Peritoneal Peritoneal Dialysis Dialysis
Kampol Kampol PattanasombatsakulPattanasombatsakul
Peritoneum: Peritoneum: 1-1.3 1-1.3 mm22
Visceral: Visceral: 90%90%
Parietal:Parietal: 10%10%
Peritoneal cavityPeritoneal cavity Potential spacePotential space
10-100 ml10-100 ml
Vascular supplyVascular supply
Peritoneal Peritoneal DialysisDialysis
จะเริ่��มอย่างไริ่จะเริ่��มอย่างไริ่
Prepare unit for PD Prepare unit for PD patientspatients Personal (Team)Personal (Team)
Nephrologist , SurgeonNephrologist , Surgeon Nurse , on call nurse Nurse , on call nurse OtherOther
EquipmentEquipment In unit : washing basin, dressing set, In unit : washing basin, dressing set,
catheter , connector , dialysis set , catheter , connector , dialysis set , At home : washing basin, storage , clean At home : washing basin, storage , clean
towel , weight towel , weight ManagementManagement
Education tools Education tools Data management , StatisticData management , Statistic First visit , hospitalization , First visit , hospitalization ,
Home Care therapy : Home Care therapy : benefit to Persons involved in dialysis benefit to Persons involved in dialysis
care teamcare team
Relatives
Co-worker
Rehabilitation
NutritionistSocial
workers
Technicians
Nurse & colleges
Nephrologist
Family physician
Patient
Prepare unit for PD Prepare unit for PD patientspatients Personal Personal
Nephrologist , SurgeonNephrologist , Surgeon Nurse , on call nurse Nurse , on call nurse OtherOther
EquipmentEquipment In unit : washing basin, dressing set, In unit : washing basin, dressing set,
catheter , connector , dialysis set , catheter , connector , dialysis set , At home : washing basin, storage , clean At home : washing basin, storage , clean
towel , weighttowel , weight ManagementManagement
Education tools Education tools Data management , StatisticData management , Statistic First visit , hospitalization , First visit , hospitalization ,
Different PD Different PD catheterscatheters
Straight 1 cuff Straight 2 cuffs
Coiled Tenckhoff Coiled Tenckhoff catheterscatheters
Coiled 1 cuff Coiled 2 cuffs
Swan Neck Tenckhoff Swan Neck Tenckhoff catheterscatheters
Straight
Coiled
•Downwards directed exit site
•Permanent bend between 2 cuffs (180°)
•Right or left
Swan Neck MissouriSwan Neck Missouri
StraightCoiled
Bead placed IP, Flange extraP
Straight Tenckhoff Straight Tenckhoff catheterscatheters
Prepare unit for PD Prepare unit for PD patientspatients Personal Personal
Nephrologist , SurgeonNephrologist , Surgeon Nurse , on call nurse Nurse , on call nurse OtherOther
EquipmentEquipment In unit : washing basin, dressing set, In unit : washing basin, dressing set,
catheter , connector , dialysis set , catheter , connector , dialysis set , At home : washing basin, storage , clean At home : washing basin, storage , clean
towel , weight towel , weight ManagementManagement
Education tools Education tools Data management , StatisticData management , Statistic First visit , hospitalization , First visit , hospitalization ,
Education toolEducation tool CKD, kidney functionCKD, kidney function Catheter care and aseptic Catheter care and aseptic
techniquetechnique Dialysis exchangeDialysis exchange Fluid and nutritional balanceFluid and nutritional balance RecordRecord ComplicationComplication MedicationMedication Follow upFollow up
Select the patientsSelect the patients
Not suitable for PDNot suitable for PD Skin disease over abdomenSkin disease over abdomen Serious abdominal surgery Serious abdominal surgery Malnourish : S. albuminMalnourish : S. albumin Large BSA > 2.0Large BSA > 2.0 Very low GFR < 2 ml/minVery low GFR < 2 ml/min Abdominal anatomical Abdominal anatomical
