Peritoneal dialysis makes use of the peritoneum as a natural permeable membrane advantage through which water and solutes can be equilibrated. Compared to hemodialysis is peritoneal dialysis
(See also overview of the renal replacement therapy.) The peritoneal dialysis makes use of the peritoneum as a natural permeable membrane advantage through which water and solutes can be equilibrated. Compared with hemodialysis, peritoneal dialysis with less physiologically stressful Makes no vascular access is required can be done at home allows patients but much greater flexibility Peritoneal dialysis requires a much higher patient involvement as an “in-center hemodialysis.” Maintaining a sterile technique is important. Of an estimated 1,200 ml / min of the entire splanchnikalen resting blood flow only about 70 ml / min come with the peritoneum in contact, so that the equilibration of the dissolved substances is much slower than in hemodialysis. However, since the clearance of solutes and water is a function of contact time and peritoneal dialysis is almost exclusively carried out continuously, the efficiency of this process in terms of the removal of dissolved substances in efficiency achieved by hemodialysis is equal. In principle, the dialysate is instilled through a catheter into the peritoneal cavity, left there and then drained. In the double bag technique, the patient drains the instilled into the abdomen liquid in a bag and then fills liquid from another bag in the peritoneal cavity. Peritoneal dialysis can be performed manually or by using an automatic device. To the manual methods include the following: The continuous ambulatory peritoneal dialysis (CAPD) does not require a machine for carrying out the liquid exchange A typical adult infused 2-3 l (children 30 to 40 ml / kg) of dialysate 4 to 5 times a day. The dialysate can be up to 4 hours during the day and 8-12 h remain during the night. The solution is drained by hand. Flushing the infusion set before filling lowers of peritoneal. Intermittent peritoneal dialysis (IPD) is easy to achieve higher solute freedom as automatic intermittent peritoneal dialysis, and is useful, v. a. in the treatment of acute renal failure (ARF). In adults, 2-3 l be infused (in children 30-40 ml / kg) of the heated to 37 ° C within 10-15 min dialysate and remain for 30-40 min in the peritoneal cavity, and then for 10-15 min again to be drained. Over 12-48 h numerous exchanges may be required. Automated Peritoneal Dialysis (APD) is the most popular form of peritoneal dialysis. It uses an automated apparatus to perform a plurality of nocturnal changes, sometimes with a residence time of a day. There are 3 types: In the continuous cyclic peritoneal dialysis (CCPD) dwells the dialysate during a long time in the peritoneal cavity (12-15 h); operated by means of an automatic cycler exchange takes place at night (3-6 hours). Nocturnal intermittent peritoneal dialysis (NIPD) includes nightly exchange, leaving the abdominal cavity of the patient without dialysate during the day. Tidal peritoneal dialysis (TPD) implies that some dialysate (often more than half) remains from an exchange to the next in the peritoneum, which (frequent repositioning z. B.) leads to greater patient comfort and avoiding problems that completely inability dialysate to run emerge. TPD images can be performed with or without a residence time of a day. Some patients require both CAPD and CCPD to achieve sufficient clearance. Access Peritoneal dialysis requires intraperitoneal access; usually a soft silicone or a porous polyurethane catheter is placed. The catheter can be implanted by means of blind insertion of trocar or under endoscopic visualization in the operating room under direct vision or in bed. Most catheters have a fabric sleeve made of polyester, which permits the ingrowth of skin or preperitoneal fascia tissue, resulting in forms in the ideal case a waterproof, bakterienundurchlässiger seam which prevents the penetration of bacteria into the catheter tract. A period of 10-14 days between catheter implantation and commissioning improves healing and reduces the incidence of early Dialysatleckage in the catheter area. Double-cuff catheters are better than catheters with single cuff. In addition, a caudal exit site directed lowers (the opening of the tunnel through which the catheter enters the abdominal cavity), the incidence of infections at the outlet point (z. B. by collecting less water during showering). If the access is established, the patient is subjected to a peritoneal Äquilibrierungstest by the dialysate is analyzed after 4 hours of retention and compared with the serum, so as to determine the clearance rate of dissolved substances. These measures will help to determine the peritoneal transport capacity of the patients who required dialysis dose and the most appropriate technology. In general, a sufficient technique is defined as weekly KT / V ? 1.7 (wherein K = urea clearance in mL / min, T = dialysis time in minutes and V is the volume of urea distribution [which corresponds approximately to the total body water] in ml). Complications of peritoneal dialysis The most important and common complications of peritoneal dialysis (see table: complications of renal replacement therapy) are peritonitis infection at the catheter tunnel exit point peritonitis symptoms and complaints of peritonitis include abdominal pain, cloudy peritoneal fluid, fever, nausea and guarding on palpation. The diagnosis of peritonitis is made by clinical criteria and tests. A sample of peritoneal fluid for Gram stain, culture and leukocyte count with differential is removed. The Gram stain is often revealing, but in> 90% of the cultures are positive. About 90% of those affected have> 100 leukocytes / ul, usually neutrophils (lymphocytes in Pilzperitonitis). Negative cultures and leukocytes <100 / ul not rule out peritonitis, so treatment is indicated when a peritonitis is suspected based on clinical and laboratory criteria and should begin immediately, before the results of the culture are present. Studies of peritoneal fluid can due to previous use of antibiotics, infection limited his false negative on the exit site or tunnel or taking of too little liquid. Tips and risks When peritonitis is suspected based on clinical criteria, treatment should immediately be independent of the laboratory results. The empirical treatment should be adapted microbes resistant patterns of the existing facility, but the typical recommendations for initial treatment with drugs that are effective against gram-positive organisms, for belonging. As either vancomycin or a cephalosporin of the first generation plus. Drugs that are effective against gram-negative organisms, such as a cephalosporin of the third generation (z. B. ceftazidime) or an aminoglycoside (eg. As gentamicin). The dose is adjusted for renal failure. Drugs are adjusted based on the results of the peritoneal dialysis fluid culture. In peritonitis, the antibiotic therapy is usually administered i.v. or intraperitoneally (IP) and given orally for infections at the exit point. Patients with peritonitis are hospitalized when an i.v. Treatment is necessary or if hemodynamic instability or other significant complications. Most cases of peritonitis respond to the prompt antibiotic therapy. When the peritonitis is not responding or within 5 days of antibiotics is caused by recurrence of the same pathogen, or fungus, the dialysis catheter entfernt.Infektion at the catheter tunnel exit point is an infection at the exit site of the catheter channel is manifested in a resistance of the tunnel or the exit point with crusting, erythema or secretions. The diagnosis is made clinically. The treatment of an infection without secretion is by topical antisepsis performed (povidone-iodine, chlorhexidine), if this is ineffective, vancomycin is given empirically as a rule, with the culture results are indicative for the subsequent therapy. Prognosis The 5-year survival rate of peritoneal dialysis patients achieved slightly better results than that of hemodialysis patients (approximately 41% for peritoneal dialysis compared with 35% in hemodialysis).