1. Turning the Light on Peritoneal Dialysis: A Basic Introduction to PD

2. Turning the light on Peritoneal Dialysis (PD)
Understanding the modality
Patient selection criteria
Components of a successful PD program
During this presentation we will discuss:
Understanding the modality
Patient Selection criteria
Components of a successful PD program

3. Goal statement
The goals of this presentation are to understand peritoneal dialysis and to recognize patient selection criteria as one component of a successful PD program.
The goal for this presentation is: (read the goal form the slide).

4. Learning objectives
At the end of this presentation the participant will be able to:
Describe the components of a successful PD program.
List the organization that provides guidelines for peritoneal dialysis including appropriate patient selection.
Describe the difference between peritoneal dialysis and hemodialysis
Describe the function of the peritoneal membrane and dialysate in peritoneal dialysis.
Read the slide.

5. Understanding the Modality: Principles of Peritoneal Dialysis
INSTRUCTOR NOTE:
Before we can discuss how to grow a PD program we need to understand the modality. The next few slides will be a brief review of Principles of PD.

6. Before we can discuss how to grow a PD program we need to understand the modality. The next few slides will be a brief review of principles of PD.
Let’s look at how PD can be used as a renal replacement therapy.

7. The structure of the peritoneum
Living, serous membrane
Can be damaged
Semi permeable and selective
Filters various kinds of solute to varying
degrees
Forms a closed sac in males and in females
the sac is open at the fimbria of the fallopian tubes
Is comprised of two principal types
Visceral peritoneum around the internal organs
Parietal peritoneum lining the abdominal wall
A. Living, serous membrane
1. Can be damaged
B. Semi permeable and selective
1. Filters various kinds of solutes to varying degrees
C. The peritoneum forms a closed sac in males, but is open in females at the fimbria of the fallopian tubes.
The peritoneal membrane is comprised of two principal types: the visceral and the partietal peritoneum.

8. The structure of the peritoneum
Size approximates body surface area
Approximates the surface area of the skin 1-2m2 in most adults
Proportionately larger in infants and small children
Effective surface area is about 1m2
Size equivalent to a hemodialyzer
Size is fixed
Can lose effective surface area
The membrane is fairly large
1. Thought to approximate the surface area of the skin - about 1 - 2m2 in most adults.
a. Proportionately larger in infants and small children
2. Effective surface area in PD is probably about 1m2
a. Compare to HD - equivalent size
b. Fixed size - unlike HD
c. Can lose effective surface area through adhesions

9. Peritoneal dialysis is an internal technique for blood purification
PD is dialysis but is unlike extracorporeal (out of the body) dialysis systems
Nature provides
Blood path
Membrane
Dialysate compartment
Let’s look at how PD can be used as a renal replacement therapy.
Peritoneal dialysis is an internal technique for blood purification. It is still hemodialysis, but unlike extracorporeal (out of the body) dialysis systems, the
- blood path
- membrane
- and dialysate compartment are provided by nature.
The peritoneal membrane forms the peritoneal cavity which functions as the dialysate compartment. Capillaries within the membrane provide the blood pathway.

10. Peritoneal dialysis is an internal technique for blood purification
The peritoneal membrane forms the peritoneal cavity which functions as the dialysate compartment
The membrane is semi-permeable and selectively filters solutes to varying degrees
Capillaries within the membrane provide the blood pathway

11. Anatomy of the peritoneum
Point out visceral and parietal peritoneum areas.
Forms folds between organs and elsewhere. The folds which are reflected from the walls over the viscera are called mesenteries. The folds can connect viscera to each other or anchor organs to the abdominal wall.
a. The greater omentum is a fold in the serosa of the stomach that hangs down like an apron over the front of the intestines.
1) Tends to be larger in heavy or previously heavy individuals.
2) The PD catheter can become entangled in the fold.
B. Peritoneal Cavity
1. Potential rather than an actual space.
a. Normally contains approx. 100 ml
b. Dialysate volumes usually L can result in:
1) Discomfort
2) Respiratory embarrassment, esp. if thoracic leak
3) Decreased food intake secondary to a sensation of fullness
4) Problems related to fluid weight or pressure - back pain, hernia, fluid leak into tissues
2. Foreign body (catheter) in cavity can cause problems
a. Discomfort (esp. rectal, bladder, penile) related to catheter or fluid pressure
b. Soft tissue penetration by catheter (rare)
c. Catheter is free floating - may result in poor drainage
1) Displaced from pelvic gutter (flipped up)
2) Omental wrapping - occasionally a partial or full omentectomy is needed
3) Entanglement in (full) bowel loops

