Continuous Ambulatory Peritoneal dialysis is a renal replacement therapy for chronic renal failure, as are hemodialysis and its variants, and kidney transplantation. All the data presented in the following section are from the book “Diagnosis and treatment of kidney diseases – guidelines, recommendations and standards of conduct”.
Continuous Ambulatory Peritoneal dialysis (DO) involves the penetration of small- and medium-molecular uremic toxins through several layers of serous peritoneal membrane, which is the equivalent of a dialysis membrane in an artificial kidney and separating the abdominal organs from the free peritoneal cavity. An electrolyte solution of dialysis fluid is cyclically introduced into the abdominal cavity. There are many advantages of peritoneal dialysis that suggest choosing this method of treatment for the patient as well as contraindications as a result of which the patient will not be able to use peritoneal dialysis (DO).
Several conditions are required to start peritoneal dialysis. The patient’s body weight should be normalized. Both obesity and underweight are a contraindication. Patient’s visual and manual skills are also necessary. To perform peritoneal dialysis procedures, it is necessary in this regard to be independent or fully burdened by a guardian or family member who has received training in peritoneal dialysis at home. Despite these requirements, peritoneal dialysis has many advantages that should encourage patients to choose this method of treatment for chronic renal failure.
Dialysis takes place at home, which is important for many patients, especially if the distance to the dialysis center is very large. No travel necessary to continue working and learning. The patient does not feel addicted to the dialysis machine. It may also use a less restrictive diet than when using hemodialysis. Thanks to peritoneal dialysis, residual kidney function can be maintained longer, the anemia is better controlled and there is no need for hemodialysis fistula. An advantage over hemodialysis is also a lower risk of infection with blood-borne viruses.
Already before the introduction of dialysis, the patient should undergo a brief training explaining the possible methods of renal replacement therapy. The patient can thus learn about the pros and cons of peritoneal dialysis, hemodialysis and transplantation.
The peritoneal dialysis catheter is inserted in the surgery department and can be used for dialysis after 2 weeks.
There are two basic types of peritoneal dialysis (DO):
CADO, i.e. continuous outpatient peritoneal dialysis and ADO –
automatic peritoneal dialysis. ADO is performed using a cycler, usually at night (NDO). It is more often chosen by professionally active people, because patients during the day are free from replacing dialysis fluid. It is also more often recommended for people without residual renal function, patients with concomitant chronic obstructive pulmonary disease (COPD) and clinical contraindications for high intraperitoneal pressure. CADO is done manually by 3 to 5 changes per day or by the cycler as a continuous cyclic peritoneal dialysis (CCDO) during the night with leaving fluid in the peritoneum for the day. CADO is a method recommended for patients who are candidates for kidney transplantation and for those with residual kidney function.
Peritoneal dialysis depends:
The success and success of peritoneal dialysis depends largely on the patient and / or their caregivers. That is why proper patient education is so important. Their skills and knowledge lead to improved treatment, reduce or even eliminate possible complications as well as improve the patient’s quality of life. Peritoneal dialysis complications are divided into non-infectious and infectious. Unfortunately, these non-infectious ones are difficult to prevent and are often the cause of the patient starting hemodialysis instead of dialysis.
Providing the patient with adequate knowledge on how to care for chronic peritoneal dialysis catheters is the key to success in the prevention of dialysis peritonitis. In the recommendations contained in the chapter “Standards of conduct related to the peritoneal catheter in the paper, it is recommended to protect the catheter mouth with a dressing, which is mainly aimed at its mechanical protection.
Dressing should be changed every day or every other day. Also, before each bath, the patient should remove the dressing and then put on clean again after disinfection and drying of the skin. Drying the skin under a dressing protects the skin against maceration and damage Patients are also advised to take a shower and not to bathe in open water because of the risk of infection of the catheter mouth.
For the prevention of Staphylococcus aureus infections, control and eradication are used in carriers of this bacterium. This is done by taking nasal swabs in the patient and his helpers. If carriage is detected, mupirocin is administered intranasal 2 times a day for 5 days every 4 weeks in 3 series. Staphylococcus aureus carrier testing should also be performed on personnel in contact with peritoneal dialysis.
