THE CHOICE OF DIALYSIS ACCES CONTROVERSY AND EVIDENCE PART 3 : Peritoneal Dialysis

1. THE CHOICE OF DIALYSIS ACCES • CONTROVERSY AND EVIDENCE • PART 3 : Peritoneal Dialysis

2. Teaching point

3. EBM ?

4. What’s new ?

5. CONTROVERSY ?

6. EXPERT BASEDGUIDELINES • Guidelines by an ad hoc European committe on elective chronic peritoneal dialysis in pediatric patients • Watson, on behalve of the European pediatric dialysis working group • Comprehensive pediatric nephrology Geary Schaefer

7. CONTROVERSY PRE-DIALYSIS INORMATION >POST DIALYSIS FOLLOW UP >PERI- OPERATIVE CARE > SURGEON > CATHETER

8. CHOICE OF CATHETER • Catheters • Length • Length between cuff’s • Place left / right fossa • Swan neck / straight • Straight / Currl

10. CONTROVERSY PRE-DIALYSIS INORMATION >POST DIALYS FOLLOW UP >PERI- OPERATIVE CARE > SURGEON > CATHETER

11. Preparation of the patient and the family 1) It is essential that the child and family are prepared by a pediatric nurse experienced in chronic peritoneal dialysis with access to appropriate written information and other teaching aids such as dolls or videos. 2) If the child has phobias then a child psychologist should be consulted 3) Home visit / School visit 4) Contact with other child /parents

12. Preparation of the patient and the family A nutritional assessment will be required for all dialysis patients. If nutritional support is required then the appropriate route for supplementation (oral. Nasogastric or gastrostomy) should ho discussed with the pediatric renal dietitian and team members. If it is appropriate to consider a gastrostomy then this can be placed at the time of the PD catheter under the same anaesthesie with minimal additional morbidity. -

13. Use of Catheter and Surgical Procedure • The placement of a peritoneal dialysis catheter requires an experienced surgeon and should be given appropriate priority, • A dialysis-catheter is a “LIFE”-line..with only few alternative options during the life-span of the patient. • “early days” nephrologist was in the theatre.. • Now???

14. Use of Catheter and Surgical Procedure • Open technique • Laparoscopic technique • Percutaneous technique

15. Use of Catheter and Surgical Procedure 2) Double cuff curled catheters are preferred in most children • pediatric size in patients 3-10 kgs body weight • and adult catheter >10 kg. • A single cuff catheter may be needed in infants <3kg. • Data from the NAPRTCS registry suggest • swan neck tunnels, • two cuff • and downward pointing exit sites.

16. Use of Catheter and Surgical Procedure 2) Presumed advantages of curled catheters • better separation between abdominal wall and bowel • More catheter holes • Less inflow pain • Less tendency for migration • Less prone for omental wrapping • Potentially less trauma to the bowel

17. Use of Catheter and Surgical Procedure • Prior to theatre the exit site for the catheter should be agreed with the child and marked on the abdomen by either the dialysis nurse or surgeon. • The exit site should avoid the belt line and be above the nappy or diaper line in infants. • In all but the smallest infants the exit site should he downward facing. • The exit site should be located as far as possible from other exits, ie gastrostomies, colostomies, urostomies to prevent infections.

18. Use of Catheter and Surgical Procedure

19. Use of Catheter and Surgical Procedure • Laxatives should be given pre-operatively to children who suffer from constipation • Empty bladder • Partial omentectomy may reduce postoperative obstruction but there are no prospective pediatric series addressing this issue. • Consider elective herniotomv if any evidence of inguinal or other hernia prior to or during catheter placement.

20. Use of Catheter and Surgical Procedure Entry into the peritoneum should be lateral or paramedian with the deep cuff outside the peritoneum. The peritoneum is closed tightly around the catheter Below the level of the deep cuff using a purse string suture. A tunneling device with a sharp point is recommended for creating the catheter tunnel and strict haemostasis is required. No incision should be made at the exit site. The subcutaneous cuff should be at least 2cms from the exit site. A cephalosporin antibiotic should he given intravenously at the time of catheter implantation.

21. Procedure in Theatre • 1) Catheter should be tested in theatre for patency and leaks with dialysis nurse or nephrologist present. • 2) No suture should be placed at the exit site which should be downward facing with the possible exveption of infants.

22. The catheter will be irrigated in theatre until the dialysate is clear then capped off. The PD fluid should contain Heparin 5OOiu/L. Catheter must be immobilised at all times and no keyhole dressing applied. If the catheter has to be used for immediate dialysis then use only low volumes, 10ml/kg/cycle. In this situation keeping the patient supine for the first few days and adequate analgesia will also help to avoid high intraperitoneal pressure and possible leaks. If possible leave catheter for two weeks until the patient returns for training. This will allow initial healing to take place.

23. IMMEDIATE POST OPERATIVE CARE • Pain controle. • Multiple low volume exchanges until clear effluent. • Dry abdomen as long as possible • Dressing is remained for 5 days. • Bedrest for 7 days.

24. FIRST WEEK POST OPERATIVE CARE • Remove primary dressing at day 5 • Exit site care done by an experienced nurse. • Secure normal position of the catheter. • Avoid lifting. • Allow catheter to heal as long as possible.

25. GENERAL INSTRUCTIONS • Forbidden: - to take a bath - to swim - contact sports (football…) • Advice against: - sand (beach) - intensive sports (basket ball…) • Tollerance of: - shower

26. CONCLUSIONS Catheter complications are to be expected • when dressing is not remained intact for 5 to 7 day (difficult healing - tunnelinfection) • immediate use of the catheter (leakkage) • poor fixation (difficult healing and outgrow cuff) Catheter characteristics are to be respected: • to prevent malpositon • to prevent outgrow cuff Exit site care is extremely important: • to prevent infection • to assure a long life of the access

27. THE CHOICE OF DIALYSIS ACCES • CONTROVERSY AND EVIDENCE

28. EVIDENCE / CONTROVERSY • SOME THINGS ARE WRONG • SOME THINGS ARE GOOD • MOST THINGS HAVE GOOD AND BAD POINTS..where the final decision balances, depending on “choices” made

29. Fistula superior to catheter ? • Yes • But if you choose for nighttime dialysis… not possible (A. Raes oral presentation ESPN)

30. Fistula superior to catheter ? • Yes • If you are going • for pre-emptive transplantation, • and waiting list is rather short.. • And time to start dialysis is not predictable

31. Integrated care model (Van Biesen) • Every patient with CKD.. may need every method for renal replacement therapy such as • Peritoneal dialysis • Transplant • Hemodialysis • Retransplant • … • …

32. Integrated care model (Van Biesen) • Peritoneal dialysis • Is probably not the best choice in adults • If there is no residual renal function • If BSA / BMI is very high • IDDM?? • So PD… and PD catheter is treatment of choice in children because • you preserve vascular access for later

33. Acute dialysis • Hemodialysis • Catheter • Single / double Lumen • Genius… then double lumen • Femoral catheter • Often the choice • To not interfere with other central catheters

34. Acute dialysis • Peritoneal catheter • Surgical • Often time… to surgery is long • Percutaneous Tenckhoff • Adults good experience • In children few reports • Seldinger place acute catheter (pigtail) (Buchmann, Vande Walle adv Perit Dialysis) • Especially in small children • Cardiac surgery • To gain time when there is hyperkaliemia (Start dialysis in 10min) • Two catheter technique • Continuous flow dialysis (Vande Walle Adv Perit Dial)