Wednesday, December 26, 2007

Treatment methods for kidney dud: peritoneal dialysis

Introduction


When Your Kidneys Fail


How PD Works


Getting Ready for PD


Types of PD


Customizing Your PD


Preventing Problems


Equipment and Supplies for PD


Testing the Effectiveness of Your Dialysis


Conditions Related to Kidney Failure and Their Treatments


Adjusting to Changes


Hope Through Research


Resources


Acknowledgements


About the Kidney Failure Series


Introduction


With peritoneal dialysis (PD), you have some choices surrounded by treating advanced and permanent kidney let-down. Since the 1980s, when PD first became a practical and general treatment for kidney failure, we've well-educated much about how to product PD more effective and minimize side effects. Since you don't enjoy to schedule dialysis sessions at a center, PD give you more control. You can give yourself treatments at home, at work, or on trips. But this nouns makes it especially impressive that you work closely with your robustness care troop: your nephrologist, dialysis nurse, dialysis technician, dietitian, and social worker. But the most important member of your health trouble team are you and your kinfolk. By learning just about your treatment, you can work with your strength care troop to give yourself the best possible results, and you can organize a full, active energy.


When Your Kidneys Fail


Healthy kidneys clean your blood by removing excess fluid, minerals, and inhospitable surroundings. They also make hormones that maintain your bones strong and your blood healthy. When your kidneys backfire, harmful wastelands build up in your body, your blood pressure may rise, and your body may retain excess fluid and not bring in enough red blood cell. When this happens, you necessitate treatment to replace the work of your failed kidneys.


How PD Works


In PD, a soft tube call a catheter is used to fill your tummy with a cleansing fluid called dialysis solution. The walls of your abdominal cavity are crumpled with a membrane call the peritoneum, which allows waste products and extra fluid to overhaul from your blood into the dialysis solution. The solution contains a sugar called dextrose that will verbs wastes and extra fluid into the abdominal cavity. These wastelands and fluid then hand down your body when the dialysis solution is drained. The used solution, containing wastes and extra fluid, is after thrown away. The process of draining and filling is call an exchange and takes something like 30 to 40 minutes. The period the dialysis solution is contained by your abdomen is call the dwell time. A typical schedule call for four exchanges a day, respectively with a dwell time of 4 to 6 hours. Different types of PD own different schedules of day by day exchanges.


The most common form of PD, continuous ambulatory peritoneal dialysis (CAPD), doesn't require a domestic device. As the word ambulatory suggests, you can walk around beside the dialysis solution in your tummy. Other forms of PD require a machine call a cycler to fill and drain your belly, usually while you sleep. The different types of cycler-assisted PD are sometimes called automated peritoneal dialysis, or APD.


Getting Ready for PD


Whether you choose an ambulatory or automated form of PD, you'll inevitability to have a soft catheter placed within your abdomen. The catheter is the tube that carry the dialysis solution into and out of your abdomen. After giving you a local anesthetic to minimize any torment, your doctor will make a small cut, habitually below and a little to the side of your navel (belly button), and consequently guide the catheter through the slit into the peritoneal cavity. As soon as the catheter is in place, you can start to receive solution through it, although you probably won't begin a full agenda of exchanges for 2 to 3 weeks. This break-in period let you build up scar tissue that will hold the catheter contained by place.


The standard catheter for PD is made of soft tubing for comfort. It has Dacron cuffs that merge next to your scar tissue to hang on to it in place. (Dacron is a polyester yard goods.) The end of the tubing i.e. inside your abdomen have many holes to allow the free flow of solution within and out.


Types of PD


The type of PD you choose will depend on the schedule of exchanges you would resembling to follow, as well as other factor. You may start with one type of PD and switch to another, or you may find that a combination of automated and nonautomated exchanges suits you best. Work beside your health safekeeping team to find the best programme and techniques to run into your lifestyle and health wishes.


Continuous Ambulatory Peritoneal Dialysis (CAPD)


If you choose CAPD, you'll drain a fresh bag of dialysis solution into your tummy. After 4 to 6 or more hours of dwell time, you'll drain the solution, which now contains inhospitable surroundings, into the bag. You after repeat the cycle with a fresh pod of solution. You don't need a device for CAPD; all you obligation is gravity to fill and aimless your abdomen. Your doctor will prescribe the number of exchanges you'll requirement, typically three or four exchanges during the day and one evening exchange near a long overnight dwell time while you sleep.


