Peritoneal dialysis Presented by Ray Agnello BSN, RN, CNN Renal Educator St. Joseph’s Medical Center.

Peritoneal dialysisPeritoneal dialysis

Presented byPresented byRay Agnello BSN, RN, CNNRay Agnello BSN, RN, CNN

Renal EducatorRenal EducatorSt. Joseph’s Medical CenterSt. Joseph’s Medical Center

To provide attendees with a To provide attendees with a summarized review of summarized review of peritoneal dialysis.peritoneal dialysis.

To highlight key points in the clinical To highlight key points in the clinical care of a PD patient.care of a PD patient.

Catheter placementCatheter placement

Care of catheterCare of catheter

Infectious complicationInfectious complication

Non-infectious complicationsNon-infectious complications

AdequacyAdequacy

Fluid balance assessment of the patient Fluid balance assessment of the patient with PDwith PD

ObjectiveObjectivess

Peritoneal DialysisPeritoneal Dialysis Alternative to hemodialysisAlternative to hemodialysis Patient is taught to perform Patient is taught to perform

dialysis exchanges in the home dialysis exchanges in the home settingsetting

Focus is on patient autonomy and Focus is on patient autonomy and self-care managementself-care management

Patient must be followed by a Patient must be followed by a licensed Peritoneal Dialysis unitlicensed Peritoneal Dialysis unit

Translucent Translucent

Vascular membraneVascular membrane

Two layersTwo layers ParietalParietal (inner surface of abdominal wall) (inner surface of abdominal wall)

Receives blood supply from the arteries of the Receives blood supply from the arteries of the abdominal abdominal wall.wall.

VisceralVisceral (covers abdominal viscera) (covers abdominal viscera)

Covers the abdominal organs.Covers the abdominal organs.

Blood is carried by the mesenteric and celiac Blood is carried by the mesenteric and celiac arteries.arteries.

Most vascular layer where most of the dialysis Most vascular layer where most of the dialysis occurs.occurs.

Envelope of space between layers called Envelope of space between layers called peritoneal peritoneal cavity.cavity.

Semi-permeable; acts as a filter.Semi-permeable; acts as a filter.

Kelley (2004)Kelley (2004)

Peritoneal MembranePeritoneal Membrane

Anatomy and Physiology

Peritoneal MembranePeritoneal Membrane Semi-permeableSemi-permeable Bi-directionalBi-directional Membrane size Membrane size – 1-2 m 1-2 m22

Vascular wall, interstitium, Vascular wall, interstitium, mesothelium , and adjacent fluid mesothelium , and adjacent fluid filmsfilms

Closed in malesClosed in males Women Women – Ovaries and fallopian tubes Ovaries and fallopian tubes

open into the peritoneal cavity open into the peritoneal cavity Peritoneal cavity normally contains Peritoneal cavity normally contains

about 100 ml transudateabout 100 ml transudate

Kinetics of Kinetics of Peritoneal DialysisPeritoneal Dialysis

DiffusionDiffusionOsmosisOsmosisUltrafiltrationUltrafiltrationDrug TransportDrug Transport

Tea Bag = Peritoneal Membrane

Tea Leaves = Waste

Water = PD Fluid

DiffusionDiffusion

Scheme of semi-permeable membrane:red = bloodblue = PD fluidyellowyellow = membrane wikipedia.org/

OsmosisOsmosis

The diffusion of pure solvent across a membrane in response

to a concentration gradient, usually from a solution of lesser

to one of greater solute concentration.

Miller-Keane 6th EditionMiller-Keane 6th Edition

1.5 % Solution

2.5 % Solution

4.25 % Solution

Osmotic Pressure of Dextrose Osmotic Pressure of Dextrose SolutionSolution

The Peritoneal Dialysis The Peritoneal Dialysis ProcessProcess

Definition-intra (within) Definition-intra (within) corporeal dialysiscorporeal dialysis

Three phases to the Three phases to the exchange processexchange process DrainDrain FillFill DwellDwell

How Does PD How Does PD Work?Work?

The semi-permeable peritoneal The semi-permeable peritoneal membrane lines the abdominal cavity membrane lines the abdominal cavity and covers the abdominal viscera.and covers the abdominal viscera.

The membrane allows (via diffusion) The membrane allows (via diffusion) the passage of toxins and electrolytes the passage of toxins and electrolytes into the dialysis solution.into the dialysis solution.

Ultra-filtration (removal of fluid) occurs Ultra-filtration (removal of fluid) occurs via osmosis.via osmosis.

A “steady state” of toxin clearance and A “steady state” of toxin clearance and fluid management is achieved due to fluid management is achieved due to daily performance of dialysis.daily performance of dialysis.

Kelley (2004).Kelley (2004).

How Does PD Work? Dialysis solution is infused and drained Dialysis solution is infused and drained

via a catheter that is surgically placed in via a catheter that is surgically placed in the peritoneal cavity.the peritoneal cavity.

