RENAL REPLACEMENT THERAPY

(RRT) WITH EMPHASIS ON

A C U T E P E R I T O N E A L D I A LY S I S
NEPHROLOGY UNIT
P A E D I AT R I C S D E P A R T M E N T
F E D E R A L M E D I C A L C E N T R E , A B E O K U TA
BY
A D E O G U N O. B
E D O K P O L O R O. O
O L U S E S I O. O
BIODATA
• Name : A.J
• Age : 8 years
• Sex : Female
• Address : 34, FH Estate Elega Abeokuta
• Religion : Christian
• INFORMANT : Mother
• D.O.A : 24/11/2018
• D.O.D : 13/12/2018
PRESENTING COMPLAINTS
Referred from Shirish Medical centre on account of
• Fever x 6 days
• Headache x 6days
• Yellow discoloration of the eye x 2 days
• Passage of dark urine x 2 days
• Reduction in urinary output x 1 day
• Convulsion x 1 day
HISTORY OF PRESENTING COMPLAIN
• fever: high grade, intermittent, transiently relieved by PCM.
• Headache was frontal, throbbing and severe to disturb activities.
• She was commenced on appropriate dose of artemeter-lumenfantrine with mild
relieve in symptom.
• Yellowness of the eye: started 4 days after onset of fever and progressively increasing
in intensity.
• Passage of dark urine noticed same time describe as cola coloured and was
deepening in intensity.
• She was placed in early morning sun on account of this.
• Reduced urinary output noticed a day prior to presentation evidenced by reduction
in frequency from thrice to no passage of urine in 24 hours.
• Convulsion noticed same day described as tonic-clonic with associated upward
rolling of the eyes and clenching of the teeth, had multiple episodes, each lasting
about 10mins.
• She thereafter became unresponsive to call.
• Child was initially admitted at her maternal aunty’s maternity center where IV fluids
and IV drugs were administered (names not known).
• On account of no improvement was taken to the referring centre and was admitted
for 3 days and placed on IVF 4.3% D/S, IV Ceftriaxone, IV PCM, IM Paluther,
Intranasal oxygen and IV diazepam.
• Investigation included PCV-24%, MP +, RBS 148mg/dl.
• She was subsequently referred based on mothers preference.
• PMH – docuemented genotype AA.
• other part of history, not contributory.
• Fully immunized for age.
• Presently pry 3 pupil, doing well in school.
• Mother is 38yr old, Bsc holder administrative officer in FMCA.
• Father is a 40yr old security officer with Ogun state civil service. Secondary level of
education.
• She Stays with maternal aunt in Lagos in a 3bed room flat
• Mother and maternal Aunt are the caregivers.
• General Examination
Unconscious, moderately pale, icteric, not cyanosed, not dehydrated, afebrile (36°c), no
pedal edema.
Weight- 25kg ( 100%)
Height- 124cm (25th centile)
• Systemic
CNS – Unconscious, GCS - E = 1
V =1 6/15
M=4
Cranial Nerves - Grossly intact
Pupil – Normal size, equal and reactive to light
Normal tone in both upper limbs and lower limbs.
Reflexes are normal.
Plantar reflex unresponsive bilaterally.
• CVS
PR- 120bpm, full volume and regular
BP- 120/60mmHg (50th-90th both systolic and diastolic).
First and Second normal heart sound, no added sound.
• Respiratory system
RR- 40cpm, dyspneic evidenced by subcostal recessions.
Spo2- 95-96( room air).
Vesicular breath sounds.
• Digestive
Mouth - NAD
Abd is full, moves with respiration.
No palpable area of tenderness.
No palpable organomegaly.
• Diagnosis –
1) Cerebral malaria ( Jaundice, Multiple convulsion, Haemoglobinuria)
2) Sepsis with AKI.
• PLAN
FBC- (PCV -20%).
RBS - 74mg/dl
RDT for Malaria – Positive.
INO₂ at 2l/min
IV Fluid 5% dextrose in ½ N/saline at 2/3 maintenance 1000ml over 24hrs at 13drops
/min.
CRP – 298.26mg/L
IV artesunate 60mg at 0 hr, 12hr, 24hr
IV diazepam 7.5mg for breakthrough seizures
IV phenobarbitone 200mg stat, 60mg 12hrly
Urinalysis -

