Guidelines for the Management of the Peritoneal Dialysis Patients in Saudi Arabia 2006

Contents Topic Page

Introduction.5 Peritoneal dialysis in Saudi Arabia.11 Guidelines statements...23 1. Initiation of dialysis.24 2. Suitable patients for peritoneal dialysis.... 26 3. Access for peritoneal dialysis.29 4. Solutions for peritoneal dialysis..... 33 5. Continuous ambulatory peritoneal dialysis..34 6. Automated Peritoneal Dialysis (APD).... ...36 7. Measures of Peritoneal Dialysis Dose.... 38 8. Measurement of Peritoneal Dialysis Dose.... .40 9. Assessment of Nutritional Status in Relation to Peritoneal Dialysis.......42 10. Adequate Dose of Peritoneal Dialysis..... ...44 11. Strategies to Achieve Better Prescribed Dose of Peritoneal Dialysis.47 12. Peritoneal Dialysis Related peritonitis. .48

Clinical Outcome Goals for Adequate Peritoneal Dialysis.52 References..........54 Disclaimer..........68

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Preface
In the era of the evidence based medicine and the presence of guidelines for practice around the world, we started to formulate Saudi Guidelines for management of the important problems such as anemia and bone disease in the chronic kidney disease (CKD) patients. The feedback from the renal community on the publication of the guidelines for the management of anemia and bone disease in the CKD and the transplanted patients has encouraged the Saudi Center for Organ transplantation (SCOT) to prepare the guidelines for the management of the peritoneal dialysis patients in the kingdom of Saudi Arabia (KSA). In addition, the recent survey of attitudes of the physicians towards the management of the PD patients in the KSA has demonstrated deficiencies such as the unavailability of enough centers and expertise that are involved in the management of the patients on this important modality of renal replacement therapy (RRT) in the dialysis centers in the KSA. Currently, there are about 600 peritoneal dialysis patients in the KSA who require attention in terms of the monitoring and management besides the need for more use of this method of treatment. Our guidelines aim at having a baseline for the development of

sound practices in the context of the local experiences. We intend to develop and maintain these guidelines in order to support the local protocols in each dialysis unit in the KSA. Such support may be fruitful in more quality care management by the providers of the CKD care such as the health planners, physicians and nursing staff. Faissal A.M. Shaheen MD., & Muhammad Ziad Souqiyyeh MD., On behalf of the advisory committee for the management of peritoneal dialysis patients

Advisory Committee for the Guidelines for the Management of Peritoneal Dialysis Patients
Dr. Othman Alfureyh Department of Medicine, King Faissal Specialist Hospital & Research Center, Riyadh. Dr. Saeed Alghamdi Division of Nephrology Department of Medicine King Faisal Specialist Hospital Jeddah Dr. Ali Alharbi Division of Nephrology Department of Medicine Security Forces Hospital Riyadh. Dr. Khaled Almeshari Department of Medicine King Faissal Specialist Hospital & Research Center Riyadh. Dr. Abdulla Alkhader Alsayyari Division of Nephrology Department of Medicine King Fahd National Guard Hospital Riyadh Dr. Mohammad Alsulaiman Department of Nephrology Armed Forces Hospital Riyadh Prof. Jamal Al-Wakeel Division of Nephrology Department of Medicine King Kaled University Hospital Riyadh. Dr. Ayman Karkar Division of Nephrology

Department of Medicine Dammam Central Hospital Dammam Dr. Ali Lehbi Division of Nephrology Department of Medicine King Faissal Specialist hospital

& Research Center Riyadh. Dr. Saadi Taher Department of Medicine King Fahd National Guard Hospital Riyadh.

Introduction
Dialysis is usually started when patients with renal disease reach end stage. Monitoring the renal function helps determine the initiation of dialysis. This can be accomplished by continuous follow-up of symptoms, nutritional status and laboratory tests.1-6 Peritoneal dialysis (PD) is a modality of renal replacement therapy that has variable popularity in the world, which ranges between 2-50%. The expansion of use of PD in the kingdom of Saudi Arabia (KSA) has been slow over the years and it forms about 10% of the dialysis population in it. The recent survey of the attitude of physicians in the dialysis centers about PD practices showed many deficiencies that need tackling. PD was started thirty years ago as intermittent mode (IPD) every few days and was unsatisfactory in terms of adequacy or quality of life. However, the advent of the continuous ambulatory peritoneal dialysis (CAPD) in the late 1970s had promoted the popularity of this method of therapy. There have been major advancements in the access for PD, connectology (connecting tubings), solutions and automation. Access and connecting tubings for dialysis have advanced in terms of the techniques and operation that contributed to a significant decrease in the incidence and severity of complications such as exit site infection, peritonitis and displacement of catheters.7-22

The use of alternative osmotic agents has been investigated including glycerol-based solutions. Icodextrin and glucose have been used for the long daily dwell in automated peritoneal dialysis (APD) and CAPD patients. Icodextrin gave greater small solute clearance, which was explained by the higher ultrafiltration in that group, especially in high transporters. 23,24 Other agents such as bicarbonate-based solutions and amino acid-based solution have been used. 25 However, no added effect was seen on small solute clearance. 26- 28 Much research has been undertaken over the past 20 years to improve the quality of treatment provided by PD. One of the most promising advances has been the introduction of APD, which is the use of a cycler for various regimens, including nightly intermittent peritoneal dialysis (NIPD), continuous cycling peritoneal dialysis (CCPD) and tidal peritoneal dialysis (TPD; nightly, NTPD, or continuous, CTPD). Intermittent peritoneal dialysis (IPD) two or three times/week is not recommended because satisfactory clearances are seldom achieved with this modality. APD has been adopted increasingly by PD units worldwide, such that global use ranges between 9.4% and 54%. 29,30 APD has been recommended by the International Society of Peritoneal Dialysis ad hoc Committee on Ultrafiltration Management for the treatment of high transporters with impaired net ultrafiltration. 31 However, the evidence justifying the prescription of APD to treat high transporters may not be very strong. 32-34 There is some evidence to suggest that, for most patients, better small solute clearances are achievable on all the APD regimens than CAPD. 35-37 More permeable peritoneal transport membrane types have more options to achieve clearance by using APD. 38 Moreover, comparing the techniques of CAPD, CCPD, TPD, 25% and 50% across a range of peritoneal transport groups, clearances were similar between the CCPD and TPD groups.39 Tidal modalities (TPD) have been proposed to more efficiently increase small solute clearances in APD, in part by reducing the impact of drain-fill multiplication but at higher cost. This is due to an effective increase in dialysis flow rate. 40 At present, there is no high level evidence that the use of TPD enhances small solute clearance. APD prescriptions should be individualized in terms of volumes and number

of exchanges, body size, transport status, residual renal function (RRF) and patient preference. The peritoneal equilibration test (PET) tests should be repeated to ensure adequacy targets are met once this modality is introduced. 41,42 Currently, the technique is in its experimental stages and technical difficulties still need to be overcome particularly relating to the type of catheter (ideally double lumen) inserted, to avoid recirculation 43 Phosphate and urea clearances were enhanced as well as ultrafiltration.44 Recent studies have not been able to confirm a differential rate of decline in RRF between CAPD and APD. 45-47 APD (in the form of NIPD) has been suggested to offer a number of psychosocial benefits over CAPD, which relate directly to fewer connections, more frequent use of reduced fill volumes, and patient independence from dialysis during the daytime, particularly for workers, school students or care takers of elderly or debilitated patients. Most costing studies report that APD is 8%-36% more expensive than CAPD.48 These additional costs include those of the machine, the greater volumes of dialysate employed, and the special tubing and connection sets used. The (PET) was introduced in 1989 and is the standard method for evaluating peritoneal transport characteristics in PD patients. 49 Based on the dialysate to plasma creatinine ratio of creatinine, patients can be classified as high, high average, low average or low transporters. The PET is very helpful for prescribing both APD and CAPD, since knowledge of a patient's peritoneal permeability allows a better estimation of the dwell time that will achieve the greatest efficiency in terms of ultrafiltration and small solute clearance. 50-52 Small solute clearance is only one marker of wellbeing in patients on PD. Monitoring of PD should include some objective measurements of the adequacy of dialysis delivery, patient compliance, dialysis reliability, individual patient response to therapy and modification of membrane characteristics by the procedure. Unfortunately, there has been a tendency in the renal literature and in other guidelines to equate adequacy with small solute clearance measurements. According to new evidence, small solute clearance must not be considered in isolation, but interpreted in the more global context of clinical and laboratory assessments of all the other manifold aspects of dialysis adequacy,

including hydration status, blood pressure and lipid control, bone disease, anemia, nutrition, etc.53 Peritoneal dialysis does not deliver adequate small solute clearance when compared with native kidneys. Ideally, PD treatment should aim to deliver the most dialysis possible in patients given time, personal preferences and financial constraints. This should minimize uremic symptoms, lead to better blood pressure control and hopefully, improve nutrition and quality of life. Possible negative consequences of interventions to improve small solute clearances include increased cost and time, potential for volume overload and abdominal distension and greater peritoneal exposure to glucose with local and metabolic effects. Increasingly, patients are using automated dialysis methods in order to enhance the amount of dialysis delivered as well as quality of life. Difficulties persist in certain subgroups such as low transporters and those without RRF.54-57 It is now realized that for patient survival, it is as important to ensure optimal preservation of RRF as to optimize small solute clearances.58 Dietary caloric intake was greater in those with more RRF but not PD solute clearances.59,60 No study has shown that a decline in residual renal function is compensated by an equal increase in peritoneal clearance. There are no studies relating small solute clearance measurements to outcomes in patients treated with APD. There is insufficient evidence to determine whether achieving a Kt/V target is more important than achieving a Ccr target or vice versa. Ccr was more strongly associated with hospitalization than Kt/V and only Ccr was significantly associated with technique failure. This finding may simply reflect the fact that Ccr is disproportionately affected by residual renal function relative to Kt/V.61-63 However, Ccr is much less susceptible to therapeutic manipulation than Kt/V. Given that low- and low-average transporters, even with lower weekly peritoneal Ccr measurements, have substantially increased survival and technique survival compared with higher transporters,61 it seems prudent to accept lower Ccr targets for these patients. Failure to do so would invariably lead to the inappropriate transfer of a group of better prognosis patients to hemodialysis. There are several formulas that can be used in the calculations of

