Pd intervention-1

1. PD administration program
Dr. Hamed Ezzat El-Eraky
Nephrology Specialist
Mansoura International Hospital

2. Kidney Function

3. Execratory function

4. REGULATORY FUNCTION

5. FORMATION & ACTIVATION OF
CERTAIN HORMONES & VITAMINS

6. CHRONIC KIDNEY DISEASE IS A GENERAL
TERM FOR HETEROGENEOUS DISORDERS
AFFECTING THE STRUCTURE AND FUNCTION OF
THE KIDNEY.
KIDNEY FAILURE IS DEFINED AS A GFR OF
LESS THAN 15 ML/MIN PER 1·73 M², OR THE
NEED FOR TREATMENT WITH DIALYSIS OR
TRANSPLANTATION.

9. Symptoms & Signs Of Renal Failure
1- Accumulation Of Waste Products (Urea, K, Po4,..)
2- Accumulation Of Salt & Water ( HTN, L.L. Edema,
Dyspnea,…)
3- Acidosis
4- Hormones & Vitamins Defiancy( Anemia, Itching,
Bonache, Deformity, HTN, Anasarca)

10. RRT

11. The right modality
at the right
time.
Complementary
Not
Competitive

12. MULTIDISCPLINARY TEAM
•Pharmacist•Social worker
•PD nurse•Ward
nurse
Dietitian
nephrologist
Tx team Access team

14. 0
50
100
150
200
250
300
350
400
UAE KSA Morocco Oman Qater Egypt Algeria

15. INDICATION OF PD:
- UNAVAILABLE HD
- HYPOTENSION
- ACCESS FAILURE
- DIABETIC PATIENT
- ISCHEMIC HEART DISEASE
- HEART FAILURE
- BLEEDING TENDENCY
- FEAR OF BLOOD
- ACTIVE PERSONS
- INFANT BELOW 12 YEARS

16. - Peritoneal adhesion due to previous
operation or inflammation
- Hernia
- Poor vision
- Psychiatric disorders
- COPD & asthma
- Morbid obesity
CONTRAINDICATION OF PD

17. Patient selection
- AGE
- GENERAL CONDITION
- PERSONALITY
- RENAL FUNCTION

18. • It’s an internal process inside the
body in which Dialysis fluid is
introduced to the peritoneal cavity
through a catheter placed in the
lower part of the abdomen.
• peritoneum serves as the dialysis
membrane. The peritoneal cavity
can often hold more then 3 liters,
but in clinical practice only 1.5 – 2.5L
of fluid are used.
• Solutes are transported across the
membrane by diffusion.
• Fluid is removed by ultrafiltration
driven by an osmotic pressure
gradient.

19. Peritoneal catheters

20. Peritoneal fluid
Osmotic agent , Electrolytes , Acid – Base buffer

21. Osmotic agent
Glucose :
Glucose was the only osmotic agent
available until 1990.
It is not directly toxic, effective and
inexpensive available in con. 1.36%
1.5% 2.5% and 4.25% with high
glucose concentration is used for
effective UF

23. Electrolytes
Sodium (Na)
Na conc. In P.D. Solution is bet 130 – 137 mEq/L.
Potassium (K)
K can in available solution from (0 to 2 mEq/L).
In hyperkalemic patient K free solution used to maximize K
removal .
To avoid hypokalemia add 1 to 4 mEq/L.
Calcium (Ca+)
Ca level in the dialysate solution varies from 0 to 1.75 mmol/L.
Ca level 1.0 to 1.25 mmol/L lead to adequate Ca balance & Ph
control with oral Ca binder.
Low Ca dialysate (0.6 – 1 mmol/L) is used in sever
hyperparathyroidism .
Magnesium
Mg. in P.D. Solution at concentration varies from 0.25 to 0.75
mmol/l may be associated with hypermagnesiumia,

24. Acid – Base buffer
The buffer composition of available P.D.
solutions can be divided into three
categories.
• Non bicarbonate buffers
• Bicarbonate / lactate combination buffers
• Bicarbonate buffers

25. PRINCIPLES OF PD EXCHANGES
Dialysis fluid is introduced to the
peritoneal cavity through a catheter
placed in the lower part of the
abdomen.
peritoneum serves as the dialysis
membrane. The peritoneal cavity can
often hold more then 3 litres, but in
clinical practice only 1.5 – 2.5L of fluid
are used.
Solutes are transported across the
membrane by diffusion.
Fluid is removed by ultrafiltration driven
by an osmotic pressure gradient.