The action of draining and infusing The action of draining and infusing dialysis solution is called an exchange.dialysis solution is called an exchange.

The frequency of exchanges and volume The frequency of exchanges and volume is determined by the presence of is determined by the presence of residual renal function and the residual renal function and the individual membrane characteristic.individual membrane characteristic.

Infusion or FillInfusion or Fill

Baxter®Baxter®

DrainDrain

Baxter®Baxter®

Dialysis occurs during the dwell phase.Dialysis occurs during the dwell phase.

Diffusion: Solutes cross from area of Diffusion: Solutes cross from area of greater greater concentration to lesser concentration to lesser one.one.

- Depends on concentration - Depends on concentration gradient.gradient.

- Enough peritoneal surface area.- Enough peritoneal surface area.

- Size of fill volume.- Size of fill volume.

Ultra-filtration: Water removal due to Ultra-filtration: Water removal due to osmotic gradient between the osmotic gradient between the hyperosmolar PD fluid and the capillary hyperosmolar PD fluid and the capillary bed.bed.Kelley (2004).Kelley (2004).

Peritoneal DialysisPeritoneal Dialysis

Historical PerspectivesHistorical Perspectives Acute Acute – Predominant use of PD prior to Predominant use of PD prior to

1960s1960s 1966 1966 – Automated cycler Automated cycler 1967 1967 – Tenckhoff catheter Tenckhoff catheter 1975 1975 – CAPD CAPD 1978 1978 – Polyvinyl bags manufactured Polyvinyl bags manufactured 1980s 1980s – New catheter designs New catheter designs 1987 1987 – PET and tidal PD PET and tidal PD – Twardowski Twardowski 1990s 1990s – Alternative dialysate solutions, Alternative dialysate solutions,

updated system designsupdated system designs

Who Are the PD Patients ?Who Are the PD Patients ? Choose PD as renal replacement therapyChoose PD as renal replacement therapy

Hemodialysis patient without accessHemodialysis patient without access

Failed allograft (transplanted kidney)Failed allograft (transplanted kidney)

Have CHF or CVD which exempts them Have CHF or CVD which exempts them from hemodialysisfrom hemodialysis

Often people without the benefit of CKD Often people without the benefit of CKD educationeducation

PD Patient SelectionPD Patient Selection Inclusion criteria include patients who:Inclusion criteria include patients who:

Choose the modality.Choose the modality.

Want “control.”Want “control.”

Prefer home for dialysis.Prefer home for dialysis.

Have residual renal function.Have residual renal function.

CVD, CHF.CVD, CHF.

Geriatric.Geriatric.

Pediatric.Pediatric.

Social support system.Social support system.

Surgical EvaluationSurgical Evaluation

Abdominal wall weakness or Abdominal wall weakness or herniahernia

Repair hernia preemptively or Repair hernia preemptively or when symptomaticwhen symptomatic

Previous abdominal surgeriesPrevious abdominal surgeries Likelihood of adhesionsLikelihood of adhesions Abdominal wall obesityAbdominal wall obesity

Surgical EvaluationSurgical EvaluationCatheter InsertionCatheter Insertion

Some units advocate insertion 2 Some units advocate insertion 2 to 6 weeks prior to dialysis to to 6 weeks prior to dialysis to optimize healing.optimize healing.

Some units advocate insertion Some units advocate insertion months in advance (burying the months in advance (burying the catheter).catheter).

In most situations, PD access is In most situations, PD access is elective.elective.

Peri-Operative RoutinesPeri-Operative RoutinesAnesthesiaAnesthesia

Local infiltration with sedationLocal infiltration with sedation Intravenous propofol with MACIntravenous propofol with MAC General anesthesiaGeneral anesthesia

Insertion TechniquesInsertion Techniques

Bedside-temporary cathetersBedside-temporary catheters Laparoscopic placementLaparoscopic placement Surgical dissectionSurgical dissection Buried catheter techniqueBuried catheter technique

Insertion TechniquesInsertion TechniquesBuried catheterBuried catheter:: Entire catheter placed in Entire catheter placed in

subcutaneous pocket for 4 to 6 subcutaneous pocket for 4 to 6 weeks or longer, allowing cuff to weeks or longer, allowing cuff to heal.heal.

Exit site is externalized in a separate Exit site is externalized in a separate procedure. procedure.

Reduced bacterial colonization (?).Reduced bacterial colonization (?). Do not have long-term outcomes Do not have long-term outcomes

yet.yet.

Flanigan & Gokal (2005).Flanigan & Gokal (2005).

Pre-Catheter InsertionPre-Catheter Insertion

Patient education and consent signedPatient education and consent signed Examination of the patient’s abdomen Examination of the patient’s abdomen

• Avoid scars and fat foldsAvoid scars and fat folds• Avoid beltlineAvoid beltline• Mark the abdomenMark the abdomen

Surgical prepSurgical prep• Empty bladderEmpty bladder• Patient showers with disinfectant Patient showers with disinfectant

soapsoap• Bowel prepBowel prep

Steps to PD Catheter Steps to PD Catheter AccessAccess

Evaluation by nephrologist for PD Evaluation by nephrologist for PD catheter placement and identified as catheter placement and identified as candidate.candidate.

