Pd aki 2019

PERITONEAL DIALYSIS
in
ACUTE KIDNEY INJURY
Prof. Dr. Montasser Zeid
Prof. Of Internal Medicine , Nephrology Unit
Faculty Of Medicine ,
Alexandria University

Outline
1. Historical Background
2. Anatomy and Physiology
3. Introduction & evidence of PD in AKI
4. Indications for acute PD & Contraindications to acute PD
5. Techniques of acute PD & Treatment schedule
6. Prescription of acute PD
7. Complications of acute PD
8. Acute PD in critically ill and hypercatabolic AKI patients
9. Urgent start PD for the late referred ESRD patient

 The first article on the use of the peritoneal
cavity in experimental uremia (induced in
guinea pigs) was published in 1923 by Ganter.
 In 1961, Boen described the use of intermittent
peritoneal dialysis (IPD) in patients with chronic
renal failure
 In1968 Tenckhoff developed an indwelling
catheter, which led to nightly dialysis.
Historical Background

 This intermittent method, using a cycler to
infuse and drain fluid while the patient slept,
was the most common form of peritoneal
dialysis (PD)from the l960s to the late l970s.
 In 1976, Popovich et al, introduced continuous
ambulatory PD (CAPD), where four to six
exchanges are done each day with long dwell
times between exchanges.
Historical Background cont.…

 Oreopoulos et al. in 1978 described their
experience with CAPD.
 From this point on, use of CAPD increased and
cycler-IPD declined.
 In 1979 , the Seattle group(Moncrief/Popovich)
used a combination of cyclic and automated PD
in two patients.

 This technique was called continuous automated
ambulatory PD (CAAPD) .
 In1979 Baxter introduced to the market the first CAPD
system that included solution bags, tubing with a
spike at one end, a titanium luer lock to connect to
the patient’s catheter, and an antiseptic solution to
clean the spike/bag connection.
 In 1981, Diaz-Buxo and coworkers described their
more extensive experience and called this technique
continuous cycling PD (CCPD)

Outline
1. Historical Background
2. Anatomy and Physiology
3. Introduction & evidence of PD in AKI
4. Indications for acute PD & Contraindications to acute PD
5.Techniques of acute PD & Treatment schedule
6.Prescription of acute PD
7. Complications of acute PD
8. Acute PD in critically ill and hypercatabolic AKI patients
9. Urgent start PD for the late referred ESRD patient

 The peritoneal cavity is a potential space lined by
the peritoneal membrane , the total surface area of
which approximates the surface area of the skin in
adults .
 The surface of the membrane is lined by a layer of
lubricated mesothelial cells, beneath which lies the
interstitium containing connective tissue and
blood vessels, The blood supply to the visceral
peritoneum is derived from celiac, superior, and
inferior mesenteric arteries and their local
Anatomy and Physiology

 The parietal peritoneum receives blood from the
lumbar, intercostals and epigastric arteries and
drains into inferior vena cava.
Anatomy and Physiology cont.….

Sagittal section of the peritoneal cavity.

 The exact blood flow to the membrane is unknown
but is probably from 60-70 ml/min .
 Venous blood drains ultimately into the hepatic
portal vein.
 Lymphatic drainage from the peritoneal cavity is
largely through the diaphragm to the lymphatics
that are associated with the internal mammary and
anterior mediastinal lymph nodes; ultimately
draining into the right lymphatic duct.

R1 : The stagnant capillary fluid overlying the
endothelium
R2 : The capillary endothelium it self.
R3 : The endothelial basement membrane.
R4 : The interstitium.
R5 : The mesothelium
R6 : The stagnant fluid film that overlies the
peritoneal membrane.
Resistance to movement during peritoneal dialysis

Resistance to movement during peritoneal dialysis
Resistance to solute Movement During Peritoneal Dialysis

 The three – pore model
This model suggests that the peritoneal capillary is
the critical barrier to peritoneal transport and that
solute and water transport across it is mediated
by pores of three different sizes.
……….

1. Ultrasmall pores (0.8 nm in radius) that are
transcellular (aquaporin), these mostly transport
water molecules.
2. intercellular small pores (4-6 nm), which mostly
transport small solutes.
3. large pores (>20 nm) transporting only large
molecules such as peptides and proteins.

Conclusion:
-High doses of CPD provided appropriate metabolic and pH control, with
a rate of survival & recovery of renal function similar to that seen with
dHD.
-CPD can be considered an alternative to other forms of RRT in AKI
Gabriel D el al, Perit Dial Int 2007

Indications for Acute PD
 Renal Indications :
Oliguria in hemodynamic unstable patients
Bleeding diathesis or Hemorrhagic conditions
Difficulty in obtaining blood access
 Clinical uremic syndrome:
pericarditis, encephalopathy

Relative contraindications for Acute PD
1. Recent abdominal or cardiothoracic surgery
2. Diaphragmatic peritoneopleural connections
3. Fecal or fungal peritonitis
4. Severe respiratory failure
5. Abdominal wall cellulitis
6. Severe gastroesophageal reflux disease
7. Low peritoneal clearances
8. Life - threatening hyperkalemia
9. Severe acute pulmonary edema
10. Extremely high catabolism

