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Guidelines for peritoneal dialysis

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Guidelines for peritoneal dialysis

RA Guidelines for peritoneal dialysis

1. Peritoneal Dialysis (PD) (Guidelines PD 1.1 – 1.5)
Guideline 1.1.1 – PD : Equipment and Resources
We recommend that Peritoneal Dialysis should be delivered in the context of a comprehensive and integrated service for renal replacement therapies, including haemodialysis (including temporary backup facilities), transplantation and conservative care. Both continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD), in all its forms should be available. (1C)
Guideline 1.1.2 – PD : Equipment and Resources
We recommend that a dedicated PD nursing team should be part of the multidisciplinary team (1C).
Guideline 1.1.3 – PD : Equipment and Resources
We recommend that where feasible, each unit has a designated lead clinician for PD (1C).
Guideline 1.1.4 – PD : Equipment and Resources
We recommend that assisted PD should be available to patients wishing to have home dialysis treatment but unable to perform self-care PD, including as a temporary measure where a patient who is, or will become, independent is unable to perform PD alone. (1C)
Guideline 1.2 – PD : Equipment and Resources
We recommend that all equipment and fluid used in the delivery and monitoring of PD therapies should comply with the relevant standards for medical fluids and devices (1C)
Guideline 1.3 – PD : Equipment and Resources
We recommend that the use of disconnect systems should be standard unless clinically contraindicated (1A)
Guideline 1.4 – PD : Equipment and Resources
We suggest that biocompatible PD solutions (solutions that have normal pH and/or low concentrations of glucose degradation products) should be used in patients experiencing infusion pain. (2B).
Guideline 1.5 – PD : Equipment and Resources
We suggest that biocompatible PD solutions (normal pH and/or low concentrations of glucose degradation products) may be considered for better preservation of residual renal function with long term (>12 month) use. (2B)

2. Peritoneal Dialysis (PD) (Guidelines PD 2.1 – 2.4)
Guideline 2.1 – PD : Preparation for Peritoneal Dialysis
We recommend that all patients (and parents of paediatric patients) should, where possible, be adequately prepared for renal replacement therapy and this should include receiving information and education about PD treatment, delivered by an experienced member of the MDT. Patients commencing RRT in an unplanned fashion for whatever reason should receive this information once appropriate (1C). Fast track education and urgent PD catheter insertion with acute start of PD should be available, and be offered to suitable patients urgently starting on RRT who wish to avoid temporary haemodialysis. (1C)
Guideline 2.2 – PD : Preparation for Peritoneal Dialysis
We recommend that, where possible, timing of PD catheter insertion should be planned to accommodate patient convenience, commencement of training between 10 days and 6 weeks and before RRT is essential to enable correction of early catheter-related problems without the need for temporary haemodialysis. (1C)
Guideline 2.3 – PD : Preparation for Peritoneal Dialysis
We recommend that PD catheter insertion practice should be managed according to the Renal Association Peritoneal Access Guidelines. Paediatric PD access procedures will routinely be performed under general anaesthetic (Ungraded).
Guideline 2.4 – PD : Preparation for Peritoneal Dialysis
We recommend that peri-operative catheter care and catheter complications (leaks, hernias, obstruction) should be managed according to the International Society of Peritoneal Dialysis guidelines 2005, and for children, the European Elective Chronic Peritoneal Dialysis Guideline 2001 (Ungraded).

3. Peritoneal Dialysis (PD) (Guidelines PD 3.1 – 3.3)
Guideline 3.1 – PD : Solute Clearance
We recommend that both residual urine and peritoneal dialysis components of small solute clearance should be measured at least six monthly or more frequently if dependant on residual renal function to achieve clearance targets or if clinically or biochemically indicated in adults and in children. Both urea and/or creatinine clearances can be used to monitor dialysis adequacy and should be interpreted within the limits of the methods. (1C)
Guideline 3.2.1 – PD : Solute Clearance
We recommend that a combined urinary and peritoneal Kt/Vurea of 1.7/week or a creatinine clearance of 50L/week/1.73m2 should be considered as minimal treatment doses for adults (1A). We recommend/suggest that clearance targets for children should be a minimum of those for adults (1C)
Guideline 3.2.2 – PD : Solute Clearance
We recommend that the dose of dialysis should be increased in patients experiencing uraemic symptoms, or inadequate growth in children, even if meeting minimum clearance targets. (1B)
Guideline 3.3 – PD : Solute Clearance
We recommend that a continuous 24 hour PD regime is preferred to an intermittent regime for anuric patients. (1B)