defectdefect ? COPD? COPD ? Diabetic? Diabetic
Theoretically not to choose PD Theoretically not to choose PD initially initially ––
BUT PD may be feasible with BUT PD may be feasible with added adjustmentsadded adjustments
Large body sizeLarge body size Diverticulosis / diverticulitisDiverticulosis / diverticulitis Severe backacheSevere backache NIPDNIPD HerniasHernias NIPDNIPD Multiple abdominal surgeryMultiple abdominal surgery Poor manual dexterityPoor manual dexterity BlindnessBlindness No complianceNo compliance
PD preferredPD preferred
Bleeding diathesis (no need of Bleeding diathesis (no need of heparinization)heparinization)
Diabetes (status of vessels, insulin i.p.)Diabetes (status of vessels, insulin i.p.) Chronic infections (prevention of the Chronic infections (prevention of the
nosocomial spread nosocomial spread –– hepatitis B, C, HIV) hepatitis B, C, HIV) Future transplantation (improved initial Future transplantation (improved initial
graft function rate) graft function rate) Multiple myeloma (improves the chances Multiple myeloma (improves the chances
of renal recovery, removes some light-of renal recovery, removes some light-chains proteins)chains proteins)
PD and HD equally PD and HD equally preferredpreferred
Polycystic kidney diseasePolycystic kidney disease Scleroderma, other conective Scleroderma, other conective
tissue diseases (tissue diseases (e.g. e.g. SLE)SLE) Patients living in nursing homesPatients living in nursing homes
Psychosocial situations in Psychosocial situations in which PD is more which PD is more
appropriate appropriate PD preferredPD preferred
Independent Independent LifeLife
Frequent travelsFrequent travels
Tendency towards PDTendency towards PD
Great need of Great need of independence independence
by the patient by the patient Need to maintain workNeed to maintain work Distance to the HD centerDistance to the HD center
Prepare the patientsPrepare the patients
Who choose method of renal Who choose method of renal replacement therapy ?replacement therapy ?
Who will take care the patients?Who will take care the patients? Uremic symptomsUremic symptoms Volume balanceVolume balance ComplianceCompliance Socioeconomic and hygiene statusSocioeconomic and hygiene status
CAPD for a new patientCAPD for a new patient
Patient educationPatient education Patient training program Patient training program Catheter placementCatheter placement Break – in period & training Break – in period & training
timetime Peritoneal testingPeritoneal testing Mode of DialysisMode of Dialysis
Patient EducationPatient Education
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ปริ่ะท้าน้ำย่าปริ่ะท้าน้ำย่า๓๓ . . อาการิ่และอาการิ่แสุดงตางๆอาการิ่และอาการิ่แสุดงตางๆ๔๔ . . ภาวะแท้ริ่กซ้�อน้ำ และ ความผิ�ดปกต�ท้*�พบภาวะแท้ริ่กซ้�อน้ำ และ ความผิ�ดปกต�ท้*�พบ
ได�ได�๕๕ . . ความสุ"าค�ญของการิ่บ"าบ�ดไตท้ดแท้น้ำความสุ"าค�ญของการิ่บ"าบ�ดไตท้ดแท้น้ำ
Patient training programPatient training program
Hand washHand wash Basic sterile Basic sterile
techniquetechnique Exchange procedureExchange procedure การิ่ท้"าแผิล การิ่ท้"าแผิล ( exit site ( exit site
care )care ) การิ่ฉี*ดย่าเข�าถุ�งน้ำ"�าย่าการิ่ฉี*ดย่าเข�าถุ�งน้ำ"�าย่า การิ่เก1บน้ำ"�าย่าสุงตริ่วจการิ่เก1บน้ำ"�าย่าสุงตริ่วจ
Catheter placementCatheter placement Pre operative preparationPre operative preparation
Ideal location should be mark by teamIdeal location should be mark by team Free of constipationFree of constipation Controversy : nose culture for S. aureus nasal Controversy : nose culture for S. aureus nasal
carrier, if positive , 5-day course intranasal carrier, if positive , 5-day course intranasal mupirocin will be used.mupirocin will be used.
