40 seyrafian peritoneal dialysis


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40 seyrafian peritoneal dialysis

  1. 1. PERITONEAL DIALYSIS Presentation and modalities Shiva Seyrafian MD Isfahan University of Medical Sciences
  2. 2. Background <ul><li>Worldwide, 12% of dialysis patients are maintained on PD </li></ul><ul><li>This varies greatly between countries </li></ul><ul><li>>50% on PD in New zealand, Hong Kong, and Mexico </li></ul><ul><li><8% on PD in Japan ,Germany and Taiwan </li></ul>PERITONEAL DIALYSIS
  3. 3. Modality Selection <ul><li>Most patients (>80%) can do either modality and the decision is not a primarily medical one although some factors may favor one modality over the other to some degree </li></ul><ul><li>Modality selection should take into account medical issues, patient’s social circumstances, wishes of patient but also overall economic circumstances in which the dialysis program operates </li></ul>PERITONEAL DIALYSIS
  4. 4. Organizing a peritoneal dialysis program PERITONEAL DIALYSIS
  5. 5. Introduction: <ul><li>PD is a very simple technique when compared to hemodialysis. </li></ul><ul><li>Set a program : needs _ a doctor _ a nurse _ a patient </li></ul><ul><li>Assure a successful one :well- planned </li></ul>PERITONEAL DIALYSIS
  6. 6. Some absolute and relative indications to PD <ul><li>Absolute indications : </li></ul><ul><li>Poor cardiac function </li></ul><ul><li>Peripheral vascular disease </li></ul><ul><li>Relative indications : </li></ul><ul><li>Free life style </li></ul><ul><li>Want to take care themselves </li></ul><ul><li>Long distance to hemodialysis center </li></ul>PERITONEAL DIALYSIS
  7. 7. Teaching plans and materials <ul><li>Demonstration is essential : </li></ul><ul><li>_by a nurse </li></ul><ul><li>_by an experienced patient </li></ul><ul><li>_via video </li></ul><ul><li>Practice on a mannequine </li></ul><ul><li>Practice on himself/herself </li></ul><ul><li>Recheck the procedure </li></ul><ul><li>Update for new knowledge </li></ul>PERITONEAL DIALYSIS
  8. 8. Equipment requirement in PD training <ul><li>Comfortable chair </li></ul><ul><li>Water sink </li></ul><ul><li>Weighing scales </li></ul><ul><li>Drip stand/hook </li></ul><ul><li>Books, booklets ,charts ,posters </li></ul><ul><li>Television and video/VCD/DVD </li></ul><ul><li>Automate PD machine </li></ul><ul><li>Shelving for consumable </li></ul>PERITONEAL DIALYSIS
  9. 9. Multi-discipline care team <ul><li>The team typically includes </li></ul><ul><li>Doctors </li></ul><ul><li>Nurses </li></ul><ul><li>Dietitians </li></ul><ul><li>Social workers </li></ul><ul><li>Often include a surgeon, a cardiologist, a psychologist, a psychiatrist, a physiotherapist etc. </li></ul>PERITONEAL DIALYSIS
  10. 10. Contraindications to PD <ul><li>Inability to make connections and lack of family member or other person willing or able to help (dementia ,stroke ,arthritis , blindness, debilitation etc) </li></ul><ul><li>Previous complicated abdominal surgery with adhesions, ostomies etc </li></ul><ul><li>Lack of space to store PD solutions </li></ul>PERITONEAL DIALYSIS
  11. 11. Contraindications to HD <ul><li>lack of vascular access-usually some years on HD </li></ul><ul><li>Cardiovascular instability in HD with recurrent large weight gains ,fluid overload, symptomatic hypotension, angina etc </li></ul><ul><li>Long distance from HD unit and unwillingness to tolerate </li></ul>PERITONEAL DIALYSIS
  12. 12. Factors favoring PD <ul><li>Young child </li></ul><ul><li>Full time work </li></ul><ul><li>Desire for autonomy </li></ul><ul><li>Mother with young children </li></ul><ul><li>Good family support </li></ul><ul><li>Good motivation </li></ul><ul><li>Early transplant likely </li></ul>PERITONEAL DIALYSIS
  13. 13. Factors favoring HD <ul><li>Poor family support </li></ul><ul><li>Poor motivation </li></ul><ul><li>Major comorbidity </li></ul><ul><li>Body size >110 kgs </li></ul><ul><li>Severe obesity </li></ul><ul><li>Irresponsible , lack of hygiene </li></ul><ul><li>Poor hand eye coordination </li></ul>PERITONEAL DIALYSIS
  14. 14. modality selection some realities <ul><li>Most patients with ESRD are anxious and unwell and will be nervous about participating in their own treatment </li></ul><ul><li>Getting them to do PD requires encouragement and support and is best done in advance before they become very uremic </li></ul>PERITONEAL DIALYSIS
  15. 15. modality selection some realities cont… <ul><li>Many nephrologist have strong biases about modality selection, most often in favor of HD over PD </li></ul><ul><li>Many nephrology trainees have very little experience of PD compared to HD and are not comfortable managing PD patients </li></ul>PERITONEAL DIALYSIS
