Pd update atmeeda

2. Dr. Osama El-Shahat
Consultant Nephrologist
Head of Nephrology Department
New Mansoura General Hospital (international)
(Egypt)
ISN Educational Ambassador

3.  Integrated Renal Care
 Advantages of PD
 Peritonitis
 PD in AKI
 PD cost
 Conclusion
Agenda

4. The word preitoneum refers to the Greek word “peritononion” and
means to stretch. Ancient Egypt were probably the first people to get
a look at the peritoneum
1st steps towards peritoneal dialysis.

5. PD … the modality first used for the treatment of KI

6. Blood Purif 2013;36:226–230 DOI: 10.1159/000356627

7. Conclusion
This review clearly shows that PD is a simple, safe, and
efficient way to correct metabolic, electrolyte, acid –
base, and volume disturbances generated by AKI and it
can be used as an RRT modality to treat AKI, both in and
out of the ICU setting.

8. A1.1 Peritoneal dialysis should be
considered as a suitable method of
continuous renal replacement therapy in
patients with acute kidney injury (1B).

9. Flexible peritoneal catheters should be
used for acute PD where resources and
expertise exist (1C) (Optimal).
It may be necessary to use rigid stylet
catheters or improvised catheters in
resource-poor environments where they
may still be lifesaving (2D) (Minimum
standard).

10. We recommend that nephrologists receive
training and be permitted to insert these
catheters to ensure timely dialysis in the
emergency setting (1B).

12. Acute PD dosing guidelines adapted from ISPD guidelines

13. Why to start with PD ?

15. Lang et al, PDI 21:52-57, 2001
Preservation of residual renal function in
CAPD, low flux & high flux HD

16. PD Patients Have an Initital Survival Advantage
Relative to HD.
Danish Registry 2001
Time (years)
J Heaf, NDT 2002
4921 patients

17. Conclusions
Peritoneal dialysis seems to be associated with 48% lower
mortality than hemodialysis over the first 2 years of dialysis therapy
independent of modality switches or differential transplantation rates.
Clin J Am Soc Nephrol 8: 619–628, 2013.

18. Prevalence of anti-HCV Among Patients
on Dialysis by Modality
Pereira KI 1997;51:981-999
7%
13%
16%
19%
23%
31%
44%
47%
50%
35%
25%
5%
2%2%
0%
17%
8%
12%
34%
5%
15%
20%
0%
20%
40%
60%
M
cIntyre
Brugnano
C
han
Jonas
C
antu
D
ussol
Barril
N
eto
Selgas
H
uang
Yoshida
HD PD

20. .Conclusions
Dialysis modality selection significantly influences the
risk of HCV infection experienced by end-stage renal
failure patients in the Asia-Pacific region. No such
association could be identified for HBV infection.

22. Conclusions.
The study suggests that the
outcome of patients starting PD
after kidney transplant failure was
similar to those starting HD.
Therefore, PD can be regarded to
be a good treatment option for
patients returning to dialysis after
kidney transplant failure

23. Most observational data indicate that there
is an initial survival advantage for patients
with ESRD started on PD therapy.
these include
 preservation of residual kidney function
 reduced infection risk
 improved patient satisfaction
 lowered health care costs

24. 24
Integrated Renal Care:The Concept
“Complementary Not Competitive” Coles 1998
“The right modality at the right time. Peter Blake, MD, John Burkart, MD
Early referral of patient
With CKD to renal center
Pre-emptive
Transplantation
PD as first option if medically suitable
Allowing for patient chioce
Patient education
program
HD Transplant
PD
Timely
referral
Timely
preparation
Best sequence of
PD, HD and TX
Therapy
management
Timely
Initiation
Therapy
transfer

25. 49.4%
15.8%
20%
17.1%
7.4%10%
0%
20%
33.2%
50%
60%
Jalisco (Mexico)New Zealand Netherlands Denmark Canada United States
%PrevalentPatientsonPD
Underutilization of Peritoneal Dialysis
U.S. Renal Data System. USRDS 2013 Annual Data Report.

