Peritoneal dialysis

 

Peritoneal dialysisPrinciples of peritoneal dialysis:

The peritoneum is a natural membrane, semi-permeable, allowing exchanges of solutes according to a concentration gradient on the one hand, and solvent according to an osmotic gradient on the other hand. These exchanges make it possible to ensure extrarenal purification, and to contribute to the maintenance of the water-based and acidobasic balance.

ANATOMY:

The effective area involved in trade is about 1 m 2 .Exchanges occur mainly in the parietal peritoneum, which accounts for only 10% of the entire peritoneum. The visceral peritoneum plays a minor role, while the subdiaphragmatic peritoneum is the seat of a dense lymphatic network, where reabsorption can take place that can play a significant role during ultrafiltration.

Microscopic anatomy is based on findings made on peritoneal biopsies during catheterization or catheter ablation.

The peritoneum consists of a unicellular layer, the mesothelium, resting on a capillary-rich interstitial tissue, of which only 20% would be perfused, with a wall consisting of endothelial cells separated by pores. The mesothelial cells are covered with microvilli increasing the exchange surface, and play a protective role vis-à-vis the underlying structures.

These secrete phosphatidylcholine, which acts as a lubricant. The determination of CA 125 in the peritoneal effluent makes it possible to evaluate the mesothelial cell mass.

PHYSIOLOGY:

Peritoneal blood flow is low, in the order of 100 to 150 mL / min. It plays a small role compared to the dialysate flow, especially in automated peritoneal dialysis. Different elements intervene, opposing the transfers between the capillary light (plasma) and the peritoneal cavity (dialysate), successively the presence of a blood film lining the capillary endothelium, the endothelial cell itself and the basement membrane on which it rests, the interstitial space, the mesothelium, and the existence of a stagnant layer of dialysate in contact with the mesothelial cells in the peritoneal cavity.

Peritoneal exchanges are based on two fundamental principles: diffusion (dialysis) and convection (ultrafiltration), as well as the three-pore model.

Dialysis or diffusion:

Passive phenomenon, it depends on a concentration gradient, with passage of molecules from the most concentrated medium to the least concentrated medium. It is bidirectional, depending on the composition of the dialysate introduced into the peritoneal cavity:

Plasma to the peritoneal cavity for urea, creatinine, phosphorus, sodium, potassium and bicarbonates;

From the peritoneal cavity to the plasma for glucose and lactates;

In either direction for calcium, depending on the calcium dialysate content (from 1.25 to 1.75 mmol / L) and glucose (15 to 40 g / L).

A state of equilibrium between plasma and dialysate is reached in a given time, a function of the size and molecular weight of the substance under consideration. This is obtained after 5 to 6 hours of exchange for urea, while at the same time the saturation of the dialysate (D / P) is only 60% for creatinine.

Convection or ultrafiltration (UF):

Active and unidirectional phenomenon, it is the consequence of an osmotic gradient inducing an ultrafiltration with attraction of water and solutes. The osmotic pressure is either of crystalloid origin (glucose) or of colloid origin (polymers of glucose or icodextrin).

Net ultrafiltration is the result of transcapillary ultrafiltration reduced by lymphatic reabsorption. In practice, it corresponds to the difference between the volume of dialysate drained and the volume of dialysate infused. It is maximal after 140 minutes of diffusion for an isotonic dialysate at 15 g / l of glucose (approximately 300 ml), and after 250 minutes of diffusion for a hypertonic dialysate at 40 g / l of glucose (approximately 1000 ml).

Intraperitoneal hydrostatic pressure (IPP), an independent factor of osmotic pressure, also influences net ultrafiltration.In adults, it is 12 ± 2 cm of water above the average axillary line with a dialysate volume of 2 L. An increase of approximately 1 cm of water decreases the net ultrafiltration volume by 35 mL after 1 hour of stasis. Beyond 18 cm of water at rest in supine position, a reduction in lung capacity is to be feared.

Model of the three pores:

According to this theory based on a computer model, there are three types of pores of different size at the level of the endothelium of the peritoneal capillaries.

