peritoneal dialysis part1

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    Prof. Dr. Montasser Zeid

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    The first article on the use of the peritoneal cavity in experimental

    uremia (induced in guinea pigs) was published in 1923 by Ganter.

    In 1961, Boen described the use of intermittent peritoneal dialysis

    (IPD) in patients with chronic renal failure

    Historical Background 4 25/02/2012

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    In1968 Tenckhoff developed an indwelling catheter, which led to

    nightly dialysis. This intermittent method, using a cycler to infuse

    and drain fluid while the patient slept, was the most common form

    of peritoneal dialysis (PD)from the l960s to the late l970s.

    In 1976, Popovich et al, introduced continuous ambulatory PD

    (CAPD), where four to six exchanges are done each day with long

    dwell times between exchanges.

    Historical Background cont 5 25/02/2012

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    In 1978, this group described their early clinical experience using

    bottled dialysis fluid.

    Oreopoulos et al. in 1978 also described their experience with

    CAPD. From this point on, use of CAPD increased and cycler-IPD


    Historical Background cont 6 25/02/2012

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    In 1979 , the Seattle group used a combination of cyclic and

    automated PD in two patients. This technique was called

    continuous automated ambulatory PD (CAAPD) .

    In1979 Baxter introduced to the market the first CAPD system that

    included solution bags, tubing with a spike at one end, a titanium

    luer lock to connect to the patients catheter, and an antiseptic

    solution to clean the spike/bag connection.

    Historical Background cont 7 25/02/2012

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    In 1981, Diaz-Buxo and coworkers described their more extensive

    experience and called this technique continuous cycling PD


    Historical Background cont 8 25/02/2012

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    The peritoneal cavity is a potential space lined by the peritoneal

    membrane , the total surface area of which approximates the

    surface area of the skin in adults .The surface of the membrane is

    lined by a layer of lubricated mesothelial cells, beneath which lies

    the interstitium containing connective tissue and blood vessels, The

    blood supply to the visceral peritoneum is derived from celiac,

    superior, and inferior mesenteric arteries and their local branches,

    Anatomy and Physiology 9 25/02/2012

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    The parietal peritoneum receives blood from the lumbar,

    intercostals and epigastria arteries and drains into inferior vena


    Anatomy and Physiology 10 25/02/2012

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    Sagittal section of the peritoneal cavity. 11 25/02/2012

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    The exact blood flow to the membrane is unknown but is probably

    from 60-70 ml/min . Venous blood drains ultimately into the

    hepatic portal vein. Lymphatic drainage from the peritoneal cavity

    is largely through the diaphragm to the lymphatics that are

    associated with the internal mammary and anterior mediastinal

    lymph nodes; ultimately draining into the right lymphatic duct.

    Anatomy and Physiology 12 25/02/2012

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    R1 : The stagnant capillary fluid overlying the endothelium

    R2 : The capillary endothelium it sell.

    R3 : The endothelial basement membrane.

    R4 : The interstitium.

    R5 : The mesothelium

    R6 : The stagnant fluid film that overlies the peritoneal membrane.

    Resistance to movement during peritoneal dialysis 13 25/02/2012

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    Resistance to movement during peritoneal dialysis 14

    Resistance to solute Movement During Peritoneal Dialysis


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    The three pore model

    This model suggests that the peritoneal capillary is the critical

    barrier to peritoneal transport and that solute and water transport

    across it is mediated by pores of three different.

    1. Ultrasmall pores (0.8 nm in radius) that are transcellular

    (aquaporin), these mostly transport water molecules.

    Anatomy and Physiology cont 15 25/02/2012

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    2. intercellular small pores (4-6 nm), which mostly transport small


    3. large pores (>20 nm) transporting only large molecules such as

    peptides and proteins.

    Anatomy and Physiology cont 16 25/02/2012

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    The essential elements of peritoneal dialysis (PD) are:

    A viable peritoneal cavity lined by a functional membrane.

    Access to the peritoneal cavity, usually by means of an

    indwelling catheter.

    Dialysis fluid and delivery mechanism.

    Technique of Peritoneal Dialysis 17 25/02/2012

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    Long-term PD was made a reality by the development by Tenckhoff

    of the first long-term indwelling catheter, created by adding

    Dacron cuffs to the earlier silicone-rubber catheters.

    Modern catheters still use Tenckhoffs design.

    The material of the catheter is either silicone rubber or polyurethane

    on which with Dacron cuffs are placed.

    Peritoneal Dialysis Catheters 18 25/02/2012

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    Each PD catheter is comprised of three parts

    An intra-abdominal segment.

    A subcutaneous tunnel segment.

    An external segment.

    Peritoneal Dialysis Catheters cont 19 25/02/2012

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    The intra-abdominal segment has multiple small holes and an

    open terminal end.

    The subcutaneous segment has two cuffs, the outer cuff is placed

    just under the skin at the exit site, and the deep cuff is placed just

    external to the fascia covering the parietal peritoneum.

    The segment between the two cuffs lies in a tunnel, classically

    curved in shape, and running from the skin exit site to the deeper


    Peritoneal Dialysis Catheters cont 20 25/02/2012

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    Table: Commonly used peritoneal catheters 21

    Easy to place by percutaneous technique

    Easy to remove and replace

    Rectal discomfort is more common and outflow

    problems are more common

    Straight Tenckhoff

    Same as above, but better patency and better outflow

    Does not impinge on the rectum Curled Tenckhoff

    Same as straight Tenckhoff

    Tunnel must be curved Swan neck

    Combination of Toronto Western and swan-neck


    Can only be place and manipulated surgically


    Can only be placed and manipulated surgically Lifecath


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    Peritoneal Catheters ( lateral views ) 22 25/02/2012

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    Three insertion techniques are used , surgical , blind ( bed side )

    percutaneous, and peritoneoscope.

    Prior to insertion of the catheter, the patient should be informed of

    the potential complications, and the bladder and rectum should be

    emptied. If the patient cannot empty their bladder, a urinary

    catheter may be used to achieve this. This is to avoid puncturing a

    full bladder, particularly a potential risk during the bedside


    Catheter Insertion Technique 23 25/02/2012

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    Comparison of the Three Techniques 24

    Disadvantages Advantages Technique

    More preparation is required

    More expensive

    Large incision

    Longer healing time

    Increased risk of fluid leak

    Under direct vision:

    Lower risk of injury to viscera

    Catheter placed in desired place

    Adhesions or large omentum can be removed


    Any type of catheter can be inserted


    Cannot be used if adhesions or

    large omentum present

    Higher failure potential

    Simple, easy, and quick procedure

    Heals quickly and can be used immediately

    Performed in patients room with full sterile

    precautions by the nephrologist

    Less expensive than the other two methods


    Higher risk of injury to viscera

    Not all catheters can be placed

    by this technique

    Expense of the scope Training

    with scope.


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