This document summarizes peritoneal dialysis (PD) and peritonitis. It provides an overview of PD, including its history in Thailand, principles, procedure, and membrane properties. Factors influencing fluid balance like sodium intake are discussed. Peritonitis, its definition, specimen processing, and treatment are covered. Statistics on peritonitis episodes from local studies are presented, showing treatment success rates and outcomes. Refractory peritonitis is also mentioned.

1. P E R I T O N E A L D I A LY S I S
K A M O L K H O S I T R A N G S I K U N , M D
2 0 A P R I L 2 0 1 8

2. S C O P E
• Introduction
• Principle of PD
• Problem
• Management

4. C A P D I N T H A I L A N D
• 2525 รพ. ศิริราช และ รพ.พระมงกุฎเกล้า
• 2526 รพ.ราชวิถี
• 2527 รพ. รามาธิบดี
• 2528 รพ. จุฬาลงกรณ์ รพ. ศรีนครินทร์
และ รพ.สงขลานครินทร์
• 2530 รพ. ภูมิพลฯ

5. h"p://www.thaipt.org/forum/index.php?topic=166.0!
11""กันยายน 2550!

7. 7

8. P D P R O G R A M

9. ผ่าตัด
วางสาย
กลับบ้าน
นัดนอน รพ.
ฝึก ล้างไต
กลับบ้าน
Training Program

10. P D T R A I N I N G

11. P D T R A I N I N G

12. P E R I T O N E A L D I A LY S I S
Andy Disc Dianeal

13. P E R I T O N E A L D I A LY S I S
Andy Disc Dianeal

14. P R I N C I P L E O F P E R I T O N E A L D I A LY S I S

15. S T E P S F O R P E R I T O N E A L D I A LY S I S

16. S T E P S F O R P E R I T O N E A L D I A LY S I S

18. D I F F E R E N T M O D E O F P D

19. P E R I T O N E A L M E M B R A N E

20. P E R I T O N E A L M E M B R A N E

21. P E R I T O N E A L M E M B R A N E A N AT O M Y
• Peritoneal blood flow: 50 - 100 ml/min
• Max.small solutes clearance is 20-30 ml/min
(peritoneal clearance is not limited by blood flow)

22. P E R I T O N E A L M E M B R A N E

23. P E R I T O N E A L M E M B R A N E

24. P E R I T O N E A L M E M B R A N E

25. P E R I T O N E A L M E M B R A N E
https://clinicalgate.com/continuous-renal-replacement-therapy/

26. P R O C E S S O F P E R I T O N E A L T R A N S P O RT

27. P R O C E S S O F P E R I T O N E A L T R A N S P O RT
Diffusion (Solutes)

28. P R O C E S S O F P E R I T O N E A L T R A N S P O RT
Osmotic gradient (UF: water)

29. P E R I T O N E A L D I A LY S I S

30. D I A LY S I S F L U I D : O S M O L A R I T Y
1.5% dextrose : 346 mOsm/L
2.5% dextrose : 396 mOsm/L (hypertonic)
4.25% dextrose : 485 mOsm/L (hypertonic)
7.5 % icodextrin (Extraneal) : 282-286 mOsm/L
http://www.baxter.com/downloads/patients_and_caregivers/products/dianeal_ultrapd2.pdf
http://www.baxter.com/downloads/patients_and_caregivers/products/extraneal_pi.pdf

31. N E T U F W I T H D W E L L T I M E U S I N G
D E X T R O S E S O L U T I O N
7.5% Icodextrin!
4.25% 85 gm
2.5% 50 gm
1.5% 30 gm
Handbook of Dialysis 3rd edition

32. PA R I E TA L P E R I T O N E A L B I O P S Y
Initiation of PD PD for 12 years

33. R E A S O N S F O R D I S C O N T I N U AT I O N

34. C A U S E O F D E AT H I N P D PAT I E N T
1,728, 56%
676, 22%
169, 6%
490, 16%
Cardiovascular-Cerebrovascular-Respiratory failure
Infection (ไม่ เกี ่ ยวข้ องกั บ peritonitis)
Peritonitis
อื ่ นๆ (เบาหวาน,มะเร็ ง,โรคระบบทางเดิ นอาหาร,อุ บั ติ เหตุ )

