Certification Review Course Peritoneal Dialysis Ray Agnello, BSN, RN, CNN Educator Saint Joseph’s Regional Medical Center Paterson, New Jersey

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Certification Review CoursePeritoneal
DialysisRay Agnello, BSN, RN,
CNNEducatorSaint Josephs Regional Medical
CenterPaterson, New Jersey
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Objectives
To provide attendees with a summarized
review of peritoneal dialysis To highlight
key points in the clinical care of a PD patient
Catheter Placement Care of Catheter Infectious
Complication Non Infectious Complications Adequac
y Fluid Balance assessment of the PD patient.
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Peritoneal Dialysis

• Alternative to hemodialysis
• Patient is taught to perform dialysis exchanges
  in the home setting
• Focus is on patient autonomy and self care
  management
• Patient must be followed by a licensed Peritoneal
  Dialysis unit Nephrologist

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Peritoneal Membrane

• Translucent
• Vascular membrane
• Two layers
• Parietal (inner surface of abdominal wall)
• Receives blood supply from the arteries of the
  abdominal wall
• Visceral (covers abdominal viscera)
• Covers the abdominal organs
• Blood is carried by the mesenteric and celiac
  arteries
• Most vascular layer where most of the dialysis
  occurs
• Envelope of space between layers called
  peritoneal cavity
• Semi-permeable-acts as a Filter
• Kelley 2004

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Anatomy and Physiology

• Peritoneal Membrane
• Semi-permeable
• Bi-directional
• Membrane size- 1-2 m2
• Vascular wall, interstitium, mesothelium , and
  adjacent fluid films
• Closed in males
• Women- ovaries and fallopian tubes open into the
  peritoneal cavity
• Peritoneal cavity normally contains about 100 ml
  transudate

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Kinetics of Peritoneal Dialysis

• Diffusion
• Osmosis
• Ultrafiltration
• Drug Transport

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Diffusion
Tea Bag Peritoneal Membrane
Water PD Fluid
Tea Leaves Waste
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Scheme of semi-permeable membranered
blood blue PD fluidyellow membrane
.wikipedia.org/
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Osmosis

• 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 Edition
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Osmotic Pressure of Dextrose Solution
1.5 Solution
2.5 Solution
4.25 Solution
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The Peritoneal Dialysis Process

• Definition- intra (within) corporeal dialysis
• Three Phases to the Exchange process
• Drain
• Fill
• Dwell

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How Does PD Work?

• The semi-permeable peritoneal membrane lines the
  abdominal cavity and covers the abdominal
  viscera.
• The membrane allows (via diffusion) the passage
  of toxins and electrolytes into the dialysis
  solution.
• Ultra-filtration (removal of fluid) occurs via
  osmosis.
• A steady state of toxin clearance and fluid
  management is achieved due to daily performance
  of dialysis.
• K. Kelly , RN
• NNJ Sept-Oct 2004

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How Does PD Work?

• Dialysis solution is infused and drained via a
  catheter that is surgically placed in the
  peritoneal cavity.
• The action of draining and infusing dialysis
  solution is called an exchange.
• The frequency of exchanges and volume is
  determined by the presence of residual renal
  function and the individual membrane
  characteristic.

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Infusion or Fill
Baxter
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Drain
Baxter
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Peritoneal Dialysis

• Dialysis occurs during the dwell phase
• Diffusion solutes cross from area of greater
  concentration to lesser one
• -depends on concentration gradient
• -enough peritoneal surface area
• -size of fill volume
• Ultra-filtration water removal due to osmotic
  gradient between the hyperosmolar PD fluid and
  the capillary bed
• Kelley 2004

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Historical Perspectives

• Acute-Predominant use of PD prior to 1960s
• 1966- Automated cycler
• 1967- Tenckhoff catheter
• 1975- CAPD
• 1978- Polyvinyl bags and manufactured in the US
  (prior PD fluid was available in glass bottles)
• 1980s- New catheter designs
• 1987- PET and tidal PD -Twardowski
• 1990s-Alternative dialysate solutions,
• updated system designs ANNA Core
  Curriculum 5th Ed

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Who Are the PD Patients ?

