Therapy Modality: Continuous Ambulatory Peritoneal Dialysis (CAPD) Renal Division Baxter Healthcare

CAPD - basic prescription Manual therapy Prescription volumes standardised 1,500ml, 2000ml, 2500ml, 3000ml solution bags 6-8 hour dwell period each night (depends on type of membrane) 4-5 day exchanges (with optional night dwell), 7 days a week 3-5 hr dwell per day exchange

CAPD Exchange Procedure 1. Fill phase (<10 Minutes)

CAPD Exchange Procedure 2. Dwell phase (4-8 hours) 3. Drain phase (<20 minutes)

CAPD CAPD Optimum dialysis for low permeability Continuous Therapy Volume Benefits Limitations 24 Time Optimum dialysis for low permeability Can be performed anywhere High transporters will have poor UF 4 x exchanges per day IP pressure with large volumes Ambulatory Anywhere 4 - 5 Exchanges Long Dwells

Procedural Modifications - increasing UF 1 2 3

Procedural Modification - fill volume Increasing fill volumes maximises the peritoneal capacity and improves solute clearances. You will notice that the time between exchanges however does NOT change.

Procedural Modification - no. of exchanges By adding a 5th exchange will also improve solute clearances in patients who cannot tolerate higher fill volumes OR for those who need shorter dwell times (perhaps due to the type of peritoneal membrane identified on the PET test). In this example, the dwell time will shorten (compared to the previous example)

PD Technique Survival % Years Kawaguchi PDI 1999;19 (supp 2):S327 This slide just highlights that patient TECHNIQUE SURVIVAL (i.e. the time a patient stays on CAPD) on PD decreases steadily over time on PD. On average therefore, a patient will remain on PD for between 4-6 years. The trend is very similar across Europe. The objective therefore is to reduce the number of patients ‘dropping’ out of PD programmes over time, and there are several strategies one can use in this respect.

PD Technique Survival Reasons for withdrawal - Loss of UF Kawaguchi PDI 1999;19 (supp 2):S327 Reasons for withdrawal - Loss of UF - Inadequate dialysis - Peritonitis - Patient choice/psychological (‘burn-out’)

CAPD Outcome - Japan 235 patients analysed between 1980 - 1997 Kawaguchi PDI 1999;19 (suppl 3):S9 235 patients analysed between 1980 - 1997 Average survival was 5.8 years 142 patients changed dialysis therapy Causes - loss of UF (23%) - inadequate dialysis (16%) - peritonitis (14%) Peritonitis rate was very good - 1 episode/54 patient months

Causes of Technique Failure in Long-term PD 14% 5% 36% 20% 25%

CAPD Systems Requirements: Minimise risk of touch contamination AIM: Safety, Simplicity, Comfort & Convenience Requirements: Minimise risk of touch contamination Maximise Flush efficiency Inactivate organisms at patient connector if touch contamination occurred. Proven and reliable connectology Increased inactivation of organisms at the patient connection if a touch contamination occurs Easy to learn and use system for all patients

Improvements in PD Connectology Gokal R., Nolph K.: Textbook of PD: 1-15, 1994. 1 in 1 1 in 5 1 in 10 1 in 15 1 in 20 1 in 25 1 in 30 1 in 35 1 in 40 78 79 80 81 82 83 84 85 86 87 88 89 90 95 2000 1977-80 Data: Nolph & Sorkin, U. Missions 1980-87 Data: CAPD Registry, USA 1987-90 Data: Anecodotal reports, Europe/USA Infections (Per Patient Months) 1979: Monthly Tubing Change Titanium Adapter 1980: New Spike CAPD Set 1985: Extended Life Transfer Set, BDP 1986: UVXD 1986: APD-PAC X 1987: Y Set 1988: TwinBag - Europe 1989: UV-Flash, Pac Xtra 1990: PD Ultra Bag 1995: Homechoice 2000: Homechoice PRO

Peritonitis – Y-set Systems Holly AJKD 1994 > Peritonitis rates have improved over the years Straight line Y-set Staph epid. 0.34 0.17 Staph aureus 0.15 0.13 Gram -ve 0.12 0.10 Fungal 0.02 0.01 Peritonitis rate episodes/pt month disconnect O-set titaneum Plastic bags Glass bottles

Sources of Contamination Routes of entry

Safety: Reduced risk of organisms entering the PD system if touch contamination occurs Kubey W., et al., Blood Purification; 2000, 19(1). Twinbag connectology allows significantly (p<0.0001) fewer bacteria to be transferred into the fluid path. A recessed luer is of particular importance. Non-Recessed luer Recessed luer

CAPD Connectology: Reduced risk Kubey W., et al., Blood Purification; 2000, 19(1). The short distance between the Y-Junction and the patient connection ensures effective removal of bacterial contamination from the patient line should connection failure occur.