OperativeOperative Prophylaxis ABOProphylaxis ABO (evidence): 1 (evidence): 1stst generation generation
cephalosporin ( randomized control : vancomycin 1 cephalosporin ( randomized control : vancomycin 1 gm iv, single dose is superior than cephalosporin ) gm iv, single dose is superior than cephalosporin ) ( odd ratio 11.5 : 6.45 : 1)( odd ratio 11.5 : 6.45 : 1)
Using Double cuff with superficial cuff should be Using Double cuff with superficial cuff should be 2-2-3 cm3 cm. from the exit site. from the exit site
Downward direct tunnel Downward direct tunnel Swan neck catheter ( not confirm )Swan neck catheter ( not confirm ) Avoid trauma and hematoma during catheter Avoid trauma and hematoma during catheter
placementplacement Suture increase riskSuture increase risk of infection and are of infection and are
contraindicatecontraindicate
Peritoneal Dialysis-Related InfectionsPeritoneal Dialysis-Related InfectionsRecommendations : 2005 update Recommendations : 2005 update
PDI 2005: 25(2) ; 107-131PDI 2005: 25(2) ; 107-131
Peritoneal catheterPeritoneal catheterExit site
Cuffs
Post operative carePost operative care
Pain managementPain management AntibioticAntibiotic Break in period : rinse peritoneumBreak in period : rinse peritoneum ? Dialysis need ? Dialysis need
Consider HD first Consider HD first HospitalizationHospitalization Training review , catheter exchange Training review , catheter exchange
system system
Immediate post operative Immediate post operative statestate
Perioperative painPerioperative pain Bloody effluentBloody effluent Dialysate leakageDialysate leakage DisplacementDisplacement Perioperative Perioperative
peritonitisperitonitis Temporary obstructionTemporary obstruction Cuff extrusionCuff extrusion
Perioperative painPerioperative pain Wound pain Wound pain Catheter related pain – reaction , Catheter related pain – reaction ,
locationlocation In flow painIn flow pain – dialysate related– dialysate related ManagementManagement
Adequate analgesic during operation and Adequate analgesic during operation and post operative periodpost operative period
Pseudo ascites during catheter insertionPseudo ascites during catheter insertion No guide-wire / smooth catheter insertionNo guide-wire / smooth catheter insertion Slow infusion / low volumeSlow infusion / low volume Non osmotic dialysate solutionNon osmotic dialysate solution Warm dialysate Warm dialysate
Immediate post operative stateImmediate post operative state
Bloody EffluentBloody Effluent Bleeding complication during surgical Bleeding complication during surgical
procedureprocedure Bleeding tendency in end stage renal diseaseBleeding tendency in end stage renal disease ThrombocytopeniaThrombocytopenia ManagementManagement
Rinse peritoneal cavity until clearRinse peritoneal cavity until clear Add heparin 500-1000 unit / L in last bag Add heparin 500-1000 unit / L in last bag
dialysatedialysate Correction of bleeding tendencyCorrection of bleeding tendency Peritoneal restingPeritoneal resting Prevention Prevention
Immediate post operative stateImmediate post operative state
Dialysate leakageDialysate leakage Leakage via insertion point, exit siteLeakage via insertion point, exit site Commonly found in midline insertion, Commonly found in midline insertion,
acute PD catheteracute PD catheter How to test – only dipstick for glucoseHow to test – only dipstick for glucose ManagementManagement
Prevention – catheter fixation first 2-3 Prevention – catheter fixation first 2-3 days , soak both cuffs with NSSdays , soak both cuffs with NSS
Decrease intraabdominal pressure – using Decrease intraabdominal pressure – using low volume , avoid constipationlow volume , avoid constipation
Temporary hemodialysisTemporary hemodialysis Late catheter useLate catheter use
Immediate post operative stateImmediate post operative state
DisplacementDisplacement Upward displacement of catheter , non Upward displacement of catheter , non
