Therapy Modality:

Continuous Ambulatory

Peritoneal Dialysis (CAPD)

Renal DivisionBaxter Healthcare

2CAPD

• Manual therapy

• Prescription volumes standardised

1,500ml, 2000ml, 2500ml, 3000ml solution bags

• 6-8 hour dwell period each night (depends on type of membrane)

• 4-5 day exchanges (with optional night dwell),

7 days a week

• 3-5 hr dwell per day exchange

CAPD - basic prescription

3CAPD

CAPD Exchange Procedure

1. Fill phase (<10 Minutes)

4CAPD

CAPD Exchange Procedure

2. Dwell phase (4-8 hours)

3. Drain phase

(<20 minutes)

5CAPD

CAPD

CAPD

ContinuousTherapy

0

Vo

lum

e

Time

Benefits Limitations

• Optimum dialysis for low permeability

• Can be performed anywhere

• High transporters will have poor UF

• 4 x exchanges per day

• IP pressure with large volumes

Ambulatory

Anywhere

4 - 5 Exchanges

Long Dwells

24

6CAPD

Procedural Modifications- increasing UF

Modifyton icity

Consideradditional exchange

Considerfi ll vo lum e

CAPD

O ptim izeshort dw ell U F

1

2

3

7CAPD

Procedural Modification - fill volume

8CAPD

Procedural Modification- no. of exchanges

9CAPD

PD Technique Survival

Years

0

20

40

60

80

100

120

0 1 2 3 4 5 6 7 8 9 10

Italy

UK

Spain

Japan

Kawaguchi PDI 1999;19 (supp 2):S327

%

10CAPD

PD Technique Survival

• Reasons for withdrawal

- Loss of UF

- Inadequate dialysis

- Peritonitis

- Patient choice/psychological (‘burn-out’)

Kawaguchi PDI 1999;19 (supp 2):S327

11CAPD

CAPD Outcome - Japan

• 235 patients analysed between 1980 - 1997

• Average survival was 5.8 years

• 142 patients changed dialysis therapy

• Causes - loss of UF (23%)

- inadequate dialysis (16%)

- peritonitis (14%)

• Peritonitis rate was very good

- 1 episode/54 patient months

Kawaguchi PDI 1999;19 (suppl 3):S9

12CAPD

Causes of Technique Failure in Long-term PD

Peritonitis

Inadequatedialysis

Notcoping/choice

Catheter

Other

36%

25%

20%

5%14%

13CAPD

CAPD Systems

Requirements:

1. Minimise risk of touch contamination

2. Maximise Flush efficiency

3. Inactivate organisms at patient connector if touch contamination occurred.

4. Proven and reliable connectology

5. Increased inactivation of organisms at the patient connection if a touch contamination occurs

6. Easy to learn and use system for all patients

AIM: Safety, Simplicity, Comfort & Convenience

14CAPD

Improvements in PD Connectology

1 in 11 in 5

1 in 101 in 151 in 201 in 251 in 301 in 351 in 40

78 79 80 81 82 83 84 85 86 87 88 89 90 95 2000

1979: Monthly Tubing Change Titanium Adapter1980: New Spike CAPD Set 1985: Extended Life Transfer Set, BDP

1986: UVXD 1986: APD-PAC X 1987: Y Set 1988: TwinBag - Europe 1989: UV-Flash, Pac Xtra 1990: PD Ultra Bag 1995: Homechoice 2000: Homechoice PRO

Infe

ctio

ns

(Per

Pat

ien

t M

on

ths)

1977-80 Data: Nolph & Sorkin, U. Missions1980-87 Data: CAPD Registry, USA1987-90 Data: Anecodotal reports, Europe/USA

Gokal R., Nolph K.: Textbook of PD: 1-15, 1994.

15CAPD

Peritonitis – Y-set Systems

Peritonitis rate

episodes/pt month

0

5

10

15

20

25

30

35

1970 1980 1990 2000

Glass bottles

Plastic bags

titaneum

O-set

disconnect

> Peritonitis rates have improved over the years

Straight line Y-set

Staph epid. 0.34 0.17Staph aureus 0.15 0.13Gram -ve 0.12 0.10Fungal 0.02 0.01

Holly AJKD 1994

16CAPD

Sources of Contamination

Routes of entry

17CAPD

Safety: Reduced risk of organisms entering the PD system if touch contamination occurs

Twinbag connectology allows significantly (p<0.0001) fewer bacteria to be transferred into the fluid path.

A recessed luer is of particular importance.

Recessed luer

Non-Recessed luer

Kubey W., et al., Blood Purification; 2000, 19(1).

18CAPD

CAPD Connectology: Reduced risk

The short distance between the Y-Junction and the patient connection ensures effective removal of bacterial contamination from the patient line should connection failure occur.

Kubey W., et al., Blood Purification; 2000, 19(1).