1. Treatment options for CKD patients: Hemodialysis and Peritoneal Dialysis

2. Introduction
The number of patients with end-stage renal disease (ESRD) are increaseing steadily
2030: 2.24 million patients with ESRD

3. Hemodialysis
In hemodialysis, a dialysis machine which contains a special filter, a dialyzer, will become the substitute of your kidney
An access is needed to be able to filter blood from the bloodstream into the tubes going to the machine
Treatments should be done at least three times a week
Each dialysis session lasts 3-5 hours

7. The “access” can be through a fistula or a catheter
Catheters are usually used as temporary access only
They can be attached at the side of the neck for jugular catheters, in the upper chest for subclavian catheters and through the inguinal area for femoral catheters

8. Jugular catheter

9. Fistulas are used for more permanent access
Fistulas are used for more permanent access. These are inserted by surgeons by connecting an artery to a nearby vein in the arm.
Fistulas can take a month to a few months to enlarge before it can be ready for access.
The advantages of fistulas are that they are less prone to infections and clogging and they are less visible because they are under the skin.

10. Hemodialysis access
The creation and maintenance of functioning vascular access, along with the associated complications, constitute the most common cause of morbidity, hospitalization, and cost in patients with end-stage renal disease.

11. Vascular Access via Percutaneous Catheters
useful method of gaining immediate access to the circulation.
associated with higher risks.
the use-life of this type of access is shorter than that of AVFs.
Noncuffed catheters
Short term: <3 weeks

12. Vascular Access via Percutaneous Catheters: cuffed catheters
Patients who will require long-term access should have a tunneled catheter placed.
allow so-called no-needle dialysis with high flow rates
eliminate the problem of vascular steal
placed in a subcutaneous tunnel under fluoroscopic guidance

13. Vascular Access via Percutaneous Catheters: cuffed catheters
The Dacron cuff allows tissue ingrowth that helps reduce the risk of infection when compared with noncuffed catheters.

14. Hemodialysis access: complications
Complications can be divided into those that occur secondary to catheter placement and those that occur later.
The early complications of subclavian or internal jugular placement include pneumothorax, arterial injury, thoracic duct injury, air embolus, inability to pass the catheter, bleeding, nerve injury, and great vessel injury.

15. Hemodialysis access: complications
A chest radiograph must be taken after catheter placement to rule out pneumothorax and injury to the great vessels and to check for position of the catheter.
The incidence of pneumothorax is 1% to 4%,the incidence of injury to the great vessels is less than 1%.
Thrombotic complications occur in 4% to 10% of patients
Infection may occur soon after placement (3 to 5 days) or late in the life of the catheter and may be at the exit site or the cause of catheter-related sepsis.
Rate of infection between 0.5 and 3.9 episodes per 1000 catheter-days.
Catheter thrombosis increases the incidence of catheter sepsis.

16. Vascular Access via Arteriovenous Fistulas
The ideal vascular access
permits a flow rate that is adequate for the dialysis prescription (³ 300 ml/min),
can be used for extended periods,
and has a low complication rate.
The native AVF remains the gold standard

17. Arteriovenous fistulas
The standard by which all other fistulas are measured, is the Brescia-Cimino fistula. (2 year patency: 55% to 89%)
radial branch-cephalic direct access (snuffbox fistula),
autogenous ulnar-cephalic forearm transposition,
autogenous brachial-cephalic upper arm direct
access (antecubital vein to the brachial artery),
autogenous brachial-basilic upper arm transposition (basilic vein transposition).
These options should be exhausted before nonautogenous material is used for dialysis access.