Educated about catheter placement, and Educated about catheter placement, and pre- and post-operative care routines.pre- and post-operative care routines.

Referred to surgeon for evaluation that Referred to surgeon for evaluation that includes determination of exit includes determination of exit site,clinical and anesthesia work-up, site,clinical and anesthesia work-up, contra-indications, completion of contra-indications, completion of consent forms, and scheduling of consent forms, and scheduling of surgery.surgery.

Selection ContinuedSelection Continued Exclusion CriteriaExclusion Criteria Patients who:Patients who:

Have abdominal aortic aneurysm AAA Have abdominal aortic aneurysm AAA (size dependent)(size dependent)

Derm. disease of the abdominal wallDerm. disease of the abdominal wallMorbid abdominal obesityMorbid abdominal obesityAltered mental status; poor coping stylesAltered mental status; poor coping stylesSolitary lifestyleSolitary lifestylePatient states lack of interest in Patient states lack of interest in modalitymodality

Multiple abdominal surgeries Multiple abdominal surgeries – adhesions adhesionsOstomies (increase risk of infection)Ostomies (increase risk of infection)Recurrent herniasRecurrent hernias

Catheter HistoryCatheter History• Early catheters were glass Early catheters were glass cannulascannulas with straight or with mushroom with straight or with mushroom ends.ends.

• 1920s 1920s – Stainless steel coil with Stainless steel coil with rubber drain first used in NYC rubber drain first used in NYC (Rosenak) (Rosenak)

• 1940s 1940s – Urinary catheters utilizedUrinary catheters utilized

• 1950s 1950s – Nylon catheters at UCLANylon catheters at UCLA

• 1960s 1960s – Button catheters Button catheters (Scribner,(Scribner, Boen) Boen)

Catheter HistoryCatheter History

1964 1964 – Slicon rubber catheters (Palmer, Slicon rubber catheters (Palmer, Quinton)Quinton)1965 1965 – Tenckhoff intermittent catheterTenckhoff intermittent catheter1968 1968 – Tenckhoff cuffed straight Tenckhoff cuffed straight cathetercatheter1970s 1970s – Single/double cuff coiled Single/double cuff coiled cathetercatheter1980s 1980s – Swan neck configurationSwan neck configuration2000s 2000s – T-shaped catheter (Ash)T-shaped catheter (Ash)The future..?The future..?

CathetersCatheters

Straight (single or double cuff)Straight (single or double cuff)Coiled (single or double cuff )Coiled (single or double cuff )Swan neck (single or double cuff)Swan neck (single or double cuff)Pre-sternal swan neckPre-sternal swan neckToronto WesternToronto WesternMissouri cathetersMissouri cathetersDisc cathetersDisc catheters

CuffsCuffs

SingleSingleDoubleDoubleElongatedElongatedBead/flange Bead/flange

configurationconfiguration

AdaptorsAdaptors

PlasticPlastic TitaniumTitanium

PD PD Catheter Access Catheter Access ComplicationComplication

Immediate/EarlyImmediate/Early

Bloody effluentBloody effluent

Pain with infusionPain with infusion

Leak at exit siteLeak at exit site

Exit site infectionExit site infection

Migration of catheter tipMigration of catheter tip

Poor fill or drain, with or without Poor fill or drain, with or without painpain

Non-infectious cloudy effluentNon-infectious cloudy effluent

(lymphatic leak or eosinophilic(lymphatic leak or eosinophilic peritonitis) peritonitis)

PD Catheter Access PD Catheter Access ComplicationComplication

Later IssuesLater Issues Exit site leaks or subcutaneous Exit site leaks or subcutaneous

leaksleaks Pleural communicationsPleural communications Excessive granulation tissueExcessive granulation tissue Chronic site or tunnel infectionChronic site or tunnel infection Cuff extrusionCuff extrusion Cracked, brittle catheterCracked, brittle catheter Repetitive episodes of peritonitisRepetitive episodes of peritonitis Bowel perforationsBowel perforations

Post-OpPost-Op

Follow up appointment with Follow up appointment with surgeonsurgeon

Remove primary dressing in 5 to 7 Remove primary dressing in 5 to 7 daysdays

Replace dressing with DSDReplace dressing with DSD Teach patient to secure catheterTeach patient to secure catheter Flush catheter during training Flush catheter during training

sessionssessions Allow catheter to heal for 14 days Allow catheter to heal for 14 days

or or longer if possiblelonger if possible Schedule training sessionsSchedule training sessions

Pain medication/prescriptionPain medication/prescriptionFollow-up in PD unit within Follow-up in PD unit within