body volume (V) and body surface area (BSA) that are beneficial in the estimations of adequacy of dialysis and dialysis dose.64-69 However, unrealistic estimates of (V) occur in subjects whose height and/or weight differ from the normal range (body mass index BMI < 20 or > 27.5 kg/m2).70,71 In a recent study, (V) in men was approximately 2-6 L greater than previously reported using the above calculations and (V) in women was 2-5 L less than reported. The mean ratio of V to weight declined with age as a function of increased body fatness (men > women). 72 There is validation for the accuracy of computer modeling of PD prescriptions in CAPD patients that should be used more often in clinical practice. 73 There should be a system to identify and correct patient-related failure to achieve prescribed PD dose. The potential patient-related causes should be investigated and corrected. These include failure to comply with the prescription, lack of understanding of the importance of adherence to the full prescription and sampling and collection errors. Moreover, potential staff-related causes of failure to achieve prescribed peritoneal dialysis dose should be investigated and corrected. These include, errors in prescription, inadequate monitoring of delivered dose and inadequate patient education. Inadequate education may stem from both poor educator understanding of the principles of clearance and lack of proper teaching technique. Staff responsible for patient education should be trained and competent in both the principles of clearance and the technique of patient instruction. 74-78 The establishment of a PD clinic is utmost importance to implement these strategies besides patients follow-up Peritonitis is the culprit of PD. Although the diagnostic criteria for peritonitis have not been validated in clinical studies, they represent an international consensus among adult and pediatric nephrologists. Antibiotic treatment should be initiated as soon as the diagnosis of peritonitis is made. While it is advisable to perform and review the results of a dialysate cell count and Gram stain prior to the initiation of treatment, therapy should be started immediately upon recognition of effluent cloudiness if signs of severe infection, such as pain and fever, are present. The response to the initial antibiotic treatment should be

evaluated daily after treatment initiation. Treatment can be considered successful if an improvement in clinical status (e.g., cessation of abdominal pain and fever, and reduction of effluent cloudiness) has been achieved by 72 hours of therapy. A reduction of the dialysate WBC count by more than 50% is an additional evidence of successful therapy. If no clinical improvement occurs within 72 hours of treatment initiation, potential sources of persistent infection should be evaluated. Treatment modifications may include an alteration of antibiotic therapy and/or catheter removal. Peritoneal dialysis catheter removal should occur as part of the recommended treatment course in situations in which failure to do so is unlikely to result in successful peritonitis therapy. The timing of catheter replacement should be 2 - 3 weeks following catheter removal in most cases. Prophylactic antibiotic therapy should be given at the time of catheter placement in the form of a single dose of a first-generation cephalosporin. Antibiotic prophylaxis should also be considered following accidental intraluminal contamination, prior to dental procedures, and prior to procedures involving the gastrointestinal or urinary tract. Prophylactic systemic long-term antibiotic treatment is not indicated.79-115 There may be ultrafiltration and solute clearance failure that is increased with increasing duration of dialysis, ranging from 2.6% at 1 year to 30.9% at 6 years especially with advanced age of the patients. 116 Some studies have suggested that peritonitis may cause an increase in membrane transport,117,118 while others did not.119Accordingly, it would seem prudent to periodically monitor PET especially if loss of ultrafiltration is detected. Several studies have shown that high transporters do have increased mortality and reduced technique survival, independent of other risk factors. 120,121 The exact mechanisms for the poor survival of high transporters is uncertain, but may relate to poor ultrafiltration and fluid overload leading to hypertension and left ventricular hypertrophy, dialysate protein losses and poorer nutrition, chronic inflammation or other unknown mechanisms.122 If high transporters are due to chronic inflammation and comorbidities with low serum albumins, higher Creactive protein (CRP), lower RRF and lower protein nitrogen appearance (PNA) will have a poor prognosis.123-126

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The Saudi Guidelines Of the PD management are intended to approach the patients on PD and to encourage both the practice of PD and research in this field.

Peritoneal Dialysis in Saudi Arabia

Over the past 20 years there has been valuable research related to this issue from the dialysis centers in Saudi Arabia. We summarize these reports in chronological sequence in order to stimulate more research in the future: 1. In 1992, Salem et al127 reported a case of a 10-year-old boy who underwent laparotomy for massive liver injury associated with internal bleeding. Following the surgery the patient developed peritonitis and septicemia complicated by acute renal failure. Peritoneal dialysis was performed over several days to remove the waste products of metabolism as well as to increase his caloric and fluid intake. The patient tolerated the procedure well and no complications were encountered. Peritonitis was managed successfully with intraperitoneal administration of antibiotics via the dialysis catheter. The renal failure resolved completely. This case demonstrated that peritoneal dialysis could be performed effectively despite recent abdominal surgery. 2. In 1992, Mitwalli et al 128 reported about the occurrence of hepatitis C virus (HCV) infection amongst chronic renal failure (CRF) patients in their center over a period of 1 year. A total of 71 patients were studied comprising 26 chronic hemodialysis (CHD) patients, 6 acute hemodialysis patients, 4 peritoneal dialysis patients and 35 CRF patients not on dialysis. Patients were screened before and after hemodialysis, and their baseline and postdialysis values of liver enzymes were determined.

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Eleven (15.5%) of the total 71 patients were HCV antibody positive. Analysis of the individual patient groups showed that 8 (30.7%) of the 26 CHD patients were positive for HCV. Their data showed a statistically significant relationship between seroconversion and duration of dialysis (p<0.05). A high statistically significant (p<0.0001) correlation was observed between the HCV antibodies and CRF. The relative risk of hepatitis C was about 22 times greater for those with CRF compared with the normal controls, which makes CRF an important risk factor. A high proportion of the HCV seroconverters had elevated liver enzyme (serum glutamic pyruvic transaminase). The data presented showed a positive correlation between HCV seroconversion, CRF, duration on dialysis and elevated serum liver enzymes. 3. In 1992, Mahmoud et al 129 reported about their experience with 50 continuous ambulatory peritoneal dialysis (Tenchkoff) catheters implanted surgically in 39 children (24 male, 15 female) age 2 months to 13 years. Fifty-nine complications were encountered. Thirteen cases had subcutaneous leak of dialysate, 11 had exit site infection, eight had local pain, six had cuff extrusion, four had tunnel infection and three developed local hematoma. Nineteen (38%) catheters failed, and seventeen (34%) were removed because of change in line of treatment or death of the patient. Fourteen (28%) were still functioning up to 32 months. The overall actuarial catheter survival rates were 40% and 30.5% at one year and two years respectively. Catheter related problems were still a major cause of dropout from continuous ambulatory peritoneal dialysis in children. 4. In 1992, Al-Wakeel et al 130 reported about the effect of continuous ambulatory peritoneal dialysis (CAPD) and hemodialysis (HD) on the serum levels of alpha-1-antitrypsin (1 AT) that was evaluated in nine patients on CAPD and 11 patients on HD. In patients on CAPD, blood and dialysate samples were collected after eight hours of dwell time. For HD patients, serum 1 AT levels were measured before and after dialysis, twice on each patient, first while on dialysis with cuprophane and the second time while on dialysis using AN69 dialyzers. The median serum level increased by 0.3 gm/L in nine (82%) patients after HD with cuprophane and in 10 (91%) patients after dialysis with AN69. No phenotypic difference was seen between the 1 AT measured in the

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pre and post-dialysis period, whether the dialysis was done using a dialyzer with cuprophane or AN69 membrane. Serum levels of 1 AT were found to be normal in patients on CAPD and it was not detected in the peritoneal dialysate. 5. In 1995, al-Rasheed et al 131 reported a case of a 10-year-old boy with glucose-6-phosphate dehydrogenase deficiency developed acute renal failure during the icteric phase of non-fulminant hepatitis A infection. He needed peritoneal dialysis for 54 days. Acute tubular necrosis was confirmed by percutaneous renal biopsy. He had complete recovery of his renal function when he was discharged. 6. In 1995, Huraib 132 reported a case of a 23-years-old patient who was initiated on CAPD using curley Tenckhoff catheter in January 1992. In May 1993, the patient presented with features suggestive of intestinal obstruction. Plain X-ray of the abdomen showed that the CAPD catheter had migrated to the left hypochondrium. During surgery for catheter removal, it was found that the intraperitoneal cuff was adherent to the greater omentum forming a band over which the jejunal loop was kinked causing obstruction. Within 24 hours of removal of the catheter, the intestinal obstruction was relieved. The problem encountered in this patient was unique in illustrating the reversible mechanical intestinal obstruction relieved by catheter removal. 7. In 1996, al-Mugeiren et al 133 reported about seropositivity to hepatitis C virus (HCV) that was evaluated in three groups of Saudi children. One group (n = 18) was maintained on hemodialysis and another group (n = 21) on continuous ambulatory peritoneal dialysis (CAPD). The third group was community-based normal controls. The prevalence of antibody to HCV (anti-HCV) in children on hemodialysis (11.2%) was significantly higher than that in the control group (n = 220) (1.4%; p = 0.056). There was no significant difference in the prevalence of anti-HCV between children on CAPD (4.8%) and the control group (1.4%; p = 0.244). Among ten children on hemodialysis who were anti-HCV-negative 4 years earlier, two seroconverted and the seroconversion was not due to transfused blood but was most likely due to environmental contamination. This was the first report on the prevalence of anti-HCV in children maintained on CAPD. The results of the study emphasize the need for separate dialysis machines for anti-

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HCV-positive patients. It seemed that CAPD therapy might reduce transmission of HCV but a large number of CAPD patients would need to be studied to confirm superiority to hemodialysis in this respect. 8. In 1997, Mirza et al 134 studied the clinical aspects of peritonitis and catheter infections in 64 children on continuous ambulatory peritoneal dialysis living in Saudi Arabia over a period of 6 years. Peritonitis occurred in 41 children (64%). The mean time from starting dialysis to the first episode of peritonitis was 7.2 months. The incidence of peritonitis was 1 episode in 9 treatment months. Gram-negative organisms were responsible for the majority of episodes (42%), followed by Gram-positive organisms (20%), and Candida albicans (6%); 32% were culture negative. Recurrent peritonitis was present in 20 cases. Catheter was replaced in 24 patients: 44% due to recurrent peritonitis. Peritoneal membrane loss occurred in 7 patients, 3 had Candida peritonitis and 3 had recurrent peritonitis due to Pseudomonas. The mortality rate was 4.6% but none of the deaths were related to peritonitis or dialysis. 9. In 1997, Abbade et al 135 studied 16 patients (8 males, 8 females) with ESRD with a mean age of 46.3 15.6 years were managed by CAPD during 1990-1994. CAPD was the first option as a renal replacement therapy (RRT) in seven (44%) and second option in nine (56%) patients. Indications for CAPD were: Vascular access problems in 10 (62.5%), cardiovascular instability in three (19%), patient preference in two (12.5%) and non-availability of nearby HD center in one (6%) patient. Standard safe leur-lock system was used for dialysis. All patients were well dialyzed with good quality of life. Peritonitis was the main complication encountered (one episode/eight patient months), cause of hospital admission and reason for returning back to hemodialysis (HD). Other complications encountered were intraperitoneal bleeding in three, accidental cutting of outline in two, leakage in one and exit site infection in one. Average survival of this method was 15 10.5 months (range 1-37 months). At the time of reporting this study seven patients continued to be on CAPD, six were transferred back to hemodialysis, one was transplanted and two died due to other reasons. They concluded that CAPD is an acceptable mode of RRT in this part of the world.