18. Noninvasive Criteria for Selection of Upper-Extremity Arteries and Veins for Dialysis Access Procedures
Venous examination    Venous luminal diameter ³ 2.5 mm for autogenous AVFs, ³ 4.0 mm for       bridge AV grafts    Absence of segmental stenoses or occluded segments    Continuity with the deep venous system in the upper arm    Absence of ipsilateral central vein stenosis or occlusion Arterial examination    Arterial luminal diameter ³ 2.0 mm    Absence of pressure differential ³ 20 mm Hg between arms    Patent palmar arch

19. radiocephalic fistula (anatomic snuff-box)
radiocephalic fistula (Brescia-Cimino)

20. Vascular access via AVFs:
brachiocephalic fistula
brachiobasilic fistula

21. Arteriovenous fistulas: Complications
Failure to mature
Stenosis at the proximal venous limb (48%).
Thrombosis (9%)
Aneurysms (7%)
Heart failure
The arterial steal syndrome and its ensuing ischemia occur in about 1.6%: pain, weakness, paresthesia, muscle atrophy, and, if left untreated, gangrene
Venous hypertension distal to the fistula : distal tissue swelling, hyperpigmentation, skin induration, and eventual skin ulceration.

22. Prosthetic Grafts for vascular access
Upper arm grafts have a high flow rate and a low incidence of thrombosis.
higher incidence of ischemia in the hand
higher rate of stenosis, sec to endothelial hyperplasia.

23. Options for treating steal
DRIL procedure
distal revascularization-interval ligation
excision of a portion of the vein
plication w/ mattress or continuous sutures
crossed PTFE band
interposition of a 4 mm PTFE

24. Treatment of venous access complications.
Venous angioplasty
Graft thrombolysis

25. Contraindications to Thrombolytic Therapy
Absolute  
  Recent major bleeding   Recent stroke   Recent major surgery or trauma   Irreversible ischemia of end organ   Intracranial pathology   Recent ophthalmologic procedure
Relative   
History of gastrointestinal bleeding or active peptic ulcer disease   Underlying coagulation abnormalities   Uncontrolled hypertension   Pregnancy   Hemorrhagic retinopathy

26. Hemodialysis access
Quality of life and overall outcome could be improved significantly for hemodialysis patients if two primary goals were achieved:
Increased placement of native AVFs: a minimum of 50% of new dialysis patients should have primary AVFs.
Detection of dysfunctional access before thrombosis of the access route occurs.
National Kidney Foundation Dialysis Outcome and Quality Initiative (NKF-DOQI)

27. Hemodialysis Advantages Disadvantages hemodynamic instability
maximum solute clearance
best tx for severe hyper-K+
ready availability
limited anti-coagulation time
bedside vascular access
hemodynamic instability
hypoxemia
rapid fluid + solute shifts
complex equipment
specialized personnel
difficult in small infants

28. PERITONEAL DIALYSIS

29. Objectives Describe the basic principles of peritoneal dialysis (PD)
Define steps required to complete a CAPD exchange using Baxter’s Ultrabag system
Describe methods for preventing infection when performing PD procedures
Describe the process for identifying & treating peritonitis
Describe steps required to complete daily PD catheter exit site care

30. Peritoneal Dialysis
Is performed as an intracorporeal (inside the body) therapy making use of the peritoneal membrane.
Is the process of cleaning the blood by using the lining of the peritoneal cavity (peritoneum) as a filter – the peritoneum acts as a dialyzing membrane, permitting wastes from the body to cross it and empty into the instilled dialysate fluid
Is a type of dialysis usually done by the patient at home

31. Peritoneal Dialysis
In peritoneal dialysis, there is no machine. Instead of an artificial filter, the lining of the abdomen, the peritoneum is used as a natural filter. The peritoneum has a lot of small vessels in it.
Excess waste and water from the blood can travel from the peritoneum into a dialysate solution that can be infused into the belly.
The access for infusing the dialysate solution is a peritoneal catheter.

33. Types of Peritoneal Dialysis
CAPD – Continuous Ambulatory Peritoneal Dialysis
Manual exchanges (approx. 30 Min. each) done approx. 4 times daily (1st thing in am, around lunchtime, around suppertime, and before bed).
Utilizing Baxter’s ultrabag system.
Aseptic technique mandatory in making all connections.
CCPD (Continuous cycling peritoneal dialysis, also k/a APD – Automated Peritoneal Dialysis)
Utilizes a machine to perform exchanges at night while the patient sleeps (8-10 Hrs on the machine).
Provides greater daytime freedom.
May or may not require 1 or 2 daytime exchanges also.
Aseptic technique mandatory in making all connections.

