Embed Size (px)
Citation preview
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!!!!!
