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.

1. Dr. Amit Jha
24-07-2017
Peritoneal Dialysis

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

3. Types of peritoneal dialysis
Continuous ambulatory
peritoneal dialysis (CAPD)
Automated peritoneal
dialysis (APD)

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

5. Automated peritoneal dialysis
 -is performed through a cycler machine.
 -during the night when the patient is asleep.

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
PERITONEAL DIALYSIS

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
PERITONEAL DIALYSIS

8. Factors favoring PD
 Young child
 Full time work
 Desire for autonomy
 Mother with young children
 Good family support
 Good motivation
 Early transplant likely
PERITONEAL DIALYSIS

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
PERITONEAL DIALYSIS

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
PERITONEAL DIALYSIS

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
PERITONEAL DIALYSIS

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
PERITONEAL DIALYSIS

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
PERITONEAL DIALYSIS

18. CAPD OR APD ?
 Medical
 Lifestyle
 Economic
PERITONEAL DIALYSIS

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 .
PERITONEAL DIALYSIS

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 .
PERITONEAL DIALYSIS

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
PERITONEAL DIALYSIS

22. MEDICAL INDICATIONS FOR APD
 Fluid resorption on standard CAPD
 High or high average transport status
 Inadequate dialysis on CAPD
 Frequent peritonitis on CAPD
PERITONEAL DIALYSIS

23. Criteria of PD adequacy

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
PERITONEAL DIALYSIS

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

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

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