Indian J Pcdiat 49 : 7%83, 1982

Peritoneal dialysis

V.P. Choudhry, M.D. and R.N. Srivastava, F.R.C,P.(E)

Key words : Peritoneal dialysis; Peritoneal device, Continuous Ambul- atory peritoneal dialysis.

Peritoneal dialysis has been esta- blished for over three decades for the management of renal failure. Unfortu- nately very few pediatric centres in India provide this life saving facility. The problem of acute renal failure is particu- larly serious in children.re The incidence is high and a large proportion of patients are inadequately managed and referred late to the dialysis centre, often in serious condition. Almost 50 per cent of patients with acute renal failure admitted in hospital require dialysis2 '3

We briefly describe the technique of peritoneal dialysis, and consider some recent developments. For detailed infor- mation on principles, applications and the technical aspects of peritoneal dialy- sis, reviews published elsewhere 4-s should be consulted.

Indications

The uses of peritoneal dialysis are given in table-I. It is preferable to start

Table I. Uses of Peritoneal Dialysis

l. Acute renal failure

2. Chronic renal failure--for maintenance, prior to renal transplantation.

3. Removal of dialysible poisons & drugs

4. Metabolic abnormalities--pH, Na, K & Ca disturbances.

5. Refractory congestive heart failure and pulmonary eder~a.

6. Peritoneal lavage--peritonitis

7. Detection of intraperitoneal hemorrhages

8. Temperature regulation--hypothermia and hyperthermia.

the dialysis early, rather than delay it till the biochemical abnormalities attain very high levels. Progressive clinical deterioration and development of senso- rial changes should prompt immediate institution of dialysis. Persistent hyper- kalemia and acidosis, and over hydration also require urgent dialysis.

From the Department of Pediatrics, All- India Institute of Medical Sciences, New Delhi-1101129

Reprint requests: Dr. V .P . Choudhry, Assistant Professor.

Procedure

Peritoneral dialysis should preferably be performed in a separate room, observing strict aseptic precautions.

80 THE INDIAN JOURNAL OF PEDIA'rRICS VO]. 49, N o . 396

Heparin 500 u/liter is added to the dialysis fluid. In the presence of hyper- kalemia, potassium should be omitted in the first 4 or 5 cycles. Dialysis set should be connected with dialysis fluid bottles and the drainage tube to the waste con- tainer. After ensuring that the bladder is empty, lignocaine is infiltrated in the midlineat a point midway belween the umbilicus and pubic symphysis. Skin should be prepared as for a surgical procedure. Dialysis fluid (20 ml/kg)is infused with an 18 gauge needle to dis- tend the peritoneal cavity to prevent injury to the abdominal viscera during the insertion of catheter. A 5 mm transverse incision is made through the skin. Peritoneal catheter alongwith stylet is introduced with a rotatory motion. A sudden decrease of resistance alongwith a gush of dialysis fluid indicates the entry of catheter into the peritoneal cavity. The trochar is withdrawn by 1-2 cm and then advanced further at an angle of 25 ~ towards the pelvis to place it in the para- colic gutter. The black markings on the special peritoneal catheter indicate the curve of the catheter, which is helpful in its correct positioning. Poor flow from the peritoneal cavity is a common diffi- culty and can be overcome by : (i) satis- factory initial placement of catheter; (ii) ensuring that the catheter holes always lie in a pool of fluid; and (iii) maintaining the system air-free, so that drainage is facilitated by the siphon effect.

The catheter is fixed with a purse- string suture, fixed by the metal/plastic retaining ring which should be pushed firmly down. The site is dressed. An inflow of dialysis fluid 30 ml/kg fs infused and allowed to equilibrate for 30

minutes, and then drained off during the dialysis procedure. The number of cycles, volume of inflow and outflow and balance ef each cycle and cumulative balance should be recorded carefully. Dialysis is usually continued for 40-50 cycles.

Peritonitis is the only common and serious complication of this procedure. Strict observance of aseptic methods, fre- quent examination of the dialysate for organisms and pus cells and appropriate treatment are important. If reinsertion of peritoneal catheter becomes necessary, it should be done at a different site. Infrequ- ent complications include over-hydration, electrolyte disturbances, hypoproteinemia, pulmonary complications, etc. These have been reviewed elsewhereT-8.

