Renal replacement therapy

Presented to : Dr .Basma salamah

Done by : Dareen AbuDayyah
: Outline
Studies at Palestine
Case study
treatment of AKI: intermittent hemodialysis (IHD)
therapy
Continuous renal replacement therapy (CRRT)
peritoneal Dialysis
Prevalence of patients with end-stage renal disease on dialysis in the West Bank, Palestine

This cross-sectional study was undertaken during the period 26-30 December
2013 at all dialysis units in the West Bank, and included all cases of ESRD on
dialysis

the highest prevalence was seen in Jericho city. There were 57.7% males and
42.4% females in the study. The majority of patients (62.3%) were living in
villages, while 28.8% were living in cities and 8.9% were living in refugee
,camps

The most majority of patients were either diabetic (22.5%) or hypertensive

.(11.1%) or both at the same time (10.6%)

The majority of recorded cases of congenital causes were from the Hebron,
.Jenin and Tubas districts
Etiology of chronic renal failure in Jenin district, Palestine
study was conducted on chronic renal failure patients treated by
medications or by hemodialysis at The Martyr Dr. Khalil Sulaiman
.Hospital in Jenin city, Palestine

The results showed that the three most common causes of chronic renal
failure in Jenin district were diabetes mellitus (33.32%), hypertension
(16.7%), and chronic glomerulonephritis (13.1%). Inherited kidney
diseases formed an important percentage (17.85%) and included
primary hyperoxaluria (10.71%),  and adult polycystic kidney disease
(1.19%)
Mid-term cumulative patency of fistula and PTFE grafts among
hemodialysis patients: A retrospective, single-center study from Palestine

this retrospective study reviewed the charts of all hemodialysis

patients between January 2017 and January 2021 at the Dialysis
Center of An-Najah National University Hospital, Nablus, Palestine

A total of 312 procedures were performed during the study period.

Primary failure was 7.1% for AVF, 13.9% for arterio-venous graft
.(AVG) procedures

Peripheral arterial disease and left-sided AVF were associated with

more primary failure rates. AVF, primary patency rates at 1, 2, and 3 
years were 82%, 69%, and 59%, respectively, while secondary
patency rates at 1, 2, and 3 years were 85%, 72%, and 63%,
.respectively
Factors associated with increased AVF patency in a proportional
.hazard model were younger age and dual antiplatelet administration
: Case study

year-old male undergoing CABG surgery-62

BMI: 32 kg/m2 •
Body weight: 102 kg •
BP: 140/90 mmHg •
LDL:400mg/dL •
Triglycerides: 205 mg/dL •
HbA1C: 7.1% •
: Medical history
Type 2 diabetes for past 17 years
Stents placed 4 years previously, after acute •
myocardial infarction
Increasing chest pain and shortness of breath in the •
past 3 days

Diagnosis: two of the stents are clotted

No history of kidney injury •
:Medication
Metformin
ß-blocker •
: Statin •
: Postoperative day 1

: Patient status
Intraoperatively, the patient experienced a poor MAP, and was •
difficult to stabilize
The patient was intubated and ventilated, and is stable in the ICU •
Dopamine administered at 30 µg/kg/min •
: Signs and symptoms
BP: 100/68 mmHg • HR: 112 beats/min • Temperature: 37°C • •
Body weight estimated increased 8 kg postoperatively

: Test results
SCr: 2.2 mg/dL • BUN: 14 mg/dL •
Plasma potassium: 5.0 mEq/L •
Urine output: 0.7 mL/kg/hy •
: Post day 3

: Patients status
Patient was weaned from mechanical ventilation after 48 hours,
with 2 L/min oxygen provided via nasal cannulation
Shortness of breath evident, resulting in 10 L/min highflow •
nasal cannula

: Signs and symptoms

BP: 100/65 mmHg •
HR: 118 beats/min •
Temperature: 38°C •
Body weight: increased 3 kg from postoperative day 1 •
Peripheral edema is evident (2 +) •
Dopamine administered at 30 µg/kg/min, reduced at 24 hours •
to 10 µg/kg/min; MAP > 65 mmHg
: Test results
Chest X-ray: right-sided infiltrates
Oxygen saturation: 96% •
SCr: 4.0 mg/dL •
Plasma potassium: 5.9 mEq/L •
Urine output: diminished to < 0.5 mL/kg/h for the •
last 24 hours