PD advantages
1. Technique
– simply & quickly
– no highly trained personnel
– no expensive & complex apparatus
2. Patients with AKI
– Debilitated – Malnourished
– Hemodynamically unstable
3. Systemic anticoagulation .. not needed

Other advantages of PD
 Avoids disequilibrium syndrome because of slow
solute removal
 Widely available
 Hyperalimentation via diffusion of glucose (in
malnourished patients)
 Can be used to treat concomitant hypothermia or
hyperthermia

 Catheter
- Semi-rigid catheter
- Single / double - cuff Tenckhof catheter
 PD catheter insertion technique
- Subcutaneous ( blind ) technique
- Bedside Fluoroscopy
- Mini exploration
 Exchange procedure
- Manual / Machine
Techniques of acute PD

Comparison of the Three Techniques
DisadvantagesAdvantagesTechnique
• More preparation is required
• More expensive
• Large incision
• Longer healing time
• Increased risk of fluid leak
Under direct vision:
• Lower risk of injury to viscera
• Catheter placed in desired place
• Adhesions or large omentum can be
removed surgically
• Any type of catheter can be inserted
Surgical
• Cannot be used if adhesions or
large omentum present
• Higher failure potential
• Simple, easy, and quick procedure
• Heals quickly and can be used
immediately
• Performed in patient’s room with full
sterile precautions by the
nephrologist
• Less expensive than the other two
methods
Percutaneous
• Higher risk of injury to viscera
• Not all catheters can be placed
by this technique
• Expense of the scope Training
with scope.
• Faster healing
• Lower risk of fluid leak
• Simple procedure
• Useful even in presence of
adhesions
Peritoneoscopic
Table : Comparison of catheter insertion techniques

Prescription of acute PD
1. Length of the dialysis session
2. Dialysate composition
3. Exchange volume
4. Exchange time
• Inflow time • Dwell time • Outflow time
5. Additives to dilaysate
6. Catheter care
7. Monitoring

3. Exchange volume
4. Exchange time
5. Additive to dilaysate
6. Catheter care
7. Monitoring

Exchange volume
• Commonly 0.5 L – 2 L, adjusted
– size of patient’s peritoneal cavity
– severity of uremic syndrome
• Start with small volume minimal leak
• Lager volume greater clearance
• Hypercatabolic : high volume/cycle

3. Exchange volume
4. Exchange time
5. Additives to dialysate
6. Catheter care
7. Monitoring

3. Exchange volume
4. Exchange time
5. Additive to dialysate
6. Catheter care
7. Monitoring

To achieve the greatest clearances in AKI, cycles should be shortened
to maximize urea clearances, typically 30 to 50 minute dwell times.

Additives to dialysate
1. Potassium: 3 - 5 mEq /L in PDF .
Hypokalemia :
– Non potassium in solution
– Correct acidosis
– Glucose: shift potassium into cell
2. Heparin – 1000 - 2000 u/2 L prevent clot
3. Insulin
4. Antibiotics

Monitoring
• Fluid balance
• Clearance
– Electrolyte
– BUN/Cr
– Glucose

43
Corrective measuresCauseComplication
1- Peritonitis
Bacterial
Fungal
Chemical/sterile
2- Inadequate dialysis.
3- Exit site and tunnel
infections
Surgical correction, if neededCaused by the
increased intra-
abdominal pressure
4- Abdominal wall
complications
In recurring cases, decrease
intra-abdominal pressure by
changing to nocturnal
intermittent peritoneal
dialysis and keeping peritoneal
cavity empty while upright
5- Hernias
Umbilical
Inguinal
Incisional
(catheter sites)
Epigastric - Ventral
Cystocele - Others
Complications of peritoneal dialysis

44
Corrective measuresCauseComplication
Most leaks improve
with rest insertion site
Reduced pressure
Secondary to either a
wall defect
6- Genital edema
(scrotal and labial)
or a leak around the
catheter
7- Hydrothorax (pleural leak)
8- Malnutrition
9- Cardiovascular
complication's
10- Sclerosing encapsulating
11- peritonitis
Decrease pressure
Regular exercise
Change in posture
due to the presence
of a large volume of
fluid
12- Back pain
13- Intra-abdominal abscesses
14- Hemoperitoneum
15- Chyloperitoneum

Common pathogenic organisms and the frequency of
their involvement in peritonitis
Frequency of isolation (%)Organism
80 - 90
30 - 40
5 - 10
5 - 10
Gram-positive bacteria
Staphylococcus epidermidis
Staphylococcus aureus
Streptococcus viridans
Streptococcus faecalis
5 - 10
5
<10
<5
<5
<5
Gram-negative bacteria
Escherichia coil
Klebsiella/Enterobacter spp.
Pseudomonas spp.
Acinetobacter spp.
Mycobacteriurn spp.
Others
1 - 10
< 5
5 - 20
Fungi
Candida spp.
Other fungi
Culture negative

Membrane Failure
There are three types of membrane failure:
 Type I failure:
In type I failures, high solute transport (see Chapter 10)
causes failure of ultrafiltration (UF).
This is due to quick absorption of glucose and the
dissipation of the osmolality of the fluid.
 Type II failure:
In type II failures, sclerosing peritonitis and chronic ongoing
inflammation cause decreased membrane permeability and
surface area.
This leads to decreased UF and solute transport.

