Certification Review Course: Peritoneal Dialysis

Certification Review Course: Peritoneal Dialysis
Peritoneal dialysis Presented by Ray Agnello BSN, RN, CNN Renal Educator St. Joseph’s Medical Center

Objectives Certification Review Course: Peritoneal Dialysis To provide attendees with a summarized review of peritoneal dialysis. To highlight key points in the clinical care of a PD patient. Catheter placement Care of catheter Infectious complication Non-infectious complications Adequacy Fluid balance assessment of the patient with PD In addition: Framework for study – CNN exam Provide list of Resources or Bibliography. Understanding the principals of PD can help you know what the intervention will be.

Alternative to hemodialysis Patient is taught to perform dialysis exchanges in the home setting Focus is on patient autonomy and self-care management Patient must be followed by a licensed Peritoneal Dialysis unit - Autonomy, self-care, care-management: Is this patient physically (dexterity, lifting bags, discarding waste) and mentally able to complete the necessary steps to safe CAPD? Does the patient have a partner (spouse, child, friend, neighbor) to assist him or her? CMS requirements.

Peritoneal Membrane Translucent Vascular membrane Two layers Parietal (inner surface of abdominal wall) Receives blood supply from the arteries of the abdominal wall. Visceral (covers abdominal viscera) Covers the abdominal organs. Blood is carried by the mesenteric and celiac arteries. Most vascular layer where most of the dialysis occurs. Envelope of space between layers called peritoneal cavity. Semi-permeable; acts as a filter. Kelley (2004) Translucent – Slightly penetratable by light rays. Micovascular – Vascular network of something translucent. [Author: Should this be microvascular?]

Anatomy and Physiology
Certification Review Course: Peritoneal Dialysis Peritoneal Membrane Semi-permeable Bi-directional Membrane size – 1-2 m2 Vascular wall, interstitium, mesothelium , and adjacent fluid films Closed in males Women – Ovaries and fallopian tubes open into the peritoneal cavity Peritoneal cavity normally contains about 100 ml transudate

Kinetics of Peritoneal Dialysis
Certification Review Course: Peritoneal Dialysis Kinetics of Peritoneal Dialysis Diffusion Osmosis Ultrafiltration Drug Transport

Diffusion Tea Bag = Peritoneal Membrane Water = PD Fluid Tea Leaves = Waste

Scheme of semi-permeable membrane: red = blood blue = PD fluid yellow = membrane wikipedia.org/

Osmosis The diffusion of pure solvent across a membrane in response to a concentration gradient, usually from a solution of lesser to one of greater solute concentration. Miller-Keane 6th Edition

Osmotic Pressure of Dextrose Solution 1.5 % Solution 2.5 % Solution 4.25 % Solution

The Peritoneal Dialysis Process
Certification Review Course: Peritoneal Dialysis The Peritoneal Dialysis Process Definition-intra (within) corporeal dialysis Three phases to the exchange process Drain Fill Dwell

How Does PD Work? The semi-permeable peritoneal membrane lines the abdominal cavity and covers the abdominal viscera. The membrane allows (via diffusion) the passage of toxins and electrolytes into the dialysis solution. Ultra-filtration (removal of fluid) occurs via osmosis. A “steady state” of toxin clearance and fluid management is achieved due to daily performance of dialysis. Kelley (2004).

How Does PD Work? Dialysis solution is infused and drained via a catheter that is surgically placed in the peritoneal cavity. The action of draining and infusing dialysis solution is called an exchange. The frequency of exchanges and volume is determined by the presence of residual renal function and the individual membrane characteristic.

Infusion or Fill Certification Review Course: Peritoneal Dialysis Fill time is affected by the height of the solution bag, the inner diameter of the catheter and tubing, the tubing length, catheter configuration, and intra-abdominal pressure. Baxter®

Drain Factors that affect the drain rate include the catheter position, internal and external occlusion of the lines, intra-abdominal pressure, catheter configuration, tubing diameter, tubing length, and the height distance from the abdomen to the drain bag. Baxter®

Dialysis occurs during the dwell phase. Diffusion: Solutes cross from area of greater concentration to lesser one. - Depends on concentration gradient. - Enough peritoneal surface area. - Size of fill volume. Ultra-filtration: Water removal due to osmotic gradient between the hyperosmolar PD fluid and the capillary bed. Kelley (2004).