12. Anatomy of the peritoneum
Forms folds between organs and elsewhere. The folds which are reflected from the walls over the viscera are called mesenteries. The folds can connect viscera to each other or anchor organs to the abdominal wall.
The greater omentum is a fold in the serosa of the stomach that hangs down like an apron over the front of the intestines.
Tends to be larger in heavy or previously heavy individuals.
PD catheter can become entangled in the omentum.

13. Peritoneal cavity Potential rather than an actual space
Normally contains approximately 100 ml
Dialysate volumes which are usually L can result in:
Discomfort
Respiratory embarrassment (especially if there is a thoracic leak)
Decreased food intake secondary to a sensation of fullness
Problems related to fluid weight or pressure such as back pain, hernia or fluid leak into tissues

14. Anatomy of the peritoneum
Point out visceral and parietal peritoneum areas.
Forms folds between organs and elsewhere. The folds which are reflected from the walls over the viscera are called mesenteries. The folds can connect viscera to each other or anchor organs to the abdominal wall.
a. The greater omentum is a fold in the serosa of the stomach that hangs down like an apron over the front of the intestines.
1) Tends to be larger in heavy or previously heavy individuals.
2) The PD catheter can become entangled in the fold.
B. Peritoneal Cavity
1. Potential rather than an actual space.
a. Normally contains approx. 100 ml
b. Dialysate volumes usually L can result in:
1) Discomfort
2) Respiratory embarrassment, esp. if thoracic leak
3) Decreased food intake secondary to a sensation of fullness
4) Problems related to fluid weight or pressure - back pain, hernia, fluid leak into tissues
2. Foreign body (catheter) in cavity can cause problems
a. Discomfort (esp. rectal, bladder, penile) related to catheter or fluid pressure
b. Soft tissue penetration by catheter (rare)
c. Catheter is free floating - may result in poor drainage
1) Displaced from pelvic gutter (flipped up)
2) Omental wrapping - occasionally a partial or full omentectomy is needed
3) Entanglement in (full) bowel loops
Peritoneal Cavity

15. Peritoneal cavity
A catheter (which is a foreign body) placed in the cavity can cause:
Discomfort related to catheter or fluid pressure (rectal, bladder, penile)
Poor drainage because the catheter floats freely in the peritoneal cavity and may become:
Displaced or flipped up from pelvic gutter
Wrapped in the omentum
Entangled bowel loops
Soft tissue penetration by the catheter (rare)

16. Function of the peritoneum - solute transport and clearance
Let’s examine how solutes are transported across the peritoneal membrane.
The peritoneal membrane is the patient's tool for doing the work of dialysis.
Membrane capability varies from person to person but is usually stable in an individual.
Let’s look at how solutes are transported across the peritoneal membrane
The peritoneal membrane is the patient's tool for doing the work of dialysis
Membrane capability varies from person to person, but
Is usually stable in an individual
However, you don’t know how good the tool is (how capable or efficient) unless you test it.

17. Diffusion
Solute movement from an area of higher concentration to an area of lower concentration
Movement continues until equilibrium occurs
A. Definition
1. Solute movement from an area of higher solute concentration to an area of lower solute concentration.