parameter Main Lab Side Lab

Blood ++++ +

Protein +++ ++

Urobilinogen + ++

Bilirubin _ +
• Urine Microscopy. • LFT
++ of amorphous deposit Total Bil = 10.1mg/dl ↑
Nil pus/red cells Conj Bil = 7.2mg/dl ↑
HBsAg – Negative Total Protein = 6.3mg/dl N
AntiHCV – Negative Albumin = 3.0 mg/dl N
• FBC ALP = 154 µl
WBC = 9.8 X 10³/mm SGOT = 120 µl
Neu = 44 % SGPT = 48 µl
Lymph = 55% GGT = 40 µl
Platelet = 61 x 10³/mm
Strict Input and Out put.
IV Ceftriaxone 1g daily.
Serial PCV monitoring.
Blood culture.
• Further Review
No convulsion since admission
Urine Out put – 0.2ml/kg/hr
GCS – 8/15
Repeat PCV – 22%
RBS – 24mg/dl and corrected with 4mls/kg, then IVF changed to 10%D in ½ saline at
2/3rd maintenance.
PRE-PERITONEAL DIALYSIS E/U/CR
RESULTS
parameters mmol/L mmol/L mmol/L mmol/L
24/11/18 25/11/18 27/11/18 28/11/18

SODIUM 128 ↓ 127 ↓ 120 116

POTASSIUM 4.5 N 4.8 N 4.2 4.0

CHLORIDE 90 N 93 N 85 86

BICARBONATE 15 ↓ 15 ↓ 11 19

UREA 234 ↑ 284 ↑ 314 249

CREATININE 5.2 ↑ 7.1 ↑ 9.6 9.9

LIVER FUNCTION TEST RESULTS
PARAMETERS 24/11/18 29/11/2018

TOTAL BILIRUBIN 10.1 3.1

Mg/dl
CONJUGATED 7.2 2.5
BILIRUBIN mg/dl
TOTAL PROTEIN 6.3 5.8
Mg/dl
ALBUMIN 3.0 2.5
Mg/dl
ALP 154 101
µL
AST 120 75
µL

ALT 48 57
µL
DAY 3 - UNIT CONSULTANT REVIEW
• No repeat convulsion in last 24 hrs
• Temperature on downward trend
• Still having recurrent hypoglycemia
• Still unconscious with GCS = 8/15
• Diagnosis
Severe sepsis with AKI and intravascular hemolysis
• Plan
Restrict IVF to 600mls over the next 24hrs (insensible loss + previous day output)
Consult to nephrology unit
RBS = Low and corrected with 4mls/kg of 10%D/W and rechecked 15mg/dl which was
corrected and IVF changed to 12.5%D in ½ saline at same rate.
NEPHROLOGY UNIT REVIEW
• Altered level of consciousness with GCS = 10/15, afebrile (37 °c), icteric, periorbital
swelling.
• Global hypotonia and hyporeflexia.
• Hepatomegaly of 4cm BRCM, firm, non tender
• Diagnosis
Cerebral Malaria with Sepsis
Acute kidney injury
• Plan
PCV -19%. Patient was transfused with 500ml of whole blood
Commenced Fortified pap via NG tube at 25mls 4hrly.
↓IVF to 500mls over 24hours at 7dpm.
CT. other care.
DAY 4
• Urine output over last 24hrs 0.09ml/kg/hr and over 6 hrs was 0.7ml/kg/hr.
• Altered level of consciousness with GCS = 11/15.
• Latest RBS was 35mg/dl.
• RR – 20 cpm, oxygen saturation 98-99% in room air
• PLAN
NG tube feed was increased to 75ml of fortified pap, 4hly
Repeat E/u/Cr.
Hourly RBS till 3 normal values, then 6 hourly.
D/C INO2.
CT other management.
DAY 5
• Still has altered level of consciousness GCS =11/15.
• Latest RBS = 30mg/dl.
• Urinary out put was 0.25mls/kg/hr
• No fever in the last 48hours.
• Other findings not significant.
• Post transfusion PCV = 29%
• PLAN
↑ feeds to 150mls 4hrly and add 4 cubes of sugar
Repeat E/u/Cr and LFT.
CT other line of management.
For peritoneal dialysis
DAY 6
• Commenced on peritoneal dialysis, procedure well tolerated.
• Clinical condition better as restlessness has subsided
• Recent E/u/cr result noted.
• RBS = 25mg/dl
• Diagnosis
AKI 2° to sepsis complicated with uraemic encephalopathy.
Recurrent hypoglycemia.
• PLAN
Fortified pap was increased to 250ml 4hrly ( Add 4 cubes of sugar)
IV ceftriaxone was reduced to 750mg daily
For more sessions of peritoneal dialysis
CT other line of management.
DAY 7
• Had 7 sessions of dialysis
• Had an episode of vomitting this morning.
• RBS = 44mg/dl
• Urine output over last 24hrs 0.62ml/kg/hr
• Still has altered level of consciousness. GCS =12/15
• PLAN
Repeat E/u/Cr
CT restriction of IVF
CT other line of management.
 DAY 8
• RBS now optimal
• Latest weight 25kg
• Fully conscious, requesting for food
• Urine output over last 24hr= 1.8ml/kg/hr
• Global hypotonia with foot drop marked on the right.
• PLAN
CT. Peritoneal dialysis
Change iv artesunate to oral artemeter-lumefantrine
For repeat CRP = 17.97
Commenced feeding as tolerated as much by mouth and remaining via N-G tube.
Repeat E/U/Cr ; PCV=25%.
DAY 9
• Latest weight = 18kg
• Urine output 4.2ml/kg/day
• Latest pcv 21% ; Tolerating 200mls 4hrly fortified pap.
• Had 3 more sessions of peritoneal dialysis.
• PLAN
Complete oral A/L
CT IV antibiotics
Repeat E/U/Cr
CT strict I/O monitoring.
DAY 10-17
• Urine output over 24hrs during this period was between 1.7 – 3.3
mls/kg/hour.
• D/C NG tube and commenced on oral feeding.
• Daily E/U/Cr result noted.
• D/C IV antibiotics,
DAY 18
• Tabs augmentin 475mg bd x1/52
• Tab vitC 200mg tds x1/52.
• D/C Strict I/O monitoring.
• Repeat E/u/Cr in 48hours.
• CT. Peritoneal wound dressing.
• Feed as tolerated.
POST-PERITONEAL DIALYSIS E/U/CR
Parame PD
ters COMM 30/11/1 1/12/18 4/12/18 05/12/1 7/12/18 10/12/1 14/12/1
ENCE 8 8 8 8
D
29/11/1
8
SODIU 111 118 122 120 125 140 136 134
M
POTASSI 3.6 3.9 3.5 2.7 2.6 3.5 3.2 4.3
UM
CHLORI 84 84 90 92 85 95 106 111
DE
BICARB 16 14 14 21 17 22 22 24
ONATE
UREA 277 295 241 255 203 139 71 34