35. R E A S O N S F O R D I S C O N T I N U AT I O N

36. R E A S O N S F O R D I S C O N T I N U AT I O N
• Poor volume control
• Peritonitis
• Other medical reason eg. Mental stress
• Preference of patient, doctor, family

37. “ Poor Volume Control ”

38. F L U I D O V E R L O A D
• Common in contemporary PD populations and has
been associated with adverse clinical outcomes
• Hypertension
• Left ventricular hypertrophy
• Congestive heart failure
• Hospitalization

39. A P P R O A C H F O R F L U I D O V E R L O A D
• salt & water intake
• blood glucose control
• cardiac status
• change in RRF
• adherence to prescription
• appropriateness of prescription
• mechanical complication
• change in peritoneal membrane function

40. F L U I D A S S E S S M E N T T O O L S
• Bioelectrical impedance analysis (BIA)
• Tracer dilution technique (Deuterium oxide, Sodium bromide)
• Dual-energy x-ray absorptiometry (DEXA)
• Biochemical markers( Cardiac natriuretic peptides level)
• Cardiothoracic ratio (CTR) & Vascular pedicle width(VPW)
• Inferior vena cava diameter (IVCD)
• Clinical syndrome( BP, Edema)

41. T O O L S T O E VA L U AT E
G. Woodrow, Perit Dial Int 2007; 27(S2):S143–S147
Body weight alterations
Daily weighing by patients is
a routine part of PD
management, and weighing
is valuable in detecting
changes in body fluid
content.

42. R E C O R D I N TA K E - O U T P U T

43. F L U I D B A L A N C E
• The most appropriate way to control fluid balance
in diabetic PD patients should be control of dietary
salt and fluid intake.
Lei Quan, Perit Dial Int 2006; 26:95–100

44. P H Y S I O L O G Y O F V O L U M E C O N T R O L
Input Output
สิริภา ช้างศิริกุลชัย, 2007 Update on CAPD, P111

45. P H Y S I O L O G Y O F V O L U M E C O N T R O L
Input Salt
Fluid

46. P H Y S I O L O G Y O F V O L U M E C O N T R O L
Input Salt
Fluid

47. S A LT I N TA K E I N P D
Blake G.,Perit Dial Int 2011;31:224

48. S A LT I N TA K E I N P D
• Sodium intake should be restricted to 65 mmol
(1500 mg) or less daily in patients with
hypervolemia (grade C).
Blake G.,Perit Dial Int 2011;31:224

49. P H Y S I O L O G Y O F V O L U M E C O N T R O L
Input Salt
Fluid

50. WAT E R M E A S U R E M E N T

51. WAT E R M E A S U R E M E N T

52. WAT E R M E A S U R E M E N T

53. ใ ค ร ไ ม่ รู้ ก ล่ า ว ไ ว้
“ คน เรา ควรดื่ม น้ำ วันละ 8 แก้ว ”

54. น้ำ 1 แ ก้ ว = กี่ มิ ล ลิ ลิ ต ร = กี่ ซี ซี
• 1 แก้ว (cup) มีหลายมาตรฐาน
• หน่วย Metric = 250 ml
• หน่วย Imperial = 284 ml (1/16 Imp gallon)
• USA ทั่วไป = 236.58 ml (1/16 US gallon)
• USA กฎหมายอาหารและยา = 240 ml
• หน่วย Japanese = 200 ml