Continuous Cycler-Assisted Peritoneal Dialysis (CCPD)


CCPD uses an automated cycler to perform three to five exchanges during the dark while you sleep. In the morning, you begin one exchange near a dwell time that lasts the entire hours of daylight.


Nocturnal Intermittent Peritoneal Dialysis (NIPD)


NIPD is like CCPD, individual the number of overnight exchanges is greater (six or more), and you don't perform an exchange during the year. NIPD is usually reserved for patients whose peritoneum is able to transport spend foolishly products very fast or for patients who still have substantial remaining kidney function.


Customizing Your PD


If you've chosen CAPD, you may own a problem with the long overnight dwell time. It's mundane for some of the dextrose in the solution to cross into your body and become glucose. The held dextrose doesn't create a problem during short dwell times. But overnight, some people hold your attention so much dextrose that it starts to draw fluid from the peritoneal cavity back into the body, reducing the efficacy of the exchange. If you have this problem, you may be capable of use a minicycler (a small version of a electrical device that automatically fills and drains your abdomen) to exchange your solution once or several times overnight while you sleep. These other, shorter exchanges will minimize solution absorption and administer you added clearance of wastes and excess fluid.


If you've chosen CCPD, you may enjoy a solution absorption problem next to the daytime exchange, which has a long dwell time. You may find you involve an additional exchange within the mid-afternoon to increase the amount of waste removed and to prevent excessive digestion of solution.


Preventing Problems


Infection is the most common problem for society on PD. Your health contemplation team will show you how to maintain your catheter bacteria-free to avoid peritonitis, which is an infection of the peritoneum. Improved catheter designs protect against the spread of bacteria, but peritonitis is still a common problem that sometimes make continuing PD impossible. You should follow your health charge team's instructions scrupulously, but here are some general rules:


* Store supplies within a cool, clean, dry place.


* Inspect respectively bag of solution for signs of contamination until that time you use it.


* Find a clean, dry, well-lit space to make your exchanges.


* Wear sterile gloves to perform exchanges.


* Wash your hand every time you need to button your catheter.


* Clean the exit site with antiseptic every afternoon.


* Wear a surgical mask when performing exchanges if you own a cold.


Keep a close watch for any signs of infection and report them so they can be treated promptly. Here are some signs to keep watch on for:


* Fever


* Nausea or vomiting


* Redness or pain around the catheter


* Unusual color or cloudiness in used dialysis solution


* A catheter cuff that have been pushed out


Equipment and Supplies for PD


Transfer Set


A verbs set is tubing that connects the bag of dialysis solution to the catheter. Two types of verbs sets are available.


* A straight transfer set is a straight piece of tubing that stays connected to your catheter. To set off each exchange, you connect the free conclusion to a fresh bag of solution and hang up the bag better than the catheter, usually attaching it to a special stand, so that gravity pulls the solution into your abdomen. While the solution is within your abdomen, you can roll up the rucksack and wear it under your clothes. When you've finished your dwell time, you cart the bag out and place it close by the floor so that gravity pushes the used solution down into the bag. When the sack is full, you disconnect it from the straight transfer set and connect a fresh case of solution to start the next exchange.


* A Y-set is a Y-shaped piece of tubing that can be disconnected between exchanges. To start, you connect the bed of the Y to your catheter. You then connect one branch of the Y to a fresh purse of solution and the other to an empty daypack. To flush away any bacteria that might be within the transfer set, you close sour the base of the Y and drain a small amount of solution from the full rucksack into the empty one. Then you close the branch that lead to the empty backpack and let the solution flow into your tummy. Once the bag have emptied, you can disconnect the Y-set from your catheter so you won't entail to conceal a bag or extra tubing below your clothes. When it's time to empty the used solution, you reconnect the catheter to the Y-set and drain the solution into an abandoned bag to discard. Then you connect a fresh pack and begin the process again.


The Y-set is full up with disinfectant when not in use. This disinfectant is flushed out near the used dialysis solution. These procedures make the Y-set more impressive at protecting against peritonitis. A Y-set can be reused for several months.


