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‘’ Selecting patients for continuous
peritoneal dialysis’’
Mitra Naseri
Associate professor
Pediatric nephrologist
Mashhad University of Medical Sciences
Mashhad, Iran
What is Peritoneal Dialysis?
❖ Peritoneal Dialysis (PD) is a treatment that utilizes the
peritoneum, as a filter to remove wastes from the
body. This type of dialysis requires a care partner to help
with the process.
❖ The peritoneum does a similar job as the dialyzer on a
dialysis machine during treatment or that the kidneys do
every day.
❖ Waste products and fluid pass through the membrane into
dialysate (dialysis fluid) and the fluid is drained with the
waste products.
❖ To prepare for PD therapy, patients need to undergo a
small surgical procedure to have a catheter inserted into
the abdomen.
❖ The catheter is a small rubber tube that is placed into
the wall of the abdomen and secured using Dacron
cuffs.
❖ Generally, two cuffs are used in adults and they help
secure the catheter and prevent some forms of
infections.
Peritoneal Dialysis Catheter
❖ The surgery can be done percutaneous, through a
laparoscopic surgery or an open surgical route.
❖ Laparoscopic surgery is a minimally invasive technique
when the operation is performed through a small incision.
A laparoscope (type of small camera) is used to view the
operation site and place the catheter.
Catheter placement
❖ involves a guidewire being placed inside of tube. The
guidewire is then used to place the catheter into the
correct spot and a tunnel is made under the skin to the
exit site. This is also a less invasive technique, but
could have complications due to the nature of the
surgery.
Percutaneous surgery
❖ A scalpel is used to make a tiny incision through
the skin and muscle of the abdomen. The “open”
area allows the surgeon to place the catheter and
the wound is stitched around it.
Open surgery

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peritoneal dialysis in children

  • 1. ‘’ Selecting patients for continuous peritoneal dialysis’’ Mitra Naseri Associate professor Pediatric nephrologist Mashhad University of Medical Sciences Mashhad, Iran
  • 2. What is Peritoneal Dialysis? ❖ Peritoneal Dialysis (PD) is a treatment that utilizes the peritoneum, as a filter to remove wastes from the body. This type of dialysis requires a care partner to help with the process. ❖ The peritoneum does a similar job as the dialyzer on a dialysis machine during treatment or that the kidneys do every day. ❖ Waste products and fluid pass through the membrane into dialysate (dialysis fluid) and the fluid is drained with the waste products.
  • 3. ❖ To prepare for PD therapy, patients need to undergo a small surgical procedure to have a catheter inserted into the abdomen. ❖ The catheter is a small rubber tube that is placed into the wall of the abdomen and secured using Dacron cuffs. ❖ Generally, two cuffs are used in adults and they help secure the catheter and prevent some forms of infections. Peritoneal Dialysis Catheter
  • 4. ❖ The surgery can be done percutaneous, through a laparoscopic surgery or an open surgical route. ❖ Laparoscopic surgery is a minimally invasive technique when the operation is performed through a small incision. A laparoscope (type of small camera) is used to view the operation site and place the catheter. Catheter placement
  • 5. ❖ involves a guidewire being placed inside of tube. The guidewire is then used to place the catheter into the correct spot and a tunnel is made under the skin to the exit site. This is also a less invasive technique, but could have complications due to the nature of the surgery. Percutaneous surgery
  • 6. ❖ A scalpel is used to make a tiny incision through the skin and muscle of the abdomen. The “open” area allows the surgeon to place the catheter and the wound is stitched around it. Open surgery
  • 7. ❖ There are two types peritoneal dialysis: Continuous-Cycler Assisted Peritoneal Dialysis (CCPD) Continuous Ambulatory Peritoneal Dialysis (CAPD) Types of Peritoneal Dialysis
  • 8. CAPD ❖ CAPD is a method of performing peritoneal dialysis exchanges using gravity to drain and fill the peritoneal membrane with solutions four times each day. ❖ It usually takes about 30 minutes to complete an exchange. The patients are free to be active during each dwell.
  • 9. ❖ CCPD is a method of performing peritoneal dialysis exchanges using a machine called a cycler during the sleeping hours. ❖ Generally, three to five exchanges are done each night. ❖ This program frees up your daytime hours. ❖ Each nightly session lasts at least eight to ten hours. CCPD
  • 10. 1) Adequate clean space to do the exchanges ❖ The room or area you choose shouldn’t have a lot of traffic in or out, shouldn’t have open windows and should if possible have enough room for your other peritoneal dialysis (PD) supplies. ❖ You will need space for around 30 boxes of supplies. ❖ The boxes do need to be kept in a dry space. Equipment needed for PD
  • 11. 2) Equipment needed for doing a clean dialysis ❖ A chair for doing exchanges. ❖ A table with a clean surface to perform an exchange. ❖ Toilet: used to dispose of dwell waste products. ❖ I.V. pole: or any other surface used to hang your dialysate bags from. ❖ Heating pad: to bring the dialysate up to body temperature scale .
