Patient selection and training for peritoneal dialysis

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