Introduction and Statistics of PD

1. PD in AKI
A ‘dispassionate’ Re-appraisal
Dr Sanjay Maitra
MD,DM(PGI,Chd),Clin.Fellowship Toronto Univ.
Sr.Consultant Nephrologist,Apollo Health City, Hyderabad

5.  In 2008 there were about 196,000 P.D. pts. worldwide (11% of total)
 59 % were from developing and 41% from developed countries
 PD prevalence increased 2.5 times in developing countries during the
period
 The proportion of patients treated with PD declined in developed
countries but remained stable in developing countries

6. PD incidence rates are on the rise in US as compared to HD
During 2012 the Annual Mortality Rates for PD & HD similar

8. Current Dialysis scenario in INDIA
Hemodialysis -82,000 pts
Perit. Dialysis -9,000
APD -700
Major PD centres ,India
SGPGI, Lucknow
CMC ,Vellore
PGIMER,Chandigarh
AIIMS,Delhi
NIMS, Hyderabad
MCH,Calicut
RIMS, Imphal
Ganga Ram Hosp,Delhi
Frontline Hospital
International Hosp,Gauhati

9. Role of PD in AKI
Complimentary not competitive

10. Advantages of PD
 Widely available and technically easy
 Particularly useful in isolated and remote areas
 After natural calamities and in battle areas
 Costs less than CRRT and Slow continuous dialysis
 Fluid removal rather easy in haemodynamically
unstable patients
 Gentler form of dialysis, no dialysis-disequilibrium
 Gradual correction of acid-base and electrolyte disturbances

11. Advantages of PD
 PD access placement is easier , particularly in children
 PD very useful modality, particularly in small children
 No need for arterial or venepuncture or anticoagulation
 Highly biocompatible technique
 Better and faster recovery from AKI is reported
 May help remove cytokines in patients with Sepsis
 PD well suited for hypotensive patients
 Dextrose in PD solutions may provide nutrition
 Intraperitoneal medication administration possible

12. Renal indications of PD in AKI
 RRT in the treatment of children
 Hemodynamically unstable patients
 Presence of bleeding diathesis or haemorrhagic
conditions
 Making vascular access or use of anti-coagulants difficult
 Patients with difficult vascular access placement
 Removal of high molecular weight toxins(10KD)

13. Non-Renal indications of PD
in AKI
 Acute Pancreatitis
 Clinically significant hypothermia or hyperthermia
 Refractory heart failure
 Liver failure
 Infusion of drugs and nutrients as supportive
therapy in critically ill patients

14. Contraindications to Acute PD
 Recent abdominal surgery
 Pleuro- peritoneal connections
 Severe respiratory failure
 Life threatening hyperkalaemia
 Extremely hypercatabolic state
 Severe volume overload in a patient not on ventilator

15. Contraindications to Acute PD
 Severe Gastro-oesophageal reflux disease
 Low peritoneal clearance
 Faecal or fungal peritonitis
 Abdominal wall cellulitis
 AKI in pregnancy

16. Current Dialysis scenario in INDIA
Hemodialysis -82,000 pts
Perit. Dialysis -9,000
APD -700
Major PD centres ,India
SGPGI, Lucknow
CMC ,Vellore
PGIMER,Chandigarh
AIIMS,Delhi
NIMS, Hyderabad
MCH,Calicut
RIMS, Imphal
Ganga Ram Hosp,Delhi
Frontline Hospital
International Hosp,Gauhati

17. The North-Eastern States
State Popln. Dia.cntr Nephr. HD
machines
HD
ssns
PD cntrs
Assam 3cr 20 15 200 6000 15
Manipur 27 lakh 8 5 3
Nagaland 23 lakh
7 3 2
Mizoram 11 lakh 5 2 3
Meghalaya 32 lakh 5 3
AP 12 lakh 1 1 1
Tripura 36 lakh 3 1

20. AKI
RIFLE Criteria and AKIN criteria compared

21. Stage Serum Creatinine Urine output
1 1.5-1.9 times baseline
Or
≥0.3mg/dl absolute increase
<0.5ml/kg/hr for 6-
12 hrs
2 2.0-2.9 times baseline <0.5ml/kg/hr for
≥12 hrs
3 3.0 times baseline
Or
↑ to ≥ 4.0 mg/dl
Or
Patients on Dialysis
Or
In patients<18yrs e-
GFR<35ml/min/1.73m2
<0.3ml/kg/hr for≥
24 hrs
Or
Anuria for≥ 12hrs
K-DIGO staging of AKI

