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PERITONEAL DIALYSIS

Peritoneal dialysis is a way to remove waste products from blood when the kidneys can no longer do the job. During peritoneal dialysis, blood vessels in the peritoneum fill in for the kidneys, with the help of a fluid (dialysate) washed in and out of the peritoneal space. Peritoneal dialysis differs from hemodialysis, more common blood-filtering procedure. With peritoneal dialysis, treatments can be given in the comfort of the patients home, at work or while traveling. It can be used with fewer medications and less restrictive diet than with hemodialysis. a Peritoneal dialysis is often done to manage kidney failure until a kidney transplant is possible. Kidney failure itself usually results from a long-term (chronic) disease that causes kidney damage over a number of years. Common causes of kidney failure include: Diabetes High blood pressure (hypertension) Kidney inflammation (glomerulonephritis) Blood vessel inflammation (vasculitis) Polycystic kidney disease (cysts in the kidney) Most people who require dialysis face a variety of serious health problems, including diseases that cause kidney failure as well as kidney failure itself. Dialysis prolongs life for many people, but life expectancy for those who need the procedure is still much lower than that of the general population. The main complications of peritoneal dialysis are:
Infections. The most common problem for people receiving peritoneal dialysis is peritonitis, an infection of the peritoneum. An infection can also develop at the site where catheter is inserted to carry the cleansing fluid into and out of abdomen.

Weight gain. The fluid used to clean blood in peritoneal dialysis contains sugar (dextrose). Patient may take in several hundred calories each day by absorbing some of this fluid, known as dialysate. The extra calories can also lead to high blood sugar if the patient has diabetes.

Weakening of the abdominal muscles. Holding fluid in the abdomen for long periods may strain belly muscles.

Other complications that can stem from dialysis or the underlying kidney disease include:

Alvin M. Ganuelas, RN, MAN

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Anemia. Anemia not having enough red blood cells in the bloodstream is a common complication of kidney failure. Failing kidneys reduce their production of a hormone called erythropoietin, which stimulates formation of red blood cells.

Bone diseases. If the damaged kidneys are no longer able to use vitamin D to absorb calcium, your bones may weaken. Overproduction of parathyroid hormone a common complication of kidney failure can strip calcium from your bones.

High blood pressure (hypertension). High blood pressure is a leading cause of kidney failure. Eating too much salt or drinking too much fluid while being treated for kidney failure, high blood pressure may get worse which takes a toll in remaining kidney function. Left untreated, high blood pressure can lead to a heart attack or stroke.

Fluid overload. While holding the dialysis fluid in your abdomen for long periods, your body may absorb too much fluid. This can cause lifethreatening complications, such as heart failure or fluid accumulation and swelling in your the (pulmonary edema).

Amyloidosis. Dialysis-related amyloidosis develops when proteins in blood are deposited on joints and tendons, causing pain, stiffness and fluid in the joints. The condition is common in people who have been on dialysis for more than five years.

Many factors affect how well peritoneal dialysis works in removing wastes and extra fluid from your blood. These factors include: Size of patient How quickly peritoneum filters waste (peritoneal transport rate) How much dialysis solution used (fill volume) The number of daily exchanges Dwell times The concentration of sugar (dextrose) in the dialysis solution Health care team will perform several tests to check if dialysis is removing enough waste products. These tests are especially important during the first weeks of dialysis to determine whether the patient receiving an adequate amount, or dose. Peritoneal equilibration test (PET). This test measures how much sugar has been absorbed from a bag of used dialysis solution and how much of two waste products; urea and creatinine, have entered into the solution during a four-hour exchange. Clearance test. Samples of used dialysis solution and a blood sample are collected to compare the amount of urea in the used solution with the amount in the blood. If the patients kidneys still produces urine, a urine sample may be taken at the same time to measure its urea concentration.

Alvin M. Ganuelas, RN, MAN

3 If the test results show that the dialysis schedule is not removing enough wastes, the doctor may change the prescription. This might involve changing the number of exchanges, increasing the amount of solution you use for each exchange or using a dialysis solution with a higher concentration of dextrose, a type of sugar.

