Dialysis

Dialysis : start when GFR 10ml/min

Deciding between PD & HD:
1. Check Left ventricular ejection function:If >50%: HD; <50%: PD
2. Consider psycho-social and financial issues, patient ability to comply and home
conditions
Survival and hospitalisation rates for Cxs are comparable for both modalities

Peritoneal Dialysis
Types:
1. Continuous Ambulatory PD (CAPD)
2. Automated PD (APD) fluid exchange performed by machine, usually 3
cycles per night.

Process:
Hypertonic lactate + glucose solution placed into peritoneum resulting in
hyperfiltration across the peritoneal membrane.
As lactate can diffuse into the blood stream as well, patients are tested and
classified into high and low transporters (of lactate). High transporters need to
remove dialysis fluid after 3 hrs.
Also, degradation products of lactate can cause sclerosis of peritoneal
membrane, compromising hyperfiltration and diffusion

Advantages
1. Home based Rx
2. Patient in control
3. Patient able to travel
4. Cheaper
5. Pain free
6. PD preserves residual renal function as BP does not fluctuate as much. BP
fluctuations during HD causes repeated renal microinfarcts, thus affecting renal
function.
7. Patients with labile BP can undergo PD but not HD

Disadvantages
1. Lifelong Rx required
2. Patient motivation and treatment compliance required
3. Limited to patients <75kg to be able to meet dialysis requirement
4. Body image problems catheter sticking out of abdomen

Ideal candidates
1. Diabetics can give insulin via intraperitoneal access. Also, difficult to obtain
vascular access for HD
2. Stroke patients
3. Paediatric patients
4. IHD patients labile BP a contraindication to HD

Contraindications
1. Multiple abdominal surgery fibrosis of peritoneal membranes reduce dialysis
efficacy
2. Colostomy / ileostomy

Preparation of backup vascular access: AVF should be created for all patients on PD as
a backup in case PD needs to be stopped eg peritonitis requiring removal of Tenchkoff
catheter

Other things to take note:

 1. weekly EPO injections for anaemia
2. Vit D and calcium supplements
3. Prepare arteriovenous fistula in case Tenchkoff catheter needs to be removed
(backup dialysis modality). Otherwise, IJ catheter will be required in the even of
PD failure.
4. High protein diet replace protein loss in dialysis
DGIM Last updated March 2005
5. Potassium supplements replace losses in dialysis

Complications of PD
1. Peritonitis:
main Cx of peritoneal dialysis
Empirical Rx with vancomycin and gentamicin for 2-3 wks until culture results return
Gram + (usually S. aureus and epidermidis)
Usually can resume peritoneal dialysis after peritonitis resolves
Gram
Usually due to faecal contaminants or diverticular disease
Take out catheter and treat with IV antibiotics
Cx of Rx: both vancomycin and gentamicin are ototoxic and nephrotoxic

3. Exit site infection

4. Tunnel infection requires removal of Tenchkoff catheter
5. Malnutrition
6. Protein loss
7. Hernia due to increased intra-abdominal pressure
8. Hyperlipidaemia
9. Lactic acidosis due to dialysate being left inside abdomen for too long
10. Hyperglycaemia due to dialysate being left inside abdomen for too long

Peritoneal Dialysis
Advantages
1. Regular supervision and nursing intervention
2. Patient free of burden of caring for self (esp for PTs with low motivation)

Disadvantages
1. Bound to dialysis center. Difficulties travelling abroad.
2. Heparin use
3. Requires vascular access Achilles heel of HD. Prone to problems eg thrombosis
and infection. AVF preferred due to longer lifespan and less complications. AVGrafts
(use of synthetic tubes or saphaneous vein) has a half-life of only 2 years.

DGIM Last updated March 2005