Historical Perspectives
Certification Review Course: Peritoneal Dialysis Historical Perspectives Acute – Predominant use of PD prior to 1960s 1966 – Automated cycler 1967 – Tenckhoff catheter 1975 – CAPD 1978 – Polyvinyl bags manufactured 1980s – New catheter designs 1987 – PET and tidal PD – Twardowski 1990s – Alternative dialysate solutions, updated system designs

Who Are the PD Patients ? Choose PD as renal replacement therapy Hemodialysis patient without access Failed allograft (transplanted kidney) Have CHF or CVD which exempts them from hemodialysis Often people without the benefit of CKD education

PD Patient Selection Inclusion criteria include patients who: Choose the modality. Want “control.” Prefer home for dialysis. Have residual renal function. CVD, CHF. Geriatric. Pediatric. Social support system. Certification Review Course: Peritoneal Dialysis

Surgical Evaluation Abdominal wall weakness or hernia Repair hernia preemptively or when symptomatic Previous abdominal surgeries Likelihood of adhesions Abdominal wall obesity

Surgical Evaluation Catheter Insertion
Certification Review Course: Peritoneal Dialysis Surgical Evaluation Catheter Insertion Some units advocate insertion 2 to 6 weeks prior to dialysis to optimize healing. Some units advocate insertion months in advance (burying the catheter). In most situations, PD access is elective.

Peri-Operative Routines Anesthesia
Certification Review Course: Peritoneal Dialysis Peri-Operative Routines Anesthesia Local infiltration with sedation Intravenous propofol with MAC General anesthesia

Insertion Techniques Bedside-temporary catheters Laparoscopic placement Surgical dissection Buried catheter technique

Insertion Techniques Certification Review Course: Peritoneal Dialysis Buried catheter: Entire catheter placed in subcutaneous pocket for 4 to 6 weeks or longer, allowing cuff to heal. Exit site is externalized in a separate procedure. Reduced bacterial colonization (?). Do not have long-term outcomes yet. Flanigan & Gokal (2005).

Pre-Catheter Insertion
Certification Review Course: Peritoneal Dialysis Pre-Catheter Insertion Patient education and consent signed Examination of the patient’s abdomen Avoid scars and fat folds Avoid beltline Mark the abdomen Surgical prep Empty bladder Patient showers with disinfectant soap Bowel prep

Steps to PD Catheter Access
Certification Review Course: Peritoneal Dialysis Steps to PD Catheter Access Evaluation by nephrologist for PD catheter placement and identified as candidate. Educated about catheter placement, and pre- and post-operative care routines. Referred to surgeon for evaluation that includes determination of exit site,clinical and anesthesia work-up, contra-indications, completion of consent forms, and scheduling of surgery.

Selection Continued Certification Review Course: Peritoneal Dialysis Exclusion Criteria Patients who: Have abdominal aortic aneurysm AAA (size dependent) Derm. disease of the abdominal wall Morbid abdominal obesity Altered mental status; poor coping styles Solitary lifestyle Patient states lack of interest in modality Multiple abdominal surgeries – adhesions Ostomies (increase risk of infection) Recurrent hernias

Catheter History Early catheters were glass cannulas with straight or with mushroom ends. 1920s – Stainless steel coil with rubber drain first used in NYC (Rosenak) 1940s – Urinary catheters utilized 1950s – Nylon catheters at UCLA 1960s – Button catheters (Scribner, Boen)

Catheter History 1964 – Slicon rubber catheters (Palmer, Quinton) 1965 – Tenckhoff intermittent catheter 1968 – Tenckhoff cuffed straight catheter 1970s – Single/double cuff coiled catheter 1980s – Swan neck configuration 2000s – T-shaped catheter (Ash) The future..?