  • 12. ❖ Disinfectant: used to keep patients and the work surfaces clean. ❖ Masks: needed for patients and the partner to minimize the risk of infection. ❖ Dialysis supplies (bags of dialysate, waste bags, connection devices). ❖ Supplies for documenting the care such as paper and pencil or a computer document.
  • 13. Different types of PD catheters
  • 15. PD solution and drain bags and transfer set
  • 17. Different types of PD belts
  • 19. ❖ The process of modality selection and how it works is a critical determinant of peritoneal dialysis (PD) utilization. ❖ This process can be break down into 6 steps and point out how problems at each step can significantly reduce the proportion of end-stage renal disease patients initiating PD. Perit Dial Int 2013; 33(3):233-241 Peritoneal dialysis and the process of modality selection
  • 20. ❖ All patients initiated on dialysis with a diagnosis of ESRD. ❖ All patients receiving outpatient dialysis. ❖ All patients with more than 30 consecutive days of dialysis dependence, even if they have a presumed diagnosis of acute kidney injury ❖ All patients with a failed graft requiring dialysis STEP 1: Identification of all Potential candidates for PD
  • 21. ❖ When patient defined as a potential PD candidate, the medical team has to assess that patient’s eligibility to do PD. ❖ Ideally, this assessment will have been made in the CKD clinic, long before initiation of dialysis. ❖ It should be noted that this assessment is not an issue of the patient choosing or not choosing to do PD, but rather of whether the team has considered the patient to be eligible for, or capable of doing PD. STEP 2: assessment for PD eligibility
  • 22. ❖ A contraindication is a factor that absolutely disqualifies the patient from doing PD regardless of physician or patient choice. ❖ This step requires an assessment of any contraindications or barriers to the PD . ❖ Barrier can be overcome if sufficient supports are available to the patient. ❖ In other words, barriers are really obstacles to self-care rather than to PD per se.
  • 25. Step 3: Offer of modality choice to the PD-eligible patient ❖ Each eligible patient should be offered the opportunity to do PD. ❖ Ideally, this “choice” is offered as part of a modality education process that might include group lectures, peer education, videos, and web sites. ❖ Again, ideally, the choice and associated modality education should have been presented before dialysis initiation.
  • 26. Step 4: patient choice ❖ Once eligible patients are offered a modality choice, most studies suggest that approximately half will select PD. ❖ Some patients in the CKD clinic may persistently refuse to attend modality education classes or to make a modality choice. ❖ Some may wish to defer that decision to the nephrology team. ❖ Others may be in a state of denial and may feel too overwhelmed to make any decision. ❖ In these situations, it might be best for the team to make the decision for the patient, perhaps in consultation with family members.
  • 27. ❖ If less than a third of patients considered eligible for PD eventually choose the modality, it suggests that insufficient opportunity and encouragement to do PD is being provided. ❖ Conversely, if more than two thirds choose PD, it suggests that patients are being aggressively pushed to choose the modality, which may be similarly undesirable. ❖ A 50% choice for PD among eligible candidates is typical of a center providing a balanced approach.
  • 28. Step 5: PD Catheter Placement ❖ A significant proportion of patients who choose to do PD after being offered an informed choice never undergo catheter insertion and eventually start on HD. ❖ Long wait lists to see the surgeon who places PD catheters, rapidly renal function deterioration than expected, and dialysis must be initiated relatively urgently are responsible factors .
  • 29. Step 6: Successful initiation of PD ❖ A significant proportion of patients who undergo a PD catheter placement attempt do not succeed in becoming successful home PD patients. The major possibilities are : 1) Catheter insertion is unsuccessful 2) Catheter itself does not function adequately to allow home PD. Catheter non-function rates of 10 – 15% are not unusual, though good centers will report rates of less than 5%. ❖ About half the cases of inadequate function will respond to corrective measures, but the others will be lost permanently to PD, either because the problem persists or because the patient refuses the required interventions.
  • 30. 3) The training itself fails because the patient or family member is found to be unable or unwilling to learn to carry out the required procedures in a safe manner. 4) Patients change their mind or experience an unexpected change in health status between catheter insertion and PD training. ❖More than 85% of patients who have an attempted PD catheter placement should eventually do home PD successfully. ❖ Anything less reflects a problem with either catheter placement or the original assessment of patient eligibility.
  • 31. Perit Dial Int 2013; 33(3):233-241
  • 32. Process Summary ❖ Ideally, the 6 steps we have described should occur in order, leading to elective initiation of the preferred modality of dialysis. However, in patients starting dialysis urgently, the sequence of steps may change. ❖ Identification as a candidate, assessment for eligibility, and patient choice might follow rather than precede initiation of dialysis. ❖ The initial modality will typically be HD because only rarely do programs use PD in urgent dialysis starts. ❖ The “urgent start” group is a large proportion of all ESRD cases, at least 20- 40% and more than 60% if the definition is expanded to include all inpatient starts.
  • 33. Kidney International (2006) 70, S118–S121.