3. The word preitoneum refers to the Greek word “peritononion” and
means to stretch. Ancient Egypt were probably the first people to get
a look at the peritoneum
1st steps towards peritoneal dialysis.
4. 4
Integrated Renal Care:The Concept
“Complementary Not Competitive” Coles 1998
“The right modality at the right time. Peter Blake, MD, John Burkart, MD
Early referral of patient
With CKD to renal center
Pre-emptive
Transplantation
PD as first option if medically suitable
Allowing for patient chioce
Patient education
program
HD Transplant
PD
Timely
referral
Timely
preparation
Best sequence of
PD, HD and TX
Therapy
management
Timely
Initiation
Therapy
transfer
5.
6. Conclusion
Peritoneal dialysis is a safe, efficacious, and
complementary alternative to HD in the urgent-start
setting, and many urgent start programs have been
successfully established worldwide. Consideration
should be given to its future integration into a structured
and patient-centered dialysis program.
7.
8. The Importance of Patient Education
Golper T. Patients education: can it maximize the success of therapy? Nephrol Dial Transplant .2001 :
(suppl 7):20-24.
The National Pre-ESRD Education Initiative Survey
After Pre-ESRD Education ,45 %Chose PD
and 33 %Actually Started PD
N = 2400100
80
60
40
20
0
Choice of Modality Actual Modality Started US Incidence
PercentageofPatients
PD
HD
9. Rioux J, Cheema H, Bargman JM, et al. Effect of an in-hospital chronic kidney disease education
program among patients with unplanned urgent-start dialysis. Clin J Am Soc Nephrol 2011;6:799.
Conclusion
Home dialysis is feasible after urgent dialysis start.
Education should be promoted among patient experiencing
acute- start dialysis.
10. 228Acute Start Between2005-2009
Education program before discharge
132
In-center HD
71
Home
49PD 22HHD
25
Died
(before discharge)
Patients’ flow through the study
Rioux J, Cheema H, Bargman JM, et al. Effect of an in-hospital chronic kidney disease education
program among patients with unplanned urgent-start dialysis. Clin J Am Soc Nephrol 2011;6:799.
11. Physician Preference For Modality
Merighi JR, Schatell DR, Bragg-Gresham JL, et al. Insights into nephrologist training, clinical
practice, and dialysis choice. Hemodial Int 2012;16:242-251.
N=629
12. Distribution of nephrologists’ modality
choice for themselves
Adapted from:
Merighi JR, Schatell DR, Bragg-Gresham JL, et al. Insights into nephrologist training,
clinical practice, and dialysis choice. Hemodial Int 2012;16:242-251.
15. Conclusions
In conclusion, PD continues to be underutilized in
many countries, including the United States. There are
many factors that contribute to this underutilization
(e.g., modality, system, and patient-related factors).
Clin J Am Soc Nephrol 6: 447–456, 2011
17. 0
1
2
3
4
5
6
7
8
0 6 12 18 24 30
RRF(ml/min/1.73m2)
Months
CAPD HD-LF HD-HF
Lang et al, PDI 21:52-57, 2001
Preservation of residual renal function in CAPD,
low flux & high flux HD
18. PD Patients Have an Initital Survival Advantage Relative to HD.
Danish Registry 2001
0
5
10
15
20
25
30
35
0.5 1 1.5 2 2.5 3 3.5 4
HD
PD
Time (years)
J Heaf, NDT 2002
4921 patients
19. Conclusions
Peritoneal dialysis seems to be associated with 48% lower
mortality than hemodialysis over the first 2 years of dialysis therapy
independent of modality switches or differential transplantation rates.
Clin J Am Soc Nephrol 8: 619–628, 2013.
20. Prospective study of 526 incident patients starting RRT.
1 year follow up. Univariate analysis:
The most common single reason for admission was creation of &
complications to vascular access for HD.
The use of temporary vascular access for HD were associated
with prolonged hospitalisation & repeated admissions.
Patients initially treated with HD rather than PD spent longer
time in hospital & were more likely to be admitted.
Hospitalisation in the First Year of RRT for ESRD
Metcalfe Et Al. Q J Med 2003; 96: 899
21. Prevalence of anti-HCV Among Patients on Dialysis
by Modality
Pereira KI 1997;51:981-999
7%
13%
16%
19%
23%
31%
44%
47%
50%
35%
25%
5%
2%2%
0%
17%
8%
12%
34%
5%
15%
20%
0%
20%
40%
60%
M
cIntyre
Brugnano
C
han
Jonas
C
antu
D
ussol
Barril
N
eto
Selgas
H
uang
Yoshida
HD PD
22.
23. .Conclusions
Dialysis modality selection significantly
influences the risk of HCV infection experienced
by end-stage renal failure patients in the Asia-
Pacific region. No such association could be
identified for HBV infection.
24. Results After Kidney Tx: Danish Registry 1990-1999
0 20 40 60 80
5 yr graft survival
5-day delayed function
10-day delayed function
Time to onset of function
HD
PD
*P<0,05
*
*
*
J. Heaf NDT 2002
Tx:1397, HD:877, PD:520
25. 50
40
30
20
10
% DGF*
0
% never
dialysis-free
following Tx
If DGF , time
until dialysis
independence
(days)**
24.1%
8.6%
13.8%
7.8
16.8
50.0%
PD (n=56)
HD (n=58)
*p<0.05 **p<0.025
50
40
30
20
10
Effect of Dialysis Modality on Initial Graft Function
Fontan MP, et al, Renal transplantation in patients undergoing chronic peritoneal dialysis. Perit Dial Int 16:48-51, 1996.
