peritoneal dialysisiranspn.com/file haye amozeshi/capd-for-nurse/azarfar.pdf · appropriate,...

PERITONEAL DIALYSIS

DR Anoush Azarfar

Background:2

• Overall there are no significant differences between the

two types of dialysis for critical outcomes which are:

- health-related quality of life

- patient involvement and satisfaction

- mortality

- preservation of renal function

- technique failure or switch

- resources use and costs including hospitalisation

• Peritoneal dialysis may preserve residual renal

function more effectively than haemodialysis.

Choosing dialysis

• Offer all patients a choice of PD or HD, but consider

peritoneal dialysis as the first choice of treatment

modality for:

- children 2 years old or younger

- people with residual renal function

- adults without significant associated comorbidities

• Before starting PD, offer all patients a choice, if

appropriate, between CAPD and APD (or aAPD if

necessary)

.

According to the USRDS Morbidity and Mortality

study (Wave 2), 1997 Annual Data Report;

75% of Hemodialysis patients

do not recall ever having had PD

discussed with them at the time

of initiating dialysis.

Incidence of Peritoneal Dialysis

USA: 7%

Canada: 27%

Australia: 28%

New Zealand: 56%

Hong Kong: 80%

Mexico: 90%

Some absolute and relative indications to PD

Absolute indications:

Poor cardiac function

Peripheral vascular disease

Relative indications:

Free life style

Want to take care themselves

PERITONEAL DIALYSIS

Appropriate candidates

Motivated ESRD patient

Patient support – family, carer, etc

Ability to understand and use sterile technique

Physical capability

Ideal candidate would have no prior abdominal

procedures

Insertion Complications

EARLY

-Leak

-Obstruction to flow

-Bleeding

-Infection

-Intestinal perforation

-Inability to insert catheter

LATE

-Obstruction to flow

-Hernia

-Hydrothorax

-Peritonitis

-Exit-site erosion / infection

-Other surgical problems

Communication is Essential

Surgeon

NurseNephrologist

Catheter Insertion

PRE-IMPLANTATION PREPARATION

Fully inform patient of details of procedure

Pre-surgical assessment (e.g. hernias)

Determination of exit-site

Skin preparation

Bowel preparation

Prophylactic antibiotics

- Evidence suggests that peri-op antibiotics

diminishes wound infection

SIDE EFFECTS OF

PERITONEAL DIALYSIS

Peritonitis(staph 60%, gram –ve 20%,

fungi<5%)

Exit site infection

Catheter malfunction

Loss of ultrafilteration

Obesity

EXIT SITE INFECTION

Risk Factors

•Trauma e.g. excessive manipulation

of catheter

•Cuff extrusion

•Staph Aurous nasal carrier

•Leak at exit site

•Skin breakdown

Peritonitis

0

0.1

0.2

0.3

0.4

0.5

عفىنت كاتتر پريتىنيت خروج كاتتر

S. aureus Related

Rate

per

year

Historical Control

Rifampin, oral N=41

Mupirocin at ES N=41

A Healthy Exit Site

0

0.05

0.1

0.15

0.2

0.25

داخل بيني

mupirocin

داخل بيني

mupirocin

exit site

mupirocin

exit site

mupirocin

شاهد پروفيالكسيS aureus

peritonitis/year

Perez-

Fontan

Mupirocin

Study GroupBernardini Thodis

0

5

10

15

20

25

30

35

40

45

بستري شدن خارج شدن كاتتر انتقال به همىدياليس

استاف كىآگىالز منفي استاف اورئىش گرم منفي ها

Bunke, et al., KI 1997

0

10

20

30

40

50

60

70

80

90

بهبىد خارج شدن كاتتر بستري انتقال به همىدياليس

% o

f P

ati

en

ts

)N=242( ا. كىآگىالز منفي

)N=149( ا.اورئىش

)N=136( گرم منفي

Bunke et al, KI 52:524-529, 1997

<<<<

<<

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

عىنت محل خروج كاتتر پريتىنيت از دست دادن كاتتر

ناقلين بيني غير ناقلS. aureus episodes/year

Data from Lye et al, 1994 Nasal carriage defined as min of 2 of 3 NC positive

22%

13%

7%8%2%

18%

4%

22%

1%

3%

CNS

S. aureus

Pseudo/Xanth

other GPC

enterococcus

other GN

bacteroides

multiple

fungus

no growth

Harwell PDI 1997;17:586-594

Exit-Site

33

Thanks for your time this morning and have a great

day!!!!!