CURICULUM VITAECURICULUM VITAE Nama : D. Yenny Kandarini, SpPDNama : D. Yenny Kandarini, SpPD TTL : TTL : Denpasar/ 6 Januari 1969Denpasar/ 6 Januari 1969 Pendidikan:Pendidikan:

KedokteranKedokteran :: FK UNUD tahun 1995 FK UNUD tahun 1995 SpesialisasiSpesialisasi :: FK UNUD tahun 2004 FK UNUD tahun 2004 KonsultanKonsultan :: - - Short Course : SGH Singapore 2005Short Course : SGH Singapore 2005

New Zealand 2005New Zealand 2005 Australia 2007Australia 2007 Budapest Nefrologic School 2007 Budapest Nefrologic School 2007

JabatanJabatan :: Staf Divisi Nephrologi dan Hipertensi Bag / SMF Staf Divisi Nephrologi dan Hipertensi Bag / SMF

Penyakit Dalam FK Unud / RS SanglahPenyakit Dalam FK Unud / RS Sanglah

C hronic AmbulatoryC hronic Ambulatory Peritonea l D ia lys is Peritonea l D ia lys is

(C APD)(C APD)

Yenny KandariniYenny Kandarini

Chronic Kidney Disease

Transplantasi PD

Hemodialisis

Dialisis

ontinuous

mbulatory

eritoneal

ialysis

Proses dialisis tidak berhenti, membersihkan darah, 24 jam se-hari, setiap hari

Bebas bergerak, tidak berhubungan dengan mesin

Menggunakan membran peritoneum yang bekerja sebagai filter untuk mengeluarkan sisa metabolisme

dan cairan dari darah

Menyaring dan membuang cairan berlebih serta sisa metabolisme tubuh.

Peritoneal Dialysis (PD)Peritoneal Dialysis (PD)DefinitionDefinition PD is a process during which the peritoneal PD is a process during which the peritoneal

cavity acts as the reservoir for dialysis fluid cavity acts as the reservoir for dialysis fluid and the peritoneum serves as the semi and the peritoneum serves as the semi permeable membrane across which excess permeable membrane across which excess body fluid and solutes including uraemic body fluid and solutes including uraemic toxins, are removed.toxins, are removed.

(Gutch, Stoner & Corea 1999)(Gutch, Stoner & Corea 1999)

Anatomy & Physiology of the Anatomy & Physiology of the PeritoneumPeritoneum

Liver

Stomach

Pancreas

Intestines

Bladder

Uterus

Rectum

Anatomy and Physiology of Anatomy and Physiology of the Peritoneumthe Peritoneum

Properties of the peritoneal membraneProperties of the peritoneal membrane Thin sackThin sack Richly supplied with blood Richly supplied with blood

supplies major organs of bodysupplies major organs of body Large surface area - 1.73mLarge surface area - 1.73m2 2

proportional to body sizeproportional to body size

Normal AnatomyNormal Anatomy Contains 100ml or less of fluidContains 100ml or less of fluid Adult can tolerate 2L or more fluid without Adult can tolerate 2L or more fluid without

pain or alteration to the respiratory pain or alteration to the respiratory functionfunction

Male: peritoneal cavity is closedMale: peritoneal cavity is closed Female: peritoneal cavity is continuous Female: peritoneal cavity is continuous

with the Fallopian tubes.with the Fallopian tubes. Rarely PD fluid become blood-stained during Rarely PD fluid become blood-stained during

a menstrual perioda menstrual period

Principles of Peritoneal DialysisPrinciples of Peritoneal Dialysis Solute and fluid exchange occur between Solute and fluid exchange occur between

peritoneal capillary blood and dialysis solution in peritoneal capillary blood and dialysis solution in peritoneal cavityperitoneal cavity

The membrane lining this cavity consists of a The membrane lining this cavity consists of a vascular wall,interstitium,mesothelium and vascular wall,interstitium,mesothelium and adjacent fluid films.adjacent fluid films.

Small MW solute transfer occurs by diffusion-Small MW solute transfer occurs by diffusion-the higher the concentration gradient the the the higher the concentration gradient the the higher the rate of passagehigher the rate of passage

Fluid movement is determined by Fluid movement is determined by osmosisosmosisincreasing the osmotic pressure increasing the osmotic pressure increase the fluid movementincrease the fluid movement

Jeremy Levy et al, Oxford Handbook of Dialysis, 2003

Basic PrinciplesBasic Principles PD utilitises the peritoneal membrane as a PD utilitises the peritoneal membrane as a

natural dialysis filter.natural dialysis filter. A PD catheter inserted surgically into the A PD catheter inserted surgically into the

peritoneal cavityperitoneal cavity PD solution is infused into the peritoneal cavity PD solution is infused into the peritoneal cavity

via the catheter and remain there for up to 6-10 via the catheter and remain there for up to 6-10 hours, during which time uraemic toxins and fluid hours, during which time uraemic toxins and fluid are removed by diffusion and UF across the are removed by diffusion and UF across the peritoneal membraneperitoneal membrane