• Choose PD as Renal Replacement Therapy
• Hemodialysis Patient without Access
• Failed allograft (transplanted kidney)
• Have CHF or CVD which exempts them
• from hemodialysis
• Often people with the benefit of CKD education

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• PD Patient Selection
• Inclusion Criteria Include
• Patients who
• Choose the modality
• Want control
• Prefer home for dialysis
• Have residual renal function
• CVD, CHF
• Geriatric
• Pediatric
• Vascular Access Failure
• Social support system available

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Selection Continued

• Exclusion Criteria
• Patients who
• Have abdominal aortic aneurysm AAA (size
  dependent)
• Derm. disease of the abdominal wall
• Morbid abdominal obesity
• Altered mental status, poor coping styles
• Solitary life style
• Patient states lack of interest in modality
• Multiple abdominal surgeries- adhesions
• Ostomies (increase risk of infection)
• Recurrent hernias

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Steps to PD Catheter Access

• Evaluation by Nephrologist for PD catheter
  placement and identified as candidate.
• Educated about catheter placement, pre and post
  operative care routines.
• Referred to surgeon for evaluation that includes
  determination of exit site,clinical anesthesia
  work-up, contraindications, completion of consent
  forms and scheduling of surgery.

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Surgical EvaluationCatheter Insertion

• Some units advocate insertion 2 to 6 weeks prior
  to dialysis to optimize healing.
• Some units advocate insertion months in
  advance.(burying the catheter)
• In most situations, PD access is elective

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Surgical Evaluation

• Abdominal wall weakness or hernia
• Repair hernia preemptively or when symptomatic
• Previous abdominal surgeries multiple surgeries
  increased likelihood of adhesions
• Abdominal wall obesity

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Pre Catheter Insertion

• Patient Education and consent signed
• Examination of the patients abdomen
• Avoid scars and fat folds
• Avoid beltline
• Mark the abdomen
• Surgical prep
• Empty bladder
• Patient showers with disinfectant soap
• Bowel prep

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Question

• Evidence-based practice suggests which of the
  following upon PD catheter implantation?
• Large fill volumes immediately post-op
• No need to wear a mask while performing PD
  exchanges
• Incision site to be exposed to air during
  immediate post-op period
• Administration of prophylactic IV antibiotics
  prior to catheter implantation to reduce the risk
  of peritonitis
• Core curriculum for Nephrology Nursing, 5th
  Edition. American Nephrology Nurses Association

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Peri Operative RoutinesAnesthesia

• Local infiltration with sedation
• Intravenous propofol with Monitored Anesthesia
  Care
• General anesthesia

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Insertion Techniques

• Bedside-temporary catheters
• Laparoscopic placement
• Surgical dissection
• Buried Catheter technique
• Percutaneous placement per Interventional
  Radiology

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Insertion Techniques

• Buried catheter
• Entire catheter placed in subcutaneous pocket for
  4-6 weeks or longer, allowing cuff tunnel to
  heal
• Exit site is externalized in a separate
  procedure
• Reduced bacterial colonization(?)
• Do not have long term outcomes yet
• Flanigan, Gokal, 2005

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Catheter History

• Early catheters were glass cannulas with straight
  or with mushroom ends
• 1920-40s Various medical devices were used in
  the beginning of PD needles, glass cannulas,
  sump drains, stainless steel coils, Foley
  catheters
• 1923-Ganter used a needle for the 1st reported
  use in humans.
• 1950s-Nylon catheters, polyethylene, plastic
  with rounded tip numerous tiny side holes
• ANNA Core Curriculum 5th Ed

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Catheter History

• 1960s-
• silicon rubber catheters, with coiled
  intraperitoneal segment (Palmer, Quinton)
• Tenckhoff Schechter published results with
  silicone elastomer (Silastic ) for chronic
  dialysis with 2 Dacron polyester felt cuffs
• 1968-Tenckhoff cuffed straight catheter
• 1970s-single/double cuff coiled catheter
  Toronto Western with 3 silicone disc
• 1980s-swan neck configuration ( bent or curved
  SQ segment Toronto Western with 2 silicone disc
• 1990s-t shaped catheter (Ash) Moncrief
  Popovich technique for leaving the exterior
  segment buried SQ for 4 wk
• The future..?
• ANNA Core Curriculum 5th Ed