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10. In 1997, Al-Salloum et al 136 reported their experience with chronic ambulatory peritoneal dialysis (CAPD) in children. Between 1984 and 1993, a total of 51 patients were treated by CAPD at King Khalid University Hospital. Eight patients were excluded from the study because of incomplete data. There were 25 boys and 18 girls aged three months to 16 years; 12 patients (27.9%) were below two years, 15 patients (34.9%) were between 2-6 years, and 16 patients (37.2%) were above six years of age. Reflux nephropathy secondary to obstructive uropathy was the main cause of ESRD in the study patients (27.9%). The rate of peritonitis was high, one episode per 4.7 patient months; one episode per 3.2 patient months in the first five years of the study period. The cause of peritonitis was gram positive organisms in 38.7% and gram negative organism in 24.9%. Seventeen (39.5%) of catheters were changed because of infection or mechanical obstruction. In 90.7% of patients, the mother was the person who was performing dialysis. At the end of the study, seven patients (16.2%) were still on CAPD, 10 patients (23.3%) shifted to hemodialysis, 16 patients (37.2%) were transplanted, six patients (14.0%) died and four patients (9.3%) recovered. The authors concluded that CAPD may be a suitable renal replacement therapy for children in a country with a wide geographical area and low population density as Saudi Arabia. 11. In 1998, Al Wakeel et al 137 reported about peritonitis in patients on CAPD at King Khalid University Hospital. Continuous ambulatory peritoneal dialysis (CAPD) was started at the King Khalid University Hospital in 1986. Peritonitis remained the most significant complication of the procedure. Earlier rates of peritonitis were high, but after gaining sufficient experience, the rates declined. To evaluate the change in peritonitis trend, 55 new patients who were recruited to their CAPD program between the period October 1993-October 1996 were analyzed for the development of peritonitis on annual basis. There were 37 (67%) males and 18 (33%) females with a mean age of 43.3 years (range 12-72 years). A total of 34 episodes of peritonitis were recorded with a rate of 1.5 episode/patient year in 1993, 0.5 episode/ patient year in 1994 and 0.8 in 1995. Only 40% of episodes showed positive cultures whereas 60% remained culture-negative despite use of recommended modified culture techniques. Organisms causing

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peritonitis included Staphylococcus epidermidis (20%), Staphylococcus aureus (6.7%), E. coli (3.3%), Streptococcus fecalis (3.3%) and Pseudomonas (6.7%). Out of 34 episodes of peritonitis, 29 (85.3%) showed response to treatment and five episodes could only be treated after removal of catheter. Of the 29 episodes that responded to treatment, three relapsed and one had recurrent infection. However, all were successfully treated though one responded only after removal of catheter. Thus, a total of six catheters (20%) necessitated removal and replacement. In spite of high diabetic patient population in their series (27.2%), only one died of peritonitis related sepsis and another died of myocardial infarction after clearing the infection. Thus mortality remained low inspite of potential risk. Although they still used straight system CAPD rather than Y system at the time of the report, peritonitisrates had declined considerably and they hoped that the procedure would gain more acceptability amongst patients with ESRD in Saudi Arabia. 12. In 1998, Mitwalli et al 138 performed bone biopsies in 57 patients with end-stage renal failure (ESRF) on dialysis, 46 on hemodialysis (HD) and 11 on peritoneal dialysis (PD). There were 29 males (mean age of 42 years) and 28 females (mean age of 39 years). Relevant presenting clinical features were pruritis in 46 cases, bone pains in 32, acute pseudogout in three, bone deformities in two, conjunctival calcification in two, cutaneous calcification in two, and corneal calcification in one. The mean value of predialysis blood investigations were as follows: urea 33.9 mmol/L, creatinine 913 mol/L, bicarbonate 18 mmol/L, calcium 2.36 mmol/L, albumin 40 g/L, phosphorus 1.69 mmol/L, alkaline phosphatase 178 U/L, parathyroid hormone 543 pmol/L, magnesium 1.06 mmol/L and aluminum 1.81 mmol/L. Skeletal survey showed no changes in 24 patients (42%), hyperparathyroid cystic changes of bones in seven, osteoporosis as the predominant features in seven, mixed picture of ROD in 12, subperiosteal resorption of the metacarpals in two, osteosclerosis (Rugger Jersey Spine) in two and osteomalacia in two patients. Bone mineral density (BMD) was measured by dual x-ray absorptiometry in the lumbar spine (LS) and femoral neck (FN). All patients had low BMD (both LS and FN). Bone biopsy (BBX) revealed mixed picture in 30 cases, predominantly

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secondary hyperparathyroid changes in 10, mild hyperparathyroid changes in five, predominant osteoporosis in three, osteomalacia in four, aplastic (adynamic) bone in four, and aluminum deposition in one. All of the patients who showed evidence of bone involvement on BBX had abnormal BMD suggesting that BMD was a good noninvasive screening test for ROD but indiscriminative for the type of bone disease. The authors believed that BBX remained the diagnostic tool to differentiate the types of bone disease. 13.In 1999, Kechrid et al 139 described hydrothorax that occurred in a patient on continuous ambulatory peritoneal dialysis (CAPD) and highlight the problems of diagnosis and management. A 48-year-old man with history of obstructive uropathy secondary to urolithiasis was started on CAPD when he reached end-stage renal failure. Two months later, he was admitted with two days history of shortness of breath on exertion and dry cough increasing in supine position. Chest examination was suggestive of right sided pleural effusion confirmed by chest Xray. Radioisotope Technetium99m labeled albumin instilled through the peritoneal catheter was detected in the right pleural fluid confirming the peritoneo-pleural leak. The peritoneal dialysis (PD) was discontinued and the patient was switched to hemodialysis. The pleural effusion subsided and did not recur . 14. In 2000, Mitwalli et al 140 studied intermittent oral versus intravenous alfacalcidol in dialysis patients on19 ESRF patients, who were on dialysis (13 on hemodialysis and six on peritoneal dialysis) for longer than six months and having serum parathormone levels at least four times normal and serum calcium less than 2.1 mmol/L, were randomly allocated to treatment with oral or intravenous (i.v.) alfacalcidol for a period of 12 months. There were six patients on hemodialysis (HD) and three on peritoneal dialysis (PD) in the oral treatment group while in the i.v. group there were seven patients on HD and three on PD. Clinical and serial biochemical assessments showed no statistically significant difference between the orally- and i.v.-treated patients in terms of suppressing secondary hyperparathyroidism and osteodystrophy. However, patients with features of mild ROD on bone histology, had more satisfactory changes in biochemistry when compared to others. Our results further support the use of intermittent oral alfacalcidol in

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ESRF patients because of its cost effectiveness, ease of administration and convenience, especially for peritoneal dialysis patients. 15. In 2001, Youmbissi et al 141 reported the Dammam Central Hospital experience in surgical placement of Tenckhoff catheter under local anesthesia. Eighteen consecutive Tenckhoff catheters were placed under local anesthesia through a mini laparotomy with a reduced operating team. There were only three total catheter failures. Complications were infrequent and operating time was less than one hour on average. The authors believed that this simple procedure should be a part of the training program of all junior surgeons and nephrologists. 16. In 2001, Souqiyyeh et al 142 reported about the dialysis centers in the Kingdom of Saudi Arabia. They surveyed 130 active hemodialysis (HD) centers using a questionnaire about their manpower, hemodialysis equipment, as well as, peritoneal dialysis and transplant patients at the end of the year 2000. Almost all the dialysis centers were on hospital campus but of variable sizes with an average ratio of 14.8 dialysis machines per center (range 2-113 machines per center). The distribution of the dialysis centers according to the geographical regions of Saudi Arabia included 18(14%) in the northern, 25(19%) in the southern, 13(10%) in the eastern, 35(27%) in the western and 39(30%) in the central region. There was a total of 6,694 dialysis patients served on 1,918 hemodialysis machines. There were 1,793(93%) HD machines capable of performing bicarbonate dialysis. There was an average ratio of 3.5 patients per one HD machine. In addition to the hemodialysis, there were 28(22%) centers engaged in peritoneal dialysis (PD) and 56(43%) centers in the follow-up of post transplant patients. The total number of the nephrologists, regardless of their expertise was 212 of whom 180(84%) spoke Arabic; the average ratio was 32 patients per nephrologist (range of 14-58). There were 1320 hemodialysis nurses of whom only 465(35%) spoke Arabic. The average ratio of patients to nurses was five patients per nurse (range of 4-6). There were 72(55%) social workers and 70(54%)dietitians with average patients ratios to these supporting services of 1:93 patients (range of 1:58-137) and 1:96 patients (range of 1:53-137), respectively. The study HD patients had a mean age of 47.8 17.1 years (range: 2-92 years); of them, 52.5% were males and 12% had non-Saudi nationality. Of the hemodialysis

