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					PD at Qatif Central
    Hospital
Dr.Saleh Al-Shorafa
  Consultant Pediatric Nephrologist
   Qatif Central Hospital, Saudi Arabia
History of Peritoneal Dialysis
1918: Blakfan + Maxy
                                                     (I.P. injection of N.S. in dehydrated pts.)
1948:            Bloxsom = Powerll
                                                                     P.D. to treat renal failure
1961:            Segar + Associates
                               Disposable Nylon Cathetor + prepared Dialysis solution in ARF
1976:            Popvich + Moncref
                                                              CAPD , 1st used (glass bottles)
1978:            Oreopolous used plastic bags

1979-1982 ??:                   , K.S.A.
                 Al-Shemaisi Hospital

1982 (June):            Elidrissy+Abu-Aisha H                    1st CAPD IN CHILDREN

APD:             Early 80s

1996:           Our unit started

                                        PAPNA.ORG
Prevalence of Children below 15 years on
     dialysis per million population


 65 patients PMP in Europe (3.5 %)
                             (EDTA data 1997)

 70 patients PMP in USA (3.0 %)
                             (USRD data 2001)

 63 patients PMP in KSA (3.2%)
                             (SCOT data 2001)




                 PAPNA.ORG
Incidence of ESRD in K.S.A.

Incidence of ESRD varies between 70-113
PMP
In Children, 13 PMP




                PAPNA.ORG
Statistics-KSA




    PAPNA.ORG
        2001 Statistics
     Qatif Central Hospital
45
40
35                         Total-42
30                         PD-29
25                         HD-7
20                         RTx-3
15                         No F/up-2
10                         Mortality-1
 5
 0
      Number of patients
                            PAPNA.ORG
Treatment Modality of ESRD
    70                          68.7


    60
                                               53.7

    50                                 47



    40                                                        QCH
         33.3
%                                                             World
    30
                      23                          22.8
                                                         20   Europe
    20
                           13
    10          8.5


     0
           PD               HD               Transplant


                                            PAPNA.ORG
    Peritoneal Dialysis

                              ESRD
       Screening               PD




   Early CRF
Estimate/control                  Pre-ESRF
  progression                     PD Prep


                     Mod. CRF
                   Prevent comp
                                             PAPNA.ORG
                   Etiology of CRF
TOTAL CASES                France   Germany USA    KSA   QCH
Hypoplasia/Dysplasia       10%      12%      18%   17%   16%

Uropathy                   43%      34%      36%   34%   35%

Heridatary Disorders       16%      19%      10%   18%   17%

Glomerulonephritis         22%      20%      10%   14%   16%

Renal Vascular Disorders   5%       4%       10%   2%    4%

Others                     4%       11%      16%   15%   12%

Total of Primary Renal     127      623      649   100   82
Dis


                                 PAPNA.ORG
          Indications of Dialysis
        in Chronic Renal Failure
Pericarditis
Pulmonary edema
Accelerated
hypertension
Growth Failure
Progressive uremic
encephalopathy
neuropathy




                     PAPNA.ORG
          Indications of Dialysis
        in Chronic Renal Failure
bleeding diathesis
nausea / vomiting
P. cr. >12mg/dl or BUN >100mg/dl
Cr.Cl >10-15 ml/min/1.73 m2 SA
KT/V >2




                  PAPNA.ORG
           Dialysis Initiation
      Clinical                     Biochemical




                   Psychological




Creatinine Clearance               KT/V < 2 ?


                       PAPNA.ORG
              Therapy Choice
Difficult Vascular Access
Distance
Morbidity Factors
Psycho-social
APD or CAPD
HD only if
–   Refusal of parents
–   Recent abdominal surgery/adhesions
–   Fungal Peritonitis and resistant tunnel infections
–   UFF/Catheter dysfunction

                           PAPNA.ORG
            Types of Peritoneal Dialysis
          CAPD                    IPD                  APD
        (continuous          (intermittent      (automated peritoneal
         ambulatory           peritoneal              dialysis )
     peritoneal dialysis)      dialysis)




40

30

20

10

 0
           low         low-Avg       high-Avg         high




                                 PAPNA.ORG
             Preparation
Information-teaching
Video
Slides
Seeing CAPD children
Home visits
  Nurse
  Social worker



                  PAPNA.ORG
                                                                                       ‫المملكة العربية السعودية‬
                                                                                                 ‫وزارة الصحة‬
                                                                                      ‫مستشفى القطيف المركسي‬



                               ‫مسابقة النجوم‬
‫التقييم‬   ‫المجموع‬   ‫الجمعة‬   ‫الخميس‬   ‫االربعاء‬   ‫الثالثاء‬   ‫االثنين‬   ‫االحذ‬   ‫السبت‬   ‫عذد االسابيع‬

‫‪‬‬           ‫4‬                 ‫‪‬‬        ‫‪‬‬          ‫‪‬‬                            ‫‪‬‬            ‫1‬
            ‫2‬                                     ‫‪‬‬                   ‫‪‬‬                     ‫2‬
‫‪‬‬           ‫6‬        ‫‪‬‬        ‫‪‬‬        ‫‪‬‬                     ‫‪‬‬        ‫‪‬‬        ‫‪‬‬            ‫3‬




                                                                              ‫‪=++‬‬
                                                              ‫‪=++++++‬‬



                                      ‫‪PAPNA.ORG‬‬
          Training Home PD
 Through a nurse for 2 persons (7-10 days CAPD(