22. Apprehensions about using PD
in AKI
 Low Clearance of uremic toxins particularly in
 Hypercatabolic and obese patients
 Those on vasopressors and with splanchnic hypoperfusion
 Potentially unpredictable fluid removal rates
 Risk of peritonitis
 Glucose absorption and hyperglycaemia
 Excessive protein loss
 Impaired diaphragmatic movement in ventilated patients
 Causing decreased Functional Reserve Capacity

23. What does the evidence tell us about the
adequacy of PD in AKI?

24. Pooled Mortality was 39.3% in PD only group
In cohort studies comparing PD with EBP
the mortalities were comparable 58% vs 56.1%
In RCT the mortalities were no different
Primary outcomes :Mortality rates
Secondary outcomes : Length of stay
Kidney recovery & complications of PD
and EBP
One half of studies are from Asia –Pacific 4 are from Brazil, 3 are from Africa
Mean age of patients ranged from 29.1-75.6 yrs
Causes of AKI were Sepsis, Pre-renal,Cardiac failure,Post-surgery and
nephrotoxic agents

25. What did the RCT’s show?
Primary Outcomes
 Two of the studies compared PD with CRRT
 George and Phu
 The third one compared PD with Intermittent HD
 4th Study compared patients of AKI or CKD on PD or
intermittent HD
 Only 8 of 40 were AKI
 Pooled results from RCT showed no difference

26. What did the RCT’s show?
Secondary Outcomes
Rapid Recovery of Renal functions in AKI pts on PD
 Doubtful , one study from Brazil found it to be true
 Studies from India and Vietnam found the opposite
 Study by Phu et al found the mortality rate to be nearly 3 times that
of CVVHD
Complications of PD
 Most common is Peritonitis (40%)
 Technique failure or catheter related problems
 In 1 study only mentioned as 10%
Difficult to generalise because
 Review spanned over 4 decades ,both PD and CRRT techniques have
changed
 Epidemiology of AKI has also changed, Sicker ,older patients

27.  RCT comparing PD with CVVHD
 70 pts: 48 with Malaria, 22 with sepsis
 34 underwent CVVHD –Mortality 15%
 36 underwent PD -Mortality 47%
 Trial stopped prematurely

28.  Patients with AKI and MODS were randomly allotted to CVVHDF or CPD
 25 patients in each group
 Primary outcome ,Composite correction of uremia and fluids and electrolytes
 Secondary outcomes, improvement of sensorium ,hemodynamic stability, cost ,
survival
 Solute correction better in HD, acidosis better corrected with PD
 Fluid overload better corrected with CVVHD
 Mortality 84% in CVVHDF and 72% in PD group, PD was cheaper too

29.  Prospective Randomised Controlled trial
 Compared effect Of HVPD vs Daily HD on AKI patient survival
 Total 120 patients ,60 in each arm ;age and severity matched
 Primary end point hospital survival and renal function recovery
 Secondary end point metabolic control
 Weekly Kt/V in HVPD -3.6 , with DH 4.7
 Mortality rates were comparable 58 and 53%, Renal recovery similar
 Patients with HVPD had shorter time to recovery in renal function

31.  Prospective randomised cross-over trial
 Pts with mild to moderately catabolic ARF
 Assigned to CEPD or TPD and then changed over to the other
 87 patients received 236 sessions of dialysis (118 each)
 TPD had better clearances than CEPD
 Normalised Creatinine clearances 68.5 vs 58.85
 Kt/V 2.43 vs 1.80
 Both were reasonable options for treating AKI

34.  The usefulness of Urea Kinetic Modelling in AKI is debatable
 Other than small solute clearance , no other parameter identified
 One RCT from Brazil compared PD to daily HD and found no difference
Kt/V urea of 3.6±0.6 per week
 Extrapolating from HD data std- Kt/V urea of 2.1 is considered adequate in
most
 There are no targets for Middle Molecular weight substances
 Ultrafiltration volume control remains difficult on PD