48 to 72 hours of discharge 48 to 72 hours of discharge Dressing intact for 5 to 7 days Dressing intact for 5 to 7 days Reinforce dressing as neededReinforce dressing as neededDressing changed by PD nurseDressing changed by PD nurseEstablish training scheduleEstablish training scheduleBowel regimen Bowel regimen No heavy liftingNo heavy liftingWritten instructions Written instructions Emergency phone numbersEmergency phone numbers

Post Operative Discharge PlanPost Operative Discharge Plan

Prevent Constipation

Peritoneal Dialysis Peritoneal Dialysis TherapiesTherapies

IPD (Intermittent Peritoneal IPD (Intermittent Peritoneal Dialysis)Dialysis)

CAPD (Continuous Ambulatory CAPD (Continuous Ambulatory Peritoneal Dialysis )Peritoneal Dialysis )

CCPD (Continuous Cycling CCPD (Continuous Cycling Peritoneal Dialysis) also known Peritoneal Dialysis) also known as APD (Automated Peritoneal as APD (Automated Peritoneal Dialysis)Dialysis)

Training Sessions for the PD PatientTraining Sessions for the PD Patient Assess readiness to learnAssess readiness to learn Provide a quiet, relaxed atmosphere Provide a quiet, relaxed atmosphere

for learningfor learning Identify patient’s learning styleIdentify patient’s learning style Individualized with respect to Individualized with respect to

patient’s expectations, cultural patient’s expectations, cultural beliefs, and coping abilitiesbeliefs, and coping abilities

Length of training based on Length of training based on patient’s clinical conditionpatient’s clinical condition

ON Call RN

OONN CCaallll

On Call RNOn Call RN

Warming the SolutionWarming the Solution Use warm, dry heatUse warm, dry heat

At home At home – PD heating pad PD heating pad

NEVER MICROWAVE!!NEVER MICROWAVE!!Uneven heating of dextrose can Uneven heating of dextrose can create acreate a1st or 2nd degree burn to peritoneum1st or 2nd degree burn to peritoneum

Leaching of plastics into dialysate canLeaching of plastics into dialysate cancreate a chemical peritonitis create a chemical peritonitis

Patients At Risk for Patients At Risk for Inadequate DialysisInadequate Dialysis

No residual renal functionNo residual renal function Low membrane Low membrane

permeabilitypermeability Large patientsLarge patients

PD Equilibration TestPD Equilibration Test First developed by Z. Twardowski at First developed by Z. Twardowski at

the University of Missouri.the University of Missouri. A 4-hour study that assesses A 4-hour study that assesses

membrane transport characteristics.membrane transport characteristics. Assessment of membrane function Assessment of membrane function

allows for accurate prescription allows for accurate prescription planning.planning.

Usually completed within the first Usually completed within the first six weeks of initiating PD.six weeks of initiating PD.

Repeated per each unit’s protocol.Repeated per each unit’s protocol.

PD Equilibration Test PD Equilibration Test continuedcontinued

What does this tell us?The results indicate the

following transport states: High High-average Low-average Low

KT/V TestKT/V Test

What is measured?What is measured? 24-hour collection of dialysate 24-hour collection of dialysate

and urineand urine

Serum values of BUN and Serum values of BUN and CreatinineCreatinine

Frequency of test is determined Frequency of test is determined by each unit’s protocols and by each unit’s protocols and interpretation of K/DOQI interpretation of K/DOQI GuidelinesGuidelines

KT/V Test continuedKT/V Test continued

What does it tell us?What does it tell us? The adequacy of the current The adequacy of the current

prescriptionprescription

Need for adjustments to insure Need for adjustments to insure appropriate dialysis appropriate dialysis prescriptionprescription

Infectious Infectious ComplicationsComplications

Exit Site CareExit Site Care Healthy exit site: Surrounding Healthy exit site: Surrounding

skin natural, darkened, or light skin natural, darkened, or light pink; no drainage or crusting; pink; no drainage or crusting; visible sinus is dry.visible sinus is dry.

Goal: Prevent exit site infection Goal: Prevent exit site infection and identify problems early.and identify problems early.

Frequency: Daily or 3 to 4 times Frequency: Daily or 3 to 4 times weekly; may be in conjunction weekly; may be in conjunction with showering.with showering.

Infection PreventionInfection Prevention Exit Site Care:Exit Site Care:

No dressing needed for established No dressing needed for established catheter exit site.catheter exit site.

Keep catheter secured to abdomen with Keep catheter secured to abdomen with 2-inch tape.2-inch tape.

Daily showers with liquid soap. Daily showers with liquid soap. Mupirocin (BactrobanMupirocin (Bactroban®®) at exit site of ) at exit site of

known staph. carrier.known staph. carrier. Inpatients Inpatients – Dry dressing to protect site, Dry dressing to protect site,

cleaned with soap and water. No cleaned with soap and water. No occlusive membrane dressings occlusive membrane dressings (Tegaderm(Tegaderm®®).).

