the Management of the Peritoneal Dialysis Patients.doc.doc.docDocument Transcript
Guidelines for the Management of
the Peritoneal Dialysis Patients
Peritoneal dialysis in Saudi Arabia………………….………11
1. Initiation of
2. Suitable patients for peritoneal dialysis……..…..………26
3. Access for peritoneal dialysis…………………………….29
4. Solutions for peritoneal dialysis…………………..…...…33
5. Continuous ambulatory peritoneal dialysis……………..34
6. Automated Peritoneal Dialysis (APD)…………..…..…...36
7. Measures of Peritoneal Dialysis Dose………..…..………38
8. Measurement of Peritoneal Dialysis Dose……..…..
9. Assessment of Nutritional Status in Relation to
10. Adequate Dose of Peritoneal Dialysis…..………...……...44
11. Strategies to Achieve Better Prescribed
Dose of Peritoneal Dialysis……………………………….47
12. Peritoneal Dialysis Related peritonitis…………….…….48
13. Clinical Outcome Goals for Adequate Peritoneal
In the era of the evidence based medicine and the presence of
guidelines for practice around the world, we started to formulate
Saudi Guidelines for management of the important problems
such as anemia and bone disease in the chronic kidney disease
(CKD) patients. The feedback from the renal community on the
publication of the guidelines for the management of anemia and
bone disease in the CKD and the transplanted patients has
encouraged the Saudi Center for Organ transplantation (SCOT)
to prepare the guidelines for the management of the peritoneal
dialysis patients in the kingdom of Saudi Arabia (KSA).
In addition, the recent survey of attitudes of the physicians
towards the management of the PD patients in the KSA has
demonstrated deficiencies such as the unavailability of enough
centers and expertise that are involved in the management of the
patients on this important modality of renal replacement therapy
(RRT) in the dialysis centers in the KSA. Currently, there are
about 600 peritoneal dialysis patients in the KSA who require
attention in terms of the monitoring and management besides the
need for more use of this method of treatment.
Our guidelines aim at having a baseline for the development of
sound practices in the context of the local experiences. We
intend to develop and maintain these guidelines in order to
support the local protocols in each dialysis unit in the KSA. Such
support may be fruitful in more quality care management by the
providers of the CKD care such as the health planners,
physicians and nursing staff.
Faissal A.M. Shaheen MD.,
& Muhammad Ziad Souqiyyeh MD.,
On behalf of the advisory committee
for the management of peritoneal dialysis patients
Advisory Committee for the Guidelines for
the Management of Peritoneal Dialysis
Dr. Othman Alfureyh Dr. Mohammad Alsulaiman
Department of Medicine, Department of Nephrology
King Faissal Specialist Hospital Armed Forces Hospital
& Research Center, Riyadh
Prof. Jamal Al-Wakeel
Dr. Saeed Alghamdi Division of Nephrology
Division of Nephrology Department of Medicine
Department of Medicine King Kaled University Hospital
King Faisal Specialist Hospital Riyadh.
Dr. Ayman Karkar
Dr. Ali Alharbi Division of Nephrology
Division of Nephrology Department of Medicine
Department of Medicine Dammam Central Hospital
Security Forces Hospital Dammam
Dr. Ali Lehbi
Dr. Khaled Almeshari Division of Nephrology
Department of Medicine Department of Medicine
King Faissal Specialist Hospital King Faissal Specialist hospital
& Research Center & Research Center
Dr. Abdulla Alkhader Alsayyari Dr. Saadi Taher
Division of Nephrology Department of Medicine
Department of Medicine King Fahd National Guard Hospital
King Fahd National Guard Hospital Riyadh.
Dialysis is usually started when patients with renal disease reach end
stage. Monitoring the renal function helps determine the initiation of
dialysis. This can be accomplished by continuous follow-up of symptoms,
nutritional status and laboratory tests.1-6
Peritoneal dialysis (PD) is a modality of renal replacement therapy
that has variable popularity in the world, which ranges between 2-50%.
The expansion of use of PD in the kingdom of Saudi Arabia (KSA) has
been slow over the years and it forms about 10% of the dialysis
population in it. The recent survey of the attitude of physicians in the
dialysis centers about PD practices showed many deficiencies that
PD was started thirty years ago as intermittent mode (IPD) every few
days and was unsatisfactory in terms of adequacy or quality of life.
However, the advent of the continuous ambulatory peritoneal dialysis
(CAPD) in the late 1970s had promoted the popularity of this method
There have been major advancements in the access for PD,
connectology (connecting tubings), solutions and automation.
Access and connecting tubings for dialysis have advanced in terms of
the techniques and operation that contributed to a significant decrease
in the incidence and severity of complications such as exit site infection,
peritonitis and displacement of catheters.7-22
The use of alternative osmotic agents has been investigated including
glycerol-based solutions. Icodextrin and glucose have been used for the
long daily dwell in automated peritoneal dialysis (APD) and CAPD
patients. Icodextrin gave greater small solute clearance, which was
explained by the higher ultrafiltration in that group, especially in high
transporters. 23,24 Other agents such as bicarbonate-based solutions and
amino acid-based solution have been used. 25 However, no added effect
was seen on small solute clearance. 26- 28
Much research has been undertaken over the past 20 years to improve
the quality of treatment provided by PD. One of the most promising
advances has been the introduction of APD, which is the use of a cycler
for various regimens, including nightly intermittent peritoneal dialysis
(NIPD), continuous cycling peritoneal dialysis (CCPD) and tidal
peritoneal dialysis (TPD; nightly, NTPD, or continuous, CTPD).
Intermittent peritoneal dialysis (IPD) two or three times/week is not
recommended because satisfactory clearances are seldom achieved
with this modality. APD has been adopted increasingly by PD units
worldwide, such that global use ranges between 9.4% and 54%. 29,30
APD has been recommended by the International Society of Peritoneal
Dialysis ad hoc Committee on Ultrafiltration Management for the treatment
of high transporters with impaired net ultrafiltration. 31 However, the
evidence justifying the prescription of APD to treat high transporters
may not be very strong. 32-34
There is some evidence to suggest that, for most patients, better small
solute clearances are achievable on all the APD regimens than CAPD.
More permeable peritoneal transport membrane types have more
options to achieve clearance by using APD. 38 Moreover, comparing
the techniques of CAPD, CCPD, TPD, 25% and 50% across a range of
peritoneal transport groups, clearances were similar between the CCPD
and TPD groups.39
Tidal modalities (TPD) have been proposed to more efficiently
increase small solute clearances in APD, in part by reducing the impact
of drain-fill multiplication but at higher cost. This is due to an effective
increase in dialysis flow rate. 40 At present, there is no high level
evidence that the use of TPD enhances small solute clearance. APD
prescriptions should be individualized in terms of volumes and number
of exchanges, body size, transport status, residual renal function (RRF)
and patient preference. The peritoneal equilibration test (PET) tests
should be repeated to ensure adequacy targets are met once this
modality is introduced. 41,42 Currently, the technique is in its experimental
stages and technical difficulties still need to be overcome particularly
relating to the type of catheter (ideally double lumen) inserted, to avoid
recirculation 43 Phosphate and urea clearances were enhanced as well as
ultrafiltration.44 Recent studies have not been able to confirm a
differential rate of decline in RRF between CAPD and APD. 45-47
APD (in the form of NIPD) has been suggested to offer a number of
psychosocial benefits over CAPD, which relate directly to fewer
connections, more frequent use of reduced fill volumes, and patient
independence from dialysis during the daytime, particularly for workers,
school students or care takers of elderly or debilitated patients. Most
costing studies report that APD is 8%-36% more expensive than
CAPD.48 These additional costs include those of the machine, the
greater volumes of dialysate employed, and the special tubing and
connection sets used.
The (PET) was introduced in 1989 and is the standard method for
evaluating peritoneal transport characteristics in PD patients. 49 Based
on the dialysate to plasma creatinine ratio of creatinine, patients can be
classified as high, high average, low average or low transporters. The
PET is very helpful for prescribing both APD and CAPD, since
knowledge of a patient's peritoneal permeability allows a better
estimation of the dwell time that will achieve the greatest efficiency in
terms of ultrafiltration and small solute clearance. 50-52
Small solute clearance is only one marker of wellbeing in patients on
PD. Monitoring of PD should include some objective measurements of
the adequacy of dialysis delivery, patient compliance, dialysis reliability,
individual patient response to therapy and modification of membrane
characteristics by the procedure. Unfortunately, there has been a
tendency in the renal literature and in other guidelines to equate
adequacy with small solute clearance measurements. According to new
evidence, small solute clearance must not be considered in isolation,
but interpreted in the more global context of clinical and laboratory
assessments of all the other manifold aspects of dialysis adequacy,
including hydration status, blood pressure and lipid control, bone
disease, anemia, nutrition, etc.53
Peritoneal dialysis does not deliver adequate small solute clearance
when compared with native kidneys. Ideally, PD treatment should aim
to deliver the most dialysis possible in patients given time, personal
preferences and financial constraints. This should minimize uremic
symptoms, lead to better blood pressure control and hopefully, improve
nutrition and quality of life. Possible negative consequences of
interventions to improve small solute clearances include increased cost
and time, potential for volume overload and abdominal distension and
greater peritoneal exposure to glucose with local and metabolic effects.
Increasingly, patients are using automated dialysis methods in order to
enhance the amount of dialysis delivered as well as quality of life.
Difficulties persist in certain subgroups such as low transporters and
those without RRF.54-57
It is now realized that for patient survival, it is as important to ensure
optimal preservation of RRF as to optimize small solute clearances.58
Dietary caloric intake was greater in those with more RRF but not PD
No study has shown that a decline in residual renal function is
compensated by an equal increase in peritoneal clearance. There are no
studies relating small solute clearance measurements to outcomes in
patients treated with APD. There is insufficient evidence to determine
whether achieving a Kt/V target is more important than achieving a Ccr
target or vice versa. Ccr was more strongly associated with
hospitalization than Kt/V and only Ccr was significantly associated
with technique failure. This finding may simply reflect the fact that C cr
is disproportionately affected by residual renal function relative to Kt/
V.61-63 However, Ccr is much less susceptible to therapeutic
manipulation than Kt/V. Given that low- and low-average transporters,
even with lower weekly peritoneal Ccr measurements, have
substantially increased survival and technique survival compared with
higher transporters,61 it seems prudent to accept lower Ccr targets for
these patients. Failure to do so would invariably lead to the inappropriate
transfer of a group of better prognosis patients to hemodialysis.
