1. Peritoneal Dialysis Julie Stinson
Specialist Nurse, Renal Community Team
University Hospitals of Leicester

2. Aims and Objectives
To give an overview of Peritoneal Dialysis – how it works, therapy options
To discuss the solutions used for PD
To discuss the pharmacological considerations in PD

3. Peritoneal Dialysis Introduced late 1970’s
Alternative treatment to Haemodialysis for End-stage Renal failure
Home therapy, self-managed by patient
Uses patients own natural membrane – the Peritoneum – for dialysis
Need identified for pts to be able to dialyse at home, self-manage dialysis

4. What is Peritoneal Dialysis?
Peritoneal Dialysis (PD) utilises one of the bodies natural membranes
Fluid flows through a small plastic tube (catheter) into the peritoneal cavity
Whilst the fluid is inside the peritoneal cavity dialysis takes place
The fluid is changed every few hours, this is called an exchange
Peritoneal membrane acts as a filter
Catheter inserted during a minor operation
Peritoneal cavity
Catheter

5. The Peritoneal Cavity

6. How peritoneal dialysis works
Removal of solutes by DIFFUSION
Removal of fluid by OSMOSIS

7. Peritoneal Dialysis Diffusion
Movement of solutes from a strong solution to a weak solution across a semi - permeable membrane 1 2
Blood
Membrane
Dialysate
1 - Red blood cell
2 - Bacteria
Sodium
Potassium
Chloride
Bicarbonate
Urea
Creatinine
Uric acid
Beta 2-m

8. Peritoneal Dialysis Osmosis Blood Dialysis Solution
Movement of water from an area of low solute concentration to an area of high solute concentration.
Blood
Dialysis Solution
Water
Solute

9. Suitable patients Well motivated/ independent Diabetic Elderly
Patients with residual renal function
Needle phobic patients
Patients with cardiac disease
Have adequate storage space for fluids/ equipment

10. Contraindications for PD
Chronic back pain
COPD
Diverticular disease
Previous abdominal surgery
Social circumstances -Lack of space at home for supplies
Inability to self- manage treatment: physical or cognitive function

11. Advantages of PD Home based therapy Easy to perform Flexible
Cheaper than hospital HD
Gentle form of dialysis
Fits into lifestyle- maintains independence
Preserves renal function

12. More advantages Less dietary restrictions
Treatment of choice for diabetics
No needles involved!
No needles for Needlephobics!

13. Catheter
A flexible, silicone catheter is inserted into the Peritoneal cavity usually laproscopically (under local or general anaesthetic)
Dacron cuffs secure in position in peritoneum
Can be used after 2-4wks (post-operatively if necessary)
SHOW CATHETER

15. Types of Peritoneal Dialysis
CAPD
APD

16. What is CAPD?
CAPD stands for Continuous Ambulatory Peritoneal Dialysis
CAPD can be performed in any clean and convenient place
The manual exchanges use gravity to drain the used fluid out of the peritoneal cavity and replace it with fresh fluid
Most CAPD patients need to do 4 bag exchanges per day
CAPD can be performed in any clean and convenient place- at home, at work, at school, or on holiday

17. CAPD Continuous Ambulatory Peritoneal Dialysis
Dialysis takes place whilst patient continues normal daily activities
Performed manually (usually) 4 times every day
1.5 – 2.5 litres of fluid per exchange
Each exchange takes minutes

18. Automated Peritoneal Dialysis
Dialysis is performed by an automated machine and exchanges are done at night while patient sleeps
Machine has 3 main functions:
Heats PD fluid to body temperature
Controls time of exchange and amount of fluid used
Monitors treatment (safety alarms)

19. APD Automated Peritoneal Dialysis Performed every night
Free from exchanges during the day
Greater flexibility in volume and time of exchanges
Can be performed by a carer so possible for for patients unable to self manage
Assisted APD will be discussed at forthcoming session

20. Types of PD fluids
Primarily made up of glucose as this provides the osmotic gradient required to remove water
Other constituents include
Lactate/bicarbonate as a buffer
Electrolytes i.e. sodium, calcium, etc
Amino Acids/bicarbonate
Varies from 1.5L to 3Litres

21. Types of PD Fluids Glucose Icodextrin - Extraneal
Amino acids - Nutrineal
Bicarbonate - Physioneal
(Baxter Healthcare)
AIM_ BIOCOMPATIBILITY.

