Renal replacement therapyperitoneal dialysis

Sh.Atabak

Problems of ESRD patients in 20101. Fast growing number of ESRD patients

2. Astonishing ESRD cost

3. Sever shortage of financial resources

4. Sever shortage of donor organ

5. Chronic rejection as a main etiology in waiting lists

6. Ethical debates in using live unrelated donors

7. Suboptimal current outcomes

RRT

If the patient is not of advanced age and is not afflicted with severe comorbid illness, renal transplantation is the preferred form of renal replacement therapy.

Living donor transplantation is preferred to cadaveric transplantation.

For the patient who awaits or who cannot undergo transplantation, either peritoneal dialysis or hemodialysis may be chosen.

Integrated Care Approach “Start renal replacement therapy in

ESRD patients with PD, transfer them to HD when problems with PD occur, and

transplant them when the possibility exists”

Lameire N, et al, Seminar of Uro-Nephrology, (1999)

Rational for a dialysis program in spite of

no waiting list for kidney Tx1) More than 15% of ESRD patients are not eligible for kidney transplantation (contrandications)

A : Malignancy B : Chronic Infection C : Sever exterarenal disease

Chronic liver disease Uncorrectable heart disease Chronic lung disease (difficult anesthesia) Sever peripheral vascular disease (Difficult anastomosis) (Limb viability)

If medically suitable, PD should be the first option for RRT when a patient reaches ESRD (in the absence of a suitable live donor).

Coles GA. Et al. , What is the place of peritoneal dialysis in the integrated treatment of renal failure? KI, 54; 2234-2240,

Types of PD

MEA PD Variations (Adults) - 2001

Manual Systems (CAPD)

Automated Systems (APD)

29%

69%

Advantages of PD Disadvantages of PD

➢Ease of performance Low efficiency ➢High safety margin Body image problem ➢Portability secondary to catheter ➢Availability Pulmonary compromise ➢Fewer dialysis-related Protein loss symptoms Metabolic Complications ➢No anticoagulation

PD as the Initial Form of Renal Replacement Therapy

• Better initial survival • Preserves residual renal function • Effective blood pressure and volume control

• PD → Transplant:

• reduced risk of early acute renal failure

• Reduced risk of being infected by a blood borne virus

• Delays the use of HD blood access sites • Quality of life

Relationship of Members of CAPD Family

Nurse

Patient

Doctor Family

PredialysisWork assessment • Suitable area for

CAPD exchange • Educate management

& personnel staff • A Home Sister is

always available at Clinic

Home Visit

What is it? Discussion Dialysis problems Health Status Social life Knowledge of Renal failure/treatment Liaison

Nephrology Consultation

• Timely appointments • accessibility

• Available for discussion • by phone • by fax • for information/direction

• Communication patterns preferred • individualized

Integrated ESRD Care

Residual Renal Function

Hemodialysis

Crea

tinine

Clear

ance

(ml/min) 20

15

10

5

0Time on Dialysis

Initiation of Dialysis

Peritoneal Dialysis

Transplant

PD

• Peritoneal dialysis (PD) may be a useful technique in the treatment of patients with congestive heart failure, both with and without primary end-stage renal disease (ESRD)

CHF

• CHF is a major and growing health program • 1% of all people above 40 years old have

HF • The prevalence doubled with each decades

of life, being around 10% over 70 years old. • 5% of all hospitalization is due to HF • Third cause of cardiovascular mortality.

A study in Spain

• Fluid accumulation worsen the HF • Renal perfusion decreased and activation

of neurohurmonal induce glomeulosclerosis and tubulointerstitial fibrosis

Results of alteration

• Some cytokine and humoral factors have been involved in the progression of HF.

• Some have myocardial depressant activity as ANP, tumor necrosis factor.

Middle molecule

Presentation Plan

1.Type of catheters 2.Pre-operative care 3.Catheter placement 4. Immediate post-op. care 5.Chronic catheter care

• Rapid rate of dialysate flow • Minimum or no - leaks - migration - exit and tunnel infections - peritonitis • Ease of insertion by all techniques • Long lasting • Inert material - durability - resistant to infection/biofilm - antimicrobial properties

Peritoneal Catheters

انواع کاتتر

Straight Tenckhoff cath. 2 cuffs

Coiled 1 cuff

CoiledTenckhoff cath. 2 cuffs

Swan Neck Missouri 2 cuffs

Swan Neck Tenckhoff Permanent bend (180o ) between the 2 cuffs

Pre sternal 1 cuff

Appropriate candidates

• Motivated ESRD patients • Patient’s family support, care givers,

etc. • Ability to understand and use sterile

techniques • Physical capability • Ideal candidate has no prior abdominal

procedures

Catheter Placement

• Operator should be interested in outcome • Percutaneous, surgical or laparoscopic • Catheter tip must be in the true pelvis • Deep cuff in rectus muscle • Arcuate tunnel- downward position • No sutures at exit site • Check flow before closure

Catheter Break-in

• Flush post-op with 500 ml to 1000 ml dialysate to check patency

Catheter Insertion

PRE-IMPLANTATION PREPARATION

❖ Fully inform patient about the details of the procedure

❖ Pre-surgical assessment (e.g. hernias) ❖ Determination of exit-site ❖ Skin preparation ❖ Bowel preparation ❖ Prophylactic antibiotics

Evidences suggest that peri-op antibiotics diminish wound infection

Catheter Implantation Techniques

RECOMMENDATIONS • Performing implantation competently, experienced

operator, having a planned manner, Care and attention to details are important

• Peritoneal entry - lateral or paramedian • Deep cuff - placed in musculature of anterior

abdominal wall or within posterior rectus fascia • Subcutaneous cuff - 2cm from exit-site • Catheter patency needs checking • Exit-site facing downward or laterally

Immediate Post Operative Care

AIMS ❖ Minimizing bacterial colonisation ❖ Preventing trauma to exit-site and traction on cuffs ❖ Minimizing intra-abdominal pressure to prevent

leakage ❖ Several approaches for post operative care ❖ No evidence to support superiority of any single

method RECOMMENDATIONS ❖ Minimizing catheter movements ❖ Minimizing catheter handling until healing of wound

and tract for 3-4 weeks

Post implantation Dialysis

RECOMMENDATIONS

• Flush catheter with small volumes (e.g. 500mL) until effluent becomes clear

• Starting CAPD depends on type of implantation technique - generally catheter should be capped for 2 weeks before starting PD

• PD in the interim should be

- intermittent - small volumes - gradual increase in volume - patient in a supine position

CAPD Exchange Procedure

1. Fill phase (<10 Minutes)

CAPD Exchange Procedure

2. Dwell phase (4-8 hours)

3. Drain phase (<20 minutes)