Peritoneal dialysis
Sahier Omar El-Khashab
Professor of Internal Medicine and
Nephrology
Kasr Al-Aini Hospital
Cairo University
EGYPT
Peritoneal Dialysis
Definition
• Sterile solution into the
peritoneal cavity
• Peritoneal membrane
as the exchange surface
• Addition of osmotic
agents (most commonly
glucose)
Types
• IPD
• CAPD Manually
(continuous ambulatory
PD),
• APD Machine -assisted
PD (automated PD)
Phases of PD
Exchange
Indications of PD
Indications Preferred
• Vascular access failure • Bleeding diathesis
• Intolerance to hemodialysis • Multiple myeloma
• Congestive heart failure • Labile diabetes mellitus
• Prosthetic valvular disease • Chronic infections
• Poor cardiac function
• Peripheral vascular disease
• Possibility of RTX in the near
future
• Children aged 0-5 years
• Age between 6 and 16 years
• Patient preference
• Needle anxiety
• Distance from a hemodialysis
center • Active lifestyle
Non Renal indications for PD
• Refractory congestive • Dialysis-associated
heart failure ascites
• Hepatic failure • Drug poisonings
• Hypothermia • Pancreatitis
• Hyperthermia • Inherited enzyme
• Hyponatremia deficiencies
Contraindications
ABSOLUTE RELATIVE
• Documented type II ultrafiltration• Severe malnutrition
failure • Multiple abdominal adhesions
• Ostomy
• Severe inflammatory bowel disease
• Proteinuria >10 g/day
• Acute active diverticulitis
• Abdominal abscess
• Active ischemic bowel disease
• Upper limb amputation with
• Severe active psychotic disorder no help at home
• Marked intellectual disability • Poor personal hygiene
• Dementia
• Women starting third trimester of • Homelessness
pregnancy
PD not preferred
• Obesity • Impaired manual
• Multiple hernias dexterity
• Severe backache • Blindness
• Multiple abdominal • Poor home situation
surgeries • Depression
PERITONEAL ACCESS
• Tenckhoff catheter • 2 weeks
• If immediate small
volumes
TYPES OF PD TREATMENT AND SOLUTIONS
• CAPD • Automated PD (APD)
• 2-4 L 3-4 Times/Day • Intermittent Night
Peritoneal Dialysis
• ( residual Renal
function) 6 L bags
• Continuous Cycling
Peritoneal Dialysis:
• ( No residual Renal
function)2 L bags
Composition of the dialysis solution
• Glucose (1.5%, 2.5% • LOW pH
4.25%) • avoid glucose
• Calcium (2.5 and 3.5
caramelization during
mEq/L)
heat sterilization.
• Sodium 132 mEq/L
• pain during infusion
• Chlorin e 95 to 102 mEq/L
• Lactate 35 to 40 mEq/L).
• pH of the dialysis solution
is low (5.5)
• Magnesium levels of 0.5 or
0.25 mM.
Osmotic agents
• ICODEXTRIN, isomolar high
• GLUCOSE molecular weight glucose polymer
• Being known • is absorbed into the plasma through
• Relatively safe the lymphatic vessels
• Inexpensive
• Source of calories • ABSORPTION
• much slower than that of glucose,
• BUT more continuous
• Hyperglycaemia
• dyslipidaemia, • Metabolised to maltose, maltotriose
• obesity and other polysaccharides.
• peritoneum damage in the long- • Maltose interfere with capillary
term, directly or through the blood glucose readings,(falsely
products of elevated )
• glucose degradation.
• In Brasil
ADEQUACY IN PERITONEAL DIALYSIS
The Guidelines of the International Society of
Peritoneal Dialysis (ISPD)
• Adequate clearance of small • Clearance of solutes
solutes
• Quality of life • 1.7 at end of first
• Laboratory tests month and every 4
• Nutritional aspects months
• Appetite
• Volume status with adequate
ultrafiltration to avoid volume
overload,
• Hb values
• Response to ESA
• Ca Po4
• BP
Peritoneal equilibrium test PET
• According to the
• Infusing 2 L of dialysate
• creatinine D/P ratio in the 2nd and 4th h,
(D) at 2.5% glucose in • the glucose D/D0 in the same period /the
the P cavity volume of dialysate drained after 4 hours,
patients can be classified into 4 categories
• Samples of D at 0, 2 ,h High transporters:
• quickly D/P balance for creatinine / urea,
4 hours • quickly absorb glucose with a rapid loss of
osmotic gradients
• benefit from short-term changes.
• A plasma sample (P) is
also obtained mid- Low transporters
period (2 h). • creatinine D/P balance is slower /incomplete
• the osmotic gradient remains longer.
• need changes with a longer permanence
COMPLICATIONS IN PD
INFECTION NON INFECTION
D Leak
Drainage failure
• Peritonitis
Hernia
Hydrothorax
• Catheter infection
Edema ‘Ultrfiltratio
Weight gain
• Wound infection
Hypertriglyceridemia
Hyperglycemia
Encapsulating peritoneal sclerosis
COMPLICATIONS IN PD
EARLY LATE
• Bowel perforation • Cuff infection
• Bleeding • Outflow obstruction
• Wound infection • Peritonitis
• Outflow obstruction
• D leakage
• Peritonitis
Protocols to decrease infection risk in PD
1. Proper catheter placement
2. Exit-site care that includes
staphylococcus aureus
prophylaxis
3. Careful training of patients
with periodic retraining
4. Treatment of
contamination
5. Prevention of procedure-
related and fungal
peritonitis.
Technique failure
Shift to HD
• Target Kt/V not reached • Severe
• Low fluid removal (with hypertriglyceridemia
no residualrenal • Frequent peritonitis
function)
• Development of
• High transporter patients
technical/mechanical
who have inadequate
problems
ultrafiltration and/or
excessive protein loss • Severe malnutrition
(relative contraindication, resistant to aggressive
obviously discovered after treatment (relative)
initiation and first PET)
Summary
• PD / HD • Complications
• IPD/ CAPD • Shift to HD
• High/ Low
• Phases
• Dialysate type
• Tenckoff
• Technique
Studies
Guidelines
• International society for • [Link]
PD guidelines/
Books and Journals
• Peritoneal Dialysis Man • Peritoneal Dialysis Inter
ual - national: SAGE Journals
Karger Publishers • Peritoneal Dialysis | Pee
• Peritoneal Dialysis - Thir r Reviewed Journals
d edition | K.D.
Nolph | Springer
• The Textbook of Periton
eal Dialysis | R.
Gokal | Springer
• Handbook of Peritoneal
Dialysis: Second Edition
...
E- links
• Step by step • CAPD /Automated
• [Link] • [Link]
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• Education
• https://
• https:// [Link]/
[Link]/ watch?v=kqSFb1rk0Uc
watch?v=9bRnG3NaCug