CREATI 11.1 10.8 10.5 12.1 9.9 4.8 1.3 0.8

NE
DAY 20

• E/U/CR
– Na 134
– K 4.3
– Cl 111
– Hco3 20
– Urea 34mg/dl
– Creatinine 4.8
• Discharged home
20/12/18 TILL DATE
• She has since attended the CHOP with repeat E/U/Cr which was normal
Na 139mmol/l
k 4.2mmol/l
Cl 107mmol/l
HCO3 21mmol/l
Urea 20mg/dl
Cr 0.7mg/dl
• PCV 32%.
• Presently back to school and now resides with her mother.
 OUTLINE
• INTRODUCTION
• HISTORIC BACKGROUND
• DEFINITION
• MODALITIES OF RRT
• INDICATION
• COMPLICATION
• ACUTE PERITONEAL DIALYSIS ( APD )
– OVERVIEW
– ANATOMY OF PERITONEAL CAVITY
– PHYSIOLOGY OF PERITONEAL TRANSPORT
– TECHNIQUE OF PERITONEAL DIALYSIS
– COMPLICATIONS
– CONTRAINDICATION
– ADVANTAGES & DISADVANTAGES
– PD IN FEDERAL MEDICAL CENTRE ABEOKUTA
– PD IN OTHER CENTRES
• CHRONIC PD
• CONCLUSION
• REFERENCE
 INTRODUCTION
• Before the middle of the 20th century, the prospect that a child with end-stage renal disease
(ESRD) would survive till adulthood was essentially nil.
• With availability of dialysis and transplantation , that death sentence was lifted, as increasing
numbers of children with ESRD were offered renal-replacement therapy.
• RRT has been available in high-income countries for more than 50 years, with rapid growth in
the number of people treated during this period
• The ability to safely and routinely deliver ongoing organ support in the outpatient setting has,
until recently, separated renal replacement therapy from other organ support.
• Renal replacement therapy (RRT) is a life-saving, high-cost treatment that requires expertise
and sustained funding.
• Globally the incidence of RRT in children vary considerably which is probably due to
differences in ;
– National wealth
– Health expenditure
– National healthcare organization and delivery
– Ethnic differences in disease prevalence
– Sociocultural variation in the approach towards congenital and chronic disease in children
• Incidence of RRT in children ;
– 4 per million age-related population in developing nations
– 14 per million age-related population in developed nations
• Information from RRT registries offers the potential of a better understanding of the factors
affecting pediatric RRT incidence rates.
• Most developed countries have established national pediatric RRT registries, either as
– stand-alone databases
– integrated into adult renal registries
• Data regarding the availability of pediatric RRT registries in many 3rd world countries
are lacking.
• Access to RRT in developed countries keeps over 2 million people alive worldwide.
• In many of the developing countries such as Nigeria , it is readily
– inaccessible
– Unaffordable
– and there is low acceptance rate
• There is difficulty in formulating policies to improve the acceptance rate of RRT in Nigeria
probably due to dearth of data .
• In 2010 , around three million patients received RRT globally , and this number is expected to
increase to between 5 and 10 million by 2030 .
• In a retrospective study of 5years review (Nov 2008 to Oct 2013 ) of children admitted into
pediatrics ward of UNNTH who required RRT done by O.I Odetunde et al done in Enugu ,
southeast Nigeria in 2014 report that ;
– Renal disease ; 194 ( 5.5% of 3,520 admission )
– No that required RRT ; 64 ( 33% ) ( mean age ; 5.3yr)
– No that access RRT ; 25 ( 39.1% )
– Modalities of RRT
• APD ; 14 (56% )
• AHD ; 11 ( 44% )
• CRRT ; nil
• In Federal Medical Centre , Abeokuta ( Jan 1, 2013 to Dec 31, 2018 )
– Total renal cases admitted ; 113
– No that require RRT : 14
– No that access RRT ; 8
– Modalities of RRT ;
PD ; 4 HD ; 4
– Outcome of RRT ; 1 mortality ( from HD )
 HISTORIC BACKGROUND
• Supporting of failing kidney began as early as 1913.
• Dr John J. Abel & Dr W.J Kolff in 1913 were credited as the forefather of modern dialysis.
• In 1923 , Dr Tracey J. Putnam use the peritoneum as a living dialyzer.
• Dr Hass in 1924 carried out the first hemodialysis in human being ;
– dialyzer consisting of U-shaped collodion tubes
– immersed in a dialysate bath placed in a glass cylinder.
– procedure lasted for only 15minutes with use of hirudin as anticoagulant.
• Dr. Willem Kolff was the first to construct a working dialyzer in 1943.
• First documented kidney transplant was in USA in 1950 .
• In 1954 , the world’s first successful renal transplant was performed by Dr. Joseph E. Murray
and Dr. J. Hartwell Harrison
• The work of Dr. Quinton and Dr. Tenckhoff led to improvement in the dialysis catheter used
with subsequent widespread use of peritoneal dialysis.
 DEFINITION

