Peritonial Dialysis

Drajad priyono
Modalities of renal replacement therapy

Interchangeable, depends on residual renal Ramesh

function
Khanna & Karl D. Nolph
 Peritoneal dialysis –
introduction
• method of RRT for 100.000 patients worldwide
• complementary to hemodialysis
Principles:
• peritoneum (capillary endothelium, matrix,
mesothelium) = semipermeable dialysis membrane
through which fluid and solute move from blood to
dialysis solution via diffusion and convection
• effective peritoneal surface area = perfused
capillaries closed to peritoneum (↓ in peritonitis)
• ultrafiltration (movement of water) enabled by
osmotic gradient generated by glucose or glucose
polymers (isodextrin)
Principles of peritoneal dialysis
 Scheme of peritoneal solute transport by
diffusion through the pores of capillary wall
Model of transport - 3 sorts of pores

Ramesh Khanna & Karl D. Nolph

 Composition of standard peritoneal
dialysis solution
Na 132 mmol/l
Ca 1,25mmol/l
Mg 0,5 mmol/l
Cl 100 mmol/l
lactate 35 mmol/l ev. lactate/bicarbonate
glukose 1,36-4,25 g/dl
osmolarity 347-486
pH 5,2
GDP (degradation products of glucose)
Ramesh Khanna & Karl D. Nolph
Urea concentration in dialysate, rate of
equalization of solute concentration depends on
molecular size of solute
Concentration of Creatinin in dialysate
equilibrium of concentrations between
dialysate and blood is slower than for urea
 Peritoneal catheter
• implanted via laparoscopy, punction or laparotomy (total
anesthesy)
• PD is started 3 weeks following the impantation of catheter
Types of peritoneal catheters
 Why to start with PD ?

1. better maintenance of residual renal

function
 Why to start with PD ?

• clinical outcomes comparable to HD, no

difference in 2 year and 5 year mortality vs. HD
(study NECOSAD)
• saves vascular access
• preferred for children (APD)
• modality choice is a lifestyle issue
 Indication / Contraindications of PD

80% of patients have no contra-indication to any of the

dialysis methods and may choose according to their
life style between HD a PD
Absolute contra-indications of PD:
1.peritoneal fibrosis and adhesions following
intraabdominal operations
2.inflammatory gut diseases

Ramesh Khanna & Karl D. Nolph

Relative contraindications of PD
• pleuro-peritoneal * diverticulosis
leakage • colostomy
• hernias • obesity
• significant loin pain • blindness
• big polycystic kidneys

• severe deformant arthritis

• psychosis
• significant decrease of lung
functions
CAPD – continual ambulatory
peritoneal dialysis
• manual exchanges
NIPD – night intermitent peritoneal
dialysis (cycler)
CCPD – continual cyclic PD
 Assessement of PD adequacy
PET (peritoneal equilibrium test) 1
• determines quick or slow passage of toxins from
the blood into the dialysis fluid
• ‘high-fast transporters’ v.s. ‘low-slow
transporters’
• helps to decide about the PD scheme (dwell
duration and intervals, CAPD vs. CCPD)
• performed in hospital, takes 5 hours
• involves doing a CAPD exchange using a 2.27%
G, samples of PD fluid and blood are taken at
set times
PET (peritoneal equilibration test) 2
Transporter Waste Water Best type of
removal removal PD
High Fast Poor Frequent
exchanges,
short dwells –
APD
Average OK OK CAPD or
APD
Slow Slow Good CAPD, 5
exchanges
daily + 1
exchange at
night
Interpretation of peritonal
equilibration test ??
Results of baseline PET

Ramesh Khanna & Karl D. Nolph

Choice of PD scheme depends of BSA and
type of transport
 Assessement of peritoneal
function

1. PET- peritoneal equilibration test (type of

transport and ultrafiltration after 4 hours)
2. weekly clearance of creatinine and urea
3. daily UF
4. dicrease of Na in dialysis fluid after 60
minutes using 3,8% G (test of
aquaporines)
Ratio D/P for Na, upper curve – 1,27% glucose,
lower curve - 3,86% G (initial drop due to transcellular
UF of water through aquaporins)
 Ultrafiltration during PD
Depends on:
- type of transporter – low transporters have better UF
- concentration and type of osmotic agent in PD fluid:
1. Fluids with glucosis (1,27%, 2,5% a 3,8% ), higher
concentration – higher osmotic pressure and UF
2. Fluid with icodextrin (Extraneal) = glucose polymer with
a large molecule, resorbs only 10-20%, offers longtime
UF, suitable for long night exchanges, 8-12 hours)
- time between exchanges, using glucose-based fluids,
maximal UF obtained after 2-3 hours, using longer
spaces UF dicreases.
Ultrafiltration in different types of PD
solutions
Criteria of PD adequacy
 Complications of PD 1
Infectious:
• exit-site inflammation (flare, suppurative secretion,
granulation)
• peritonitis (turbid dialysate, abdominal pain, fever)
Non-infectious:
• hernias
• hydrothorax
• sclerosing encapsulating peritonitis (rare, life threatening
complication, mostly after ≥ 6 years on PD, peritoneum is
massively thickened and calcificated, leading to intestinal
obstruction)
 Complications of PD 2