There are several formulas that can be used in the calculations of
body volume (V) and body surface area (BSA) that are beneficial in
the estimations of adequacy of dialysis and dialysis dose.64-69 However,
unrealistic estimates of (V) occur in subjects whose height and/or
weight differ from the normal range (body mass index BMI < 20 or >
27.5 kg/m2).70,71 In a recent study, (V) in men was approximately 2-6 L
greater than previously reported using the above calculations and (V)
in women was 2-5 L less than reported. The mean ratio of V to weight
declined with age as a function of increased body fatness (men >
There is validation for the accuracy of computer modeling of PD
prescriptions in CAPD patients that should be used more often in
clinical practice. 73
There should be a system to identify and correct patient-related failure to
achieve prescribed PD dose. The potential patient-related causes should be
investigated and corrected. These include failure to comply with the
prescription, lack of understanding of the importance of adherence to
the full prescription and sampling and collection errors. Moreover,
potential staff-related causes of failure to achieve prescribed peritoneal
dialysis dose should be investigated and corrected. These include, errors
in prescription, inadequate monitoring of delivered dose and inadequate
patient education. Inadequate education may stem from both poor
educator understanding of the principles of clearance and lack of
proper teaching technique. Staff responsible for patient education should
be trained and competent in both the principles of clearance and the
technique of patient instruction. 74-78 The establishment of a PD clinic is
utmost importance to implement these strategies besides patients
Peritonitis is the culprit of PD. Although the diagnostic criteria for
peritonitis have not been validated in clinical studies, they represent an
international consensus among adult and pediatric nephrologists.
Antibiotic treatment should be initiated as soon as the diagnosis of
peritonitis is made. While it is advisable to perform and review the
results of a dialysate cell count and Gram stain prior to the initiation of
treatment, therapy should be started immediately upon recognition of
effluent cloudiness if signs of severe infection, such as pain and fever,
are present. The response to the initial antibiotic treatment should be
evaluated daily after treatment initiation. Treatment can be considered
successful if an improvement in clinical status (e.g., cessation of
abdominal pain and fever, and reduction of effluent cloudiness) has
been achieved by 72 hours of therapy. A reduction of the dialysate
WBC count by more than 50% is an additional evidence of successful
therapy. If no clinical improvement occurs within 72 hours of treatment
initiation, potential sources of persistent infection should be evaluated.
Treatment modifications may include an alteration of antibiotic therapy
and/or catheter removal. Peritoneal dialysis catheter removal should
occur as part of the recommended treatment course in situations in
which failure to do so is unlikely to result in successful peritonitis
therapy. The timing of catheter replacement should be 2 - 3 weeks
following catheter removal in most cases. Prophylactic antibiotic
therapy should be given at the time of catheter placement in the form
of a single dose of a first-generation cephalosporin. Antibiotic prophylaxis
should also be considered following accidental intraluminal contamination,
prior to dental procedures, and prior to procedures involving the
gastrointestinal or urinary tract. Prophylactic systemic long-term
antibiotic treatment is not indicated.79-115
There may be ultrafiltration and solute clearance failure that is
increased with increasing duration of dialysis, ranging from 2.6% at 1
year to 30.9% at 6 years especially with advanced age of the patients.
Some studies have suggested that peritonitis may cause an increase
in membrane transport,117,118 while others did not.119Accordingly, it
would seem prudent to periodically monitor PET especially if loss of
ultrafiltration is detected.
Several studies have shown that high transporters do have increased
mortality and reduced technique survival, independent of other risk
factors. 120,121 The exact mechanisms for the poor survival of high
transporters is uncertain, but may relate to poor ultrafiltration and fluid
overload leading to hypertension and left ventricular hypertrophy,
dialysate protein losses and poorer nutrition, chronic inflammation or
other unknown mechanisms.122 If high transporters are due to chronic
inflammation and comorbidities with low serum albumins, higher C-
reactive protein (CRP), lower RRF and lower protein nitrogen
appearance (PNA) will have a poor prognosis.123-126
The Saudi Guidelines Of the PD management are intended to
approach the patients on PD and to encourage both the practice of PD
and research in this field.
Peritoneal Dialysis in Saudi Arabia
Over the past 20 years there has been valuable research related to this
issue from the dialysis centers in Saudi Arabia. We summarize these
reports in chronological sequence in order to stimulate more research
in the future:
1. In 1992, Salem et al127 reported a case of a 10-year-old boy who
underwent laparotomy for massive liver injury associated with internal
bleeding. Following the surgery the patient developed peritonitis and
septicemia complicated by acute renal failure. Peritoneal dialysis was
performed over several days to remove the waste products of metabolism
as well as to increase his caloric and fluid intake. The patient tolerated
the procedure well and no complications were encountered. Peritonitis
was managed successfully with intraperitoneal administration of
antibiotics via the dialysis catheter. The renal failure resolved completely.
This case demonstrated that peritoneal dialysis could be performed
effectively despite recent abdominal surgery.
2. In 1992, Mitwalli et al 128 reported about the occurrence of hepatitis
C virus (HCV) infection amongst chronic renal failure (CRF) patients
in their center over a period of 1 year. A total of 71 patients were
studied comprising 26 chronic hemodialysis (CHD) patients, 6 acute
hemodialysis patients, 4 peritoneal dialysis patients and 35 CRF patients
not on dialysis. Patients were screened before and after hemodialysis,
and their baseline and postdialysis values of liver enzymes were determined.
Eleven (15.5%) of the total 71 patients were HCV antibody positive.
Analysis of the individual patient groups showed that 8 (30.7%) of the
26 CHD patients were positive for HCV. Their data showed a
statistically significant relationship between seroconversion and duration
of dialysis (p<0.05). A high statistically significant (p<0.0001) correlation
was observed between the HCV antibodies and CRF. The relative risk
of hepatitis C was about 22 times greater for those with CRF compared
with the normal controls, which makes CRF an important risk factor. A
high proportion of the HCV seroconverters had elevated liver enzyme
(serum glutamic pyruvic transaminase). The data presented showed a
positive correlation between HCV seroconversion, CRF, duration on
dialysis and elevated serum liver enzymes.
3. In 1992, Mahmoud et al 129 reported about their experience with 50
continuous ambulatory peritoneal dialysis (Tenchkoff) catheters
implanted surgically in 39 children (24 male, 15 female) age 2 months
to 13 years. Fifty-nine complications were encountered. Thirteen cases
had subcutaneous leak of dialysate, 11 had exit site infection, eight had
local pain, six had cuff extrusion, four had tunnel infection and three
developed local hematoma. Nineteen (38%) catheters failed, and
seventeen (34%) were removed because of change in line of treatment
or death of the patient. Fourteen (28%) were still functioning up to 32
months. The overall actuarial catheter survival rates were 40% and 30.5%
at one year and two years respectively. Catheter related problems were
still a major cause of dropout from continuous ambulatory peritoneal
dialysis in children.
4. In 1992, Al-Wakeel et al 130 reported about the effect of continuous
ambulatory peritoneal dialysis (CAPD) and hemodialysis (HD) on the
serum levels of alpha-1-antitrypsin (α1 AT) that was evaluated in nine
patients on CAPD and 11 patients on HD. In patients on CAPD, blood
and dialysate samples were collected after eight hours of dwell time.
For HD patients, serum α1 AT levels were measured before and after
dialysis, twice on each patient, first while on dialysis with cuprophane
and the second time while on dialysis using AN69 dialyzers. The
median serum level increased by 0.3 gm/L in nine (82%) patients after
HD with cuprophane and in 10 (91%) patients after dialysis with AN69.
No phenotypic difference was seen between the α1 AT measured in
the pre and post-dialysis period, whether the dialysis was done using a
dialyzer with cuprophane or AN69 membrane. Serum levels of α1 AT
were found to be normal in patients on CAPD and it was not detected
in the peritoneal dialysate.
5. In 1995, al-Rasheed et al 131 reported a case of a 10-year-old boy
with glucose-6-phosphate dehydrogenase deficiency developed acute
renal failure during the icteric phase of non-fulminant hepatitis A
infection. He needed peritoneal dialysis for 54 days. Acute tubular
necrosis was confirmed by percutaneous renal biopsy. He had complete
recovery of his renal function when he was discharged.
6. In 1995, Huraib 132 reported a case of a 23-years-old patient who was
initiated on CAPD using curley Tenckhoff catheter in January 1992. In
May 1993, the patient presented with features suggestive of intestinal
obstruction. Plain X-ray of the abdomen showed that the CAPD
catheter had migrated to the left hypochondrium. During surgery for
catheter removal, it was found that the intraperitoneal cuff was
adherent to the greater omentum forming a band over which the jejunal
loop was kinked causing obstruction. Within 24 hours of removal of
the catheter, the intestinal obstruction was relieved. The problem
encountered in this patient was unique in illustrating the reversible
mechanical intestinal obstruction relieved by catheter removal.
7. In 1996, al-Mugeiren et al 133 reported about seropositivity to
hepatitis C virus (HCV) that was evaluated in three groups of Saudi
children. One group (n = 18) was maintained on hemodialysis and
another group (n = 21) on continuous ambulatory peritoneal dialysis
(CAPD). The third group was community-based normal controls. The
prevalence of antibody to HCV (anti-HCV) in children on hemodialysis
(11.2%) was significantly higher than that in the control group (n =
220) (1.4%; p = 0.056). There was no significant difference in the
prevalence of anti-HCV between children on CAPD (4.8%) and the
control group (1.4%; p = 0.244). Among ten children on hemodialysis
who were anti-HCV-negative 4 years earlier, two seroconverted and
the seroconversion was not due to transfused blood but was most likely
due to environmental contamination. This was the first report on the
prevalence of anti-HCV in children maintained on CAPD. The results
of the study emphasize the need for separate dialysis machines for anti-
HCV-positive patients. It seemed that CAPD therapy might reduce
transmission of HCV but a large number of CAPD patients would need
to be studied to confirm superiority to hemodialysis in this respect.
8. In 1997, Mirza et al 134 studied the clinical aspects of peritonitis and
catheter infections in 64 children on continuous ambulatory peritoneal
dialysis living in Saudi Arabia over a period of 6 years. Peritonitis
occurred in 41 children (64%). The mean time from starting dialysis to
the first episode of peritonitis was 7.2 months. The incidence of
peritonitis was 1 episode in 9 treatment months. Gram-negative organisms
were responsible for the majority of episodes (42%), followed by
Gram-positive organisms (20%), and Candida albicans (6%); 32%
were culture negative. Recurrent peritonitis was present in 20 cases.