Membrane Failure
 Type III failure:
Type III failures are caused by excessive lymphatic
absorption leading to a loss of net UF, with
unchanged solute transport characteristics.
Type I membrane failure is the most common.
Both types I and II can be characterized easily by
peritoneal equilibration test (PET) results.
Type III is a diagnosis of exclusion.

Metabolic Complications of Peritoneal Dialysis in
AKI

Contraindications to PD in acute setting
 Severe hyperkalemia
 Abdominal and thoracic surgery – hydrothorax
may develop after thoracic surgery
 Respiratory problems – increases intraabdominal
pressure
 GERD
 Pregnancy

Access
 Semirigid (Cook) catheter
- Can be done at bedside without surgeon
- Must be removed within 72 hours because of
risk
of bowel perforation and infection
 Cuffed permanent catheter
- More comfortable
- Avoids repeated punctures

Table: Commonly used peritoneal catheters
Easy to place by percutaneous technique
Easy to remove and replace
Rectal discomfort is more common and outflow
problems are more common
Straight Tenckhoff
Same as above, but better patency and better
outflow
Does not impinge on the rectum
Curled Tenckhoff
Same as straight Tenckhoff
Tunnel must be curved
Swan neck
Combination of Toronto Western and swan-neck
catheter
Can only be place and manipulated surgically
Missouri
Can only be placed and manipulated surgicallyLifecath

Peritoneal Catheters ( lateral views )

Peritoneal Dialysis Catheters
Tenckhoff technique with curved tunnel

Clin J Am Soc Nephrol 7: 887 – 894, 2012. doi: 10.2215/CJN.11131111

Nephrol Dial Transplant (2010) 25: 3155 – 3160 doi: 10.1093/ndt/gfq178
Advance Access publication 29 March 2010

Acute PD Rx
 Short dwell times
 Can be done manually or by automated cycling
device
 Warm PD fluid to body temperature
 Often dialysate volume 2-3L and dialysate flow
rate 2-6L/hr
 Important to ensure complete outflow at finish

Standard PD solution
Volume (L)
0.25, 0.5, 1.0, 1.5, 2.5,
3.0, 5.0, 6.0
Sodium (mEq/L) 132
Potassium (mEq/L) 0-2, mostly 0
Glucose (g/dL) 1.5, 2.5, 4.0, 25
Calcium (mEq/L) 2.5-3.5
Magnesium (mEq/L) 0.5-1.5
Lactate (mEq/L) 35-40

Additives
 Heparin – 200 to 500u per liter, not absorbed
systemically
 Potassium
 Insulin
- 4-5u/L for 1.5% dextrose

Commonly available peritoneal Dialysis
Solution Formulations
These may differ slightly in name and in formulation from region to region.
All glucose-based solutions are available in Three strengths (1.36, 2.27, and 3.86 ma/dL of glucose, equivalent to1.5,2.5,
and 4.25 mg/dl of dextrose as glucose monohydrate
To convert calcium from mmol/l. (mM] to rng/dl. multiply by 4.
To convert maqnesium from mmulfl. (mM) to mg/dI. multiply by 2.43.
FMC, Fresenius Medical Care.

Gabriel D el al, Perit Dial Int 2007

Urgent start PD for the late referred ESRD patient
 Patients who have reached ESRD without prior
dialysis access are often given temporary vascular
access and initiated on RD.
 The benefits of PD, however, such as better
preservation of residual kidney function, quality of
life, early survival advantage in many patient
groups, lower risk of sepsis and Hepatitis B and C
transmission, and preservation of vascular access
for future options, all suggest that initiation of
dialysis with PD is advantageous.

Urgent start PD for the late referred ESRD patient
 In the late referred ESRD patient, PD can be
initiated urgently and temporary vascular access
can be avoided.
 With dual cuff catheter placement, the PD access
can be used for both the acute/urgent start to PD
and then matured to become the chronic access –
avoiding the multiple procedures involved with
converting temporary HD access to permanent
access.

Conclusions
 Selected modality should be guide by individual pt.,
clinical status, medical personnel expertise &
available RRT modality.
 Renal programs should include an integrated PD/HD
program where therapies are not competitive but
rather complementary.
 PD remains a therapy :
– Easily
– simply
– Adequately instituted, especially for infants and
children with AKI
– Within &outside of ICU settings

Conclusions cont.….
 PD can be intiated acutely for the treatment of AKI
or for the late-referred CKD patient needing to
start dialysis.
 Initiating PD two days after catheter insertion is
possible by employing supine, lower dwell
volume exchanges.
 Percutaneous PD catheter placement avoids
surgical referral and operating room scheduling
and can facilitate the urgent initiation of PD.

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