Catheters Straight (single or double cuff) Coiled (single or double cuff ) Swan neck (single or double cuff) Pre-sternal swan neck Toronto Western Missouri catheters Disc catheters

Cuffs Single Double Elongated Bead/flange configuration

Adaptors Plastic Titanium

PD Catheter Access Complication
Certification Review Course: Peritoneal Dialysis Immediate/Early Bloody effluent Pain with infusion Leak at exit site Exit site infection Migration of catheter tip Poor fill or drain, with or without pain Non-infectious cloudy effluent (lymphatic leak or eosinophilic peritonitis)

PD Catheter Access Complication
Certification Review Course: Peritoneal Dialysis Later Issues Exit site leaks or subcutaneous leaks Pleural communications Excessive granulation tissue Chronic site or tunnel infection Cuff extrusion Cracked, brittle catheter Repetitive episodes of peritonitis Bowel perforations

Post-Op Follow up appointment with surgeon Remove primary dressing in 5 to 7 days Replace dressing with DSD Teach patient to secure catheter Flush catheter during training sessions Allow catheter to heal for 14 days or longer if possible Schedule training sessions

Post Operative Discharge Plan
Certification Review Course: Peritoneal Dialysis Pain medication/prescription Follow-up in PD unit within 48 to 72 hours of discharge Dressing intact for 5 to 7 days Reinforce dressing as needed Dressing changed by PD nurse Establish training schedule Bowel regimen No heavy lifting Written instructions Emergency phone numbers Prevent Constipation

Peritoneal Dialysis Therapies
Certification Review Course: Peritoneal Dialysis Peritoneal Dialysis Therapies IPD (Intermittent Peritoneal Dialysis) CAPD (Continuous Ambulatory Peritoneal Dialysis ) CCPD (Continuous Cycling Peritoneal Dialysis) also known as APD (Automated Peritoneal Dialysis) Peritoneal dialysis regimens are either intermittent or continuous. Intermittent Treatments are performed intermittently several times during the week, typically performed at night, but can also be done during the day. No fluid is left in the patient’s peritoneal cavity between treatments. Continuous Dialysis solution is present in the cavity 24/7, except for drain and fills. All methods require a monthly visit to the peritoneal dialysis unit for follow-up.

Training Sessions for the PD Patient
Certification Review Course: Peritoneal Dialysis Training Sessions for the PD Patient Assess readiness to learn Provide a quiet, relaxed atmosphere for learning Identify patient’s learning style Individualized with respect to patient’s expectations, cultural beliefs, and coping abilities Length of training based on patient’s clinical condition

On Call RN ON Call RN ON Call

Warming the Solution Certification Review Course: Peritoneal Dialysis Use warm, dry heat At home – PD heating pad NEVER MICROWAVE!! Uneven heating of dextrose can create a 1st or 2nd degree burn to peritoneum Leaching of plastics into dialysate can create a chemical peritonitis

Patients At Risk for Inadequate Dialysis
Certification Review Course: Peritoneal Dialysis Patients At Risk for Inadequate Dialysis No residual renal function Low membrane permeability Large patients

PD Equilibration Test First developed by Z. Twardowski at the University of Missouri. A 4-hour study that assesses membrane transport characteristics. Assessment of membrane function allows for accurate prescription planning. Usually completed within the first six weeks of initiating PD. Repeated per each unit’s protocol.

PD Equilibration Test continued
Certification Review Course: Peritoneal Dialysis PD Equilibration Test continued What does this tell us? The results indicate the following transport states: High High-average Low-average Low

KT/V Test What is measured? 24-hour collection of dialysate and urine Serum values of BUN and Creatinine Frequency of test is determined by each unit’s protocols and interpretation of K/DOQI Guidelines

KT/V Test continued What does it tell us? The adequacy of the current prescription Need for adjustments to insure appropriate dialysis prescription

Infectious Complications
Certification Review Course: Peritoneal Dialysis Infectious Complications

Exit Site Care Healthy exit site: Surrounding skin natural, darkened, or light pink; no drainage or crusting; visible sinus is dry. Goal: Prevent exit site infection and identify problems early. Frequency: Daily or 3 to 4 times weekly; may be in conjunction with showering.

