Divisi Ginjal Hipertensi

Bag / SMF Ilmu Penyakit Dalam

FK UNUD / RSUP Sanglah Denpasar
Yenny Kandarini
Integrated Treatment of ESRD
HEMODIALYSIS CAPD
KIDNEY TRANSPLANTATION
RRT
DIALYSIS
Is the process of cleansing or filtering the blood
Intermittent Peritoneal Dialysis
Dialysis
Hemodialysis
Peritoneal dialysis
Peritoneal
Dialysis
Automated Peritoneal Dialysis
Tidal Peritoneal Dialysis
Continuous Ambulatory
Peritoneal Dialysis (CAPD)
1975 CAPD developed by Moncrief & Popovich
1978 Oreopoulus et al pioneered collapsible plastic
containers for dialysat & titanium connector
1980 Buocristiani-Y set, Bazzota-double bag- applied
drainage before fill concept, straight & disconnect
system available
0
20
40
60
80
100
120
81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97
(000's)
Years
115,000 Patients
1993 - 1997
7.3% Annual Growth
Source: 1997 Baxter Patient Report
Definition
PD is a process during which the peritoneal cavity
acts as the reservoir for dialysis fluid and the
peritoneum serves as the semi permeable
membrane across which excess body fluid and
solutes including uraemic toxins, are removed.

(Gutch, Stoner & Corea 1999)
ontinuous
mbulatory
eritoneal
ialysis
Proses dialisis tidak berhenti, secara
berkesinambungan membersihkan darah,
24 jam se-hari, setiap hari
Bebas bergerak, tidak berhubungan dengan
mesin
Menggunakan rongga peritoneum yang bekerja
sebagai filter untuk mengeluarkan sisa
metabolisme dan cairan dari darah
Menyaring dan membuang cairan berlebih
serta sisa metabolisme tubuh.
Physiology of
Peritoneal Dialysis
The peritoneum is a serosal membrane
that lines the peritoneal cavity
Thin
Semipermiable
Large surface area (0,55 m
2
)
Divide into 2 parts:
Parietal peritoneum (20% area)
Visceral peritoneum (80% area)

Contains 100 ml or less of fluid
Adult can tolerate 2 L or more fluid without
pain or alteration to the respiratory function
Male: peritoneal cavity is closed
Female: peritoneal cavity is continuous with
the Fallopian tubes.
Rarely PD fluid become blood-stained during a
menstrual period

Total peritoneal blood supply is
estimated to be 60 100 mL/min.
Only 25% of the peritoneal capillaries are
perfused
The number of perfused peritoneal
capillaries is the most important
determinant of peritoneal solute and
water transport, rather than the total
anatomical surface area.
PD utilities the peritoneal membrane as a natural dialysis
filter.
A PD catheter inserted surgically into the peritoneal
cavity
PD solution is infused into the peritoneal cavity via the
catheter and remain there for up to 6-10 hours, during
which time uraemic toxins and fluid are removed by
diffusion and UF across the peritoneal membrane

Time on dialysis
Blood flow
Peritoneal surface area
Membrane permeability
Peritoneal lymphatics
Ultra filtration
Transfer of fluid
Jeremy Levy et al, Oxford Handbook of Dialysis, 2003
Definition
Selective diffusion- movement of solutes
from area of high solute concentration to an
area of low solute concentration across a
semi-permeable membrane.
Driving Force - Concentration gradient
Initial
Final
Solutes flux
Driving force: concentration
gradient
The transport rate of small solutes is higher than that of
large solutes. Small solutes diffuse faster than large solutes
Diffusion
Solute
removal
Dwell Time
Increasing solute size
Diffusion
Definition
Osmosis - movement of water from an area of
high water concentration to an area of low water
concentration across a semi-permeable
membrane.
Or the movement of water from an area of low solute
concentration to an area of high solute concentration.
Driving force - concentration gradient






