PD TRAINING

Pivithuru Bandara
(MBA(UK) ,MITBCCT(UK) (Counselling & Psychotherapy(IMH),Psycotromatology,(IMH)CCHRM, Chem.Sp, Pharma APP)
Clinical Head & Counselor
LCX Collaboration with National Peritoneal Dialysis Program
WHY People Need Dialysis?
When develop an end stage
kidney faliure.Usually by the
time that loss about 85% to
90% of the kidney and have
a GFR of less than 15.
 What does dialysis do?
When the kidneys fail, Dialysis keeps
body in balance by,
• Removing waste, salt and extra water
to prevent them from building up in the
body.
• Keeping a safe level of certain
chemicals in the body, such as
creatinine,potassium, sodium and
bicarbonate
• Helping to control blood pressure.
 Outline

1) Accessories Required
2) Mechanism of PD
3) Exchange Procedure
4) Common Complications
5) Infections Control
6) Advantages & Disadvantages
 CAPD Catheters
The peritoneal dialysis catheter is composed of a flexible silicone tube
with an open-end port and several side holes to provide optimal drainage
and absorption of the dialysate. The extra peritoneal component of
the catheter has either one or two Dacron cuffs. The Dacron cuffs are for
optimal in growth and fixation
 Different Types Of PD Catheters
Straight Tenckhoff catheters Coiled Tenckhoff catheters

Swan Neck Tenckhoff cathéters Swan Neck Missouri

Common Adults Catheter

Swan Neck Double cuff curl Catheter

 What is the peritoneal Cavity ?

● The peritoneal cavity is a

potential space between
the
parietal peritoneum and
visceral peritoneum, that
is, the two membranes
that separate the organs in
the
abdominal cavity from
the abdominal wall.
 Transfer Set

Solution Bag

Mini Cap

Titanium Adepter Blue Clamp

Transfer Set

Better to change once in 6 months

Ti Adepters

Lock Nut Main Body

T.Set Connected with the
catheter
Different Types of Pd Solutions
I. 1.5% Dextrose Solution Dianeal

II. 2.5% Dextrose Solution

III.4.25% Dextrose Solution
IV. Low Calcium Solutions
Extraneal

V. 7.5% Icodextrin -
(Not Available in SL)
Compositions contain in Solution
bag

•Dextrose •Magnesium chloride

•Sodium chloride •Calcium Chloride
•Sodium lactate •water
 A Basic Concept of
Peritoneal Dialysis
 The transport of solutes and
water across a “membrane” Peritoneal cavity
Dialysate
that separates two fluid con- membrane
taining compartments.
The blood in the peritoneal cap-
illaries
Dialysis solution in the peri-
PERITONE
toneal cavity AL TISSUE
BLOOD

Blood
WASTES & WATER
ELIMINATED DURING PD
● DIFFUSION ● OSMOSIS
 Diffusion
Definition:
Solute movement due to concentration gradient
of two solutes between components across a
semi-permeable membrane

Osmosis
Osmotic Ultra filtration
Movement of water from a chamber with
lower osmotic pressure to higher one across
a semi-permeable membrane
Peritoneal Dialysis

Fresh Dialysis Solution

Catheter

Peritoneum

Peritoneal Cavity

Old dialysis solution

Three different concentrations of
solutions…
• The higher the osmotic pressure difference, the higher
the ultra filtration UFR&UFV
• 1.5w/v % <2.5w/v % <4.25w/v %
• The higher UFV, the higher Convective transport

• Osmolality of dialysis solutions:

• 1.5 %; 345 mOsm/L
• 2.5 % ; 395 mOsm/L
• 4.25 %; 484 mOsm/L
Classification of patients according
to membrane permeability

1. High transporter
High membrane permeability.
More efficient with rapid
exchanges with short dwell
times
2. High average
transporter

3. Low average
Low permeability. Need long
dwell times.
4. Low transporter
 Diffusion
Definition:
Solute movement due to concentration gradient
of two solutes between components across a
semi-permeable membrane

Osmosis
Osmotic Ultra filtration
Movement of water from a chamber with
lower osmotic pressure to higher one across
a semi-permeable membrane
Low Calcium PD Solution
• Standard Pd solution contains 1.75mmol/L of calcium
• Low calcium pd soultion contains 1.25mmol/L of calcium
• Other compositions and the concentraions are same in both
solutions
Benifits Of Using LCD
•Increases the PTH levels.
•The LCD solution allowed a higher oral
intake of calcium salts with a satisfactory
control of the serum Calcium–Phosphorus
product.
•Better control of renal osteodystrophy.
•The administration of 1.25 mmol/L calcium
dialysate may benefi t abnormal calcium-
phosphatemetabolism and decrease
EXCHANGE PROCEDURE
EXCHANGE PROCEDURE
6 Step Hand washing
Dressing Procedure
Sterilization & Autoclaving
Common complications