in appropiated positionin appropiated position How to diagnose – plain abdomenHow to diagnose – plain abdomen ManagementManagement
Prevention – constipationPrevention – constipation During catheter insertion – pain During catheter insertion – pain
management , deep cuff fixation , management , deep cuff fixation , subcutaneous tract subcutaneous tract
Laxtive along with early ambulationLaxtive along with early ambulation Guide wire manipulationGuide wire manipulation Re-explorationRe-exploration
Immediate post operative stateImmediate post operative state
Perioperative peritonitisPerioperative peritonitis Early peritonitisEarly peritonitis Cause – infection , reactionCause – infection , reaction( plasticizer, air , ( plasticizer, air ,
fluid component ) fluid component ) How to diagnose – cell count & How to diagnose – cell count &
differential differential ( PMN , Eosinophil ) ( PMN , Eosinophil )
ManagementManagement Prevention – antibiotic prophylaxisPrevention – antibiotic prophylaxis Sterile techniqueSterile technique Wound dressing Wound dressing Antibiotic , prefere i.v. for infectionAntibiotic , prefere i.v. for infection Symptomatic treatment for reaction / Symptomatic treatment for reaction /
allergy – usually resolve in 2 weeksallergy – usually resolve in 2 weeks
Immediate post operative stateImmediate post operative state
Temporary obstructionTemporary obstruction Inflow obstruction – fibrin , clotInflow obstruction – fibrin , clot Outflow obstruction ( one way valve ) – Outflow obstruction ( one way valve ) –
omentum occlusion , catheter clinking, omentum occlusion , catheter clinking, displacementdisplacement
Complete obstructionComplete obstruction ManagementManagement
Prevention –gently catheter insertion without guide Prevention –gently catheter insertion without guide wire , control bleeding before insertion , catheter wire , control bleeding before insertion , catheter testing immediate insertion , pseudoascites testing immediate insertion , pseudoascites
NSS flush , intraluminal fibrinolytic agents, heparin NSS flush , intraluminal fibrinolytic agents, heparin locked catheter, brush , guidewire manipulationlocked catheter, brush , guidewire manipulation
NSS 100 ml + heparin 1000 u intraperitoneally , NSS 100 ml + heparin 1000 u intraperitoneally , peritoneum restingperitoneum resting
Guidewire manipulation , reinsertionGuidewire manipulation , reinsertion
Immediate post operative stateImmediate post operative state
Before starting PD Before starting PD
Make sure dialysis exchange and Make sure dialysis exchange and septic techniqueseptic technique
Select type of dialysis solutionSelect type of dialysis solution Do we need PET?Do we need PET? Select mode of dialysis Select mode of dialysis Select dialysis doseSelect dialysis dose
Volume : Guideline Volume : Guideline
• Acute dialysis• small volume : 1000 ml• - increase 1500 2000 ml in
supine position• Chronic dialysis
• - volume 2 0 0 0 3 0 0 0 ml
Peritoneal dialysis solutionPeritoneal dialysis solution Buffer compositions Buffer compositions
- 35 40Lactate mEq/L - 35 40Lactate mEq/L - Bicarbonate 25 39 mEq/L - Bicarbonate 25 39 mEq/L
Osmotic compositions Osmotic compositions Glucose ( Dextrose ) : 1.36% , 2.25% , 3.8 Glucose ( Dextrose ) : 1.36% , 2.25% , 3.8
6% glucose 6% glucose
1.5% , 2.5% , 4.25% 1.5% , 2.5% , 4.25%dextrosedextrose
ElectrolytesElectrolytes - Sodium : 132 134 mEq/L dialysate - Sodium : 132 134 mEq/L dialysate - :0.5 1.0 / - :0.5 1.0 / - :02 .0 / - :02 .0 / - - :2.0 3.5 / ( 1.0 1.75 / ) - - :2.0 3.5 / ( 1.0 1.75 / )
PD solution : Calcium PD solution : Calcium
• 2.0 - 3.5 mEq/L ( 1.0 - 1.75 mmol/L )
• Precaution of low calcium dialysate• Negative calcium balance• induce severe hyperparathyroidism
•Indication for low calcium dialysate ( 2.0 mEq/L )• hypercalcemia • serum phosphate > 3.0 mEq/L with oral calcium• serum phosphate < 3.0 mEq/L with hyperparathyroidism with oral vitamin D• hypoparathyroidism
Ectopic CalcificationEctopic Calcification
