1. Update in Home Peritoneal Dialysis Care
Presented by DeVonne Rice, RN,BSN,CNN

2. Objectives
Describe the peritoneal dialysis options available to the patient who chooses to do peritoneal dialysis
Discuss the advantages and challenges of peritoneal dialysis
Outline the basics of the PD training program
Peritoneal dialysis has a lesser need for equipment and space, a higher level of convienence for patients and helps preserve residual renal function, Zongpei et al, 2010.

3. Continuous ambulatory peritoneal dialysis (CAPD)
All manual
Patient performs 4-5 peritoneal infusion dwells/ drains (exchanges) daily
It is preferable to present to the patient all peritoneal options in an attempt to empower the patient and give them more control. Outcome studies show that there is no difference in survival between CAPD and APD modalities, Guest, 2010.

4. No power source is required as no machine is involved
Advantages of CAPD
No power source is required as no machine is involved
Also, as no machine is involved patient can be more mobile and not confined to a chair/bed for long period of time
Takes about 30 minutes to do an exchange, so not much time involved per exchange

5. Requires a private/clean area to perform exchanges if working/school
Disadvantages of CAPD
Convenience as busy schedules require the time to perform the exchanges
Requires a private/clean area to perform exchanges if working/school

6. Automated Peritoneal Dialysis (APD)
Peritoneal dialysis exchanges are performed by a cycler machine while the patient sleeps
The prescription for a chronic PD regimen is understanding the patients peritoneal membrane status, the daily required solute removal and how much residual kidney funtion the patient has left, Guest, 2010.

7. Can free up patient during the day Portable machine, so easy to travel
Advantages of APD
Can free up patient during the day
Portable machine, so easy to travel

8. Disadvantages of APD
Confined to the cycler for the time that the doctor has ordered (maybe up to 8-10 hours)

9. Challenges of Peritoneal Dialysis
Infectious
Mechanical
Non-infectious

10. Peritonitis Remains a leading complication of peritoneal dialysis
Around 18% of the infection-related mortality in PD patients is the
result of peritonitis
Remains a major cause of patients discontinuing PD and switching to hemodialysis
32% of PD patients with peritonitis transfer to HD
PD community must focus attention on prevention and treatment of PD-related infections
25% of PD hospital admissions related to peritonitis
Li, Szeto, et al, 2010

11. Causes of Peritonitis Contamination At the time of connection
Hole in exchange tubing or catheter
Loss of cap on end of tubing or failure to close clamp with leaking
Product defects
Exit Site
Improper anchorage of PD catheter
Improper hygiene
Constipation
Bowel-source
Diverticulitis
Colitis

12. Causes of peritonitis cont.
Procedural
Colonoscopy
From dental procedures
Gynecologic source
Piraino, et. al, 2011

13. Diagnosis of Peritonitis
Cloudy peritoneal fluid
Abdominal pain
Fever
Nausea
Diarrhea
White cell count of >100mm3
Note: Symptoms can vary by organism

14. Management of Peritonitis
Assess the need for hospitalization
Management of the pain
Limit oral fluids, use stronger glucose percentages due to possible ultra filtration problems
Treat with identified antibiotics as ordered by protocol or doctor
Keep a close watch on the exit site/tunnel

15. Peritonitis cont.
Close attention must be paid to preventing exit site infections and peritonitis
Every home program should work diligently to help prevent infections in their peritoneal patients
The PD team, including the nephrologists, nurses, social workers, and dieticians should meet regularly to review all peritoneal related infections

16. Exit Site Infection Definition:
Presence of purulent drainage, with or without erythema of the skin at the peritoneal catheter-skin site

17. Management of Exit-Site Infections
Empiric antibiotic therapy may be initiated immediately
Culture with sensitivity testing is important in determining antibiotic therapy
Antibiotic therapy must be continued until the exit site appears entirely normal
Note: Patient with an exit-site infection that progresses to peritonitis will often require catheter removal
Note: S. aureus and P. aeruginosa are responsible for the majority of infections

18. Exit Site Care to Prevent Infection
Anchoring and securing the PD catheter to prevent excessive movement around the exit site area
Routine exit-site care by the patient when the exit site is well healed
Water and antibacterial soap are recommended by many centers
Excellent hand hygiene before any exam of the patient’s exit site
Patient should use topical antibiotic either at the catheter exit site, intranasally or both

19. Mechanical/Non-Infectious Challenges
PD catheter malfunction
Migration of catheters
Blockage due to omental trapping
Note: Can often be corrected through laparoscopic means
Catheter occlusion
Severe Constipation
Note: May be corrected with use of laxatives

20. Membrane / Ultrafiltration failure/Volume status
Challenges cont.
Membrane / Ultrafiltration failure/Volume status
Glucose, the osmotic agent in standard PD solutions, causes changes in the membrane over time with eventually leads to membrane failure
Repeated cases of Peritonitis
Note: Newer biocompatible solutions without dextrose have shown less membrane damage and might better preserve the peritoneal membrane
Chaudhary, 2011

21. PD Training Program PD Training Nurse
Must have good communication skills, be innovative and consistent, and believe in patient self-care
Must develop proper training skills based on principles of adult learning
Experience in medial/surgical nursing is beneficial, as PD patients often have other co-morbid conditions
Bernardini, et al, 2006

22. Trainer Objectives Provide an effective environment for learning
Present an overview of the PD training plan to the patient
Demonstrate the steps of the procedures consistently
Encourage and support the learner through repetition
Prevent the learner from practicing procedures until all steps have been learned in order

23. Trainer Objectives cont.
Provide immediate feedback during learner practice
Help the learner problem solve by defining problems and talking about possible solutions
Recognize that learners need repetition of new information in order for it to move from short-term memory to long-term memory
Bernardini et al, 2006

24. Assessment You must assess for any special needs of the patient
Pediatric patients
Diabetic patients
Mentally challenged patients
Visually impaired

25. Equipment Patient preference for CAPD/APD
If diabetic, must assure correct instrument to measure blood sugar
Supply ordering/storage
Note: All of our patients are trained on CAPD in case of emergency.

26. In Closing Disadvantages of peritoneal dialysis include:
Risk of infections
Patient may get tired of doing their treatment every day
Logistical problems, supply delivery and storage space for the supplies

27. Closing cont. Advantages of peritoneal dialysis include:
Portable equipment
2 x monthly clinic visits vs. 3 x weekly in-center hemodialysis treatments
Fewer restrictions of diet and fluid
Flexible life style
NO needles
Improves the preservation of residual renal function

28. We as providers have to be ready.
Conclusion
The recent bundling of services for dialysis care into one payment offers PD as a cost-effective therapy and has generated a renewed interest the dialysis community.
The bundling may lead to improved provider expertise and greater PD utilization.
We as providers have to be ready.
Techniques to prevent and minimize episodes of peritonitis, use of more biocompatible solutions in preserving the peritoneal membrane, and careful manage of volume status can sustain the patient longer on PD.
Chaudhary, 2011