The small, intercellular pores are the seat of the passage of water and molecules of low molecular weight, electrolytes, urea, creatinine, glucose in particular.

The ultrapetits pores, the most numerous, are characterized by transcellular channels or aquaporins. They provide the exclusive transport of free water, thus achieving a dilution of the dialysate with lowering of the initial concentration of sodium and a transfer from the plasma by concentration gradient or sieving of sodium.

The large pores, few in number, allow the passage of large substances, such as proteins, polymers of glucose (icodextrin), in intercellular spaces.

This model of the three pores makes it possible to explain the peritoneal convective transfers according to the osmotic pressure of crystalloid or colloid origin, and according to the intraperitoneal hydrostatic pressure.

Peritoneal approach:

Developed by Tenckhoff, the catheter allows permanent access to the peritoneal cavity. Its implementation must meet the requirements on which the success of the technique depends.

CATHETER:

It is silastic, more rarely polyurethane, which gives it flexibility and flexibility essential for proper use. It is most often equipped with two Dacron cuffs or cuffs, one deeply anchored under the aponeurosis of the rectus muscles, the other superficial located 1 or 2 cm from the cutaneous outlet of the catheter, thus allowing a epithelialization of the sinus.

It consists of three segments:

– Intraperitoneal right or stick, seat many orifices, the end being located in the cul-de-sac of Douglas;

– intramural, between the two sleeves, corresponding to the subcutaneous tunnel;

– external, beyond the caudal opening skin opening, to prevent retention of secretion at the sinus, source of infections.The so-called “gooseneck” catheter meets these requirements.

CATHETER IMPLANTATION SITE:

The location of the catheter outlet, which should be visible to the patient, will be determined prior to placement in a sitting subject. It is important to take into account the existence of pre-existing abdominal scars, obesity (situation outside the folds), the level of the belt (friction), waiting for a kidney transplant (lateralization of the opposite side). at the graft implantation site).

INSTALLATION TECHNIQUE:

It is primarily surgical under local or general anesthesia, rarely medical percutaneously to the patient’s bed. The approach is paramedian, sub-umbilical, through the rectus muscles (transrecta).

The technique according to Moncrieff, with burial of the external segment in subcutaneous position prior to use, is more recent. The duration of externalization is variable, ranging from 4 to 6 weeks to several months. It would allow better healing of the outlet.

Laparoscopy is usually reserved for the repositioning of the catheter following its displacement. It can be recommended from the outset in case of suspicion of adhesions, if there is a surgical history.

Modalities of peritoneal dialysis:

PERITONEAL DIALYSIS CONTINUES AMBULATORY (DPCA):

It is a manual, continuous-regime method with constant presence of dialysate (2 L) in the peritoneal cavity. The dialysis solution, packaged in flexible plastic bags of variable capacity (0.5 to 3 L) is changed four times a day.

The usual daily distribution is characterized by three isotonic pockets (glucose 15 g / L) and a hypertonic pocket (glucose 40 g / L).

The infusion of the dialysate preheated to 37 ° C is done in 10 to 20 minutes, followed by a diffusion period of a duration of 4 to 6 hours a day, and 10 to 12 hours at night, then a drainage period of 20 to 30 minutes. The bag is equipped with an injection site for the administration of drugs (heparin, insulin, antibiotics …).

The single-use disposable dual-pouch system is the most widely used in autonomous patients. A single connection at the extension on the catheter is necessary, minimizing the risk of infection.

In DPCA, pocket changes are made during the day, allowing the intervention of a nurse in the home of non-autonomous patients. In younger subjects, diurnal pocket changes can impede quality of life and work activity.

Two variables can be proposed: either the addition of an automated exchange in the middle of the night, or the suppression of the night exchange.

AUTOMATED PERITONEAL DIALYSIS (DPA):

It uses the assistance of a cycler, and allows individualization of the prescription to obtain adequate dialysis. It allows to carry out several nocturnal exchanges. It requires a sufficient level of understanding, and does not usually apply to elderly and non-autonomous subjects.