55. V I S I B L E F L U I D
• น้ำสำหรับทานยา
• น้ำดื่มแก้กระหาย
• น้ำแข็งอมแก้คอแห้ง

56. ส อ น ผู้ ป่ ว ย ป ร ะ เ มิ น ต น เ อ ง

57. เ ป รี ย บ เ ที ย บ ใ ห้ ผู้ ป่ ว ย ดู

58. รู้ จั ก ต น เ อ ง

59. P D T E C H N I Q U E & P R E S C R I P T I O N

60. P E R I T O N E A L E Q U I L I B R AT I O N T E S T

61. Evaluation of peritoneal membrane function test ( modified PET)
modified PET -4.25%
High Low HA/LA
• Idiopathic
• Peritonitis
• Peritoneal
membrane
change
Adhesion
< 5 mEq/L
Sodium dipping
>5 mEq/L
Aquaporin
deficiency
Increase
Lymphatic
absorption
จิรายุทธ จันทร์มา, 2008 Optimal Care on CAPD in Thailand, P125

62. PET PRESCRIPTION
High Transporter Short dwell time, increase cycle
High Average NIPD / CAPD
Low Average High Dose CAPD / CCPD
Low Transporter
High Dose CCPD + RRF
Switch to HD if without RRF
P D T E C H N I Q U E & P R E S C R I P T I O N

63. R E A S O N S F O R D I S C O N T I N U AT I O N
• Poor volume control
• Peritonitis
• Other medical reason eg. Mental stress
• Preference of patient, doctor, family

64. P E R I TO N I T I S
• Defined as the presence of at least 2 of the following
conditions:
• Clinical features consistent with peritonitis, i.e.
abdominal pain and/or cloudy dialysis effluent.
• Dialysis effluent white cell count > 100/μL or > 0.1
x 109/L (after a dwell time of at least 2 hours), with
> 50% polymorphonuclear.
• Positive dialysis effluent culture.
ISPD Peritonitis Recommendations: 2016 Update On Prevention & Treatment; Perit Dial Int 2016; 36(5):481–508

65. P E R I TO N I T I S - I S P D A S P E C T
PD Related Infections Recommendations: 2010 update, Perit Dial Int : 2010; 30:393 - 423
ISPD Peritonitis Recommendations: 2016 Update On Prevention & Treatment; Perit Dial Int 2016; 36(5):481–508

66. P E R I TO N I T I S - PAT I E N T A S P E C T

67. https://en.wikipedia.org/wiki/File:Hans_Christian_Gram.png

68. S P E C I M E N P R O C E S S I N G - 1 / 2
• Standard culture technique is the use of
blood-culture bottles.
• Blood-culture bottles can be directly
injected with 5 – 10 mL of effluent
Perit Dial Int 2010; 30:393–423Philip Li, Perit Dial Int 2016; 35:481-508

69. S P E C I M E N P R O C E S S I N G - 2 / 2
• A large-volume culture
• Culturing the sediment
after centrifuging 50 mL
of effluent.
Perit Dial Int 2010; 30:393–423Philip Li, Perit Dial Int 2016; 35:481-508

71. Collect specimen for cell diff, cell count, Gram’s stain.
Report for result from specimen.
Make decision for treatment or not.
Culture Specimen & Add IP antibiotics.
Change new dialysate bag for continue IP antibiotics.

73. Peritonitis
4,080
3,100
1,200
Day 1 Day 2 Day 3
PD cell count [mm3]
PD cell count [mm3]
Start IP Rx

74. Chow KM, Clin J Am Soc Nephrol 1: 768–773, 2006.

75. O V E R A L L P E R I T O N I T I S
565 episodes of peritonitis in 280 PD patients
Treatment success
465 episodes (82%)
Treatment failure
100 episodes (18%)
Aug 2001 - July 2005
70 - required catheter removal
30 - peritonitis related dead within 2 weeks
Diagnosis of peritonitis ( 2 of 3 )
- Abdominal pain or cloudy PD effluent
- Leucocytosis in PD effluent ( WBC > 100/ mm 3 )
- Positive Gram stain or culture from effluent
Chow KM, Clin J Am Soc Nephrol 1: 768–773, 2006.
IP Cefazolin & Ceftazidime
Prophylactic Nystatin 500,000 U x 3 times daily
IV antibiotics - in patient seemed septic clinically

76. Chow KM, Clin J Am Soc Nephrol 1: 768–773, 2006.

77. Chow KM, Clin J Am Soc Nephrol 1: 768–773, 2006.

78. 3 1,000
Chow KM, Clin J Am Soc Nephrol 1: 768–773, 2006.

