CAPD sebagai alternatif pilihan terapi

dialisis di masa pandemi covid-19

Atma Gunawan
PD center RSSA/FKUB Malang
Nephrol Dial Transplant, Volume 35, Issue 12, December 2020, Pages 2172–2182, https://doi.org/10.1093/ndt/gfz278
Asia : Taiwan, Korea, SGP
 Patients survival probability
for patients initiating dialysis
with CAPD/CCPD compared to
hemodialysis. N=10,333

Fenton SA et al. American Journal of Kidney Diseases, Vol 30, No 3 (September), 1997: pp 334-342
Comparisons of quality of life between patients underwent peritoneal
dialysis and hemodialysis: a systematic review and meta-analysis

Chuasuwan et al. Health and Quality of Life Outcomes (2020) 18:191

 Beberapa aspek perbedaan PD dibandingkan HD di era
pandemic covid-19
Aspek PD HD
Kunjungan ke rumah sakit Fleksible Harus terjadwal
Konsultasi dengan nakes Bisa melalui media Kontak langsung seminggu beberapa
kali
Cluster Pasien di rumah masing-masing, tak Cluster HD sering terjadi
ada cluster
Nakes yang melayani Relatif cukup Rasio nakes/pasien berkurang,
karena nakes banyak menjalani
isolasi
Stabilitas hemodinamik pada saat Stabil, karena fluid dan toxin removal Sering hipotensi pada saat HD
infeksi covid-19 pelan
Respirasi Sesak lebih ringan apabila ultrafiltrasi Sering mengalami overload diantara
bagus jadwal HD
 Covid 19 infection rate : HD vs CAPD
di RSSA-Malang th 2020

Modalitas Jumlah pasien Pasien % Pasien covid- %

terinfeksi covid- 19
19 meninggal
Hemodialisis 665 112 17 % 18 16%
CAPD 363 16 4% 6 36%
 Peritonitis Rate
Malang CAPD Centre Tahun 2019
Bulan Jumlah
Jan 11
Feb 8
Mar 15
Apr 15
Mei 18
Jun 6
Jul 9
Ags 10
Sep 5
Okt 5
Nov 9
Des 4
TOTAL 115

• Total Episode Peritonitis = 115 episode/tahun

• Total days at Risk = 138,9 ( (Pasien Lama + Pasien baru) – Drop Out) ) x hari / 365 hari = 138,9
• Peritonitis Rate = 138,9 / 115 = 1,2 episode/year
 Peritonitis Rate
Malang CAPD Centre Tahun 2020
Bulan Jumlah
Jan 7
Feb 9
Mar 4
Apr 9
Mei 4
Jun 12
Jul 3
Ags 6
Sep 3
Okt 7
Nov 5
Des 2
TOTAL 71

• Total Episode Peritonitis = 71 episode/tahun

• Total days at Risk = ( (Pasien Lama + Pasien baru) – Drop Out) ) x hari / 366 hari = 140,5
• Peritonitis Rate = 140,5/71 = 1,9 episode/year at risk
Progress Pasien CAPD di Malang PD Center
Tahun 2010 - 2020

408

Jumlah Pasien Baru dan Jumlah Kumulatif per Tahun 372

364

305
284
274

204
188
175 178
160
151 150
135
120
108 104
101
84 90

52
37

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Jumlah Pasien Baru
 Pasien Baru per Bulan
Malang CAPD Center Tahun 2020

18

15

13

11

9
8
7 7
6

4
3 3

JAN FEB MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Total pasien insersi baru (dikerjakan oleh divisi nefrologi dan divisi bedah digestif : 104 pasien di tahun 2020
 Angka Drop Out dan Kematian
Malang CAPD Centre Tahun 2020

Angka Drop Out ANGKA KEMATIAN

15
14
4

10 10
9
8
7 7
2 2 6
5
4
1 1 1
0 0 0 0 0 0
0
JAN FEB MAR APR MEI JUN JUL AGS SEP OKT NOV DES Jan Feb Mar Apr Mei Jun Jul Ags Sep Okt Nov Des

Total Drop Out 11 pasien/tahun = 3% Angka Kematian Total 95 pasien/tahun = 26%

Aff CAPD oleh karena sebab apapun dan (Mortality Rate)
pindah ke terapi pengganti ginjal lain
Mapping Jumlah Pasien CAPD di Indonesia tahun 2020 di Berbagai Centre (n=2612)
75