18. Diffusion and dialysis
Diffusion occurs across a membrane that is semi-permeable.
There are different degrees of permeability to solutes of different sizes.
Net transfer of molecules occurs
until an equal concentration of a given solute on both sides of the membrane.
Movement continues but there is no net change in concentration from
one side to another.
B. In dialysis, diffusion occurs across a membrane that is semipermeable
1. Differing degrees of permeability to solutes of different size
In this diagram the green triangles and red circles represent two different molecules that transport at different rates. We see that the red circles are already in equilibrium on both sides of the membrane while the green triangles are not yet equilibrated. If this were to represent dialysis, then there would be no further removal of the red circles, but green triangles could still be further dialyzed off.
C. Net transfer of molecules occurs until equilibrium is reached - an equal concentration (not amount) of a given solute on both sides of the membrane
1. Movement continues but there is no net change in concentration from one side to another

19. Diffusion and dialysis
In this diagram the green triangles and red circles represent two different molecules that transport at different rates.
We see that the red circles are already in equilibrium on both sides of the membrane while the green triangles are not yet equilibrated.
B. In dialysis, diffusion occurs across a membrane that is semipermeable
1. Differing degrees of permeability to solutes of different size
In this diagram the green triangles and red circles represent two different molecules that transport at different rates. We see that the red circles are already in equilibrium on both sides of the membrane while the green triangles are not yet equilibrated. If this were to represent dialysis, then there would be no further removal of the red circles, but green triangles could still be further dialyzed off.
C. Net transfer of molecules occurs until equilibrium is reached - an equal concentration (not amount) of a given solute on both sides of the membrane
1. Movement continues but there is no net change in concentration from one side to another
If this were to represent dialysis, then there would be no further removal of the red circles but green triangles could still be further dialyzed off.

20. Osmosis
Blood Dialysate
Water movement from an area of lower to higher solute concentration
Ultrafiltration, or the amount of water removed, is related to the osmotic pressure gradient
A. Definition
1. Water movement from an area of lower solute concentration to an area of higher solute concentration
In this diagram the “D”s represent dextrose, the solute used as an osmotic agent. The dialysate solution is very highly concentrated compared to blood.
a. Movement of water from an area of relatively more water to an area where there is relatively less water
B. The amount of water removed is related mainly to the osmotic pressure gradient.

21. Osmosis and dialysis O s m o i
Blood Dialysate
In this diagram the “D”s represent dextrose, the solute used as an osmotic agent.
The dialysis solution is very highly concentrated compared to blood so that water moves into the dialysate.
A. Definition
1. Water movement from an area of lower solute concentration to an area of higher solute concentration
In this diagram the “D”s represent dextrose, the solute used as an osmotic agent. The dialysate solution is very highly concentrated compared to blood.
a. Movement of water from an area of relatively more water to an area where there is relatively less water
B. The amount of water removed is related mainly to the osmotic pressure gradient.

22. Test yourself
1. The peritoneum removes solutes and fluids much like the dialyzer or artificial kidney in hemodialysis.
True False
2. The peritoneal membrane forms the peritoneal cavity which functions as the dialysate compartment.
3. Osmosis moves solutes out of the blood and into the dialysate.
True False

23. Answers for test yourself
1. The peritoneum removes solutes and fluids much like the dialyzer or artificial kidney in hemodialysis.
Answer: True. The peritoneum is a semi-permeable membrane and filters solutes and water during peritoneal dialysis.
2. The peritoneal membrane forms the peritoneal cavity which functions as the dialysate compartment.
Answer: True
3. Osmosis moves solutes out of the blood and into the dialysate.
Answer: False. Osmosis is the movement of water from an area of lower concentration to an area of higher concentration.

24. PD Therapies: Understanding the different types of PD

25. Continuous therapies Continuous Ambulatory Peritoneal Dialysis (CAPD)
4 - 5 exchanges* /24 hours
2L - 2.5L exchanges*
8 - 10L per 24 hours*
The exchanges are done manually by the patient
*May be more
Dialysate is present in the peritoneal cavity at all times

26. Continuous therapies Continuous Cycling Peritoneal Dialysis (CCPD)
Machine automated during sleep hours
hours at night
8L or more at night
2L or more during the day
10L or more in 24 hours
Dialysate is present in the peritoneal cavity at all times