Dialysis Solution


Dialysis solution comes in 1.5-, 2-, 2.5-, or 3-liter bags. A liter is slightly more than 1 quart. The dialysis dose can be increased by using a larger pouch, but only inwardly the limit of the amount your belly can hold. The solution contains a sugar called dextrose, which pulls extra fluid from your blood. Your doctor will prescribe a formula that fits your requirements.


You'll need a verbs space to store your bags of solution and other supplies. You may also want a special heating device to reheat each daypack of solution to body temperature back use. Manufacturers do not recommend using microwave ovens to warm solution because they loose change its chemical makeup.


Cycler


The cycler--which automatically fills and drains your tummy, usually at night while you sleep--can be programmed to deliver specified volumes of dialysis solution on a specified calendar. Most systems include the following components:


* Solution storage. At the beginning of the session, you connect lots of dialysis solution to tubing that feeds the cycler. Most systems include a separate tube for the finishing bag because this solution may enjoy a higher dextrose content so that it can work for a daylong dwell time.


* Pump. The pump sends the solution from the storage plenty to the heater backpack before it enter the body and then sends it from the weigh rucksack to the disposal container after it's been used. The pump doesn't compress and drain your abdomen; gravity perform that job more soundly.


* Heater bag. Before the solution enter your abdomen, a measured dose is warm to body temperature. Once the solution is the right warmth and the previous exchange has be drained, a clamp is released to allow the warmed solution to flow into your tummy.


* Weigh bag. The cycler's timer releases a clamp to consent to the used dialysis solution drain from your abdomen into a weigh pack that measures and records how much solution have been removed. Some systems compare the amount of solution inserted near the amount drained and display the net difference between the two volumes. This let you know whether the treatment is removing enough fluid from your body.


* Disposal container. After the used solution is weigh, it's pumped to a disposal container that you can throw away in the morning.


* Alarms. Sensors will trigger an alarm and shut off the device if there's a problem near inflow or outflow.


An example of a system used for cycler-assisted peritoneal dialysis. Solution is heated before use and weigh after use. The last purse of solution may have a different concentration to later throughout the day.


Testing the Effectiveness of Your Dialysis


To see if the exchanges are removing ample waste products, such as urea, your condition care troop must perform several test. These tests are especially significant during the first weeks of dialysis to determine whether you're receiving an average amount, or dose, of dialysis.


The peritoneal equilibration test (often call the PET) measures how much sugar has be absorbed from a case of infused dialysis solution and how much urea and creatinine have enter into the solution during a 4-hour exchange. The peritoneal transport rate varies from creature to person. If you hold a high rate of transport, you hold your attention sugar from the dialysis solution quickly and should avoid exchanges near a very long dwell time because you're promising to absorb too much solution from such exchanges.


In the clearance interview, samples of used solution drained over a 24-hour term are collected, and a blood sample is obtain during the day when the used solution is collected. The amount of urea surrounded by the used solution is compared with the amount within the blood, to see how effective the PD rota is in removing urea from the blood. For the first months or even years of PD treatment, you may still produce small amounts of urine. If your urine output is more than several hundred milliliters per year, urine is also collected during this period to calculate its urea concentration.


From the used solution, urine, and blood measurements, your health watchfulness team can compute a urea clearance, call Kt/V, and a creatinine clearance rate (adjusted to body surface area). The residual clearance of the kidneys is also considered. These measurements will show whether the PD prescription is adequate.


If the laboratory results show that the dialysis agenda is not removing enough urea and creatinine, the doctor may revision the prescription by


* Increasing the number of exchanges per day for patients treated near CAPD or per night for patients treated beside CCPD or NIPD.


* Increasing the volume of each exchange (amount of solution within the bag) in CAPD.


* Adding an extra, automated middle-of-the-night exchange to the CAPD agenda.


* Adding an extra middle-of-the-day exchange to the CCPD schedule.


For more information around testing the worth of your dialysis, see the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) fact sheet Peritoneal Dialysis Dose and Adequacy.


Compliance


One of the big problems next to PD is that patients sometimes don't perform adjectives of the exchanges prescribed by their medical team. They any skip exchanges or sometimes skip entire treatment days when using CCPD or NIPD. Skipping PD treatments has be shown to increase the risk of hospitalization and death.