A healed and non-infected exit site is A healed and non-infected exit site is crucial to longevity on Peritoneal crucial to longevity on Peritoneal Dialysis.Dialysis.

Exit Site InfectionExit Site Infection

Teach patient to identify and report Teach patient to identify and report immediatelyimmediately

to the PD Unit:to the PD Unit: Redness, tenderness, edema, presence of Redness, tenderness, edema, presence of

exudate either at exit site or insertion exudate either at exit site or insertion site.site.Treatment:Treatment: Culture exudate if possibleCulture exudate if possible Specific antibiotic protocolSpecific antibiotic protocol Oral or IV/IP antibiotics depending on extent of Oral or IV/IP antibiotics depending on extent of

infectioninfection Saline soaks/dressing changes for care of local Saline soaks/dressing changes for care of local

cellulitiscellulitis

Exit Site InfectionExit Site Infection

A chronic exit site infection can produce a A chronic exit site infection can produce a systemic inflammatory response.systemic inflammatory response.

Inflammation can lead to poor nutrition, Inflammation can lead to poor nutrition, inadequate dialysis, and possible inadequate dialysis, and possible antibiotic resistance. Vital role of antibiotic resistance. Vital role of dietitian.dietitian.

Chronic exit site infections may result in Chronic exit site infections may result in peritonitis.peritonitis.

Multiple infections can lead to removal Multiple infections can lead to removal and replacement of catheter.and replacement of catheter.

Consistent assessment and Consistent assessment and documentation is needed to appropriately documentation is needed to appropriately track infections.track infections.

Exit Site InfectionExit Site Infection Signs and Symptoms: Redness, Signs and Symptoms: Redness,

swelling, tenderness or pain, and swelling, tenderness or pain, and purulent drainage.purulent drainage.

Risk Factors: Poor catheter healing, Risk Factors: Poor catheter healing, sutures at the exit site, trauma to the sutures at the exit site, trauma to the exit site, cuff extrusion, and improper exit site, cuff extrusion, and improper catheter care.catheter care.

Diagnosis: Observation and culture.Diagnosis: Observation and culture. Treatment: Antibiotics, IP, PO, or IV;Treatment: Antibiotics, IP, PO, or IV;

vigilant daily exit site care.vigilant daily exit site care.

Responsible OrganismsResponsible Organisms

Staphylococcus AureusStaphylococcus Aureus Pseudomonas speciesPseudomonas species Other gram-positive speciesOther gram-positive species Serratia speciesSerratia species Other gram-negative Other gram-negative

organismsorganisms FungiFungi

Tunnel InfectionTunnel InfectionSigns and SymptomsSigns and Symptoms Erythema over the tunnelErythema over the tunnelPain and tenderness Pain and tenderness Drainage from exit site – No other signs Drainage from exit site – No other signs of an infectionof an infection

Risk factorsRisk factors Exit-site infection Exit-site infection Exit-site traumaExit-site traumaLeak Leak External cuff extrusionExternal cuff extrusionTreatment Treatment – Antibiotic therapy to Antibiotic therapy to prevent need for catheter removalprevent need for catheter removal

Prevention of Prevention of PeritonitisPeritonitis Basics of Aseptic Technique: 5-min. Basics of Aseptic Technique: 5-min.

hand scrub, face masks during hand scrub, face masks during exchanges, warming of PD bags using exchanges, warming of PD bags using dry heat, aseptic technique for adding dry heat, aseptic technique for adding medicines.medicines.

Aseptic technique when making critical Aseptic technique when making critical connections to solution containers and connections to solution containers and the patient’s transfer set.the patient’s transfer set.

Masks reduce the risk of contamination Masks reduce the risk of contamination with nasopharyngeal organisms.with nasopharyngeal organisms.

PeritonitisPeritonitis

Portals of EntryPortals of Entry Transluminal Transluminal – Technique failure, Technique failure,

contaminationcontamination Periluminal Periluminal – Incomplete Incomplete

healing ,leakinghealing ,leaking Hematogenous Hematogenous – Bacteremia Bacteremia Transmurl Transmurl – Through the bowel wall Through the bowel wall

ANNA Core CurriculumANNA Core Curriculum

Diagnosis of PeritonitisDiagnosis of Peritonitis Effective culture techniques:Effective culture techniques:

Minimum sample volume of 50-Minimum sample volume of 50-100 ml. Large samples reduce 100 ml. Large samples reduce false negative results.false negative results.

Dialysate must be mixed well by Dialysate must be mixed well by inverting bag several times inverting bag several times before sampling.before sampling.

Sample port is disinfected before Sample port is disinfected before sampling.sampling.

Sample is obtained using aseptic Sample is obtained using aseptic technique.technique.

PeritonitisPeritonitis Defined as the presence of WBC in the Defined as the presence of WBC in the

effluent numbering 100 or greater.effluent numbering 100 or greater.

