Peritoneal Dialysis

Goal of PD: correct what the kidneys would

keep in balance if they still worked:
 Remove waste products of
metabolism
 Remove Potassium
 Correct acidosis
 remove excess volume (Na and
H2O)

Indications in Acute Renal Failure

 hemodynamic instability
 bleeding or vascular access
contraindications that prevent
hemodialysis
 removal of high molecular weight toxins

Non-Renal Indications:
 Acute pancreatitis – Refractory heart failure
 Significant hypo- or hyper-thermia – Liver Failure
 Infusion of drugs by PD as supportive therapy

Contraindications:
 Recent abdominal surgery – Diaphragmatic severe respiratory failure
 Pleuroperitoneal communication – Pregnancy
 Extremely hypercatabolic state – Severe GERD
 Low peritoneal clearance – Fecal or fungal peritonitis
 Abdominal wall cellulitis

Catheter is placed inside the Peritoneal Cavity

The peritoneal membrane (peritonium) lines the abdominal cavity. It is highly

vascular and semi-permeable, allowing filtration to occur across it between blood
supply (capillaries) and the dialysate in the abdominal cavity.

The peritoneum has two layers:

- Parietal Peritoneum: 20% of total SA
Blood supply from abdominal wall
- Visceral Peritoneum: 80% of total SA
Blood supply from mesenteric arteries

Surface are is approximately equal to body

surface area: 1.5-2m2 in adults.
Inflammation increases the effective surface area, increasing the rate of filtration.

Amy Neufeldt, RN, BscN April 2015, adapted from Lawton, 2013
3 Phases for each Dialysis Exchange:
Fill – when dialysate (fluid for dialysis) is going into peritoneal cavity (peritoneum)
Dwell – when the dialysate is remaining inside and filtration is occurring
Drain – when the dialysate (now effluent) is being removed from the patient

The volume in is measured positive and the volume out is negative, so when the volume
drained is greater than the volume put in, the balance is negative.

Process of Filtration – 3 main processes:

Diffusion: movement of solute from an area of high

concentration to low concentration, trying to form equal
concentration between the two sides

For example: urea and creatinine

By 4h, urea is >90% equilibrated

creatinine is >60% equilibrated

Osmosis: movement of water through a semi-permeable membrane from an area with low
solute concentration to an area of high solute
concentration
Convection: the solute that moves with
the water when moving by osmosis

PD fluid includes: Na+, K+, Cl-, Lactate,

Ca++, Mg+, Glucose and sometimes H+

Glucose provides main osmotic gradient

(drives osmosis to cause fluid movement)

These are characteristics of the ideal osmotic agent, let's see how glucose compares:
 non-toxic (glucose is OK short term, but may be toxic to membrane long-term)
 not absorbed from peritoneal cavity (no, Glucose is absorbed)
 sustained osmotic effect (no, as filtration happens effectiveness decreases)
 if absorbed, causes no harm (no, absorbed glucose can cause harm for diabetics)
 biocompatible (no, the dialysate can cause complications: immune response,
peritoneal sclerosis, and neovascularization, all causing failure in filtration)

So, Glucose is not ideal, but it is the best we have.

Solution mL D50 in 1L Fluid Osmolarity Ultrafiltrate over 1h
concentration Lactated Ringer mOsm/L mL/exchange
1.5% 30cc 346 50-150
2.5% 50cc 396 100-300
4.25% 85cc 485 300-400

Amy Neufeldt, RN, BscN April 2015, adapted from Lawton, 2013
Ultrafiltration – water removal during PD due to osmosis

We want to choose the appropriate solution for the needed level of ultrafiltration. When
renal failure is quite progressed prior to treatment, doctors may use higher concentration
or shorter dwell times to more quickly correct fluid and electrolyte imbalances that have
built up. Due to osmosis, the most ultrafiltration occurs at the beginning of the dwell period.

Rate of filtration depends on:

 solute concentration (the amount of glucose added)
 amount of time fluid is in the abdomen
 peritoneum characteristics:
Fast transport Slow Transport
Peritoneal membrane is “leaky” Peritoneal membrane is “tight”
↓ ↓
glucose diffuses out of peritoneum quickly glucose takes longer to diffuse out of cavity
↓ ↓
osmotic gradient dissipates quickly osmotic gradient maintained longer
↓ ↓
less ultrafiltration, less water removed more ultrafiltration, more water removed

Prescription includes:
1. Concentration of dialysate – how much D50 to mix into Lactated Ringer
2. Exchange volume – how much fluid to put in each time
In children, volumes will be smaller so use a scale to determine how much
fluid you are delivering.
3. Inflow and Outflow periods – how much time to allow to put fluid in, and to drain
4. Dwell time – how long the fluid stays inside the abdomen for each exchange
Typically 4 hours, but it may be less if the patient is extremely ill.
5. Any other additives, such as:
- Heparin - Insulin - Potassium - Antibiotics
6. Monitoring of fluid balance

Monitor for signs of intolerance, if present consider decreasing exchange volume.