34. Phases of Peritoneal Dialysis
Fill
Takes approx. 10 minutes.
Usual volume is 2000 – 2500 ml’s.
Dwell
CAPD – usually 4-6 Hrs during the day, and 8-10 Hrs during the night.
APD – usually shorter dwells while sleeping and longer dwells during the day.
Drain
Takes approx. 20 minutes.
Usual volume may be slightly less, the same as, or more than infused amt.
Effluent (drained fluid) is normally clear (colorless or yellow).

35. Clearance Across the Peritoneal Membrane
Waste products & excess fluid move from the blood into the dialysate by diffusion & osmosis
Fluid removal can be increased by increasing the amount of dextrose in the dialysate
Some medications will move across the membrane also
Blood
Dialysate
Semipermeable Membrane

36. Access to The Peritoneum
Considered the patients’ lifeline.
Sterile technique required when connecting (or disconnecting) transfer set to catheter
Transfer set is clamped prior to opening to protect the PD catheter (strict aseptic technique is required when minicap is removed)
Twist Clamp
Transfer Set
Titanium Adaptor
Exit Site
Peritoneal Catheter
Minicap
All procedures requiring opening of the closed
system will be done by trained staff only

37. CAPD Exchange Baxter’s Ultrabag System
Aseptic technique mandatory in making all connections!
Check dialysis orders for % of dextrose, & fill volume.
Drained volume must be measured & documented (a spring scale may be used).
Dialysate should be warmed to body temperature using dry heat.
Baxter’s Ultrabag System
Full & Empty Bags Connected
by Tubing

38. Warming Dialysis Solution
The PD solution will be heated to approximately body temperature using a dry-heat heating pad, which is used only for this purpose, set on low
Any heating pad in use must have an inspection sticker attached before it is put into service

39. Intraperitoneal (IP) Medication
If IP medications are prescribed, there is a strict sterile procedure to be followed. (At CVPH the pharmacists mix any IP meds)
Some medications (i.e. Vancomycin, Tobramycin etc.) must be infused slowly (regulate by adjusting twist clamp on transfer set and/or lowering the IV pole).

40. Preparing for an Exchange
Clean the work area.
Gather supplies (Check expiration dates)
Provide privacy, close doors / curtains, utilize “Do Not Enter” signs. (It is preferred that PD patients have private rooms. If they must share a room, the roommate must be free of infectious organisms).
Fans / blowers must be turned off.
Limit visitors (Anyone in room during an exchange must wear a mask).

41. Completing a Safe Exchange
Follow the steps provided in the “Baxter Ultrabag Aseptic Exchange Procedure” step-by-step guide shown here and found in the Peritoneal Dialysis binder on R7.
Proper hand washing using liquid antimicrobial soap is important prior to connecting and / or disconnecting the ultrabag.

42. Documentation Documentation : All exchanges Exit Site care
Daily weights CVPH utilizes a 24 Hour Peritoneal Dialysis Record to document.

43. PD Patients Are Knowledgeable
Keep in mind that PD patients (or a caregiver), have been through extensive training and carry out their dialysis at home daily.
They are protective of their “lifelines”, and will want to ensure that proper technique is used.
If you get them the supplies they need, encourage them to carry out the exchange themselves if they are able.

44. Fluid Balance
Fluid & electrolyte balance must be maintained to prevent dehydration and/or fluid overload. Assess the patient for fluid volume status and obtain orders from the MD to adjust dextrose in dialysate if needed. Monitor:
Daily weights.
Lung sounds.
Presence of edema.
Total I & O (including + and – PD fluid balances).
Blood pressure.
Other S&S of dehydration or fluid overload.

45. Catheter Care
Exit site care will be done daily by the patient if able, or by trained staff.
Scrub hands well.
Examine exit site for S&S of infection, irritation, or leakage – if any, notify the nephrologist.
Check the catheter & connections – They should be free from cracks, tears or leaks.
Feel the catheter tunnel, report any swelling or pain.