Infection Prevention Certification Review Course: Peritoneal Dialysis Exit Site Care: No dressing needed for established catheter exit site. Keep catheter secured to abdomen with 2-inch tape. Daily showers with liquid soap. Mupirocin (Bactroban®) at exit site of known staph. carrier. Inpatients – Dry dressing to protect site, cleaned with soap and water. No occlusive membrane dressings (Tegaderm®). A healed and non-infected exit site is crucial to longevity on Peritoneal Dialysis.

Exit Site Infection Certification Review Course: Peritoneal Dialysis Teach patient to identify and report immediately to the PD Unit: Redness, tenderness, edema, presence of exudate either at exit site or insertion site. Treatment: Culture exudate if possible Specific antibiotic protocol Oral or IV/IP antibiotics depending on extent of infection Saline soaks/dressing changes for care of local cellulitis

Exit Site Infection Certification Review Course: Peritoneal Dialysis A chronic exit site infection can produce a systemic inflammatory response. Inflammation can lead to poor nutrition, inadequate dialysis, and possible antibiotic resistance. Vital role of dietitian. Chronic exit site infections may result in peritonitis. Multiple infections can lead to removal and replacement of catheter. Consistent assessment and documentation is needed to appropriately track infections.

Exit Site Infection Signs and Symptoms: Redness, swelling, tenderness or pain, and purulent drainage. Risk Factors: Poor catheter healing, sutures at the exit site, trauma to the exit site, cuff extrusion, and improper catheter care. Diagnosis: Observation and culture. Treatment: Antibiotics, IP, PO, or IV; vigilant daily exit site care.

Responsible Organisms
Certification Review Course: Peritoneal Dialysis Responsible Organisms Staphylococcus Aureus Pseudomonas species Other gram-positive species Serratia species Other gram-negative organisms Fungi

Tunnel Infection Certification Review Course: Peritoneal Dialysis Signs and Symptoms Erythema over the tunnel Pain and tenderness Drainage from exit site – No other signs of an infection Risk factors Exit-site infection Exit-site trauma Leak External cuff extrusion Treatment – Antibiotic therapy to prevent need for catheter removal

Prevention of Peritonitis
Certification Review Course: Peritoneal Dialysis Prevention of Peritonitis Basics of Aseptic Technique: 5-min. hand scrub, face masks during exchanges, warming of PD bags using dry heat, aseptic technique for adding medicines. Aseptic technique when making critical connections to solution containers and the patient’s transfer set. Masks reduce the risk of contamination with nasopharyngeal organisms.

Peritonitis Certification Review Course: Peritoneal Dialysis Portals of Entry Transluminal – Technique failure, contamination Periluminal – Incomplete healing ,leaking Hematogenous – Bacteremia Transmurl – Through the bowel wall ANNA Core Curriculum

Diagnosis of Peritonitis
Certification Review Course: Peritoneal Dialysis Diagnosis of Peritonitis Effective culture techniques: Minimum sample volume of ml. Large samples reduce false negative results. Dialysate must be mixed well by inverting bag several times before sampling. Sample port is disinfected before sampling. Sample is obtained using aseptic technique.

Peritonitis Certification Review Course: Peritoneal Dialysis Defined as the presence of WBC in the effluent numbering 100 or greater. Effluent appears cloudy and milky. Patient may have fever, chills, abdominal pain, nausea, vomiting, and diarrhea. Some present initially with cloudy fluid as the first sign and no symptoms. Patient must be taught to contact their PD nurse or nephrologist immediately for cloudy effluent.