I. Peritonitis
II. Exit site infection
III. Fluid overload
Peritonitis
PERITONITIS

● INFLAMATION OF THE PERITONEAL

MEMBRANE

● POTENTIALLY A LIFE-THREATNING
SITUATION
 Complications of peritonities

• Blood stream infections -Baterimia

• Infections throughout the body-Sepsis
• Hepatic Encepalopathy
• Hepatorenal Syndrome
• Intra abdominal abscess
• Intra peritoneal adhesions caused by bands
of fibrous
 PERITONITIS
● CLOUDY DRAINAGE
● Color Change

● ABDOMINAL PAIN

● FEVER

● MAY HAVE VOMITING & DIARRHOEA

● MAY HAVE SOME FIBRINS IN DRAINAGE

● POOR OUTFLOW
 Change of color

Normal Drained out Infected

Change of color
Poor Out Flow
 CAUSES OF PERITONITIS

CONTAMINATION
DURING BAG
EXCHANGE
PROCEDURE

CONTAMINATED PD
SOLUTION

ENVIRONMENT

FOLLOWING EXIT SITE

INFECTION
Types of Peritonities
●Bacterial Peritonitis
●Fungal Peritonitis
●Chemical Peritonitis
●Eosinophilic Peritonitis
Antibiotic Combinations
[Empiric Treatment Before Culture
Source: Royal free London NHS Foundation Trust & Royal National orthopedic Hospital

IP antibiotic Continuous / all

exchanges
mg/L

Gentamicin Loading 8 mg, Check Gentamacine level on day 3 and

Maintenance 4mg 7 to avoid ototoxicity and loss of RRF
If the level is >2mg/L reduce the
dosage

Cefuroxim Loading 500 mg, Increase dose by 25% if patient passes

Maintenance 125mg >500ml urine/day

Vancomycin 15 -30 mg/Kg once in 5 Loading 1000 , Maintenance 25

-7days
Antibiotic Combinations
Source: Royal free London NHS Foundation Trust & Royal National orthopedic Hospital

Flucanazol-50mg OD PO along with the

combination

Rifampicine 450mg OD PO-Recurrent

Infections

Total Duration :14-21 days Modify antibiotic treatment when culture and sensitivity known
 Chemical Peritonities
• Chemical peritonitis, described as peritoneal inflammation caused by a non-
infectious agent (such antibiotics and dialysis solutions) is
• A rare condition.
• Induced by Vancomycine & Icodextrine (Nefrología (Madr.) vol.31 no.5
Cantabria ,2011)
• Chemical peritonitis induced by vancomycin was first described in 1986
• Icodextrin-induced peritonitis has first described in 1999.
• The treatments depend on the causes of chemical peritonitis. If it’s related to
icodextrin, symptoms will quickly relieve once you stop the icodextrin
(ISPD,2011)
• At presentation of chemical peritonitis, abdominal pain was absent or mild
and dialysate leukocyte counts were moderately elevated
• It is reported a case in 2009 of chemical peritonitis in a patient treated with
icodextrin and intraperitoneal vancomycin, in which vancomycin seems to
be the offending agent.(Nefrología (Madr.) vol.31 no.5 Cantabria ,2011)
Case;A 34-year-old man, with renal failure secondary to diabetic nephropathy, was in PD since 2006.
Icodextrin was introduced one year after PD initiation. No peritonitis episodes were detected in the
following years.

In 2009, he came to hospital with mild abdominal pain with four hours of evolution. He hadn't other
symptoms, exit-site hadn't inflammatory signs and effluent was clear. Effluent analysis revealed 26 cells/µl
(table 1), abdominal radiography and ultrasound were normal.
• Intraperitoneal vancomycin (2 g each 5 days) and ceftazidime (1 g each
day) were administrated and patient was discarried, maintaining icodextrin.

• In the next day, he returned with cloudy effluent (table 1). The same
treatment was maintained and cloudy effluent disappeared in the two
following days
• At the 5th day, he was asymptomatic and came for second vancomycin
administration. Latter in that day, abdominal pain and cloudy effluent
reappeared (table 1).

• PD was suspended and hemodialysis was started. Vancomycin and

ceftazidime were switch to intravenous route and an extra daily dose of
intraperitoneal ceftazidime (500 mg) was maintained. He became
asymptomatic and cloudy effluent disappeared in the following two days.
All cultures, including fungus and Mycobacterium tuberculosis were
sterile.