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patients, 1,815(27%) were diabetics. The calculated net increase of dialysis population was 988 patients per year (14.8%). There were 5,700(85%) patients on regular bicarbonate dialysate. Chronic viral infection were noted in more than half of all the dialysis population: thus 3,380(50%) were positive for hepatitis C viral (HCV) serology, 448(7%) had positive hepatitis B (HBV) antigenemia and six (0.1%) had the human acquired immunodeficiency syndrome. In conclusion, The authors findings demonstrated a satisfactory advancement achieved in many Saudi dialysis centers in terms of equipment, personnel and patients care. However, they believed that there should be more emphasis in the future on quality care through better self-assessment of the performance of these centers. 17. In 2001, Youmbissi et al 143 studied 31 patients who were offered continuous ambulatory peritoneal dialysis (CAPD) for their end-stage renal disease (ESRD) at the Dammam Central Hospital, Dammam, Saudi Arabia over a period of five years. The group included 21 women and 10 men with a mean age of 41.3 17.2 years. The main indication for CAPD was poor or failed vascular access (51.4%). Peritonitis remained the major complication with an overall incidence of 0.62 episodes per patient year. Staphylococcus epidermidis was the main causative organism. Therapy with CAPD lasted a mean of 26 7.4 months. The investigators results, showing good technique survival and low peritonitis rate, suggested that CAPD should be promoted to become a full arm of the integrated care of ESRD in Saudi Arabia. 18. In 2003, Malik et al 144 described two cases of tuberculous (TB) peritonitis on chronic peritoneal dialysis (PD). The cases were diagnosed by positive acid fast bacilli (AFB) culture from the PD fluid effluent. Catheter removal and transfer to hemodialysis were needed in one, while the other remained on continuous ambulatory peritoneal dialysis. The patients recovered with antituberculous therapy. A high index of suspicion for early diagnosis and treatment was emphasized. A sixmonth course of anti-TB drugs for TB peritonitis was a viable option of therapy. 19. In 2004, Tarif 145 reported a case of a 69-year-old African American female with end-stage renal disease secondary to hypertensive nephrosclerosis on chronic ambulatory peritoneal dialysis (CAPD) for

19

five years. Her past was uneventful. She presented with symptoms and signs of acute peritonitis related to CAPD. There was initial response to antibiotics and culture was negative. The condition of the patient deteriorated despite the antibiotic. The peritoneal catheter was removed after five days of starting the antibiotic. The patient died at day seven of presentation due to septic shock and the culture eventually grew Candida lusitaniae, a rare agent of peritonitis in CAPD patients, which was resistant in vitro to amphotericin B. 20. In 2004, Al-Hashemy et al 146 described a two port technique for laparoscopic placement of PD catheters in nine patients. This prospective study was carried out at The Armed Forces Hospital, Khamis Mushayt, Saudi Arabia. Nine patients with ESRD underwent laparoscopic placement of the PDC between January 2001 and May 2002. There were seven females and two males, with a mean age of 52 years (range 38-75 years). The mean operating time was 41 minutes (range 30 75 min). The mean post-operative hospital stay was 4.5 days (range 2-15 days). Two patients (22.2%) developed leakage of dialysate from the 5 mm-port and one patient (11.1%) had migration of the PDC. this study suggested that this new modified technique appeared to be safe and simple and was associated with rapid post-operative recovery. 21. In 2005, Al Wakeel et 147 studied the complications of CAPD in 65 patients treated at their hospital from October 1996 to January 2002. There were 32 (49%) males and the mean age of the patients was 48 16 years. All the patients were on the twin bag CAPD system. The mean duration of follow-up on CAPD was 29 20 months. There were 75 episodes of complications occurring in the patients with a rate of 0.41 episodes/patient years. Peritonitis was the most frequent and serious complication accounting for 55 episodes with a rate of 0.35 episodes/patient years. Only 51% of the episodes showed positive culture; the organisms included Staphylococcus epidermidis (18.2%), Staphylococcus aureus (3.6%), Pseudomonas (16.4%), E. coli (1.8%), Azadobacter (5.45%) and Serratia (3.6%). All the episodes of infection, except one, responded to treatment but 10 patients had recurrent infection; one patient was cured only after removal of the catheter. There were 12 exit site infection episodes and five catheters were removed due to mechanical and infectious reasons. Three patients were

20

switched to hemodialysis (HD), nine patients were transplanted and 11 patients expired; none died due to peritonitis. The authors concluded that the mortality rate of the complications on CAPD had declined in the present study compared to their previous report early in the 1990s due mostly to the adoption of the twin bag CAPD system. 22. In 2005, Kari 148 reported about the peritoneal dialysis in children at King Abdul Aziz Hospital, Jeddah, Saudi Arabia, from June 2000 to June 2004. A total of 15 children (9 boys and 6 girls) with end-stage renal failure (ESRF) received PD for a mean duration of 9 8.6 months; 11 children received continuous ambulatory dialysis (CAPD) and four received automated PD. The mean age of the children at the start of PD was 7.3 4.3 years. All the children had low socioeconomic status. The most common complication was peritonitis (53%) followed by exit site infection (26.6%). The over all rate of peritonitis was one episode per 5.9 patients treatment months. Five children had recurrent peritonitis. Gram negative bacteria were the cause of peritonitis in 43.5% of the cases, gram positive in 30.4%, fungi in 8.9% and unknown in 17.4%. PD catheters were removed in five children; four because of infection and one because of obstruction. Three children were shifted to hemodialysis permanently; two children received renal transplantation from living donors and five children died. There was no difference in the age, duration of therapy or number of siblings, between the eight children who had peritonitis and the seven children who did not have peritonitis. However, illiteracy was higher and a separate room was less available in the peritonitis group compared to the peritonitis free group (37.5% vs 14.3% and 50% vs 100%, respectively). The author concluded that PD might still be a suitable modality of renal replacement therapy for children living in low socioeconomic conditions despite the challenging problems in them. 23. In 2006, Souqiyyeh et al 149 studied the attitude of physicians toward establishing and maintaining peritoneal dialysis programs in Saudi Arabia. The authors sent a questionnaire to 160 physicians; the heads of the 148 active dialysis centers in the KSA and 12 more consultants working in them. This covered decision makers in 109/148 (73.6 %) centers in ministry of health (MOH), 18/148 (12.2%) centers in governmental (non-MOH) and 21/148 (14.2 %) centers in private

21

hospitals that care for a population of more than 7300 chronic hemodialysis and 559 peritoneal dialysis. The study was performed between September and December, 2005. There were 145 out of 160 (90.6%) physicians who answered the questionnaire from 141 (95.2%) of the dialysis centers that covered 620 (98.2%) of the dialysis patients in the KSA. There were 81 (56.3%) respondents who believed that the follow-up of the PD patients should be available in all the dialysis centers, 80 (55.2%) would like to have a PD clinic at their hemodialysis (HD) centers and only 20 (13.8%) had already PD clinics in them. However, 93 (66.4%) respondents did not request from the administration of their hospitals to open a PD clinic and 62 (44.6%) admitted to having no expertise in managing the patients on PD, while 53 (38.1%) claimed no enough space in their dialysis centers as the obstacle to start a PD program. The response to the question about the training, which the staff had received previously showed that 57(40.7 %), 58 (43.3 %), 48 (35.6 %), 72 (52.9 %) physicians had training on continuous ambulatory PD (CAPD), Intermittent peritoneal dialysis (IPD), Automated peritoneal dialysis (APD) or continuous cyclic peritoneal dialysis (CCPD), and acute PD, respectively. Only 36 (36%) respondents believed that at least one nurse in their respective centers had training on any of the modes of PD. The comparisons between the health sectors in the KSA showed that MOH had significantly less number of active PD programs and this reflected tremendously on the knowledge of the staff. We conclude that the current practices concerning the PD programs in the dialysis centers in the KSA are modest and require a new strategy to spread this modality of therapy horizontally in all the dialysis centers and vertically by implicating the newest technologies in the field of PD such automated PD machines and connectology. There is also a need to increase the awareness of physicians about the benefits and applicability of PD in those centers that lack this service. The authors believed that national guidelines and training were indispensable and could not be overemphasized to improve this service especially in the MOH hospitals.

22

GUIDELINES
STATEMENTS

23

I. Initiation of Dialysis
1.
1

When to Initiate Dialysis

Patients should be advised to initiate some form of dialysis when the weekly renal Kt/Vurea (Krt/Vurea) falls below 2.0. A weekly Krt/Vurea of 2.0 approximates a kidney urea clearance of 7 mL/min and a kidney creatinine clearance that varies between 9 to 14 mL/min/1.73 m2. Urea clearance should be normalized to total body water (V) and creatinine clearance should be expressed per 1.73 m2 of body surface area. The GFR, which is estimated by the arithmetic mean of the urea and creatinine clearances, will be approximately 10.5 mL/min/ 1.73 m2 when the Krt/Vurea is about 2.0. 2 The conditions that may indicate dialysis is not yet necessary even though the weekly Krt/Vurea is less than 2.0 are: 2.1 Stable or increased edema-free body weight. 2.2 Supportive objective parameters for adequate nutrition such as a lean body mass >63% or subjective global assessment (SGA) score indicative of adequate nutrition. 2.3 Complete absence of clinical signs or symptoms attributable to uremia. 3 The PD outcome data for a weekly Kt/Vurea of 2.0 are so compelling that using the same figure for initiation of dialysis justifies the small risks of performing peritoneal dialysis.

24

The risks of early initiation of PD are not known, but that the risks of late initiation are known and are unacceptable. 5 Patients with diabetes should initiate dialysis at levels of RKF higher than in patients with causes of ESRD other than diabetes. 6 The nephrologists must explain to the patient the risk of malnutrition with delayed initiation of dialysis and the strong inferential evidence that survival might be improved with an earlier start of dialysis.
4

2.
1.

Indications for Renal Replacement Therapy

In patients with chronic kidney failure (eg, GFR < 15 to 20 mL/min) who are not undergoing maintenance dialysis, if proteinenergy malnutrition (PEM) develops or persists despite vigorous attempts to optimize protein and energy intake and there is no apparent cause for malnutrition other than low nutrient intake, initiation of maintenance dialysis or a renal transplant is recommended. 2. Patients with CKD need to undergo nutritional assessment at frequent intervals so that any deterioration in nutritional status can be detected early. 3. Any of the following nutritional indicators show evidence of deterioration that warrant the initiation of dialysis: 3.1 More than a 6% involuntary reduction in edema-free usual body weight (%UBW) or to less than 90% of standard body weight in less than 6 months. 3.2 A reduction in serum albumin by greater than or equal to 3 g/L and to less than 40 g/L in the absence of acute infection or inflammation, confirmed by repeat laboratory testing. 3.3 A deterioration in SGA by one category (i.e. normal, mild, moderate, or severe).