Automatic peritoneal diMysis device 9

Peritoneal dialysis procedure requires manual closing and opening of valves at fixed time intervals to direct the inflow and outflow of the fluid (Fig, I). The dialysis bottles need to be changed fre- quently. Thus, close supervision by trained staff is necessary. Automatic peritoneal dialysis devices have been developed to obviate these problems.

1

Fig. 1. Peritoneal diab'sis procedure.

C H O U D H R Y AND SRIVASTAV ~, : PERVI"ONEAL DIALYSIS 81

An automatic dialysis unit has been indigenously fabricated in which the in- flow and outflow of the dialysis fluid are controlled by electromagnetic valves, which can be opened for the desired period of time. Opening and closing of various electromagnetic valves is con- trolled by an automatic electronic time sequence system. Fluid drained from the peritoneal cavity is accurately measured by a weighing system. The unit provides audiovisual alarm in case the outflow is poor. The time period for various phases of peritoneal dialysis can be varied bet- ween 1 to 99 minutes. The number of completed cycles is indicated by digital display fitted on the electronic time sequence controlling system. It is not necessary to sterilize the unit as dialysis fluid does not come in direct contact with any of its components. Preliminary use of

this unit in laboratory animals, and in a few patients with renal failure has been satisfactory The dialysis fluid bottles need to be changed less frequently since eight one litre bottles can be connected to this unit at a time.

This unit still needs further trials before it can be recommended for com- mercial manufacture. A heating system needs to be incorporated in the machine to warm the dialysis fluid to body temperature.

Peritoneal catheter

Peritoneal catheters made by Mac- Gaw or Vygon are satisfactory. For patients with chronic renal failure who need long term dialysis, implantable peritoneal catheters have been developed. These are surgically placed in the perito- neal cavity. After the d~alysis, 6 ml of

isetonic saline with 4000 units of heparin are instilled to avoid blockage of the catheter. Tenckhoff catheter is widely used2 o

Peritoneal dialysis in chronic renal failure

With the development of Tenckhoff peritoneal catheter, long term peritoneal dialysis is being used for patients with chronic renal failurelL Initially intermittent peritoneal dialysis was done in which 12 or more exchanges were done on 3 days a week basis, either manually or by auto- matic peritoneal di,~lysis units. In the last five years a continuous ambulatory dialysis system has been employed and considered superior to intermittent perito- neal dialysis system,

Popovich and his colleagues in 1976 ~z, described the technique of continuous ambulatory peritoneal diaiysis for management of patients with chronic rena! failure. Indwelling Tenckhoff peri- t,,neal dialysis catheter is used. The external end of the catheter is capped and fixed close to the skin. Fluid instillation and drainage is done 5 times/day for 5 days a week (7& 11 AM, 3,7 & 10 P.M.). The solution is warmed to the body temperature before instillation into the peritoneal cavity. Dialysis set is removed and the catheter tip is capped aseptically. If the tubing is to be used again, it should be submerged in betadine solution.

Initially the incidence of peritonitis was high, but lately this method has been modified to reduce it. In the modified system plastic bags are used 14. After the inflow, the bag remains attached to the connecting tube which is carried rolled

82 THE INDIAN JOURNAL OF PEDIATRICS Vo!. 49, N~'. 396

up in a cloth waist purse under the pa t i en t ' s clothing. Af t e r the diffusion pe r iod the dialysate is d r a ined into the same bag. A fresh bag is used for insti l- 3. l a t ion o f fluid for the next cycle. The connect ing tube is changed at weekly intervals under asept ic condi t ions . These 4. au thors r ecommend 4 exchanges on each day o f the week.

The per i toneal c learances o f urea, inul in expressed as ml /min , are low. 5. However , the weekly c learances of small-

er molecules such as urea are signifi- 6. cant ly h igher (48 vs 45 L/week on

convent iona l in termi t tent per i toneal dialysis) as the dialysis is cont inuous pro- 7.

cess. C learance o f middle molecules such

as inul in is also better . Thus cont inuous

a m b u l a t o r y per i toneal dialysis is consi- 8. dered super ior to in termi t ten t per i toneal dialysis 13. Compl ica t ions o f cont inuous

a m b u l a t o r y per i tonea l dialysis a re per i to- 9.

nit/s, high p ro te in losses, lower urea

c learances per week c o m p a r e d to hemo- dialysis , re tent ion of body fluids, main te-

nance p rob lems o f the indwell ing I0. ca theter , and pos tura l hypotens ion . F u r t h e r ref inements o f this p rocedu re are

being car r ied out. I t is h o p e d tha t long

te rm per i toneal dialysis p r o c e d u r e would 11.

become eomplemen to ry to hemodia lys i s in the managemen t o f chronic renal failureA6

Proc.'eding~ of XV[I Na ional Conference of Indian Academy of Pediatrics, Bangalore, 1980. p 104

Srivastava RN, C~roudhry VP : Acute renal failure in chttdren. Indian J Pediatr49 : 63.1982.