DPA can be continuous or intermittent:

– Continuous cyclic peritoneal dialysis (DPCC) involves four to eight short nocturnal exchanges and a long diurnal exchange;

– Optimized continuous peritoneal dialysis (DPCO) is identical to the DPCC with additional diurnal exchange;

– intermittent nocturnal peritoneal dialysis (DPIN) has four to eight short nocturnal exchanges, the peritoneal cavity being empty during the day;

– intermittent peritoneal dialysis (IPD) consists of three weekly sessions lasting 10 to 12 hours each, with 30 to 40 L of dialysate per session.

All modalities of DPA exist in a fluctuating mode characterized by the permanent presence of dialysate in the peritoneal cavity at the end of the drainage phase, thus increasing the number of cycles and the volume of dialysate per session.

A particular mode of treatment may be proposed, depending on the residual renal function and the type of peritoneal permeability.

Peritoneal dialysis solutions:

The dialysate consists of three essential components: the electrolytes, an osmotic agent and a buffer substance.

ELECTROLYTES:

The sodium content is between 132 and 136 mmol / L. The transfer of free water via the aquaporins makes it possible to obtain a dilution of the dialysate, inducing a passage of sodium from the plasma to the dialysate until an equilibrium is obtained between the two media. Dialytic sodium extraction is a function of the sodium content of the dialysate and the peritoneal dialysis modality.

The calcium concentration is variable, between 1.25 and 1.75 mmol / L. The movements of calcium through the peritoneal membrane depend on the calcium content and the osmolarity of the dialysate. The use of a low concentration makes it possible to propose higher doses of calcium carbonate and vitamin D to curb the secondary hyperparathyroidism, while controlling the hyperphosphoremia. Prescribing a concentration of 1.75 mmol / L may induce adynamic osteopathy. The magnesium concentration ranges from 0.25 to 0.75 mmol / L.

OSMOTIC AGENTS:

Crystalloid agents (glucose, amino acids, glycerol) and colloids (glucose polymer) are distinguished.

Glucose remains the most used osmotic agent at concentrations of 15, 25 and 40 g / L, which corresponds to an osmolarity of 340, 400 and 480 mosm / L respectively. However, the high glucose content, the hyperosmolarity and the pH at 5.2 of the solution constitute factors of aggression of the peritoneal membrane, causing a reduction of phagocytosis of bacterial agents favoring peritoneal infections. , a vasodilatation of the peritoneal capillaries source of hyperpermeability, the formation of glycosylation products. All these elements contribute to the fibrosis of the peritoneal membrane.

Amino acids have a nutritional and osmotic power. They are used at the concentration of 1.1% at the rate of a single pocket of 2 L per day. The peritoneal absorption is 60 to 80% during an exchange of 4 to 6 hours, corresponding to a protein intake of about 20 g per day. The more physiological pH of the solution at 6.7 makes it more biocompatible. In addition to the use of such a solution in case of malnutrition in patients with adequate dialysis, it seems interesting in case of peritoneal infection.

Glycerol has been proposed as an alternative to glucose in diabetics.

The polymers of glucose or icodextrin, products of the hydrolysis of corn starch, are used at a concentration of 7.5%.They are iso-osmotic plasma (282 mosm / L) but keep a low pH to 5.5. Their prescription during a nocturnal exchange in CAPD or diurnal exchange in DPA, during 8 to 12 hours, makes it possible to decrease the frequency of use of hypertonic solutions rich in glucose, by maintaining a sufficient ultrafiltration, in particular during the peritoneal infections. Skin intolerances, peritoneal reactions simulating peritonitis have been reported. The finding of stable and reversible plasma levels of maltose seems acceptable, but the long-term effects are not known.

BUFFERS:

Acetate is definitely abandoned, because of the risks of aseptic and sclerosing peritonitis. Lactate is most commonly used at a level ranging from 35 to 40 mmol / L. However, the biocompatibility of such a solution remains insufficient.

