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1. CAPD
dr. Aida Lydia

2. Modality Selection
Some Realities
 Most patients with ESRD are anxious and
unwell and will be nervous about
participating in their own treatment
 Getting them to do requires
encouragement and support and is best
done in advance before they become very
uremic.

3. Modality Selection
Some Realities
 Many nephrologists have strong biases
about modality selection, most often in
favour of HD over PD.
 Many nephrology trainees have very little
experience of PD compared to HD and are
not comfortable managing PD patients.

4. Modality Selection
How to do it well
 Pre dialysis clinic
 Meeting with PD and HD staff
 Meeting with PD and HD patients
 Seeing PD and HD units
 Providing good educational material

5. Modality Selection
Pre Dialysis Clinics
 These allow time for patient to be educated re
modalities before they become a medical
emergency
 Patients who present late with uremic
symptoms almost always are treated with HD
and stay on it subsequently
 Pre dialysis education in critical for increasing
PD use.

6. Modality Selection
Education
 Meeting with PD and HD patients and nurses
is very helpful for patients
 A program should make such opportunities
available
 Good videos, books etc are available from
kidney disease organizations and from
industry.

7. PD versus HD
Which is best ?
 This may not be best way to pose the question
of modality selection.
 PD may best be seen as a therapy for early
years of dialysis with HD being used as a back
up if or when PD fails.
 This approach which has recently been called
“integrated Dialysis Care” has economic as
well as medical advantages.

8. Factors Favouring PD
 Young child
 Full time work
 Desire for autonomy
 Mother with young children
 Good family support
 Good motivation
 Early transplant likely

9. Factors Favouring PD
 Poor family support
 Poor motivation
 Major comorbidity
 Body size > 110 kgs
 Severe obesity
 Irresponsible, lack of hygiene
 Poor hand eye coordination

10. Contraindications to PD
 Inability to make connections and lack of family
member or other person willing or able to help
(dementia, stroke, arthritis, blindness,
debilitation etc)
 Previous complicated abdominal surgery with
adhesions, ostomies etc.
 Lack of space to store PD solutions.

11. Contraindications to HD
 Lack of vascular access - usually after some
years on HD
 Cardiovascular instability on HD with
recurrent large weight gains, fluid overload,
symptomatic hypotension, angina etc
 Long distance from HD unit and unwillingness
to relocate

12. Integrated Dialysis Care
 Idea that HD and PD are complementary
rather than competitive therapies.
 Many patients will need both at some stage in
their time on dialysis
 Switching modalities should not be seen as a
failure
 PD has particular benefits as initial dialysis
modality

13. ‘PD First’
Advantages of PD as Initial Modality
1. Preserves residual renal function better
2. May allow better blood pressure and volume
control with cardiovascular benefits
3. May give better quality of life
4. Has less anemia and lower EPO dose
5. Lower risk of Hepatitis C
6. Equal or better survival in early years
7. Cost advantages in many countries

15. Factors for successful PD unit
 Multidisciplinary approach
 Team spirit
 Good communication with rest of renal team
 Patients - centered care
 Data / IT system

16. The Multidisciplinary Team
PATIENT
PD Nursing Team
Ward Nursing Team Medical Team
Administration of fluid
deliveries
Dietitian
Counsellor
Social Worker

17. The Nurse’s Role
 “I am convinced that a well-informed and
enthusiastic nurse is a great blessing to the
nephrologist and the peritoneal dialysis patient”
DIMITRIOS OREOPOULOS
THE PERITONEAL DIALYSIS NURSE : THE NURSE :
THE KEY TO SUCCESS
PERITONEAL DIALYSIS BULLETIN 1981 1 113-114
A successful PD program depends on a highly motivated,
Educated, professional nurse.

18. What makes up a PD Unit
 Nursing team : Outpatient, inpatient and
community
 Medical team : Outpatient and inpatient
 Support staff : Dietitian, counsellor, and
worker
 Administration : Supplies, holidays
 Space

19. Patient pathway through PD unit
 Initial assessment
 Pre dialysis education
 When to start
 Catheter insertion
 Training
 Maintenance
 Complications
 Dropout
 Post PD care

20. Pre-dialysis Assessment
 Should ideally start 1 - 2 years before dialysis
needed.
 Pace of assessment and education depends
on predicted time until dialysis needed.
 All dialysis modalities should be explained to
patient to enable freedom of choice
 Early choice allows elective creation of access
for dialysis

21.  Early referral is therefore essential for successful
Replacement Renal Therapy and application of
incremental PD

22. PD Assessment
 Essential before accepting patient on to PD
 Carried out experienced PD nurse :
 Practical demonstration
 Family hand dexterity
 Carry over of information
 Social / work issues
 APD v CAPD
 PD nurses can reject patients thought suitable by
medics!

23. Pre Dialysis Clinic
treatment options
medical conditions
social / work routines
family commitments / support
personal preference
financial constraints

24. Pre dialysis
 Home assessment :
CAPD - area for exchange
adequate storage space
Hemodialysis - space
plumbing
drains

25. Pre Dialysis
Work assessment
 Suitable area for CAPD
exchange
 Educate management
& personal staff
 A Home Sister is always
available at clinic

26. Home Visit
What is it
Discussion
Dialysis problems
Health status
Social life
Knowledge of renal failure / treatment
L

27. Summary of pre-dialysis phase
 Time to select modality of dialysis
 Transplant work-up, particularly for living
donor
 Education of patient and family about renal
failure - diet, need for medications.
 Sort out social issues - accommodation, work,
travel
 Medical issues - treat anaemia, bone disease,
repair hernias etc

28. Patient pathway through PD Unit
 Initial assessment
 Pre-dialysis education
 When to start
 Catheter insertion
 Training
 Maintenance
 Complications
 Dropout
 Post PD care

29. When to start PD
 Has to be done electively as PD catheter is best
left unused for 2 weeks
 Patients therefore have to understand that best
to start before really ill
 No absolute guidelines, but start when GFR
< 10-15 ml/min depending on symptoms
 Early start allows for catheter complications
without needing dialysis.

30. Involvement of PD team in decision to start
 Elective start should be timed round anticipated
time for training – no point in putting in catheter
if no training slot for 6 weeks.
 PD nurses should arrange training round work /
holiday / family commitments.

31. Involvement of PD team in decision to start
 Extra session with PD nurses advisable if initial
assessment some time ago :
 Revise what PD is about
 Assess if any social changes
 Assess if any physical changes e.g. eyesight

32. Catheter insertion
 Involves PD team, ward nurses and medics
 Communication essential re protocols, marking exit site
 Specialist nurses needed :
 To assist at catheter insertion if done on ward
 To flush catheter after insertion
 Carry out exit site dressings
 Post catheter care to be arranged by PD nurses before
discharge

33. Training
 Should be done by designated nurse
 Should be done in quiet area away form ward
 Opportunity for dietetic review
 Medication review and assessment of dry weight
by medical team
 Review by social if needed

34. Aims of training
 Learn about renal failure and principal of PD
 Learn PD techniques
 Troubleshooting - what to do if ……
 Fluid management
 Diagnosing peritonitis
 Exit site and wound care
 How to order supplies
 How to dispose used equipment
 Discuss how to go on holiday