After his surgery, this patient meets (Kidney Disease

Improving Global Outcomes) criteria for Stage 2 AKI
sCR : 2.0-2.9 times baseline with urine output < 0.5
mL/kg/h for ≥ 12 hours
INITIATION OF CRRT

Body weight: 110 kg

Filter: M150 •
BF : 250 mL/min •
PBP: Renal replacement solution BGK 2/3.5 at 1000 mL/h •
Dialysate solution: BGK 4/2.5 at 1300 mL/h •
Renal replacement solution BK 4/2.5 at 1000 mL/h •
Net fluid removal: 100 mL/h •
Anticoagulation: 500 unit of heparin •

: Rational of choice
Fluid overload with left- and right-sided infiltrates and •
shortness of breath
Patient still requires vasoactive substances •
PVCs due to hyperkalemia •
: ICU discharge

Patient received 5 days of CRRT, which was stopped

days ago 5
Patient no longer receives supplemental oxygen and
shows no shortness of breath during physical therapy
No infiltrations in X-ray
BP: 130/80 mmHg • HR: 100 beats/min
Body temperature: 37°C • Body weight: 100 kg
Oxygen saturation: 98% • SCr: 1.5 mg/dL • BUN: 19 mg/dL
Plasma potassium: 4.5 mEq/L • Urine output: increased to ~
1500 mL/day

Patient will be reassessed prior to hospital discharge for •

nephrology follow-up and future RRT requirements
RENAL REPLACEMENT THERAPY: DIALYSIS

types of renal replacement therapy are :available for the

treatment of AKI: intermittent hemodialysis (IHD)-1
therapy
Continuous renal replacement therapy (CRRT) -2
peritoneal Dialysis -3
Indications for Hemodialysis
Indications :
Blood urea nitrogen level greater than 90 mg/dL •
Serum creatinine level of 9 mg/dL •
Hyperkalemia more than 6.5 •
Medication toxicity •
Intravascular and extravascular fluid overload •
Metabolic acidosis •
Symptoms of uremia •
Pericarditis •
Gastrointestinal bleeding •
Changes in mentation •
Contraindications to other forms of dialysis •
intermittent hemodialysis (IHD) therapy
As a treatment, hemodialysis separates and
removes from the blood the excess electrolytes, fluids,
and toxins by means of a hemodialyzer

Hemodialysis is efficient in removing solutes. Because

levels of electrolytes, toxins, and fluids increase between
. treatments, hemodialysis occurs on a regular basis

Traditional hemodialysis treatments last 3 to 4 hours

: Dialysis pathway
Hemodialyzer

Hemodialysis works by circulating blood outside the body

through synthetic tubing to a dialyzer, which consist of
.hollow fiber tubes
: Dialysate
,The mixture of acid , bicarbonate and RO water
While the blood flows through the membranes, which are
semipermeable , a fluid (dialysate bath) bathes the
.membranes and, through osmosis and diffusion

Per forms exchanges of fluid, electrolytes, and toxins from

,the blood to the bath

The blood and the dialysate bath are shunted in

opposite directions (countercurrent flow) through the
dialyzer to match the osmotic and chemical gradients at
. The most efficient level for effective dialysis
Ultrafiltration
To remove fluid, a positive hydrostatic pressure is
applied to the blood, and a negative hydrostatic
pressure is applied to the dialysate bath. The two
. forces together, called trans membrane pressure
.pull the excess fluid from the blood
Anticoagulation
Heparin or sodium citrate is added to the system just before the
blood enters the dialyzer to anticoagulant the blood within the
.tubing

,Without an anticoagulant, the blood clots

because its passage through the foreign tubular substances of
the dialysis machine activates the clotting mechanism
It has a short half-life, and its effects subside within 2 to 4
.hours
If necessary, the effects of heparin are easily reversed with the
.antidote protamine sulfate

When there is concern about the development of heparin-induced

thrombocytopenia, alternative used with Citrate can be infused as
an anticoagulant by intermittent bolus or continuous infusion
Anticoagulation in chronic kidney disease: from guidelines to clinical practice (2019)

Hypothesis: There are no consensus recommendations

regarding anticoagulation in CKD. Due to the currently
limited data, clinicians need practical clues for monitoring
and optimizing the treatment