Catheter was replaced in 24 patients: 44% due to recurrent peritonitis.
Peritoneal membrane loss occurred in 7 patients, 3 had Candida
peritonitis and 3 had recurrent peritonitis due to Pseudomonas. The
mortality rate was 4.6% but none of the deaths were related to
peritonitis or dialysis.
9. In 1997, Abbade et al 135 studied 16 patients (8 males, 8 females)
with ESRD with a mean age of 46.3 ± 15.6 years were managed by
CAPD during 1990-1994. CAPD was the first option as a renal
replacement therapy (RRT) in seven (44%) and second option in nine
(56%) patients. Indications for CAPD were: Vascular access problems
in 10 (62.5%), cardiovascular instability in three (19%), patient
preference in two (12.5%) and non-availability of nearby HD center in
one (6%) patient. Standard safe leur-lock system was used for dialysis.
All patients were well dialyzed with good quality of life. Peritonitis
was the main complication encountered (one episode/eight patient
months), cause of hospital admission and reason for returning back to
hemodialysis (HD). Other complications encountered were intraperitoneal
bleeding in three, accidental cutting of outline in two, leakage in one
and exit site infection in one. Average survival of this method was 15 ±
10.5 months (range 1-37 months). At the time of reporting this study
seven patients continued to be on CAPD, six were transferred back to
hemodialysis, one was transplanted and two died due to other reasons.
They concluded that CAPD is an acceptable mode of RRT in this part
of the world.
10. In 1997, Al-Salloum et al 136 reported their experience with chronic
ambulatory peritoneal dialysis (CAPD) in children. Between 1984 and
1993, a total of 51 patients were treated by CAPD at King Khalid
University Hospital. Eight patients were excluded from the study
because of incomplete data. There were 25 boys and 18 girls aged
three months to 16 years; 12 patients (27.9%) were below two years,
15 patients (34.9%) were between 2-6 years, and 16 patients (37.2%)
were above six years of age. Reflux nephropathy secondary to
obstructive uropathy was the main cause of ESRD in the study patients
(27.9%). The rate of peritonitis was high, one episode per 4.7 patient
months; one episode per 3.2 patient months in the first five years of the
study period. The cause of peritonitis was gram positive organisms in
38.7% and gram negative organism in 24.9%. Seventeen (39.5%) of
catheters were changed because of infection or mechanical obstruction.
In 90.7% of patients, the mother was the person who was performing
dialysis. At the end of the study, seven patients (16.2%) were still on
CAPD, 10 patients (23.3%) shifted to hemodialysis, 16 patients
(37.2%) were transplanted, six patients (14.0%) died and four patients
(9.3%) recovered. The authors concluded that CAPD may be a suitable
renal replacement therapy for children in a country with a wide
geographical area and low population density as Saudi Arabia.
11. In 1998, Al Wakeel et al 137 reported about peritonitis in patients on
CAPD at King Khalid University Hospital. Continuous ambulatory
peritoneal dialysis (CAPD) was started at the King Khalid University
Hospital in 1986. Peritonitis remained the most significant complication
of the procedure. Earlier rates of peritonitis were high, but after gaining
sufficient experience, the rates declined. To evaluate the change in
peritonitis trend, 55 new patients who were recruited to their CAPD
program between the period October 1993-October 1996 were
analyzed for the development of peritonitis on annual basis. There
were 37 (67%) males and 18 (33%) females with a mean age of 43.3
years (range 12-72 years). A total of 34 episodes of peritonitis were
recorded with a rate of 1.5 episode/patient year in 1993, 0.5 episode/
patient year in 1994 and 0.8 in 1995. Only 40% of episodes showed
positive cultures whereas 60% remained culture-negative despite use
of recommended modified culture techniques. Organisms causing
peritonitis included Staphylococcus epidermidis (20%), Staphylococcus
aureus (6.7%), E. coli (3.3%), Streptococcus fecalis (3.3%) and
Pseudomonas (6.7%). Out of 34 episodes of peritonitis, 29 (85.3%)
showed response to treatment and five episodes could only be treated
after removal of catheter. Of the 29 episodes that responded to treatment,
three relapsed and one had recurrent infection. However, all were
successfully treated though one responded only after removal of
catheter. Thus, a total of six catheters (20%) necessitated removal and
replacement. In spite of high diabetic patient population in their series
(27.2%), only one died of peritonitis related sepsis and another died of
myocardial infarction after clearing the infection. Thus mortality
remained low inspite of potential risk. Although they still used straight
system CAPD rather than Y system at the time of the report, peritonitis-
rates had declined considerably and they hoped that the procedure
would gain more acceptability amongst patients with ESRD in Saudi
12. In 1998, Mitwalli et al 138 performed bone biopsies in 57 patients
with end-stage renal failure (ESRF) on dialysis, 46 on hemodialysis
(HD) and 11 on peritoneal dialysis (PD). There were 29 males (mean
age of 42 years) and 28 females (mean age of 39 years). Relevant
presenting clinical features were pruritis in 46 cases, bone pains in 32,
acute pseudogout in three, bone deformities in two, conjunctival
calcification in two, cutaneous calcification in two, and corneal
calcification in one. The mean value of predialysis blood investigations
were as follows: urea 33.9 mmol/L, creatinine 913 µmol/L, bicarbonate
18 mmol/L, calcium 2.36 mmol/L, albumin 40 g/L, phosphorus 1.69
mmol/L, alkaline phosphatase 178 U/L, parathyroid hormone 543 pmol/L,
magnesium 1.06 mmol/L and aluminum 1.81 mmol/L. Skeletal survey
showed no changes in 24 patients (42%), hyperparathyroid cystic changes
of bones in seven, osteoporosis as the predominant features in seven,
mixed picture of ROD in 12, subperiosteal resorption of the
metacarpals in two, osteosclerosis (Rugger Jersey Spine) in two and
osteomalacia in two patients. Bone mineral density (BMD) was
measured by dual x-ray absorptiometry in the lumbar spine (LS) and
femoral neck (FN). All patients had low BMD (both LS and FN). Bone
biopsy (BBX) revealed mixed picture in 30 cases, predominantly
secondary hyperparathyroid changes in 10, mild hyperparathyroid
changes in five, predominant osteoporosis in three, osteomalacia in
four, aplastic (adynamic) bone in four, and aluminum deposition in
one. All of the patients who showed evidence of bone involvement on
BBX had abnormal BMD suggesting that BMD was a good non-
invasive screening test for ROD but indiscriminative for the type of
bone disease. The authors believed that BBX remained the diagnostic
tool to differentiate the types of bone disease.
13.In 1999, Kechrid et al 139 described hydrothorax that occurred in a
patient on continuous ambulatory peritoneal dialysis (CAPD) and
highlight the problems of diagnosis and management. A 48-year-old
man with history of obstructive uropathy secondary to urolithiasis was
started on CAPD when he reached end-stage renal failure. Two months
later, he was admitted with two days history of shortness of breath on
exertion and dry cough increasing in supine position. Chest examination
was suggestive of right sided pleural effusion confirmed by chest X-
ray. Radioisotope Technetium99m labeled albumin instilled through the
peritoneal catheter was detected in the right pleural fluid confirming
the peritoneo-pleural leak. The peritoneal dialysis (PD) was discontinued
and the patient was switched to hemodialysis. The pleural effusion
subsided and did not recur .
14. In 2000, Mitwalli et al 140 studied intermittent oral versus intravenous
alfacalcidol in dialysis patients on19 ESRF patients, who were on
dialysis (13 on hemodialysis and six on peritoneal dialysis) for longer
than six months and having serum parathormone levels at least four
times normal and serum calcium less than 2.1 mmol/L, were randomly
allocated to treatment with oral or intravenous (i.v.) alfacalcidol for a
period of 12 months. There were six patients on hemodialysis (HD)
and three on peritoneal dialysis (PD) in the oral treatment group while
in the i.v. group there were seven patients on HD and three on PD.
Clinical and serial biochemical assessments showed no statistically
significant difference between the orally- and i.v.-treated patients in
terms of suppressing secondary hyperparathyroidism and osteodystrophy.
However, patients with features of mild ROD on bone histology, had
more satisfactory changes in biochemistry when compared to others.
Our results further support the use of intermittent oral alfacalcidol in
ESRF patients because of its cost effectiveness, ease of administration
and convenience, especially for peritoneal dialysis patients.
15. In 2001, Youmbissi et al 141 reported the Dammam Central Hospital
experience in surgical placement of Tenckhoff catheter under local
anesthesia. Eighteen consecutive Tenckhoff catheters were placed under
local anesthesia through a mini laparotomy with a reduced operating
team. There were only three total catheter failures. Complications were
infrequent and operating time was less than one hour on average. The
authors believed that this simple procedure should be a part of the
training program of all junior surgeons and nephrologists.
16. In 2001, Souqiyyeh et al 142 reported about the dialysis centers in
the Kingdom of Saudi Arabia. They surveyed 130 active hemodialysis
(HD) centers using a questionnaire about their manpower, hemodialysis
equipment, as well as, peritoneal dialysis and transplant patients at the
end of the year 2000. Almost all the dialysis centers were on hospital
campus but of variable sizes with an average ratio of 14.8 dialysis
machines per center (range 2-113 machines per center). The distribution
of the dialysis centers according to the geographical regions of Saudi
Arabia included 18(14%) in the northern, 25(19%) in the southern,
13(10%) in the eastern, 35(27%) in the western and 39(30%) in the
central region. There was a total of 6,694 dialysis patients served on
1,918 hemodialysis machines. There were 1,793(93%) HD machines
capable of performing bicarbonate dialysis. There was an average ratio
of 3.5 patients per one HD machine. In addition to the hemodialysis,
there were 28(22%) centers engaged in peritoneal dialysis (PD) and
56(43%) centers in the follow-up of post transplant patients. The total
number of the nephrologists, regardless of their expertise was 212 of
whom 180(84%) spoke Arabic; the average ratio was 32 patients per
nephrologist (range of 14-58). There were 1320 hemodialysis nurses of
whom only 465(35%) spoke Arabic. The average ratio of patients to
nurses was five patients per nurse (range of 4-6). There were 72(55%)
social workers and 70(54%)dietitians with average patients ratios to
these supporting services of 1:93 patients (range of 1:58-137) and 1:96
patients (range of 1:53-137), respectively. The study HD patients had a
mean age of 47.8 ± 17.1 years (range: 2-92 years); of them, 52.5%
were males and 12% had non-Saudi nationality. Of the hemodialysis
patients, 1,815(27%) were diabetics. The calculated net increase of
dialysis population was 988 patients per year (14.8%). There were
5,700(85%) patients on regular bicarbonate dialysate. Chronic viral
infection were noted in more than half of all the dialysis population:
thus 3,380(50%) were positive for hepatitis C viral (HCV) serology,
448(7%) had positive hepatitis B (HBV) antigenemia and six (0.1%)
had the human acquired immunodeficiency syndrome. In conclusion,
The authors findings demonstrated a satisfactory advancement achieved
in many Saudi dialysis centers in terms of equipment, personnel and
patients’ care. However, they believed that there should be more
emphasis in the future on quality care through better self-assessment of
the performance of these centers.