Peritonitis Presentation
Certification Review Course: Peritoneal Dialysis Peritonitis Presentation Signs and Symptoms: Fever, abdominal pain, nausea and vomiting, diarrhea, and cloudy effluent. Incubation: hours; if within 6 hours suspect an enteric source. Kinetic effects: Increased solute removal and protein loss; increased glucose absorption leading to a decreased osmotic gradient and decreased ultrafiltration. The typical presentation of peritonitis is abdominal discomfort or pain, cloudy dialysate effluent because of an increase in white blood cells, and fibrin, fever, nausea and vomiting, chills, and diarrhea. The incubation period for a touch contamination is 24 to 48 hours. Some incubation periods are as short as 6 to 12 hours. Symptoms decrease dramatically after initiation of appropriate antibiotic therapy and usually resolve within 1 to 2 days. Changes in dialysis kinetics that occur with a peritonitis infection are increased solute removal and protein loss, increased glucose absorption leading to a decreased osmotic gradient, and decreased ultrafiltration. Patients may need to use higher dextrose percentage solutions to maintain fluid balance.

Prevention of Peritonitis
Certification Review Course: Peritoneal Dialysis Careful individualized patient training Adequate daily hygiene Meticulous hand washing On-going retraining

Peritonitis Certification Review Course: Peritoneal Dialysis Treatment protocols Patient may be treated in PD Unit or Emergency Room depending on the severity of symptoms and availability of resources. Effluent is sent for cell count, C&S, and gram stain. Fungal cultures should be included if patient is immunosuppressed or has had frequent infections requiring antibiotics. PD Unit should have specific antibiotic protocols for gram-positive and gram-negative coverage.

Peritonitis Certification Review Course: Peritoneal Dialysis Organisms Gram-Positive: Staphylococcus epidermidis Staphylococcus aureus Streptococcus species Enterococcus Gram-Negative: Pseudomonas Klebsiella Escherichia coli Enterobacter Fungal Organisms

PD Affects Drug Transport By:
Certification Review Course: Peritoneal Dialysis PD Affects Drug Transport By: Systemic drug removal via effluent Drugs can be administered IP Dose related to urine output and mechanism for elimination of drug

Membrane changes Certification Review Course: Peritoneal Dialysis Sclerosing, Encapsulating Peritonitis A thick fibrous layer of tissue encapsulates the bowel Membrane becomes thick and opaque Onset gradual or rapid Presentation Decreased ultrafiltration and solute clearances Recurrent abdominal pain Intermittent nausea and vomiting Partial and/or complete bowel obstruction Intervention – Emergency laparotomy

Clinical Management Issues for the PD Patient
Certification Review Course: Peritoneal Dialysis Clinical Management Issues for the PD Patient Catheter insertion and healing of exit site Prevention of infection Blood pressure control and fluid management Nutrition evaluation and interventions Systems assessment Medication evaluation Anemia/Ca/Phos./PTH management PET and initial Kt/V Coping with stress of chronic illness Transplantation

Current Issues in Peritoneal Dialysis
Certification Review Course: Peritoneal Dialysis Revision of K/DOQI Co-morbidities Role of sodium Volume Control Blood pressure control Utilization of Icodextrin Role of inflammation Integrated dialysis care Improving fellow education CKD education for patients and families ADEMEX study-adequacy European APD Outcome Study (2003) Underutilization of Peritoneal Dialysis

Questions ?

References Ash [Author: Need full reference] Flanigan, M. & Gokal,R. (2005). Peritoneal catheters and exit site practices toward optimum peritoneal access: A review of current developments. Peritoneal Dialysis International, 25, Kelley, K. (2004) How peritoneal dialysis works. Nephrology Nursing Journal, 31(5), Palmer & Quinton {Author: Need full reference] Rosenak [Author: Need full reference] Scribner & Boen [Author: Need full reference]