Remaining Kidney Function


Normally the PD prescription factor in the amount of residual, or remaining, kidney function. Residual kidney function typically falls, although slowly, over months or even years of PD. This system that more often than not, the number of exchanges prescribed, or the volume of exchanges, desires to increase as residual kidney function falls.


The doctor should determine your PD dose on the basis of practice standards established by the National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF-DOQI). Work closely next to your health consideration team to ensure that you receive the proper dose, and follow instructions carefully to craft sure you get the most out of your dialysis exchanges.


Conditions Related to Kidney Failure and Their Treatments


Your kidneys do much more than remove wilderness and extra fluid. They also make hormones and match chemicals in your system. When your kidneys stop working, you may own problems with anemia and conditions that affect your bones, nerves, and skin. Some of the more adjectives conditions caused by kidney bomb are fatigue, bone problems, joint problems, itching, and "restless legs."


Anemia and Erythropoietin (EPO)


Anemia is a condition where the volume of red blood cells is low. Red blood cell carry oxygen to cell throughout the body. Without oxygen, cells can't use the heartiness from food, so someone with anemia may tire effortlessly and look pale. Anemia can also contribute to heart problems.


Anemia is adjectives in society with kidney disease because the kidneys produce the hormone erythropoietin, or EPO, which stimulates the bone marrow to produce red blood cell. Diseased kidneys often don't engineer enough EPO, and so the bone marrow make fewer red blood cell. EPO is available commercially and is commonly given to patients on dialysis.


For more information about the cause of and treatments for anemia in kidney downfall, see the NIDDK fact sheet Anemia within Kidney Disease and Dialysis.


Renal Osteodystrophy


The term "renal" describes things related to the kidneys. Renal osteodystrophy, or bone disease of kidney bomb, affects up to 90 percent of dialysis patients. It causes bones to become weaken and weak or malformed and affects both children and adults. Symptoms can be see in growing children near kidney disease even before they start dialysis. Older patients and women who enjoy gone through menopause are at greater risk for this disease.


For more information about the cause of this bone disease and its treatment in dialysis patients, see the NIDDK certainty sheet Renal Osteodystrophy.


Itching (Pruritus)


Many people treated next to peritoneal dialysis complain of itchy skin, which is often worse during or merely after treatment. Itching is common even contained by people who don't own kidney disease; in kidney damp squib, however, itching can be made worse by uremic toxins in the blood that dialysis doesn't adequately remove. The problem can also be related to dignified levels of parathyroid hormone (PTH). Some individuals have found dramatic nouns after having their parathyroid glands removed. But a cure that works for everyone have not been found. Phosphate binders seem to be to help some nation; others find relief after exposure to ultraviolet street light. Still others improve beside EPO shots. A few antihistamines (Benadryl, Atarax, Vistaril) have be found to help; also, capsaicin cream applied to the skin may relieve itching by freezing nerve impulse. In any case, taking guardianship of dry skin is important. Applying creams next to lanolin or camphor may help.


Sleep Disorders


Patients on dialysis normally have insomnia, and some culture have a specific problem call the sleep apnea syndrome. Episodes of apnea are breaks in breathing during sleep. Over time, these sleep disturbances can head to "day-night reversal" (insomnia at night, sleepiness during the day), headache, depression, and decreased alertness. The apnea may be related to the effects of advanced kidney bomb on the control of breathing. Treatments that work with populace who have sleep apnea, whether they enjoy kidney failure or not, include losing weightiness, changing sleeping position, and wearing a costume that gently pumps nouns continuously into the nose (nasal continuous positive airway pressure, or CPAP).


Many citizens on dialysis have trouble sleeping at dark because of aching, mortified, jittery, or "restless" legs. You may feel a strong fad to kick or thrash your legs. Kicking may take place during sleep and disturb a bed partner throughout the night. Theories almost the causes of this syndrome include brass neck damage and chemical imbalance.


