD unit and unwillingness to tolerate
    PERITONEAL DIALYSIS
  • 12. Factors favoring PD
    • Young child
    • Full time work
    • Desire for autonomy
    • Mother with young children
    • Good family support
    • Good motivation
    • Early transplant likely
    PERITONEAL DIALYSIS
  • 13. Factors favoring HD
    • Poor family support
    • Poor motivation
    • Major comorbidity
    • Body size >110 kgs
    • Severe obesity
    • Irresponsible , lack of hygiene
    • Poor hand eye coordination
    PERITONEAL DIALYSIS
  • 14. modality selection some realities
    • Most patients with ESRD are anxious and unwell and will be nervous about participating in their own treatment
    • Getting them to do PD requires encouragement and support and is best done in advance before they become very uremic
    PERITONEAL DIALYSIS
  • 15. modality selection some realities cont…
    • Many nephrologist have strong biases about modality selection, most often in favor of HD over PD
    • Many nephrology trainees have very little experience of PD compared to HD and are not comfortable managing PD patients
    PERITONEAL DIALYSIS
  • 16. modality selection How to do it well
    • Predialysis clinic
    • Meeting with PD and HD staff
    • Meeting with PD and HD patients
    • Seeing PD and HD units
    • Providing good educational material
    PERITONEAL DIALYSIS
  • 17. ‘ PD FIRST ‘ Advances of PD as Initial Modality
    • Preserves residual renal function better
    • May allow better blood pressure and volume control with cardiovascular benefits
    • May give better quality of life
    • Has less anemia and lower EPO doses
    • Lower risk of Hepatitis C
    • Equal or better survival in early years
    • Cost advantages - in many countries
    PERITONEAL DIALYSIS
  • 18. Modality Selection Pre Dialysis Clinics
    • This allow time for patient to be educated remodalities before they became a medical emergency
    • Patients who present late with uremic symptoms almost always are treated with HD and stay on it subsequently
    • Predialysis education is critical for increasing PD use
    PERITONEAL DIALYSIS
  • 19. Modality Selection Education
    • Meeting with PD and HD patients and nurses is very helpful for patients
    • A program should make such opportunities available
    • Good videos , books etc are available from kidney disease organizations and from industry
    PERITONEAL DIALYSIS
  • 20. PD versus HD Which is best?
    • This may not be best way to pose the question of modality selection
    • PD may best be seen as a therapy for early years of dialysis with HD being used as a back up if or when PD fails
    • This approach which has recently been called “integrated dialysis care” has economic as well as medical advantages
    PERITONEAL DIALYSIS
  • 21. Integrated Dialysis Care
    • Idea that HD and PD are complementary rather than competitive therapies
    • Many patients will need both at some stage in their time on dialysis
    • Switching modalities modalities should not be seen as a failure
    • PD has particular benefits as initial dialysis modality
    PERITONEAL DIALYSIS
  • 22. Conventional Classification of PD
    • Daily CAPD DAPD NIPD CCPD
    • Intermittent IPD × 2-3 per week
    PERITONEAL DIALYSIS
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  • 28. CAPD OR APD ?
    • Medical
    • Lifestyle
    • Economic
    PERITONEAL DIALYSIS
  • 29. Economic of APD versus CAPD
    • APD is more costly than CAPD.
    • Paradoxically, however the difference is greater in poorer developing countries and least in wealthier countries .
    PERITONEAL DIALYSIS
  • 30. LIFESTYLE
    • Given free choice ,most patients choose APD over CAPD because it involves less daytime procedures and so less disruptive .
    • Exceptions are people who are nervous about machines or who have difficulty staying in bed ~ 8 hrs .
    PERITONEAL DIALYSIS
  • 31. LIFESTYLE INDICATIONS FOR APD
    • Children to allow uninterrupted school time
    • Those who work full time
    • Those who depend on working family members to do their PD
    • Those who live in nursing homes-- , in order to minimize PD workload for staff
    PERITONEAL DIALYSIS
  • 32. MEDICAL INDICATIONS FOR APD
    • Fluid resorption on standard CAPD
    • High or high average transport status
    • Inadequate dialysis on CAPD
    • Frequent peritonitis on CAPD
    PERITONEAL DIALYSIS
  • 33. PERITONITIS
    • Remains the biggest cause of PD technique failure in most countries
    • Also causes hospitalization, catheter loss and even death
    • Rates have fallen over past 2 dacades , mainly due to improved connectology
    PERITONEAL DIALYSIS
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  • 43. ‘ Y SET ’ IS SUPERIOR TO ‘ STRAIGHT LINE ‘
    • One peritonitis per 33 months versus one per 11 months (Maiorca et al 1983)
    • One peritonitis per 22 months versus one per 10 months in Canadian Multicenter Study ( PDI 1989 )
    PE RITONEAL DIALYSIS
  • 44. ‘ DOUBLE BAG ‘ IS SUPERIOR TO STANDARD ‘Y SET ‘
    • 1 peritonitis per 34 months versus one per 12 months (US) (Kiernan et al, JASN 1995)
    • 1 peritonitis per 47 months versus 1 per 14 months (Australia) (Harris et al, JASN 1996)
    PERITONEAL DIALYSIS
  • 45.  
  • 46. THE NURSE’S ROLE
    • “ I am convinced that a well-informed and enthusiastic nurse is a great blessing to the nephrologist and the peritoneal dialysis patient “ Dimitrios Oreopulos
    • A successful PD program depends on a highly motivated ,educated , professional nurse
    PERITONEAL DIALYSIS
  • 47.