The solution combining bicarbonate (25 mmol / L) and lactate (15 mmol / L) at pH 7.4 in bicompartmental pouch seems ideal. It allows a better control of the acidosis, factor of proteinular hypercatabolism, decreases the accumulation of products of glycosylation at the level of the peritoneal membrane. A decrease in pain and discomfort during infusion has been reported. The physiological pH of the solution is probably one of the factors of long-term preservation of the peritoneal membrane.

The future is moving towards iso-osmolar solutions combining a crystalloid agent and a colloidal agent, at physiological pH, with a low glucose content, the only way to improve the biocompatibility of the solutions.

Functional explorations in peritoneal dialysis:

The peritoneum has its own characteristics, in terms of speed and efficiency of transfer of dissolved substances.

The study of peritoneal permeability is based on the measurement of transfer rates of solutes of low molecular weight.The tools used, the peritoneal equilibration test (PET) or the accelerated peritoneal equilibration examination (APEX), make it possible to personalize the prescription.

The Twardowski PET is made using 2 L of semihypertonic solution (glucose 25 g / L) over a period of 4 hours. It is imperative to use the same solution during the long night stasis preceding the test. The relationship between dialysate concentration and concentration in plasma (D / P) of substances appearing in the peritoneal cavity (urea, creatinine, phosphorus) and those disappearing (D / Do) such as glucose is studied. There are four types of peritoneal permeability, ranging from frank or moderate hypopermeability to moderate or frank hyperpermeability.

APEX according to Verger also appreciates the clean ultrafiltration and the sieving of sodium, witnessing the transfer of free water. It is performed using a hypertonic solution (glucose 40 g / L) over a period of 2 hours. The urea saturation and glucose decay curves, expressed as percentages, intersect at a given time or APEX time (normal 65 ±30 minutes). A decrease in dialysate sodium concentration of at least 5 mmol / L corresponds to normal permeability.APEX time is increased in case of hypopermeability, decreased in case of hyperpermeability.

Other parameters can be used to explore the peritoneal cavity, such as PIP measurement, peritoneal residual volume, and catheter flow.

Measurement of the dialysis dose:

The calculation of the dialysis dose makes it possible to affirm that the dialysis is “adequate”, that is to say that it corresponds to a minimum dialysis dose, insofar as its influence is great on morbidity and mortality.

Residual renal function (FRR) plays a major role. It corresponds to the glomerular filtration rate evaluated by the sum of the renal clearance (C1) of urea and creatinine, divided by 2.

FRR = renal urea + renal renal creatinine 2

It is maintained longer in peritoneal dialysis than in hemodialysis. It determines the peritoneal dialysis modality, with a preferential prescription of the DPA if the FRR is reduced ( < 2 mL / min).

The total clearance of creatinine is obtained by summing the renal and peritoneal clearances of creatinine. It requires a strict collection of urine and all the dialysate drained over 24 hours. It is expressed in liters per week and 1.73 m 2 of body surface area.

Total weekly creatinine Cl = renal Cl + peritoneal Cl (L / wk / 1.73 m 2 )

Kt / V represents the ratio of the sum of the weekly renal and peritoneal clearance of urea, and the total volume of water expressed in liters. The latter can be appreciated from various formulas including Watson’s, taking into account age, height and body weight, but is often equated with 58% of body weight.

Kt / V weekly urea = renal urea clea + peritoneal urea 0.58 x body weight

The evaluation of protein catabolism is based on the calculation of the nPCR or normalized protein catabolic rate, which is the amount of protein metabolized by the body within 24 hours. Stable, it is equivalent to the amount of protein ingested. It is calculated from the amount of urea eliminated urinary and that extracted by peritoneal dialysis.Different formulas are available, allowing to evaluate a normal nPCR between 50 and 60 grams per day.

It is recommended to evaluate the peritoneal membrane performance and adequate dialysis criteria 1 month after the start of treatment, then every 6 to 12 months, except complications requiring immediate control.