Moderate exercise during the day may relief, but exercising a few hours before bedtime can manufacture it worse. People with restless leg syndrome should shrink or avoid caffeine, alcohol, and tobacco; some people also find nouns with massage or warm baths. A class of drugs call benzodiazepines, often used to treat insomnia or anxiety, may relief as well. These prescription drugs include Klonopin, Librium, Valium, and Halcion. A newer and sometimes more effectual therapy is Sinemet (levodopa), a drug used to treat Parkinson's disease.


Sleep disorders may come across unimportant, but they can impair your ability of life. Don't wane to raise these problems beside your nurse, doctor, or social worker.


Amyloidosis


Dialysis-related amyloidosis (DRA) is common surrounded by people who own been on dialysis for more than 5 years. DRA develops when proteins in the blood deposit on joint and tendons, causing affliction, stiffness, and fluid in the joint, as is the case beside arthritis. Working kidneys filter out these proteins, but dialysis is not as effective. For more information, see the NIDDK certainty sheet Amyloidosis and Kidney Disease.


Adjusting to Changes


You can do your exchanges in any clean space, and you can embezzle part within many undertakings with solution contained by your abdomen. Even though PD give you more flexibility and freedom than hemodialysis, which requires being connected to a apparatus for 3 to 5 hours three times a week, you must still stick to a strict schedule of exchanges and maintain track of supplies. You may have to cut put money on on some responsibilities at work or in your home life span. Accepting this new genuineness can be very tricky on you and your family. A counselor or social worker can comfort you cope.


Many patients feel depressed when starting dialysis, or after several months of treatment. Some populace can't get used to the reality that the solution makes their body look larger. If you discern depressed, you should talk beside your social worker, nurse, or doctor because depression is a common problem that can repeatedly be treated effectively.


How Diet Can Help


Eating the right foods can help remodel your dialysis and your health. You may hold chosen PD over hemodialysis because the diet is less restrictive. With PD, you're removing inhospitable surroundings from your body slowly but constantly, while in hemodialysis, wilderness may build up for 2 or 3 days between treatments. You still need to be severely careful in the order of the foods you eat, however, because PD is much smaller number efficient than working kidneys. Your clinic have a dietitian to help you plan meal. Follow the dietitian's advice closely to win the most from your dialysis treatments. You can also ask your dietitian for recipes and titles of cookbooks for patients beside kidney disease. Following the restrictions of a diet for kidney failure might be strong at first, but with for a moment creativity, you can make spicy and satisfying meal.


The National Kidney Foundation has a brochure on Nutrition and Peritoneal Dialysis, which give general guidelines on calorie and nutrient intake. See the "Additional Reading" cubicle for contact information.


Financial Issues


Treatment for kidney failure is expensive, but Federal form insurance programs pay much of the cost, usually up to 80 percent. Often, private insurance or State programs reimburse the rest. Your social worker can help you locate resources for financial assistance. For more information, see the NIDDK certainty sheet Financial Help for Treatment of Kidney Failure.


Hope Through Research


NIDDK, through its Division of Kidney, Urologic, and Hematologic Diseases, supports several programs and studies devoted to improving treatment for patients near progressive kidney disease and permanent kidney let-down, including patients on PD.


* The End-Stage Renal Disease Program promotes research to reduce medical problems from bone, blood, scared system, metabolic, gastrointestinal, cardiovascular, and endocrine abnormalities surrounded by kidney failure and to boost the effectiveness of dialysis and transplantation. The research focuses on reusing hemodialysis membranes and on using alternative dialyzer sterilization methods; on devising more modernized, biocompatible membranes; on refining high-flux hemodialysis; and on developing criteria for dialysis adequacy. The program also seek to increase kidney graft and patient survival and to maximize standard of life.


* The U.S. Renal Data System (USRDS) collects, analyzes, and distributes information going on for the use of dialysis and transplantation to treat kidney failure surrounded by the United States. The USRDS is funded directly by NIDDK in conjunction next to the Health Care Financing Administration. The USRDS publishes an Annual Data Report, which characterizes the total population of people mortal treated for kidney failure; reports on incidence, prevalence, mortality rates, and trends over time; and develops facts on the effects of various treatment modalities. The report also help identify problems and opportunities for more focused special studies of renal research issues.


Acknowledgments


The National Institute of Diabetes and Digestive and Kidney Diseases gratefulness these dedicated strength professionals for their careful review of this publication.

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