25

26

II. Suitable Patients for Peritoneal Dialysis

1.
1. 1.1 (HD). 1.2 Patients who cannot tolerate HD (eg, some patients with congestive or ischemic heart disease, extensive vascular disease, or in whom vascular access is problematic, including the majority of young children). 1.3 Patients who prefer home dialysis but have no assistant for HD. or whose assistant cannot be trained for home HD.

Indications for PD
Indications for PD include: Patients who prefer PD or will not do hemodialysis

2.
1. 1.1

Absolute Contraindications for PD

Absolute contraindications for PD include: Documented loss of peritoneal function or extensive abdominal adhesions that limit dialysate flow. 1.2 In the absence of a suitable assistant, a patient who is physically or mentally incapable of performing PD. 1.3 Uncorrectable mechanical defects that prevent effective PD or increase the risk of infection (eg, surgically irreparable hernia, omphalocele, gastroschisis, diaphr-agmmatic hernia, and bladder extrophy). 2. PD advantages include: 2.1 Flexible treatment schedule 2.2Less restricted diet 2.3Prolonged residual renal function 2.4Better for patients awaiting transplantation and have no HCV infection. 2.5Patients have more freedom to travel.

3.

Relative Contraindications for PD

1. Relative contraindications for PD include: 1.1. Fresh intra-abdominal foreign bodies (eg, 4-month wait after

27

abdominal vascular prostheses, recent ventricular peritoneal shunt). 1.2 Peritoneal leaks into subcutaneous tissues, pleural space, or genitalia can be painful and cause local problems. Leaking into the vagina or rectum increases the risk of contamination. 1.3 Body size limitations when the patient is either too small to tolerate the prescribed dialysate volume or too large to achieve adequate dialysis. 1.4 Intolerance to PD volumes that are necessary to achieve adequate PD dose. 1.5 Inflammatory or ischemic bowel disease or frequent episodes of diverticulitis. 1.6 Abdominal wall or skin infection. 1.7 Morbid obesity (in short individuals). The possibility that increased caloric absorption from the dialysate could lead to further weight gain should also be considered. 1.8 Severe malnutrition. Wound healing is compromised in severely malnourished patients. Furthermore, peritoneal protein losses may not be tolerated.

4.
1.

Indications for Switching from PD to HD

The decision to transfer a PD patient to HD should be based on clinical assessment, the patient's ability to reach HD dose target levels, and the patient's wishes. 2. Indications for switching from PD to HD include: 2.1 Consistent failure to achieve target Kt/Vurea and Ccr when there are no medical, technical, or psycho-social contraindications to HD. 2.2 Inadequate solute transport or fluid removal. High transporters may have poor ultrafiltration and/or excessive protein losses (relative contraindication, obviously discovered after initiation and the first PET). 2.3 Unmanageably severe hyper-triglyceridemia resulting from, or exacerbated by, the dextrose load intrinsic to the dialysate, may increase the risk for cardiovascular disease. 2.4 Unacceptably frequent peritonitis or other PD-related

28

complications. The definition of unacceptably frequent peritonitis has to be individually determined for each patient. Such considerations as the availability of hemodialysis facili-ties will inevitably play a role. 2.5 Development of technical/mech-anical problems such as catheter malposition resulting in access failure, hydrothorax, hernia, or hydrocele. 2.6 Severe malnutrition resistant to aggressive management (relative). 2.7 Patients should be informed of the risks of staying on PD at a level of adequacy below that recommended by their physician.

29

III. Access for Peritoneal Dialysis

1. Choice of Catheter and General Rules
1. 2. Catheter survival of >80% at 1 year is a reasonable goal. Convincing data exist to indicate that the double-cuff catheter is preferable to the single-cuff catheter; therefore a double-cuff configuration is advocated. 3. A downward-directed exit may decrease the risk of catheterrelated peritonitis. 4. Properly implanted, preformed arcuate or pail-handle catheters, will always have a downward-directed exit and are, therefore, advantageous in this respect. 5. Overall, no catheter yet appears to be superior to the original 2-cuff, standard Tenckhoff catheter, although experience with Swan neck catheters is promising. The size of the catheter for should be: adult or pediatric. 6. The experience in general surgical practice indicates that perioperative antibiotics, especially in the presence of a foreign body, diminish the incidence of wound infection. 6.1A first-generation cephalosporin has been most frequently used in this context and is advocated especially in centers with high postoperative wound or exit infections. 6.2Vancomycin should not be routinely used for perioperative prophylaxis to avoid the development of resistant microorganisms such as vancomycin-resistant enterococci (VRE) and vancomycin-resistant Staph aureus. 6.3Assess the bowel condition and apply cleansing enema. 6.4Mark the exit site while the patient is in the sitting position. 6.5Ensure good abdomen hygiene. 6.6Nasal ointment application for treatment of Staphylococcal colonization in the patient and sitter.

2.
1.

Implantation of the Catheter

The implantation must be performed by a competent and experienced operator, in a planned manner. Laparoscopic insertion may be attempted by expert hands.

30

2.

The procedure must be regarded as an important surgical intervention demanding care and attention to detail equal to any other surgical procedure. 2.1 Peritoneal entry should be lateral (deep cuff in or below the rectus musculature), or paramedian (deep cuff at the medial edge of the rectus muscle), to give good deep-cuff fixation and minimize herniation and fluid leaks. 2.2Other entry sites (midline through the linea alba) are used with trocar insertions. 2.3The deep cuff should be placed in the musculature of the anterior abdominal wall or in the preperitoneal space. 2.4Good results have also been obtained with the cuff placed within the posterior rectus fascia. 2.5The deep cuff should never be placed within the peritoneal cavity. 2.6After proper positioning of the catheter tip, the peritoneum is closed tightly around the catheter below the level of the deep cuff using a purse-string suture. 2.7The subcutaneous cuff should be located near the skin surface and at a distance of at least 2 cm from the exit site. Care should also be taken to avoid mechanically stressing the cuff material. 2.8Check for catheter patency. The catheter should be tested to ensure that there is adequate inflow and outflow without leakage. Techniques to accomplish this include infusing 1 L of peritoneal fluid over 5 minutes and allowing an equal time for drainage, or injecting 60 mL of 0.9% saline and observing if 30-40 mL is easily aspirated. 2.9The exit site should be facing downwards or be directed laterally. Upward-directed exit sites should, in general, be avoided. 2.10 The intra-abdominal portion of the catheter should be placed between the visceral and parietal peritoneum toward the pouch of Douglas and should not be placed within loops of bowel or directly in omental tissue. 2.11 Generally, the catheter should be capped for at least 2 weeks before initiating CAPD.

31

2.12 Peritoneal dialysis

in this interim period should be intermittent, using small volumes and with the patient in a supine position. 2.13 Avoid irritating or toxic solutions for cleansing; if povidone iodine or hydrogen peroxide are used, keep them out of the sinus or wound. 2.14 Use absorbent dressings and keep the exit as dry as possible. 2.15 Continue sterile dressings until the exit is healed. 2.16 Immobilize the catheter. 2.17 Infrequent dressings' changes (once per week) suffice for the first 2-3 weeks.

3. Care of the Exit Site

1. Catheter exit sites should be washed daily or every other day with antibacterial soap or a medical antiseptic to keep the exit clean and to diminish resident bacteria. 2. The choice of soap or cleansing agent may need to be individualized because of skin sensitivities or allergies. 3. It is important not to forcibly remove crusts or scabs during cleansing because this may traumatize the exit, causing a break in the skin and thus increase the risk of exit infection. 4. The exit should be patted dry after cleansing. The use of sterile gauze or cotton-tipped applicators is not necessary for care of the healed exit; a clean wash cloth and towel is sufficient. 5. Liquid soap and disinfectants should not be transferred to other containers because of the risk of cross-contamination. 6. Antibiotic therapy is essential for established exit and tunnel infections. 7. Duration of therapy is for a minimum of 2 weeks, at which stage the nonresponders need further evaluation and therapy. 8. Therapy with cuff shaving may be successful in difficult situations but long-term outlook for these catheters in not good. 9. Topical applications may cure equivocally infected exits; they are of no proven value in eradication of overt infections. 10. Catheter removal is essential in nonresponding tunnel infections, especially where there is associated peritonitis.

32

11.

Increased frequency of exit-site care (1-2 times daily) is recommended when there is an exit or tunnel infection. Crusts should not be forcibly removed. 12. Patients who are nasal carriers of Staphylococci aureus may receive prophylaxis; no one regimen of era-dication is superior. As a maneuver to prevent exit-site infections, applica-tion of mupirocin to the exit site as part of the daily routine is advocated. 13. Trauma to the catheter tract should be avoided by proper immobilization and should be reported to the dialysis unit if it causes severe pain or bleeding, or if there is subsequent deterioration of the exit-site appearance with redness, exudates, persistent pain or tenderness. 14. For a recurrent leak, surgical repair is essential and the site of the leak may be localized using computerized tomography. 15. Before treating a catheter obstruction, the type of obstruction must be established, if necessary, by catheter fluoroscopy. The treatment includes: 15.1 Conservative or noninvasive approaches should be undertaken such as: a. Body position change. b. Walk on staircases. c. Laxatives. d. Flushing with heparinized saline. 15.2 If these fail, then instillation of fibrinolytic agents (urokinase, streptokinase 10,000 U in 2 mL left in the catheter for 2 hours) may be tried. 15.3 In the case of recurrent fibrin clots, heparin in doses of 500 1000 U/L dialysis fluid may prevent obstruction. 15.4 Aggressive therapies include: a. Blind techniques using fluoroscopically guided stiff wires or stylet manipulation (rotating maneuver) combined with the whiplash technique cleaning out with a Fogarty catheter, or use of an intraluminal brush; b. Direct or visualized techniques of peritoneoscopy, open surgical catheter revision, or catheter replacement.

