This document discusses various topics related to continuous ambulatory peritoneal dialysis (CAPD) including: 1. Assessment of adequacy, membrane failure, peritonitis treatment in CAPD, and the importance of a multidisciplinary team approach to CAPD programs. 2. Guidelines for prescribing and assessing CAPD adequacy, managing membrane failure, treating peritonitis, and the benefits of a multidisciplinary team. 3. Key factors in evaluating and adjusting CAPD prescriptions including residual kidney function, solute clearance targets, membrane transport type, and lifestyle factors. Managing complications like peritonitis, ultrafiltration failure and ensuring adequate solute clearance is essential for successful CAPD.

1. Penilaian Adekuasi, Kegagalan Membran,
Penanganan Peritonitis pada CAPD, Serta
Kerjasama Tim dalam Program CAPD
Darmawan
Fasilitator: dr.Pringgodigdo Nugroho,SpPD-KGH

2. Sub Topik
• Peresepan dan Penilaian adekuasi CAPD
• Pengelolaan CAPD yang gagal
• Penanganan Peritonitis pada CAPD
• Pendekatan multidisiplin dalam pengelolaan program CAPD

3. Peritoneal Dialysis
• PD allows flexibility in
regimen such that the
prescription can be
individualized
• Continuous or intermittent
• Manual exchanges or be
automated using a cycler

4. Selection of PD Modality
• APD vs CAPD?
• Based upon their preferences and lifestyle.
• Similarities for most clinical outcomes
• A systematic review of three randomized, controlled trials; 139 patients, similar
mortality and hospitalization rates, risk of peritonitis, and fluid leaks
• RKF: A large, observational study of 505 CAPD and 78 APD patients showed a
higher risk of loss of residual kidney function in the first year with APD
compared with CAPD (adjusted hazard ratio [HR] 2.66, 95% CI 1.60-4.44) >>> a
systematic review of randomized trials

5. • APD
• allows the patient to go to work or pursue other activities during the
day without performing manual exchanges
• significantly more time for work, family, and social activities
• CAPD
• does not require the use of machinery (cycler)
• does not require being "tethered" to the cycler for several hours at night

6. CAPD Adequacy
• Adequate dialysis
• an effective dosage of dialysis solution, keeping a patient clinically
asymptomatic and active and maintaining sufficient correction
of the altered metabolic and homeostatic components
secondary to the loss of kidney function.

7. CAPD Adequacy
• Indicators to Evaluate Dialysis Adequacy
• Often based on clinical evaluations as the presence/absence of
symptoms related to uremia: highly subjective
• Marker of dialysis dose: Clearance of urea (conjunction with
other indicators)
• low molecular weight (60 kDa)
• rapid diffusion between body compartments
• previously created for HD

8. Optimal amount of dialysis (target Kt/Vurea)
• The amount of delivered dialysis should be sufficient
• Control uremic symptoms
• Maintain optimal mineral metabolism
• Electrolytes values
• Fluid balance
• provide a minimum total small-solute clearance, defined by the
Kt/V urea
• associated with better patient outcomes
• consider patient-reported outcomes of well-being, fluid status, and
nutrition status when evaluating the optimal amount of dialysis

9. CAPD Adequacy

10. • CAPD
• Suggest that total (residual kidney plus peritoneal) Kt/Vurea should be
≥1.7 per week
• Randomized study from Hong Kong in which 320 new CAPD patients were
assigned to a target Kt/Vurea of 1.5 to 1.7, 1.7 to 2.0, or >2.0: more patients
assigned to a dialysis dose of <1.7 were switched from peritoneal dialysis to
hemodialysis; required higher doses of erythropoietin than those in the other two
groups
• APD
• Based on studies of CAPD patients: Kt/Vurea should be ≥1.7 per week