Effluent appears cloudy and milky.Effluent appears cloudy and milky.

Patient may have fever, chills, Patient may have fever, chills, abdominal pain, nausea, vomiting, and abdominal pain, nausea, vomiting, and diarrhea.diarrhea.

Some present initially with cloudy fluid Some present initially with cloudy fluid as the first sign and no symptoms.as the first sign and no symptoms.

Patient must be taught to contact their Patient must be taught to contact their PD nurse or nephrologist immediately PD nurse or nephrologist immediately for cloudy effluent.for cloudy effluent.

Peritonitis PresentationPeritonitis Presentation Signs and Symptoms: Fever, abdominal Signs and Symptoms: Fever, abdominal

pain, nausea and vomiting, diarrhea, pain, nausea and vomiting, diarrhea, and cloudy effluent.and cloudy effluent.

Incubation: 24-48 hours; if within 6 Incubation: 24-48 hours; if within 6 hours suspect an enteric source.hours suspect an enteric source.

Kinetic effects: Increased solute Kinetic effects: Increased solute removal and protein loss; increased removal and protein loss; increased glucose absorption leading to a glucose absorption leading to a decreased osmotic gradient and decreased osmotic gradient and decreased ultrafiltration.decreased ultrafiltration.

Prevention of Prevention of PeritonitisPeritonitis

Careful individualized patient Careful individualized patient trainingtraining

Adequate daily hygieneAdequate daily hygiene

Meticulous hand washingMeticulous hand washing

On-going retrainingOn-going retraining

PeritonitisPeritonitis

Treatment protocolsTreatment protocols Patient may be treated in PD Unit or Patient may be treated in PD Unit or

Emergency Room depending on the severity of Emergency Room depending on the severity of symptoms and availability of resources.symptoms and availability of resources.

Effluent is sent for cell count, C&S, and gram Effluent is sent for cell count, C&S, and gram stain.stain.

Fungal cultures should be included if patient is Fungal cultures should be included if patient is immunosuppressed or has had frequent immunosuppressed or has had frequent infections requiring antibiotics.infections requiring antibiotics.

PD Unit should have specific antibiotic PD Unit should have specific antibiotic protocols for gram-positive and gram-negative protocols for gram-positive and gram-negative coverage.coverage.

PeritonitisPeritonitis

OrganismsOrganisms Gram-Positive:Gram-Positive:

Staphylococcus epidermidisStaphylococcus epidermidis

Staphylococcus aureusStaphylococcus aureus

Streptococcus speciesStreptococcus species

EnterococcusEnterococcus

Gram-Negative:Gram-Negative:PseudomonasPseudomonas

KlebsiellaKlebsiella

Escherichia coliEscherichia coli

EnterobacterEnterobacter

Fungal OrganismsFungal Organisms

PD Affects Drug Transport PD Affects Drug Transport By:By:

Systemic drug removal via Systemic drug removal via effluenteffluent

Drugs can be administered IPDrugs can be administered IP Dose related to urine output Dose related to urine output

and mechanism for and mechanism for elimination of drugelimination of drug

Membrane changesMembrane changes Sclerosing, Encapsulating PeritonitisSclerosing, Encapsulating Peritonitis

A thick fibrous layer of tissue A thick fibrous layer of tissue encapsulates the bowel encapsulates the bowel

Membrane becomes thick and opaqueMembrane becomes thick and opaque Onset gradual or rapidOnset gradual or rapid PresentationPresentation

Decreased ultrafiltration and solute Decreased ultrafiltration and solute clearancesclearances

Recurrent abdominal painRecurrent abdominal pain Intermittent nausea and vomitingIntermittent nausea and vomiting Partial and/or complete bowel Partial and/or complete bowel

obstructionobstruction Intervention – Emergency laparotomyIntervention – Emergency laparotomy

Clinical Management Issues Clinical Management Issues for the PD Patientfor the PD Patient

Catheter insertion and healing of exit Catheter insertion and healing of exit sitesite

Prevention of infectionPrevention of infection Blood pressure control and fluid Blood pressure control and fluid

managementmanagement Nutrition evaluation and interventionsNutrition evaluation and interventions Systems assessmentSystems assessment Medication evaluationMedication evaluation Anemia/Ca/Phos./PTH managementAnemia/Ca/Phos./PTH management PET and initial Kt/VPET and initial Kt/V Coping with stress of chronic illnessCoping with stress of chronic illness Transplantation Transplantation

Current Issues in Peritoneal Current Issues in Peritoneal DialysisDialysis

Revision of K/DOQI Revision of K/DOQI Co-morbiditiesCo-morbidities Role of sodiumRole of sodium Volume ControlVolume Control Blood pressure controlBlood pressure control Utilization of IcodextrinUtilization of Icodextrin Role of inflammationRole of inflammation Integrated dialysis careIntegrated dialysis care Improving fellow educationImproving fellow education CKD education for patients and familiesCKD education for patients and families ADEMEX study-adequacyADEMEX study-adequacy European APD Outcome Study (2003)European APD Outcome Study (2003) Underutilization of Peritoneal DialysisUnderutilization of Peritoneal Dialysis

Questions ?Questions ?