33

IV. Solutions for Peritoneal Dialysis

There is increasing awareness of the unfavorable properties of glucose as an osmotic agent. 2. In selected patients (those with high small solute transfer rates and little or no residual function) specialized solutions such as glucose polymers (icodextrin) are preferable to standard solutions. 3. Icodextrin may have particular value in improving ultrafiltration in patients and claimed to extend time on PD. Thus, it may be a cost effective method that avoids a transfer to HD. 4. Other solutions with variations in the concentration of sodium, calcium, magnesium, osmotic agents and buffers (bicarbonate) may also be required. Such solutions are likely to be more expensive. 5. The place of amino acid-containing dialysis fluid still has to be determined. 6. In the future, newer PD solutions with more effective osmotic agents may be of use in resolving chronic fluid overload. In the meantime, consider the following strategies: 6.1 The use of loop diuretics in patients with persisting urine output (more then 200 ml output) 6.2 The addition of a fifth exchange via a night exchange device in patients who tend to reabsorb their nocturnal dwell (High glucose concentration or icodextrin) is recommended. 6.3 Switching patients who do not ultrafitrate well on CAPD to APD short day dwells on APD according to the membrane profile. 6.4 If volume status is not well controlled, switching patients to well-prescribed hemodialysis.
1.

34

V. Continuous ambulatory peritoneal dialysis (CAPD)

1. Known for its simplicity, CAPD is the preferred mode of peritoneal dialysis to initiate most patients on. 2. In CAPD, dialysis solution is constantly present in the abdomen. The solution is typically changed four times daily, with a range of three to five times depending on individual patient requirements. 3. Drainage of "spent" dialysate and inflow of fresh dialysis solution are performed manually, using gravity to move fluid into and out of the peritoneal cavity 4. The Y disconnects and disposable tubing is the transfer set of choice for CAPD patients. A Y-shaped piece of tubing is attached by its stem to the patient's catheter or extension tubing at the time of each solution exchange. During the exchange, the afferent and efferent limbs of the Y are attached to a bag of fresh peritoneal dialysis solution and to a drain bag, respectively. In some cases, the drain bag is the empty solution bag that was used in the previous exchange. 5. Most Y sets are not attached directly to the catheter but rather to a short (15 to 24 cm) adapter or extension tubing inserted between the catheter and the stem of the Y set. The extension tubing avoids the need for, and the risk of damage associated with, repeated clamping of the catheter 6. The exchange procedure includes: 6.1 Spike/lock: The fresh bag of dialysis solution is attached to the afferent limb of the Y set via a spike or Luer lock. 6.2 Connect: The stem of the Y set is connected to the adapter tubing.

35

Drain: The stem and efferent limb of the Y are unclamped and the spent dialysate is drained from the peritoneal cavity into the drain bag. 6.4 Flush: With the stem of the Y set clamped, approximately 100 mL of fresh solution is flushed from the new bag through the afferent limb of the Y into the efferent limb and so into the drain bag. 6.5 Fill: The efferent limb is clamped and the stem unclamped, and the peritoneal cavity is filled from the new bag of dialysis solution. 6.6 Disconnect: The Y set is then disconnected from the adapter tubing and a new set is used for the next new cycle. 7. The double-bag systems are a variant of the Y set in which the solution bag comes preattached to the afferent limb of the Y tubing obviating the need for any spike or Luer lock connection: 7.1 The drain bag is similarly preattached to the efferent limb, and the only connection the patient needs to make is thus between the transfer set and the extension tubing. 7.2 A flush-before-fill step is still performed, but the purpose is only to flush out residual air and not to prevent peritoneal cavity contamination, as this is no longer relevant in the absence of a need to make a transfer set-to-solution container connection. 8. The double bag system is now more popular system than the standard Y sets. 9. Catheter-to-transfer set (or extension tubing-to transfer set) connection includes 9.1 Catheter connector: A special Luer lock connector made of tita- nium was developed as an adaptor. Titanium was chosen for its light weight and resistance to electrolyte containing solutions. Designed for easier handling and a tighter connection. The new product functions very well. The catheter-to-transfer set connect-ors constructed from more durable plastics are also available.

6.3

36

With the advent of the disconnect Y sets and double bags, the need for easy yet sterile connection at the catheter-to-transfer set joint (or adapter-to-transfer set joint) has arisen. A number of new connectors for this purpose are now available. 10. With the advent of the double bag systems, technologies to facilitate the connection between the transfer set and the peritoneal dialysis solution container are less relevant such as the spike-and-port design and the easy-lock connectors

9.2

37

VI. Automated Peritoneal Dialysis (APD)

1.
1.

Patients selection for APD

APD refers to the use of a cycler for various regimens, including nightly intermittent peritoneal dialysis (NIPD), continuous cycling peritoneal dialysis (CCPD) and tidal peritoneal dialysis (TPD; nightly, NTPD, or continuous, CTPD). Intermittent peritoneal dialysis (IPD) two or three times/week is not recommended because satisfactory clearances are seldom achieved with this modality. APD should be prescribed in preference to continuous ambulatory peritoneal dialysis (CAPD) for patients in whom minimizing the time spent performing peritoneal dialysis (PD) is an important consideration (e.g. workers, school pupils, students, carers of elderly or debilitated patients). APD treatment is associated with lower rates of peritonitis, overall hospital admissions and hospital admissions for dialysisrelated problems. Low-low average transport patients generally achieve better clearances with continuous regimens such as continuous ambulatory peritoneal dialysis (CAPD) and continuous cyclic peritoneal dialysis (CCPD) whereas high-high average transport patients achieve better small solute clearances with short dwell techniques such as nocturnal peritoneal dialysis (NPD), and nocturnal tidal peritoneal dialysis (NTPD).Table 1 shows the peritoneal membrane characteristics according to PET result. Increasing the fill volume, the number of exchanges or the amount of ultrafiltration should increase clearances in most patients. Some patient populations may not tolerate increasing dwell volumes in CAPD, especially small patients. Even larger patients often cannot achieve targets set despite the increase in dialysis dose on CAPD. Use of APD should be considered in this group. APD may not enhance peritoneal ultrafiltration in PD patients with high and high-average transport status. APD is associated with poorer sodium removal than CAPD. Sodium removal can be

2.

3.
4.

5.

6.

38

enhanced in APD patients by the use of icodextrin, supplementary diurnal exchanges and longer nocturnal dwell times. 7. There are no randomized, double-blind controlled trials to confirm that the use of APD accelerates the loss of RRF. Theoretical reasons why APD might accelerate the loss include rapid changes in fluid volume resulting in an ischemic insult to the kidney or the use of icodextrin or hypertonic glucose. 8. Use of the 'dry day' in NIPD reduces clearance by up to 10%15% compared with CAPD or CCPD. Therefore, a daytime exchange is often necessary. 9. Tidal modalities (TPD) have been proposed to more efficiently increase small solute clearances in APD, in part by reducing the impact of drain-fill multiplication but at higher cost. This is due to an effective increase in dialysis flow rate. 9.1 In the low-low average group, IPD improved urea and creatinine clearances compared with TPD at low flow rates with similar volumes and length of treatment, but not once flows were increased. 9.2 In high transporters, urea and creatinine clearances were greater than in low-low average transporters, with no difference between the PD modalities at low and high flow rates. 9.3 Ultrafiltration does not improve with increasing volumes. 9.4 Anuric, low peritoneal membrane transport patients have difficulty achieving adequate small solute clearances with TPD.
Membrane type 4-hr dialysate/ Non-DM peritoneal (D/P) creatinine 0.81-1.03 9% 0.65-0.80 0.50-0.64 0.34-0.49 56% 32% 3% DM

High High Average Low Average Low

10% 51% 37% 2%

DM: Diabetes mellitus.

39

VII. Measures of Peritoneal Dialysis Dose

1.
1.

Frequency of Delivered PD Dose and Total Solute Clearance Measurement within Six Months of Initiation

The total solute clearance (delivered PD dose plus residual kidney function determined by CCr and Kt/V urea) should be measured at least twice and possibly three times within the first 6 months after initiation of PD; the first measurement should be performed approximately 2-4 weeks after initiation of PD. 2. Delivered peritoneal dialysis dose depends on many factors, including the transport properties of the peritoneal membrane, assessed by the peritoneal equilibration test (PET). The results after a month of PD may more accurately reflect peritoneal transport properties for the subsequent period. 3. In the absence of substantial renal kidney function (RKF), waiting 1 month to measure delivered dose may result in inadequate dialysis for 1 month. Patients as such should undergo measurement of delivered dose of PD at 2 weeks. 4. While decrease of urine production rate is presumed to be a clue to deteriorating RKF, that is not always the case. Accordingly, RKF should be measured every 2-4 months or when urine output decreases.

2.

Measures of PD Dose and Total Solute Clearance

surface area (BSA) and total weekly Kt/Vurea should be used to measure delivered PD doses.

1. Both total weekly creatinine clearance normalized to 1.73 m2 body

3.
1.

Frequency of Measurement of Kt/Vurea, Total CCr> PNA, and Total Creatinine Appearance

After 6 months, total Kt/Vurea, total CCr, and PNA (with all its components) should be measured every 6 months, unless the prescription has been changed or there has been a significant change in clinical status 2. A change in clinical condition, which warrants measurement

40

of delivered PD dose is defined as: Any serious problem, which affects the nutritional status. The decrease in the ability of the patient to perform PD mechanically or technically (such as stroke or arthritis, loss of surface area from surgery. 2.3 The decreased exchange volumes due to hernias, etc. 2.4 The permanently affected transport properties of the peritoneum (eg, protracted peritonitis). 2.5 Any suggestion of exacerbation of uremia.
2.1 2.2

4.
1.

Assessing Residual Kidney Function

Residual kidney function (RKF), which can provide a significant component of total solute and water removal, should be assessed by measuring the renal component of Kt/Vurea (Krt/Vurea). 2. Creatinine clearance corrected for renal secretion and Kt/Vurea are both valuable measures in the management of PD patients. Each measure offers different information. 3. The measurement of GFR with endogenous solutes is best done by defining GFR as the arithmetic mean of urea and creatinine clearance .This arithmetic mean essentially corrects for secretion of creatinine.

