Peritoneal dialysis

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Peritoneal dialysis

• Jana Fialová
• Martina Peiskerová
• Klinika nefrologie 1. LF a VFN
• Praha
• 10/2007

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Modalities of renal replacement therapy
Interchangeable, depends on residual renal
function
Ramesh Khanna Karl D. Nolph
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Peritoneal dialysis - outline

• Principles of PD
• PD solutions
• PD catheter
• Indication / contraindication of PD
• PD schemes CAPD, CCPD
• Assessement of PD adequacy, ultrafiltration
• Assessement of peritoneal function
• Complications
• Perspectives new dialysis solutions

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Peritoneal dialysis introduction

• method of RRT for 100.000 patients worldwide
• complementary to hemodialysis
• Principles
• peritoneum (capillary endothelium, matrix,
  mesothelium) semipermeable dialysis membrane
  through which fluid and solute move from blood
  to dialysis solution via diffusion and convection
• effective peritoneal surface area perfused
  capillaries closed to peritoneum (? in
  peritonitis)
• ultrafiltration (movement of water) enabled by
  osmotic gradient generated by glucose or glucose
  polymers (isodextrin)

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Principles of peritoneal dialysis
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Scheme of peritoneal solute transport by
diffusion through the pores of capillary wall
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Model of transport - 3 sorts of pores
Ramesh Khanna Karl D. Nolph
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Composition of standard peritoneal dialysis
solution
Na 132 mmol/l Ca 1,25mmol/l Mg 0,5
mmol/l Cl 100 mmol/l lactate 35 mmol/l
ev. lactate/bicarbonate glukose 1,36-4,25
g/dl osmolarity 347-486 pH 5,2 GDP
(degradation products of glucose)
Ramesh Khanna Karl D. Nolph
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Urea concentration in dialysate, rate of
equalization of solute concentration depends on
molecular size of solute
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Concentration of Creatinin in dialysate
equilibrium of concentrations between dialysate
and blood is slower than for urea
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Peritoneal catheter

• implanted via laparoscopy, punction or
  laparotomy (total anesthesy)
• PD is started 3 weeks following the impantation
  of catheter

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Types of peritoneal catheters
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Why to start with PD ?
1. better maintenance of residual renal function
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Why to start with PD ?

• clinical outcomes comparable to HD, no difference
  in 2 year and 5 year mortality vs. HD (study
  NECOSAD)
• saves vascular access
• preferred for children (APD)
• modality choice is a lifestyle issue

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Indication / Contraindications of PD
80 of patients have no contra-indication to any
of the dialysis methods and may choose according
to their life style between HD a PD Absolute
contra-indications of PD 1.peritoneal fibrosis
and adhesions following intraabdominal operations
2.inflammatory gut diseases
Ramesh Khanna Karl D. Nolph
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Relative contraindications of PD

• pleuro-peritoneal leakage
• hernias
• significant loin pain
• big polycystic kidneys

• diverticulosis
• colostomy
• obesity
• blindness

• severe deformant arthritis
• psychosis
• significant decrease of lung functions

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CAPD continual ambulatory peritoneal dialysis

• manual exchanges

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NIPD night intermitent peritoneal dialysis
(cycler)
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CCPD continual cyclic PD
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Assessement of PD adequacyPET (peritoneal
equilibrium test) 1

• determines quick or slow passage of toxins from
  the blood into the dialysis fluid
• high-fast transporters v.s. low-slow
  transporters
• helps to decide about the PD scheme (dwell
  duration and intervals, CAPD vs. CCPD)
• performed in hospital, takes 5 hours
• involves doing a CAPD exchange using a 2.27 G,
  samples of PD fluid and blood are taken at set
  times

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PET (peritoneal equilibration test) 2
Transporter Waste removal Water removal Best type of PD
High Fast Poor Frequent exchanges, short dwells APD
Average OK OK CAPD or APD
Slow Slow Good CAPD, 5 exchanges daily 1 exchange at night
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Interpretation of peritonal equilibration test ??
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Results of baseline PET
Ramesh Khanna Karl D. Nolph
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Choice of PD scheme depends of BSA and type of
transport
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Assessement of peritoneal function

• PET- peritoneal equilibration test (type of
  transport and ultrafiltration after 4 hours)
• weekly clearance of creatinine and urea
• daily UF
• dicrease of Na in dialysis fluid after 60 minutes
  using 3,8 G (test of aquaporines)