• Renal replacement therapy refers to modalities of treatment that are used

for the replacement of waste filtering functions of a normal kidney .
• Renal replacement therapy (RRT) is the process of supporting renal function through the use
of dialysis or renal transplantation.
• Renal replacement therapy (RRT) via dialysis can be applied intermittently or continuously
using ;
– Extracorporeal method ( HD or CRRT )
– Paracorporeal method ( PD )
 MODALITIES OF RRT

RRT

Acute Chronic

Peritoneal Hemodial Peritoneal Renal

Dialysis CRRT
ysis Dialysis Transplant
Hemodial ation
ysis
intermitte continuou
nt s
intermittent continuous
intermitte continuou
nt s

intermittent
COMPARISON OF MODALITIES OF DIALYSIS
 Factors influencing the choice of RRT
• Goal of dialysis.
• Clinical status & hemodynamic stability.
• Feasibility of peritoneal or large vascular access.
• Training of medical personnel , institutional preference.
• Need for anticoagulation.
• Cost of treatment and supplies.
 INDICATION FOR RRT
• AKI
• CKD
• Intoxication
• Inborn Error of Metabolism
• Hypercatabolic state
 COMPLICATIONS OF RRT
• Hypotension
• Clotting in the circuit
• Immununosuppresion
• Electrolyte imbalance
• Peritonitis
• Hyperglycemia
• Vessel thrombosis
• Abdominal pain
 ACUTE PERITONEAL DIALYSIS
Overview
• Peritoneal dialysis is a form of dialysis in which the peritoneal membrane is use as a natural
dialyzing membrane for removal of waste product and excess fluid from blood.
• Whenever it is use for acute condition such as AKI it is called Acute Peritoneal Dialysis ( APD ).
• It is simple, convenient, easily instituted and requires a minimum no equipment & expertise.
• It is a lifesaving procedure in patients with AKI, especially in regions with limited resources.
• Treatment of choice for neonate & infant with AKI because of the technical difficulty of
hemodialysis.
• Method of RRT used by about 200,000 patient world wide.
• APD is usually performed continuously but can also be done intermittently .
• Technical requirements for procedure
– simple, improvised setups
– programmable devices and industry-manufactured sets of dialysate bags and tubing
• It involves
– Transport of solutes & water
– Membrane that separate 2 fluid containing compartment
• Peritoneal capillaries
• Peritoneal cavity
Indication for Acute Peritoneal Dialysis
– Renal indications
• AKI +/- oligoanuria
• Volume overload with evidence of hypertension/pulmonary oedema
• Persistent hyperkalemia
• Severe metabolic acidosis unresponsive to medical therapy
• Symtomatic uremia
– Non –Renal indication
• Severe acidosis
• Severe hyperkalemia
• Nutritional support
• Hypothermia or hyperthermia
• Hepatic failure
 ANATOMY
Sagittal
section of
the peritoneal
cavity
 Peritoneal Dialysis system
• Peritoneal microcirculation:
– Peritoneal capillary blood flow has been suggested to vary between 50 and 100 ml/min
– The effective amount involve in peritoneal exchange may be lower
• Peritoneal membrane
– Represents the barrier that solutes and water have to cross
– It consists of
• Capillary wall ;
– plays a central role in the control of vascular permeability
• Interstitium ;
– Hyaluronan is an important determinant of the resistance to fluid & solute transport
• Layer of lubricated mesothelial cells
– participate in glucose transport
– regulate of water and solute fluxes through tight junction modulation
• Dialysis fluid compartment
– composition of the solution
– the modalities of delivery

