Update in Home Peritoneal Dialysis Care Presented by DeVonne Rice, RN,BSN,CNN

Objectives Describe the peritoneal dialysis options available to the patient who chooses to do peritoneal dialysis Discuss the advantages and challenges of peritoneal dialysis Outline the basics of the PD training program Peritoneal dialysis has a lesser need for equipment and space, a higher level of convienence for patients and helps preserve residual renal function, Zongpei et al, 2010.

Continuous ambulatory peritoneal dialysis (CAPD) All manual Patient performs 4-5 peritoneal infusion dwells/ drains (exchanges) daily It is preferable to present to the patient all peritoneal options in an attempt to empower the patient and give them more control. Outcome studies show that there is no difference in survival between CAPD and APD modalities, Guest, 2010.

No power source is required as no machine is involved Advantages of CAPD No power source is required as no machine is involved Also, as no machine is involved patient can be more mobile and not confined to a chair/bed for long period of time Takes about 30 minutes to do an exchange, so not much time involved per exchange

Requires a private/clean area to perform exchanges if working/school Disadvantages of CAPD Convenience as busy schedules require the time to perform the exchanges Requires a private/clean area to perform exchanges if working/school

Automated Peritoneal Dialysis (APD) Peritoneal dialysis exchanges are performed by a cycler machine while the patient sleeps The prescription for a chronic PD regimen is understanding the patients peritoneal membrane status, the daily required solute removal and how much residual kidney funtion the patient has left, Guest, 2010.

Can free up patient during the day Portable machine, so easy to travel Advantages of APD Can free up patient during the day Portable machine, so easy to travel

Disadvantages of APD Confined to the cycler for the time that the doctor has ordered (maybe up to 8-10 hours)

Challenges of Peritoneal Dialysis Infectious Mechanical Non-infectious

Peritonitis Remains a leading complication of peritoneal dialysis Around 18% of the infection-related mortality in PD patients is the result of peritonitis Remains a major cause of patients discontinuing PD and switching to hemodialysis 32% of PD patients with peritonitis transfer to HD PD community must focus attention on prevention and treatment of PD-related infections 25% of PD hospital admissions related to peritonitis Li, Szeto, et al, 2010

Causes of Peritonitis Contamination At the time of connection Hole in exchange tubing or catheter Loss of cap on end of tubing or failure to close clamp with leaking Product defects Exit Site Improper anchorage of PD catheter Improper hygiene Constipation Bowel-source Diverticulitis Colitis

Causes of peritonitis cont. Procedural Colonoscopy From dental procedures Gynecologic source Piraino, et. al, 2011

Diagnosis of Peritonitis Cloudy peritoneal fluid Abdominal pain Fever Nausea Diarrhea White cell count of >100mm3 Note: Symptoms can vary by organism

Management of Peritonitis Assess the need for hospitalization Management of the pain Limit oral fluids, use stronger glucose percentages due to possible ultra filtration problems Treat with identified antibiotics as ordered by protocol or doctor Keep a close watch on the exit site/tunnel

Peritonitis cont. Close attention must be paid to preventing exit site infections and peritonitis Every home program should work diligently to help prevent infections in their peritoneal patients The PD team, including the nephrologists, nurses, social workers, and dieticians should meet regularly to review all peritoneal related infections

Exit Site Infection Definition: Presence of purulent drainage, with or without erythema of the skin at the peritoneal catheter-skin site

Management of Exit-Site Infections Empiric antibiotic therapy may be initiated immediately Culture with sensitivity testing is important in determining antibiotic therapy Antibiotic therapy must be continued until the exit site appears entirely normal Note: Patient with an exit-site infection that progresses to peritonitis will often require catheter removal Note: S. aureus and P. aeruginosa are responsible for the majority of infections

Exit Site Care to Prevent Infection Anchoring and securing the PD catheter to prevent excessive movement around the exit site area Routine exit-site care by the patient when the exit site is well healed Water and antibacterial soap are recommended by many centers Excellent hand hygiene before any exam of the patient’s exit site Patient should use topical antibiotic either at the catheter exit site, intranasally or both

Mechanical/Non-Infectious Challenges PD catheter malfunction Migration of catheters Blockage due to omental trapping Note: Can often be corrected through laparoscopic means Catheter occlusion Severe Constipation Note: May be corrected with use of laxatives

Membrane / Ultrafiltration failure/Volume status Challenges cont. Membrane / Ultrafiltration failure/Volume status Glucose, the osmotic agent in standard PD solutions, causes changes in the membrane over time with eventually leads to membrane failure Repeated cases of Peritonitis Note: Newer biocompatible solutions without dextrose have shown less membrane damage and might better preserve the peritoneal membrane Chaudhary, 2011

PD Training Program PD Training Nurse Must have good communication skills, be innovative and consistent, and believe in patient self-care Must develop proper training skills based on principles of adult learning Experience in medial/surgical nursing is beneficial, as PD patients often have other co-morbid conditions Bernardini, et al, 2006

Trainer Objectives Provide an effective environment for learning Present an overview of the PD training plan to the patient Demonstrate the steps of the procedures consistently Encourage and support the learner through repetition Prevent the learner from practicing procedures until all steps have been learned in order

Trainer Objectives cont. Provide immediate feedback during learner practice Help the learner problem solve by defining problems and talking about possible solutions Recognize that learners need repetition of new information in order for it to move from short-term memory to long-term memory Bernardini et al, 2006

Assessment You must assess for any special needs of the patient Pediatric patients Diabetic patients Mentally challenged patients Visually impaired

Equipment Patient preference for CAPD/APD If diabetic, must assure correct instrument to measure blood sugar Supply ordering/storage Note: All of our patients are trained on CAPD in case of emergency.

In Closing Disadvantages of peritoneal dialysis include: Risk of infections Patient may get tired of doing their treatment every day Logistical problems, supply delivery and storage space for the supplies

Closing cont. Advantages of peritoneal dialysis include: Portable equipment 2 x monthly clinic visits vs. 3 x weekly in-center hemodialysis treatments Fewer restrictions of diet and fluid Flexible life style NO needles Improves the preservation of residual renal function

We as providers have to be ready. Conclusion The recent bundling of services for dialysis care into one payment offers PD as a cost-effective therapy and has generated a renewed interest the dialysis community. The bundling may lead to improved provider expertise and greater PD utilization. We as providers have to be ready. Techniques to prevent and minimize episodes of peritonitis, use of more biocompatible solutions in preserving the peritoneal membrane, and careful manage of volume status can sustain the patient longer on PD. Chaudhary, 2011