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• Anatomy• Physiology

The peritoneal membraneThe peritoneal membrane

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Peritoneal Dialysis Training

Oshakati hospital 2014

MD. JOSE L. RODRIGUEZNEPHROLOGIST

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IntroductionIntroduction

• DEAR STUDENTS THIS TRAINING ALLOWED YOU TO PROVIDE BETTER CARE TO THE CHRONIC RENAL FAILURE PATIENTS .

• WE ARE SURE THAT THE OBJECTIVES OF THIS TRAINING WILL BE ACHIEVED.

PROFESSORS……

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Chronic Kidney FailureChronic Kidney Failure

• Chronic kidney failure, also called chronic kidney disease, describes the gradual loss of kidney function. Your kidneys filter wastes and excess fluids from your blood, which are then excreted in your urine. When chronic kidney failure reaches an advanced stage, dangerous levels of fluid, electrolytes and wastes can accumulate in your body.

7.2.1 The peritoneal membrane / P. Martin 3

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The peritoneal anatomThe peritoneal anatomyy

A sagittal section trough the peritoneal cavity General facts

• Living membrane• Reusable• Provides lubrication for internal organs• Normally contains 10 - 100 cc's fluid• Semipermeable• Bi-directional

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Sagittal view of the peritonealSagittal view of the peritonealcavity during peritoneal dialysiscavity during peritoneal dialysis

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Mesothelium is not just a covering layer, it consists of active metabolic cells.Some of the secretory activities are provoked by the dialysis procedure.

The covering layer of peritonealThe covering layer of peritonealcells is called mesotheliumcells is called mesothelium

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Transport across the peritoneumTransport across the peritoneum

• OsmosisOsmosis

• DiffusionDiffusion

• ConvectionConvection

Peritoneal physiologyPeritoneal physiology

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Diffusion

Peritoneal physiologyPeritoneal physiology

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RANDOM movement of solutes across the peritoneal membrane from an area of high concentration to an area of low concentration (without assistance by any flow of fluid)

DiffusionDiffusion

HIGH low

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Factors affecting diffusion

• solute size• concentration gradient• electrical charge• blood flow rates

Peritoneal physiologyPeritoneal physiology

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Movement of water across the

peritoneal membrane from

an area of low concentration to

an area of high concentration.

OsmosisOsmosis

low HIGH

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Osmotic Ultrafiltration

Peritoneal physiologyPeritoneal physiology

Glucose generates a high osmotic pressure which induces ultrafiltration from the capilaries (blood) to the peritoneal cavity

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Factors affecting osmosis

• dextrose concentration

• dwell time

• membrane permeability

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• the dwell time • the peritoneum characteristics

rapid transperitoneal absorption with decline of the osmoticgradient in time:

Dextrose 1.5%: maximum UF rate of 9.27 mL/minDextrose 4.25%: maximum UF rate of 21.0 mL/min

Dextrose 1.5% removes 100-300 cc of extra waterDextrose 2.3% removes 300-500 cc of extra waterDextrose 4.25% removes 600-800 cc of extra water

Fluid removal is dependent on:Fluid removal is dependent on:

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Convection

Solutes move across the peritoneal membrane in an'orderly flow' from one area to another by being carried by a flowing fluid.

Peritoneal physiologyPeritoneal physiology

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• Diffusion• Convection• Ultrafiltration (osmotic pressure gradient)

solute removalfluid removal

The composition of PD solution is the key factorthat governs diffusion, convection as well as the removal of fluid excess from the body

· Electrolytes correction· Body fluid balance· Acid-base control· Blood purification

Peritoneal dialysisPeritoneal dialysis

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Causes of Chronic Renal Failure:Causes of Chronic Renal Failure:

• HIVAN (Namibia)

• Diabetes

• Hypertension

• Renal vascular disease (also vascular disease)

• Nephritis

• Pyelonephritis & chronic UT I

• Polycystic kidney disease

• Renal Neoplasms

• Analgesic nephropathy

• Immunological disorders: Lupus, Goodpasture syndrome, scleroderma

• Metabolic disorders: gout

• Nephrotic Syndrome primary or secondary7.2.1 The peritoneal membrane / P. Martin 17

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Peritoneal Dialysis CatheterPeritoneal Dialysis Catheter• Two double-cuff Tenckhoff peritoneal

catheters: standard (A), curled (B).