Methods: Based on the available data, this review outlines the benefit-

risk ratio of all types of anticoagulants in each stage of CKD and
provides practical recommendations for accurate dosage adjustment,
reversal of antithrombotic effect, and monitoring of renal function on a
.regular basis
 :Results
Evidence from randomized controlled trials supports the efficient and
safe use of warfarin and direct oral anticoagulants (DOACs) in mild and
.moderate CKD
On the contrary, the data are poor and controversial for advanced stages.
.DOACs are preferred in CKD stages 1 to 3

In patients with stage 4 CKD, the choice of warfarin vs DOACs

dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), (
edoxaban (Savaysa), and betrixaban (Bevyxxa) will take into
consideration the pharmacokinetics of the drugs and patient
.characteristics

Warfarin remains the first-line treatment in end-stage renal disease,

although in this case the decision to use or not to use anticoagulation is
strictly individualized. Anticoagulation with heparins is safe in
nondialysis-dependent CKD, but remains a challenge in the
.hemodialysis patients
vascular Access

Various types of temporary and permanent devices are in

clinical use

This design helps to prevent dialyzing the same blood just

returned to the area (recirculation )
.permanent vascular access
Arteriovenous fistula-1
creating a side-by-side opening in the artery and the vein to join
.the two vessels together

Fistulas are the preferred mode of access because of the

durability of blood vessels, relatively few complications, and
.less need for revision compared with other access methods

disadvantage of a fistula concerns the time required

for development 6 months of sufficient arterial flow to enlarge
the new
. Access
The critical care nurse frequently assesses the quality of
.blood flow through the fistula

A patent fistula has a thrill when palpated gently with the

palm of hand and has a bruit if auscultated with a
.stethoscope

The extremity should be pink and warm to the touch. No

blood pressure measurements, IV infusions, or laboratory
procedures are performed on the arm with the fistula
: When we used AVF

Fistulae are more likely to be useable when they meet the 

:Rule of 6s characteristics
,flow greater than 600 mL/min
,diameter at least 0.6 cm
,no more than 0.6 cm deep
and discernible margins

:Recommendation 2: Initial cannulation is attempted only after

If AVF, there are signs that maturation has occurred; or-1
if AVG, there is no longer swelling in the AVG limb; AND

A physician, vascular access (VA) coordinator, or advanced cannulator -2

(opinion) has confirmed the access is ready to cannulate
An AVF is more likely to be usable (or mature) when the following
characteristics are
:present

Thrill palpable at the arterial anastomosis only and disappears •

when AVF or AVG is
.momentarily occluded
.Soft, easily compressible pulse within the fistula •
.Low pitch, continuous bruit present •
Diameter of vein is at least 0.6 cm and vein is no more than 0.6 cm •
deep and has
discernible margins (for initial cannulation, vein diameter needs to
be a minimum of
.)cm 0.4
Flow >500 mL/min as measured by Doppler ultrasound (>650 •
mL/min/1.732
)in pediatrics
: Recommendation how to used AVF

Aseptic technique is used for all cannulation procedures -1

Chlorhexidine 2%((
For arm AVFs or AVGs, regular hand-arm exercises are-2
recommended for several weeks/months prior to and resuming post-
access creation

While not required for the majority of patients, local or topical-3

anaesthetics may be helpful in relieving needle discomfort in a small
:subset of patients where
cannulation has been attempted and the patient continues to -1
;complain of pain
cannulation has not been attempted because the patient has a )2(
;severe fear of needles
-children 19 and under )3(
Consider the following principles for needle size-4
and placement and blood pump speed

Once cannulation has been established, correlate

needle gauge, blood pump speed to achive (Kt/V URR
)
Use the rope ladder technique (rotating sites) for -5
cannulation of AVGs and nurse cannulated AVFs

Rope ladder technique tends to have a

lower rate of infection while the buttonhole-1
technique has been shown to reduce cannulation
,discomfort

increase cannulation ease and have fewer incidences-2

of hematomas, access interventions and aneurysm
.formations
Hemodialysis access recirculation occurs when
dialyzed blood returning through the venous needle re-
enters the extracorporeal circuit through the arterial
needle, rather than returning to the systemic circulation

Significant hemodialysis access recirculation is  

abnormal
and is usually due to venous stenosis, which obstructs
venous outflow, resulting in increased pressure and
backflow into the arterial needle

Recirculation does not result from placing needles too

closely together as long as access blood flow exceeds
the machine blood flow rate
: To prevent the recirculation