27. Continuous therapies
PD Plus: Utilizing the cycler for a daytime exchange in addition to cycling at night
Night cycles for 8 – 10 hours
All exchanges delivered by cycler
Pause exchange
Night exchanges
Daytime fill
10L or more / 24 hours
Dialysate is present in the peritoneal cavity at all times

28. PD solutions: Understanding what is in the dialysate
Composition of PD solutions:
Sodium 132 mEq/L
Potassium none
Calcium mEq/L
Chloride mEq/L
Sodium lactate 448 gm/100ml
Magnesium mEq/L
Dextrose 1.5% %

29. Dialysis exchange process
An exchange should take approximately minutes to complete.
An entire exchange should take approximately minutes to complete.
Drain
Fill
Dwell

30. The drain phase Drain About 15 - 25 minutes and depends on:
Catheter function
Amount of solution
Gravity
Diameter of tubing
Position or intra-abdominal
pressure
Condition of system

31. The fill phase Fill About 10 minutes and depends on Amount of solution
Solution bag height
Diameter of tubing
Intra-abdominal pressure
Condition of system

32. The dwell Dwell (a prescribed time)
Dialysis takes place during the dwell time
Time required for transport of solutes across the peritoneum
CAPD
Usually hours during the day and
9 hours at night
Cycling
Usually hours at night and
15 hours during the day

33. Test yourself
Peritoneal dialysis can be done manually or by a machine as the patient prefers.
True False
The fill time is the time that it takes to
a. Stay in the peritoneal cavity
b. Allow the dialysate to flow out of the cavity into a bag
c. Drain fresh dialysate from the bag into the peritoneal cavity

34. Answers for test yourself
Peritoneal dialysis can be done manually or by a machine as the patient prefers.
Answer: True
The fill time is the time that it takes to
c. Drain fresh dialysate from the bag into the peritoneal cavity, filling the cavity with the dialysate fluid

35. Test yourself An exchange consists of _____ and ______.
a. drain and fill
b. fill and dwell
c. fill, dwell and drain
Continuous means that dialysate
a. is always present in the peritoneal cavity
b. is present except during the day
c. is present except at night
PD cyclers are most commonly used while the patient sleeps
True False

36. Answers to test yourself
An exchange consist of _____ and ______.
a. drain and fill
Continuous means that dialysate
a. is always present in the peritoneal cavity
PD cyclers are most commonly used while the patient sleeps
True

37. Patient selection criteria: Who should do peritoneal dialysis?
There are some patients for whom PD may be a better option than hemodialysis. There are pros and cons regarding modality selection for any patient. We’ll mention a few of the patients who may do better on PD or for whom PD may be contraindicated as per the KDOQI guidelines.

38. Patient selection criteria
There are some patients for whom PD may be a better option than hemodialysis.
There are pros and cons regarding modality selection for any patient.
Selection of patients who may do better on PD or for whom PD may be contraindicated as per the KDOQI guidelines will be reviewed.

39. K/DOQI Guideline 291: Indications for PD
Patients who prefer PD or will not do hemodialysis.
Patients report improved quality of life2 and that they are more satisfied with their treatments when compared to hemodialysis (HD) patients
Pediatric patients
No vascular access needed
Due to the difficulties in maintaining vascular access in infants and small children, PD is usually the modality of choice when weight is < 20 kg.
More gentle treatment
Regular school attendance
Can be best achieved by a home modality.
Patients on PD have :
Patients who prefer PD have been reported to have an improved quality of life, as sited in numerous publications. It is also been widely publicized that patients on PD report being more satisfied with their treatments and physicians when compared to patients on HD. -
Due to the rapid shifting of volume within compartments during hemodialysis, some patients with severe cardiac disease may be better managed on PD.
Advantages of PD in patients with cardiovascular disease include:
-better hemodynamic control
-less electrolytes shifts which could result in arrhythmia
-better control of anemia
Extensive peripheral or central venous occlusive disease prohibits surgical placement of some types of hemodialysis access. These patients are at risk of severe ischemia, even gangrene of the hands following placement of vascular access. In addition, marginal vascular beds are at risk for ischemia or reduced perfusion during hypotension, which is frequent in some HD patients. These patients benefit from the increased vascular stability achieved with PD.
We know that patients on PD have a lower incidence of LVH, arrhythmias, severe arrhythmias and hypertension compared to that of HD patients.
Due to the difficulties in maintaining vascular access in infants and small children, PD is usually the modality of choice when weight is < 20 kg. Additionally, regular school attendance by children of all ages can be best achieved by a home modality.
National Kidney Foundation. NKF K/DOQI Guidelines Retrieved December 10, 2007 from
Merkus, MP. Quality of life in patients on chronic dialysis: self-assessment 3 months after the start of treatment. The Necosad Study Group. American Journal of Kidney Disease 29: , 1997
Canziani, ME. Hemodialysis versus continuous ambulatory peritoneal dialysis: effects on the heart. Artificial Organs 19(3): , 1995
1.National Kidney Foundation. NKF K/DOQI Guidelines
2.Merkus, MP. American Journal of Kidney Disease 29: , 1997