  16. 16. modality selection How to do it well <ul><li>Predialysis clinic </li></ul><ul><li>Meeting with PD and HD staff </li></ul><ul><li>Meeting with PD and HD patients </li></ul><ul><li>Seeing PD and HD units </li></ul><ul><li>Providing good educational material </li></ul>PERITONEAL DIALYSIS
  17. 17. ‘ PD FIRST ‘ Advances of PD as Initial Modality <ul><li>Preserves residual renal function better </li></ul><ul><li>May allow better blood pressure and volume control with cardiovascular benefits </li></ul><ul><li>May give better quality of life </li></ul><ul><li>Has less anemia and lower EPO doses </li></ul><ul><li>Lower risk of Hepatitis C </li></ul><ul><li>Equal or better survival in early years </li></ul><ul><li>Cost advantages - in many countries </li></ul>PERITONEAL DIALYSIS
  18. 18. Modality Selection Pre Dialysis Clinics <ul><li>This allow time for patient to be educated remodalities before they became a medical emergency </li></ul><ul><li>Patients who present late with uremic symptoms almost always are treated with HD and stay on it subsequently </li></ul><ul><li>Predialysis education is critical for increasing PD use </li></ul>PERITONEAL DIALYSIS
  19. 19. Modality Selection Education <ul><li>Meeting with PD and HD patients and nurses is very helpful for patients </li></ul><ul><li>A program should make such opportunities available </li></ul><ul><li>Good videos , books etc are available from kidney disease organizations and from industry </li></ul>PERITONEAL DIALYSIS
  20. 20. PD versus HD Which is best? <ul><li>This may not be best way to pose the question of modality selection </li></ul><ul><li>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 </li></ul><ul><li>This approach which has recently been called “integrated dialysis care” has economic as well as medical advantages </li></ul>PERITONEAL DIALYSIS
  21. 21. Integrated Dialysis Care <ul><li>Idea that HD and PD are complementary rather than competitive therapies </li></ul><ul><li>Many patients will need both at some stage in their time on dialysis </li></ul><ul><li>Switching modalities modalities should not be seen as a failure </li></ul><ul><li>PD has particular benefits as initial dialysis modality </li></ul>PERITONEAL DIALYSIS
  22. 22. Conventional Classification of PD <ul><li>Daily CAPD DAPD NIPD CCPD </li></ul><ul><li>Intermittent IPD × 2-3 per week </li></ul>PERITONEAL DIALYSIS
  23. 28. CAPD OR APD ? <ul><li>Medical </li></ul><ul><li>Lifestyle </li></ul><ul><li>Economic </li></ul>PERITONEAL DIALYSIS
  24. 29. Economic of APD versus CAPD <ul><li>APD is more costly than CAPD. </li></ul><ul><li>Paradoxically, however the difference is greater in poorer developing countries and least in wealthier countries . </li></ul>PERITONEAL DIALYSIS
  25. 30. LIFESTYLE <ul><li>Given free choice ,most patients choose APD over CAPD because it involves less daytime procedures and so less disruptive . </li></ul><ul><li>Exceptions are people who are nervous about machines or who have difficulty staying in bed ~ 8 hrs . </li></ul>PERITONEAL DIALYSIS
  26. 31. LIFESTYLE INDICATIONS FOR APD <ul><li>Children to allow uninterrupted school time </li></ul><ul><li>Those who work full time </li></ul><ul><li>Those who depend on working family members to do their PD </li></ul><ul><li>Those who live in nursing homes-- , in order to minimize PD workload for staff </li></ul>PERITONEAL DIALYSIS
  27. 32. MEDICAL INDICATIONS FOR APD <ul><li>Fluid resorption on standard CAPD </li></ul><ul><li>High or high average transport status </li></ul><ul><li>Inadequate dialysis on CAPD </li></ul><ul><li>Frequent peritonitis on CAPD </li></ul>PERITONEAL DIALYSIS
  28. 33. PERITONITIS <ul><li>Remains the biggest cause of PD technique failure in most countries </li></ul><ul><li>Also causes hospitalization, catheter loss and even death </li></ul><ul><li>Rates have fallen over past 2 dacades , mainly due to improved connectology </li></ul>PERITONEAL DIALYSIS
  29. 43. ‘ Y SET ’ IS SUPERIOR TO ‘ STRAIGHT LINE ‘ <ul><li>One peritonitis per 33 months versus one per 11 months (Maiorca et al 1983) </li></ul><ul><li>One peritonitis per 22 months versus one per 10 months in Canadian Multicenter Study ( PDI 1989 ) </li></ul>PE RITONEAL DIALYSIS
  30. 44. ‘ DOUBLE BAG ‘ IS SUPERIOR TO STANDARD ‘Y SET ‘ <ul><li>1 peritonitis per 34 months versus one per 12 months (US) (Kiernan et al, JASN 1995) </li></ul><ul><li>1 peritonitis per 47 months versus 1 per 14 months (Australia) (Harris et al, JASN 1996) </li></ul>PERITONEAL DIALYSIS
  31. 46. THE NURSE’S ROLE <ul><li>“ I am convinced that a well-informed and enthusiastic nurse is a great blessing to the nephrologist and the peritoneal dialysis patient “ Dimitrios Oreopulos </li></ul><ul><li>A successful PD program depends on a highly motivated ,educated , professional nurse </li></ul>PERITONEAL DIALYSIS