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Ratio D/P for Na, upper curve 1,27 glucose,
lower curve - 3,86 G (initial drop due to
transcellular UF of water through aquaporins)
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Ultrafiltration during PD

• Depends on
• - type of transporter low transporters have
  better UF
• - concentration and type of osmotic agent in PD
  fluid
• Fluids with glucosis (1,27, 2,5 a 3,8 ),
  higher concentration higher osmotic pressure
  and UF
• Fluid with icodextrin (Extraneal) glucose
  polymer with a large molecule, resorbs only
  10-20, offers longtime UF, suitable for long
  night exchanges, 8-12 hours)
• - time between exchanges, using glucose-based
  fluids, maximal UF obtained after 2-3 hours,
  using longer spaces UF dicreases.

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Ultrafiltration in different types of PD
solutions
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Criteria of PD adequacy
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Complications of PD 1

• 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)

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Complications of PD 2

• 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.

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Causes of UF failure

• Large vascular surface of peritoneum (due to
  neo-angiogenesis, vasodilation), leading to high
  (fast) type of transport including fast loss of
  osmotic glucose pressure
• Decreased function of aquaporins
• High lymfatic absorption

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Morphologic changes of peritoneum due to PD (1)
Obr.1-before starting PD, norm. peritoneum
(omentum)
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Morphologic changes of peritoneum due to PD (2)
Obr.2-after 3 years of PD, submesotelial fibrosis
and neo-angiogenesis (enlargement of vascular
surface of peritoneum)
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Peritonitis

• Clinical features cloudy PD effluent, abdominal
  pain, nausea, vomiting,
• Laboratory leucocytosis, CRP, gt 100wbc/ mm3, PD
  fluid culture
• Bacteriology Gram cocci (incl. S.aureus) in
  75, Gram (incl. Pseudomonas) in 25, culture
  negative, mycobacterial (1), fungal (3),
  allergic (Icodextrin)
• Complications relapses, antibiotic treatment
  failure, acute and chronic UF failure
• Treatment for. 14-21 days Gram cocci
  Vankomycin / cephalosporin, Gram -
  aminoglycoside / cephalosporin III. Generation (
  antimycotics, metronidazole)
• Goal lt peritonitis / 18 months

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From PD gudelines (ISPD)

• biocompatible PD solutions - normal pH, low
  concentration of glucose
• insertion of PD catheter 10 days-6 weeks before
  RRT
• urea / creatinine clearance measured every 6
  months
• PET 6 weeks after commencing treatment
  annually
• avoid routine use of high glucose concentrations
  )use of icodextrin, aminoacids instead)
• preserve residual diuresis, obtain UF above 750
  ml/day
• peritonitis and exit-site infection rates,
  regular revision of technique
• invasive procedures cover by ATB prophylaxis
• topical ATB administration if needed (S.aureus,
  Ps. aeruginosa)
• beware central obesity

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Perspectives - New dialysis solutions protect
peritoneal membrane
Physioneal1
Extraneal2

• Isosmolar to plasma
• No glucose exposure
• ? GDPs and AGEs
• ? Membrane and immune cell function

• ? GDPs and AGEs
• ? Lactate
• Physiologic pH and pCO2
• ? Membrane and immune cell function

• Nutrineal2
• No glucose exposure
• No GDPs or AGEs
• ? Membrane and immune cell function

1Skoufos, et al. Kidney Int. 200364(suppl
88)S94-S99. 2Vardhan, et al. Kidney Int.
200364(suppl 88)S114-S123.

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Clinical advantages of new dialysis solutions

• Physioneal
• ? Infusion pain
• ? Peritonitis
• ? Glycemic control
• ? Appetite
• ? Patient acceptance
• No ? UF

• Extraneal
• ? Glucose load
• ? Glycemic control
• ? UF, control of fluid status
• ? Dyslipidemia
• ? Quality of life
• ? Time on PD

• Nutrineal
• ? Glucose load
• ? Glycemic control
• ? Protein intake, nutritional status

Pecoits-Filho, et al. Kidney Int. 200364(suppl
88)S100-S104. Vardhan, et al. Kidney Int.
200364(suppl 88)S114-S123.
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Absorbtion of glucose from peritoneal solutions

1. Solutions containing glucose (green) lead to
   significant glucose absorbtion
2. Solutions based on another osmotic agent (blue,
   violet) do not lead to glucose absorbtion, so
   decrease total daily glucose load).

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