despite better P control, PD patients may despite better P control, PD patients may be at increased risk for vascular be at increased risk for vascular calcification because of low turnover bonecalcification because of low turnover bone
vascular medial calcification associated vascular medial calcification associated with arterial stiffening and increased with arterial stiffening and increased afterloadafterload
vascular intimal calcification associated vascular intimal calcification associated with luminal narrowing and occlusive with luminal narrowing and occlusive diseasedisease
Fate of Ingested Calcium – Fate of Ingested Calcium – Normal or Increased Bone Normal or Increased Bone
TurnoverTurnover
Oral Ca Gut absorption
Bone uptake
Visceral Calc’n
Vascular Calc’n
Fate of Ingested Calcium – Fate of Ingested Calcium – Low Bone TurnoverLow Bone Turnover
Oral Ca Gut absorption
Bone uptake
Visceral CalcVisceral Calc’’nn
Vascular Calc’n
Intimal Intimal CalcificationCalcification
tends to correlate with tends to correlate with plaque areaplaque area
may be responsible for may be responsible for occlusive vascular occlusive vascular diseasedisease
Medial Medial CalcificationCalcification
produces stiff produces stiff arteriesarteries
may be may be responsible for responsible for LVH and CHFLVH and CHF
How to diagnosed adynamic bone How to diagnosed adynamic bone disease disease
in dialysis patients?in dialysis patients? Bone markerBone marker
Bone turnover Bone turnover Parathyroid hormoneParathyroid hormone (<150 (<150 pg.ml)pg.ml)
Resorption Resorption Tartarate resistant acid phosphatase Tartarate resistant acid phosphatase ( TRAP)( TRAP)
Pyridinoline and deoxypyridinoline Pyridinoline and deoxypyridinoline ( PYD,DPD)( PYD,DPD)
Procollagen type I cross linked C-terminal Procollagen type I cross linked C-terminal telopeptide ( ICTP)telopeptide ( ICTP)
Formation : Formation : Total alkaline phosphatase ( TAP)Total alkaline phosphatase ( TAP)
Bone alkaline phosphatase Bone alkaline phosphatase ( BAP) < 27 U/L( BAP) < 27 U/L
Osteoclacin ( OC) < 14 ng/mlOsteoclacin ( OC) < 14 ng/mlProcollagen type I carboxy Procollagen type I carboxy
terminal terminal propeptide ( PICP)propeptide ( PICP)
Bone biopsyBone biopsy
Before starting PD Before starting PD
Make sure dialysis exchange and Make sure dialysis exchange and septic techniqueseptic technique
Select type of dialysis solutionSelect type of dialysis solution Do we need PET?Do we need PET? Select mode of dialysis Select mode of dialysis Select dialysis doseSelect dialysis dose
Standard PET Standard PET Standard PET Standard PET - 812Upright , drain the overnight ( hr) - 812Upright , drain the overnight ( hr)
20over min. 20over min. RRRR RRRR RR RRRR ,2.0 ,2.5 % 10 . RRRR RRRR RR RRRR ,2.0 ,2.5 % 10 . every every
400 ml or 2 min.400 ml or 2 min. R RRR RRRR R RRRRRRR RR RR RR RRRRRRRRR R () 2,200 ,, 10 , R RRR RRRR R RRRRRRR RR RR RR RRRRRRRRR R () 2,200 ,, 10 ,
190reinfuse ml 190reinfuse ml 2Collect blood at hr. 2Collect blood at hr. RRR RRRRR R RRR RRRR R RRRRRRR RRRRRR R4. , , RRR RRRRR R RRR RRRR R RRRRRRR RRRRRR R4. , ,
nd collect sample nd collect sample
Peritoneal Equilibration Test
Solute clearanceUltrafiltration
Before starting PD Before starting PD
Make sure dialysis exchange and Make sure dialysis exchange and septic techniqueseptic technique
Select type of dialysis solutionSelect type of dialysis solution Do we need PET?Do we need PET? Select mode of dialysis Select mode of dialysis Select dialysis doseSelect dialysis dose
CAPDCAPD (continuous (continuous
ambulatory PD)ambulatory PD)
NIPD NIPD ( nocturnal ( nocturnal
intermittent PD)intermittent PD)
CCPDCCPD ( continuous ( continuous cyclical PD)cyclical PD)
DAPD DAPD ( day time ( day time
ambulatory PD)ambulatory PD)
CAPD prescriptionCAPD prescription
Adequacy recommendationAdequacy recommendationAdequacy recommendationAdequacy recommendation
Method Weekly Kt/VCreatinine clearance( L/wk/1.73sq.m.)