Osmosis occurs between two solutions separated by a
membrane which is non-permeable (or partially
permeable) to the solutes
Definition
The movement of solutes with a water-flow,
"solvent drag", e.g. the movement of membrane-
permeable solutes with water.
Start of Dialysis
Fluid removal by
osmosis include
solutes removed by
convection
Lost into the dialysate Absorbed into the
circulation
Small molecules (e.g. urea,
creatinine)
Dextrose (if dextrose-containing
PD solution)
Some electrolytes (notably
potassium)
Calcium
Protein (up to 5 10 g/d)
Amino acids, trace minerals,
hormones, drugs
Glucose 1.5%, 2.3%, 4.25%
Sodium 134 mmol/l
Calcium 1 mmol/l, 1.75mmol/l
Magnesium 0.5 mmol/l
Chloride 102 mmol/l
Lactate 35 mmol/l

Note:- No potassium, no urea and no
creatinine
After a two litre bag has dwelled for four
hours average ultrafiltration
1.5% 200 ml ultrafiltrate
2.3% 200 - 400 ml ultrafiltrate
4.25% 600 ml 800 ml ultrafiltrate
Indications for PD in preference to HD
Very small/very young patients
Lack of vascular access
Contraindications to anticoagulation
Cardiovascular instability
Poorly controlled hypertension /
hypertensive cardiomiopathy (relative)
Lack of proximity to pediatric HD center (relative)
Desire for normal school attendance
More liberal fluid intake
Absolute
Abdominal wall stoma
high risk of peritonitis
Diaphragmatic fluid leak
peritoneal dialysis fluid causes
Adhesions
hinder flow of peritoneal dialysis fluid
Loss of peritoneal function or integrity
peritoneal dialysis not technically possible
Severe inflammatory bowel ds
Medical contraindications to peritoneal dialysis
Medical contraindications to peritoneal dialysis
Relative
Large muscle mass-potentially
inadequate dialysis
Obesity
difficulty with catheter insertion
Intestinal disease
potential to initiate peritonitis
Respiratory disease
intolerance of splinting of diaphragm by intraperitoneal
fluid
Hernia
exacerbated by peritoneal dialysis fluid it not surgically
correctable


Relative contraindications to PD
Imminent living-related transplantation
Impending/recent major abdominal surgery
Lack of an appropriate caregiver
PERITONEAL DIALYSIS ADVANTAGES
Continuous dialysis
Self care dialysis
Home based dialysis
Simple to learn and perform
Minimal dietary restrictions
No needle puncture required
No blood access problems
Mobility during dialysis
Ease of travel
Minimal cardiovascular stress
No blood loss
PERITONEAL DIALYSIS DISADVANTAGES
Peritonitis
Protein loss
Potential for elevated blood lipid (fat) and
triglyceride levels
Peritoneal catheter
Daily dialysis schedules
Possible weight gain
o Systemic metabolic effects of glucose dialysate
o Dyslipidemia
o Protein loss
o Hyponatremia / hypernatremia
o Hypokalemia / hyperkalemia
o Hypocalcemia / hypercalcemia
o Hemoperitoneum
o Encapsulating peritoneal sclerosis
o Hydrothorax
o Hernia
o Abdominal and genital leaks
Noninfectious Complications
of Peritoneal Dialysis
Gram-positive (50%)
Gram-negative,non pseudomonas
Pseudomonas
Fungal (2%)
Tuberculosis
Biofilm

(15%)
External appearance of a
perfect exit (magnified 4.5X)
Natural color, no scab, no
granulating tissue, no
redness, no drainage
Sinus appearance of perfect
exit strong and mature,
cover visible sinus
Acutely Infected
Exit
Painful
Swollen
Red with erythema > 13
mm in diameter
Exuberant granulation
tissue
Bleed easily upon touch
Visible around exit
and/or in visibly sinus
Drainage
Purulent and / or bloody
Wet exudates on dressing
Crust or scab around exit
(or in the sinus)
Chronically Infected
Exit
Evolved from acute infection that
is unresolved for > 4 weeks
Signs of pain, swelling and
redness are absent
Granulation tissue : exuberant
around exit and/or sinus
Epithelium: absent or covers only
part of sinus
Sometimes visible sinus and exit
appears normal
Drainage:
Purulent or bloody,
spontaneous or after pressure
on sinus
Wet exudate on dressing
Crust or scab around the exit or
in the sinus
External cuff gets infected
Tunnel Infection
Functional parts of the peritoneal catheter
Symptoms:
- cloudy fluid; and/or
- abdominal pain (79%); and/or
- fever (53%)



