PERITONEAL

( AS SEMIPERMEABLE MEMBRANE)

ASSESS ITS TYPES AND

FUNCTIONS

Nyoman Sutarka

TABANAN GENERAL HOSPITAL

 Peritoneal dialysis

Principles:
• peritoneum (capillary endothelium, matrix,
mesothelium) = semipermeable dialysis membrane
through which solute move from blood to dialysis
solution via diffusion and convection

• effective peritoneal surface area = perfused capillaries

closed to peritoneum (↓ in peritonitis)

• ultrafiltration (movement of water) enabled by osmotic

gradient generated by glucose or glucose polymers
(isodextrin)
 Scheme of peritoneal solute transport by
diffusion through the pores of capillary wall
 Anatomy of The Peritoneum

• The lining of the abdominal cavity

• Two layers:
parietal
- lines the anterior wall and undersurface of
the diaphragm
- 20% of total Surface Area; blood supply from
abdominal wall

visceral
- covers the abdominal organs
- 80% of total SA; blood supply from
mesenteric aa and portal vv
Anatomy of The Peritoneum

• Size 1.5 – 2 m2; approximates BSA

• Highly Vascular

• Semi-permeable/bi-directional

• Continuous with Fallopian Tubes in females

 Transport Processes in Peritoneal
Dialysis

Diffusion Osmosis

Movement of solute Movement of water from an

from an area of higher area of higher concentration
concentration (lower solute concentration)
to an area of lower to an area of lower
concentration concentration
. (higher solute
concentration)
 Transport Across the Peritoneal Endothelium:
The Three Pore Model

• Large pores (100 - 200 Å)

- few in number (3% of SA)
- transport macromolecules
- clefts between endothelial cells

• Small pores (40 - 60 Å)

- most numerous (95% of SA)
- allow transport of small solutes and water
- postulated to be clefts in the endothelium
• Ultrasmall (transcellular) pores (4 - 6 Å)
- many in number (but only 2% of SA)
- transport water only (Na sieving)
Model of transport - 3 sorts of pores

Ramesh Khanna & Karl D. Nolph

 Two Clinical Endpoints for
Peritoneal Transport

• Solute Clearance
 diffusive
 convective

• Fluid Removal
 Factors Influencing Solute Diffusion

• Surface Area
• Peritoneal Permeability
• Solute Characteristics
• Concentration Gradient
• Temperature of Dialysis Solution
• Blood Flow
• Dialysis Solution Volume in 24 hrs.
• Dwell Time
 Ultrafiltration during PD
Depends on:
- type of transporter – low transporters have better UF
- concentration and type of osmotic agent in PD fluid:
1. Fluids with glucosis (1,27%, 2,5% a 3,8% ), higher
concentration – higher osmotic pressure and UF
2. Fluid with icodextrin (Extraneal) = glucose polymer with
a large molecule, resorbs only 10-20%, offers longtime
UF, suitable for long night exchanges, 8-12 hours)
- time between exchanges, using glucose-based fluids,
maximal UF obtained after 2-3 hours, using longer
spaces UF dicreases.
Ultrafiltration in different types of PD
solutions
 Perspectives - New dialysis solutions protect
peritoneal membrane

Physioneal1 Extraneal2
•  GDPs and AGEs • Isosmolar to plasma
•  Lactate • No glucose exposure
• Physiologic pH and pCO2 •  GDPs and AGEs
•  Membrane and immune cell •  Membrane and immune cell
function function

Nutrineal2
• No glucose exposure
• No GDPs or AGEs
•  Membrane and immune cell
function

1Skoufos, et al. Kidney Int. 2003;64(suppl 88):S94-S99.

2Vardhan, et al. Kidney Int. 2003;64(suppl 88):S114-S123.
 Clinical advantages of new dialysis
solutions
Physioneal Extraneal
 Infusion pain  Glucose load
 Peritonitis  Glycemic control
 Glycemic control  UF, control of fluid status
 Appetite  Dyslipidemia
 Patient acceptance  Quality of life
No  UF  Time on PD

Nutrineal
 Glucose load
 Glycemic control
 Protein intake, nutritional status

Pecoits-Filho, et al. Kidney Int. 2003;64(suppl 88):S100-S104.

Vardhan, et al. Kidney Int. 2003;64(suppl 88):S114-S123.
 Absorbtion of glucose from peritoneal solutions
1. Solutions containing glucose (green) lead to significant glucose
absorbtion
2. Solutions based on another osmotic agent (blue, violet) do not
lead to glucose absorbtion, so decrease total daily glucose load).