17. In 2001, Youmbissi et al 143 studied 31 patients who were offered
continuous ambulatory peritoneal dialysis (CAPD) for their end-stage
renal disease (ESRD) at the Dammam Central Hospital, Dammam,
Saudi Arabia over a period of five years. The group included 21 women
and 10 men with a mean age of 41.3 ± 17.2 years. The main indication
for CAPD was poor or failed vascular access (51.4%). Peritonitis
remained the major complication with an overall incidence of 0.62
episodes per patient year. Staphylococcus epidermidis was the main
causative organism. Therapy with CAPD lasted a mean of 26 ± 7.4
months. The investigators results, showing good technique survival
and low peritonitis rate, suggested that CAPD should be promoted to
become a full arm of the integrated care of ESRD in Saudi Arabia.
18. In 2003, Malik et al 144 described two cases of tuberculous (TB)
peritonitis on chronic peritoneal dialysis (PD). The cases were diagnosed
by positive acid fast bacilli (AFB) culture from the PD fluid effluent.
Catheter removal and transfer to hemodialysis were needed in one,
while the other remained on continuous ambulatory peritoneal dialysis.
The patients recovered with antituberculous therapy. A high index of
suspicion for early diagnosis and treatment was emphasized. A six-
month course of anti-TB drugs for TB peritonitis was a viable option
19. In 2004, Tarif 145 reported a case of a 69-year-old African American
female with end-stage renal disease secondary to hypertensive
nephrosclerosis on chronic ambulatory peritoneal dialysis (CAPD) for
five years. Her past was uneventful. She presented with symptoms and
signs of acute peritonitis related to CAPD. There was initial response
to antibiotics and culture was negative. The condition of the patient
deteriorated despite the antibiotic. The peritoneal catheter was
removed after five days of starting the antibiotic. The patient died at
day seven of presentation due to septic shock and the culture eventually
grew Candida lusitaniae, a rare agent of peritonitis in CAPD patients,
which was resistant in vitro to amphotericin B.
20. In 2004, Al-Hashemy et al 146 described a two port technique for
laparoscopic placement of PD catheters in nine patients. This prospective
study was carried out at The Armed Forces Hospital, Khamis Mushayt,
Saudi Arabia. Nine patients with ESRD underwent laparoscopic placement
of the PDC between January 2001 and May 2002. There were seven
females and two males, with a mean age of 52 years (range 38-75 years).
The mean operating time was 41 minutes (range 30 –75 min). The
mean post-operative hospital stay was 4.5 days (range 2-15 days). Two
patients (22.2%) developed leakage of dialysate from the 5 mm-port
and one patient (11.1%) had migration of the PDC. this study suggested
that this new modified technique appeared to be safe and simple and
was associated with rapid post-operative recovery.
21. In 2005, Al Wakeel et 147 studied the complications of CAPD in 65
patients treated at their hospital from October 1996 to January 2002.
There were 32 (49%) males and the mean age of the patients was 48 ±
16 years. All the patients were on the twin bag CAPD system. The
mean duration of follow-up on CAPD was 29 ± 20 months. There were
75 episodes of complications occurring in the patients with a rate of
0.41 episodes/patient years. Peritonitis was the most frequent and
serious complication accounting for 55 episodes with a rate of 0.35
episodes/patient years. Only 51% of the episodes showed positive
culture; the organisms included Staphylococcus epidermidis (18.2%),
Staphylococcus aureus (3.6%), Pseudomonas (16.4%), E. coli (1.8%),
Azadobacter (5.45%) and Serratia (3.6%). All the episodes of infection,
except one, responded to treatment but 10 patients had recurrent
infection; one patient was cured only after removal of the catheter.
There were 12 exit site infection episodes and five catheters were
removed due to mechanical and infectious reasons. Three patients were
switched to hemodialysis (HD), nine patients were transplanted and 11
patients expired; none died due to peritonitis. The authors concluded
that the mortality rate of the complications on CAPD had declined in
the present study compared to their previous report early in the 1990s
due mostly to the adoption of the twin bag CAPD system.
22. In 2005, Kari 148 reported about the peritoneal dialysis in children at
King Abdul Aziz Hospital, Jeddah, Saudi Arabia, from June 2000 to
June 2004. A total of 15 children (9 boys and 6 girls) with end-stage
renal failure (ESRF) received PD for a mean duration of 9 ± 8.6
months; 11 children received continuous ambulatory dialysis (CAPD)
and four received automated PD. The mean age of the children at the
start of PD was 7.3 ± 4.3 years. All the children had low socio-
economic status. The most common complication was peritonitis (53%)
followed by exit site infection (26.6%). The over all rate of peritonitis
was one episode per 5.9 patients treatment months. Five children had
recurrent peritonitis. Gram negative bacteria were the cause of
peritonitis in 43.5% of the cases, gram positive in 30.4%, fungi in 8.9%
and unknown in 17.4%. PD catheters were removed in five children;
four because of infection and one because of obstruction. Three children
were shifted to hemodialysis permanently; two children received renal
transplantation from living donors and five children died. There was no
difference in the age, duration of therapy or number of siblings,
between the eight children who had peritonitis and the seven children
who did not have peritonitis. However, illiteracy was higher and a
separate room was less available in the peritonitis group compared to
the peritonitis free group (37.5% vs 14.3% and 50% vs 100%, respectively).
The author concluded that PD might still be a suitable modality of
renal replacement therapy for children living in low socioeconomic
conditions despite the challenging problems in them.
23. In 2006, Souqiyyeh et al 149 studied the attitude of physicians
toward establishing and maintaining peritoneal dialysis programs in
Saudi Arabia. The authors sent a questionnaire to 160 physicians; the
heads of the 148 active dialysis centers in the KSA and 12 more
consultants working in them. This covered decision makers in 109/148
(73.6 %) centers in ministry of health (MOH), 18/148 (12.2%) centers
in governmental (non-MOH) and 21/148 (14.2 %) centers in private
hospitals that care for a population of more than 7300 chronic hemodialysis
and 559 peritoneal dialysis. The study was performed between September
and December, 2005. There were 145 out of 160 (90.6%) physicians
who answered the questionnaire from 141 (95.2%) of the dialysis
centers that covered 620 (98.2%) of the dialysis patients in the KSA.
There were 81 (56.3%) respondents who believed that the follow-up of
the PD patients should be available in all the dialysis centers, 80
(55.2%) would like to have a PD clinic at their hemodialysis (HD)
centers and only 20 (13.8%) had already PD clinics in them. However,
93 (66.4%) respondents did not request from the administration of their
hospitals to open a PD clinic and 62 (44.6%) admitted to having no
expertise in managing the patients on PD, while 53 (38.1%) claimed no
enough space in their dialysis centers as the obstacle to start a PD
program. The response to the question about the training, which the
staff had received previously showed that 57(40.7 %), 58 (43.3 %), 48
(35.6 %), 72 (52.9 %) physicians had training on continuous ambulatory
PD (CAPD), Intermittent peritoneal dialysis (IPD), Automated peritoneal
dialysis (APD) or continuous cyclic peritoneal dialysis (CCPD), and
acute PD, respectively. Only 36 (36%) respondents believed that at
least one nurse in their respective centers had training on any of the
modes of PD. The comparisons between the health sectors in the KSA
showed that MOH had significantly less number of active PD
programs and this reflected tremendously on the knowledge of the
staff. We conclude that the current practices concerning the PD
programs in the dialysis centers in the KSA are modest and require a
new strategy to spread this modality of therapy horizontally in all the
dialysis centers and vertically by implicating the newest technologies
in the field of PD such automated PD machines and connectology.
There is also a need to increase the awareness of physicians about the
benefits and applicability of PD in those centers that lack this service.
The authors believed that national guidelines and training were
indispensable and could not be overemphasized to improve this service
especially in the MOH hospitals.
I. Initiation of Dialysis
1. When to Initiate Dialysis
1 Patients should be advised to initiate some form of dialysis when
the weekly renal Kt/Vurea (Krt/Vurea) falls below 2.0. A weekly Krt/
Vurea of 2.0 approximates a kidney urea clearance of 7 mL/min and
a kidney creatinine clearance that varies between 9 to 14 mL/min/
1.73 m2. Urea clearance should be normalized to total body water
(V) and creatinine clearance should be expressed per 1.73 m 2 of
body surface area. The GFR, which is estimated by the arithmetic
mean of the urea and creatinine clearances, will be approximately
10.5 mL/min/ 1.73 m2 when the Krt/Vurea is about 2.0.
2 The conditions that may indicate dialysis is not yet necessary even
though the weekly Krt/Vurea is less than 2.0 are:
2.1 Stable or increased edema-free body weight.
2.2 Supportive objective parameters for adequate nutrition such as
a lean body mass >63% or subjective global assessment (SGA)
score indicative of adequate nutrition.
2.3 Complete absence of clinical signs or symptoms attributable to
3 The PD outcome data for a weekly Kt/Vurea of ≥2.0 are so
compelling that using the same figure for initiation of dialysis
justifies the small risks of performing peritoneal dialysis.
4 The risks of early initiation of PD are not known, but that the risks
of late initiation are known and are unacceptable.
5 Patients with diabetes should initiate dialysis at levels of RKF
higher than in patients with causes of ESRD other than diabetes.
6 The nephrologists must explain to the patient the risk of
malnutrition with delayed initiation of dialysis and the strong
inferential evidence that survival might be improved with an
earlier start of dialysis.