35. Techniques of PD used for AKI
Technique Description Clearance
Acute Intermittent
Peritoneal Dialysis(AIPD)
Fequent small exchanges with volumes
of 1-2 litres
Dialysate flow 2-6 ltrs /hr
Each session 16-20hrs,3times/wk
Urea Cl
8-12ml/min
Continuous Equilibrating
Peritoneal Dialysis (CEPD)
Long dwells of 2-6 hrs (like CAPD)
2 ltrs. dialysate volume
? Low small mol.clearance
Tidal Peritoneal Dialysis
(TPD)
Portion of Dialysate ,Tidal drain volume
is removed (1-1.5 ltrs)
Replaced by Tidal fill volume
Reserve volume remains in abd.
Urea Cl
15/ml/min
High Volume Peritoneal
dialysis (HVPD)
Continuous therapy proposed to increase
small solute clearance
Cycler based 18-48 exchanges /24hrs
2ltr exchanges. Total dial 36-70 ltrs /day
Continuous Flow peritoneal
Dialysis(CFPD)
2 accesses for inflow and outflow
Dialysis flows of 300ml/min achieves
good urea clearance
Urea Cl
30-35ml/min

36. Intra-Peritoneal fluid volumes in different PD regimes

37. Catheter placement for CFPD.
1. Lateral catheter halfway superior iliac crest and umbilicus, pointing
laterally (dedicated to inflow).
2. 2. Umbilicus.
3. Midline catheter 1 cm below umbilicus, pointing downward and
contralaterally away from 1 (dedicated to outflow).
Continuous Flow Peritoneal Dialysis

38. Continuous Flow Peritoneal Dialysis Circuit

39. Catheter Types
Rigid and Flexible

40. Type of PD Catheter to be used
 Flexible peritoneal catheters should be used wherever available
 Tunneled catheters have lesser peritonitis and peri-catheter leaks
 Prophylactic antibiotics prior to Tenckhoff catheter implantation
 Closed fluid delivery system with Y connection preferable
 In Low-resource areas spiking of bags and make-shift connections may
be used

41. Choice the technique
 Depending on patient profile , available resources and local
expertise
 PD catheter implantation by nephrologist is safe and to be
encouraged
 Patient with midline scars and high risk of peritoneal
adhesions should avoid blind insertions
PD Insertion Techniques

42. Type of PD solution for acute PD
 In patients with Shock or liver failure , bicarbonate based solutions
should be used, when not available lactate containing ones to be used
 Commercially prepared solutions in collapsible bags are better,
 If not, locally manufactured solutions under sterile conditions to be used

43. Components of Acute PD prescription
1.) Length of the dialysis session
2.) Dialysate composition
3) Exchange volume
4) Inflow and outflow periods
5) Dwell time
6) Number of exchanges
7)Additives
8) Monitoring of fluid balance
Objectives
 When resources permit, target weekly Kt/V of 3.5,outcomes same as HD
 For many patients a weekly Kt/V of 2.1 may be adequate
 During initial 24 hrs of therapy, duration of cycle times needs adjustment
 Short cycles to correct hyperkalemia ,metabolic acidosis and fluid
overload are necessary
 Avoid Fluid overload
 Drug levels ,particularly antibiotics to be monitored

46. Complications of PD in AKI
 Peritonitis
 Diagnosis may be challenging
 Abdominal pain, cloudy effluent
 PD fluid WBC >100cells/µL after 2 hours dwell, repeat daily
 Leucocyte esterase 2+ on Urine dipstick
 Treat clinically if in doubt
 Antibiotics to be given I.P and with every exchange
 Mechanical complications
 Catheter malfunction , blockage ,displacement
 Reported incidence between 7-10%
 Protein loss
 About 6- 12 gm/day in CAPD, upto 48 gms/day in Peritonitis
 Brazilian study with HVPD found 4.2 ±6.1 gm/24 hr in AKI
 Hyperglycaemia
 Maintain eu -glycaemia

47. Summary
 PD can be a useful option in treating patients of AKI in
low resource settings, far-flung areas or as part of
disaster management.
 It is particularly useful in certain patient population like
small children or those with cardio-renal syndromes or
vascular access problems
 PD, both manual and automated can provide reasonable
doses of dialysis in mild to moderately hyper-catabolic
patients
 Cycler based therapies with a closed drainage system
have lesser degrees of peritonitis

48. Summary
 Automated peritoneal Dialysis and newer PD solutions
have restricted use in developing countries mainly
because of cost and lack of infrastructure
 Hyperglycaemia and protein loss in PD are not un
surmountable problems
 Use of PD should be encouraged by the nephrology
community as well as the state policy makers in
developing countries
 Patients of AKI here have less associated comorbidities and
are generally younger

49. Thank You

58. PD in AKI
A ‘dispassionate’ Re-appraisal