Peritoneal Dialysis

Suitable Candidates

Equipment and Resources

Preparation for Peritoneal Dialysis

Initiating Peritoneal Dialysis

Ultrafiltration and Fluid Management

Solute Clearance

Metabolic Factors

Infectious Complications in Patients on Peritoneal Dialysis

Diet and Peritoneal Dialysis

Indications for Switching from PD to HD

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Suitable Candidates

• Patients with a “virgin abdomen” or minor prior abdominal surgery, and residual renal function, should be offered the option of peritoneal dialysis
• The abdominal musculature should be reasonable, i.e., exclude those with significant obesity and/or hernias
• The patient should be physically capable of doing bag changes for continuous ambulatory peritoneal dialysis (CAPD), particularly with regards to visual acuity and limb dexterity
• The patient should be psychologically able to perform repetitive bag changes per sterile protocol
• Suitable storage space for dialysate and adequate hand washing facilities should be available.

Equipment and Resources

• Peritoneal dialysis should be delivered in the context of a comprehensive and integrated service for renal replacement therapy, which includes haemodialysis (including temporary backup HD), transplantation and conservative care
• Both continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD) should ideally be available
• Dedicated PD nursing staff with a minimum of 1 PD nurse per 20 patients should be part of the multidisciplinary team.

Preparation for Peritoneal Dialysis

• All patients should be adequately prepared for renal replacement therapy and receive information and education about PD treatment, delivered by an experienced member of the team
• Patients commencing RRF in an unplanned fashion for whatever reason should receive this information once appropriate.

Initiating Peritoneal Dialysis

Timing of referral and surgery:

• Whenever possible, catheter insertion should be performed at least 2 weeks before starting PD
• Small dialysate volumes in the supine position can be used if dialysis is required earlier
• It is advisable to enable correction of early catheter related problems without the need for temporary haemodialysis
• For timing of PD initiation refer to When to initiate dialysis

The Access Team

• All renal physicians should be familiar with the percutaneous technique of insertion of the Tenckhoff catheter
• Each centre should have a dedicated surgical team involved in the implantation and care of peritoneal catheters
• The access team should comprise nurses, nephrologists, and surgeons who have experience in peritoneal dialysis and understand the importance of successful access placement and the need for attention to detail in the reduction of complications.

Insertion Protocol

• Treatment units should have clear protocols for perioperative catheter care, including the use of antibiotic prophylaxis
• Local expertise should govern the choice of method of PD catheter insertion; insertion should not be delegated to inexperienced, unsupervised operators
• A dedicated area should be used for catheter insertion, with appropriate staffing, suction, oxygen, and patient monitoring facilities
• PD catheter insertion training should be available to all nephrology trainees
• Preoperative: check for hernias and identify a catheter of suitable length; mark the exit site with the patient sitting or standing; screen for nasal carriage of methicillin resistant Staphylococcus aureus (MRSA) and S. aureus
• Pre-implantation: prepare the bowel with laxatives; ensure bladder emptying and prepare the surgical site; use antibiotic prophylaxis
• Post-procedure: flush catheter and cap off; immobilise the catheter; cover the exit site with a non-occlusive dressing and, if possible, do not disturb for 5-10 days; discharge the patient home with supply of laxatives and advice on recognising potential complications
• Once the catheter is placed and until healing is completed, the dressing changes should be done by a dialysis nurse using a sterile technique
• Peri-operative catheter care and catheter complications (leaks, hernias, obstruction) should be managed according to the International Society of Peritoneal Dialysis guidelines (www.PDIconnect.com).

Ultrafiltration and Fluid Management

• Peritoneal membrane function should be monitored 6 weeks after commencing treatment and at least annually or when clinically indicated using a peritoneal equilibration test (PET) or equivalent
• Daily urine and peritoneal ultrafiltration volumes should be monitored at least six-monthly. A patient diary of UF volumes should be kept for evaluation
• Dialysis regimens resulting in fluid reabsorption should be avoided. Knowledge of transporter status is useful in individualising prescriptions. Patients with high or high average solute transport should be considered for automated PD (APD) and the use of icodextrin
• Residual renal function must be formally assessed and preserved by avoidance of nephrotoxins or episodes of hypovolaemia/ hypotension, and by the use of ACE inhibitors and ARBs
• Dialysis regimens resulting in routine utilisation of hypertonic (3.86% or 4.25%) glucose exchanges should be avoided
• Anuric patients who consistently achieve a daily ultrafiltration of less than 750 ml should be closely monitored and the benefits of a modality switch considered.

Solute Clearance

• Both residual urine and peritoneal dialysis components of small solute clearance should be measured to assess clearance targets
• A combined urinary and peritoneal Kt/Vurea of 1.7/ week or a creatinine clearance of 50L/week/1.73m² is the minimum treatment dose
• The dose should be increased in patients experiencing uremic symptoms
• A continuous 24 hour PD regime is preferred to an intermittent regime.

Metabolic Factors

• Use standard strategies to optimise diabetic control; complement these with dialysis prescriptions that minimise glucose, where possible
• Central obesity can worsen or develop in some PD patients; this risk can be reduced by avoiding excessive glucose prescription
• Plasma bicarbonate should be maintained within the normal range; this can be achieved by adjusting the dialysis dose and/or dialysate buffer concentration; occasionally bicarbonate buffered solutions will be required.

Infectious Complications in Patients on Peritoneal Dialysis

• PD units should undertake regular audit of their peritonitis and exit-site infection rates, including causative organisms, treatment and outcomes. They should enter into active dialogue with their microbiology department and infection control teams to develop optimal local treatment and prevention protocols
• The flush-before-fill dialysis delivery systems should be used
• Patients should undergo regular revision of their technique (annually or more frequently if indicated, such as after an episode of PD-related infection or an interruption to performing PD) and receive intensified training if required.

Treatment

• Exit site infection is suggested by pain, swelling, crusting, erythema and serous discharge; purulent discharge always indicates infection. Swabs should be taken for culture and initial empiric therapy should be with oral antibiotics that will cover S. aureus and P. aeruginosa
• Methicillin resistant S. aureus (MRSA) will require systemic treatment (e.g. with vancomycin) and will need to comply with local infection control policies
• Initial treatment for peritonitis should include cover for bacterial Gram positive and Gram negative organisms including Pseudomonas species until the result of culture and antibiotic sensitivities are obtained
• Intraperitoneal administration of antibiotics is superior to IV dosing for treating peritonitis; intermittent and continuous dosing of antibiotics are equally efficacious
• Once culture results and sensitivities are known, antibiotic therapy should be adjusted to narrow spectrum agents as appropriate. For patients with substantial residual renal function the dose of antibiotics may need to be adjusted
• The full ISPD treatment guidelines for PD-related infections are available from www.PDIconnect.com.

Diet and Peritoneal Dialysis

Substantial loss of protein into dialysate occurs with PD. The average loss varies between 5 and 15 g/24 h.

A protein intake of 1.0 g/kg body weight/day is enough to preserve nutritional status. Energy requirements are dependent on the level of physical activity. In general, dietary energy intake for adult PD patients should be 35 kcal/kg/day, adjusted for age.

Indications for Switching from PD to HD

The decision to transfer a patient from PD to HD should be based on clinical assessment. Indications include the following:

• Inadequate solute transport or fluid removal
• Unacceptably frequent peritonitis, persistent peritonitis or other PD-related complications
• Development of technical/mechanical problems
• Severe malnutrition resistant to aggressive management (relative).

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Paget G, Naicker S, et al. Guideline for the optimal care of patients on chronic dialysis in South Africa. South African Renal Society; 2015.