2. Indications for Renal Replacement Therapy
1. In patients with chronic kidney failure (eg, GFR < 15 to 20
mL/min) who are not undergoing maintenance dialysis, if protein-
energy malnutrition (PEM) develops or persists despite vigorous
attempts to optimize protein and energy intake and there is no
apparent cause for malnutrition other than low nutrient intake,
initiation of maintenance dialysis or a renal transplant is
2. Patients with CKD need to undergo nutritional assessment at
frequent intervals so that any deterioration in nutritional status can
be detected early.
3. Any of the following nutritional indicators show evidence of
deterioration that warrant the initiation of dialysis:
3.1 More than a 6% involuntary reduction in edema-free usual body
weight (%UBW) or to less than 90% of standard body weight in
less than 6 months.
3.2 A reduction in serum albumin by greater than or equal to 3 g/L
and to less than 40 g/L in the absence of acute infection or
inflammation, confirmed by repeat laboratory testing.
3.3 A deterioration in SGA by one category (i.e. normal, mild,
moderate, or severe).
II. Suitable Patients for Peritoneal Dialysis
1. Indications for PD
1. Indications for PD include:
1.1 Patients who prefer PD or will not do hemodialysis (HD).
1.2 Patients who cannot tolerate HD (eg, some patients with
congestive or ischemic heart disease, extensive vascular disease,
or in whom vascular access is problematic, including the
majority of young children).
1.3 Patients who prefer home dialysis but have no assistant for HD.
or whose assistant cannot be trained for home HD.
2. Absolute Contraindications for PD
1. Absolute contraindications for PD include:
1.1 Documented loss of peritoneal function or extensive abdominal
adhesions that limit dialysate flow.
1.2 In the absence of a suitable assistant, a patient who is physically
or mentally incapable of performing PD.
1.3 Uncorrectable mechanical defects that prevent effective PD or
increase the risk of infection (eg, surgically irreparable hernia,
omphalocele, gastroschisis, diaphr-agmmatic hernia, and bladder
2. PD advantages include:
2.1 Flexible treatment schedule
2.2 Less restricted diet
2.3 Prolonged residual renal function
2.4 Better for patients awaiting transplantation and have no HCV
2.5 Patients have more freedom to travel.
3. Relative Contraindications for PD
1. Relative contraindications for PD include:
1.1. Fresh intra-abdominal foreign bodies (eg, 4-month wait after
abdominal vascular prostheses, recent ventricular peritoneal
1.2 Peritoneal leaks into subcutaneous tissues, pleural space, or
genitalia can be painful and cause local problems. Leaking into
the vagina or rectum increases the risk of contamination.
1.3 Body size limitations when the patient is either too small to
tolerate the prescribed dialysate volume or too large to achieve
1.4 Intolerance to PD volumes that are necessary to achieve adequate
1.5 Inflammatory or ischemic bowel disease or frequent episodes of
1.6 Abdominal wall or skin infection.
1.7 Morbid obesity (in short individuals). The possibility that
increased caloric absorption from the dialysate could lead to
further weight gain should also be considered.
1.8 Severe malnutrition. Wound healing is compromised in severely
malnourished patients. Furthermore, peritoneal protein losses
may not be tolerated.
4. Indications for Switching from PD to HD
1. The decision to transfer a PD patient to HD should be based on
clinical assessment, the patient's ability to reach HD dose target
levels, and the patient's wishes.
2. Indications for switching from PD to HD include:
2.1 Consistent failure to achieve target Kt/Vurea and Ccr when there
are no medical, technical, or psycho-social contraindications to
2.2 Inadequate solute transport or fluid removal. High transporters
may have poor ultrafiltration and/or excessive protein losses
(relative contraindication, obviously discovered after initiation
and the first PET).
2.3 Unmanageably severe hyper-triglyceridemia resulting from, or
exacerbated by, the dextrose load intrinsic to the dialysate, may
increase the risk for cardiovascular disease.
2.4 Unacceptably frequent peritonitis or other PD-related
complications. The definition of unacceptably frequent
peritonitis has to be individually determined for each patient.
Such considerations as the availability of hemodialysis facili-ties
will inevitably play a role.
2.5 Development of technical/mech-anical problems such as
catheter malposition resulting in access failure, hydrothorax,
hernia, or hydrocele.
2.6 Severe malnutrition resistant to aggressive management
2.7 Patients should be informed of the risks of staying on PD at a
level of adequacy below that recommended by their physician.
III. Access for Peritoneal Dialysis
1. Choice of Catheter and General Rules
1. Catheter survival of >80% at 1 year is a reasonable goal.
2. Convincing data exist to indicate that the double-cuff catheter is
preferable to the single-cuff catheter; therefore a double-cuff
configuration is advocated.
3. A downward-directed exit may decrease the risk of catheter-related
4. Properly implanted, preformed arcuate or pail-handle catheters,
will always have a downward-directed exit and are, therefore,
advantageous in this respect.
5. Overall, no catheter yet appears to be superior to the original 2-
cuff, standard Tenckhoff catheter, although experience with Swan
neck catheters is promising. The size of the catheter for should be:
adult or pediatric.
6. The experience in general surgical practice indicates that
perioperative antibiotics, especially in the presence of a foreign
body, diminish the incidence of wound infection.
6.1 A first-generation cephalosporin has been most frequently used
in this context and is advocated especially in centers with high
postoperative wound or exit infections.
6.2 Vancomycin should not be routinely used for perioperative
prophylaxis to avoid the development of resistant micro-
organisms such as vancomycin-resistant enterococci (VRE) and
vancomycin-resistant Staph aureus.
6.3 Assess the bowel condition and apply cleansing enema.
6.4 Mark the exit site while the patient is in the sitting position.
6.5 Ensure good abdomen hygiene.
6.6 Nasal ointment application for treatment of Staphylococcal
colonization in the patient and sitter.
2. Implantation of the Catheter
1. The implantation must be performed by a competent and experienced
operator, in a planned manner. Laparoscopic insertion may be
attempted by expert hands.
2. The procedure must be regarded as an important surgical intervention
demanding care and attention to detail equal to any other surgical
2.1 Peritoneal entry should be lateral (deep cuff in or below the
rectus musculature), or paramedian (deep cuff at the medial
edge of the rectus muscle), to give good deep-cuff fixation and
minimize herniation and fluid leaks.
2.2 Other entry sites (midline through the linea alba) are used with
2.3 The deep cuff should be placed in the musculature of the
anterior abdominal wall or in the preperitoneal space.
2.4 Good results have also been obtained with the cuff placed
within the posterior rectus fascia.
2.5 The deep cuff should never be placed within the peritoneal
2.6 After proper positioning of the catheter tip, the peritoneum is
closed tightly around the catheter below the level of the deep
cuff using a purse-string suture.
2.7 The subcutaneous cuff should be located near the skin surface
and at a distance of at least 2 cm from the exit site. Care should
also be taken to avoid mechanically stressing the cuff material.
2.8 Check for catheter patency. The catheter should be tested to
ensure that there is adequate inflow and outflow without leakage.
Techniques to accomplish this include infusing 1 L of
peritoneal fluid over 5 minutes and allowing an equal time for
drainage, or injecting 60 mL of 0.9% saline and observing if
30-40 mL is easily aspirated.
2.9 The exit site should be facing downwards or be directed later-
ally. Upward-directed exit sites should, in general, be avoided.
2.10 The intra-abdominal portion of the catheter should be placed
between the visceral and parietal peritoneum toward the pouch
of Douglas and should not be placed within loops of bowel or
directly in omental tissue.
2.11 Generally, the catheter should be capped for at least 2 weeks
before initiating CAPD.
2.12 Peritoneal dialysis in this interim period should be
intermittent, using small volumes and with the patient in a
2.13 Avoid irritating or toxic solutions for cleansing; if povidone
iodine or hydrogen peroxide are used, keep them out of the
sinus or wound.
2.14 Use absorbent dressings and keep the exit as dry as possible.
2.15 Continue sterile dressings until the exit is healed.
2.16 Immobilize the catheter.
2.17 Infrequent dressings' changes (once per week) suffice for the
first 2-3 weeks.
3. Care of the Exit Site
1. Catheter exit sites should be washed daily or every other day with
antibacterial soap or a medical antiseptic to keep the exit clean and
to diminish resident bacteria.
2. The choice of soap or cleansing agent may need to be individualized
because of skin sensitivities or allergies.
3. It is important not to forcibly remove crusts or scabs during cleansing
because this may traumatize the exit, causing a break in the skin
and thus increase the risk of exit infection.
4. The exit should be patted dry after cleansing. The use of sterile
gauze or cotton-tipped applicators is not necessary for care of the
healed exit; a clean wash cloth and towel is sufficient.
5. Liquid soap and disinfectants should not be transferred to other
containers because of the risk of cross-contamination.
6. Antibiotic therapy is essential for established exit and tunnel
7. Duration of therapy is for a minimum of 2 weeks, at which stage
the nonresponders need further evaluation and therapy.
8. Therapy with cuff shaving may be successful in difficult situations
but long-term outlook for these catheters in not good.
9. Topical applications may cure equivocally infected exits; they are
of no proven value in eradication of overt infections.
10. Catheter removal is essential in nonresponding tunnel infections,
especially where there is associated peritonitis.
11. Increased frequency of exit-site care (1-2 times daily) is
recommended when there is an exit or tunnel infection. Crusts
should not be forcibly removed.
12. Patients who are nasal carriers of Staphylococci aureus may receive
prophylaxis; no one regimen of era-dication is superior. As a
maneuver to prevent exit-site infections, applica-tion of mupirocin
to the exit site as part of the daily routine is advocated.
13. Trauma to the catheter tract should be avoided by proper
immobilization and should be reported to the dialysis unit if it
causes severe pain or bleeding, or if there is subsequent deterioration
of the exit-site appearance with redness, exudates, persistent pain
14. For a recurrent leak, surgical repair is essential and the site of the
leak may be localized using computerized tomography.
15. Before treating a catheter obstruction, the type of obstruction must
be established, if necessary, by catheter fluoroscopy. The treatment
15.1 Conservative or noninvasive approaches should be undertaken
a. Body position change.
b. Walk on staircases.
d. Flushing with heparinized saline.
15.2 If these fail, then instillation of fibrinolytic agents (urokinase,
streptokinase 10,000 U in 2 mL left in the catheter for 2 hours)
may be tried.