Criteria for adequate dialysis:

Adaptation of the dialysis dose takes into account the patient’s clinical condition, residual renal function and the need to reach the defined targets. Similarly, the peritoneal dialysis modality involves the permeability of the peritoneal membrane.

The weekly Kt / V of urea should be greater than 2.0 in DPCA and 2.2 in DPA. Total weekly clearance of creatinine should be greater than 60 L / week / 1.73 m 2 body surface area. Discrepancies can be observed between these two parameters. Kt / V urea is preferable in cases of residual renal function, whereas total clearance of creatinine is more reliable in the anuric subject. A decrease in Kt / V urea of ​​0.1 and total creatinine clearance of 5 L / week is associated with increased mortality of 6% and 7% respectively.

The peritoneal dialysis program is adapted according to the degree of peritoneal permeability:

– in case of hyperpermeability (D / P creatinine > 0.65 and D / Do glucose < 0.38), short cycles in DPA are recommended;

– in case of hypopermeability (D / P creatinine < 0.65 and D / Do glucose > 0.38), long cycles of DPCA are prescribed.However, if the FRR is less than 2 mL / min in a patient whose body surface area is greater than 2 m 2 , only transfer to hemodialysis can achieve adequate dialysis.

There is a close link between nutrition and adequate dialysis. Nutritional criteria are assessed from clinical (subjective global assessment or SGA and anthropometric measurements), biological (albuminemia) and nPCR. A GAS A score, an albumin level greater than 35 g / L and a minimum nPCR of 1.2 g / kg / day are essential.

Complications of peritoneal dialysis:

Infectious complications and non-infectious complications represented by mechanical and parietal complications, ultrafiltration losses and metabolic and nutritional complications should be distinguished.

INFECTIOUS COMPLICATIONS:

Peritoneal infection:

Peritoneal infection is the most common complication, the leading cause of discontinuation of the technique with an average of one episode every 20 to 30 patient-months. It is mainly of endoluminal origin secondary to a handling error (manual contamination), more rarely of periluminal origin in connection with an infection of the catheter outlet orifice, or transmural origin of digestive origin.

Drained dialysate becomes cloudy, and inconstant abdominal pain is associated with it. A test strip allowing the detection of leucocytes is positive, which confirms a cytological examination of the dialysate, with more than 100 elements / mm 3 , of which more than 50% of neutrophils. A direct bacteriological examination makes it possible, according to the case, to direct the antibiotic therapy in case of Gram positive or negative germs. Cultivation can isolate Gram-positive cocci (50-60% of the Staphylococcus epidermidis or aureus type), Gram-negative bacteria (15-20%), and more rarely yeasts (3-5%). %). In 10 to 20% of cases, no germ is detected. Antibiotic therapy is administered intraperitoneally for 7 to 21 days depending on the germ, combined with standard heparin (2500 IU per 2 L bag) as long as the drained dialysate is cloudy. Probabilistic antibiotic therapy includes a first-generation cephalosporin alone (cefazolin 125 to 250 mg / L) or in combination with an aminoglycoside.

A favorable evolution is obtained in 80 to 90% of cases. In case of persistence of a turbid dialysate, ablation of the catheter is recommended.

In order to avoid hypertonic glucose solutions and to minimize nutritional complications in the elderly, daily use of an icodextrin bag and an amino acid bag is recommended.

The presence of a Gram-negative germ or a polymicrobial peritoneal infection should suggest a digestive origin. It requires the rapid realization of an abdominal ultrasound, or even a CT scan.

Sclerosing peritonitis has become rare, favored by the bioincompatibility of solutions and a high frequency of peritoneal infections. It imposes a transfer in hemodialysis, and its prognosis is dark in a context of undernutrition.

Tuberculous peritonitis should be suspected if the dialysate is sterile to the usual cultures, while the cytology shows lymphocyte predominance.

Icodextrin alone seems to be responsible for a cloudy dialysate. Cytology is highly polymorphic, with the presence of macrophages and sometimes eosinophilic polynuclear cells.

