1. ‘’ Selecting patients for continuous
peritoneal dialysis’’
Mitra Naseri
Associate professor
Pediatric nephrologist
Mashhad University of Medical Sciences
Mashhad, Iran

2. What is Peritoneal Dialysis?
❖ Peritoneal Dialysis (PD) is a treatment that utilizes the
peritoneum, as a filter to remove wastes from the
body. This type of dialysis requires a care partner to help
with the process.
❖ The peritoneum does a similar job as the dialyzer on a
dialysis machine during treatment or that the kidneys do
every day.
❖ Waste products and fluid pass through the membrane into
dialysate (dialysis fluid) and the fluid is drained with the
waste products.

3. ❖ To prepare for PD therapy, patients need to undergo a
small surgical procedure to have a catheter inserted into
the abdomen.
❖ The catheter is a small rubber tube that is placed into
the wall of the abdomen and secured using Dacron
cuffs.
❖ Generally, two cuffs are used in adults and they help
secure the catheter and prevent some forms of
infections.
Peritoneal Dialysis Catheter

4. ❖ The surgery can be done percutaneous, through a
laparoscopic surgery or an open surgical route.
❖ Laparoscopic surgery is a minimally invasive technique
when the operation is performed through a small incision.
A laparoscope (type of small camera) is used to view the
operation site and place the catheter.
Catheter placement

5. ❖ involves a guidewire being placed inside of tube. The
guidewire is then used to place the catheter into the
correct spot and a tunnel is made under the skin to the
exit site. This is also a less invasive technique, but
could have complications due to the nature of the
surgery.
Percutaneous surgery

6. ❖ A scalpel is used to make a tiny incision through
the skin and muscle of the abdomen. The “open”
area allows the surgeon to place the catheter and
the wound is stitched around it.
Open surgery

7. ❖ There are two types peritoneal dialysis:
Continuous-Cycler Assisted Peritoneal Dialysis
(CCPD)
Continuous Ambulatory Peritoneal Dialysis
(CAPD)
Types of Peritoneal Dialysis

8. CAPD
❖ CAPD is a method of performing peritoneal
dialysis exchanges using gravity to drain and fill
the peritoneal membrane with solutions four
times each day.
❖ It usually takes about 30 minutes to complete an
exchange. The patients are free to be active during
each dwell.

9. ❖ CCPD is a method of performing peritoneal dialysis
exchanges using a machine called a cycler during
the sleeping hours.
❖ Generally, three to five exchanges are done each
night.
❖ This program frees up your daytime hours.
❖ Each nightly session lasts at least eight to ten hours.
CCPD

10. 1) Adequate clean space to do the exchanges
❖ The room or area you choose shouldn’t have a lot of
traffic in or out, shouldn’t have open windows and
should if possible have enough room for your other
peritoneal dialysis (PD) supplies.
❖ You will need space for around 30 boxes of
supplies.
❖ The boxes do need to be kept in a dry space.
Equipment needed for PD

11. 2) Equipment needed for doing a clean dialysis
❖ A chair for doing exchanges.
❖ A table with a clean surface to perform an
exchange.
❖ Toilet: used to dispose of dwell waste products.
❖ I.V. pole: or any other surface used to hang your
dialysate bags from.
❖ Heating pad: to bring the dialysate up to body
temperature scale .

12. ❖ Disinfectant: used to keep patients and the
work surfaces clean.
❖ Masks: needed for patients and the partner to
minimize the risk of infection.
❖ Dialysis supplies (bags of dialysate, waste bags,
connection devices).
❖ Supplies for documenting the care such as
paper and pencil or a computer document.

13. Different types of PD catheters

14. PD cap
PD connectors

15. PD solution and drain bags and transfer set

16. Continuous Ambulatory Peritoneal
Dialysis

17. Different types of PD belts

18. CCPD machines (cycler )

19. ❖ The process of modality selection and how it works is
a critical determinant of peritoneal dialysis (PD)
utilization.
❖ This process can be break down into 6 steps and point
out how problems at each step can significantly reduce
the proportion of end-stage renal disease patients
initiating PD.
Perit Dial Int 2013; 33(3):233-241
Peritoneal dialysis and the
process of modality selection