Principle of CAPDPrinciple of CAPD A typical patient perform 3-4 exchange per A typical patient perform 3-4 exchange per

day, 7 day a week day, 7 day a week free of uraemic free of uraemic symptomssymptoms

The procces is continuous so as to The procces is continuous so as to achieve adequate dialysisachieve adequate dialysis

Does not need a machine. Patient dialysis Does not need a machine. Patient dialysis himself day and nighthimself day and night

Factors Effecting Efficiency of PDFactors Effecting Efficiency of PD

Time on dialysisTime on dialysis BloodflowBloodflow Peritoneal surface areaPeritoneal surface area Membrane permeabilityMembrane permeability Peritoneal lymphaticsPeritoneal lymphatics UltrafiltrationUltrafiltration Transfer of fluidTransfer of fluid

Jeremy Levy et al, Oxford Handbook of Dialysis, 2003

CAPD SchemeCAPD Scheme

Requirements of CAPDRequirements of CAPD Prepare the patient for implantation of peritoneal Prepare the patient for implantation of peritoneal

catheter in usual way (for any operation)catheter in usual way (for any operation) After catheter insertion, ensure catheter is patentAfter catheter insertion, ensure catheter is patent If patient need dialysis the catheter can be used If patient need dialysis the catheter can be used

immediately with small fill volumes or patient immediately with small fill volumes or patient placed on HDplaced on HD

Normally catheter is capped up for 10-14 days Normally catheter is capped up for 10-14 days and then CAPD can be startedand then CAPD can be started

Requirements of CAPDRequirements of CAPD Peritoneal dialysis solution is drained into Peritoneal dialysis solution is drained into

patient`s abdomenpatient`s abdomenadult 2 literadult 2 literdisconnect systemdisconnect systemdifferent glucosa concentration different glucosa concentration (1,5%, 2,3%, 4,25%)(1,5%, 2,3%, 4,25%)

Composition of PD solutionComposition of PD solution Glucose Glucose 1.5%, 2.3%, 4.25%1.5%, 2.3%, 4.25% SodiumSodium 134 mmol/l134 mmol/l CalciumCalcium 1 mmol/l, 1.75mmol/l1 mmol/l, 1.75mmol/l MagnesiumMagnesium 0.5 mmol/l0.5 mmol/l ChlorideChloride 102 mmol/l102 mmol/l LactateLactate 35 mmol/l35 mmol/l

Note:- No potassium, no urea and no Note:- No potassium, no urea and no creatininecreatinine

Glucose as osmotic agentGlucose as osmotic agent

After a two litre bag has dwelled for four After a two litre bag has dwelled for four hours average ultrafiltrationhours average ultrafiltration

1.5% 1.5% 200 ml ultrafiltrate 200 ml ultrafiltrate 2.3% 2.3% 200 - 400 ml ultrafiltrate 200 - 400 ml ultrafiltrate 4.25%4.25% 600 ml 800 ml ultrafiltrate 600 ml 800 ml ultrafiltrate

The ultrafiltration effectThe ultrafiltration effect

CAPD CAPD exchangeexchange

drain drain flush flush

fill fill dwell dwell

DrainDrain

Spent dialysate is drained out. This process takes approximately 10-20 minutes

FlushFlush

Fresh dialysate is flushed from the fresh solution baginto the drain bag. This process takes approximately 5 seconds

Fresh dialysate is infused into the peritoneal cavity. This takes 8-10 minutes

FillFill

DwellDwell

ODialysate remains in the peritoneal cavity for 4 8 hoursDuring this time waste products and excess fluid is removed

1. Drain1. Drain

CAPD Process 2. Fill

3. Dwell

Which patients are suitable for Which patients are suitable for CAPD?CAPD?

Diabetes mellitusDiabetes mellitus CV disease: angina, CV disease: angina,

arrhytmia, prosthetic arrhytmia, prosthetic val. dsval. ds

Chronic Ds : anemia, Chronic Ds : anemia, HIV +, Bleeding ds, HIV +, Bleeding ds, hepatitishepatitis

Active lifestylesActive lifestyles Variable schedulesVariable schedules Needle anxietyNeedle anxiety Demand for flexible Demand for flexible

dietdiet Far from HD centreFar from HD centre

Contra indications for CAPDContra indications for CAPD Medical :Medical :

Severe inflammatory bowel dsSevere inflammatory bowel ds Psychosocial :Psychosocial :

Severe active psychotic ds or manic Severe active psychotic ds or manic depressivedepressive

Marked intellectual disability with no helperMarked intellectual disability with no helper

Advantages of PD compared to Advantages of PD compared to HDHD

Home based-can be performed in remote Home based-can be performed in remote geographical locationsgeographical locations

Self care dialysis-no helper required Self care dialysis-no helper required unless patient has physical or social unless patient has physical or social problemsproblems

Simple to learn and perform-training Simple to learn and perform-training period 1-2 weeksperiod 1-2 weeks

Greater patient independence and travel- Greater patient independence and travel- holiday is easy to arrangeholiday is easy to arrange

Advantages of PD compared Advantages of PD compared to HDto HD

Flexible schedule-not restricted to Flexible schedule-not restricted to hospital rules and appoinmentshospital rules and appoinments

As dialysis is continuous the patients is As dialysis is continuous the patients is allowed more liberal dietary and fluid allowed more liberal dietary and fluid intakeintake

There are no haemodynamic There are no haemodynamic complications or need for chronic complications or need for chronic vascular accessvascular access

It is especially suited to patients with CV It is especially suited to patients with CV ds or the elderlyds or the elderly

Advantages of PD compared to Advantages of PD compared to HDHD

PD preserves residual renal function better PD preserves residual renal function better than does with HDthan does with HD

Patients survival is better or equivalent to Patients survival is better or equivalent to that with during the first 3 years. that with during the first 3 years.