Peritoneal Dialysis catheter infection:
A patient undergoing dialysis may develop a number of complications not related to dialysis catheter infection. They were listed in the chapter “Standards for peritoneal dialysis” at work. Non-infectious complications include those dependent on increased intra-abdominal pressure, such as: abdominal hernia, dialysis fluid streaks, musculoskeletal, gastrointestinal and reproductive disorders. At first, the intermittent ADO method is used in a supine position. Dialysis fluid infiltration may affect the abdominal cavity, pleural cavity, or genitals.
The procedure in their case depends on the moment of its detection. In early infiltrations, a 1-3 week break in dialysis is sufficient, and sometimes even just a reduction in the volume of exchanges and a change in the manner of conducting dialysis to discontinued ADO. In latex stains, surgery is necessary, and in pleural cavities, pleural puncture may be required to drain fluid. Gastrointestinal disorders include: constipation, diarrhea, vomiting and nausea. Their cause is high intraperitoneal pressure. In the event of gastroesophageal reflux disease, a change in the dialysis method from CADO to ADO is indicated.
Adverse Gastrointestinal effects:
Persistence of adverse gastrointestinal effects may result in the patient being transferred to a hemodialysis program. On the part of the musculoskeletal system patients may experience symptoms of sciatica or lumbago. As in previous cases, it is recommended to change the way of dialysis from CADO to ADO. In women, prolapse of the reproductive organ may also occur and in this case it is recommended to change from CADO to ADO using a reduced daily exchange volume.
Hemoperitoneum and Encapsulating:
Non-infectious complications also include those independent of increased intra-abdominal pressure. These include hemoperitoneum and encapsulating peritoneal sclerosis. Hemoperitoneum, or bleeding we divide into 3 degrees of severity. Management varies in every degree, only hemoperitoreum grade 3 requires surgical intervention. In other cases, there is usually no contraindication to continuing peritoneal dialysis.
Encapsulating peritoneal sclerosis (EPS) leads to peritoneal loss as a dialysis membrane. Risk factors include long-term dialysis therapy, lasting over 5 years, frequent cases of dialysis peritonitis, use of dialysis fluids with high glucose concentration.Symptoms are: blood dialysate, abdominal pain of unknown cause, and repeated episodes of intestinal obstruction. There is a decrease in peritoneal ultrafiltration, ascites, and intra-abdominal resistance accompanied by reduced intestinal peristalsis.
Infectious complications of peritoneal Dialysis:
Infectious complications of peritoneal dialysis include dialysis peritonitis (DZO). Its symptoms include the presence of turbid dialyses, fever, nausea, vomiting, peritoneal symptoms, abdominal pain, and ultrafiltration impairment. The cause of DZO are most often errors made by the patient during independent dialysis replacement. However, dialysis peritonitis may also have iatrogenic background such as: endoscopic examinations, enema, prolonged antibiotic therapy, gynecological and dental procedures. The most common pathogens responsible for DZO include Staphylococcus epidermidis and Staphylococcus aureus. Most often, effective antibiotic therapy cures the patient and no need to give up peritoneal dialysis.
Advantages of Peritoneal Dialysis:
Despite the many advantages of peritoneal dialysis, there may be a point in the treatment program at which point the patient must or is advised to give up DO for hemodialysis. Information on the indications for ending peritoneal dialysis has been taken from the chapter “Diagnosis and treatment of dialysis peritonitis” from a paper edited by B. Rutkowski and S. Czekalski. This may occur due to the deterioration of the patient’s physical and mental condition with the lack of a helper.
The patient is no longer able to perform dialysis on his own at home. Sometimes, however, despite the willingness to continue this method of treatment on the part of the treatment, he is forced to start hemodialysis.This may occur as a result of peritoneal insufficiency due to its fibrosis, intraperitoneal adhesions, inefficiency of peritoneal dialysis manifested by abnormal creatinine clearance and ultrafiltration results. Also in the case of recurrent diverticulitis, peritoneal cancer and severe ischemic bowel disease, the patient is forced to give up the continuation of the DO program.
The indication for peritoneal catheter removal is persistent dialysis peritonitis despite treatment or an acute process requiring operative abdominal opening. The same indication is a catheter tunnel infection that caused or threatens to peritonitis.
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