27. Conclusions
In conclusion, PD continues to be underutilized in
many countries, including the United States. There are
many factors that contribute to this underutilization
(e.g., modality, system, and patient-related factors).
Clin J Am Soc Nephrol 6: 447–456, 2011

28. The Importance of Patient Education
Golper T. Patients education: can it maximize the success of therapy? Nephrol Dial Transplant .2001 :(suppl 7):20-24.
The National Pre-ESRD Education Initiative Survey
After Pre-ESRD Education ,45 %Chose PD and 33 %Actually Started PD
N = 2400100
80
60
40
20
0
Choice of Modality Actual Modality Started US Incidence
PercentageofPatients
PD
HD

29. Rioux J, Cheema H, Bargman JM, et al. Effect of an in-hospital chronic kidney disease education
program among patients with unplanned urgent-start dialysis. Clin J Am Soc Nephrol 2011;6:799.
Conclusion
Home dialysis is feasible after urgent dialysis start.
Education should be promoted among patient experiencing
acute- start dialysis.

30. 228Acute Start Between 2005-2009
Education program before discharge
132
In-center HD
71
Home
49PD 22HHD
25
Died
(before discharge)
Patients’ flow through the study
Rioux J, Cheema H, Bargman JM, et al. Effect of an in-hospital chronic kidney disease education
program among patients with unplanned urgent-start dialysis. Clin J Am Soc Nephrol 2011;6:799.

31. Physician Preference For Modality
Merighi JR, Schatell DR, Bragg-Gresham JL, et al. Insights into nephrologist training, clinical
practice, and dialysis choice. Hemodial Int 2012;16:242-251.
N=629

32. Distribution of nephrologists’ modality
choice for themselves
Adapted from:
Merighi JR, Schatell DR, Bragg-Gresham JL, et al. Insights into nephrologist training,
clinical practice, and dialysis choice. Hemodial Int 2012;16:242-251.

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

36. CONCLUSION
We have demonstrated that direct xenograft of HUMSCs into the rat intraperitoneum
effectively prevented PD/MGO 3W-induced abdominal cocoon formation,
ultrafiltration failure, and peritoneal membrane alterations such as peritoneal
thickening, fibrosis, and inflammation. These findings provide a basis for a novel
approach with therapeutic benefits in the treatment of encapsulating peritoneal
sclerosis.

37. Transports
Hospitalisation
Pharmaceuticals
(e.g. EPO)
Equipment costs
(Lease, depreciation,
maintenance)
Disposables
Labor
Water Treatment
Infrastructure
Transports
Hospitalisation
Pharmaceuticals
(e.g. EPO)
Equipment costs
Disposables
Labor
Infrastructure
Schematic RRT Cost Comparison Available
Modalities

38. Modality Cost Comparison In KSA

41. Results
From the regional population ([9,700,000 inhabitants), 1067 patients (34.3 % females)
initiating dialysis were identified, of whom 82 % underwent only hemodialysis (HD), 13
% only peritoneal dialysis (PD) and the remaining 5 % both treatments. Direct healthcare
costs/patient were € 5239, € 12,303 and € 38,821 (€ 40,132 for HD vs. € 30,444 for PD
patients) for the periods 24–12 months pre-dialysis, 12–0 months pre-dialysis, and in the
first year of dialysis, respectively.
Conclusions
This study highlights a significant economic burden related to CKD and an increase in
direct healthcare costs associated with the start of dialysis, pointing to the importance of
prevention programs and early diagnosis.

42. Conclusion
The decline of PD in the Netherlands cannot be explained by medical reasons. Whatever
the causes, it has resulted in a downward spiral where loss of experience and insufficient
knowledge on important pathophysiological and other related pertinent issues of this
home dialysis modality have resulted in an almost exclusive attention to hemodialysis.

43.  Integrated care approach is the optimal treatment for ESRD.
 PD is the modality of choice to start RRT if kidney Tx not available.
 PD is the solution for overcrowded dialysis units.
 PD is underutilize, more effort from nephrologists, government and
local companies to support PD program.