Burns RD, Henderson LW, Hager E8, Merril JP: Peritoneal dialysis. Clinical experier~ce. New Engl J Med 267: I060, 1962

Miller RB, Tassistro CR : Currznt cor~cepts: Peritoneal dialysis. New Engl. J. Med. 2~!l : 945, 1969.

Penry JJ : Per dialysis. Brit Med Bull 27 : 1~5, 19"1

L'houdh~y VP, Srivastava RN: Peritoneal dialysis 11 Principles, Applications and Problems. Indian Pediatr 12 : 997, 1975

Ackri[I P : Pract!c~l proceudres: How to insert a peritoneal dialysis catheter. J Appli- ed Med 7 : 847, 1981

Choudhry VP, Bhattacharya B. Rehman SMK and Tandon SN: Indigenous automa- tic peritoneal dialysis unit. Submitted for publication IJMR.

Tenckhoff H : Home peritoneal dialysis, bt, Clinical Aspects of Uremia and Dial)sis, edited by Massrev SG, Sellers AL, Spring field, Illinois. Charles C Thomas, 1976

Lorentz Jr WB, Hamilton RW, Disher B, Carter C : Home peritoneal dialysis during infancy. Clin Nephrol 15 : 194, 1981

2.

References

Choudhry VP, Srivastava RN, Vellodi A, Bhuyau UN, Ghai OP: A study of acute renal failure. Indian Pediatr 17 : 405, t980

Raghupathy P, Date A, Shastry JCM, Jadhav M, Pereira SM : Acute renal failure in chi!dhood. Ten years' experience.

12.

13.

Popovich RP, Moncrief JW, Decberd JB, Bomar JB, Pyle WK: The definition of a novel portable/wearable equilibrium perito- neal dialysis technique. Abstracts of the Amer. Soc Artif Intern Organs 5 : 64, 1976

Popovich RP, Moo, crier JW, Nolpih KD, Ghods AJ, Twardowshi ZJ, Pyle WK: Continuou~ ambulatory peritoneal dialysis. Ann Intern Med 88 : 449, 1978

CHOUDHRY AND SRIVASTAVA -" PERITONEAL DIALYSIS 83

14. Oreopoulos DG, Robson M, Failer B, Ogilvie R, Rapoport A, de Veber GA: Continuous ambulatory peritoneal dialysis : a new era in the treatment of chronic renal failure. Clin Nephrol 11 : 125, 1979

15. Twardowski Z, Ksiazek A, Majdan M, Janicka L, Bochenska-Nowacka G,

Soko~ska G, Gutka A, Zoiko~ska A: Kinetics of continuous ambalatory Devito- nell dialysis (CAPD) with fore" exchanges per day. ChinNcphrol 15; 119, 1981

16. Forbes AMV, Reed V, Goldsmith RJ: CAPD--.a scheme to allow reduction of daily bag exchange. Chin Nephro! 5 : 264, 1981

Successful treatment of fetal congestive heart failure secondary to tachycardia

.Fetal cardiac arrhythmia is being detected with increasing frequency as a result of continuous electronic monitoring of the fetal heart rate. Most cases are recognized during labour, and a few during early antepartum period. The supraventricular tachycardia can persist in neonatal period with or without con- gestive heart failure.

The authors report a case of fetal tachycardia in which CHF developed in utero (heart beat 260 per min., scalp

edema, and ascites recognized by ultra- sonography). The problem was identi- fied at 26 week's gestation and treated

successfully by administration of digoxin to the mother (1.5 mg over 14 hours). A normal infant was delivered at term and subsequently cardiac evaluations revealed no structural or conductive abnormalities. This experience indicates the necessity to recognize tachycardia in the fetus and to search for sonographic evidence of CHF. Pharmacological intervention is required when the fetal heart rate is persistently over 200 beats per minute.

Harridan J T et al : New Engl J M e d 304 : 1527, 1981