ReferencesReferencesAsh [Author: Need full reference]

Flanigan, M. & Gokal,R. (2005). Peritoneal catheters and exit site practices toward optimum peritoneal access: A review of current developments. Peritoneal Dialysis International, 25, 132-139.

Kelley, K. (2004) How peritoneal dialysis works. Nephrology Nursing Journal, 31(5), 481-491.

Palmer & Quinton {Author: Need full reference]

Rosenak [Author: Need full reference]

Scribner & Boen [Author: Need full reference]

Additional ReadingsAdditional ReadingsAbu-Alfa, A. (2003) The Ademex Study: Expanding the Boundaries of peritoneal dialysis

adequacy beyond small solute clearances. Dialysis and Transplantation, 32(3), 115-124.American Nephrology Nurses’ Association (ANNA). (YEAR?). Chronic kidney disease – What

every nurse should know. Partnering for quality care. Retrieved May 31, 2007, from www.annalink.com

American Nephrology Nurses’ Association (ANNA). (2006). Peritoneal dialysis. (2006) In Molzahn, A.E., & Butera, E. (Eds.). contemporary nephrology nursing: Principles and practice (2nd ed.) (pp. 629-687). Pitman, NJ: Author.

American Nephrology Nurses’ Association (ANNA) Peritoneal Dialysis Special Interest Group. (2003). Peritoneal dialysis nurse resource guide. Nephrology Nursing Journal, 30(5), 535.

American Nephrology Nurses’ Association (ANNA) Peritoneal Dialysis Special Interest Group. (2004). A monograph on peritoneal dialysis. Nephrology Nursing Journal, 31(5).

American Nephrology Nursing Association (ANNA) Peritoneal Dialysis Special Interest Group. (2005) The Peritoneal equilibration test. Nephrology Nursing Journal, 32(4), 452-453.

Bargman, J. (1995). Preventing hernias and leaks in long-term patients on peritoneal dialysis. Seminars in Dialysis., 8(6), 370-372.

Additional ReadingsAdditional ReadingsBabcock, D.E., & Miller, M.A. (1994). Client education: Theory and practice. St. Louis, MO:

Mosby.Bargman, J. (2000). Non-infectious complications of peritoneal dialysis. In R.Gokal, R.Khanna,

R.Krediet, & K. Nolph (Eds.), Textbook of peritonealdialysis (2nd ed.) (pp. 609-646). London: Kluwer Academic Publishers.

Bernardini, J. (2004). Peritoneal dialysis: Myths, barriers, and achieving optimum outcomes . Nephrology Nursing Journal, 31(5), 494-498.

Bernardini, J., Bender, F., Florio,T., Sloand, J., Palmmontalbano, L., Fried, L., et al. (2005). Randomized, double-blind trial of antibiotic exit site cream for prevention of exit site infection in peritoneal dialysis patients. Journal of American Society of Nephrologists. 16(2), 539-545.

Burkart, J. (2003). The Ademex Study and its implications for peritoneal dialysis adequacy. Seminars in Dialysis, 16(1), 1-4.

Burrows-Hudson, S. (2005) Chronic kidney disease: An overview. American Journal of Nursing, 105(2), 40-49.

Crawford-Bonadio, T., & Diaz-Buxo, J. (2004) Comparison of peritoneal dialysis solutions . Nephrology Nursing Journal, 31(5), 500-513.

Additional ReadingsAdditional ReadingsDana, C. (2004). What is missing in making PD a success? Nephrology News and

Issues, 18(9), 25-28.Davies, S.J., Woodrow, G., Donovan, K., Plum, J., Williams, P., Johansson, A.C., et

al (2003) Icodextrin improves the fluid status of peritoneal dialysis patients: Results of a double-blind randomized controlled trial. Journal of American Society of Nephrology, 14(9), 2338-2344.

DeHaan, B. (2003) Why peritoneal dialysis should be the first treatment option. Dialysis & Transplantation, 32(3), 160-164.

Diffusion. www2.merriam-webster.com/mwmednl. Accessed 8/23/2007 Gokal, R., Khanna, R., Krediet, R., & Nolph, K. (2000) Textbook of peritoneal

dialysis (2nd ed.). London: Kluwer Academic Publishers.Gokal, R. (2002). What is the evidence that PD is underutilized as an ESRD therapy.

Seminars in Dialysis, 15(3), 149-150.Heaf, J. (2004). Underutilization of peritoneal dialysis. Journal of the American

Medical Society, 291(6), 740-742.Knowles, M.S. (1990). The adult leaner. A neglected species (4th ed.). Houston:

Gulf Publishing.