The nurse must applied 3 finger between the two

cannula
:Kt/V

Kt/V is the preferred method for measuring the dialysis

. dose and adequacy

K :stand for dialyzer clearance , the rate of at which blood

through the dialyzer , expressed in milliliter per min (ml
/min)

T: stands for time ( the duration of treatment per min )

.V: stands for the volume of water a patient's body contains

Normal range of KT/V should be at least 1.2

: Example
If the dialyzer clearance 300ml/min and a dialysis
session lasts 180min (3hrs ) , K X T will be 300
ml/min multiple by 180min
.The result comes to 54000ml or 54 L

KT =300ml/min
Also the body is about 60% by weight , if the pt wt
70kgs

V = 70kg X 0.6 = 42L

So the KT/V = 54/42 = 1.3

The timing and method of obtaining the postdialysis
BUN affect the Kt/V. This is because the
concentration of urea in blood samples drawn from
the arterial access
The Kt/V can be greater than 1.2 with a URR slightly
.below 65 percent—in the range of 58 to 65 percent
 The used method to withdrawal BUN post HD

at the end of HD , less than 5 mins-1

stop the UF and make the UF zero -2

make blood flow 50-70ml/min-3

make dialysate flow 300 ml /min -4

after 20 seconds , stop the machine , then take the -5

sample from the arterial rubber site
URR
Urea reduction ratio : meaning reduction in urea as a result of
. hemodialysis

The URR : is one measure of how effectively a dialysis treatment

removed waste products from the body and is expressed s a percentage
.
the normal should be exceed 65%
Example : if the initial or predialysis level urea was 50mg/dL
Post dialysis urea level was 5mg /dL , the amount of urea removed
was 35 mg/dL

URR = (predialysis BUN - post dialysis BUN ) / predialysis

BUN*100%

URR = 35/70= 70/100= 70%

: KT/v improvement

: increase blood flow through the dialyzer -1

increase time on dialysis -2

identify and elimination circulation problem , arterial and-3

. venous pressure are monitored by hemodialysis machine
: Alarm will go of if the pressure is too high or too low
A-infiltration of access ( bleeding inside the access )
B-clotting in the access or needle
C-a needle against the access wall
D- A kink in blood tubing
E- low blood pressure
Comparison of Kt/V and urea reduction ratio in measuring dialysis
adequacy in paediatric haemodialysis in England 2014
Objectives: To determine the methods used to measure paediatric haemodialysis
adequacy and to assess consistency between calculations of single pool Kt/V
.(spKt/V) and URR

Design: A service evaluation was conducted to establish current practices in

measuring dialysis adequacy. A prospective longitudinal study was conducted to
.compare spKt/V and URR

Participants: Thirty-two children were recruited consisting of 13 males and 19

.females in five paediatric dialysis centres

Results: Inconsistencies were reported of the method of post-urea sampling with 4

of the 10 centres using the KDOQI recommended sampling method. Five dialysis
centres reported using URR and five reported using spKt/V. There were
substantial differences between the two measures. Using URR suggested that up
to 44% of children did not receive adequate dialysis, whereas measurement by
spKt/V suggested no more than 6% of the same dialysis sessions were not
..adequate
Medical Management:

Medical management involves the decision to place a

vascular access device and then to choose the most
.appropriate type and location for each patient

The exact quantity of fluid and solute removal to be

achieved by hemodialysis is determined individually
for each patient by clinical examination and review of all
relevant laboratory result
Nursing Management

The essential role of the critical care nurse during dialysis is to-1
monitor the patient’s hemodynamic status and ensure the patient
.remains hemodynamically stable

creating a mutual relationship of trust and safety between-2

patient and nurse, giving priority to the care necessary for their
.treatment

The nurse plays a fundamental role in the diagnosis of -3

complications during the hemodialysis session
the complications that may arise during the hemodialysis session
are: hypotension, muscle cramps, nausea and vomiting, chest
and lumbar pain, fever and chills, imbalance syndrome, among
. others

Disequilibrium syndrome (DDS) is a rare but serious

complication of hemodialysis. It is characterized mainly by
neurological symptoms such as fatigue, mild headaches, nausea,
vomiting, disturbed consciousness, convulsions and coma. The
symptoms are usually mild, transient and self-limiting and rarely,
.it can be fatal
Management for DDS
:High Sodium Dialysate/Sodium Profiling-1
utilization of a high dialysate sodium concentration (fixed or
profiled). An increase in serum sodium of 2 mEq/l