Peritoneal transport
• There are 6 regions of resistance to movement of solute and water across the peritoneum
from capillary blood to peritoneal fluid
Components of the peritoneal transpor t barrier
• Two concepts of peritoneal transport are popular ;
– distributed model ;
 Distribution of capillaries in the peritoneal membrane is important for transport
 Distance that molecules have to travel from the capillaries across the interstitium to the mesothelium is
also important in transport
• Transport is dependent on the surface area of the peritoneal capillaries
• The cumulative contribution of all of the peritoneal capillaries determines the effective surface area and the
resistance properties of the membrane
• Effective peritoneal surface area ; This is the area of the peritoneal surface that is sufficiently close to the
peritoneal capillaries to play a role in transport
• The degree of vascularity of the peritoneum is more important than its surface area in determining the
transport characteristics of an individual patient.
– three pore model ;
THREE-PORE MODEL
O F P E R I TO N E A L
T R A N S P O RT.
- States that the peritoneal capillary is

the critical barrier to peritoneal

transport

- The peritoneal capillary has several

pores of 3 different sizes for the

movement of various molecules.

- Large pore

- Small pore

- Ultrapores
Physiology of peritoneal transport
• Transport process occurring simultaneously during peritoneal dialysis are
– Diffusion
• Transmembrane concentration gradient
• Molecular weight
• Effective surface area
 Vascular surface area
 Fill volume
 Posture
• Permeability of peritoneal membrane
– Convection
• Rate of ultrafiltration
• Membrane permeability
 – Ultrafiltration
• Magnitude of transmembrane osmotic gradient.
• The effects of hydrostatic pressure gradient are usually of minor importance in PD.

Techniques of Peritoneal Dialysis

• Essential elements are
– Viable peritoneal cavity
– Access to peritoneal cavity
– Dialysis fluid and modalities of delivery
 Access to peritoneal cavity
• Usually by means of indwelling peritoneal dialysis catheter
• Based on design and use, peritoneal catheters can be classified as acute or chronic
• Acute catheter can either be
– Rigid noncuffed catheters
• Composed of relatively rigid plastic
• provided in straight and slightly curved configurations
• numerous side holes in the intraperitoneal segment
• the generally accepted period of maximum use is 3 days
• short course of peritoneal dialysis
– Soft cuffed catheters
• Continue demands for a single-cuff catheter is to provide acute access.
• one-cuff soft tube can be left in peritoneum indefinitely
• it is easier to insert and remove than two-cuff chronic devices.
• Chronic catheter
– Most of the chronic catheters can serve as acute peritoneal access devices.
– Development of the 1st long-term indwelling catheter by Tenckhoff made long-term dialysis a reality.
– Modern catheters are base on Tenckhoff’s design.
– Presently all catheters are made of silicone rubber with Dacron cuffs placed on it.
• Other catheter used are improvised
– NG tube
– Foleys catheter
• Each PD catheter is comprised of three parts
– An intra-abdominal segment.
– A subcutaneous tunnel segment.
– An external segment.
 comparison of commonly used peritoneal catheters
Straight Tenckhoff Easy to place by percutaneous technique
Easy to remove and replace
Rectal discomfort is more common and outflow
problems are more common
Curled Tenckhoff Same as above + better patency and better
outflow
Does not impinge on the rectum
Missouri Combination of Toronto Western and
swan-neck catheter
Can only be place and manipulated
Surgically
Swan neck Same as straight Tenckhoff
Tunnel must be curved
Lifecath Can only be placed and manipulated surgically
Commonly used peritoneal catheters
C AT H E T E R I N S E R T I O N
TECHNIQUE

Three insertion techniques are used,

namely
Surgical
Percutaneous
Laparascopic

- The larger catheters have to be

placed surgically

- Tenckhoff catheters can be placed by

any of the three techniques

- Prior to insertion of the catheter

the bladder and rectum should be
emptied
Comparison of catheter inser tion techniques
C om mon inc ision sit e s Te n c kh off t e c h n iq u e wi t h t u n n e l
 Best Practices in Patient Preparation for PD Catheter Insertion
• Preoperative assessment to select the most appropriate catheter type and exit-site location
• Bowel prep the day before surgery .
• Shower on the day of surgery with chlorhexidine soap wash of the abdomen/chest
• Removal of body hair in the preoperative holding area.
• Empty the bladder before procedure.
• Single preoperative dose of prophylactic antibiotic to provide antistaphylococcal coverage.
Best practices for peritoneal dialysis catheter insertion