HEMODIALYSIS
Hemodialysis is the most common method of dialysis. Hemodialysis is used for patients who are acutely ill and require short-term dialysis (days to weeks) and for patients with ESRD who require long-term or permanent therapy. A dialyzer (also referred to as an artificial kidney) serves as a synthetic semipermeble membrane, replacing the renal glomeruli and tubules as the filter for the impaired kidneys. For patients with chronic renal failure, hemodialysis prevents death, although it does not cure renal disease and does not compensate for the loss of endocrine or metabolic activities of the kidneys. Treatments usually occur three times a week for 3 to 4 hours per treatment. Patients receive chronic or maintenance dialysis when they require dialysis therapy for survival and control of uremic symptoms. The trend in managing ESRD is to initiate treatment before the signs and symptoms associated with uremia become severe. The objectives of hemodialysis are to extract toxic nitrogenous substances from the blood and to remove excess water. In hemodialysis, the blood, laden with toxins and nitrogenous wastes, is diverted from the patient to a machine, a dialyzer, where toxins are removed and the blood is returned to the patient. Diffusion, osmosis, and ultra filtration are the principles on which hemodialysis is based. The toxins and wastes in the blood are removed by diffusionthat is, they move from an area of higher concentration in the blood to an area of lower concentration in the dialysate. The dialysate is a solution made up of all the important electrolytes in their ideal extra cellular concentrations. The semi permeable membrane impedes the diffusion of large molecules, such as RBCs and proteins. Excess water is removed from the blood by osmosis, in which water moves from an area of higher solute concentration (the blood) to an area of lower solute concentrations (the dialysate bath). In ultra filtration, water moves under high pressure to an area of lower pressure. The bodys buffer system is maintained using a dialysate bath made up of bicarbonate (most common) of acetate, which is metabolized to form bicarbonate. The anticoagulant heparin is administered to keep blood Alvin M. Ganuelas, RN, MAN

4 from clotting in the dialysis circuit. Cleansed blood is returned to the body. By the end of the dialysis treatment, many waste products have been removed, the electrolyte balance has been restored to normal, and the buffer system has been replenished. There are three types of hemodialysis: conventional hemodialysis, daily hemodialysis, and nocturnal hemodialysis. 1. Conventional hemodialysis The procedure of conventional hemodialysis are: patients attached to a dialysis machine; the function of a dialysis machine is to push blood to circulate through the patients body and machine, at the same time, monitor temperature, blood pressure and time of the procedure; if patient is using fistula or graft, two huge-gate needles on patients side: one brings wastes- full blood from patients body to the dialyzer, while another needle carries clean blood back to the body; it is offered three times a week and 3 or 4 hours per session. Patients are required to follow their rigid schedule.

2. Daily hemodialysis The procedure of daily hemodialysis is similar to the conventional hemodialysis except it is performed six days a week and about 2 hours per session. 3. Nocturnal hemodialysis The procedure of nocturnal hemodialysis is similar to conventional hemodialysis except it is performed six nights a week and six-ten hours per session while the patient sleeps.

A nephrology nurse should perform: Hemodialysis Vascular Access: Assess the fistula/graft and arm before, after each dialysis or every shift: the access flow, complications Assess the complication of central venous catheter: the tip placement, exit site, complications document and notify appropriate health care provider regarding any concerns. Educates the patient with appropriate cleaning of fistula/graft and exit site; with recognizing and reporting signs and symptoms of infection and complication. Hemodialysis adequacy: Assesses patient constantly for signs and symptoms of inadequate dialysis. Assesses possible causes of inadequate dialysis. Educating patients the importance of receiving adequate dialysis. Hemodialysis treatment and complications: Performs head to toe physical assessment before, during and after hemodialysis regarding complications and accesss security. Confirm and deliver dialysis prescription after review most update lab results. Address any concerns of the patient and educate patient when recognizing the learning gap. Alvin M. Ganuelas, RN, MAN

5 Medication management and infection control practice: Collaborate with the patient to develop a medication regimen. Follow infection control guidelines as per unit protocol.

Alvin M. Ganuelas, RN, MAN