Peritoneal Dialysis

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 2 4-07-2017 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 Preserves residual renal function better May allow better blood pressure and volume control with cardiovascular benefits May give better quality of life Has less anemia and lower EPO doses Lower risk of Hepatitis C Equal or better survival in early years 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 Mujais et al; Kidney Int Suppl 2006; 70: S21-36

28. Composition of PD solution 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

29. 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 PERITONEAL DIALYSIS

30. 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.

31. 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 dialysis and haemodialysis across the world".  Nephrol Dial Transplant .