Non-infectious:
• Leakage of dialysate along the peritoneal catheter
• Drainage failure of dialysate (dislocation or catheter
obstruction by fibrin)
• Morphologic changes of peritoneum following long-
lasting PD (peritoneal fibrisis, mesotelial damage,
vasculopathy and neo-angiogenesis) leading to loss of UF
capacity – reason for PD cessation in 24% of all patients,
and in 51% of patients treated above 6 years.
 Causes of UF failure

• Large vascular surface of peritoneum (due to

neo-angiogenesis, vasodilation), leading to
high (fast) type of transport including fast loss
of osmotic glucose pressure
• Decreased function of aquaporins
• High lymfatic absorption
Morphologic changes of peritoneum due
to PD (1)

Obr.1-before starting PD, norm. peritoneum (omentum)

Morphologic changes of peritoneum due to PD
(2)

Obr.2-after 3 years of PD, submesotelial fibrosis and

neo-angiogenesis (enlargement of vascular surface of
peritoneum)
 Peritonitis
• Clinical features: cloudy PD effluent, abdominal pain,
nausea, vomiting,
• Laboratory: leucocytosis, CRP, > 100wbc/ mm3, PD fluid
culture
• Bacteriology: Gram + cocci (incl. S.aureus) in 75%,
Gram – (incl. Pseudomonas) in 25%, culture negative,
mycobacterial (1%), fungal (3%), allergic (Icodextrin)
• Complications: relapses, antibiotic treatment failure,
acute and chronic UF failure
• Treatment for. 14-21 days : Gram + cocci: Vankomycin /
cephalosporin, Gram -: aminoglycoside /
cephalosporin III. Generation (+ antimycotics,
metronidazole)
• Goal: < peritonitis / 18 months
 From PD gudelines (ISPD)
• biocompatible PD solutions - normal pH, low
concentration of glucose
• insertion of PD catheter – 10 days-6 weeks before
RRT
• urea / creatinine clearance measured every 6 months
• PET: 6 weeks after commencing treatment + annually
• avoid routine use of high glucose concentrations )use
of icodextrin, aminoacids instead)
• preserve residual diuresis, obtain UF above 750 ml/day
• peritonitis and exit-site infection rates, regular revision
of technique
• invasive procedures cover by ATB prophylaxis
• topical ATB administration if needed (S.aureus, Ps.
aeruginosa)
• beware central obesity
 Perspectives - New dialysis solutions
protect peritoneal membrane
Physioneal1 Extraneal2
•  GDPs and AGEs • Isosmolar to plasma
•  Lactate • No glucose exposure
• Physiologic pH and pCO2 •  GDPs and AGEs
•  Membrane and immune cell •  Membrane and immune cell
function function

Nutrineal2
• No glucose exposure
• No GDPs or AGEs
•  Membrane and immune cell
function

1Skoufos, et al. Kidney Int. 2003;64(suppl 88):S94-S99.

2Vardhan, et al. Kidney Int. 2003;64(suppl 88):S114-S123.
 Clinical advantages of new dialysis
solutions
Physioneal Extraneal
 Infusion pain  Glucose load
 Peritonitis  Glycemic control
 Glycemic control  UF, control of fluid status
 Appetite  Dyslipidemia
 Patient acceptance  Quality of life
No  UF  Time on PD

Nutrineal
 Glucose load
 Glycemic control
 Protein intake, nutritional status

Pecoits-Filho, et al. Kidney Int. 2003;64(suppl 88):S100-S104.

Vardhan, et al. Kidney Int. 2003;64(suppl 88):S114-S123.
 Absorbtion of glucose from peritoneal
solutions
1. Solutions containing glucose (green) lead to significant glucose
absorbtion
2. Solutions based on another osmotic agent (blue, violet) do not
lead to glucose absorbtion, so decrease total daily glucose load).

Glucose absorbed = 159 g/day

1 2.5 L 2.5 L 2.5 L 2.5 L

Physioneal Physioneal Physioneal Physioneal
1.36% 1.36% 1.36% 3.86%

Glucose absorbed = 50 g/day

2.5 L 2.5 L
2 Physioneal 2.5 L Physioneal 2.5 L
1.36% Nutrineal 1.36% Extraneal
Thank you
 Peritoneal dialysis - outline
• Principles of PD
• PD solutions
• PD catheter
• Indication / contraindication of PD
• PD schemes : CAPD, CCPD
• Assessement of PD adequacy,
ultrafiltration
• Assessement of peritoneal function
• Complications
• Perspectives – new dialysis solutions
Ideal)PD)access
! Minimal)trauma)/)pain
! Rapid)fluid)infusion)without)pain
! Allow)complete)drain
!
Maintain)stable)position)without)extrusion)of)
deep)and)superficial)cuffs
! Allow)PD)therapy)for)many)years)
2
Saturday, March 30, 13