Disadvantages of PDDisadvantages of PD The need for chronic peritoneal access-The need for chronic peritoneal access-

risk of infectionsrisk of infections Two thirds of patients may experience of Two thirds of patients may experience of

an episode of peritonitis (1 episodes every an episode of peritonitis (1 episodes every 2-3 years)2-3 years)

Long term technique survival remains Long term technique survival remains inferior to that of HDinferior to that of HD

It may provide insufficient dialysis for It may provide insufficient dialysis for large or anuric patientslarge or anuric patients

Disadvantages of PDDisadvantages of PD Nutritional problems-due to protein lossesNutritional problems-due to protein losses PD must be performed every single day PD must be performed every single day

using strictly sterile technique, which can using strictly sterile technique, which can lead to patients burnout.lead to patients burnout.

PD can result in social isolation of the PD can result in social isolation of the patientspatients

Storage space is needed at home for PD Storage space is needed at home for PD solutions-usually 2 msolutions-usually 2 m

Preservation of residual renal function Cardiovascular benefits

Offers better haemodynamic stability (Iess peaks & troughs)

Preserves vascular access Less cardiovascular risk factors Anaemia management

Hepatitis C prevention

The Advantageous of CAPD First

Quality of Life Home Therapy

PD is a home therapy and encourages self care and independence

Allows for flexible travel Less Nursing Staff Required

PD = 1 nurse 25 patients whereas HD = 1nurse 4-6 patients

Cost It is more cost effective than incentre HD

The Advantageous of CAPD First

Start treatment early (residual creatinine clearance ~10-15 ml/min)

Deliver adequate dialysis dose (peritoneal creatinine clearance of >45 L/week / 1.73 m2)

Perform close clinical follow-up of your patients Consider that peritoneal membrane function may change with time on treatment

Strategies te Achieve Quality in PD

Outcome of patients on chronic PDOutcome of patients on chronic PD

One-quarter of all chronic dialysis patients One-quarter of all chronic dialysis patients perform PDperform PD

Patients survival and death censored technique Patients survival and death censored technique survial are about 50% at 3 yearssurvial are about 50% at 3 years

Only a small percentage of patients remain Only a small percentage of patients remain continously on PD for 5 years or morecontinously on PD for 5 years or more

Social factor and infections complications are Social factor and infections complications are the main reason for technique failure.the main reason for technique failure.

ConclusionsConclusions CAPD is one of renal replacement therapy CAPD is one of renal replacement therapy

modality choice.modality choice. CAPD has been shown to be an effective CAPD has been shown to be an effective

treatment option for CKD patients.treatment option for CKD patients. CAPD patients require close follow up and CAPD patients require close follow up and

monitoring assesing all aspect of the monitoring assesing all aspect of the prescription and delivery and the respon of prescription and delivery and the respon of treatment.treatment.

Appropiate patient selection is imperative to Appropiate patient selection is imperative to the development and growth of successful PD the development and growth of successful PD programs.programs.

Disconnect system with a mandatory flush before fill Reduced number of steps Improved handling

The ANDY. disc CAPD System

The ANDY disc Procedure

Improved Patient Handling

Less steps Central control disc Regulation of solution flow No clamps No breaking of frangible pins

PIN Reduced handling risk Easy to learn automatic

closing of the patient catheter before disconnection

Betadine Cap Integrated disinfection

Organiser Reduces touch

contamination

Reduced Risk Of Contamination

The easy and safe double-bag system for CAPD

THANK THANK YOUYOU

CURICULUM VITAEChronic Ambulatory Peritoneal Dialysis (CAPD)Slide 3Slide 4Peritoneal Dialysis (PD)Anatomy & Physiology of the PeritoneumAnatomy and Physiology of the PeritoneumNormal AnatomyPrinciples of Peritoneal DialysisBasic PrinciplesPrinciple of CAPDFactors Effecting Efficiency of PDCAPD SchemeRequirements of CAPDSlide 15Composition of PD solutionGlucose as osmotic agentThe ultrafiltration effect CAPD exchange drain flush fill dwell Drain Flush Fill Dwell Slide 24Which patients are suitable for CAPD? Contra indications for CAPDAdvantages of PD compared to HDSlide 28Slide 29Disadvantages of PDSlide 31Slide 32Slide 33Slide 34Outcome of patients on chronic PDConclusionsSlide 37Slide 38Slide 39Slide 40Slide 41Slide 42Slide 43Slide 44Slide 45