20. ❖ All patients initiated on dialysis with a diagnosis
of ESRD.
❖ All patients receiving outpatient dialysis.
❖ All patients with more than 30 consecutive
days of dialysis dependence, even if they have a
presumed diagnosis of acute kidney injury
❖ All patients with a failed graft requiring dialysis
STEP 1:
Identification of all Potential candidates for PD

21. ❖ When patient defined as a potential PD candidate, the
medical team has to assess that patient’s eligibility to do
PD.
❖ Ideally, this assessment will have been made in the CKD
clinic, long before initiation of dialysis.
❖ It should be noted that this assessment is not an issue of
the patient choosing or not choosing to do PD, but rather
of whether the team has considered the patient to be
eligible for, or capable of doing PD.
STEP 2: assessment for PD eligibility

22. ❖ A contraindication is a factor that absolutely disqualifies
the patient from doing PD regardless of physician or patient
choice.
❖ This step requires an assessment of any contraindications
or barriers to the PD .
❖ Barrier can be overcome if sufficient supports are available
to the patient.
❖ In other words, barriers are really obstacles to self-care
rather than to PD per se.

25. Step 3:
Offer of modality choice to the PD-eligible patient
❖ Each eligible patient should be offered the
opportunity to do PD.
❖ Ideally, this “choice” is offered as part of a
modality education process that might include
group lectures, peer education, videos, and web
sites.
❖ Again, ideally, the choice and associated modality
education should have been presented before
dialysis initiation.

26. Step 4: patient choice
❖ Once eligible patients are offered a modality choice,
most studies suggest that approximately half will
select PD.
❖ Some patients in the CKD clinic may persistently
refuse to attend modality education classes or to make
a modality choice.
❖ Some may wish to defer that decision to the
nephrology team.
❖ Others may be in a state of denial and may feel too
overwhelmed to make any decision.
❖ In these situations, it might be best for the team to
make the decision for the patient, perhaps in
consultation with family members.

27. ❖ If less than a third of patients considered eligible
for PD eventually choose the modality, it suggests
that insufficient opportunity and encouragement to
do PD is being provided.
❖ Conversely, if more than two thirds choose PD, it
suggests that patients are being aggressively pushed
to choose the modality, which may be similarly
undesirable.
❖ A 50% choice for PD among eligible candidates is
typical of a center providing a balanced approach.

28. Step 5: PD Catheter Placement
❖ A significant proportion of patients who choose to do PD
after being offered an informed choice never undergo
catheter insertion and eventually start on HD.
❖ Long wait lists to see the surgeon who places PD catheters,
rapidly renal function deterioration than expected, and dialysis
must be initiated relatively urgently are responsible factors .

29. Step 6: Successful initiation of PD
❖ A significant proportion of patients who undergo a PD
catheter placement attempt do not succeed in
becoming successful home PD patients.
The major possibilities are :
1) Catheter insertion is unsuccessful
2) Catheter itself does not function adequately to allow
home PD. Catheter non-function rates of 10 – 15% are
not unusual, though good centers will report rates of
less than 5%.
❖ About half the cases of inadequate function will
respond to corrective measures, but the others will be
lost permanently to PD, either because the problem
persists or because the patient refuses the required
interventions.

30. 3) The training itself fails because the patient or family
member is found to be unable or unwilling to learn to carry
out the required procedures in a safe manner.
4) Patients change their mind or experience an unexpected
change in health status between catheter insertion and PD
training.
❖More than 85% of patients who have an attempted PD
catheter placement should eventually do home PD
successfully.
❖ Anything less reflects a problem with either catheter
placement or the original assessment of patient eligibility.

31. Perit Dial Int 2013; 33(3):233-241

32. Process Summary
❖ Ideally, the 6 steps we have described should occur in
order, leading to elective initiation of the preferred
modality of dialysis. However, in patients starting
dialysis urgently, the sequence of steps may change.
❖ Identification as a candidate, assessment for eligibility,
and patient choice might follow rather than precede
initiation of dialysis.
❖ The initial modality will typically be HD because only
rarely do programs use PD in urgent dialysis starts.
❖ The “urgent start” group is a large proportion of all
ESRD cases, at least 20- 40% and more than 60% if the
definition is expanded to include all inpatient starts.

33. Kidney International (2006) 70, S118–S121.