CURICULUM VITAE

Nama : D. Yenny Kandarini, SpPD

TTL : Denpasar/ 6 Januari 1969
Pendidikan:

Kedokteran
: FK UNUD tahun 1995
Spesialisasi : FK UNUD tahun 2004
Konsultan
:Short Course : SGH Singapore 2005
New Zealand 2005
Australia 2007
Budapest Nefrologic School 2007

Jabatan :

Staf Divisi Nephrologi dan Hipertensi Bag / SMF

Penyakit Dalam FK Unud / RS Sanglah

C hro nic A m bula to ry

P erito nea l D ia lys is
(C A P D )
Yenny Kandarini

Chronic Kidney
Disease
Dialisis

PD

Transplantasi
Hemodialisis

ontinuous

mbulatory

eritoneal

ialysis

Proses
dialisis
tidak
berhenti,
membersihkan darah, 24 jam se-hari,
setiap hari

Bebas bergerak, tidak

berhubungan dengan mesin

Menggunakan membran peritoneum yang bekerja

sebagai filter untuk mengeluarkan sisa metabolisme
dan cairan dari darah

Menyaring dan membuang cairan berlebih

serta sisa metabolisme tubuh.

Peritoneal Dialysis (PD)

Definition

PD is a process during which the peritoneal

cavity acts as the reservoir for dialysis fluid
and the peritoneum serves as the semi
permeable membrane across which excess
body fluid and solutes including uraemic
toxins, are removed.
(Gutch, Stoner & Corea 1999)

Anatomy & Physiology of the

Peritoneum
Liver
Stomach
Pancreas
Intestines
Bladder
Uterus
Rectum

Anatomy and Physiology of

the Peritoneum
Properties of the peritoneal membrane
Thin sack
Richly supplied with blood

supplies major organs of body

Large surface area - 1.73m2

proportional to body size

Normal Anatomy
Contains 100ml or less of fluid
Adult can tolerate 2L or more fluid without
pain or alteration to the respiratory
function
Male: peritoneal cavity is closed
Female: peritoneal cavity is continuous
with the Fallopian tubes.

Rarely PD fluid become blood-stained during

a menstrual period

Principles of Peritoneal Dialysis

Solute and fluid exchange occur between

peritoneal capillary blood and dialysis solution in
peritoneal cavity
The membrane lining this cavity consists of a
vascular wall,interstitium,mesothelium and
adjacent fluid films.
Small MW solute transfer occurs by diffusionthe higher the concentration gradient the the
higher the rate of passage
Fluid movement is determined by
osmosisincreasing the osmotic pressure
increase the fluid movement
Jeremy Levy et al, Oxford Handbook of Dialysis, 2003

Basic Principles

PD utilitises the peritoneal membrane as a

natural dialysis filter.
A PD catheter inserted surgically into the
peritoneal cavity
PD solution is infused into the peritoneal cavity
via the catheter and remain there for up to 6-10
hours, during which time uraemic toxins and fluid
are removed by diffusion and UF across the
peritoneal membrane

Principle of CAPD
A typical patient perform 3-4 exchange per
day, 7 day a week free of uraemic
symptoms
The procces is continuous so as to
achieve adequate dialysis
Does not need a machine. Patient dialysis
himself day and night

Factors Effecting Efficiency of PD

Time on dialysis
Bloodflow
Peritoneal surface area
Membrane permeability
Peritoneal lymphatics
Ultrafiltration
Transfer of fluid

Jeremy Levy et al, Oxford Handbook of Dialysis, 2003

CAPD Scheme

Requirements of CAPD

Prepare the patient for implantation of peritoneal

catheter in usual way (for any operation)
After catheter insertion, ensure catheter is patent
If patient need dialysis the catheter can be used
immediately with small fill volumes or patient
placed on HD
Normally catheter is capped up for 10-14 days
and then CAPD can be started

Requirements of CAPD

Peritoneal dialysis solution is drained into

patient`s abdomen
adult 2 liter
disconnect system
different glucosa concentration
(1,5%, 2,3%, 4,25%)

Composition of PD solution
Glucose
Sodium
Calcium
Magnesium
Chloride
Lactate

1.5%, 2.3%, 4.25%

134 mmol/l
1 mmol/l, 1.75mmol/l
0.5 mmol/l
102 mmol/l
35 mmol/l

Note:- No potassium, no urea and no

creatinine

Glucose as osmotic agent

After a two litre bag has dwelled for four
hours average ultrafiltration
1.5%
2.3%
4.25%

200 ml ultrafiltrate
200 - 400 ml ultrafiltrate
600 ml 800 ml ultrafiltrate

The ultrafiltration effect

CAPD
exchange
drain
flush
fill
dwell

Drain

Spent dialysate is drained out.

