PERITONEAL DIALYSIS

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PERITONEAL DIALYSIS

• Presentation and modalities
• Shiva Seyrafian MD
• Isfahan University of Medical Sciences

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Background
PERITONEAL DIALYSIS

• Worldwide, 12 of dialysis patients are
  maintained on PD
• This varies greatly between countries
• gt50 on PD in New zealand, Hong Kong, and Mexico
• lt8 on PD in Japan ,Germany and Taiwan

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Modality Selection
PERITONEAL DIALYSIS

• Most patients (gt80) can do either modality and
  the decision is not a primarily medical one
  although some factors may favor one modality over
  the other to some degree
• Modality selection should take into account
  medical issues, patients social circumstances,
  wishes of patient but also overall economic
  circumstances in which the dialysis program
  operates

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Organizing a peritoneal dialysis program
PERITONEAL DIALYSIS
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Introduction
PERITONEAL DIALYSIS

• PD is a very simple technique when compared to
  hemodialysis.
• Set a program needs _ a doctor _
  a nurse _ a patient
• Assure a successful one well- planned

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Some absolute and relative indications to PD
PERITONEAL DIALYSIS

• Absolute indications
• Poor cardiac function
• Peripheral vascular disease
• Relative indications
• Free life style
• Want to take care themselves
• Long distance to hemodialysis center

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Teaching plans and materials
PERITONEAL DIALYSIS

• Demonstration is essential
• _by a nurse
• _by an experienced patient
• _via video
• Practice on a mannequine
• Practice on himself/herself
• Recheck the procedure
• Update for new knowledge

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Equipment requirement in PD training
PERITONEAL DIALYSIS

• Comfortable chair
• Water sink
• Weighing scales
• Drip stand/hook
• Books, booklets ,charts ,posters
• Television and video/VCD/DVD
• Automate PD machine
• Shelving for consumable

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Multi-discipline care team
PERITONEAL DIALYSIS

• The team typically includes
• Doctors
• Nurses
• Dietitians
• Social workers
• Often include a surgeon, a cardiologist, a
  psychologist, a psychiatrist, a
  physiotherapist etc.

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Contraindications to PD
PERITONEAL DIALYSIS

• 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

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Contraindications to HD
PERITONEAL DIALYSIS

• lack of vascular access-usually some years on HD
• Cardiovascular instability in HD with recurrent
  large weight gains ,fluid overload, symptomatic
  hypotension, angina etc
• Long distance from HD unit and unwillingness to
  tolerate

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Factors favoring PD
PERITONEAL DIALYSIS

• Young child
• Full time work
• Desire for autonomy
• Mother with young children
• Good family support
• Good motivation
• Early transplant likely

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Factors favoring HD
PERITONEAL DIALYSIS

• Poor family support
• Poor motivation
• Major comorbidity
• Body size gt110 kgs
• Severe obesity
• Irresponsible , lack of hygiene
• Poor hand eye coordination

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modality selection some realities
PERITONEAL DIALYSIS

• Most patients with ESRD are anxious and unwell
  and will be nervous about participating in their
  own treatment
• Getting them to do PD requires encouragement and
  support and is best done in advance before they
  become very uremic

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modality selection some
realities cont
PERITONEAL DIALYSIS

• 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

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modality selection How to do it well
PERITONEAL DIALYSIS

• Predialysis clinic
• Meeting with PD and HD staff
• Meeting with PD and HD patients
• Seeing PD and HD units
• Providing good educational material

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PD FIRST Advances of PD as
Initial Modality
PERITONEAL DIALYSIS

• 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

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Modality Selection Pre Dialysis Clinics
PERITONEAL DIALYSIS

• This allow time for patient to be educated
  remodalities before they became a medical
  emergency
• Patients who present late with uremic symptoms
  almost always are treated with HD and stay on it
  subsequently
• Predialysis education is critical for increasing
  PD use

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Modality Selection Education
PERITONEAL DIALYSIS

• Meeting with PD and HD patients and nurses is
  very helpful for patients
• A program should make such opportunities
  available
• Good videos , books etc are available from kidney
  disease organizations and from industry

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PD versus HD Which is best?
PERITONEAL DIALYSIS

• 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

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Integrated Dialysis Care
PERITONEAL DIALYSIS

• 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 modalities should not be
  seen as a failure
• PD has particular benefits as initial dialysis
  modality

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Conventional Classification of PD
PERITONEAL DIALYSIS

• Daily CAPD DAPD
  NIPD CCPD
• Intermittent IPD2-3 per week

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CAPD OR APD ?
PERITONEAL DIALYSIS

• Medical
• Lifestyle
• Economic

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Economic of APD versus CAPD
PERITONEAL DIALYSIS

• APD is more costly than CAPD.
• Paradoxically, however the difference is greater
  in poorer developing countries and least in
  wealthier countries .

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LIFESTYLE
PERITONEAL DIALYSIS

• 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 .

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LIFESTYLE INDICATIONS FOR APD
PERITONEAL DIALYSIS

• 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

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MEDICAL INDICATIONS FOR APD
PERITONEAL DIALYSIS

• Fluid resorption on standard CAPD
• High or high average transport status
• Inadequate dialysis on CAPD
• Frequent peritonitis on CAPD

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PERITONITIS
PERITONEAL DIALYSIS

• 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

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Y SET IS SUPERIOR TO STRAIGHT LINE
PERITONEAL DIALYSIS

• One peritonitis per 33 months versus one per 11
  months (Maiorca et al 1983)
• One peritonitis per 22 months versus one per 10
  months in Canadian Multicenter Study ( PDI 1989 )

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DOUBLE BAG IS SUPERIOR TO STANDARD Y
SET
PERITONEAL DIALYSIS

• 1 peritonitis per 34 months versus one per 12
  months (US) (Kiernan et al, JASN 1995)
• 1 peritonitis per 47 months versus 1 per 14
  months (Australia) (Harris et al, JASN 1996)

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THE NURSES ROLE
PERITONEAL DIALYSIS

• 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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