Dialysis therapy             Medication
Exit site/catheter care      Dietary management
Peritonitis                  Contacting Hospital
signs/treatment              Management Supplies
Recording
– Dry weight
– BP
– Fluid Balance




                     PAPNA.ORG
PAPNA.ORG
   Complications of PD

 Infection                  Metabolic




              Mechanical




Respiratory                Psychological

              PAPNA.ORG
                         Infection
CAPD Peritonitis

        1.2

Exit Site Infection
            1
   Annual




        0.8
    Rate




        0.6

Tunnel Infection
        0.4

        0.2

            0
                <2 yrs     2-5 yrs   6-12 yrs    > 12 yrs

Other Infection
              Dialysis Initiation
                     Age
                                                NAPRTCS,2000

                             PAPNA.ORG
Criterion to Diagnose Peritonitis
  Cloudy fluid
  WBCs > 100 × 106
  PMN > 50%
  Abd.pain/fever
  Culture




               PAPNA.ORG
                                              Infection Rate
Infection rate
  7
                                                                               • Single Bag
  6
                                                                                     – 1 episode/15.8 patient months
  5                                                                                     (staph.aureus + epidermides)


  4
                                                                               • Twin bag + Y system
                                                                               CAPD – 1 episode/24.1 treatment
  3                                                                            APD    months (staph.aureus + epidermides)
  2                                                                            • APD
   1996
          1997
                 1998




                                                                                     – 1 episode/33 patient months
                        1999
                               2000




                                                                            CAPD
                                      2001
                                             2002
                                                    2003
                                                           2004
                                                                  2005




                                                                                        (staph aureus)

                                      Year




                                                                         PAPNA.ORG
                Peritonitis Rate
    1/2
    9/20
    2/5
    7/20
    3/10
    1/4
    1/5
    3/20
    1/10
    1/20
0
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                          PAPNA.ORG
                                              Malnutrition
• Malnutrition is common
     100

      90

      80

      70
                                                             High PD Volume
      60


 %    50

      40           35

      30
                                         22
                               19
      20

      10

       0

             QCH        Hong Kong   UK                  Less Gastric Emptying Time
• Hypo-albuminaemia is
  common
                                                              Low Appetite
           – 41 % our center
           – 43 % Toronto series
                                                               Low Growth




                                                 PAPNA.ORG
           Recommendations
            Oral/NG/Gastrostomy
Infants:                         2.5 to 4.0 gm/kg/day

Toddlers/Children:               2.0 to 4.0 gm/kg/day
                      + oral supplements



I.P. AA solution:                once a day (   NA)


rhGH:                            Routine, but not   so effective




                     PAPNA.ORG
       Other complications
Mechanical
  Hernia
  Abdominal wall +
  Catheter Leak
  Presence of fibrin
  Genital Edema
Metabolic
  Glucose
  Lipid
  Protein
  Electrolyte


                       PAPNA.ORG
     Other Complications
Respiratory
  Hydrothorax
  Altered Mechanisms
  of breathing
  Back pain
Psychological
  Body image
  Parents anxiety
  Family Burden
    Less with APD

                    PAPNA.ORG
  Lipid abnormalities in ESRD
Factor             PD        HD
T. Cholesterol              NL
LDL                         NL
HDL                          
Triglycerides               
Apo A1 protein               
Apo B protein              NL
Lp(a)                      
LDL oxidation                
                 PAPNA.ORG
                    Adequacy
Gained much attention in recent years
  peritonitis rate
Is Dialysis adequacy different in KSA from West
–   Different culture
–   Ethnics
–   Environment
–   Disease patterns        (Limited data)
–   Economy rules
–   Education



                        PAPNA.ORG
                 Adequacy
Good Clinical outcome depends on Dialysis
Adequacy
CANUSADOQI PD Group
  KT/V urea ≥ 2.0 /wk
  Creatinine Clearance = 50-60 L/wk
     Obstacle =Creatinine clearance was not constant as
     Renal functions decline




                       PAPNA.ORG
               Adequacy
ADMEX (Mexico) 4 Exchanges –best
Hong Kong / Korea survival rate > USA
KT/V =1.7
ASIA ↔ WEST




                    PAPNA.ORG
                 Adequacy
    Optimal Dialysis or Adequate Dialysis

Clinical Improvement         Fluid Removal
Growth                        RRF
Biochemical parameters       UF
KT/V ? >2 ↔ 1.7 ↔ ?           Glucose
Creatinine Clearance, 50-     OSM burden
60 L/wk/1.73 m2 SA            PMP
                              Solute Transport




                     PAPNA.ORG
    Action/ Adequacy
Clinical   Cr Cl    Kt / v   action
                            
                    -        
           -                
           -         -       
  -         -         -       
  -         -                
  -                  -       
              PAPNA.ORG
NO donor
                  Renal Graft

     No
Transplantation




Dialysis pts

   PAPNA.ORG
      Future of PD in QCH
Re-imbursement issues
                                          Industry
Cost
Education                  Nephrologist              Government
Outcome of PD/drop
out
                                          PD 
  Better adequacy
  PD solution (Imp)           Media                  Healthcare
                                                      Provider
     Patient + technique
     survival
                                           Nurses



                       PAPNA.ORG
                Conclusion
 Population means
   Patients
   RRT means
   PD
APD has been an important mode of RRT
Ways needed to improve clinical outcome by
preventing progression to ESRD
Improving RRT with peritoneal dialysis
More researches are needed for proper usage of
peritoneum

                     PAPNA.ORG
Thank you




            PAPNA.ORG

				
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posted:10/20/2011
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