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Catheters

• Straight (single or double cuff)
• Coiled (single or double cuff )
• Swan neck (single or double cuff)
• Pre sternal swan neck
• Toronto Western
• Missouri catheters
• Disc catheters

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Cuffs

• Single
• Double
• Elongated
• Bead/flange configuration

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Question

• What is one advantage of implanting a cuffed PD
  catheter?
• Acts as a barrier to prevent infection
• Can only be used for CAPD
• Ensures optimal adequacy
• Can be implanted at the bedside
• Core curriculum for Nephrology Nursing, 5th
  Edition. American Nephrology Nurses Association

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Adaptors

• Plastic
• Titanium

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PD Catheter Access Complication

• Immediate/Early
• Bloody effluent
• Pain with infusion
• Leak at exit site
• Exit site infection
• Migration of catheter tip
• Poor fill or drain, with or without pain
• Non-infectious cloudy effluent
• (lymphatic leak or eosinophilic peritonitis)

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Question

• The patients fill volume is 2000mL. Upon
  draining, the patients volume is 1500mL. The
  nurse should assess the patient for which of the
  following?
• a. Peritonitis
• b. Catheter removal
• c. Constipation
• d. Subcutaneous tunnel infection
• Core curriculum for Nephrology Nursing, 5th
  Edition. American Nephrology Nurses Association

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PD Catheter Access Complication

• Later Issues
• Exit site leaks or subcutaneous leaks
• Pleural communications
• Excessive granulation tissue
• Chronic site or tunnel infection
• Cuff extrusion
• Cracked, brittle catheter
• Repetitive episodes of peritonitis
• Bowel perforations

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Post Op

• Follow up appointment with surgeon
• Instructions (written verbal) to patient, which
  include emergency contact numbers
• Follow-up in PD unit within
• 48 to 72 hours of discharge
• Pain medication/prescription
• Reinforce dressing as needed
• Teach patient to secure catheter
• Flush catheter during training sessions

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Post Operative Discharge Plan

• Remove primary dressing in 5 to 7 days by PD
  nurse
• Dressing changed by PD nurse
• Replace dressing with DSD, non-occlusive
• Establish training schedule
• Bowel regimen
• No heavy lifting
• Allow catheter to heal for 14 days or
  longer if possible before use

Prevent Constipation
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Peritoneal Dialysis Therapies

• IPD (Intermittent Peritoneal Dialysis)
• CAPD (Continuous Ambulatory Peritoneal Dialysis )
• CCPD (Continuous Cycling Peritoneal Dialysis)
  also known as APD (Automated Peritoneal Dialysis)

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Training Sessions for the PD Patient

• Assess readiness to learn
• Provide a quiet, relaxed atmosphere for learning
• Identify patients learning style
• Individualized with respect to patients
  expectations, cultural beliefs, and coping
  abilities
• Length of training based on patients clinical
  condition

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On Call RN
ON Call RN
ON Call
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Warming the Solution

• Use warm, dry heat
• At home- PD heating pad
• NEVER MICROWAVE!!
• Uneven heating of dextrose can create a
• 1st or 2nd degree burn to peritoneum
• Leaching of plastics into dialysate can
• Create a chemical peritonitis
• NEVER MICROWAVE!!

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Patients at risk for inadequate dialysis

• No residual renal function
• Low membrane permeability
• Large patients
• Patients not doing their treatments

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PD Equilibration TestAKA PET

• First developed by Z. Twardowski at the
  University of Missouri
• A four hour study that assesses membrane
  transport characteristics.
• Assessment of membrane function allows for
  accurate prescription planning.
• Usually completed within the first six weeks of
  initiating PD
• Repeated per each units protocol

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PD Equilibration Test continued

• What does this tell us?
• The results indicate the following transport
  states
• High
• High-average
• Low-average
• Low

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http//www.homedialysis.org/files/pdf/resources/to
m/200801.pdf
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KT/V Test

• What is measured?
• 24 hour collection of dialysate and urine
• Serum values of BUN and Creatinine
• Frequency of test is determined by each units
  protocols and interpretation of K/DOQI
  guidelines. (Unit specific, usually quarterly or
  bi-annually)

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KT/V Test continued

• What does it tell us?
• The adequacy of the current prescription
• Need for adjustments to insure appropriate
  dialysis prescription