94

75

86 40 20
45
PLB 8

30
40
18

20

22 35

60
495
75 42
75

265
442 Solo
25
50
96
15

RSSA
Malang
364

CAPD Data per Des 2020

CAPD Px
 20 Org
2%

JUMLAH PASIEN
408 Org
INSTALASI DIALISIS 31%
RSSA
TAHUN 2019 877 Org
67%

1 HEMODIALISA 2 CAPD 3 TRANSPLANTASI

Regulasi di CAPD center
RSSA/FKUB Malang
Social distancing di ruang tunggu
Social distancing di ruang tunggu
Social distancing di ruang training
Sekat screen acrylic di meja konsultasi
Sekat screen acrylic di meja resepsionis
Memakai APD level 2 di ruang ganti
extension catheter
Memakai APD level 3 di ruang operasi
Donasi masker untuk pasien dan pengantar
 Regulasi pencegahan Covid 19
di PD center RSSA
1. Kunjungan ke poliklinik setiap 3 bulan, atau bila ada masalah kesehatan
2. Kunjungan rawat jalan setiap bulan untuk konsultasi,resep cairan dan
obat diwakilkan ke keluarga atau social worker RS .
3. Pasien rawat jalan dan rawat inap dilakukan skrening risiko covid : cek
suhu, mengisi check list
4. Pasien dan pengantar memakai masker
5. Menyediakan hand-sanitizer di ruang tunggu dan konsultasi
6. Jumlah kunjungan poliklinik dibatasi dan dibagi 3 group : jam 8-10 ;10-
12. Setiap group 10-12 pasien.
7. Operasi insersi kateter PD, ganti extension catheter, training PD, tetap
dikerjakan.
 Regulasi pencegahan Covid 19
di PD center RSSA
8. Ruang tunggu, ruang training : protocol distancing
9. Ganti transfer set : protocol APD level 2
11. Operasi insersi kateter CAPD : protokol APD level 3
10. Pre procedure : rapid atau swab PCR/antigen
11. Semua staf di screening rapid atau swab PCR
12. Desinfeksi permukaan meja, sekat screen, handle, lantai
ISPD recommendation : prevention
• Perform preliminary screen for COVID-19 to all patients planning for
hospital visits
• Non-essential procedures e.g. PET, clearance measurement etc should
be avoided during the pandemic to minimise unnecessary patient
contact
• Seating in the waiting area should be arranged so that people are at
least 1.5m apart
• Hand hygiene properly with alcohol-based hand sanitizer before they
enter the clinic area; and when leaving the consulting room
• Masks should also be worn.
ISPD recommendation : prevention
• Design a one-way, quick workflow in the PD clinic visit,
• Patient visits should be kept to a minimum and should only be for
essential issues such as peritonitis, severe exit site infection, or
training new patients.
• Elective and non-urgent admissions should be rescheduled, and
inpatient elective surgical and procedural cases should be delayed.
• Patients should have at least 2 weeks PD supplies and sufficient
medications in case they have to self isolate, or there is a break in the
supply chain
ISPD recommendation : prevention
• PPE should be available for all members of the PD team and used according
to their national guidance depending on nature of contact with patient
• Hand hygiene should be performed (a) before and (b) after every patient
contact, (c) after body fluid exposure or risk, (d) after touching a patient’s
immediate environment, (e) before clean/aseptic procedures, (f) before
wearing and (g) after removing PPE.
• Rooms should be ventilated by opening the windows or by turning on an
air conditioner with the fresh air system or purification system to ensure air
circulation.
• Wipe and disinfect the surface of objects and floor thoroughly before and
after each patient visits. Desk surfaces, computer screens and keyboards in
office areas should also be disinfected daily and between users
ISPD recommendation : diagnosis and
treatment
• Management of COVID-19 infection is the same for PD patients as for all
other patients
• Mild or moderate patients on PD can continue PD treatment as usual, with
prescription adjustment according to general evaluation.
• Severe or critically severe cases requiring life support due to multiple organ
dysfunction syndrome can be temporarily transferred to automated
peritoneal dialysis or bedside continuous kidney replacement therapy
(CKRT).As in patients on hemodialysis, it is advisable to keep patients ‘dry’,
so increased ultrafiltration may be needed if remaining on PD
• There is a variety of opinion for disposal of drained dialysate from PD
patients with COVID-19 from doing nothing additional to standard methods
or disinfection by adding 500mg/L chlorine-containing solution for 1hr
before pouring into the toilet.
Canadian Society of Nephrology COVID-19 Rapid
Response Team Home Dialysis Recommendations
1. We suggest that PD catheter insertions (bedside and surgical) be
designated as “urgent/emergent” procedures and continue to be placed
for patients who are expected to require dialysis in the next 2 months
(eGFR < 12 mL/min/1.73 m2 and declining) during the COVID-19
pandemic
2. We suggest that home dialysis be preferentially offered to all patients
who require chronic kidney replacement therapy
3. We recommend, for eligible candidates, PD over HHD because of the
shorter training time.
4. We suggest building personnel capacity for training, and using and
creating video and online modules to reduce 1:1 time spent with trainers
and so maximize the number of patients trained.
Canadian Journal of Kidney Health and Disease Volume 7: 1–7. 2020
Canadian Society of Nephrology COVID-19 Rapid
Response Team Home Dialysis Recommendations
1. We recommend that screening questions be answered in keeping with
local policy, before a patient enters a home dialysis unit or clinic, and
before staff and health care workers come into contact with the patient.
2. We suggest delaying transfer set changes for up to 6 to 9 months unless
there appears to be a compromise to the integrity of the transfer set
3. We suggest that consideration be given to a local policy, reducing the
frequency of laboratory testing for stable patients from the current
practice of every 1 to 2 months, to every 2 to 3 months, to minimize
patient visits for blood tests.
4. We suggest changing all PD and HHD visits to telehealth (video or
telephone), with the exception of patients who, in the judgment of the
team, would benefit from an in-person assessment.
Canadian Journal of Kidney Health and Disease Volume 7: 1–7. 2020
Wassalam