Infection of the catheter:

Infection of the catheter outlet is suspected in the presence of local signs such as perioperative redness, edema or induration, pain, discharge. Isolation of a germ associated with the presence of pus requires local care and antibiotic therapy adapted generally for 10 to 15 days. The prophylaxis of infections is based on the routine screening of nasal carriage of Staphylococcus aureus and local treatment (mupirocin nasal application) in case of positivity.

The infection of the subcutaneous tunnel or “tunnellite” corresponds to a real abscess located between the two sleeves of the catheter. It requires the immediate removal of the catheter.

NON-INFECTIOUS COMPLICATIONS:

Mechanical complications:

They are connected to the catheter.

A defect of drainage in the course of the pose is in connection with a bad placement. A radiograph of the abdomen without intraoperative preparation makes it possible to diagnose it.

Late, associated with abdominal pain, it corresponds to a displacement. An acceleration of intestinal transit can sometimes reposition it. In the opposite case, repositioning under laparoscopy is possible.

Dialysate leaks occur at the outlet or are suspected intraparietal leakage in oedematous infiltration of the abdominal wall. Temporary discontinuation of peritoneal dialysis is necessary. Failure to use the catheter within 10 to 20 days of placement minimizes the frequency.

The cracking or perforation of the catheter, the externalization of the superficial sleeve are rare. The perforation of a viscera is manifested by an acute abdominal syndrome requiring surgery.

Wall complications:

They are dominated by inguinal or umbilical hernias, especially in the elderly and the obese. The hernia search should be carefully done before the catheter is implanted. A surgical cure can be envisaged at the same time. The repermeabilization of the peritoneal-vaginal canal with edema of the bursa and hydrocele, a diaphragmatic breach with hydrothorax revealed by acute dyspnea and poor drainage of the peritoneal cavity most often require the definitive cessation of the technique.

Hemoperitoneum, sometimes concomitant menses, and chylous ascites are rare and not serious.

Loss of ultrafiltration:

They are characterized by a water-soluble retention (weight gain, edematous syndrome, insufficient drainage) related to a decrease in net ultrafiltration. PET or APEX time confirm whether or not there is peritoneal hyperpermeability requiring transfer of DPCA to DPA or DPA in hemodialysis. If any of these tests are normal, a drainage defect related to the catheter is likely.

Undernutrition:

Undernutrition is a frequent complication in elderly patients on peritoneal dialysis. Supplementation with amino acids is essential to achieve the targets of 1.2 to 1.5 g of protein associated with 30 to 35 kcal per kilogram of body weight per day, as long as dialysis is adequate. Oral or peritoneal protein supplementation should be considered.

Lipid abnormalities:

Lipid abnormalities, including hypertriglyceridemia, are more severe than hemodialysis. Dietary and medical measures may be necessary. Aggravation or the discovery of diabetes induced by peritoneal dialysis may result in reinforcement or initiation of insulin therapy.

Abdominal discomfort or exacerbation of low back pain by peritoneal dialysis is sometimes resolving by reducing intraperitoneal volume. Poor psychological, personal or family tolerance may require transfer to hemodialysis.

Contraindications to peritoneal dialysis:

Severe malnutrition, prior to starting treatment, is a temporary or definitive contraindication. Obesity is a relative contraindication, due to technical problems (catheter dysfunction), risks of under-dialysis especially in the anuric subject, weight gain related to peritoneal absorption of glucose (120 to 150 g / day).

In the case of a history of abdominal surgical procedures that is a source of adhesions with peritoneal cavity partitioning limiting the effective surface area involved in the exchange, laparoscopic catheterization is recommended.

In case of chronic respiratory insufficiency, the degree of the attack must be evaluated, but this pathology must not exclude peritoneal dialysis in a systematic way.

In patients with a gastrointestinal and / or urinary stoma, in case of depressive syndrome or isolation of the patient, an orientation towards hemodialysis is often preferable, because of the pre-existing psychological disturbances.