Additional ReadingsAdditional ReadingsLuongo, M., & Kennedy, S. (2004) Interviewing prospective patients for peritoneal dialysis: A

five-step approach Nephrology Nursing Journal, 31(5), 513-520.Maaz, D. (2004). Troubleshooting non-infectious peritoneal dialysis issues. Nephrology

Nursing Journal, 31(5), 521-532.Miller, D., MacDonald, D., Kolnack, K., & Simek, T. (2004). Challenges for nephrology nurses

in the management of children with chronic kidney disease. Nephrology Nursing Journal, 31(3), 287-294.

Mujais, S., Nolph, K., Gokal, R., Blake, P, Burkart, J., Coles, G., et al. (2000). Evaluation and management of ultrafiltration problems in peritoneal dialysis. Peritoneal Dialysis International, 20(Suppl 4), S5-S21.

Oreopoulos, D.G., Lobbedez, T., & Gupta, S. (2004) Peritoneal dialysis: Where is it now and where is it going? International Journal of Artificial Organs, 27(2), 88-94.

Paniagua, R., Amato, D., Vonesh, E., Correa-Rotter, R., Ramos, A., Moran, J., et al. (2002). Effects of increased peritoneal clearances on mortality rates in peritoneal dialysis: ADEMEX, a prospective, randomized controlled trial. Journal of American Society of Nephrology, 13(5), 1307-1320.

Piraino, B. (2005) Peritoneal Dialysis-Related inrections recommendations:2005 Update . Peritoneal Dialysis International. Vol 25(2) 107-131

Prasad, N., & Gupta,A. (2005) Fungal peritonitis in peritoneal dialysis patients. Peritoneal Dialysis International, 25(3), 207-222.

Additional ReadingsAdditional ReadingsPritchard, S. (2005). Will peritoneal dialysis be left behind? Seminars in Dialysis, 18(3), 167-170.Prowant, B. (2001) Peritoneal dialysis. In L.E. Lancaster (Ed.), ANNA core curriculum for nurses (4th ed.) (pp.

331-375) Pitman, NJ: American Nephrology Nurses’ Association (ANNA).Prowant, B., & Twardowski, Z. (1996) Recommendations for exit care. Peritoneal Dialysis International,

16(Suppl. 3), S94-S99.Ramon, G. (1998). Hydrothorax in peritoneal dialysis. Peritoneal Dialysis International, 18(1), 5-10.Robinson, K. (2001). Does pre-ESRD education make a difference? The patient’s perspective. Dialysis &

Transplantation, 30(9), 571-574. Rubin, H.R., Fink, N.E., Plantinga, L.C., Sadler, J.H., Kliger, A.S., & Powe, N.R. (2004) Patient ratings of

dialysis care with peritoneal dialysis vs.hemodialysis. Journal of the American Medical Society, 291(6), 697-703.

Salzer, W. (2005). Antimicrobial-resistant gram positive bacteria in PD peritonitis and the newer antibiotics used to treat them. Peritoneal Dialysis International, 25(4), 313-319.

Schatell, D., Ellstrom-Calder, A., Alt, P.S., & Garland, J.S. (2003). Survey of CKD patients reveals significant gaps in knowledge about kidney disease. Nephrology News & Issues, 17(6), 17-19.

Sturdivant, R., & McArthur, J. (2004). Eosinophilic peritonitis associated with atopy. Dialysis & Transplantation, 33(2), 97-104.

Twardowski, Z.J., & Nichols, W.K. (2001). Peritoneal dialysis access and exit-site care including surgical aspects. Textbook of peritoneal dialysis (2nd ed.). London: Kluwer Academic Publishers.

Twardowski, Z. (1987). Peritoneal equilibration test. Peritoneal Dialysis Bulletin, 7, 138-147.

Additional ReadingsAdditional Readings

Van Dijk, C., Ledesma, S., & Teitelbaum, I. (2005). Patient characteristics associated with defects of the peritoneal cavity boundary. Peritoneal Dialysis International, 25(40), 367-373.

Von Biesen, W. (2002). Peritoneal dialysis in anuric patients: Concerns and cautions. Seminars in Dialysis, 15(5), 305-310.

Von Biesen, W. et al. (2004). Improving salt balance in peritoneal dialysis patients. Peritoneal Dialysis International, 25(Suppl 3), S73-S75.

Wingard, R. (2005). Patient education and the nursing process: Meeting the patient’s needs. Nephrology Nursing Journal, 31(3), 211-214.

Wolfson, M. (2002). A randomized controlled trial to evaluate the efficacy and safety of icodextrin in peritoneal dialysis. American Journal of Kidney Diseases, 40(5), 1055-1065.

Zorzanello, M. Fleming,W., & Prowant, B. (2004). Use of tissue plasminogen activator in peritoneal dialysis catheters:a literature review and one center’s experience. Nephrology Nursing Journal, 31(5), 534-537.