4. Peritoneal Dialysis (PD) (Guidelines PD 4.1 – 4.5)
Guideline 4.1 – PD : Ultrafiltration and Fluid Management
We recommend that peritoneal membrane function should be monitored regularly (6 weeks after commencing treatment and at least annually or when clinically indicated) using a peritoneal equilibration test (PET) or equivalent. Daily urine and peritoneal ultrafiltration volumes, with appropriate correction for overfill, should be monitored at least six-monthly. (1C)
Guideline 4.2 – PD : Ultrafiltration and Fluid Management
We recommend that dialysis regimens resulting in fluid reabsorption should be avoided. Patients with high or high average solute transport, at greatest risk of this problem, should be considered for APD and icodextrin. (1A)
Guideline 4.3 – PD : Ultrafiltration and Fluid Management
We recommend that dialysis regimens resulting in routine utilisation of hypertonic (3.86%) glucose exchanges should be minimised. Where appropriate this should be achieved by using icodextrin or diuretics. (1B)
Guideline 4.4 – PD : Ultrafiltration and Fluid Management
We recommend that treatment strategies that favour preservation of renal function or volume should be adopted where possible. These include the use of ACEi, ARBs (in adults only) and diuretics, and the avoidance of episodes of dehydration. (1B)
Guideline 4.5 – PD : Ultrafiltration and Fluid Management
We recommend that anuric patients who are overhydrated and consistently achieve a daily ultrafiltration of less than 750 ml in adults (or equivalent volume for body size in paediatrics) should be closely monitored. These patients may benefit from prescription changes and/or modality switch. (1B)

5. Peritoneal Dialysis (PD) (Guidelines PD 5.1 – 5.2)
Guideline 5.1 – PD : Infectious Complications
Guideline 5.1.1 – PD Infectious Complications : Prevention Strategies We recommend that PD units should undertake regular audit of their peritonitis and exit-site infection rates, including causative organism, treatment and outcomes. They should enter into active dialogue with their microbiology department and infection control team to develop optimal local treatment and prevention protocols. (1B)
Guideline 5.1.2 – PD Infectious Complications : Prevention Strategies
We recommend that flush-before-fill dialysis delivery systems should be used for CAPD. (1A)
Guideline 5.1.3 – PD Infectious Complications : Prevention Strategies
We recommend that patients (and/or carers or parents) should undergo regular revision of their technique (at least annually or more frequently if indicated, such as after an episode of PD-related infection or a significant interruption to the patient performing PD) and receive intensified training if this is below standard. (1C)
Guideline 5.1.4 – PD Infectious Complications : Prevention Strategies
We recommend that initial catheter insertion should be accompanied by antibiotic prophylaxis. (1B)
Guideline 5.1.5 – PD Infectious Complications : Prevention Strategies
We recommend that invasive procedures should be accompanied by antibiotic prophylaxis and emptying the abdomen of dialysis fluid for a period commensurate with the procedure. (1C)
Guideline 5.1.6 – PD Infectious complications : Prevention Strategies
We recommend that topical antibiotic administration should be used to reduce the frequency of exit-site infection and peritonitis. (1A)
Guideline 5.2 – PD : Infectious complications
Guideline 5.2.1 – PD Infectious complications : Treatment
We recommend that exit site infection is suggested by pain, swelling, crusting, erythema and serous discharge; purulent discharge always indicates infection. Swabs should be taken for culture and initial empiric therapy should be with oral antibiotics that will cover S. aureus and P. aeruginosa. (1B)
Guideline 5.2.2 – PD Infectious complications : Treatment
We recommend that methicillin resistant organisms (MRSA) will require systemic treatment (e.g. vancomycin) and will need to comply with local infection control policies. (1C)
Guideline 5.2.3 – PD Infectious complications : Treatment
We recommend that initial treatment regimens for peritonitis should include cover for bacterial Gram positive and Gram negative organisms including Pseudomonas species until result of culture and antibiotic sensitivities are obtained. (1C)

