1. Dr. Leonid Feldman Nephrology and Hypertension Division Assaf Harofeh Medical Center November, 2007 Peritoneal Dialysis

2. AJKD 2002:39:S32 3.3

3. Three options for renal replacement therapy

4. Criteria for initiation of chronic dialysis Uremic syndrome Hyperkalemia Volume expansion Metabolic acidosis Bleeding diathesis CrCl ≤ 10 ml/min resistant to conservative therapy

5. KidneyDialyzer

6. Peritoneal Membrane

7. What is peritoneal dialysis?  PD involves the transport of solutes and water across a “membrane” that separates two fluid- containing compartments: 1.blood in the peritoneal capillaries 2.dialysis solution in the peritoneal cavity

12. Peritoneal Transport  Tree Distinct Processes: Diffusion Ultrafiltration ( Convection ) Fluid Absorption

13. Peritoneal Transport  Two Clinical Endpoints: Clearance Fluid Removal

14. Peritoneal Membrane

15. Manual CAPD: Continuous Ambulotary Peritoneal Dialysis

16. Cycler: performs four or five exchanges overnight, while patient sleep

17. Two double-cuff Tenckhoff peritoneal catheters: standard (A), curled (B).

20. Paradox of UF with glucose-based solutions: small pore radius 40-60 A, glucose molecule 2-3A How does glucose exerts it’s osmotic gradient?

21. Peritoneal Membrane

24. Directed primarily at small solutes clearance Use of 2.5% dextrose – osmotic drive not optimal Normal ranges for UF volume for each transport category - not fully defined Standard PET Peritoneal Equilibration Test

29. Prognosis and transport type What happens with our high transporters?

30. The high transporters in the beginning have reduced patient survival Wang, NDT 1998

32. Adequate dose of peritoneal dialysis Weekly Kt/V ≥ 1.7-2.0 Creatinine clearence ≥ 50-65 L/week K – urea clearence, L of blood/hour t – time, hours V – volume of Urea distribution

34. Complications of peritoneal dialysis  Peritonitis and Exit site infections  Catheter problems (malfunction, leak)  Fluid overload  Hyperglycemia  Hyper- and hyponatremia  Hypoalbuminemia  Hernias

35. Exit site infection

38. Sclerosing encapsulating peritonitis. Abdominal CT scan of a patient with sclerosing encapsulating peritonitis. The thickened peritoneum is clearly visible

39. Patients on dialysis in Israel Total dialysis HD PD 497 pts.–26% 545 pts.–23% 376 pts. – 8%

40. Percent distribution of prevalent dialysis patients, by modality, USRDS 2006

42. Thank you

44. Composition of Peritoneal Dialysis Solution 4.25%2.5%1.5% 132 0 96 3.5* 0.5 40 3860 5.2 484 132 0 96 3.5* 0.5 40 2270 5.2 395 132 0 96 3.5* 0.5 40 1360 5.2 345 Sodium(mEq/L) Potassium (mEq/L) Chloride (mEq/L) Calcium (mEq/L) Magnesium(mEq/L) Lactate (mEq/L) Glucose (mg/dL) pH Osmolality (mosm/kg) *Low Ca has 2.5 mEq/L

45. Blood vessels in the parietal peritoneum. Transverse sections of peritoneal arterioles (a) normal, (b) vasculopathy in a patient on PD; the vascular lumen is occluded by connective tissue containing fine calcific stippling (toluidine blue)

55. Peritonitis  Empiric Treatment IP Cefazoline (15 mg/kg/d) + Ceftazidime (1g/d) Once culture results and sensitivities are known, antibiotic therapy should be adjusted as appropriate