Additional Readings Abu-Alfa, A. (2003) The Ademex Study: Expanding the Boundaries of peritoneal dialysis adequacy beyond small solute clearances. Dialysis and Transplantation, 32(3), American Nephrology Nurses’ Association (ANNA). (YEAR?). Chronic kidney disease – What every nurse should know. Partnering for quality care. Retrieved May 31, 2007, from American Nephrology Nurses’ Association (ANNA). (2006). Peritoneal dialysis. (2006) In Molzahn, A.E., & Butera, E. (Eds.). contemporary nephrology nursing: Principles and practice (2nd ed.) (pp ). Pitman, NJ: Author. American Nephrology Nurses’ Association (ANNA) Peritoneal Dialysis Special Interest Group. (2003). Peritoneal dialysis nurse resource guide. Nephrology Nursing Journal, 30(5), 535. American Nephrology Nurses’ Association (ANNA) Peritoneal Dialysis Special Interest Group. (2004). A monograph on peritoneal dialysis. Nephrology Nursing Journal, 31(5). American Nephrology Nursing Association (ANNA) Peritoneal Dialysis Special Interest Group. (2005) The Peritoneal equilibration test. Nephrology Nursing Journal, 32(4), Bargman, J. (1995). Preventing hernias and leaks in long-term patients on peritoneal dialysis. Seminars in Dialysis., 8(6),

Additional Readings Babcock, D.E., & Miller, M.A. (1994). Client education: Theory and practice. St. Louis, MO: Mosby. Bargman, J. (2000). Non-infectious complications of peritoneal dialysis. In R.Gokal, R.Khanna, R.Krediet, & K. Nolph (Eds.), Textbook of peritonealdialysis (2nd ed.) (pp ). London: Kluwer Academic Publishers. Bernardini, J. (2004). Peritoneal dialysis: Myths, barriers, and achieving optimum outcomes. Nephrology Nursing Journal, 31(5), Bernardini, J., Bender, F., Florio,T., Sloand, J., Palmmontalbano, L., Fried, L., et al. (2005). Randomized, double-blind trial of antibiotic exit site cream for prevention of exit site infection in peritoneal dialysis patients. Journal of American Society of Nephrologists. 16(2), Burkart, J. (2003). The Ademex Study and its implications for peritoneal dialysis adequacy. Seminars in Dialysis, 16(1), 1-4. Burrows-Hudson, S. (2005) Chronic kidney disease: An overview. American Journal of Nursing, 105(2), Crawford-Bonadio, T., & Diaz-Buxo, J. (2004) Comparison of peritoneal dialysis solutions. Nephrology Nursing Journal, 31(5),

Additional Readings Dana, C. (2004). What is missing in making PD a success? Nephrology News and Issues, 18(9), Davies, S.J., Woodrow, G., Donovan, K., Plum, J., Williams, P., Johansson, A.C., et al (2003) Icodextrin improves the fluid status of peritoneal dialysis patients: Results of a double-blind randomized controlled trial. Journal of American Society of Nephrology, 14(9), DeHaan, B. (2003) Why peritoneal dialysis should be the first treatment option. Dialysis & Transplantation, 32(3), Diffusion. www2.merriam-webster.com/mwmednl. Accessed 8/23/2007 Gokal, R., Khanna, R., Krediet, R., & Nolph, K. (2000) Textbook of peritoneal dialysis (2nd ed.). London: Kluwer Academic Publishers. Gokal, R. (2002). What is the evidence that PD is underutilized as an ESRD therapy. Seminars in Dialysis, 15(3), Heaf, J. (2004). Underutilization of peritoneal dialysis. Journal of the American Medical Society, 291(6), Knowles, M.S. (1990). The adult leaner. A neglected species (4th ed.). Houston: Gulf Publishing.