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DialysisDialysis

Dialysis is the diffusion of solute molecules through a semipermiable membrane, passing from higher concentration to that of lower concentration. It is the process of separating colloids and crystalline substances in solution by the difference in their rate of diffusion through a semi permeable membrane.

The purpose of dialysis is to remove endogenous and exogenous toxins and to maintain fluid electrolyte and acid- base balance till the renal function recovers. It is a substitute for some excretory functions of kidneys but does not replace the endocrine and metabolic functions.

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INDICATIONSINDICATIONS

• Uremic symptoms with neurologic abnormalities

• Persistent hyperkalemia, above 6.5 mEq/L

• Blood urea level more than 50 mmol/l

• Serum Creatinine more than 900 µmol/l

• Severe acidosis, pH less than 7.2,

• TCO2 less than 10-12 mEq/L

• Hyperphosphatemia

• Pulmonary edema and CCF

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Peritoneal dialysisPeritoneal dialysis

Peritoneal dialysis is a technique that employs the patient’s peritoneal membrane as a dialyzer. Excess body water is removed by an osmotic gradient created by the high dextrose concentration in the dialysate; wastes are removed by diffusion from the peritoneal capillaries into the dialysate.

Because peritoneal dialysis is not as efficient as hemodialysis, it must be performed daily rather than 3 times weekly as in hemodialysis.

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3 steps in peritoneal dialysis3 steps in peritoneal dialysis

Infusion :

A sterile, dialysis solution flows into your peritoneal cavity by gravity via a catheter or tube that has been surgically placed into the abdomen. The filling takes about 10 minutes. Once the filling is complete, the catheter is shut so that it does not leak. 

Dwell :

The lining of the peritoneal cavity called the peritoneum acts as a natural filter. It lets the waste products and excess fluids in the blood filter through into the dialysis solution, while holding back important substances that the body needs. The length of time varies from 3 - 6 hours. While the solution is in the body you can move about. 

Drain :

The dialysis solution containing the wastes is drained again by gravity from your body through the catheter into an empty bag. This takes about 10-20 minutes. A bag containing sterile dialysis solution replaces the bag containing waste products. The whole process is then repeated. Each of these replacements is called a ' Bag Exchange'.

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INTERMITTEN PERITOENEAL DIALYSISINTERMITTEN PERITOENEAL DIALYSISIPD IPD (USUALLY DONE IN HOSPITAL)(USUALLY DONE IN HOSPITAL)

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1.Continuous ambulatory 1.Continuous ambulatory peritoneal dialysisperitoneal dialysis

It is the most commonly used method of peritoneal dialysis. The filtration process occurs most hours of the day. The exchange usually take about 3 minutes 3-4 times a day and only require a solution bag with tubing attached to it that connects to the child’s blood stream. It gives freedom.

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2.Automated Peritoneal Dialysis 2.Automated Peritoneal Dialysis

a)Continuous Cyclic Peritoneal Dialysis

Continuous regimen means that the dialysis solution is present in the peritoneal cavity continuously, with the exception of short significant periods between exchange.

It uses duel lumen catheterization, i.e., 2 catheters, one for inflow and other for outflow.

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Intermittent Peritoneal DialysisIntermittent Peritoneal Dialysis

-USUALLY DONE IN HOSPITAL

It means the dialysis sessions are performed several times a week.

This technique uses one catheter for inflow and outflow.

Flow is interrupted after both inflow and outflow during exchange.

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PROCEDUREPROCEDURE

• The abdomen is cleaned in preparation for surgery, and a catheter is surgically inserted with one end in the abdomen and the other protruding from the skin. Before each infusion the catheter must be cleaned, and flow into and out of the abdomen tested.

• The warmed solution is allowed to enter the peritoneal cavity by gravity and remains a variable length of time (usually 10-15 minutes) according to the rate of solute removal and glucose absorption in individual patients. The total volume is referred to as dwell while the fluid itself is referred to as dialysate.

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The dwell can be as much as 2.5 litres, and medication can also be added to the fluid immediately before infusion. The dwell remains in the abdomen and waste products diffuse across the peritoneum from the underlying blood vessels. After a variable period of time depending on the treatment (usually 4–6 hours), the fluid is removed and replaced with fresh fluid. 

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