5.
5.1

PD Dose Troubleshooting
In adult patients, a daily creatinine excretion in urine and dialysate that differs from the baseline rate by >15% should prompt an investigation for noncompliance, improper collection of drained dialysate and/or urine, or altered peritoneal transport function. Compliance should not be assessed by comparing measured to predicted creatinine excretion.

41

VIII. Measurement of Peritoneal Dialysis Dose

1.
1.

Reproducibility of Measurement
Accurate measurement of total Kt/Vurea and total creatinine clearance (CCr) requires collection and analysis of urine, dialysate, and serum in a way that yields reproducible and valid results. Dialysate creatinine concentration must be corrected for the presence of glucose in some assays. Peritonitis precludes reliable measurement of delivered PD dose for up to a month. Compliance with complete collections is mandatory. For patients who void 3 times per day, a 24-hour urine collection is sufficient. For patients who void less frequently, a 48-hour collection is recommended. For CAPD patients, the serum sample can be obtained at any convenient time. For NIPD patients, the serum sample should be obtained at the midpoint of the daytime empty period. For CCPD patients, the serum sample should be obtained at the midpoint of the daytime dwell.

2. 3.

4.
5.

6.

7.
8.

2.
1.

Estimating Total Body Water and Body Surface Area

V (total body water) should be estimated by either the Watson or Hume method in adults using actual body weight and by the Mellits-Cheek method in children using actual body weight. 1.1.Watson method: For Men: V (liters) = 2.447 + 0.3362*Wt (kg) + 0.1074*Ht (cm) - 0.09516*Age (years). For Women: V = -2.097 + 0.2466*Wt + 0.1069*Ht 1.2 Hume method: For Men: V = -14.012934+0.296785*Wt+0.192786*Ht. For Women: V= -35.270121 +0.183809*Wt + 0.344547*Ht 1.3 Mellits-Cheek method for children: a- For Boys: V (liters) = -1.927 +0.465*Wt (kg) + 0.045*Ht (cm), when Ht < 132.7 cm. V= -21.993 + 0.406* Wt + 0.209*Ht, when height is > 132.7 cm.

42

b. For Girls: V = 0.076 + 0.507*Wt + 0.013*Ht, when height is < 110.8 cm. V = -10.313 + 0.252* Wt + 0.154*Ht, when height is >110.8 cm 2. Body surface area. BSA, should be estimated by either the Dubois and Dubois method, the Gehan and George method, or the Haycock method using actual body weight. For all formulae, Wt is in kg and Ht is in cm: 2.1. DuBois and DuBois method: BSA (m2) = 0.007184*Wt 0.425*Ht
0.725

2.2. Gehan and George method: BSA (m2) = 0 0235*Wt 0.45l456*Ht 0.42246 2.3. Haycock method: BSA (m2) = O.O24265*Wt.5378*Ht 0.3964 3. Amputation alters the relationship between body height and weight. This causes a mathematical distortion of the calculation of both anthropometric V and BSA.

3.
1.

Timing of Measurement
Routine measurements of total Kt/Vurea and total creatinine clearance should be performed when the patient is clinically stable (eg, stable weight, stable BUN and creatinine concentrations) and at least 4 weeks after resolution of peritonitis.

43

IX. Assessment of Nutritional Status in Relation to Peritoneal Dialysis

1.
1.

Assessment of Nutritional Status

Nutritional status of adult PD patients should be assessed on an ongoing basis in association with Kt/V urea and CCr measurements using the Protein equivalent of Nitrogen Appearance (PNA) and Subjective Global Assessment (SGA). 2. PNA(g/24 hours) = 15.1 +(6.95 X urea nitrogen appearance in g/24h)+ dialystate and urine protein in g/24 hours 3. In the absence of direct measurement of urinary and dialystate protein losses, a less accurate formula may be used: PNA (g/24hours) = 20.1 + (7.50 x urea nitrogen appearance in g/24 h) 4. For pediatric PD patients, nutritional status should be assessed using the PNA and other standard nutritional assessments 5. SGA addresses four items (recent weight change, anorexia, subcutaneous tissue, and muscle mass) scored on a 7point scale, where 1 or 2 is severe malnutrition, 3 to 5 is moderate to mild malnutrition, and 6 or 7 is mild malnutrition to normal nutritional status. 5.1 The SGA can be performed by physicians, nurses, or registered dietitians during routine clinic visits. 5.2 Higher SGA is associated with a lower risk of death. 5.3 The SGA should be performed in association with measurement of Kt/ Vurea and CCr, every 4 months after the initial 6 months 6. Although nutritional status is influenced by many nondialysis-related factors, appetite suppression, nausea, and vomiting are major clinical features of uremia and inadequate dialysis.

2.
1.

Determining Fat-Free, Edema-Free Body Mass

Total creatinine appearance should be used to determine fat-free, edema-free body mass (lean body mass) 2. In adults, fat-free, edema-free body mass in kilograms

44

is computed by the equation: Fat-free, edema-free body mass = 0.029 X total creatinine production in mg/day+7.38 2.1 Norms vary by patient gender and size. A steady-state of creatinine excretion should exist for the equation result to be valid. 2.2 Fat-free, edema-free body mass estimates by creatinine kinetics may be a better index of nutritional status in PD patients, because they reflect dry fat-free, edema-free body mass and changes in muscle mass better than dual-energy x-ray absorptiometry or bioimpedance. 2.3 A change in serum creatinine concentration may indicate changes in creatinine and urea removal to a much larger extent than a change in serum urea concentration. 2.4 A rising serum creatinine concentration is usually caused by a decrease in total creatinine clearance, often secondary to a loss of residual kidney function, and much less frequently by an increase in muscle mass 2.5 A decreasing serum creatinine concentration is caused more often by progressive loss in muscle mass and less often by an increase in total clearance.

3.
1.

Use of the Modified Borah Equation to Assess Nutritional Status of Pediatric PD Patients
Nutritional status of pediatric PD patients should be assessed at least every 6 months by standard clinical nutritional evaluations and by the modified Borah equation: PNA(g/d) = [6.49*UNA] + [0.294*V]+protein losses(g/day)

45

X. Adequate Dose of Peritoneal Dialysis

1.
1.

Weekly Dose of CAPD

For CAPD, the delivered PD dose should be a total Kt/Vurea of at least 2.0 per week and a total creatinine clearance (CCr) of at least 60 L/wk/ 1.73 m2 for high and high-average transporters, and 50 L/wk/1.73 m2 in low and low-average transporters. 2. There are currently no definitive outcome data in pediatric patients to suggest that any measure of dialysis adequacy is predictive of well-being, morbidity, or mortality.

2.
1.

Weekly Dose of NIPD and CCPD

For NIPD, the weekly delivered PD dose should be a total Kt/Vurea of at least 2.2 and a weekly total creatinine clearance of at least 66 L/1.73 m2. 2. For CCPD, the weekly delivered PD dose should be a total Kt/Vurea of at least 2.1 and a weekly total creatinine clearance of at least 63 L/1.73 m2.

3.
1.

PD Dose in Subpopulations
There is no adequate basis for recommending any change in the target doses of dialysis: Weekly Dose of CAPD, Weekly Dose of NIPD and CCPD, for various patient subpopulations (eg, patients with diabetes or who are elderly), with the exception of the malnourished patient, whose target dose is increased by the ratio of the Vdcsircd/ Vactual for Kt/Vurea.

4.
1.

Approach for Determination of Dose of Peritoneal Dialysis

General Evaluation of the Patient with Kidney Failure Explain all options (transplant, HD, and PD) to patients/parents/ care-givers in a nonbiased manner. 1.2 Review medical condition/co morbidities to
1.1

46

determine if contraindications, relative or absolute, exist for any modality. 1.3 If no medical contraindications exist and the patient is a candidate for self therapy, allow patient to choose a modality. 1.4 Place the chronic dialysis access (PD or HD). Vascular accesses can be placed in patients on PD. This decision should be made on an individual patient basis. 1.5 If dialysis is needed at the time of presentation, place the temporary HD access, or after placing the PD catheter, initiate therapy as suggested under point B.2, below. 2. Initiation of Peritoneal Dialysis 2.1If possible, wait 10 days to 2 weeks after catheter placement to start PD. 2.2If PD must be started in less than 10 days following catheter placement, do low-volume, supine dialysis. 2.3Obtain baseline 24-hour urine collection for urea and creatinine clearance. These collections are for solute clearance calculations, assessment of creatinine gene-ration, and PNA determinations. 2.4Note patient's weight and the presence or absence of edema. 2.5At initiation of dialysis explain to patient/ parents/caregivers that the patient's prescription will be individualized. Specifically, state that their instilled volume almost certainly will need to increase over time. For patients who choose Automated Peritoneal Dialysis (APD), one or more daytime dwells will be needed in approximately 85% of patients. 2.6Patients should know from the start of PD that their total solute clearance will be monitored and that, if their residual kidney function or peritoneal transport changes over time, their prescription may need to change as well. 3. Initial Dialysis Prescription for Adults 3.1Initial dialysis can be prescribed empirically based on patient's weight, amount of residual kidney function, and lifestyle choices (CAPD, NIPD, or CCPD) 3.2These empiric recommendations should be implemented prior to PET

47

4. Observations Needed During Training and Early Follow-up 4.1 Determine 4-hour drain volumes during training. This is to note if drain volumes are as expected for typical 4-hour dwells with 1.5%, 2.5%, or 4.25% dextrose ex-changes. This is not a formal PET, but is done to determine if the patient's peritoneal membrane transport characteristics are markedly different from the mean. 4.2 Monitor for evidence of leakage in the vicinity of the catheter. 4.3 Complete laboratory studies. a.Delay baseline PET until after training. b. Perform serum chemistries and complete blood count. c. If a computer-assisted kinetic modeling system is available, enter preliminary data to predict if the current prescription will be adequate. 5. Adjusting Dialysis Prescription 5.1 If kinetic modeling is not available: a.Unless PET has changed, dialysis dose is most effectively increased by increasing the instilled volume, therefore maximizing mass transfer and dwell time. OR b.Increase the number of ex-changes/day while maintaining maximum dwell time, ie, by using a single nighttime exchange to increase to 5 equal dwells/day. To this end, simplified mechanical exchange systems have been developed to perform a nocturnal exchange. 5.2 If computerized kinetic modeling is available, the dialysis team can use these programs to tailor a new prescription to meet the adequate dose of peritoneal dialysis.