• At the 9th day, he reassumed PD (with icodextrin) and at 10th day

intraperitoneal vancomycin was delivered. Cloudy effluent reappeared
after vancomycin administration. At 12th day, he was asymptomatic and
 Eosinophilic Peritonities

• Eosinophilic peritonitis is usually defined as an eosinophil count

greater than 10% of the total WBC count when the absolute
number of eosinophils is greater than 40/mm3 of peritoneal
effluents, or an absolute eosinophil count of greater than
100/mm3 of peritoneal effluents

• Most cases occur within the first 4 weeks of peritoneal catheter

insertion and they usually have a benign and self-limited course.

• It is reported that, a patient of eosinophilic peritonitis that was

successfully resolved without special treatment.

(Yong, Kim, Kang, & Sung Ho Lim, 2004)

• Eosinophilic peritonitis should be considered when repeated
cultures are always negative and the turbidness of peritoneal
dialysis effluent persists in spite of an antibiotic therapy.

• The cause of eosinophilic peritonitis is obscure, but is

probably due to an allergic reaction to some component of
the peritoneal dialysis system or may be associated with
atopic tendency with high serum IgE concentration and
rapid intraperitoneal osmotic fluctuation
(Korean J Intern Med. 2004 Jun; 19(2): 121–123 )

• Although eosinophilic peritonitis usually resolves

spontaneously, some have reported success with
intraperitoneal, low-dose hydrocortisone or oral
antihistamine or oral, low-dose prednisolone for patients
with abdominal pain, or to maintain catheter patency if the
peritoneal fluid is markedly turbid
(Se Yong Oh, M.D., Hyang Kim, M.D., Jeung Mook Kang et.el ,2004)
MANAGEMENT

● CONTACT CAPD CENTRE IMMEDIATELY

● SAVE CLOUDY DIALYSATE
● FLUSH 3 TIMES CONTINUOUSLY 1.5%
DISLYSATE
● EXCHANGES WITH 1.5%
DIALYSATE(MOSTLY WITH HEPARINE)
● BRINGS THE CLOUDY BAG & A NEW
DIALYSATE TO CAPD CENTRE
● COMPLETE COURSE OF ANTIBIOTIC AS
YOUR DOCTOR ADVISED
Exit Site Infections
 Grade/Category Pain Induration

0: Perfect P-0 None I-0 None

1: Good P-0 None I-0 None

2: Equivocal P-0 None I-0 None

3: Acute infection P-3 Painful I-3 Yes – at exit

4: Chronic infection P-4 Tenderness I-4 Slight

5: Cuff infection P-5 Tenderness I-5 Yes – at cuff

6: Traumatized P-6 Pain or

tenderness
PERFECT
Grade 0
 GOOD
Grade 1

Natural skin, dark brown, or pale pink

EQUIVOCAL
Grade 2
Purplish, bright
pink, or red
 Grade 3 Grade 3

Purulent, bloody, or Around exit or in sinus.

plentiful serous. Crust or scab every day.
 Chronic infection
Grade 4

Exuberant, bulging, bleeds

easily, vessels visible.
Cuff Infection

External Exudate (X) Internal Epithelium (E)

Grade 5 Grade 5

Purulent or bloody, intermittent Intermittent, chronic

or chronic, or after cuff macerated
expression
Page 78
 TW #46 TW #48

Pain Bleeding
Grade P-6

Depends on severity Depends on severity

Fluid Overload
Intra Peritoneal Leak
Tip Migration
Common Reason for Infections
in Hospitals
●Wrong Connection techniques
Strong medical indication for PD

●
Difficulties with vascular access
●
Congestive heart failure
●
Prosthetic valvular disease
●
Intolerance of HD
• Frequent episodes of hypotension
• Others
●
Children
 Theoretically not to choose PD initially
BUT PD may be feasible with added
adjustments

●
Large body size
●
Severe backache
●
Hernias
●
Multiple abdominal surgery
●
Poor manual dexterity
●
Blindness
 Advantages
* Preservation of RRF
✓Flexible treatment schedule
✓Less restricted diet
✓Manage your own care at home
✓No needles
✓Less stress on body
✓Greater independence and control
✓Blood pressure control
✓Lower cost
 Disadvantages
Dialysis every day
Permanent catheter
Body image changes
Risk of infection
Possible weight gain

Hernia
Malnutrition
Need Space for store supplies.
 Thank you and Congratulations

You are all now PD

Experts !
More importantly, you
will transform your
colleagues to PD
Experts

Contact:
Pivithuru Bandara
Clinical Head & Counselor
National Peritoneal Dialysis Program
0711-258108