26.  CAPD (Continuous Ambulatory Peritoneal
Dialysis)
 APD (Automated Peritoneal Dialysis)
 CCPD (Continuous Cycling Peritoneal Dialysis)
 IPD (Intermittent Peritoneal Dialysis)
 NIPD (Nocturnal Intermittent Peritoneal
Dialysis)
 TPD (Tidal Peritoneal Dialysis)
Types of Chronic Peritoneal
Dialysis

27. 1. Fill Phase
(<15 minutes)
* Disconnect
2. Dwell phase
(4-8 hours)
3.Drain phase
(<20 minutes)
CAPD

28.  Preservation of RRF
 Higher Hb concentration
 Less risk of acquiring blood
borne infections e.g. HCV
 Better quality of life
 It allows expansion with
limited resources
 Lower staff / patient ratio
 saves vascular access
 preferred for children
ADVANTAGES OF PD

29. Complications of PD therapy
infectious Non infectious
Peritonitis TunnelExit site
Acute Chronic

30. peritonitis
• It is the major complication of PD and
remains the main reason for switching
patient to HD .
• The rate should not be > 1 episode/18
patient-month or 0.67 episode / year at
risk (ISPD guidelines)

31. clinical presentation of peritonitis
abdominal pain ( 80% )
fever ( 50%)
nausea ( 30% )
diarrhea ( 7-10% )
poor drainage
cloudy fluid or drainage
loss of UF function

32. Diagnosis of peritonitis
Based on the number of WBCs :100 wbc / mm3.
 A gram stain should be done.
 Bacteria are present in low concentrations in PD fluid.
 positive culture, in the absence of WBCs usually
represent contamination
 Culture negative ~ 20% of cases.
 sterile culture: antibiotic, poor culture technique, early
sampling.

33. Initiate empiric therapy with Cefazolin or Cephalothin and OR Glycopeptide (
Vancomycin or Teicoplanin) and Ceftazidime
Initial therapy
Continuous dosing Intermitt. dosing
Cefazolin or
cephalothin
250 mg/L load,then 125 mg/L in each
exchange
15 mg/kg in a single
exchange/day
Ceftazidime 250 mg/L load,then 125 mg/L /change 15 mg/kg in a single
exchange /day
Vancomycin 500 mg/L load,then 30mg/L /change 30 mg/kg in a single
exchange q 5-7 days
Teicoplanin 200 mg/L load,then 20mg/L /change 15 mg/kg in a single
exchange q 5-7 d.

34. Maintenance therapy
Staph. aureus Enterococcus strepto. Other gram +ve
Methicilin sensitive:
continue cephalosporin
Discontiue ceftazidime and
glycopeptide.
Add rifampicin
20mg/kg/day, orally.
Mehticillin resistant:
Discontinue ceftazidime
Continue glycopeptide
Discontiue cephalosporin or
glycopeptide and ceftazidime,start
ampicillin 125 mg/L.
Aminoglycoside may be added
based on sensitivity result and
patient response.
Vancomycin for ampicillin resitancs
cases
Methicillin sensitive:
Discontinue ceftazidime and
glycopeptide, continue
cephalosporin
Duration: 21 days 14 days 14 days

35. Single gram –ve /non
Pseudomonas
pseudomonas Multiple organisms and
/or anaerobe
Adjust antibiotics to
sensitivity pattern.
May continue ceftazidime
Discontinue cephalosporin
or glycopeptide.
Continue ceftazidime, add
agent with activity against
pseudomonas (
piperacillin,ciprofloxacin,a
minoglycoside or
aztreonam
Consider surgical
intervention and add :
Metronidazole 15
mg/kg/day in divided
doses (max. 1.5gm/day).
Duration: 14 days 21 days 21 days
Maintainance therapy