Additional Readings Luongo, M., & Kennedy, S. (2004) Interviewing prospective patients for peritoneal dialysis: A five-step approach Nephrology Nursing Journal, 31(5), Maaz, D. (2004). Troubleshooting non-infectious peritoneal dialysis issues. Nephrology Nursing Journal, 31(5), Miller, D., MacDonald, D., Kolnack, K., & Simek, T. (2004). Challenges for nephrology nurses in the management of children with chronic kidney disease. Nephrology Nursing Journal, 31(3), Mujais, S., Nolph, K., Gokal, R., Blake, P, Burkart, J., Coles, G., et al. (2000). Evaluation and management of ultrafiltration problems in peritoneal dialysis. Peritoneal Dialysis International, 20(Suppl 4), S5-S21. Oreopoulos, D.G., Lobbedez, T., & Gupta, S. (2004) Peritoneal dialysis: Where is it now and where is it going? International Journal of Artificial Organs, 27(2), Paniagua, R., Amato, D., Vonesh, E., Correa-Rotter, R., Ramos, A., Moran, J., et al. (2002). Effects of increased peritoneal clearances on mortality rates in peritoneal dialysis: ADEMEX, a prospective, randomized controlled trial. Journal of American Society of Nephrology, 13(5), Piraino, B. (2005) Peritoneal Dialysis-Related inrections recommendations:2005 Update. Peritoneal Dialysis International. Vol 25(2) Prasad, N., & Gupta,A. (2005) Fungal peritonitis in peritoneal dialysis patients. Peritoneal Dialysis International, 25(3),

Additional Readings Pritchard, S. (2005). Will peritoneal dialysis be left behind? Seminars in Dialysis, 18(3), Prowant, B. (2001) Peritoneal dialysis. In L.E. Lancaster (Ed.), ANNA core curriculum for nurses (4th ed.) (pp ) Pitman, NJ: American Nephrology Nurses’ Association (ANNA). Prowant, B., & Twardowski, Z. (1996) Recommendations for exit care. Peritoneal Dialysis International, 16(Suppl. 3), S94-S99. Ramon, G. (1998). Hydrothorax in peritoneal dialysis. Peritoneal Dialysis International, 18(1), 5-10. Robinson, K. (2001). Does pre-ESRD education make a difference? The patient’s perspective. Dialysis & Transplantation, 30(9), Rubin, H.R., Fink, N.E., Plantinga, L.C., Sadler, J.H., Kliger, A.S., & Powe, N.R. (2004) Patient ratings of dialysis care with peritoneal dialysis vs.hemodialysis. Journal of the American Medical Society, 291(6), Salzer, W. (2005). Antimicrobial-resistant gram positive bacteria in PD peritonitis and the newer antibiotics used to treat them. Peritoneal Dialysis International, 25(4), Schatell, D., Ellstrom-Calder, A., Alt, P.S., & Garland, J.S. (2003). Survey of CKD patients reveals significant gaps in knowledge about kidney disease. Nephrology News & Issues, 17(6), Sturdivant, R., & McArthur, J. (2004). Eosinophilic peritonitis associated with atopy. Dialysis & Transplantation, 33(2), Twardowski, Z.J., & Nichols, W.K. (2001). Peritoneal dialysis access and exit-site care including surgical aspects. Textbook of peritoneal dialysis (2nd ed.). London: Kluwer Academic Publishers. Twardowski, Z. (1987). Peritoneal equilibration test. Peritoneal Dialysis Bulletin, 7,

Additional Readings Van Dijk, C., Ledesma, S., & Teitelbaum, I. (2005). Patient characteristics associated with defects of the peritoneal cavity boundary. Peritoneal Dialysis International, 25(40), Von Biesen, W. (2002). Peritoneal dialysis in anuric patients: Concerns and cautions. Seminars in Dialysis, 15(5), Von Biesen, W. et al. (2004). Improving salt balance in peritoneal dialysis patients. Peritoneal Dialysis International, 25(Suppl 3), S73-S75. Wingard, R. (2005). Patient education and the nursing process: Meeting the patient’s needs. Nephrology Nursing Journal, 31(3), Wolfson, M. (2002). A randomized controlled trial to evaluate the efficacy and safety of icodextrin in peritoneal dialysis. American Journal of Kidney Diseases, 40(5), Zorzanello, M. Fleming,W., & Prowant, B. (2004). Use of tissue plasminogen activator in peritoneal dialysis catheters:a literature review and one center’s experience. Nephrology Nursing Journal, 31(5),

Certification Review Course: Peritoneal Dialysis

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