 Discomfort
 Declining respiratory status
 Leaking at exit site

Exit Site Care

Keep surgical dressing intact as long as possible, unless soiled.
If changing the dressing, clean hands well and use sterile technique (including masks).
Cleanse the site with Normal Saline and then Providone Iodine, begin at exit site and go
around in progressively larger circles.
Be sure to immobilize the catheter well – tape it with a loop or H-taping so any tension
pulls on loop not exit site.
Cover site with dry gauze and tape on sides.

Amy Neufeldt, RN, BscN April 2015, adapted from Lawton, 2013
 Potential Complications
Basic signs of complication that the doctor should be notified of immediately:
 change in colour of dialysate (especially bloody or cloudy)
 patient notably hypotensive
 increasing temperature
 poor dialysate flow
 positive balance twice in a row (greater volume “in” than “out”)

Complication Signs & Symptoms Potential Causes Potential Treatments

Catheter One way: fluid flows A bend in the - Abdominal X-ray
blockage in but is not draining catheter or - flushing with heparinized
obstruction saline
- bowel clean-out
Two way: fluid is not Constipation or - surgery to reposition
flowing in and out Catheter migration
Pain on Inflow Improper catheter - warm fluid
and Outflow or positioning - consider changing solution
Abdominal pain concentration
Increased - slow in- or outflow
abdominal pressure - exercises to strengthen
abdominal muscles
- “tidal PD” - leaving a small
amount inside and
exchanging a smaller
volume
- possible X-ray to
investigate
Exit Site Redness, swelling, Contamination, - Notify doctor
Infection purulent drainage improper exit site - Antibiotics will be given
and tenderness at care - give good exit site care
prevent with exit site
good site care!
Hydrothorax Difficulty breathing Communication with - Shown on X-ray
(right side Decreased fluid thoracic cavity by - Doctor may consider
pleural effusion) return defect in diaphragm thoracentesis
Abdominal Wall Weight gain without Increased - consider lower volume
or Genital peripheral edema abdominal pressure - have patient in supine
Edema Low fluid return position
Hernias Visible hernia Increased - observe for discomfort
abdominal pressure - decrease exchange
volume
- consider surgical repair
Fluid Overload Shortness of breath Excessive Na and - Use higher concentration
Increased BP water intake solution

Amy Neufeldt, RN, BscN April 2015, adapted from Lawton, 2013
 Edema - decrease dietary sodium
Weight gain and water
Excessive Fluid Thirst Hypertonic solution - Decrease concentration of
Loss Decreased BP solution
Inadequate Na and - increase dietary sodium
water intake and water
Peritonitis – Cloudy effluent Improper sterile - Antibiotic administration by
infection of the Fever technique PD catheter
peritoneum Abdominal pain - monitor blood work
Normal defense - fluid should improve within
Complications: mechanisms are 48 hours
Potential Note: inflammation compromised by - If fungal, may need to
permanent increases effective fluid in the remove catheter
damage to surface area, peritoneal cavity
peritoneum increasing filtration

(Lawton, 2013, Cormier, 2014)

Resources

Lawton, W.J. (May, 2013). Peritoneal Dialysis; Presentation: Mbingo Baptist Hospital.
[PowerPoint slides]. Obtained from personal communication.
Lawton, W.J. (May, 2013). Peritoneal Dialysis - Complications; Presentation: Mbingo
Baptist Hospital. [PowerPoint slides]. Obtained from personal communication.
Cormier, A. (2014). Peritoneal Dialysis Education Package. Alberta Health Services:
Canada.
Tobrocke, J. (2007). Care of the Hospitalized Peritoneal Dialysis Patient [Powerpoint
slides]. Retrieved from: www.ppt-search.net/1/peritoneal-ppt.html

Amy Neufeldt, RN, BscN April 2015, adapted from Lawton, 2013
 Questions
What substances move by diffusion in PD?

What moves by osmosis in PD?

For each of the following, state whether it moves primarily from the blood to peritoneum or
from the peritoneum to the blood and by what mechanism(s) the movement occurs.

Na+ K+
H20 BUN
Creatinine Glucose

What is ultrafiltration? What is it driven by? What are some problems with this osmotic
agent?

A patient is having increased difficulty breathing. What would you do? And what could be
happening?

You notice the patient's effluent is cloudy. What do you think it might be? What do you do?
Why might this have occurred? What other problems can result from this complication?
What treatment do you expect?

Amy Neufeldt, RN, BscN April 2015, adapted from Lawton, 2013