• Operative personnel are attired in cap, mask, and sterile gown and gloves
• Surgical site is prepared with chlorhexidine–gluconate scrub, povidone–iodine (gel or scrub),
or other suitable antiseptic agent and sterile drapes applied around the surgical field
• Peritoneal catheter is rinsed and flushed with saline and air squeezed out of the Dacron cuffs
by rolling the submerged cuffs between fingers
• Paramedian insertion of the catheter through the body of the rectus muscle
• Deep catheter cuff positioned within or below the rectus muscle
• Pelvic location of the catheter tip
• Catheter flow test performed to confirm acceptable function
• Skin exit site directed lateral or downward (not upward)
• Subcutaneous tunneling instrument should not exceed the diameter of the catheter
• Exit site should be smallest skin hole possible that allows passage of the catheter
• Position subcutaneous cuff 2–4 cm from the exit site
• No catheter anchoring sutures at the exit site
• Attach transfer (extension) set at time of procedure
• Exit site protected and catheter immobilized by non-occlusive dressing
 Peritoneal Dialysis fluid
• It is available in two forms ;
• Commercially prepared fluid
• Locally mixed fluid
– can be produced from physiological intravenous fluids by adding glucose and bicarbonate.
– Other commercial intravenous solutions that can relatively be used include
Ringer’s lactate , half normal saline, and Plasmalyte B
• Standard PD solutions generally use lactate as a buffer.
• This is converted to bicarbonate mainly through liver and muscle pyruvate dehydrogenase
enzymes
Special PD fluids needed in special situations
• bicarbonate-based PD fluid
– Children with severely compromised liver functions and AKI
– low birth weight newborns with sepsis and lactic acidosis
– Its prepare as ;
– Prepare solution A: 440 ml of 5 % dextrose + 60 ml of NaHCO3
– Prepare solution B: 500 ml of normal saline
– Solution A 250 ml + solution B 500 ml
– This gives Na 140mEq/l , HCO3 30mEq/l, dextrose 1.5 g/dl.
– Heparin and potassium can be added, if required
• chloride-based
– Children with severe metabolic alkalosis associated with a chloride depleted state
– Composition is 0.9 % NaCl based PD fluid
– Maintenance doses of potassium, calcium, and magnesium can be infused intravenously
– Inadequate ultrafiltration is a concern as the PD fluid is isotonic
.
 Constituents of a standard PD solution
Electrolyte Standard Solution ( mmol/l )

Sodium 130

Chloride 100

Lactate 3.88

Magnesium 1.23

Calcium 1.5

Osmolality ( mOsm/kg ) 355

Dextrose ( g/dl ) 1.7

 Osmotic Agent
• Dextrose
– Dextrose or glucose are the osmotic agents that have traditionally been used in PD Solutions
– UF rates depends on the concentration of the dextrose in the solution.
– Several osmotic agents other than glucose have been tried with varying degrees of success
• Amino acid solutions have been studied as an alternative
– UFR that are similar to that of glucose
– 1% amino acid solution is equivalent to 1.5% dextrose in terms of UF volume,
– Amino acids tend, however, to be absorbed faster than dextrose
A lt er nat iv e os m ot ic a g ent s t o d ext r os e a nd t heir p ot ent ia l c om p lic a t ions
 Delivery Mechanism
• Can be manual of automated with the use of machine ( cycler )
• Delivery of fluid from the source to the peritoneal catheter is usually accomplished by using a
transfer set
• Two main types of transfer set are in common use
– Straight transfer sets
• This comprises a straight piece of tubing, one end of which is connected to the catheter, the
other end to the PD bags
• The transfer sets are changed periodically
– Y Sets
• This comprises a Y tube with one empty and one full bag connected to the two arms of the Y
• The third arm connected to an extension tube that is connected to the catheter
• Use of the Y-set with a flush before the peritoneal fill (inflow) has been reported to decrease
the incidence of peritonitis.
Y-transfer set
 Modalities of Acute Peritoneal Dialysis
• The process of dialysate instillation and removal can be automated with a PD cycler.
• Automated cyclers have been used extensively to perform Acute Peritoneal Dialysis
particularly when high volume peritoneal dialysis (HVPD) is used .
• In a resource-poor setting , manual method is usually use because cyclers may be unavailable
or too expensive
• The choice of the type of PD to be utilized should be based on
– the experience of the medical and nursing team
– available resources
– the safety and efficacy of the technique
– the needs of the individual patient.
• Intermittent PD (IPD)
– This is the PD technique that historically has been most frequently used in AKI
– it is still the most common,
– Patients are treated for 48–72 hours, or occasionally longer
• Tidal PD (TPD)
– A trocar-style PD catheter is traditionally used & removed after the dialysis treatment is completed
– TPD is performed with a dedicated cycler
– TPD may result in higher small-MW-solute clearances
– major determinants of TPD efficiency
• total volume of delivered PD fluid
• individual peritoneal transport
– May reduce the frequency of pain on drainage of dialysate
– Minimize idle dialysis time
• High-volume PD (HVPD)
– HVPD is a continuous modality designed to achieve high small-MW-solute clearances
– It requires an automated cycler and a Tenckhoff catheter.