CAPD 20> . 6>0NIPD 22> . 66
CCPD 2163
Calculation of renal creatinine clearance for 24 hours:Calculation of renal creatinine clearance for 24 hours: Total urinary creatinine removal divided by serum creatinine levelTotal urinary creatinine removal divided by serum creatinine level
U/Pcreatinine x urine volumeU/Pcreatinine x urine volume Standardized by body surface areaStandardized by body surface area
Calculation of peritoneal clearance (Urea/Creatinine) Calculation of peritoneal clearance (Urea/Creatinine) for 24 hoursfor 24 hours Total peritoneal removal divided by serum levelTotal peritoneal removal divided by serum level
D/P x total dialysate volumeD/P x total dialysate volume Standardized by body surface area (creatinine)-Standardized by body surface area (creatinine)-
Peritoneal creatinine clearancePeritoneal creatinine clearance Standardized by body water content (urea): Standardized by body water content (urea): Kt/VureaKt/Vurea
Adequacy recommendationAdequacy recommendationAdequacy recommendationAdequacy recommendation
At least Kt/V > 1.7 in CAPD ;
At least Kt/V 1.7 & CCr 45 L/wk/1.73 sq.m for APD
Krt/V 2.0 = GFR ปริ่ะมาณ 9.38 – 12.43 ml/min
Estimate GFR = - 0.4462 + ( 4.9179 * Krt/V ) ;
หริ่�อ Krt/V = 0.09 + estimate GFR /4.9179
Before starting PD Before starting PD
Make sure dialysis exchange and Make sure dialysis exchange and septic techniqueseptic technique
Select type of dialysis solutionSelect type of dialysis solution Do we need PET?Do we need PET? Select mode of dialysis Select mode of dialysis Select dialysis doseSelect dialysis dose
PD prescriptionPD prescription
Determine RRF
High RRF Low RRF, urine vol
Start with NIPD, may be with 3 x 2L
Start with CAPD, 4 x 2L unless very small size
Inadequate UF/clearance
NIPD with 4 x 2 L,Or 5 x 2L
Inadequate UFHigh transport
High transportHigh transport 高转运高转运
Low transportLow transport Inadequate clearance
Yet adequate UF
Increase volume / frequency, day dwell
CCPD/NIPD +mid-day exchange
Inadequate Clearance
Increase dwell vol/mid-day ex.CCPD?? PD+HD
Complication in CAPDComplication in CAPD
Immediate complication – first 6 monthsImmediate complication – first 6 months Immediate post operative periodImmediate post operative period
Early complication – up to 24 monthsEarly complication – up to 24 months Late complication – more than 24 monthsLate complication – more than 24 months
Complication in CAPDComplication in CAPD
Immediate complication – first 6 monthsImmediate complication – first 6 months Immediate post operative periodImmediate post operative period
Early complication – up to 24 monthsEarly complication – up to 24 months Late complication – more than 24 monthsLate complication – more than 24 months
Early period complication Early period complication in CAPD in CAPD
Catheter displacement / obstructionCatheter displacement / obstruction Cuff extrusion Cuff extrusion Catheter infectionCatheter infection
PeritonitisPeritonitis Exit site infectionExit site infection
Blood pressure and volume controlBlood pressure and volume control Metabolic , Electrolytes and Metabolic , Electrolytes and
Nutritional compliactionNutritional compliaction
Complication in CAPDComplication in CAPD
Immediate complication – first 6 monthsImmediate complication – first 6 months Immediate post operative periodImmediate post operative period
Early complication – up to 24 monthsEarly complication – up to 24 months Late complication – more than 24 monthsLate complication – more than 24 months
Late complication in Late complication in CAPD CAPD
Catheter problem & infectionCatheter problem & infection Prolong increase intraabdominal Prolong increase intraabdominal
pressurepressure Peritoneal changePeritoneal change Cardiovascular complicationCardiovascular complication
THANK YOUTHANK YOU
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