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

2. 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

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

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

5. 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

6. Procedural Modifications - increasing UF1 2 3

7. 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.

8. 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)

9. 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.

10. 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’)

11. CAPD Outcome - Japan 235 patients analysed between 1980 - 1997
Kawaguchi PDI 1999;19 (suppl 3):S9
235 patients analysed between
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

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

13. 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

14. 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
Data: Nolph & Sorkin, U. Missions Data: CAPD Registry, USA Data: Anecodotal reports, Europe/USA
Infections (Per Patient Months)
1979: Monthly Tubing Change Titanium Adapter 1980: New Spike CAPD Set : Extended Life Transfer Set, BDP : UVXD : APD-PAC X : Y Set : TwinBag - Europe : UV-Flash, Pac Xtra : PD Ultra Bag : Homechoice
2000: Homechoice PRO

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

16. Sources of Contamination
Routes of entry

17. 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

18. 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.