48

XI. Strategies to Achieve Better Prescribed Dose of Peritoneal Dialysis

1.
1.

Identify and Correct Patient-Related Failure to Achieve Prescribed PD Dose

Potential patient-related causes of failure to achieve prescribed peritoneal dialysis dose should be investigated and corrected. These include: 1.1 Failure to comply with the prescription (estimated 1118%). Proper instructions and periodic reinforcement of education cannot be overemphasized. 1.2 Lack of understanding of the importance of adherence to the full prescription. 1.3 Sampling and collection errors.

2.
1.

Identify and Correct Staff-Related Failure to Achieve Prescribed PD Dose

Potential staff-related causes of failure to achieve prescribed peritoneal dialysis dose should be investigated and corrected. These include: 1.1 Errors in prescription. Nephrologists must ensure adequate education and training in PD. 1.2Inadequate monitoring of delivered dose. 1.3 Inadequate patient education. 2. Establishing a designated area as a peritoneal dialysis clinic for follow-up is a must in order to achieve stable service. It is as important as the establishment of the hemodialysis area in any dialysis.

49

XII. Peritoneal Dialysis Related Peritonitis

1.
1.

Presentation and evaluation

Peritoneal dialysis patients presenting with cloudy effluent should be presumed to have peritonitis. This is confirmed by obtaining effluent cell count, differential, and culture 2. Culture-negative peritonitis should not be greater than 20% of episodes. Standard culture technique is the use of blood-culture bottles, but culturing the sediment after centrifuging 50 mL of effluent is ideal for low culture-negative results 3. If a program has a rate of culture-negative peritonitis greater than 20%, then the culture methods should be reviewed and improved 4. Terminology for Peritonitis includes: 4.1 Recurrent: an episode that occurs within 4 weeks of completion of therapy of a prior episode but with a different organism 4.2 Relapsing: an episode that occurs within 4 weeks of completion of therapy of a prior episode with the same organism or one sterile episode 4.3 Repeated: an episode that occurs more than 4 weeks after completion of therapy of a prior episode with the same organism 4.4 Refractory: failure of the effluent to clear after 5 days of appropriate antibiotics 4.5 Catheter-related peritonitis: peritonitis in conjunction with an exit-site or tunnel infection with the same organism or one site sterile.

2.
1.

Initial choice of antibiotic therapy

Empiric antibiotics must cover both gram-positive and gramnegative organisms. Selection of empiric therapy should be dependent on the history of sensitivities of organisms causing peritonitis Gram-positive organisms may be covered by vancomycin or a cephalosporin, and gram-negative organisms by a thirdgeneration cephalosporin or aminoglycoside 2. Vancomycin, aminoglycosides, and cephalosporins can be

50

mixed in the same dialysis solution bag without loss of bioactivity. Aminoglycosides should not be added to the same exchange with penicillins because of chemical incompatibility. 4. For any antibiotics that are to be admixed, separate syringes must be used for adding the antibiotics such as vancomycin and ceftazidime, which are compatible when added to dialysis solutions but incompatible if combined in the same syringe or added to an empty dialysate bag for reinfusion into the patient 5. Antibiotics should be added using sterile technique (placing povidone iodine on the medication port for 5 minutes prior to insertion of the needle through the port). Dwell time of the exchange must be a minimum of 6 hours. 6. Data suggest that some antibiotics are stable for variable times when added to dextrose-containing dialysis solution. 6.1Vancomycin (25 mg/L) is stable for 28 days in dialysis solution stored at room temperature, although high ambient temperatures will reduce the duration of stability. 6.2Gentamicin (8 mg/L) is stable for 14 days, but the duration of stability is reduced by admixture of heparin. 6.3Cefazolin (500 mg/L) is stable for at least 8 days at room temperature or for 14 days if refrigerated; addition of heparin has no adverse influence. 6.4Ceftazidime is less stable; concentrations of 125 mg/L are stable for 4 days at room temperature or 7 days refrigerated, and 200 mg/L is stable for 10 days if refrigerated. 6.5Little is known about intermittent dosing requirements in patients treated with APD. 6.6Intraperitoneal (IP) dosing of antibiotics for peritonitis is preferable to IV dosing in CAPD, since IP dosing results in very high local levels of antibiotics. The IP route has the added advantage that it can be done by the patient at home. 6.7Monitoring drug levels for aminoglycosides and vancomycin is recommended. 3.

3.
1.

Adjustment of antibiotic therapy

Once culture results and sensitivities are known, antibiotic

51

therapy should be adjusted as appropriate. Antibiotic dosing for anuric CAPD patients defined as daily urine output of less than 100 mL are different from those with RRF. For the later patients the dose should be increased by 25% for those antibiotics that have renal excretion 2. Patients who are high transporters and those with high dialysate clearances may have a more rapid removal of some antibiotics. Adjustments in dosing for such patients are not yet known, but the clinician should aim at higher dosing. 3. Refractory peritonitis, defined as failure to respond to appropriate antibiotics within 5 days, should be managed by removal of the catheter to protect the peritoneal membrane for future use. 4. Coagulase-negative staphylococcus peritonitis, including S. epidermidis that is due primarily to touch contamination. It is generally of a mild form of peritonitis and responds readily to antibiotic therapy, but can sometimes lead to relapsing peritonitis due to biofilm involvement. In such circumstances catheter replacement is advised. 5. Streptococcal and enterococcal peritonitis tend to be severe and are best treated with IP ampicillin. 6. Vancomycin-resistant Enterococcus faecium (VREF) has been reported but remains uncommon in PD patients; limited data are available on proper management. 7. Staphylococcus aureus causes severe peritonitis. It is often due to catheter infection. Catheter-related peritonitis is unlikely to respond to antibiotic therapy without catheter removal. 8. Pseudomonas aerugenousa peritonitis is similar to S. aureus peritonitis. Catheter removal will be required and two antibiotics should always be used to treat it. 9. Other single organism gram-negative peritonitis may be due to touch contamination, exit-site infection, or transmural migration from constipation or colitis. 10. If multiple enteric organisms are grown, particularly in association with anaerobic bacteria, the risk of death is increased and a surgical evaluation should be obtained

52

Peritonitis due to multiple gram-positive organisms will generally respond to antibiotic therapy. 12. Catheter removal is indicated immediately after fungi are identified by microscopy or culture. 13. Mycobacteria are an infrequent cause of peritonitis but can be difficult to diagnose. When under consideration, special attention must be paid to culture techniques. Treatment requires multiple drugs. 14. The minimum therapy for peritonitis is 2 weeks, although for more severe infections, 3 weeks is recommended. 15. The removal of the catheter for relapsing peritonitis, refractory peritonitis, fungal peritonitis, and refractory catheter infections stems from the fact that we should always be focusing on preservation of the peritoneum rather than saving the peritoneal catheter. 16. Peritonitis is still the most frequent cause of failure of peritoneal dialysis and switch to hemodialysis.
11.

53

XIII. Clinical Outcome Goals for Adequate Peritoneal Dialysis

4.
1.

Measurement of PD Patient Survival

Survival of PD patients should be quantitated serially as an outcome measure.

5.
1.

Measurement of PD Technique Survival

PD technique survival, both dependent and independent of peritonitis, should be quantitated serially in PD patients as an outcome measure. 2. For some patients, for optimal outcome, it may be medically appropriate to transfer from PD to HD; this does not imply failure of the therapy or the dialysis facility. 3. PD technique survival is dependent upon many factors including infections, patient motivation, ultrafiltration (transport characteristics), and total solute clearance. Thus, PD technique survival is not a simple outcome measure for the adequacy of PD. 4. Centers should strive to achieve the goal of a 75% 2-year technique survival rate.

6.
1.

Measurement of Hospitalizations

ESRD-related and ESRD-unrelated hospitalizations (admissions/ year, hospitalized days/ year) in PD patients should be quantitated as an outcome measure. 2. PD patients are hospitalized an average of 1.8 times per year. 3. Centers should also monitor reasons for hospitalization (related versus unrelated to ESRD, and specific reason for admission).

54

7.
1.

Measurement of Patient-Based Assessment of Quality of Life

Patient-based assessment of quality of life (QOL) in PD patients should be evaluated serially as an outcome measure. 2. A patient-based quality of life instrument should have both generic and disease/treatment-specific measures of health-related quality of life and should be shown to be valid, reliable, and responsive prior to use. Once such an instrument is available, it should be administered at initiation of dialysis and at intervals determined to be appropriate by its validation studies. 3. There are many measures used in peritoneal dialysis patients and reported in the literature such as Medical Outcomes Study Short Form 36 (SF-36) and Sickness Impact Profile (SIP). According to the current evidence, no particular instrument can be strongly recommended over another.

8.
1.

Measurement of School Attendance, Growth, and Developmental Progress in Pediatric PD Patients

School attendance (in the absence of other comorbidities precluding school attendance), growth, and developmental progress should be measured serially in pediatric PD patients.

9.

Measurement of Albumin Concentration in PD Patients

1. A stable or rising serum albumin concentration that is greater than or equal to the lower limit of normal for each laboratory should be used as an outcome goal. 2. Low serum albumin is a strong predictor of mortality and morbidity in PD patients. 3. Efforts to maintain serum albumin in the normal range should include adequate nutrition, adequate clearances, and prevention and treatment of catabolic illness.

55

10.
1.

Measurement of Hemoglobin in PD Patients

Providers should strive to achieve a hemoglobin level of 110 to 120 g/L in 75% of PD patients.

11.
1.

Measurement of Normalized PNA in PD Patients

Providers should strive to achieve a normalized PNA (nPNA) of greater than or equal to 0.9 g/kg/day in PD patients. 2. A dietary protein intake of 1.2 to 1.3 g/kg body weight/day in clinically stable chronic peritoneal dialysis patients. Should lead to an nPNA equal to or greater than 0.9 g/kg/day.

56

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Disclaimer These Guidelines are based upon the best information available at the time of publication. They are designed to provide information and assist decision-making. They are not intended to define a standard of care, and should not be construed as one. Neither should they be interpreted as prescribing an exclusive course of management. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients,

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available resources, and limitations unique to an institution or type of practice. Every health-care professional making use of these Guidelines is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation. The development of the Saudi Guidelines for the management of peritoneal dialysis patients is supported by an educational grant from Baxter Company.

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