The use of a fixed high dialysate sodium of 143–146 mEq/l for

.the initial treatment may be used in high risk patients
Teach patients to avoid wearing constrictive clothing on limbs containing -1
.access

Teach patients to avoid sleeping on or bending accessed limb for -2

.prolonged periods

.Use aseptic technique when cannulating access-3

.Avoid repetitious cannulation of one segment of access-4

Offer comfort measures, such as warm Compresses and ordered analgesics, -5

.to lessen pain of vascular steal

Teach patients to develop blood flow in fistulas through exercise -6

)squeezing a rubber ball(

Avoid too-early cannulation of new access-7

continuous Renal Replacement Therapy

CRRT is a continuous mode of dialysis that has been used for more than 40 years and
.has many similarities to hemodialysis

Indications:
Need for large fluid volume removal in hemodynamically unstable •
patient
Hypervolemic or edematous patients unresponsive to diuretic therapy •
Patients with multiple-organ dysfunction syndrome •
Ease of fluid management in patients requiring large daily fluid volume •
Replacement for oliguria •
Administration of total parenteral nutrition •
Contraindication to hemodialysis and peritoneal dialysis •
Inability to be anticoagulated •
The CRRT system allows the continuous removal
of fluid from the plasma. The patient’s blood flow is
100 to 200 mL/min, and the dialysate flow ranges from
.20 to 30 mL/kg per minute

The fluid removal rate varies depending on the particular

CRRT method used and removal of creatinine, urea and
,)electrolytes

The removed of fluid is described as ultrafiltration

However, because many critically ill patients are
hypotensive and cannot provide adequate flow through the
hemofilter, an electric roller pump
milks” the tubing to augment flow“ .

Because controlled removal and replacement of fluid possible

over many hours or days with
CRRT

This makes CRRT highly advantageous for use in

hemodynamically unstable patients with multisystem
.problems
Continuous Renal Replacement Therapy Terminology
Diffusion describes :the movement of solutes along a
concentration gradient from a high concentration to a
..low concentration across a semipermeable membrane
Convection. Convection occurs when a pressure gradient is set up
so that the water is pushed or pumped across the dialysis filter
,and carries the solutes from the bloodstream with it

This method of solute removal is known as solvent drag, and it

.is commonly used in CRRT
Absorption: The filter attracts solute, and
molecules attach (adsorb) to the dialysis
filter

Ultrafiltrate volume. The fluid that is

.removed

.
Anticoagulation
To prevent the hemofilter from becoming obstructed by clotting,
.… or clotting off, must be used low dose anticoagulation
.heparin and sodium citrate

Citrate is an effective prefilter anticoagulant, which has the side

effect that it chelates (binds to and removes) calcium from the
, blood

Consequently, ionized calcium levels are verified, calcium is

replaced per protocol when sodium citrate is the anticoagulant
Replacement fluid

some of the ultrafiltrate is replaced through the CRRT

.circuit by a sterile replacement fluid

The replacement fluid can be added before the prefilter

.dilution) or after the filter (postfilterdilution)

The purpose is to increase the volume of fluid passing

through the hemofilter and improve solute convection
Several modes of CRRT are used in critical care units; a partial
:list follows

Slow continuous ultrafiltration (SCUF)-1

Continuous venovenous hemofiltration (CVVH)-2
Continuous venovenous hemodialysis (CVVHD)-3
Continuous venovenous hemodiafiltration-4
(CVVHDF)
Slow continuous ultrafiltration. SCUF slowly-1
removes fluid (100 to 300 mL/h) through a process of
. ultrafiltration

Because small amounts of fluid are gently removed, initially it

was hoped that SCUF would be a suitable choice for edematous
patients with acute heart failure and diminished perfusion to
.the kidneys that were unresponsive to diuretics
.Slow continuous ultrafiltration
Continuous venovenous hemofiltration-2
CVVH is indicated when the patient’s clinical condition
warrants removal of significant volumes of fluid and
. solutes

The replacement fluid rate of flow through the

CRRT circuit can be altered to achieve desired fluid
and solute removal without causing hemodynamic
.instability
Because large volumes of fluid may be removed in CVVH, some
of the removed ultrafiltrate volume must be replaced hourly with
a continuous infusion (replacement fluid) to avoid
, intravascular dehydration