40. K/DOQI Guideline 29: Indications for PD
Patients who cannot tolerate HD
Congestive/ischemic heart disease1
Due to the rapid shifting of volume within fluid compartments during HD, some patients with severe cardiac disease may be better managed on PD.
Patients on PD have a lower incidence of left ventricular hypertrophy, arrhythmias, and hypertension compared to that of HD patients.
Due to the rapid shifting of volume within compartments during hemodialysis, some patients with severe cardiac disease may be better managed on PD.
Advantages of PD in patients with cardiovascular disease include:
-better hemodynamic control
-less electrolytes shifts which could result in arrhythmia
-better control of anemia
Extensive peripheral or central venous occlusive disease prohibits surgical placement of some types of hemodialysis access. These patients are at risk of severe ischemia, even gangrene of the hands following placement of vascular access. In addition, marginal vascular beds are at risk for ischemia or reduced perfusion during hypotension, which is frequent in some HD patients. These patients benefit from the increased vascular stability achieved with PD.
We know that patients on PD have a lower incidence of LVH, arrhythmias, severe arrhythmias and hypertension compared to that of HD patients.
Canziani, ME. Hemodialysis versus continuous ambulatory peritoneal dialysis: effects on the heart. Artificial Organs 19(3): , 1995
Merkus, MP. Quality of life in patients on chronic dialysis: self-assessment 3 months after the start of treatment. The Necosad Study Group. American Journal of Kidney Disease 29: , 1997
1. Canziani, ME. Artificial Organs 19(3): , 1995

41. K/DOQI Guideline 29: Indications for PD
Extensive vascular disease and
Vascular access problematic patients
Extensive peripheral or central venous occlusive disease prohibits surgical placement of some types of hemodialysis access. These patients are at risk of severe ischemia or even gangrene following placement of vascular access.
Marginal vascular beds are at risk for ischemia or reduced perfusion during hypotension, which is frequent in some HD patients. These patients benefit from the increased vascular stability achieved with PD.
Due to the rapid shifting of volume within compartments during hemodialysis, some patients with severe cardiac disease may be better managed on PD.
Advantages of PD in patients with cardiovascular disease include:
-better hemodynamic control
-less electrolytes shifts which could result in arrhythmia
-better control of anemia
Extensive peripheral or central venous occlusive disease prohibits surgical placement of some types of hemodialysis access. These patients are at risk of severe ischemia, even gangrene of the hands following placement of vascular access. In addition, marginal vascular beds are at risk for ischemia or reduced perfusion during hypotension, which is frequent in some HD patients. These patients benefit from the increased vascular stability achieved with PD.
We know that patients on PD have a lower incidence of LVH, arrhythmias, severe arrhythmias and hypertension compared to that of HD patients.
Canziani, ME. Hemodialysis versus continuous ambulatory peritoneal dialysis: effects on the heart. Artificial Organs 19(3): , 1995
Merkus, MP. Quality of life in patients on chronic dialysis: self-assessment 3 months after the start of treatment. The Necosad Study Group. American Journal of Kidney Disease 29: , 1997
Canziani, ME. Artificial Organs 19(3): , 1995

