Peritoneal dialysis access

The peritoneal dialysis access catheter placement simulation is ideal to teach aviation safety principles emphasizing the importance of knowing basic facts, such as the tools and instruments needed for the procedure and how the use of checklists improves patient safety. An abdominal simulator is currently under development for the laparoscopic technique of placing the peritoneal dialysis catheter [12]. 

Intravenous administration in the dialysis center has been practical and effective for patients undergoing hemodialysis [51, 52], but impractical for patients without vascular access who are receiving peritoneal dialysis. Studies of subcutaneous administration showed lower but more sustained peak plasma EPO concentrations (Cmax) than occurred using the intravenous route. The efficacy of subcutaneous administration supports the concept of a sustained minimal effective EPO concentration. High Gnax values after intravenous administration appear unnecessary the dose response relationship seen with intravenous administration most likely correlates with serum EPO concentrations maintained above a minimal effective level. 

Timely referral of patients suffering from progressive CKD to the nephrologist has a positive influence on patients outcome in terms of mortality, morbidity, dialysis modality selection in favor of peritoneal dialysis, dialysis access outcome, dialysis technique failure, renal transplant eligibility, and total cost at initiation of dialysis [72],... 

In other advances, we see polymers and natural tissue in competition. For example, in small diameter blood vessel repair, the saphenous vein is still the best. However, we are now approaching the first human implantation of small diameter synthetic polymer vascular prostheses to help those patients who have no useable saphenous vein. The ball and disc type of heart valve prostheses are still not as good as the processed natural tissue porcine valve. Yet even here we use a polymeric or metal stint to support the porcine tissue. The artificial kidney has been miniaturized, but in terms of patient well-being it has improved very little since the 1940 s. Also, the A/V shunts have given way to A/V fistulas since we do not have good polymers for long-term access. Peritoneal dialysis is becoming a better dialysis procedure for the patient, primarily because of the improvement of a polymeric access to the peritoneal cavity. 

The intraperitoneal (i.p.) route of administration is particularly advantageous if access to the cavity already exists (i.e., a peritoneal dialysis catheter) and if the infection or disease process is confined to the cavity. Medication levels in the i.p. solution can be maintained one to two orders of magnitude above toxic levels in the plasma. Transfer to the systemic circulation is relatively slow, and peak concentrations in the plasma will be a fraction of what they would be if the same dose were administered i.v. This provides for maximal pharmacologic activity locally while sparing the remainder of the body from the toxic side effects. The pharmacokinetic advantage of regional administration into the peritoneal cavity (or any body cavity) over that of intravenous administration can be calculated by... 

Special attention in such patients focuses on the presence and function of preexisting arteriovenous fistulae, hemodialysis central venous catheters, or access for peritoneal dialysis. Arms with vascular accesses are kept free from blood pressure cuffs, pulse oximeters, tourniquets and peripheral venous cannulae. 

National Kidney Foundation KDOQI Clinical practice guidelines and clinical practice recommendations for 2006 updates hemodialysis adequacy, peritoneal dialysis adequacy and vascular access. Am J Kidney Dis 2006 48(suppl) Sl S322. 

Moncrief JW, Popovich RP, Broadrich LJ, He ZZ, Simmons EE, Tate RA The Moncrief-Popovich Catheter. A new peritoneal access technique for patients on peritoneal dialysis. ASAIO J 1993 39 62-65. 

Hemodialysis (HD) catheter-associated bloodstream infections (BSls) are a type of CLABSI due to a central venous catheter (CVC) specifically designed for HD. In 2002, it was estimated that 50,000 CLABSIs occur in dialysis patients in the US annually. A more recent surveillance study found the rate of access-related BSIs to be 0.73 events per 100 patient-months [5]. Aside from catheters, patients in need of renal replacement therapy should eventually use arteriovenous fistula (AVF) or arteriovenous grafts (AVG) for HD, or alternatively, may receive peritoneal dialysis. All renal replacement therapies are associated with a risk of infection however, this risk varies with the method selected. Data from a CDC surveillance program display nicely how the type of access influences the BSI rate per 100 patient-months 0.5 (for AVFs), 0.9 (AVG), 4.2 (permanent CVCs), and an impressive 27.1 for temporary CVCs [6]. Another, more practi-... 

NKF KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for 2006 Updates Hemodialysis Adequacy, Peritoneal Dialysis Adequacy and Vascular Access. Am J Kidney Dis 2006 48 S1-S322. 

Taylor PM (2002) Image-guided peritoneal access and management of complications in peritoneal dialysis. Semin Dial 15 250-258... 

Dialysis should be initiated electively rather than urgently in patients with chronic kidney disease (see Chap. 44). Because of the progressive nature of the disease, the planning for dialysis should begin once the patient s creatinine clearance (Clcr) drops below 30 mL/min per 1.73m .Beginning the preparation process at this point allows adequate time for proper education of the patient and family and for the creation of suitable vascular or peritoneal access. 

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