This process takes approximately 10-20 minutes

Flush

Fresh dialysate is flushed from the fresh solution bag

into the drain bag.
This process takes approximately 5 seconds

Fill

Fresh dialysate is infused into the peritoneal cavity.

This takes 8-10 minutes

Dwell

O
Dialysate remains in the peritoneal cavity for 4 8 hours
During this time waste products and excess fluid is removed

CAPD Process
1. Drain

2. Fill

3. Dwell

Which patients are suitable for

CAPD?

Diabetes mellitus
CV disease: angina,
arrhytmia, prosthetic
val. ds
Chronic Ds : anemia,
HIV +, Bleeding ds,
hepatitis

Active lifestyles
Variable schedules
Needle anxiety
Demand for flexible
diet
Far from HD centre

Contra indications for CAPD

Medical :

Severe inflammatory bowel ds

Psychosocial :
Severe active psychotic ds or manic
depressive
Marked intellectual disability with no helper

Advantages of PD compared to
HD
Home based-can be performed in remote
geographical locations
Self care dialysis-no helper required
unless patient has physical or social
problems
Simple to learn and perform-training
period 1-2 weeks
Greater patient independence and travelholiday is easy to arrange

Advantages of PD compared
to HD

Flexible schedule-not restricted to

hospital rules and appoinments
As dialysis is continuous the patients is
allowed more liberal dietary and fluid
intake
There are no haemodynamic
complications or need for chronic
vascular access
It is especially suited to patients with CV
ds or the elderly

Advantages of PD compared to
HD
PD preserves residual renal function better
than does with HD
Patients survival is better or equivalent to
that with during the first 3 years.

Disadvantages of PD
The need for chronic peritoneal accessrisk of infections
Two thirds of patients may experience of
an episode of peritonitis (1 episodes every
2-3 years)
Long term technique survival remains
inferior to that of HD
It may provide insufficient dialysis for
large or anuric patients

Disadvantages of PD
Nutritional problems-due to protein losses
PD must be performed every single day
using strictly sterile technique, which can
lead to patients burnout.
PD can result in social isolation of the
patients
Storage space is needed at home for PD
solutions-usually 2 m

The Advantageous of CAPD First

Preservation of residual renal function

Cardiovascular benefits
Offers better haemodynamic stability
(Iess peaks & troughs)
Preserves vascular access
Less cardiovascular risk factors
Anaemia management

Hepatitis C prevention

The Advantageous of CAPD First

Quality of Life
Home Therapy
PD is a home therapy and encourages self care
and independence
Allows for flexible travel
Less Nursing Staff Required
PD = 1 nurse 25 patients whereas HD = 1
nurse 4-6 patients
Cost
It is more cost effective than incentre HD

Strategies te Achieve Quality in PD

Start treatment early

(residual creatinine clearance ~10-15 ml/min)

Deliver adequate dialysis dose

(peritoneal creatinine clearance of >45 L/week / 1.73 m2)

Perform close clinical follow-up of your patients

Consider that peritoneal membrane function may
change with time on treatment

Outcome of patients on chronic PD

One-quarter of all chronic dialysis patients

perform PD
Patients survival and death censored technique
survial are about 50% at 3 years
Only a small percentage of patients remain
continously on PD for 5 years or more
Social factor and infections complications are
the main reason for technique failure.

Conclusions

CAPD is one of renal replacement therapy

modality choice.
CAPD has been shown to be an effective
treatment option for CKD patients.
CAPD patients require close follow up and
monitoring assesing all aspect of the
prescription and delivery and the respon of
treatment.
Appropiate patient selection is imperative to
the development and growth of successful PD
programs.

The ANDY. disc CAPD System

Disconnect system with a mandatory flush before fill

Reduced number of steps

Improved handling

The ANDY disc Procedure

Improved Patient Handling

Less steps
Central control disc
Regulation of solution flow
No clamps
No breaking of frangible pins

Reduced Risk Of Contamination

PIN
Reduced handling risk
Easy to learn automatic
closing of the patient
catheter before disconnection
Betadine Cap
Integrated disinfection
Organiser
Reduces touch
contamination

The easy and safe double-bag system for CAPD

THANK
YOU