36. Non-infectious Complications of Peritoneal Dialysis
Mechanical complications Metabolic Disturbances
Early
Pain
Bleeding
Perforation of a
viscera
Exit site leak
Late
Catheter – related
complications
Pain
Bleeding
Catheter obstruction
Catheter cuff
extrusion
Increased intra –
peritoneal pressure
Fluid leak
Hernias
Low back pain
GERD
Alteration of
diaphragmatic mechanics
Alteration of peritoneal
transport
Peritoneal –
membrane
related
complications
Ultrafiltration Failure
(UFF)
Encapsulating
peritoneal Sclerosis
Hyperglycaemia Hyperlipidemia
Malnutrition Hypokalemia
Hypermagnesaemia

37. • Closed system
• Semi closed
• Open system

40. Failure of PD program
Cost Problems
• Limited number of patients
– Local production of peritoneal bags is not feasible except on
a large scale >500 – 1000 pts [All bags are imported from
western countries therefore, they are relatively very
expensive ].!
– Manufacture of local bags will not be feasible due to limited
number of patients.
– Difficulty in increasing the number of patients due to the
high cost of CAPD
• Limited Resources
– Depending only on government subsidy
– Lack of a integrated insurance system

41. PD program in Mansoura
PD program in Nephrology Department Of New
Mansoura General Hospital ( international ) is
established about 6 years ago.
The service in our department introduced to the
patient for free.
At 1st Its mainly depend on donation supported by
‫البريتونى‬ ‫الغسيل‬ ‫لدعم‬ ‫المصرية‬ ‫االهلية‬ ‫الجمعية‬

42. ‫البري‬ ‫الغسيل‬ ‫لدعم‬ ‫المصرية‬ ‫االهلية‬ ‫الجمعية‬‫تونى‬

49. ‫دولة‬ ‫نفقة‬
‫صحى‬ ‫تأمين‬

50. 240 * 5.5 = 1320
120 * 28 = 3360
monthly cost = 4680
240 * 12 = 2880
120 * 50 = 6000
monthly cost = 8880

51. • Home visit
• Dialysis
• Monthly visit
• complication
• Patient selection
• Education
• Catheter insertion
• Wash
PREPARATION FOR PD

52. • Home visit
• Dialysis
• Monthly visit
• complication
• Patient selection
• Education
• Catheter insertion
• Wash
PREPARATION FOR PD

53. Patient selection
• From the start for cases of CKD either
young age , cardiac or difficult access.
• Transformed from HD: mainly due to
access failure or life style.

54. • Home visit
• Dialysis
• Monthly visit
• complication
• Patient selection
• Education
• Catheter insertion
• Wash
PREPARATION FOR PD

55. Patient education
posters

56. Educational Meetings

57. Patient education
videos

58. • Home visit
• Dialysis
• Monthly visit
• complication
• Patient selection
• Education
• Catheter insertion
• Wash
PREPARATION FOR PD

59. Insertion Of PD Catheter

60. • Home visit
• Dialysis
• Monthly visit
• complication
• Patient selection
• Education
• Catheter insertion
• Wash
PREPARATION FOR PD

61. Catheter Wash &
Flushing

62. • Home visit
• Dialysis
• Monthly visit
• complication
• Patient selection
• Education
• Catheter insertion
• Wash
PREPARATION FOR PD

63. Home visit

64. • Home visit
• Dialysis
• Monthly visit
• complication
• Patient selection
• Education
• Catheter insertion
• Wash
PREPARATION FOR PD

65. Dialysis

66. 1. Fill Phase
(<15 minutes)
* Disconnect
2. Dwell phase
(4-8 hours)
3.Drain phase
(<20 minutes)
CAPD

67. • Home visit
• Dialysis
• Monthly visit
• complication
• Patient selection
• Education
• Catheter insertion
• Wash
PREPARATION FOR PD

68. Monthly visit

69. ‫الدقهلية‬2
‫الغربية‬1