Replacement fluids may consist of standard solutions of

bicarbonate, potassium-free lactated Ringer solution, acetate,
or dextrose. Electrolytes such as potassium, sodium, calcium
chloride, magnesium sulfate, and sodium bicarcabonte

The formula used to calculate the volume removed from the

:patient
Ultrafiltrate in bag + Other output –(CVVH replacement fluid
+IV/oral/NG intake)
Continuous Venovenous Hemodialysis-3
It removes solute by diffusion because of a slow (15 to
30 mL/min) countercurrent drainage flow on the
.membrane side of the hemofilter

Countercurrent means the blood flows in one direction,

.and the dialysate flows in the opposite direction

CVVHD is indicated for patients who require large-

volume removal for severe uremia or critical acid
base imbalances or for patients who are resistant
to .diuretics
Continuous Venovenous Hemodialysis
A mean arterial pressure of at least 70 mm Hg is desirable for
effective volume removal and dialysis, and it is most
effective .when used over days, not hours

The critical care nurse is responsible for calculating the

hourly
intake and output, identifying fluid trends and replacing
.excessive losses

This therapy is ideal for hemodynamically unstable patients in

the critical care setting because they do not experience the
abrupt fluid and solute change
.Continuous venovenous hemodiafiltration -4
to achieve maximal fluid and solute )CVVH and CVVHD(
removal

A strong trans membrane pressure is applied to )CVVH method (

the hemofilter to push water across the filter, and a negative
pressure is applied at the other side to pull fluid across the
membrane and produce large volumes of ultrafiltrate and to
”create a “solvent drag

)hemodialysis method(
The blood and the dialysate are circulated in a countercurrent
flow pattern to remove fluid and solutes by diffusion
: Complication

The most common reasons for interruption in CRRT are

clotting and patient clinical issues
Decreased ultrafiltration rate due to Hypotension-1
Dehydration ,Kinked lines, Clotting of filter

Filter clotting, Obstruction ,Insufficient-2

heparinization

Hypotension due to Increased ultrafiltration rate-3

Blood leak
Fluid and electrolyte changes due to Too much or too-4
.little removal of fluid

Bleeding ,System disconnection, increased Heparin-5

.dose

Access dislodgment or infection Catheter or-6

connections not secured ,Break in sterile technique
Excessive patient movement
Circuit
Air embolism •
Clotted hemofilter •
Poor ultrafiltration •
Blood leaks •
Broken filter •
Recirculation or disconnection •
Access failure •
Catheter dislodgment •
Pump:
Circuit pressure alarm •
Decreased inflow pressure •
Decreased outflow pressure •
Increased outflow resistance •
Air bubble detector alarm •
Power failure •
Mechanical dysfunction •
Patient
Code or emergency situation •
Dehydration •
Hypotension •
Electrolyte imbalances •
Acid base imbalances •
Blood loss or hemorrhage •
Hypothermia •
Infection •
Nursing Management
:The critical care nurse
,monitors fluid intake and output -1
prevents or detects potential complications(e.g.bleed-2
,ing, hypotension)

iidentifies trends in electrolyte laboratory-3

,values
provides patient and family education about the-4
patient’s conditionthe use of CRRT
Observe filter and arteriovenous system-5
Control blood flow-6

Control coagulation time-7

Position patient on back-8
Lower height of collection container-9
Control anticoagulation (heparin/citrate)-10

Monitor serum calcium if using citrate as an anticoagulant-11

Observe dressing on vascular access for blood loss-12
Observe for blood in filtrate (filter leak-13

)Observe strict sterile technique when dressing vascular access-14

peritoneal Dialysis
Peritoneal dialysis (PD) is a less “high-tech” modality used in
.patients with CKD
PD involves the introduction of sterile dialyzing fluid through an
.implanted catheter into the abdominal cavity

The dialysate bathes the peritoneal membrane, by process

of osmosis, diffusion, and active transport, excess fluid
and solutes travel from the peritoneal capillary fluid through
the capillary walls, through the peritoneal membrane, and
.into the dialyzing fluid
After a selected period, the fluid is drained out of the
.abdomen by gravity
The process is then repeated at regular, prescribed
intervals. At home patients generally have four
. peritoneal dialysate exchanges per day

PD solutions are available in three concentrations:

1.5%, 2.5%, and 4.25% glucose monohydrate

PD solutions also contain electrolytes. The various

glucose dialysate concentrations provide different rates
.of fluid removal
The small capillary pores, the capillary membrane, the
interstitium, the mesothelium of the peritoneum, and the
fluid film layers in the capillary and peritoneal cavity provide
.formidable barriers and solute passage