14. Factors to Be Considered at the First Start of PD
• Solute Clearance
• Total weekly Kt/ Vurea ≥1.7 as the minimum target of solute clearance
• Peritoneal Membrane Transport Type
• A peritoneal equilibration test (PET) is used to delineate membrane transport type at
approximately 4 weeks after initiation of PD and regularly thereafter
• Renal Function
• Full dose X Incrimental
• Body Size
• Fill volume ~ BSA
• Patients with BSA of 1.7–2.1 m2: tolerate 2 L of fill volume
• Lifestyle and Patient’s Preferences

15. • The initial PD prescription is defined empirically

18. Peritoneal equilibration test
• approximately 2/3 of patients had average transport rates
on the baseline PET
• association initial peritoneal transport status-clinical features
• 3188 patients from Australia and New Zealand: PD between 1991 and
2002 and underwent a baseline PET within the first six months
• a high transporter was associated with increased age (odds ratio [OR]
1.08 for each 10 years, 95% CI 1.03-1.13) and ethnicity (OR 1.48 for Maori and
Pacific Islander racial origin, 95% CI 1.13-1.94)
• Not associated with sex, diabetes and other comorbid conditions, smoking,
previous HD therapy or transplantation, or RKF

22. Prescription Adjustment During Maintenance of PD
• Actual solute clearance and
characteristics of peritoneal
membrane should be determined
within 4–8 weeks after dialysis
initiation and monitored serially
• Total solute clearance: every 4 mo
• PET annualy or when clinically indicated
• Various clinical and laboratory indicators
representing optimal dialysis such as fluid
balance, nutritional status, or RRF should
also be evaluated during routine visit

24. Prescription Adjustment in Patients with Insufficient Solute Clearance

25. Prescription Adjustment in Patients with Volume Overload
• PD prescription traditionally had been focused on small solute
removal >>> Achieving adequate ultrafiltration to
maintain euvolemia is considered another important
goal to improve the outcomes
• If daytime dwell is too long or an inappropriate osmotic
agent is used, fluid and electrolytes may be absorbed
• Increasing fill volume and dialysate tonicity
• The use of glucose polymer (icodextrin)- based dialysate to maintain osmotic
gradient

28. Peritoneal Ultrafiltration Failure
• There are three types of ultrafiltration failure depending on
peritoneal membrane transport status.
• Fast Transport Status
• Characterized by low ultrafiltration volume and fast transport status
• High amount of glucose exposure and PD-related peritonitis are two main factors
• Short and frequent exchanges are generally recommended
• Resting the peritoneum for 4 weeks is another option
• Slow Transport Status
• Possible causes for this ultrafiltration failure are peritoneal adhesions and scarring after a
severe peritonitis or other intra-abdominal complication
• Transfer to HD
• Average Transport Status
• It is caused by aquaporin deficiency or increased lymphatic reabsorption

31. • UF FAILURE
• Modified PET be performed >> the standard PET (resulting in a
maximal osmotic drive )
• Failure is defined as a UF volume of less than 400 mL after a four-
hour dwell with 2 liters of 4.25 percent dextrose (3.86 percent glucose).
• Treatment — dietary sodium and fluid restriction, increased
dosing of loop diuretics or the addition of combination
diuretics, and the use of osmotic solute during a long dwell
• If solute transport characteristics have changed >> modify the dialysis
prescription >> according to PET

32. Peritonitis
• Common complication of peritoneal dialysis
• Significant morbidity
• Catheter loss
• Transfer to hemodialysis
• Transient loss of ultrafiltration
• Possible permanent membrane damage
• Death

33. Peritonitis
• Peritoneal dialysis-related
• Contamination with pathogenic skin bacteria during exchanges (ie,
touch contamination)
• Exit-site infection
• Tunnel infection
• Secondary peritonitis (6%)
• Underlying pathology of the gastrointestinal tract
• Cholecystitis, appendicitis, ruptured diverticulum, treatment of severe
constipation, bowel perforation, bowel ischemia, and incarcerated hernia
• Hematogenous spread
• Related to invasive procedures

