patient selection and training for peritoneal dialysis
TRANSCRIPT
Dr Ayman Seddik ,MD
Ass. Prof. Nephrology Ain Shams University
Nephrology Consultant Dubai hospital
Jean-Louis Clémendot
Review the issues encountered during the assessment phase of a
CKD patient , selection for peritoneal dialysis .
Discuss the issues encountered upon initiating peritoneal dialysis , and training program .
Ramesh Khanna & Karl D. Nolph
Modalities of renal replacement therapy
Interchangeable, depends on residual renal function
Trained nephrologists
Trained PD nurses
Unit Infrastructure
Active and effective
educational programm
1. Efficacy of the therapy – Patients’
survival
2. Clinical advantages of specific therapy
3. Quality of life
4. Rate of complications eg infections ,
access problems
• 4568 HD and 2443 records from
4921 patients
• Treatment period – 1990 – 1999
• PD mortality rate vs HD
• ITT analysis – 0.65; P<0.001
• As treated – 0,86; P<0.001
Why to start with PD ?
1. better maintenance of residual renal
function
Patients with chronic kidney disease typically seen in OPD Clinics at various stages
Early referrals (CKD2 – 3GFR >30 ml/min)
Typical referrals( CKD4-5 GFR , 30ml/min)
Urgent referral ( Uremia,Hypercalemia, Fluid overload) Translpant recipient with failing renal
allograft.
LATE REFERRAL AND INITIAL MODALITY
EDUCATION ABOUT MODALITIES
Initial assessment
Renal clinic
In hospital
consultation
Death
Transfer to HD
Transplantation
CKD Education
Modality choice
Life planning
Timing of initiation of PD
PD catheter r insertion
Training for PD
Maintenance care
Management of complications
JOURNEY THRU
PD CLINIC
pleuro-peritoneal
leakage
hernias
significant loin pain
big polycystic kidneys
• severe deformant arthritis
• psychosis
• significant decrease of lung
functions
* diverticulosis
• colostomy
• obesity
• blindness
Timing of the start of the dialysis
Timing of placement of PD catheter
Dose of dialysis to be targeted
Maintenance of volume control
Psychosocial status and quality of the life of the
patient and their family
Clearance or GFR as general guide
Presence or absence early symptoms and signs of Uremia
Other complication of advanced CKD
Changes in nutritional status and decrease in calorie intake
Deterioration in cognitive functioning/quality of life
Best inserted close to time of initiation about 4 to 5 weeks prior to initiation of PD
Exception use of buried PD catheters
Partnership with surgeon or nephrologist inserting the catheters
Marking of the skin for best exit site locations
Proper function of PD catheter as well as low incidence of exit sites complications
Critical for successful start to PD regime
Exit site dressing best kept intact for 5-7 days
Avoidance of poviodine or hydrogen peroxide around the wound and sinus
Immobilize catheter for first few weeks
Showering best avoided till exit site is healed
TIMING OF CATHETER PLACEMENT AND INITIATION
Close follow up and clinical evaluations by nephrologists are critical
o Avoidance of interim hemodialysis, hospitalization and temporary venous catheters is highly desirable
o
o Avoidance of nephrotoxins such as iodinated contrast for venous mapping
this is different than hemodialysis when a arterio- venous fistula is usually created 3-4 months in advance
PD training in the centre according to the protocol
Home visit
REVIEW OF ALL MEDICATIONS Reassessment of antihypertensive medicines
ADVISABLE to continue or restart diuretics
Recommended to restart ACEI or ARB
Therapies for anemia, secondary hyperparathyrodism and hyperphosphatemia
PD DELIVERED MANUALLY OR WITH THE ASSISTANCE OF THE MACHINE – CYCLER
DESCISION MADE AFTER DISCUSSION WITH PATIENT AND PATIENTS FAMILY
CAPD
APD
HIGH DOSE CCPD OR OPTIMIZED
Interpretation of peritonal
equilibration test ??
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, 4-5
exchanges
daily + 1
exchange at
night
OPTIONS
Hemodialysis using temporary venus cath.
PD administered in the clinic by the nurse while patient being trained
Low fill volume manual or APD
FIRST FEW WEEKSON PD IMPROVEMENT
CONSTIPATION
CATHETAR MIGRATION AND OCLUSION
Exit site infections , bleeding, leakage
Ultrafiltration in different types of PD
solutions
Documentation
: All exchanges
Exit Site care
Daily weights
CVPH utilizes a 24 Hour
Peritoneal Dialysis Record
to document.
Evaluating candidacy for PD is a MULTI-DISCIPLINARY task
Timing of initiation of PD requires close assessment and follow up by the Nephrologist and Renal team
PLACEMENT of catheter is best done about 4 to 5 weeks prior to anticipated initiation of PD as to allow 2 weeks of healing and 2 to 3 weeks of training
Catheter care is best done according to a SET
PROTOCOL
Adequate and complete training for PD is
critical
Early serious problems can usually be
addressed without permanently discontinuing
PD
Comprehensive care of the PD patient starts
early