15.3 In the case of recurrent fibrin clots, heparin in doses of 500 -
1000 U/L dialysis fluid may prevent obstruction.
15.4 Aggressive therapies include:
a. Blind techniques using fluoroscopically guided stiff wires
or stylet manipulation (rotating maneuver) combined with
the whiplash technique cleaning out with a Fogarty
catheter, or use of an intraluminal brush;
b. Direct or visualized techniques of peritoneoscopy, open
surgical catheter revision, or catheter replacement.
IV. Solutions for Peritoneal Dialysis
1. There is increasing awareness of the unfavorable properties of
glucose as an osmotic agent.
2. In selected patients (those with high small solute transfer rates and
little or no residual function) specialized solutions such as glucose
polymers (icodextrin) are preferable to standard solutions.
3. Icodextrin may have particular value in improving ultrafiltration in
patients and claimed to extend time on PD. Thus, it may be a cost
effective method that avoids a transfer to HD.
4. Other solutions with variations in the concentration of sodium,
calcium, magnesium, osmotic agents and buffers (bicarbonate) may
also be required. Such solutions are likely to be more expensive.
5. The place of amino acid-containing dialysis fluid still has to be
6. In the future, newer PD solutions with more effective osmotic
agents may be of use in resolving chronic fluid overload. In the
meantime, consider the following strategies:
6.1 The use of loop diuretics in patients with persisting urine output
(more then 200 ml output)
6.2 The addition of a fifth exchange via a night exchange device in
patients who tend to reabsorb their nocturnal dwell (High
glucose concentration or icodextrin) is recommended.
6.3 Switching patients who do not ultrafitrate well on CAPD to
APD short day dwells on APD according to the membrane
6.4 If volume status is not well controlled, switching patients to
V. Continuous ambulatory peritoneal dialysis
1. Known for its simplicity, CAPD is the preferred mode of peritoneal
dialysis to initiate most patients on.
2. In CAPD, dialysis solution is constantly present in the abdomen.
The solution is typically changed four times daily, with a range of
three to five times depending on individual patient requirements.
3. Drainage of "spent" dialysate and inflow of fresh dialysis solution
are performed manually, using gravity to move fluid into and out
of the peritoneal cavity
4. The Y disconnects and disposable tubing is the transfer set of
choice for CAPD patients. A Y-shaped piece of tubing is attached
by its stem to the patient's catheter or extension tubing at the time
of each solution exchange. During the exchange, the afferent and
efferent limbs of the Y are attached to a bag of fresh peritoneal
dialysis solution and to a drain bag, respectively. In some cases,
the drain bag is the empty solution bag that was used in the previous
5. Most Y sets are not attached directly to the catheter but rather to a
short (15 to 24 cm) adapter or extension tubing inserted between
the catheter and the stem of the Y set. The extension tubing avoids
the need for, and the risk of damage associated with, repeated
clamping of the catheter
6. The exchange procedure includes:
6.1 Spike/lock: The fresh bag of dialysis solution is attached to the
afferent limb of the Y set via a spike or Luer lock.
6.2 Connect: The stem of the Y set is connected to the adapter
6.3 Drain: The stem and efferent limb of the Y are unclamped and
the spent dialysate is drained from the peritoneal cavity into the
6.4 Flush: With the stem of the Y set clamped, approximately 100
mL of fresh solution is flushed from the new bag through the
afferent limb of the Y into the efferent limb and so into the drain
6.5 Fill: The efferent limb is clamped and the stem unclamped, and
the peritoneal cavity is filled from the new bag of dialysis
6.6 Disconnect: The Y set is then disconnected from the adapter
tubing and a new set is used for the next new cycle.
7. The double-bag systems are a variant of the Y set in which the
solution bag comes preattached to the afferent limb of the Y tubing
obviating the need for any spike or Luer lock connection:
7.1 The drain bag is similarly preattached to the efferent limb, and
the only connection the patient needs to make is thus between the
transfer set and the extension tubing.
7.2 A flush-before-fill step is still performed, but the purpose is only
to flush out residual air and not to prevent peritoneal cavity
contamination, as this is no longer relevant in the absence of a
need to make a transfer set-to-solution container connection.
8. The double bag system is now more popular system than the
standard Y sets.
9. Catheter-to-transfer set (or extension tubing-to transfer set)
9.1 Catheter connector: A special Luer lock connector made of tita-
nium was developed as an adaptor. Titanium was chosen for its
light weight and resistance to electrolyte containing solutions.
Designed for easier handling and a tighter connection. The new
product functions very well. The catheter-to-transfer set connect-
ors constructed from more durable plastics are also available.
9.2 With the advent of the disconnect Y sets and double bags, the
need for easy yet sterile connection at the catheter-to-transfer set
joint (or adapter-to-transfer set joint) has arisen. A number of
new connectors for this purpose are now available.
10. With the advent of the double bag systems, technologies to
facilitate the connection between the transfer set and the peritoneal
dialysis solution container are less relevant such as the spike-and-
port design and the easy-lock connectors
VI. Automated Peritoneal Dialysis (APD)
1. Patients selection for APD
1. APD refers to the use of a cycler for various regimens, including
nightly intermittent peritoneal dialysis (NIPD), continuous cycling
peritoneal dialysis (CCPD) and tidal peritoneal dialysis (TPD;
nightly, NTPD, or continuous, CTPD). Intermittent peritoneal dialysis
(IPD) two or three times/week is not recommended because
satisfactory clearances are seldom achieved with this modality.
2. APD should be prescribed in preference to continuous ambulatory
peritoneal dialysis (CAPD) for patients in whom minimizing the
time spent performing peritoneal dialysis (PD) is an important
consideration (e.g. workers, school pupils, students, carers of
elderly or debilitated patients).
3. APD treatment is associated with lower rates of peritonitis, overall
hospital admissions and hospital admissions for dialysis-related
4. Low-low average transport patients generally achieve better clearances
with continuous regimens such as continuous ambulatory peritoneal
dialysis (CAPD) and continuous cyclic peritoneal dialysis (CCPD)
whereas high-high average transport patients achieve better small
solute clearances with short dwell techniques such as nocturnal
peritoneal dialysis (NPD), and nocturnal tidal peritoneal dialysis
(NTPD).Table 1 shows the peritoneal membrane characteristics
according to PET result.
5. Increasing the fill volume, the number of exchanges or the amount
of ultrafiltration should increase clearances in most patients. Some
patient populations may not tolerate increasing dwell volumes in
CAPD, especially small patients. Even larger patients often cannot
achieve targets set despite the increase in dialysis dose on CAPD.
Use of APD should be considered in this group.
6. APD may not enhance peritoneal ultrafiltration in PD patients with
high and high-average transport status. APD is associated with
poorer sodium removal than CAPD. Sodium removal can be
enhanced in APD patients by the use of icodextrin, supplementary
diurnal exchanges and longer nocturnal dwell times.
7. There are no randomized, double-blind controlled trials to confirm
that the use of APD accelerates the loss of RRF. Theoretical reasons
why APD might accelerate the loss include rapid changes in fluid
volume resulting in an ischemic insult to the kidney or the use of
icodextrin or hypertonic glucose.
8. Use of the 'dry day' in NIPD reduces clearance by up to 10%-15%
compared with CAPD or CCPD. Therefore, a daytime exchange is
9. Tidal modalities (TPD) have been proposed to more efficiently
increase small solute clearances in APD, in part by reducing the
impact of drain-fill multiplication but at higher cost. This is due to
an effective increase in dialysis flow rate.
9.1 In the low-low average group, IPD improved urea and creatinine
clearances compared with TPD at low flow rates with similar
volumes and length of treatment, but not once flows were increased.
9.2 In high transporters, urea and creatinine clearances were greater
than in low-low average transporters, with no difference between
the PD modalities at low and high flow rates.
9.3 Ultrafiltration does not improve with increasing volumes.
9.4 Anuric, low peritoneal membrane transport patients have
difficulty achieving adequate small solute clearances with TPD.
Membrane type 4-hr dialysate/ Non-DM DM
High 0.81-1.03 9% 10%
High Average 0.65-0.80 56% 51%
Low Average 0.50-0.64 32% 37%
Low 0.34-0.49 3% 2%
DM: Diabetes mellitus.
VII. Measures of Peritoneal Dialysis Dose
1. Frequency of Delivered PD Dose and Total Solute Clearance
Measurement within Six Months of Initiation
1. The total solute clearance (delivered PD dose plus residual kidney
function determined by CCr and Kt/V urea) should be measured at
least twice and possibly three times within the first 6 months after
initiation of PD; the first measurement should be performed
approximately 2-4 weeks after initiation of PD.
2. Delivered peritoneal dialysis dose depends on many factors, including
the transport properties of the peritoneal membrane, assessed by
the peritoneal equilibration test (PET). The results after a month of
PD may more accurately reflect peritoneal transport properties for
the subsequent period.
3. In the absence of substantial renal kidney function (RKF), waiting
1 month to measure delivered dose may result in inadequate dialysis
for 1 month. Patients as such should undergo measurement of
delivered dose of PD at 2 weeks.
4. While decrease of urine production rate is presumed to be a clue to
deteriorating RKF, that is not always the case. Accordingly, RKF
should be measured every 2-4 months or when urine output
2. Measures of PD Dose and Total Solute Clearance
1. Both total weekly creatinine clearance normalized to 1.73 m2 body
surface area (BSA) and total weekly Kt/Vurea should be used to
measure delivered PD doses.
3. Frequency of Measurement of Kt/Vurea, Total CCr>
PNA, and Total Creatinine Appearance
1. After 6 months, total Kt/Vurea, total CCr, and PNA (with all its
components) should be measured every 6 months, unless the
prescription has been changed or there has been a significant
change in clinical status
2. A change in clinical condition, which warrants measurement of
delivered PD dose is defined as:
2.1 Any serious problem, which affects the nutritional status.
2.2 The decrease in the ability of the patient to perform PD
mechanically or technically (such as stroke or arthritis, loss of
surface area from surgery.
2.3 The decreased exchange volumes due to hernias, etc.
2.4 The permanently affected transport properties of the peritoneum
(eg, protracted peritonitis).
2.5 Any suggestion of exacerbation of uremia.
4. Assessing Residual Kidney Function
1. Residual kidney function (RKF), which can provide a significant
component of total solute and water removal, should be assessed
by measuring the renal component of Kt/Vurea (Krt/Vurea).
2. Creatinine clearance corrected for renal secretion and Kt/Vurea are
both valuable measures in the management of PD patients. Each
measure offers different information.