80. P D F L U I D C U LT U R E R E P O R T E D

81. Peritonitis Start IP Rx
4,080
3,100
1,200 950 670
Day 1 Day 2 Day 3 Day 4 Day 5
PD cell count [mm3]
PD cell count [mm3]

82. R E F R A C T O RY P E R I T O N I T I S
Perit Dial Int 2010; 30:393–423

83. M.Krishnan et al: PDI 2002; 573-581
485
episodes
399 episodes were
analyzed
53 episodes
C/S negative
33 episodes
Fungal
peritonitis
• Retrospective study, single study
• Collected all episodes of peritonitis occurring
between March 1995 an July 2000.
P R E D I C T O R O F O U T C O M E F O L L O W I N G
P E R I T O N I T I S I N P E R I T O N E A L D I A LY S I S

84. M.Krishnan et al: PDI 2002; 573-581
399 episodes
317
episodes
Successful
82 episodes
Non-
resolved
9 Died 73
transferred
to HD
❑ Mean number of days in
which cell count > 100/µL
▪ Successful gr : 4.8+3.3 days
VS [p < 0.0001]
▪ Non-resolved : 7.4+1.4 days
❑ PD cell count > 100/µL for > 5
days
▪ Nonresolution rate 45.6%
VS [p=0.001]
▪ Resolution rate 4.2%
P R E D I C T O R O F O U T C O M E F O L L O W I N G
P E R I T O N I T I S I N P E R I T O N E A L D I A LY S I S

85. Chow KM, Clin J Am Soc Nephrol 1: 768–773, 2006.

86. Chow KM, Clin J Am Soc Nephrol 1: 768–773, 2006.

87. C U LT U R E N E G AT I V E P E R I T O N I T I SCulture-negative peritonitis:
After Culture negative on Day 3
Clinical assessment
Repeat PDF cell diff & count
Infection Resolving
Patient resolving
clinically
Continue initial
therapy for 14 days
Infection Not Resolving
Patient resolving clinically
Consider special culture technique
Now culture positive
consider specific Rx
Still Culture
negative
No clinical
improvement after 5
days
remove catheter
Clinical improvement:
continue antibiotics
14 days
Adapted from Perit Dial Int 2010; 30:393–423

88. T I M E L I N E O F P E R I T O N I T I S

89. PERITONITIS
Start IP Rx
Culture
reported
Make
decision
Peritonitis Course

90. K E Y P E R F O R M A N C E I N D E X

92. R I S K FA C TO R S F O R P E R I TO N I T I S
• Non- medical condition
• Socioeconomic status
• Personal hygienic care
• Medical condition
• Patient associated condition eg. co-morbid disease
• System associated condition eg. connection system
Textbook of Peritoneal dialysis; ISBN 978-974-16-5787-2, p. 269

93. P R E V E N T I O N - P D R E L AT E D I N F E C T I O N S
• Catheter placement
• Exit-site care
• Connection methods
• Training methods
• Antibiotic prophylaxis procedure
• Prevention bowel source of infection
• Prevention of fungal peritonitis
Perit Dial Int 2005; 25:107–131

94. M O D I F I A B L E R I S K FA C TO R S F O R
P E R I TO N I T I S
• Hypoalbuminemia
• Hypokalemia
• Constipation
• Vitamin D insufficiency
• Depression
Piraino, Perit Dial Int 2011; 31(6):614-630
• Prolonged antibiotics
• Medical procedures
• Exit-site colonization
and infections
• Technique errors

95. C A U S E O F C U LT U R E N E G AT I V E
• Most cases of culture-negative peritonitis in PD
patients can be explained by
• Recent antibiotic therapy
• Technical problems during effluent culture.
Perit Dial Int. 2012 Jul-Aug; 32(4): 476–478.

96. Thank You
Kamol Khositrangsikun, MD.