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peritoneal dialysis; continuous abdominal/ambulatory (cycling) peritoneal dialysis (CAPD, CCPD)

Advantages: - does not require systemic anticoagulation - produces less stress on the cardiovascular system - fewer abrupt changes in blood pressure - fewer abrupt changes in electrolytes - allows greater patient independence [6] - ~$20,000/year less expensive than hemodialysis [5] - outcomes similar to hemodialysis [6] * vs hemodialysis Disadvantages: - less efficient, but outcomes similar [5] - mortality may be 8% higher for hemodialysis than peritoneal dialysis [7] * vs hemodialysis Indications: 1) cardiovascular instability 2) poor hemodialysis access 3) patient preferences [3] Contraindications: 1) recent abdominal surgery 2) history of multiple abdominal surgeries with adhesions 3) colostomy 4) nephrostomy 5) obesity may be relative contraindication [6] Procedure: - CAPD uses the peritoneum as a dialysis membrane - solutes are removed by diffusion into dialysate introduced into the peritoneal cavity through a catheter - the osmotic gradient for dialysis is created by the addition of glucose to the dialysate - higher glucose concentrations & more frequent exchanges increase the rate of fluid removal - peritoneal catheters are placed ~ 1 month prior to initiation of dialysis [6] - 2 liters of dialysate is infused into the peritoneal cavity. - glucose concentrations are generally 1.5-4.25 g/dL - following a period of equilibration, the dialysate is drained - sterile technique is necessary - continuous ambulatory peritoneal dialysis (CAPD) generally involves 4-5 exchanges/day performed by the patient, but the procedure may be performed hourly if indicated - an automatic cycler is available to perform exchanges during sleep Complications: 1) infections a) peritonitis (see bacterial peritonitis) b) infection of the catheter site 2) hyperglycemia a) regular insulin may be added to the dialysate b) 2 units to 2 liters 1.5% dextrose c) 6 units to 2 liters of 4.25% dextrose 3) protein loss a) hypoalbuminemia is common b) increase dietary protein to 1.2-1.4 g/kg/day 4) catheter leak 5) hyperlipidemia 6) obesity 7) pancreatitis 1.8%/year, 3-fold risk for hemodialysis [4] - may be more common in blacks

Related

bacterial peritonitis (BP) hemodialysis

General

renal dialysis

References

  1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 275
  2. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 618
  3. Journal Watch 24(6):45, 2004 Rubin HR et al, JAMA 291:697, 2004 PMID: 14871912 Heaf J, JAMA 291:740, 2004 PMID: 14871920
  4. Quraishi ER, Goel S, Gupta M, Catanzaro A, Zasuwa G, Divine G. Acute pancreatitis in patients on chronic peritoneal dialysis: an increased risk? Am J Gastroenterol. 2005 Oct;100(10):2288-93. PMID: 16181382
  5. Mehrotra R et al. Similar outcomes with hemodialysis and peritoneal dialysis in patients with end-stage renal disease. Arch Intern Med 2010 Sep 27 PMID: 20876398 http://dx.doi.org/10.1001/archinternmed.2010.352) - Kutner NG et al. Patient awareness and initiation of peritoneal dialysis. Arch Intern Med 2010 Sep 27; PMID: 20876396 http://dx.doi.org/10.1001/archinternmed.2010.361) - Johansen KL. Choice of dialysis modality in the United States. Arch Intern Med 2010 Sep 27 PMID: 20876395 http://dx.doi.org/10.1001/archinternmed.2010.370
  6. Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18. American College of Physicians, Philadelphia 2012, 2015, 2018. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  7. Weinhandl ED, Foley RN, Gilbertson DT et al Propensity-matched mortality comparison of incident hemodialysis and peritoneal dialysis patients. J Am Soc Nephrol. 2010 Mar;21(3):499-506. PMID: 20133483 Free PMC Article
  8. Hansson JH, Watnick S. Update on Peritoneal Dialysis: Core Curriculum 2016. Am J Kidney Dis. 2016 Jan;67(1):151-64. PMID: 26376606
  9. Peritoneal Dialysis Dose and Adequacy http://kidney.niddk.nih.gov/kudiseases/pubs/peritonealdose/index.htm - Treatment Methods for Kidney Failure: Peritoneal Dialysis http://kidney.niddk.nih.gov/kudiseases/pubs/peritoneal/index.htm