The primary nursing consideration is

to avoid contamination of the access point and monitor the-1
.patient’s vital signs during process
The dialysate should be instilled at body temperature to be -2
,comfortable, provide some vasodilation
The length of time the solution remains in the
.peritoneal cavity, called the dwell time

The dwell time affects the amount of fluid removed from the
.,peritoneal capillaries

Normally, PD-dependent patients are well versed in the amount,

type, and frequency of dialysate to be infused into the
. abdomen, with subsequent drainage by gravity into a waste bag
catheter Placement

:Most catheters have four segments

,an external segment outside the abdomen-1
a tunnel segment that passes through subcutaneous tissue and-2
muscle
,a cuff for stabilization at the peritoneal membrane-3
an internal segment with numerous holes for fast delivery and -4
drainage of dialysate

The infusion of and removal of the dialysate fluid are sterile

.procedures
: Infection
The most significant infection risk to the patient with the use of
PD is development of peritonitis and sepsis from catheter
.contamination

Clinicians must remain vigilant for signs of localized catheter or

abdominal infection manifested by catheter site redness, site
swelling, cloudy dialysis effluent after the dwell time, and
.abdominal tenderness or pain

Assessment for signs and symptoms of systemic infection, such

as a sudden increase in the white blood cell count, increased
.temperature, and malaise, is also required
Nursing Management

The critical care nurse observes for signs and symptoms of-1
,infection
,monitors fluid volume status-2
observes drainage of the ultra fluid, prevents complications-3
,associated with the PD catheter
.provides patient and family education-4

Assess for signs and symptoms: cloudy effluent, abdominal-5

pain, rebound tenderness, nausea and vomiting, fever

Monitor site daily for signs and symptoms of infection:-6

-induration, erythema, purulence, hyperthermia
Comparison of peritoneal dialysis and hemodialysis as first renal replacement therapy
in patients with end-stage renal disease and diabetes: a systematic review 2019

Diabetes has become the most common cause of end-stage renal disease (ESRD)
requiring renal replacement therapy (RRT) in most countries around the world.
Peritoneal dialysis (PD) is valuable for patients newly requiring RRT because of
the preservation of residual renal function (RRF), higher quality of life, and
hemodynamic stability in comparison with hemodialysis (HD)

Methods
For this systematic review, the MEDLINE, EMBASE, and CENTRAL databases
were searched to identify articles published between February 2014 and August
2017. The quality of studies was assessed using the GRADE approach. Outcomes
of interest were all-cause mortality; RRF; major morbid events, including
cardiovascular disease (CVD) and infectious disease; and glycemic control
)
: Results

In the present systematic review, the risk of death tended

to be higher among diabetic patients with ESRD newly
initiating RRT with incident PD in comparison with
incident HD. However, we could not obtain definitive
results reflecting the superiority of PD or HD with regard
to patient outcomes because of the severe risk of bias
and the heterogeneity of management strategies for
diabetic patients receiving dialysis. Further studies are
needed to clarify the advantages of PD and HD as RRT
for diabetic patients with ESRD
:References

Khader MI, Snouber S, Alkhatib A, Nazzal Z, Dudin A. Prevalence of 

patients with end-stage renal disease on dialysis in the West Bank, Palestine.
Saudi J Kidney Dis Transpl. 2013 Jul;24(4):832-7. doi: 10.4103/1319-
2442.113913. PMID: 23816745
Abumwais, J. Q. (2012). Etiology of chronic renal failure in Jenin district, 
Palestine. Saudi Journal of Kidney Diseases and Transplantation, 23(1), 158

Khanfar, O., Aydi, R., Saada, S., Shehada, M., Hamdan, Z., Sawalmeh, O., ... 
& Nazzal, Z. (2021). Mid-term cumulative patency of fistula and PTFE grafts
among hemodialysis patients: A retrospective, single-center study from
.Palestine. The Journal of Vascular Access, 11297298211040988

Urden, L. D., Stacy, K. M., & Lough, M. E. (2019). Critical Care Nursing, 

Diagnosis and Management, 9: Critical Care Nursing. Elsevier Health
Sciences..5

Laing, B., Merlino, E., & Nelson, C. (2019).

Prevention of Access Recirculation During