Look for :
CLOUDY BAGS
Stomach Pain Fever
Do your exchanges just as
you are taught
Dialysate volume : 2 L for 4 cycle exchange
schedule :
08.00, 12.00, 16.00, 24.00
(before bed time)
Ultrafiltration:
08.00, 12.00, 16.00 1.5%
24.00 2.5%
CAPD
0
500
1000
1500
2000
2500
Time (24 hour clock)
V
o
l
u
m
e

Spent dialysate is drained out.
This process takes approximately 10-20 minutes
Fresh dialysate is flushed from the fresh solution bag
into the drain bag.
This process takes approximately 5 seconds
Fresh dialysate is infused into the peritoneal cavity.
This takes 8-10 minutes
O
Dialysate remains in the peritoneal cavity for 4 8 hours
During this time waste products and excess fluid is removed
Ultra Bag Disconnect System
Andy -Twin Bag Disconnect
system
CAPD system in Indonesia
Initiation to CAPD
Implant catheter
Provide educational materials to caregivers, patients
Immediate PD required?
2-to 6-weeks healing period, then start dialysis with 4-
8 excahnges using 300 mL/m
2
BSA volume,* increase
fill volume to 1100 mL/m
2
BSA within 7-14 days
Start supine dialysis with 12-24 exchanges using
300 mL/m
2
BSA volume* for 7 days, increase fill
volume to 1100 mL/min
2
BSA within 14-21 days
Establish maximally tolerable fill volume by either repeated IPP measurements or clinical
judgment. Adjust to maximally tolerable fill volume
Initial prescription: 3 3-to 5-hour daytime + 1 9- to 12-hour nighttime cycles with macimally
tolerable fill volume (usually 1100 mL/m
2
BSA
Preformed PET, measure urinary and dialysate creatinine and urea clearances at the end of
training (preferably 4 weeks after start of PD
Use PD dosing tables or software (PD adequest or renalsoft PD Rx Management) to adjust PD
prescription
No Yes
* 200 mL/m
2
BSA during infancy
Criteria of CAPD adequacy
Total Kt / V
urea
> 2.0/week
Total CrCI / 60 L/1.73 m
2
/week in high / high average
transporters, > 50 in low/low average transporters
Clearance associated with normal status for hydration,
electrolyte balance, blood pressure, growth, nutrition and
psychomotor development
Outcome evaluation
Monthly assessment of growth and weight gain, head circumference
(infants); blood pressure, acid-base status, electrolytes, serum
creatinine, BUN, hemoglobin/hematocrit, serum albumin, record urine
output and daily ultra filtration
Serum ferritin, serum iron, total iron binding capacity (monthly until
stable, then every 2-3 months)
Every 3 months assessment of intact PTH, alakaline phosphatase
Every 4 months assessment of 24-hour dialysate and urine collection for
CrcI, Kt/Vurea; possibly more frequent if prior assessment reveals failure
adequacy targets; school evaluation
Every months neurodevelopmental assessment in infants < 4 years of age
Consider annual:
Ambulatory blood pressure monitoring (ABPM), especially if casual
BP frequently borderline or discrepant from home measurements,
echocardiography
Hand and wrist X-ray (especially if intact PTH frequently outside
therapeutic range
Outcome evaluation
Practice Points
Peritoneal dialysis should be considered in all
patients approaching ESRF
Planning for peritoneal dialysis is a multidisciplinary
process that should be instituted well before the
requirement for dialysis
Patients maintained on peritoneal dialysis should be
assessed regularly for the adequacy of solute
clearance and ultra filtration; inadequate dialysis is
associated with increased morbidity and mortality
Infective complications of peritoneal dialysis,
particularly peritonitis, must be identified and treated
promptly.