6. Peritoneal Dialysis (PD) (Guidelines PD 6.1 – 6.4)
Guideline 6.1 – PD : Metabolic Factors
We recommend that standard strategies to optimise diabetic control should be used; these should be complemented by dialysis prescription regimens that minimise glucose, including glucose free-solutions (icodextrin and amino-acids), where possible. (1B)
Guideline 6.2 – PD : Metabolic Factors
We recommend that plasma bicarbonate should be maintained within the normal range. This can be achieved in the vast majority of patients by adjusting the dialysis dose and/or dialysate buffer concentration. (1B)
Guideline 6.3 – PD : Metabolic Factors
We suggest that central obesity can worsen or develop in some PD patients. The risk of this problem, and associated metabolic complications, notably increased atherogenicity of lipid profiles and insulin resistance, can be reduced by avoiding excessive glucose prescription and using icodextrin. (2C)
Guideline 6.4 – PD : Metabolic Factors
We recommend that awareness of the effects of icodextrin on assays for estimation of amylase and glucose (using glucose dehydrogenase) should be disseminated to patients, relatives, laboratory and clinical staff. (1C)

7. Peritoneal Dialysis (PD) (Guidelines PD 7.1)
Guideline 7.1 – PD : Encapsulating Peritoneal Sclerosis
Guideline 7.1.1 – PD : Encapsulating Peritoneal Sclerosis: Diagnosis We recommend that the diagnosis of encapsulating peritoneal sclerosis (EPS) requires the presence of a combination of clinical and radiological features of intestinal obstruction and encapsulation GRADE 1B.
Guideline 7.1.2 – PD : Encapsulating Peritoneal Sclerosis: Diagnosis
We recommend that the radiological technique of choice for the diagnosis of encapsulating peritoneal sclerosis (EPS) is CT scanning GRADE 1B.
Guideline 7.1.3 – PD : Encapsulating Peritoneal Sclerosis: Diagnosis
We recommend that radiological and biochemical screening methods are NOT of sufficient sensitivity and specificity to be used clinically to identify early or imminent development of EPS in asymptomatic PD patients (GRADE 1C).
Guideline 7.2 – PD : Encapsulating Peritoneal Sclerosis
Guideline 7.2.1 – PD : Encapsulating Peritoneal Sclerosis: Management
We recommend that patients with suspected encapsulating peritoneal sclerosis (EPS) should be referred or discussed early with units who have expertise in EPS surgery. Surgery should be performed by teams experienced in EPS surgery (GRADE 1B).
Guideline 7.2.2 – PD : Encapsulating Peritoneal Sclerosis: Management
We recommend that patients with EPS should have early dietetic referral and monitoring of nutritional status, with nutritional support by oral enteral, or often parenteral supplementation usually required (GRADE 1C).
Guideline 7.2.3 – PD : Encapsulating Peritoneal Sclerosis: Management
We suggest that there is no clear evidence to support a recommendation for the use of any medical therapy for treating EPS. Corticosteroids, immunosuppressants and tamoxifen have been used, and may be tried at the physician’s discretion (GRADE 2C).
Guideline 7.2.4 – PD : Encapsulating Peritoneal Sclerosis: Management
We suggest that PD should usually be discontinued after diagnosis of EPS with transfer to haemodialysis. However, this should be an individual patient decision considering, patient wishes, life expectancy and quality of life (GRADE 2C).
Guideline 7.3 – PD : Encapsulating Peritoneal Sclerosis
Guideline 7.3 1– PD : Encapsulating Peritoneal Sclerosis: Duration of PD therapy
We recommend that there is no optimal duration of peritoneal dialysis or indication for routine elective modality switching. Decisions regarding the duration of therapy should be tailored to the individual patient, taking into account clinical and social factors and patient wishes, and should follow the principles outlined in the ISPD Length of Time on Peritoneal Dialysis and Encapsulating Peritoneal Sclerosis Position Paper (GRADE 1C).