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Exit Site Care

• Healthy exit site surrounding skin natural,
  darkened, or light Pink no drainage or crusting
  visible sinus is dry
• Goal prevent exit site infection and identify
  problems early
• ES Care daily or 3-4 times weekly may be in
  conjunction with showering

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Infection Prevention

• Exit Site Care
• No dressing needed for established catheter exit
  site (unit or pt specific)
• Keep catheter secured to abdomen with 2 inch tape
• Daily showers with liquid soap
• Mupirocin (Bactroban ) or Gentamycin Cream at
  exit site of known staph. Carrier
• Inpatients-dry dressing to protect site, cleaned
  with soap and water, No occlusive membrane
  dressings (Tegaderm )
• A healed and non-infected exit site is crucial to
  longevity on Peritoneal Dialysis

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Question

• Following peritoneal dialysis catheter
  implantation, a patient is instructed that
• The exit will always be tender
• Baggy clothes will have to be worn
• The catheter will need to be changed monthly
• Well-healed healthy exit-sites make swimming
  possible
• Core curriculum for Nephrology Nursing, 5th
  Edition. American Nephrology Nurses Association

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Infectious Complications
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Exit Site Infection

• Teach patient to identify and report immediately
  to the PD Unit
• Redness, tenderness, edema, presence of exudate
  either at exit site or insertion site
• Treatment
• Culture exudate if possible
• Specific antibiotic protocol
• Oral or IV/IP antibiotics depending on extent of
  infection
• Saline soaks/dressing changes for care of local
  cellulitis (unit/Nephrologist specific)

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Exit Site Infection

• S S redness, swelling, tenderness or pain and
  purulent drainage
• Risk Factors poor catheter healing, sutures at
  the exit site, trauma to the exit site, cuff
  extrusion and improper catheter care
• Diagnosis Observation and culture
• Treatment Antibiotics, IP,PO, or IV
• vigilant daily exit site care

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Exit Site Infection

• A chronic exit site infection can produce a
  systemic inflammatory response.
• Inflammation can lead to poor nutrition,
  inadequate dialysis and possible antibiotic
  resistance. Vital role of Dietitian
• Chronic exit site infections may result in
  peritonitis.
• Multiple infections can lead to removal and
  replacement of catheter.
• Consistent assessment and documentation is needed
  to appropriately track infections.

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Responsible Organisms

• Staphylococcus Aureus
• Pseudomonas species
• Other Gram positive species
• Serratia species
• Other gram-negative organisms
• Fungi

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Tunnel Infection

• S S
• erythema over the tunnel
• pain and tenderness
• drainage from exit site no other signs of an
  infection
• Risk factors
• exit-site infection
• exit site trauma
• leak
• external cuff extrusion
• Treatment- antibiotic therapy to prevent need
  for catheter removal

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Prevention of Peritonitis

• Careful individualized patient training
• Adequate daily hygiene
• Meticulous hand washing
• On going retraining

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Prevention of Peritonitis

• Basics of Aseptic Technique 5 min. hand scrub,
  face masks during exchanges, warming of PD bags
  using dry heat, aseptic technique for adding
  medicines
• Aseptic technique when making critical
  connections to solution containers and the
  patients transfer set
• Masks reduce the risk of contamination with
  nasopharyngeal organisms

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Peritonitis

• Inflammation of the peritoneal cavity
• Defined as the presence of WBC in the effluent
  numbering 100 or greater 50 polys (neutrophil)
  or segs
• Effluent appears cloudy and milky.
• Patient may have fever, chills, abdominal pain,
  nausea, vomiting and diarrhea.
• Some present initially with cloudy fluid as the
  first sign and no symptoms.
• Patient must be taught to contact their PD Nurse
  or Nephrologist immediately for cloudy effluent.