Indications for peritoneal dialysis:

PERITONEAL DIALYSIS BY AGE:

In children, DPA is the method of choice because of a high frequency of peritoneal hyperpermeability. In addition, performing a vascular approach for hemodialysis is often difficult. This modality of the treatment allows a normal schooling.

In the elderly, CAPD may be preferred to hemodialysis because of numerous cardiovascular comorbidities and the possibility of home care. The use of a third person (entourage, nurses) is necessary in the majority of cases.

In practice, peritoneal dialysis may be offered as first-line treatment regardless of age, but in the absence of a possible renal transplantation, it may be a temporary treatment with subsequent transfer to hemodialysis.

PERITONEAL DIALYSIS BEFORE RENAL TRANSPLANTATION:

DPA is preferable for professional and quality of life reasons. Survival of the graft is identical in patients previously on peritoneal dialysis or hemodialysis. Improvement of kidney function of the graft is more rapidly achieved in patients previously on peritoneal dialysis. The frequency of infectious complications is not increased in the post-transplant phase.

In case of peritoneal infection, a temporary contraindication to the transplant is essential, from 10 to 30 days depending on the isolated germ.

Intraoperative ablation of the catheter is recommended in the event of an exit port infection or a history of fungal peritonitis. This is usually delayed between the third and sixth weeks, at a time when the dosage of immunosuppressants has been reduced.

PERITONEAL DIALYSIS IN DIABETICS:

The diabetes factor significantly increases morbidity and mortality, regardless of the type of extrarenal treatment envisaged. Prolonged maintenance of residual renal function is an argument in favor of peritoneal dialysis in diabetics, in order to slow the progression of extrarenal complications. However, there are no sufficient arguments to favor peritoneal dialysis over hemodialysis. The frequency of peritoneal infections is not increased in this population. The use of icodextrin should be preferred to hypertonic glucose solutions to achieve satisfactory ultrafiltration. The use of insulin intraperitoneally can be proposed.

PERITONEAL DIALYSIS IN CARDIAC INSUFFICIENT:

Chronic end-stage renal failure associated with heart failure is a preferred indication of CAPD. Progressive and continuous ultrafiltration is better tolerated than conventional hemodialysis. A favorable impact is noted on the quality of life, with a reduction in the frequency and duration of hospitalizations.

Factors limiting the management of peritoneal dialysis:

Data from the Canadian registry show that patient survival is better in the first 2 years of peritoneal dialysis compared to hemodialysis. These results were confirmed by a study by Lameire et al. The prolonged maintenance of residual renal function in peritoneal dialysis, the individualisation of the prescription with the development of the DPA, constitute favorable factors.

Nevertheless, peritoneal dialysis accounts for only 10% of chronic end stage renal failure patients treated by extrarenal treatment in France, around 17% worldwide, but 25 to 40% in some countries in Europe.

The management of a patient with chronic end stage renal failure in an emergency setting is an adverse factor in the setting up of peritoneal dialysis. Predialysis information is an important step in order to objectively present the methods of extrarenal treatment. Unfortunately, many regional studies show that in France 25 to 30% of patients reach the stage of extrarenal treatment, without prior nephrological care. The choice of the method must also take into account the patient’s socio-professional conditions, in order to maintain an acceptable quality of life. Finally, an improvement in the financial coverage by health insurance for patients on peritoneal dialysis is essential

Conclusion:

Progress in the field of peritoneal dialysis over the last 20 years has been significant. They concern in particular the understanding of the phenomena of transfer through the peritoneal membrane, the improvement of the material made available and the available solutions. This results in a decrease in the frequency of complications, including peritoneal infections. The establishment of adequate dialysis criteria and increased monitoring of nutritional status have reduced morbidity and mortality. Peritoneal dialysis and hemodialysis should be considered as complementary and non-competitive methods. Peritoneal dialysis, considered first-line for many patients, will be definitive for some, temporary for others. A transfer of DPCA to DPA and hemodialysis should be considered in due course. The most appropriate therapy for a given patient should be proposed at some point in the life of chronic renal failure.

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