42. Additional considerations for patients that would do well on PD
Distance from dialysis facility
Patients living in rural communities or where severe weather could be problematic.
Nursing home patients
Eliminates the difficulties with transportation three times per week.
Working patients
Avoids treatment scheduling conflicts
Patients who work report increased satisfaction with dialysis
Diabetic patients
No vascular access needed
IP (intra-peritoneal) insulin option

43. K/DOQI Guideline 30: Absolute Contraindications for PD
Documented loss of peritoneal function or extensive abdominal adhesions that limit dialysate flow.
PD efficiency relies on effective peritoneal blood flow, dialysate flow, sufficient peritoneal surface area and peritoneal transport rate to allow adequate solute and fluid removal.
Any compromise in these functions may result in inadequate peritoneal dialysis and thus the failure of PD.
There is no way of knowing the functionality of the peritoneum until it is tried. Many patients who have been on PD and were transplanted have successfully returned to PD post transplant failure.
We have no way of knowing the functionality of the peritoneum until we try. Many patients who have been on PD and were transplanted have successfully returned to PD post transplant failure. PD efficiency relies on effective peritoneal blood flow, dialysate flow, sufficient peritoneal surface area and peritoneal transport rate to allow adequate solute and fluid removal. Any compromise in these functions may result in inadequate peritoneal dialysis and thus the failure of PD.
Performing PD requires certain physical and intellectual capabilities in the patient and/or caregiver. It is important that the patient and/or the caregiver be able to identify and troubleshoot any problems that may arise during PD. Be open minded, we have seen blind patients, patients who cannot read, and patients with severe physical limitations be successful PD patients.
The dialysate must come into contact with the vascular bed of the peritoneum, otherwise dialysis will not be accomplished. The above mentioned disorders are all congenital birth defects which involve a weakening of some degree in the abdominal wall wherein abdominal organs herniate and begin to grow in a place that is not normal.
Omphalocele: birth defect known as a ventral wall defect that involves the abdominal area. Abdominal organs herniated into the base of the umbilical cord.
Gastroschisis- rare congenital disorder wherein a small abdominal cavity with herniated abdominal organs develops on the right side of the abdomen
Bladder Extrophy- abdominal wall defect in which the bladder and related structures are turned inside out
Diaphragmatic hernia- Life threatening birth defect in which the diaphragm does not completely form allowing some of the contents of the abdomen to protrude into the chest and hinder growth of lung tissue.
1. National Kidney Foundation. NKF K/DOQI Guidelines Retrieved December 10, 2007 from
National Kidney Foundation. NKF K/DOQI Guidelines

44. K/DOQI Guideline 30: Absolute Contraindications for PD
Absence of suitable assistant in the patient who is physically or mentally incapable of performing PD.
Performing PD requires certain physical and intellectual capabilities in the patient and/or caregiver.
It is important that the patient and/or the caregiver be able to identify and troubleshoot any problems that may arise during PD.
Be open minded, blind patients, patients who cannot read, and patients with severe physical limitations have been successful PD patients.
National Kidney Foundation. NKF K/DOQI Guidelines

45. K/DOQI Guideline 30: Absolute Contraindications for PD
Uncorrectable mechanical defects that prevent effective PD or increase the risk of infection (e.g., surgically irreparable hernia, omphalocele, gastroschisis, diaphragmatic hernia and bladder extrophy.)
The dialysate must come into contact with the vascular bed of the peritoneum, otherwise dialysis will not be accomplished.
These congenital birth defects involve a weakening of in the abdominal wall wherein abdominal organs herniate.
National Kidney Foundation. NKF K/DOQI Guidelines