Cycler
– Is a simple machine that allows the desired volume of fluid to flow into the peritoneum
automatically
– After a set time it permits the outflow to begin and measures the volume
– It estimate ultrafiltration volume.
– The cyclers also warm the dialysate and can repeat outflow if the desired volume has not been
recovered
 Procedure
• Catheterize the bladder.
• Ensure that the dialysis fluid is warmed to the body temperature.
• Prepare and drape abdomen with the patient in supine position.
• Identify the midpoint of the line joining the umbilicus to the pubic symphysis or in a neonate
on a paramedian line a little lateral to rectus sheath.
• Give local anesthesia down to the peritoneum.
• Insert an 18-gauge needle at the planned site and infuse 20–30 ml/kg of dialysate fluid to create
a fluid cushion.
• Make a stab skin incision and insert the catheter with stylet perpendicular to the
abdominal wall with a twisting motion.
• Penetration of peritoneum will be indicated by sudden feeling of “give way” and gush of
dialysate fluid out via the catheter.
• Withdraw the stylet gradually, simultaneously advancing the catheter toward the opposite
pelvic cavity.
• Attach the connecting set to the catheter and run in dialysate fluid to confirm free flow.
• Allow about half of dialysate fluid to drain out by gravity. Start the next inflow. The initial 2–3
cycles can be rapid without a dwell time.
• Secure the catheter in place, if required with a purse string suture.
 Peritoneal Dialysis Prescription
• Each cycle usually lasts for 1 h.
– Fill volume 30–50 ml/kg,
– Run-in time 5–10 min,
– Dwell time 20–30 min,
– Out flow time 10–20 min.
• Addition of potassium to the dialysis fluid may be withheld for initial 8–10 cycles.
Subsequently 2–4 mmol/l of KCl can be added depending on the serum potassium level.
• Heparin (500 IU/l) may be added to prevent clot formation particularly to the first liter of fluid
and when out flow contains blood and fibrinous material.
• Dialysis can be continued for 48–72 h (total treatment time).
• It is preferable to remove the acute PD catheter after 72 h and reinsert later if required..

Modifications:
• In patients with pulmonary edema, dwell time can be shortened to 15–20 min and 2.5 %
dextrose containing PD fluid can be used to remove fluid rapidly.
• KEY POINT
• In the critical care setting,
– PD is better initiated as continuous, rapid cycle (1 h) procedure over 24 h
• If fluid removal is desired
– shorten cycles to 30 min or 45min
– increase dextrose concentration or exchange volume
• Improve solute clearance
– increasing the exchange volume
– dwell time
 C lin ic a l A s sessment o f P D T r ea tment A d equ a cy in P ed ia t ric P a t ie nts
• Clinical and laboratory results
• Peritoneal and renal clearances
• Hydration status
• Nutritional status
• Dietary intake of energy, proteins, salts, and trace elements
• Electrolyte and acid/base balance
• Calcium phosphate homeostasis
• Control of anemia
• Blood pressure control
• Growth and mental development
• Level of psychosocial rehabilitation
 Monitoring during PD
• pulse.
• blood pressure,
• intake/output .
• serum electrolytes.
• blood sugar.
• blood urea and creatinine.
• changes in appearance of returning peritoneal fluid.
 Complications
• Blood-stained effluent
• Poor drainage
• Pericatheter leak
• Abdominal pain during in flow
• Hypokalemia
• hyperglycemia
• Respiratory embarrassment
• Peritonitis
• Hernia
• Hypoalbuminemia.
 Contraindications to PD
• Absolute contraindications
– Congenital malformation
– Severe adhesions
– Peritoneal membrane failure
• Relative contraindications
– Planned or recent major abdominal surgery
– Poor psychosocial condition
– Single caregiver with no support
– Unhygienic home conditions
 ADVANTAGES
• No need for vascular access
• Minimal equipment needs
• Minimal training needs
• Feasible in small infants
• Continuous treatment
• Less risk of dysequilibrium syndrome
DISADVANTAGES
• Less efficient than HD/CRRT
• Variable UF
• It is less effective in extreme catabolic states
 APD in Federal Medical Centre Abeokuta
• Modalities ; Intermittent Peritoneal Dialysis ( manual )
• Dialysate : commercially produced
locally mixed using IVF with additions of electrolyte
• Duration of cycle ; 1hr
• Fill volume ; 10 – 20ml/kg
• Dwell time : 40min
• Outflow time ; 10min
• Challenges ; Financial constraint
Dialysis fluid not readily available
Availability of dialysis catheter & cost
Non availability of Cycler machine
• Delay in initiation of PD
 CHRONIC PERITONEAL DIALYSIS
• Can performed
– manually (CAPD)
– by utilizing a device (automated PD, APD)
• The PD regimen can be administered
– Continuous
– Intermittent
CAPD ( Continuous Ambulating Peritoneal Dialysis )
– CAPD is performed by three to five daily exchanges
– This includes three to four of approximately equal length during the daytime and a nighttime exchange of
8 to 12 hours
– It can compromises appetite
– According to the guidelines of the European Paediatric Peritoneal Dialysis Working Group on the
adequacy of pediatric PD prescription
• initial fill volume can be 600 to 800 ml/m2 during the day
• 800 to 1000 ml/m2 overnight
 APD ( Automated Peritoneal Dialysis )
– Is performed at night with the help of a device that delivers PD fluid to the patient
– Preference for APD are base on psychosocial and clinical reason.
– APD enables children to attend school full time
– Nighttime dialysis in the supine position allows for large fill volumes,
– wide range of treatment options available