34. Peritonitis
• CLINICAL PRESENTATION
• The most common symptoms
• Abdominal pain
• Cloudy peritoneal effluent
• Others: fever, nausea, and diarrhea
• May not occur at the same time
• Physical exam reveals abdominal tenderness and rebound tenderness
• Occasionally systemic signs of sepsis
Abdominal pain 79-88%
Fever (greater than 37.5ºC) 29-53%
Nausea or vomiting 31-51%
Cloudy effluent –84%
Hypotension –18%

35. Peritonitis
• Evaluation
• The peritoneal fluid: cell count and differential, gram stain and culture
• Patients who are febrile or appear septic: complete blood count and
blood cultures
Cell count and differential:
> 100 cells/mm3 (n<8 cells/mm3)
< 100 cells/mm3 / >50% neutrophils (10%)
Gram stain and culture
Culture positive in approximately 80 to 95 percent
peritoneal dialysis-related peritonitis: gram-positive organisms
secondary peritonitis: enteric organisms (such as Bacteroides) or culture of multiple organisms
Gram stain usually negative
Culture of exit site
The exit-site infection may be the cause of peritonitis

36. Peritonitis
• Presumptive diagnosis
• Untreated bacterial peritonitis is associated with morbidity and
mortality >>> presumptive diagnosis
• The diagnosis of peritonitis should be suspected in a peritoneal
dialysis patient with abdominal pain or cloudy effluent
• APD: a presumptive diagnosis > 50% PMN, independent of the
absolute white cell count
• CAPD: consistent clinical history and physical exam, even if the
peritoneal leukocyte count is low (if neutrophils >50%), causes of
abdominal pathology have been excluded

37. Peritonitis
• Confirmed diagnosis
• a positive dialysate culture (80-95% if proper culture technique)
• Peritonitis should be diagnosed if two or more of following are
present
• Consistent clinical features (abdominal pain or cloudy effluent).
• Peritoneal fluid white count is greater than 100 cells/mm3 (or 0.1 x 109/L after
dwell time of at least two hours) and the percentage of neutrophils is greater than
50 percent.
• Positive effluent culture.

38. Peritonitis
• Treatment
• Empiric antibiotics
• Initiated as soon as possible
• Broad spectrum (based on local sensitivity, history of ab therapy)
• 2016 International Society for Peritoneal Dialysis (ISPD) guidelines
 Gram-positive organisms may be covered by vancomycin or a first-generation
cephalosporin (such as cefazolin). In centers with a high rate of methicillin-resistant
organisms, vancomycin should be used
 Gram-negative organisms may be covered by a third- or fourth-generation
cephalosporin (such as cefepime or ceftazidime), an aminoglycoside, or aztreonam
• Antifungal agents >>> prompt catheter removal

39. Peritonitis
• Treatment
• Definite Antibiotics
• There are no high-quality, randomized studies that have examined the optimal
duration of antibiotics >> the duration of antibiotics based on the
organism
• coagulase-negative Staphylococcus and Streptococcus infections for two weeks or
three weeks with history of prior infection
• all other gram-positive infections and all gram-negative infections are treated for
three weeks
• Polymicrobial peritonitis (1-4%)
• concurrent intra-abdominal condition such as ischemic bowel or diverticular disease?
• Empiric ab: coverage for anaerobes and gram-negative enteric bacilli
• Ab for a minimum of two weeks after the catheter is removed

40. Peritonitis
• Treatment
• Culture-negative peritonitis (20-40%)
• empiric antibiotics covering both gram-positive and negative organisms
• repeat the cell count and culture after three days of empiric therapy
• vancomycin or a first-generation cephalosporin for a total of two weeks
• no improvement after three days of antibiotics? -> other cause?
• DD: mycobacterial and fungal pathogens
• Nonmicrobial causes: endotoxin contamination, adverse reaction to icodextrin,
allergic reactions, or reaction to intraperitoneal or retroperitoneal disease
• After 2 weeks: If the patient is doing well clinically >> stop ab >> one follow-up
culture
• If the patient continues to be symptomatic with persistently elevated cell counts
>>> remove the catheter

