This document discusses key considerations in assessing patients for peritoneal dialysis and initiating the therapy. It addresses issues like timing of catheter placement, adequacy of training, and management of early complications. Selection of appropriate patients and initiation of peritoneal dialysis is positioned as a multidisciplinary task requiring close monitoring by the renal team. Placement of the catheter 4-5 weeks before starting therapy and adherence to protocols for catheter care and training are emphasized.

1. Dr Ayman Seddik ,MD
Ass. Prof. Nephrology Ain Shams University
Nephrology Consultant Dubai hospital

2. Jean-Louis Clémendot

3. Review the issues encountered during the assessment phase of a
CKD patient , selection for peritoneal dialysis .
Discuss the issues encountered upon initiating peritoneal dialysis ,
and training program .

4. Ramesh Khanna & Karl D. Nolph
Modalities of renal replacement therapy
Interchangeable, dependson residual renal function

5. Trained nephrologists
Trained PD nurses
Unit Infrastructure
Active and effective
educational programm

6. 1. Efficacy of the therapy – Patients’
survival
2. Clinical advantages of specific therapy
3. Quality of life
4. Rate of complications eg infections ,
access problems

7. • 4568 HD and 2443 records from
4921 patients
• Treatment period – 1990 – 1999
• PD mortality rate vs HD
• ITT analysis – 0.65; P<0.001
• As treated – 0,86; P<0.001

8. Why to start with PD ?
1. better maintenance of residual renal
function

9. Patients with chronic kidney disease typically
seen in OPD Clinics at various stages
 Early referrals (CKD2 – 3GFR >30 ml/min)
 Typical referrals( CKD4-5 GFR , 30ml/min)
 Urgent referral ( Uremia,Hypercalemia, Fluid
overload)
 Translpant recipient with failing renal
allograft.

10. LATE REFERRAL AND INITIAL MODALITY

11. EDUCATION ABOUT MODALITIES

12. Initial assessment
Renal clinic
In hospital
consultation
Death
Transfer to HD
Transplantation
CKD Education
Modality choice
Life planning
Timing of initiation of PD
PD catheter r insertion
Training for PD
Maintenance care
Management of complications
JOURNEY THRU
PD CLINIC

27. pleuro-peritoneal
leakage
hernias
significant loin pain
big polycystic kidneys
• severe deformant arthritis
• psychosis
• significant decrease of lung
functions
* diverticulosis
• colostomy
• obesity
• blindness

33.  Timing of the start of the dialysis
 Timing of placement of PD catheter
 Dose of dialysis to be targeted
 Maintenance of volume control
 Psychosocial status and quality of the life of the
patient and their family

34.  Clearance or GFR as general guide
 Presence or absence early symptoms and signs of
Uremia
 Other complication of advanced CKD
 Changes in nutritional status and decrease in calorie
intake
 Deterioration in cognitive functioning/quality of life

36. Best inserted close to time of initiation
about 4 to 5 weeks prior to initiation of
PD
Exception use of buried PD catheters

38.  Partnership with surgeon or nephrologist
inserting the catheters
 Marking of the skin for best exit site locations

40.  Proper function of PD catheter as well as low incidence of
exit sites complications
 Critical for successful start to PD regime
 Exit site dressing best kept intact for 5-7 days
 Avoidance of poviodine or hydrogen peroxide around the
wound and sinus
 Immobilize catheter for first few weeks
 Showering best avoided till exit site is healed

43.  TIMING OF CATHETER PLACEMENT AND
INITIATION
 Close follow up and clinical evaluations
by nephrologists are critical
o Avoidance of interim hemodialysis, hospitalization
and temporary venous catheters is highly desirable
o
o Avoidance of nephrotoxins such as iodinated
contrast for venous mapping
 this is different than hemodialysis when
a arterio- venous fistula is usually created
3-4 months in advance

44.  PD training in the centre according to the protocol
 Home visit
 REVIEW OF ALL MEDICATIONS
 Reassessment of antihypertensive medicines
 ADVISABLE to continue or restart diuretics
 Recommended to restart ACEI or ARB
 Therapies for anemia, secondary hyperparathyrodism
and hyperphosphatemia

45. PD DELIVERED MANUALLY OR WITH THE
ASSISTANCE OF THE MACHINE – CYCLER
DESCISION MADE AFTER DISCUSSION
WITH PATIENT AND PATIENTS FAMILY

46. CAPD

47. APD

48. HIGH DOSE CCPD OR OPTIMIZED

49. Interpretation of peritonal
equilibration test ??

50. Transporter Waste
removal
Water
removal
Best type of
PD
High Fast Poor Frequent
exchanges,
short dwells –
APD
Average OK OK CAPD or
APD
Slow Slow Good CAPD, 4-5
exchanges
daily + 1
exchange at
night

51. OPTIONS
Hemodialysis using temporary venus
cath.
PD administered in the clinic by the
nurse while patient being trained
Low fill volume manual or APD

52. FIRST FEW WEEKSON PD IMPROVEMENT

53.  CONSTIPATION
 CATHETAR MIGRATION AND OCLUSION

54. Exit site infections , bleeding, leakage

57. Ultrafiltration in different types of PD
solutions

58. Documentation
:
 All exchanges
 Exit Site care
 Daily weights
CVPH utilizes a 24 Hour
Peritoneal Dialysis Record
to document.

60.  Evaluating candidacy for PD is a MULTI-
DISCIPLINARY task
 Timing of initiation of PD requires close assessment and
follow up by the Nephrologist and Renal team
PLACEMENT of catheter is bestdone about 4 to 5
weeks prior to anticipated initiation of PD as to allow
2 weeks of healing and 2 to 3 weeks of training

61.  Catheter care is best done according to a SET
PROTOCOL
 Adequate and complete training for PD is
critical
 Early serious problems can usually be
addressed without permanently discontinuing
PD
 Comprehensive care of the PD patient starts
early