• Other type of PD are variants of Automated PD

Nightly intermittent PD (NIPD)
– consists of a series of short nocturnal cycles without a daytime dialysate dwell
– Assessment of peritoneal transport status is important before choosing NIPD .
 Continuous cycling PD (CCPD),
– a fresh exchange of PD solution is left in the abdomen at the end of the nocturnal APD session
– Volume left ranges from 50% to 100% of the fill volume applied at night
– Daytime exchange can be drained at bedtime when the cycler is reconnected

Tidal PD (TPD)

Continuous-flow PD (CFPD)
– Is an old concept and represents one of the first PD techniques used
– Has various technical problems and high costs.
• There is need for continuous dialysate flow at a high rate
• requires a highly efficient dual-lumen peritoneal catheter or two catheters with endings separated
as distantly as possible.
 CONCLUSION
• All effort should be applied to treat any cause , keep residual renal
function and slow progression to ESRD
• Our target is to save the patient, improve his quality of life, reduce
morbidity and mortality rather than to decrease serum urea & creatinine
• Give appropriate treatment to appropriate patient at the appropriate
time using appropriate dose with less side effect
• Do not hesitate to start dialysis if indicated and urgently needed.
THANK YOU!!!!!
 REFERENCE
• Ajayi S, Raji Y, Bello T, Jinadu L. ScienceDirect Unaffordability of renal replacement therapy in
Nigeria. Hong Kong J Nephrol [Internet]. 2016;18:15–9. Available from:
http://dx.doi.org/10.1016/j.hkjn.2015.11.002
• Taylor P, Fleming GM, Fleming GM. Renal replacement therapy review Past , present and future
2011;(August 2015):1–12.
• Liyanage T, Ninomiya T, Jha V, Neal B, Patrice HM, Okpechi I, et al. Worldwide access to treatment for
end-stage kidney disease : Lancet [Internet]. 2013;385(9981):1975–82. Available from:
http://dx.doi.org/10.1016/S0140-6736(14)61601-9
• Odetunde OI, Okafor HU, Uwaezuoke SN, Ezeonwu BU, Ukoha OM. Renal Replacement Therapy in
Children in the Developing World : Challenges and Outcome in a Tertiary Hospital in Southeast
Nigeria. 2014;2014.
• Amstel SP Van, Noordzij M, Warady BA, Cano F, Craig JC, Groothoff JW, et al. Renal replacement
therapy for children throughout the world : the need for a global registry. 2017;
• Milliner DS. Pediatric Renal-Replacement Therapy — Coming of Age. 2004;2637–9.
• Vidal E. Peritoneal dialysis and infants : further insights into a complicated relationship. 2018;547–51.
• AbdelAziz Y. Elzouki ,Harb A. Harfi , HisHam M. Nazer , F. Bruder Stapleton ,William OH ,
Richard J. Whitley ; Textbook of Clinical Pediatrics ; 2nd edition , Springer ;Acute Renal
Replacement Therapy pg 2895 - 2897.
• Suhail Ahmad ; Manual of clinical dialysis ; 2nd edition , Springer ; Peritoneal Dialysis ,
pg 123 – 167 .
• Allen R. Nissenson , Richard N. Fine ; 5th edition , Elsevier ; Peritoneal access devices ,
Placement ; pg 97- 120.