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Peritonitis

• Portals of Entry
• Transluminal- technique failure, contamination
• Periluminal- incomplete healing ,leaking
• Hematogenous- bacteremia
• Transmural- through the bowel wall
• ANNA Core Curriculum

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Peritonitis Presentation

• S S fever, abdominal pain, N V, diarrhea,
  and cloudy effluent
• Incubation 24-48 hours if within 6 hours
  suspect an enteric source
• Kinetic effects increased solute removal and
  protein loss increased glucose absorption
  leading to a decreased osmotic gradient and
  decreased ultrafiltration

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Diagnosis of Peritonitis

• Effective culture techniques
• Minimum sample volume of 50-100 ml. Large samples
  reduce false negative results
• Dialysate must be mixed well by inverting bag
  several times before sampling
• Sample port is disinfected before sampling
• Sample is obtained using aseptic technique

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Question

• A PD effluent cell count differential can
  determine if peritonitis is present when there is
  an elevation in ?
• a. eosinophils
• b. neutrophils
• c. lymphocytes
• d. granulocytes
• Core curriculum for Nephrology Nursing, 5th
  Edition. American Nephrology Nurses Association

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Peritonitis

• Treatment protocols
• Patient may be treated in PD unit or Emergency
  Room depending on severity of symptoms and
  availability of resources.
• Effluent is sent for cell count, CS and gram
  stain
• Fungal cultures should be included if patient is
  immunosuppressed or had had frequent infections
  requiring antibiotics
• PD Unit should have specific antibiotic protocols
  for gram positive and gram negative coverage.

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Peritonitis

• Organisms
• Gram positive-
• Staphylococcus epidermidis
• Staphylococcus aureus
• Streptococcus species
• Enterococcus
• Gram Negative-
• Pseudomonas
• Klebsiella
• Escherichia coli
• Enterobacter
• Fungal organisms

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Question

• Catheter removal is recommended when the patient
  has peritonitis associated by which of the
  following organisms?
• Staph aureus
• Fungal
• Staph epi
• Pseudomonas
• Core curriculum for Nephrology Nursing, 5th
  Edition. American Nephrology Nurses Association

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Non Infectious Complications
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Non Infectious Complications

• Pericatheter and Subcutaneous Leaks
• Peritoneal Catheter Obstruction most commonly
  early, yet can occur at any time.
• Hernia significant abdominal wall hernias
  should be surgically repaired prior to initiation
  of PD. Enlargement may occur due to increased
  abdominal wall pressure.

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Non Infectious Complications

• Pneumoperitoneum (Shoulder Pain) usually
  resulting from air infusion
• Hemoperitoneum blood loss into the peritoneal
  cavity. A few drops of blood will produce
  grossly bloody effluent. Most common in women in
  menses. Any bleeding needs to be monitored.
• Hydrothorax secondary to a pleuroperitoneal
  communication.

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PD Affects Drug Transport By

• Systemic drug removal via effluent
• Drugs can be administered IP
• Dose related to Urine output and mechanism for
  elimination of drug

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Non Infectious Complications

• Catheter Adapter Disconnect or Fracture of
  Peritoneal Catheter. Stop Dialysis, obtain
  culture, replace or repair, prophylactic
  antibiotics pending culture results

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Membrane changes

• Sclerosing, Encapsulating Peritonitis serious,
  yet rare, not exclusive to PD
• A thick fibrous layer of tissue encapsulates the
  bowel
• Membrane becomes thick and opaque
• Onset gradual or rapid
• Presentation
• Decreased ultrafiltration and solute clearances
• Recurrent abdominal pain
• Intermittent nausea and vomiting
• Partial and/or complete bowel obstruction
• Intervention emergency laparotomy

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Clinical Management Issues for the PD Patient

• Catheter insertion and Healing of exit site
• Prevention of infection
• Blood pressure control Fluid management
• Nutrition evaluation and interventions
• Systems assessment
• Medication evaluation
• Anemia,Ca/Phos./PTH management
• PET and initial Kt/V
• Coping with stress of chronic illness
• Transplantation

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Current Issues in Peritoneal Dialysis

• Revision of K/DOQI
• Co-morbidities
• Role of sodium
• Volume Control
• Blood pressure control
• Utilization of Icodextrin
• Role of inflammation
• Integrated dialysis care
• Improving nephrology fellow education
• CKD education for patients and families
• ADEMEX study-adequacy
• European APD Outcome Study (2003)
• Underutilization of Peritoneal Dialysis

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Final Note

• The success of PD can be attributed to the
  combined efforts of researchers, individuals on
  PD, and healthcare professionals who, in
  collaboration with the industrial community, have
  realized the potential benefits of the treatment.
  Despite a slow start in comparison to HD, PD has
  evolved into a modality that equals HD in long
  term outcomes.
• Contemporary Nephrology Nursing p 633

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Questions ??