46. Daily Exit Site Care
Clean the skin around the catheter with a sterile gauze pad & antibacterial soap (Start close to the catheter & move out).
Rinse well to remove all the soap.
Dry the exit site area with a sterile gauze pad.
Tape the tubing to the abdomen in a natural position to anchor/ immobilize it, & protect it from trauma.
If patient uses mupirocin ointment, obtain an order from MD, & apply to exit site. If they use povidone-iodine prep pads, paint a 1” circle around the exit site & allow to air dry.

47. Exit Site Care
Apply a sterile gauze dressing ( if Pt. doesn’t normally wear a dressing, they must wear one while in the hospital).
Loop the catheter around & tape again to secure it better.
Repeat exit site care if exit becomes wet or soiled.
Document any findings & that site care was done.

48. Peritonitis in the PD Patient
CVPH has a protocol for peritonitis in the PD patient which can be found in policy manager.
Patients with peritonitis usually present with cloudy fluid and abdominal pain.
Send the first cloudy drain bag to the lab for stat cell count w/ diff, gram stain & culture.
Prompt initiation of antibiotic therapy for peritonitis is critical to prevent complications & limit damage to the peritoneal membrane. (If the patient has cloudy effluent & Abd pain, antibiotic therapy should be initiated without waiting for confirmation of the cell count).
The nephrologist on-call must be notified.

49. Abdominal Pain in Peritonitis
Ranges from mild or even no pain to severe pain.
The degree of pain is somewhat organism specific.
If the patient is experiencing severe abdominal pain, rapid exchanges may be done up to two times to decrease pain (This delays initiation of antibiotics, & should only be used in cases of extreme pain).
In most cases, symptoms decrease rapidly after initiation of antibiotic therapy.
Pain medications may be ordered PRN.

50. Peritonitis Continued
Heparin 2000 units per bag is added (by the pharmacist) to dialysate when effluent is cloudy.
Vancomycin should be infused over 45 minutes to prevent adverse reactions.
Antibiotics must dwell in peritoneum for at least 4 Hrs. (6-8 Hrs. preferred).
Assess patient for possible source of infection (i.e. Catheter exit site, break in technique, recent contamination, constipation or diarrhea, cracks or leak in the catheter or transfer set).

51. Documentation Record assessment data in nurses’ notes.
Record medications given.
Notify Peritoneal Dialysis unit staff of peritonitis episode (so follow-up care can be arranged).

52. Emergencies
Clamp tubing above disconnected area (nearer to the patient), immediately if system becomes disconnected, or if a leak is noted.
Notify Nephrologist (prophylactic antibiotic orders may be needed).
Stop any further instillation of fluid to the patient until a complete tubing change is made, and orders are received from the Nephrologist.

58. Miscellaneous
Assess for alterations in blood glucose levels in diabetics from the use of dextrose-based dialysate.
Check visually for changes in the appearance of the effluent with each exchange.
If fibrin is present, an order can be obtained for the pharmacy to add heparin to the bags.
If effluent is cloudy, Notify Nephrologist & initiate peritonitis protocol.
Document clarity of each exchange on PD flow sheet.
Reinforce exit site dressing for newly inserted PD catheters. Do not remove original dressing unless trained to do so.
Be alert to tubing getting kinked or caught under patient, which will prevent infusion or draining of dialysate.

59. Bibliography
B. Piraino, et al., ISPD Guidelines/Recommendations, Peritoneal Dialysis – Related Infections, Recommendations: Update.
Baxter Healthcare Corp. “Introduction to Peritoneal Dialysis for Hospital Nursing Staff” / 2004.
CVPH Policy Manager:
Peritonitis Protocol in the Peritoneal Dialysis (PD) Patient.
Protocol for PD Patient, Care of the Patient Receiving.
Policy for CAPD exchanges.
Procedure for PD Using the Manifold System.
Catheter and Exit Site Care, Baxter Healthcare Corp

60. Thank You!