Glucose absorbed = 159 g/day

1 2.5 L 2.5 L 2.5 L 2.5 L

Physioneal Physioneal Physioneal Physioneal
1.36% 1.36% 1.36% 3.86%

Glucose absorbed = 50 g/day

2.5 L 2.5 L
2 Physioneal 2.5 L Physioneal 2.5 L
1.36% Nutrineal 1.36% Extraneal
 Assessement of peritoneal
function

1. PET- peritoneal equilibration test (type of

transport and ultrafiltration after 4 hours)
2. weekly clearance of creatinine and urea
3. daily UF
4. dicrease of Na in dialysis fluid after 60
minutes using 3,8% G (test of
aquaporines)
Criteria of PD adequacy
 PET
(Peritoneal Equilibrium Test)
 Keuntungan dari PET

Ф Identifikasi karakteristik dari membran peritoneal

Ф Menilai ultrafiltrasi yang tidak adekuat

Ф Membedakan antara dialisis yang tidak adekuat

dengan pasien yang tidak patuh

Ф Dinilai jika peritonitis berulang akan mempengaruhi

permeabilitas membran
Kapan dilakukan PET

 Pasien dengan kesehatan yang optimum

 Kateter peritoneal berfungsi dengan baik

 Pasien tidak konstipasi

Tidak ada overload cairan pada pasien

 PENETAPAN FAKTOR KOREKSI

• KIRIM CONTOH DARI CAIRAN YANG BARU DARI 2.5%

DIANEAL KE LABORATORIUM UNTUK GLUCOSE DAN
CREATININE

• BAGI NILAI KREATININ DENGAN NILAI GLUKOSA UNTUK

MENGHITUNG FAKTOR KOREKSI KREATININ
• KREATININ TERKOREKSI mg/dl = KREATININ mg/dl -
(GLUKOSA X CORRECTION FACTOR)

Contoh . SERUM kreatinin =12

GLUKOSA = 95
CORRECTION FACTOR FROM FRESH 2.5% DIANEAL
= .000210526

CORRECTED SERUM CREATININE = 12 - (95 X .000210526)

12-.0199975= 11.9
 PET CALCULATIONS

D/P Corrected Dialysate Creatinine Concentration at 0 hr, 2 hr, 4 hr Dwel

CREATININE Plasma Creatinine Concentration at 2 hr Dwel

D/Do Dialysate Glucose Concentration at 2 hr and 4 hr Dwel

GLUCOSE Dialysate Glucose Concentration at 0 hr Dwel
Interpretation of peritonal
equilibration test ??
HIGH

HIGH
AVERAGE

LOW
AVERAGE

LOW
Choice of PD scheme depends of BSA and
type of transport
CAPD – continual ambulatory
peritoneal dialysis
• manual exchanges
NIPD – night intermitent peritoneal
dialysis (cycler)
CCPD – continual cyclic PD
 FAKTOR2 YANG MEMPENGARUHI
AKURASI DARI PET

➢ Ketidakseimbangan dari volume dialisat sisa pada awal PET

➢ Cavum peritoneal tidak kosong dengan sempurna

➢ Drainase akhir tidak dinilai dengan benar

➢ Contoh dialisat tidak dikumpulkan pada waktu yang benar

PET TROUBLESHOOTING GUIDELINE

❖ Gunakan 2 L larutan untuk tes

❖ Kurva dari Dr. Twardowski dibuat untuk Dianeal 2 L/2,5 %

❖ NIPD/DAPD pasien tidak mempunyai dwell yang panjang,

maka buatlah pertukaran extra dan biarkan cairan untuk
dwell time minimal 4 jam sebelum prosedur tes dimulai.
Idealnya siapkan dwell time untuk 8 – 12 jam.

❖ Jika pasien datang terlambat untuk pengambilan sampel

pada jam 2 dan jam 4, lanjutkan tes sesuai dengan prosedur
tapi catat waktu pengambilan sampel, dan ulangi tes jika ha-
silnya tidak konsisten.
 Pasien dengan peritonitis : jangan melakukan tes, tunggu
6 minggu untuk melakukan tes.

 Ketidakakuratan dalam menilai 200 cc untuk pencampuran

awal, maka gunakan timbangan

 Volume drainase 4 jam siknifikan kurang daripada 2 L vo-

lume yang dimasukkan. Maka rubah posisi pasien dan lan-
jutkan drainase.
Jika drainase tidak sempurna :
- konstipasi, fibrin dan malposisi
- tipe membran high transporter
- absorpsi dari limfatik

 Jika serum glukosa > 300 mg/dl : cek glukosa serum pasien
sebelum tes diulang. Glukosa > 300 dapat mempengaruhi UF
❖ Tes tidak memakai konsentrasi 2,5 %. Jika hasil akan
dibandingkan dengan kurva dari dr. Twardowski, maka
harus digunakan dextrose 2,5 %, jadi ulangi tes.

❖ Glukosa awal pada jam 0 < 2000. Jika digunakan konsentrasi

glukosa 2,5 %,drainase dari abdomen mungkin tidak sem –
purna terutama pada awal PET. Lihat D/P, D/D0 dan volume
drainase, mungkin perlu diulang PET nya.

❖ Rasio D/P tidak sesuai dengan D/D0. Plot rasio dalam grafik
PET. Jika hasilnya dalam 1 standar deviasi, hasilnya masih
dapat diterima.
CORRECTION FACTOR FROM FRESH 2.5% DIANEAL
= .000210526
Do/Do = 1
D2/Do = 0,4980
D4/Do = 0,2900

D4/p = 0,7426
D2/p = 0,5666
Do/p = 0,1026

Corection = corection faktor x blood sugar

Corection = 0,000210526 x 80 = 0,0168416