PERITONEAL DIALYSIS

Presentation and modalities

Shiva Seyrafian MD

Isfahan University of Medical Sciences

Background

• Worldwide, 12% of dialysis patients are maintained on PD

• This varies greatly between countries

• >50% on PD in New zealand, Hong Kong, and Mexico

• <8% on PD in Japan ,Germany and Taiwan

PERITONEAL DIALYSIS

Modality Selection

• Most patients (>80%) 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, patient’s social circumstances, wishes of patient but also overall economic circumstances in which the dialysis program operates

PERITONEAL DIALYSIS

Organizing a peritoneal dialysis program

PERITONEAL DIALYSIS

Introduction:

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

PERITONEAL DIALYSIS

Some absolute and relative indications to PD

Absolute indications:

Poor cardiac function

Peripheral vascular disease

Relative indications:

Free life style

Want to take care themselvesLong distance to

hemodialysis center

PERITONEAL DIALYSIS

Teaching plans and materials• 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

PERITONEAL DIALYSIS

Equipment requirement in PD training

• Comfortable chair

• Water sink

• Weighing scales

• Drip stand/hook

• Books, booklets ,charts ,posters

• Television and video/VCD/DVD

• Automate PD machine

• Shelving for consumable

PERITONEAL DIALYSIS

Multi-discipline care teamThe team typically includes

• Doctors

• Nurses

• Dietitians

• Social workers

• Often includea surgeon, a cardiologist, a

psychologist, a psychiatrist, a physiotherapist etc.

PERITONEAL DIALYSIS

Contraindications to PD

• 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

PERITONEAL DIALYSIS

Contraindications to HD

• 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

PERITONEAL DIALYSIS

Factors favoring PD• Young child

• Full time work

• Desire for autonomy

• Mother with young children

• Good family support

• Good motivation

• Early transplant likely

PERITONEAL DIALYSIS

Factors favoring HD• Poor family support

• Poor motivation

• Major comorbidity

• Body size >110 kgs

• Severe obesity

• Irresponsible , lack of hygiene

• Poor hand eye coordination

PERITONEAL DIALYSIS

modality selection some realities

• 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

PERITONEAL DIALYSIS

modality selection some realities cont…

• 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

PERITONEAL DIALYSIS

modality selection How to do it well

• Predialysis clinic

• Meeting with PD and HD staff

• Meeting with PD and HD patients

• Seeing PD and HD units

• Providing good educational material

PERITONEAL DIALYSIS

‘ PD FIRST ‘Advances of PD as Initial Modality

1. Preserves residual renal function better

2. May allow better blood pressure and volume control with cardiovascular benefits

3. May give better quality of life

4. Has less anemia and lower EPO doses

5. Lower risk of Hepatitis C

6. Equal or better survival in early years

7. Cost advantages - in many countries

PERITONEAL DIALYSIS

Modality Selection Pre Dialysis Clinics

• 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

PERITONEAL DIALYSIS

Modality Selection Education

• 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

PERITONEAL DIALYSIS

PD versus HD Which is best?

• 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

PERITONEAL DIALYSIS

Integrated Dialysis Care

• 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

PERITONEAL DIALYSIS

Conventional Classification of PD

• Daily CAPD DAPD

NIPD CCPD

• Intermittent IPD×2-3 per week

PERITONEAL DIALYSIS

CAPD OR APD ?

• Medical

• Lifestyle

• Economic

PERITONEAL DIALYSIS

Economic of APD versus CAPD

•APD is more costly than CAPD.

•Paradoxically, however the difference is greater in poorer developing countries and least in wealthier countries .

PERITONEAL DIALYSIS

LIFESTYLE

• 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 .

PERITONEAL DIALYSIS

LIFESTYLE INDICATIONS FOR APD

• 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

PERITONEAL DIALYSIS

MEDICAL INDICATIONS FOR APD

• Fluid resorption on standard CAPD

• High or high average transport status

• Inadequate dialysis on CAPD

• Frequent peritonitis on CAPD

PERITONEAL DIALYSIS

PERITONITIS

• 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

PERITONEAL DIALYSIS

‘ Y SET ’ IS SUPERIOR TO ‘ STRAIGHT LINE ‘

• 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 )

PERITONEAL DIALYSIS

‘ DOUBLE BAG ‘ IS SUPERIOR TO STANDARD ‘Y SET ‘

• 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)

PERITONEAL DIALYSIS

THE NURSE’S ROLE

• “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

PERITONEAL DIALYSIS