3. The measurement of GFR with endogenous solutes is best done by
defining GFR as the arithmetic mean of urea and creatinine
clearance .This arithmetic mean essentially corrects for secretion
5. PD Dose Troubleshooting
5.1 In adult patients, a daily creatinine excretion in urine and dialysate
that differs from the baseline rate by >15% should prompt an
investigation for noncompliance, improper collection of drained
dialysate and/or urine, or altered peritoneal transport function.
Compliance should not be assessed by comparing measured to
predicted creatinine excretion.
VIII. Measurement of Peritoneal Dialysis Dose
1. Reproducibility of Measurement
1. Accurate measurement of total Kt/Vurea and total creatinine
clearance (CCr) requires collection and analysis of urine, dialysate,
and serum in a way that yields reproducible and valid results.
2. Dialysate creatinine concentration must be corrected for the
presence of glucose in some assays.
3. Peritonitis precludes reliable measurement of delivered PD dose
for up to a month.
4. Compliance with complete collections is mandatory.
5. For patients who void ≥3 times per day, a 24-hour urine collection
is sufficient. For patients who void less frequently, a 48-hour
collection is recommended.
6. For CAPD patients, the serum sample can be obtained at any
7. For NIPD patients, the serum sample should be obtained at the
midpoint of the daytime empty period.
8. For CCPD patients, the serum sample should be obtained at the
midpoint of the daytime dwell.
2. Estimating Total Body Water and Body Surface Area
1. V (total body water) should be estimated by either the Watson or
Hume method in adults using actual body weight and by the
Mellits-Cheek method in children using actual body weight.
1.1.Watson method: For Men: V (liters) = 2.447 + 0.3362*Wt (kg) +
0.1074*Ht (cm) - 0.09516*Age (years). For Women: V = -2.097 +
0.2466*Wt + 0.1069*Ht
1.2 Hume method: For Men: V = -14.012934+0.296785*Wt+0.192786*Ht.
For Women: V= -35.270121 +0.183809*Wt + 0.344547*Ht
1.3 Mellits-Cheek method for children:
a- For Boys: V (liters) = -1.927 +0.465*Wt (kg) + 0.045*Ht (cm),
when Ht < 132.7 cm. V= -21.993 + 0.406* Wt + 0.209*Ht, when
height is > 132.7 cm.
b. For Girls: V = 0.076 + 0.507*Wt + 0.013*Ht, when height is < 110.8 cm.
V = -10.313 + 0.252* Wt + 0.154*Ht, when height is >110.8
2. Body surface area. BSA, should be estimated by either the Dubois
and Dubois method, the Gehan and George method, or the Haycock
method using actual body weight. For all formulae, Wt is in kg and
Ht is in cm:
2.1. DuBois and DuBois method: BSA (m2) = 0.007184*Wt 0.425*Ht
2.2. Gehan and George method: BSA (m2) = 0 0235*Wt 0.45l456*Ht 0.42246
2.3. Haycock method: BSA (m2) = O.O24265*Wt°.5378*Ht 0.3964
3. Amputation alters the relationship between body height and weight.
This causes a mathematical distortion of the calculation of both
anthropometric V and BSA.
3. Timing of Measurement
1. Routine measurements of total Kt/Vurea and total creatinine
clearance should be performed when the patient is clinically stable
(eg, stable weight, stable BUN and creatinine concentrations) and
at least 4 weeks after resolution of peritonitis.
IX. Assessment of Nutritional Status in Relation to
1. Assessment of Nutritional Status
1. Nutritional status of adult PD patients should be assessed on an
ongoing basis in association with Kt/Vurea and CCr measurements
using the Protein equivalent of Nitrogen Appearance (PNA) and
Subjective Global Assessment (SGA).
2. PNA(g/24 hours) = 15.1 +(6.95 X urea nitrogen appearance in
g/24h)+ dialystate and urine protein in g/24 hours
3. In the absence of direct measurement of urinary and dialystate protein
losses, a less accurate formula may be used: PNA (g/24hours) =
20.1 + (7.50 x urea nitrogen appearance in g/24 h)
4. For pediatric PD patients, nutritional status should be assessed
using the PNA and other standard nutritional assessments
5. SGA addresses four items (recent weight change, anorexia,
subcutaneous tissue, and muscle mass) scored on a 7-point scale,
where 1 or 2 is severe malnutrition, 3 to 5 is moderate to mild
malnutrition, and 6 or 7 is mild malnutrition to normal nutritional
5.1 The SGA can be performed by physicians, nurses, or registered
dietitians during routine clinic visits.
5.2 Higher SGA is associated with a lower risk of death.
5.3 The SGA should be performed in association with measurement of
Kt/ Vurea and CCr, every 4 months after the initial 6 months
6. Although nutritional status is influenced by many nondialysis-
related factors, appetite suppression, nausea, and vomiting are
major clinical features of uremia and inadequate dialysis.
2. Determining Fat-Free, Edema-Free Body Mass
1. Total creatinine appearance should be used to determine fat-free,
edema-free body mass (lean body mass)
2. In adults, fat-free, edema-free body mass in kilograms is computed
by the equation: Fat-free, edema-free body mass = 0.029 X total
creatinine production in mg/day+7.38
2.1 Norms vary by patient gender and size. A steady-state of
creatinine excretion should exist for the equation result to be
2.2 Fat-free, edema-free body mass estimates by creatinine kinetics
may be a better index of nutritional status in PD patients, because
they reflect dry fat-free, edema-free body mass and changes in
muscle mass better than dual-energy x-ray absorptiometry or
2.3 A change in serum creatinine concentration may indicate changes
in creatinine and urea removal to a much larger extent than a
change in serum urea concentration.
2.4 A rising serum creatinine concentration is usually caused by a
decrease in total creatinine clearance, often secondary to a loss of
residual kidney function, and much less frequently by an increase
in muscle mass
2.5 A decreasing serum creatinine concentration is caused more often
by progressive loss in muscle mass and less often by an increase
in total clearance.
3. Use of the Modified Borah Equation to Assess
Nutritional Status of Pediatric PD Patients
1. Nutritional status of pediatric PD patients should be assessed at
least every 6 months by standard clinical nutritional evaluations
and by the modified Borah equation: PNA(g/d) = [6.49*UNA] +
X. Adequate Dose of Peritoneal Dialysis
1. Weekly Dose of CAPD
1. For CAPD, the delivered PD dose should be a total Kt/V urea of at
least 2.0 per week and a total creatinine clearance (CCr) of at least
60 L/wk/ 1.73 m2 for high and high-average transporters, and 50 L/
wk/1.73 m2 in low and low-average transporters.
2. There are currently no definitive outcome data in pediatric patients
to suggest that any measure of dialysis adequacy is predictive of
well-being, morbidity, or mortality.
2. Weekly Dose of NIPD and CCPD
1. For NIPD, the weekly delivered PD dose should be a total Kt/V urea
of at least 2.2 and a weekly total creatinine clearance of at least 66
2. For CCPD, the weekly delivered PD dose should be a total Kt/Vurea
of at least 2.1 and a weekly total creatinine clearance of at least 63
3. PD Dose in Subpopulations
1. There is no adequate basis for recommending any change in the
target doses of dialysis: Weekly Dose of CAPD, Weekly Dose of
NIPD and CCPD, for various patient subpop-ulations (eg, patients
with diabetes or who are elderly), with the exception of the
malnourished patient, whose target dose is increased by the ratio of
the Vdcsircd/ Vactual for Kt/Vurea.
4. Approach for Determination of Dose of Peritoneal Dialysis
1. General Evaluation of the Patient with Kidney Failure
1.1 Explain all options (transplant, HD, and PD) to patients/parents/
care-givers in a nonbiased manner.
1.2 Review medical condition/co morbidities to determine if
contraindications, relative or absolute, exist for any modality.
1.3 If no medical contraindications exist and the patient is a
candidate for self therapy, allow patient to choose a modality.
1.4 Place the chronic dialysis access (PD or HD). Vascular accesses
can be placed in patients on PD. This decision should be made
on an individual patient basis.
1.5 If dialysis is needed at the time of presentation, place the
temporary HD access, or after placing the PD catheter, initiate
therapy as suggested under point B.2, below.
2. Initiation of Peritoneal Dialysis
2.1 If possible, wait 10 days to 2 weeks after catheter placement to
2.2 If PD must be started in less than 10 days following catheter
placement, do low-volume, supine dialysis.
2.3 Obtain baseline 24-hour urine collection for urea and creatinine
clearance. These collections are for solute clearance
calculations, assessment of creatinine gene-ration, and PNA
2.4 Note patient's weight and the presence or absence of edema.
2.5 At initiation of dialysis explain to patient/ parents/caregivers
that the patient's prescription will be individualized.
Specifically, state that their instilled volume almost certainly
will need to increase over time. For patients who choose
Automated Peritoneal Dialysis (APD), one or more daytime
dwells will be needed in approximately 85% of patients.
2.6 Patients should know from the start of PD that their total solute
clearance will be monitored and that, if their residual kidney
function or peritoneal transport changes over time, their
prescription may need to change as well.
3. Initial Dialysis Prescription for Adults
3.1 Initial dialysis can be prescribed empirically based on patient's
weight, amount of residual kidney function, and lifestyle
choices (CAPD, NIPD, or CCPD)
3.2 These empiric recommendations should be implemented prior
4. Observations Needed During Training and Early Follow-up
4.1 Determine 4-hour drain volumes during training. This is to note
if drain volumes are as expected for typical 4-hour dwells with
1.5%, 2.5%, or 4.25% dextrose ex-changes. This is not a formal
PET, but is done to determine if the patient's peritoneal
membrane transport characteristics are markedly different from
4.2 Monitor for evidence of leakage in the vicinity of the catheter.
4.3 Complete laboratory studies.
a. Delay baseline PET until after training.
b. Perform serum chemistries and complete blood count.
c. If a computer-assisted kinetic modeling system is available,
enter preliminary data to predict if the current prescription
will be adequate.
5. Adjusting Dialysis Prescription
5.1 If kinetic modeling is not available:
a. Unless PET has changed, dialysis dose is most effectively
increased by increasing the instilled volume, therefore
maximizing mass transfer and dwell time.
b. Increase the number of ex-changes/day while maintaining
maximum dwell time, ie, by using a single nighttime exchange
to increase to 5 equal dwells/day. To this end, simplified
mechanical exchange systems have been developed to perform a
5.2 If computerized kinetic modeling is available, the dialysis team
can use these programs to tailor a new prescription to meet the
adequate dose of peritoneal dialysis.