46. K/DOQI Guideline 31: Relative Contraindications for PD
Peritoneal leaks
Body size limitations
Intolerance to PD volumes necessary to achieve adequate PD dose
Inflammatory or ischemic bowel disease
Abdominal wall or skin infection
Morbid obesity (in short people)
Severe malnutrition
Frequent episodes of diverticulitis
These relative contraindications are important to mention. It is also important to note that these patients account for a only small portion of PD candidates and this population is not significant enough to impact the low PD utilization rate that we see in the US today.
It is important to note that this section of the KDOQI guidelines is opinion based and furthermore keep in mind that these are relative contraindications. We have seen many patients with a large body surface area and good residual renal function meet the adequacy guidelines and thrive well on PD. We also have seen peritoneal leaks that have resolved without surgical intervention.
We also know that fill volumes are tolerated well by most patients unless they have significant respiratory disease. These patients may not be able to tolerate large fill volumes in relation to their respiratory status.
National Kidney Foundation. NKF K/DOQI Guidelines Retrieved December 10, 2007 from
National Kidney Foundation. NKF K/DOQI Guidelines

47. K/DOQI Guideline 31: Relative Contraindications for PD
Patients with relative contraindications account for a only small portion of PD candidates and this population is not significant enough to impact the low PD utilization rate that we see in the US today.
This section of the K/DOQI guidelines is opinion based.
National Kidney Foundation. NKF K/DOQI Guidelines

48. Test yourself
There are written guidelines regarding patient selection criteria
True False
For some patients PD is a better option because it places less stress on the cardiovascular system.
Documented extensive abdominal adhesions that limit dialysate flow will not impede PD

49. Answers to test yourself
There are written guidelines regarding patient selection criteria
True
For some patients PD is a better option because it places less stress on the cardiovascular system.
Documented extensive abdominal adhesions that limit dialysate flow will not impede PD
False, this is a contraindication for peritoneal dialysis.

50. Building the components of a successful PD program
Physician support
Active and effective modality education program
Program infrastructure
Throughout the remainder of our time together, we will explore each of these components of a successful PD program.

51. Physician support - why it may be low
Minimal training of PD during fellowships leads to physician:
Lack of confidence
Concern with managing side effects
Perception that adjustments of Rx are more involved with PD than HD
Perception that PD is more labor/time intensive
The amount of time devoted to learning peritoneal dialysis during fellowships varies from program to program. Often times the fellows spend the majority of their time involved with acute renal replacement therapies, acute/chronic hemodialysis, and transplant. Unfortunately, their exposure to peritoneal dialysis is minimal and lends to a low comfort level with this important modality. In general, physicians lack confidence in managing possible side effects, do not understand the adjustments necessary to improve kinetics, and as a result view PD as more labor and time intensive.
For physicians that fall into this category, we are able to offer some assistance.
1. Campbell, D. What is Missing in Making PD a Success? Nephrology News and Issues 25-27, 2004
Campbell, D. Nephrology News and Issues 25-27, 2004

52. Steps to improve physician support
Encourage the physician to attend an education program designed to increase comfort with PD
Provide articles that promote the modality and the importance of modality options education
First, we must take the time to get to know our physicians and understand their barriers to PD. You may encounter a young physician who falls into the category that we mentioned on the previous slide. However, there are more seasoned physicians who have been swept away by hemo and perhaps lost their comfort level with PD.
No matter which category your physician may fit into, there is help. The best way to boost physician belief and comfort level is to have him or her become involved in a physician education course on peritoneal dialysis. Programs are generally two-three days in length and provide in depth information that the physician can then put to use in his or her own PD program.
Not all physicians will be able to attend this type of program, then we as PD nurses can utilize the many articles that provide positive information regarding PD.

53. Components of a successful modality education program
Modality education process developed and agreed upon by multidisciplinary team
Dedicated nurse with hours specified to monthly patient modality education meetings
Physician commitment to refer patients
Education of hemodialysis staff
PD awareness days for hemodialysis patients
Tracking program to monitor success and identify opportunities for improvement
In order for a modality education program to be successful, you will first need to develop a process that is agreed upon by all involved. The importance of having a dedicated nurse with dedicated hours to lead this program is essential. This dedicated nurse should then hold monthly meetings.
A dedicated kidney options nurse has been proven to increase the percentage of patients choosing PD as their therapy of choice..