41. • Peritonitis
• Antibiotic dosing and administration
• Intraperitoneal administration, continuously-intermitten
• Commonly AB can be mixed in the same dialysis bag without loss of bioactivity
• Antifungal prophylaxis
• systemic antibiotics is a major risk factor for the development of fungal peritonitis
among peritoneal dialysis patients >>> Antifungal prophylaxis
• antibiotics for longer than three days

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43. Copyrights apply

44. • Peritonitis
• Monitoring clinical response
• Clinical improvement should be observed within 48 hours; the fluid should be
less cloudy, the cell count should be decreasing
• The absence of improvement in the cell count suggests lack of
response to treatmen
• 565 case of peritonitis, a persistent dialysate cell count >1000 by the third day of
peritonitis: 64% likelihood of treatment failure
• If no improving clinically by 48 hours and cultures demonstrate a susceptible
organism, we switch from intermittent to continuous dosing
• If a cloudy effluent persists after five days of appropriate antibiotic therapy >>>
remove catheter

45. • Peritonitis
• Rapid exchanges
• Addition of heparin to dialysate
• Heparin (500 units/L of dialysate)
• When fibrin strands are observed
• Adjustment for volume overload
• Decreased ultrafiltration is due to an increase in the solute transport rate that
results in rapid equilibration of fluid and solute
• Cessation of dialysis?
• Severe cases of peritonitis >>> Catheter removal

46. • Peritonitis
• Indications for catheter removal
• Refractory peritonitis,
• Relapsing peritonitis
• Fungal or mycobacterial peritonitis
• Peritonitis occurring in association with intra-abdominal pathology
• Culture-negative peritonitis with persistent symptoms and high peritoneal white
blood cell count
a minimum period of three to four weeks between the time of catheter removal
and new catheter placement
treat with oral or intravenous antibiotics for a minimum of two weeks after the
catheter is removed

47. • Peritonitis
• PROGNOSIS
• The reported peritonitis-associated mortality: 2-6% (Highest with fungal
pathogens, gram-negative organisms, and S. aureus)
• In one retrospective Spanish study of 565 patients (693 episodes of peritonitis),
mortality rates of 28, 19, and 15 percent were associated with fungus,
enteric organisms, and S. aureus
• Peritonitis is also associated with increased mortality from noninfectious causes:
• there was a marked increase in the risk of having had peritonitis in the 30 days prior
to death among patients who died of cardiovascular, cerebrovascular, or peripheral
vascular disease (odds ratio 3.4, 95% CI 2.4-4.6)

48. • Peritonitis
• PROGNOSIS
• Secondary peritonitis is associated with a worse prognosis
• In one report, 11 of 26 patients with secondary peritonitis died compared with
an overall peritonitis-associated mortality of approximately 2 to 3 percent among all
peritoneal dialysis patients with peritonitis
• Extended-spectrum beta-lactamase- or carbapenemase-producing gram-negative
organisms: higher mortality
• Peritonitis due to MDR gram-negative pathogens: patients who have
previously received broad-spectrum AB/ in a long-term care facility/ endemic
area

49. • Peritonitis
• Catheter removal (20%)
• Coagulase-negative staphylococci, streptococci, and culture-negative peritonitis
(<20 percent)
• Corynebacteria, enterococci, S. aureus, and non-Pseudomonas gram-negative
peritonitis (20 to 40 percent)
• Pseudomonas (>40 percent)
• Concurrent exit-site or tunnel infection
• >>> Transfer to hemodialysis (5-20%)

50. PD Team
• To have a successful PD program >>> need a supportive PD
team
• PD Champion
• Core Team: Nephrologist, nurse, renal dietitian, medical social worker
• The administrative assistants and technicians
• Extended teams: outpatient clinics, the access placement team, and the
hospital, the transplant program and infectious disease specialist

54. Thank You