XI. Strategies to Achieve Better Prescribed
Dose of Peritoneal Dialysis
1. Identify and Correct Patient-Related Failure to Achieve
Prescribed PD Dose
1. Potential patient-related causes of failure to achieve prescribed
peritoneal dialysis dose should be investigated and corrected.
1.1 Failure to comply with the prescription (estimated 11-18%).
Proper instructions and periodic reinforcement of education
cannot be overemphasized.
1.2 Lack of understanding of the importance of adherence to the full
1.3 Sampling and collection errors.
2. Identify and Correct Staff-Related Failure to Achieve
Prescribed PD Dose
1. Potential staff-related causes of failure to achieve prescribed
peritoneal dialysis dose should be investigated and corrected.
1.1 Errors in prescription. Nephrologists must ensure adequate
education and training in PD.
1.2 Inadequate monitoring of delivered dose.
1.3 Inadequate patient education.
2. Establishing a designated area as a peritoneal dialysis clinic for
follow-up is a must in order to achieve stable service. It is as
important as the establishment of the hemodialysis area in any
XII. Peritoneal Dialysis Related Peritonitis
1. Presentation and evaluation
1. Peritoneal dialysis patients presenting with cloudy effluent should
be presumed to have peritonitis. This is confirmed by obtaining
effluent cell count, differential, and culture
2. Culture-negative peritonitis should not be greater than 20% of
episodes. Standard culture technique is the use of blood-culture
bottles, but culturing the sediment after centrifuging 50 mL of
effluent is ideal for low culture-negative results
3. If a program has a rate of culture-negative peritonitis greater than
20%, then the culture methods should be reviewed and improved
4. Terminology for Peritonitis includes:
4.1 Recurrent: an episode that occurs within 4 weeks of completion
of therapy of a prior episode but with a different organism
4.2 Relapsing: an episode that occurs within 4 weeks of completion
of therapy of a prior episode with the same organism or one
4.3 Repeated: an episode that occurs more than 4 weeks after
completion of therapy of a prior episode with the same organism
4.4 Refractory: failure of the effluent to clear after 5 days of appropriate
4.5 Catheter-related peritonitis: peritonitis in conjunction with an
exit-site or tunnel infection with the same organism or one site
2. Initial choice of antibiotic therapy
1. Empiric antibiotics must cover both gram-positive and gram-negative
organisms. Selection of empiric therapy should be dependent on
the history of sensitivities of organisms causing peritonitis Gram-
positive organisms may be covered by vancomycin or a cephalosporin,
and gram-negative organisms by a third-generation cephalosporin
2. Vancomycin, aminoglycosides, and cephalosporins can be mixed
in the same dialysis solution bag without loss of bioactivity.
3. Aminoglycosides should not be added to the same exchange with
penicillins because of chemical incompatibility.
4. For any antibiotics that are to be admixed, separate syringes must
be used for adding the antibiotics such as vancomycin and ceftazidime,
which are compatible when added to dialysis solutions but
incompatible if combined in the same syringe or added to an empty
dialysate bag for reinfusion into the patient
5. Antibiotics should be added using sterile technique (placing povidone
iodine on the medication port for 5 minutes prior to insertion of the
needle through the port). Dwell time of the exchange must be a
minimum of 6 hours.
6. Data suggest that some antibiotics are stable for variable times
when added to dextrose-containing dialysis solution.
6.1 Vancomycin (25 mg/L) is stable for 28 days in dialysis solution
stored at room temperature, although high ambient temperatures
will reduce the duration of stability.
6.2 Gentamicin (8 mg/L) is stable for 14 days, but the duration of
stability is reduced by admixture of heparin.
6.3 Cefazolin (500 mg/L) is stable for at least 8 days at room
temperature or for 14 days if refrigerated; addition of heparin has
no adverse influence.
6.4 Ceftazidime is less stable; concentrations of 125 mg/L are stable
for 4 days at room temperature or 7 days refrigerated, and 200
mg/L is stable for 10 days if refrigerated.
6.5 Little is known about intermittent dosing requirements in
patients treated with APD.
6.6 Intraperitoneal (IP) dosing of antibiotics for peritonitis is
preferable to IV dosing in CAPD, since IP dosing results in very
high local levels of antibiotics. The IP route has the added
advantage that it can be done by the patient at home.
6.7 Monitoring drug levels for aminoglycosides and vancomycin is
3. Adjustment of antibiotic therapy
1. Once culture results and sensitivities are known, antibiotic therapy
should be adjusted as appropriate. Antibiotic dosing for anuric
CAPD patients defined as daily urine output of less than 100 mL
are different from those with RRF. For the later patients the dose
should be increased by 25% for those antibiotics that have renal
2. Patients who are high transporters and those with high dialysate
clearances may have a more rapid removal of some antibiotics.
Adjustments in dosing for such patients are not yet known, but the
clinician should aim at higher dosing.
3. Refractory peritonitis, defined as failure to respond to appropriate
antibiotics within 5 days, should be managed by removal of the
catheter to protect the peritoneal membrane for future use.
4. Coagulase-negative staphylococcus peritonitis, including S. epidermidis
that is due primarily to touch contamination. It is generally of a
mild form of peritonitis and responds readily to antibiotic therapy,
but can sometimes lead to relapsing peritonitis due to biofilm
involvement. In such circumstances catheter replacement is advised.
5. Streptococcal and enterococcal peritonitis tend to be severe and are
best treated with IP ampicillin.
6. Vancomycin-resistant Enterococcus faecium (VREF) has been
reported but remains uncommon in PD patients; limited data are
available on proper management.
7. Staphylococcus aureus causes severe peritonitis. It is often due to
catheter infection. Catheter-related peritonitis is unlikely to respond to
antibiotic therapy without catheter removal.
8. Pseudomonas aerugenousa peritonitis is similar to S. aureus
peritonitis. Catheter removal will be required and two antibiotics
should always be used to treat it.
9. Other single organism gram-negative peritonitis may be due to
touch contamination, exit-site infection, or transmural migration
from constipation or colitis.
10. If multiple enteric organisms are grown, particularly in association
with anaerobic bacteria, the risk of death is increased and a
surgical evaluation should be obtained
11. Peritonitis due to multiple gram-positive organisms will generally
respond to antibiotic therapy.
12. Catheter removal is indicated immediately after fungi are
identified by microscopy or culture.
13. Mycobacteria are an infrequent cause of peritonitis but can be
difficult to diagnose. When under consideration, special attention
must be paid to culture techniques. Treatment requires multiple
14. The minimum therapy for peritonitis is 2 weeks, although for more
severe infections, 3 weeks is recommended.
15. The removal of the catheter for relapsing peritonitis, refractory
peritonitis, fungal peritonitis, and refractory catheter infections stems
from the fact that we should always be focusing on preservation of
the peritoneum rather than saving the peritoneal catheter.
16. Peritonitis is still the most frequent cause of failure of peritoneal
dialysis and switch to hemodialysis.
XIII. Clinical Outcome Goals for
Adequate Peritoneal Dialysis
4. Measurement of PD Patient Survival
1. Survival of PD patients should be quantitated serially as an
5. Measurement of PD Technique Survival
1. PD technique survival, both dependent and independent of peritonitis,
should be quantitated serially in PD patients as an outcome
2. For some patients, for optimal outcome, it may be medically
appropriate to transfer from PD to HD; this does not imply failure
of the therapy or the dialysis facility.
3. PD technique survival is dependent upon many factors including
infections, patient motivation, ultrafiltration (transport characteristics),
and total solute clearance. Thus, PD technique survival is not a
simple outcome measure for the adequacy of PD.
4. Centers should strive to achieve the goal of a 75% 2-year
technique survival rate.
6. Measurement of Hospitalizations
1. ESRD-related and ESRD-unrelated hospitalizations (admissions/
year, hospitalized days/ year) in PD patients should be quantitated
as an outcome measure.
2. PD patients are hospitalized an average of 1.8 times per year.
3. Centers should also monitor reasons for hospitalization (related
versus unrelated to ESRD, and specific reason for admission).
7. Measurement of Patient-Based Assessment of Quality of Life
1. Patient-based assessment of quality of life (QOL) in PD patients
should be evaluated serially as an outcome measure.
2. A patient-based quality of life instrument should have both generic
and disease/treatment-specific measures of health-related quality
of life and should be shown to be valid, reliable, and responsive
prior to use. Once such an instrument is available, it should be
administered at initiation of dialysis and at intervals determined to be
appropriate by its validation studies.
3. There are many measures used in peritoneal dialysis patients and
reported in the literature such as Medical Outcomes Study Short
Form 36 (SF-36) and Sickness Impact Profile (SIP). According to
the current evidence, no particular instrument can be strongly
recommended over another.
8. Measurement of School Attendance, Growth, and
Developmental Progress in Pediatric PD Patients
1. School attendance (in the absence of other comorbidities
precluding school attendance), growth, and developmental
progress should be measured serially in pediatric PD patients.
9. Measurement of Albumin Concentration in PD Patients
1. A stable or rising serum albumin concentration that is greater than
or equal to the lower limit of normal for each laboratory should be
used as an outcome goal.
2. Low serum albumin is a strong predictor of mortality and
morbidity in PD patients.
3. Efforts to maintain serum albumin in the normal range should
include adequate nutrition, adequate clearances, and prevention
and treatment of catabolic illness.
10. Measurement of Hemoglobin in PD Patients
1. Providers should strive to achieve a hemoglobin level of 110 to
120 g/L in 75% of PD patients.
11. Measurement of Normalized PNA in PD Patients
1. Providers should strive to achieve a normalized PNA (nPNA) of
greater than or equal to 0.9 g/kg/day in PD patients.
2. A dietary protein intake of 1.2 to 1.3 g/kg body weight/day in
clinically stable chronic peritoneal dialysis patients. Should lead to
an nPNA equal to or greater than 0.9 g/kg/day.
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These Guidelines are based upon the best information available
at the time of publication. They are designed to provide information
and assist decision-making. They are not intended to define a
standard of care, and should not be construed as one. Neither
should they be interpreted as prescribing an exclusive course of
Variations in practice will inevitably and appropriately occur
when clinicians take into account the needs of individual patients,
available resources, and limitations unique to an institution or
type of practice. Every health-care professional making use of
these Guidelines is responsible for evaluating the appropriateness
of applying them in the setting of any particular clinical situation.
The development of the Saudi Guidelines for the management of
peritoneal dialysis patients is supported by an educational grant
from Baxter Company.