54. Modality education Benefits of early referral
Improves management of comorbid conditions
Allows for timely education in treatment options and referral for permanent access placement
Identifies target patient population:1
Creatinine > 3mg/dl
Anticipated treatment start within 1 year
New hemo starts who did not receive information
The parameters of your program should be clearly defined by the multi disciplinary team, especially your referring Nephrologist. The Nephrologist will need to convey his wishes for patient referral to his office staff, as they play an integral role in this process. Working with your Nephrologist to develop a simple referral process for the office staff will ensure a positive flow of patients to your modality education monthly class. An example of a referral form can be found in the Kidney Options manual.
In addition to CKD patients, a successful program should include education of hemodialysis patients that did not have the opportunity to participate in a modality education course prior to initiating dialysis. Many modality educators partner with clinic managers to obtain monthly admission reports to identify such patients and then meet with them during their next scheduled hemo treatment.
The benefits of modality education are many. The medical team can better manage the patients co morbid conditions as well as take a proactive approach to access placement thus decreasing the percentage of vascular catheters being utilized.
The point at which patients enter this program vary due to physician belief, but can be anywhere from one year to six months prior to initiation of dialysis.
National Kidney Foundation. Guidelines for peritoneal dialysis adequacy. NKF K/DOQI Guidelines Retrieved December 10, 2007 from:
1. National Kidney Foundation. NKF K/DOQI Guidelines

55. Modality education
There are defined parameters for the program developed by the multi disciplinary team, especially the referring nephrologist
The nephrologist must clearly communicate patient referrals to the staff
The referral process will ensure a positive flow of patients to your modality education monthly class
In addition to new CKD patients, a successful program will include education of hemodialysis patients

56. Modality education
Educators partner with clinic managers to obtain admission reports
Education promotes a proactive approach to access placement thus decreasing the percentage of vascular catheters being utilized
The points at which patients may enter the program vary and but can be anywhere from one year to six months prior to initiation of dialysis

57. Monthly modality education classes should:
Provide regular monthly treatment education programs discussing
Treatment options
Diet and nutrition
Living with dialysis
Support systems
Financial needs/concerns
In successful modality education programs, monthly meetings should be held on a consistent basis. For example, the first Tuesday of each month at 1 pm in the conference room of dialysis unit XYZ. Meetings should be held each month at the same day, time and place regardless of how many patients are registered. This will also make it easy for the physician and the office staff to easily refer patients to these important educational sessions.
The information covered should be non-biased in how it is presented and should cover all of the topics mentioned in this slide.

58. Education of hemodialysis staff
Increases understanding of peritoneal dialysis
Assists PD nurse to identify potential candidates who did not have the opportunity to participate in their own modality selection
( such as acute starts)
Dissolves myths regarding PD
“You will get an infection”
“You are on the machine for 15 hours at night”
“Large patients cannot meet adequacy targets”

59. PD awareness days for hemodialysis patients
Objective: Heighten awareness of HD patients to the clinical and lifestyle benefits of PD therapy.
Acute starts
Patients who were uremic when they started and now want to know more about PD.
Patients who have returned to work and desire a more flexible lifestyle

60. How to conduct a PD awareness day
Requires support of physician and entire staff
Provide a lunch-n-learn for hemo staff prior to PD awareness days to ensure it’s success
Place posters marking the PD awareness dates throughout the facility
Meet with each hemodialysis patient during treatment
Follow up with physician, PD nurse and/or educator regarding patients who are interested in possibly switching

61. Methods to develop a positive PD program infrastructure
Dedicate a PD nurse with regularly scheduled hours for PD
Ensure on-call PD support
Develop new PD programs where appropriate, to reduce travel time for patients and physicians
Develop float positions to cover smaller and new programs and backup for large programs
Utilize vendor on site education and continuous education sessions
Establish protocols for ease of treatment
Educate local hospitals and extended care facilities for continuity of treatment

62. In summary To have a successful PD program Understand the modality
Understand the right type of patient for PD
Know your physician’s beliefs and offer positive educational offerings to increase his/her support
Develop and implement an active and effective modality options program
Promote a positive infrastructure within your home training program
In summary to have a successful PD program you need to:
(read bullet points above).