22. Glucose (as osmotic agent) in different concentrations:
Traditional PD fluids are glucose based and use Lactate as buffer - Bioincompatible
Glucose (as osmotic agent) in different concentrations:
1.36%, 2.27% 3.86%
More glucose = more fluid removal
High concentrations of glucose – 1.36% bag = 75mmol/litre, 3.86% = 215mmol/l
Risk of peritoneal damage increases with time

23. Constant exposure to glucose can damage Peritoneum in time
Absorption of glucose leads to hyperglycaemia in Diabetics, insulin resistance, obesity

24. Glucose polymer, starch based fluid – 7.5% Icodextrin
Extraneal
Glucose polymer, starch based fluid – 7.5% Icodextrin
Allows better ultrafiltration
Used once daily for longer dwell time (at least 8 hours)
Reduces glucose load, so maintains better glycaemic control for diabetics; reduces weight gain
AIM - Reduce Glu load, preserve peritoneum = Biocmpatible

25. 1.1% Amino acid – 87mmol/litre
Nutrineal
1.1% Amino acid – 87mmol/litre
One bag per day – at mealtime exchange in CAPD, with o/night mix in APD
Absorption rate 70-80% amino acids, hence can use in malnourished pts
No glucose = less load!

26. Uses Bicarbonate + Lactate as buffer – Biocompatible
Physioneal
Uses Bicarbonate + Lactate as buffer – Biocompatible
Prolongs efficiency of peritoneum as dialysis membrane
Prolong peritoneum – can aid length of time on PD

27. PHARMACOLOGICAL CONSIDERATIONS IN PD

28. Complications of PD (with Pharmacy involvement)
Peritonitis
Exit site and Tunnel infection
Constipation
Mechanical
Emphasise concentrate on comps with Pharm implications

29. Treatment protocols given are specific to University Hospitals of Leicester
Most PD units will have variations in protocols! – Please refer to your local policies
EMPHASISE

30. Important to take regular laxatives Usually Lactulose and Senna
Constipation
Constipation can lead to PD catheter problems- fluid will not drain out/in
Important to take regular laxatives
Usually Lactulose and Senna
Some patients may need Sodium Docusate
Picolax if severe constipation
Lact and Senna usual

31. Blocked catheter caused by Fibrin May require UROKINASE lock
Urokinase 5000u in 5mls Saline - for 2 hour dwell into catheter
Fibrin – protein naturally lost in PD

32. PD Peritonitis Inflammation of peritoneum usually due to infection
Signs and symptoms: Cloudy PD fluid +/- abdominal pain, ?fever, nausea, D and V
Diagnosis based on symptoms of cloudy fluid, pain
Fluid will show > 100 white cells; Identification of organisms on Gram stain or subsequent culture of fluid
Dx – based on CLOUDY FLUID/Pain

33. Treatment of peritonitis
Outpatient ‘APD regime’
Gram positive - Bolus IP Vancomycin – 1-2gram dependant on body weight
Gram negative - oral Ciprofloxacin (500mg bd)
No organism – both Vanc and Cipro
Day 4 – vanc level checked; <15mg/ml=further dose: Repeat at days 8 and 12

34. Inpatients regime
Gram positive organisms -
IP Vancomycin 25mg/litre for 10days
Gram negative –
IP Gentamycin 5mg/litre
No growth – give both

35. Special considerations for Pseudomonas, fungal
IP Gentamycin 7.5mg/l alternate bags +
Oral Ciprofloxacin 750mg bd
Continued for 4 weeks (weekly Gent levels)? Tube removed if recurrent, non-resolving peritonitis
Fungal – Tube removal
(Ref: UHL Policy – PD peritonitis diagnosis and treatment)

36. Recurrent peritonitis:
Rifampicin 600mg once day for 4 weeks
(weekly LFTs) + Urokinase flush 5000u/5mls on day 4 and 7/8

37. Exit Site and Tunnel infections
Commonly caused by skin commensals
Clinical signs of infection:-
swab taken; Instigate abx treatment- Flucloxacillin 500mg qds x 5days (as appropriate) /Erythromicin 500mgs qds if Penicillin sensitive
Gram positive organism -continue 7 days
Gram negative – Ciprofloxacin 500mg bd x7days )

38. If pt is Staph Aureus carrier, treated with nasal and topical Mupiricin (Swab each clinic visit
(ref: UHL policy: PD catheter ESI)

39. Tunnel infection
Cause usually unresolved ESI.
Inflammed tract under skin along tube tunnel= erythema, tenderness
Treated with IV Vancomycin 1g; likely admission
Tube removal if unresolved (r/v 48hrs)

40. THANK YOU!