Peritoneal dialysis is a way to remove waste products from your blood when your kidneys can no longer do the job adequately.
A cleansing fluid flows through a tube (catheter) into part of your abdomen and filters waste products from your blood. After a prescribed period of time, the fluid with filtered waste products flows out of your abdomen and is discarded.
Peritoneal dialysis differs from hemodialysis, a more commonly used blood-filtering procedure. With peritoneal dialysis, you can give yourself treatments at home, at work or while traveling.
2. Background
Worldwide, 12% of dialysis patients are
maintained on PD
This varies greatly between countries
>50% on PD in New zealand, Hong Kong, and
Mexico
<8% on PD in Japan ,Germany and Taiwan
PERITONEAL DIALYSIS
4. Continuous ambulatory
peritoneal dialysis (CAPD)
Carried out during day time , manually by patients
or by caregivers
Dialysis fluid is infused to the peritoneal cavity
Dwell time for between 3 - 10 hrs
6. Some absolute and relative indications
to PD
Absolute indications:
Poor cardiac function
Peripheral vascular disease
Relative indications:
Free life style
Want to take care themselves
Long distance to hemodialysis
center
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7. 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
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8. Factors favoring PD
Young child
Full time work
Desire for autonomy
Mother with young children
Good family support
Good motivation
Early transplant likely
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9. Factors favoring HD
Poor family support
Poor motivation
Major comorbidity
Body size >110 kgs
Severe obesity
Irresponsible , lack of hygiene
Poor hand eye coordination
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10. modality selection some
realities
Many nephrologist have strong biases about
modality selection, most often in favor of HD over
PD
Many nephrology trainees have very little
experience of PD compared to HD and are not
comfortable managing PD patients
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11. History of Peritoneal Dialysis
The basics of dialytic therapy was laid
down by Thomas Graham (1805-1869).
- “Father” of modern dialysis.
René Dutrochet (1776-1846):
“Grandfather” of dialysis. He
introduced the term “osmosis” which
explains ultrafiltration.
12. First attempt at PD
Georg Ganter (Germany, 1923) was the
first person who applied PD in humans.
He published his work in his paper: “On
the elimination of toxic substances from
the blood by dialysis”.
Moncreif & Popovich (Austin, Texas;
1975): initiated patients on “continuous
mode of PD” and named it CAPD.
Ann Intern Med 1978; 88(4): 449-55
.
13. How Does PD Work?
The semi-permeable peritoneal membrane lines
the abdominal cavity and covers the abdominal
viscera.
The membrane allows (via diffusion) the passage
of toxins and electrolytes into the dialysis solution.
Ultra-filtration (removal of fluid) occurs via osmosis.
A “steady state” of toxin clearance and fluid
management is achieved due to daily performance
of dialysis.
K. Kelly , RN
NNJ Sept-Oct 2004
14. How Does PD Work?
Dialysis solution is infused and drained via a
catheter that is surgically placed in the peritoneal
cavity.
The action of draining and infusing dialysis
solution is called an exchange.
The frequency of exchanges and volume is
determined by the presence of residual renal
function and the individual membrane
characteristic.
15. ‘ PD FIRST ‘
Advances 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 doses
5. Lower risk of Hepatitis C
6. Equal or better survival in early years
7. Cost advantages - in many countries
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16. 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
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17. 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
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18. CAPD OR APD ?
Medical
Lifestyle
Economic
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19. Economic of APD versus CAPD
APD is more costly than CAPD.
Paradoxically, however the
difference is greater in poorer
developing countries and least in
wealthier countries .
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20. LIFESTYLE
Given free choice ,most patients
choose APD over CAPD because it
involves less daytime procedures and
so less disruptive .
Exceptions are people who are
nervous about machines or who have
difficulty staying in bed ~ 8 hrs .
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21. LIFESTYLE INDICATIONS FOR APD
Children to allow uninterrupted school time
Those who work full time
Those who depend on working family members to
do their PD
Those who live in nursing homes-- , in order to
minimize PD workload for staff
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22. MEDICAL INDICATIONS FOR APD
Fluid resorption on standard CAPD
High or high average transport status
Inadequate dialysis on CAPD
Frequent peritonitis on CAPD
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24. Infectious:
• exit-site inflammation (flare, suppurative secretion,
granulation)
• peritonitis (turbid dialysate, abdominal pain, fever)
Non-infectious:
• hernias
• hydrothorax
• sclerosing encapsulating peritonitis (rare, life
threatening complication, mostly after ≥ 6 years
on PD, peritoneum is massively thickened and
calcificated, leading to intestinal obstruction)
Complications of PD
25. Non-infectious:
• Leakage of dialysate along the peritoneal catheter
• Drainage failure of dialysate (dislocation or catheter obstruction
by fibrin)
• Morphologic changes of peritoneum following long-lasting PD
(peritoneal fibrisis, mesotelial damage, vasculopathy and neo-
angiogenesis) leading to loss of UF capacity – reason for PD
cessation in 24% of all patients, and in 51% of patients treated
above 6 years.
26. PERITONITIS
Remains the biggest cause of PD
technique failure in most countries
Also causes hospitalization, catheter
loss and even death
Rates have fallen over past 2 dacades ,
mainly due to improved connectology
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27. Causes of transfer to HD among PD
patients
28%
17%
18%
15%
22%
Infection Catheter
Inadequate dialysis Psychosocial
Others
Mujais et al; Kidney Int Suppl 2006; 70: S21-36
28.
29. Composition of PD solutio
Components
Na 132 mmol/l
Ca 1.25mmol/l
Mg 0.5mmol/l
Cl 100mmol/l
Lactate 35mmol/l
Glucose 1.36-4.25g/dl
Osmolarity 347-486
pH 5.2
30.
31.
32.
33. THE NURSE’S ROLE
“I am convinced that a well-informed and
enthusiastic nurse is a great blessing to
the nephrologist and the peritoneal
dialysis patient “ Dimitrios Oreopulos
A successful PD program depends on a
highly motivated ,educated , professional
nurse
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34. Conclusion :
Long term outcomes associated with peritoneal
dialyses are good.
The treatment is usually effective for years.
However scarring of the peritoneum and
repeated infections may require a change to
hemodialysis
The success of PD can be attributed to the
combined efforts of researchers, individuals on
PD, and healthcare professionals who, in
collaboration with the industrial community,
have realized the potential benefits of the
treatment.
Despite a slow start in comparison to HD, PD
has evolved into a modality that equals HD in
long term outcomes.
35. Bibliography :
• Pendse S, Singh A, Zawada E. Initiation of Dialysis.
In: Handbook of Dialysis. 4th ed. New York, NY;
2008:14–21
• Brundage D. Renal Disorders. St. Louis, MO:
Mosby; 1992
• Nolph, K. D. "History of peritoneal
dialysis". Peritoneal dialysis. Springer Science &
Business Media. p. 1.0 and 2.0.
• McPhee, SJ; Tierney LM; Papadakis MA
(2007). Current medical diagnosis and
treatment. McGraw-Hill. pp. 934–935
• Daugirdas, JT; Blake PG; Ing TS (2006).
"Physiology of Peritoneal Dialysis". Handbook of
dialysis. Lippincott Williams & Wilkins
• Karopadi, AN; Mason G; Rettore E; Ronco C
(2013). Zoccali, Carmine, ed. "Cost of peritoneal