26.
27. Conclusions.
The study suggests that the
outcome of patients starting PD
after kidney transplant failure was
similar to those starting HD.
Therefore, PD can be regarded to
be a good treatment option for
patients returning to dialysis after
kidney transplant failure
28. Lifestyle Flexibility: Employment
1Merkus M, et al.: Am J Kidney Dis, 1997. 4Powe, N. RPA/REF Annual Meeting, 1997. 5Julius M, et al.: Arch
Intern Med, 1989. 6CENSIS, Italy, 1997. 7ALCER, Spain, 1997. 8ACOS, Germany, 1996.
%ofPatientsEmployed
10%
20%
30%
40%
50%
70%
80%
60%
Merkus Choice
Study
Julius CENSIS Alcer
0
1
4
5 6 7
HD
PD
% of patients employed within modality group
ACOS8
29. Most observational data indicate that there
is an initial survival advantage for patients
with ESRD started on PD therapy.
these include
preservation of residual kidney function
reduced infection risk
improved patient satisfaction
lowered health care costs
30.
31.
32.
33. Results:
A total of 1321 patients were included. The mean age was 48.1 ± 15.3 years,
41.3% were female, and 23.5% with diabetes mellitus. The median (interquartile)
follow-up time was 34 (21–48) months. After adjusting for confounders, peritonitis
was independently associated with 95% increased risk of all-cause mortality (hazard
ratio, 1.95; 95% confidence interval: 1.46–2.60), 90% increased risk of
cardiovascular mortality (hazard ratio, 1.90; 95% confidence interval: 1.28–2.81)
and near 4-fold increased risk of infection-related mortality (hazard ratio, 4.94; 95%
confidence interval: 2.47–9.86). Further analyses showed that peritonitis was not
significantly associated with mortality within 2 years of peritoneal dialysis initiation,
but strongly influenced mortality in patients dialysed longer than 2 years.
Conclusions:
Peritonitis was independently associated with higher risk of all-cause,
cardiovascular and infection-related mortality in peritoneal dialysis patients, and its
impact on mortality was more significant in patients with longer peritoneal dialysis
duration.
34. CONCLUSION
We have demonstrated that direct xenograft of HUMSCs into the rat intraperitoneum
effectively prevented PD/MGO 3W-induced abdominal cocoon formation,
ultrafiltration failure, and peritoneal membrane alterations such as peritoneal
thickening, fibrosis, and inflammation. These findings provide a basis for a novel
approach with therapeutic benefits in the treatment of encapsulating peritoneal
sclerosis.
35. PD … the modality first used for the treatment of KI
38. Conclusion
This review clearly shows that PD is a simple, safe,
and efficient way to correct metabolic, electrolyte,
acid – base, and volume disturbances generated by
AKI and it can be used as an RRT modality to treat
AKI, both in and out of the ICU setting.
44. Results From the regional population ([9,700,000 inhabitants), 1067 patients (34.3 %
females) initiating dialysis were identified, of whom 82 % underwent only
hemodialysis (HD), 13 % only peritoneal dialysis (PD) and the remaining 5 % both
treatments. Direct healthcare costs/patient were € 5239, € 12,303 and € 38,821 (€
40,132 for HD vs. € 30,444 for PD patients) for the periods 24–12 months pre-dialysis,
12–0 months pre-dialysis, and in the first year of dialysis, respectively.
Conclusions This study highlights a significant economic burden related to CKD and
an increase in direct healthcare costs associated with the start of dialysis, pointing to
the importance of prevention programs and early diagnosis.
45.
46. Conclusion
The decline of PD in the Netherlands cannot be explained by medical reasons.
Whatever the causes, it has resulted in a downward spiral where loss of experience
and insufficient knowledge on important pathophysiological and other related
pertinent issues of this home dialysis modality have resulted in an almost
exclusive attention to haemodialysis. This happened while it is now evident that
patient survival on PD is at least similar or even better than that on haemodialysis,
also in the long-term. To change the tide, the quality of education of patients,
nurses and doctors needs updating. The above review is an effort by a group of
professionals involved in peritoneal dialysis to revitalise the interest of the
Nephrology and Internal Medicine communities in up-to-date PD. Important
conclusions are that patient education can be improved, that PD leads to better
preservation of residual kidney function, that the value of small uraemic toxin
removal is less important than good management of the hydration state of patients,
that peritonitis is a manageable problem, that EPS is a lesser problem than it used
to be, and that imminent EPS can be identified before the clinical signs and
symptoms appear. Therefore it can be concluded that PD is an excellent chronic
dialysis modality that deserves a larger penetration than is currently present.
47. Integrated care approach is the optimal treatment for ESRD.
PD is the modality of choice to start RRT if kidney Tx not
available.
PD is the solution for overcrowded dialysis units.
PD is underutilize, more effort from nephrologists,
government and local companies to support PD program.
Conclusion
48.
49.
50.
51. Clin J Am Soc Nephrol 7: 887 – 894, 2012. doi: 10.2215/CJN.11131111
Conclusion
High- volume peritoneal dialysis is effective for a
selected AKI patient group, allowing adequate
metabolic and fluid control. Age, sepsis, and urine
output as well as nitrogen balance and ultrafiltration
after three high volume peritoneal dialysis sessions
were associated significantly with death.
