Poor or slow inflow or outflow in Peritoneal Dialysis

What is Poor or slow inflow or outflow in Peritoneal Dialysis?

Slow Flow Peritoneal Dialysis

Poor or slow inflow or outflow of Peritoneal Dialysis fluid is a problem that more frequently occurs during the initial break-in period of a Peritoneal Dialysis catheter.

This condition also can occur at any time in the course of treatment.

What causes Slow Flow Peritoneal Dialysis?

The most common cause of Slow Flow Peritoneal Dialysis is constipation.

It is so very important to prevent constipation after placing the Peritoneal Dialysis catheter

Not moving your bowels enough can lead to problems with catheter function

These problems with catheter function are slow drain time or problems with completely draining the belly.

So, what should be done to address this?

The immediate first step is to effectively clear the bowel of excessive stool.

What if this does not work?

If this is not effective at resolving the problem, then other causes need to be investigated.

Discernment as to whether the flow problem is bidirectional or unidirectional (only poor outflow) helps determine the cause of the problem.

Poor flow on a Peritoneal Dialysis Exchange

The ideal drain time of the fluid during peritoneal dialysis is around 10-20 minutes

Usually the next bag should run through in less than 5 minutes.

If it takes longer, this usually means that there is some constipation.

Usually you can sort this out yourself, and the fluid will drain if you move into a different position.

Bidirectional flow problems usually indicate obstruction of the catheter lumen by clot, fibrin, or a kink or bend in the catheter.

Conversely, unidirectional poor outflow suggests either of the following:

  1. Malposition of the Peritoneal Dialysis catheter in a place where the Peritoneal Dialysis fluid cannot be drained (i.e., migration of the catheter out of the true pelvis).
  2. Encumbrance of catheter drainage pores by tissue or viscera. Although the force of Peritoneal Dialysis fluid inflow can more easily push bowels engorged with stool, epiploic appendices, omental wraps, or adhesions aside, the negative pressure of outflow results in collapse of these organs and tissues on the draining catheter.

Plain-film roentgenographic imaging of the abdomen provides diagnostic assistance in determining the presence of constipation or malposition or kinking of the Peritoneal Dialysis catheter.

Catheters can be repositioned by trocar or laparoscopy.

By exclusion, outflow occlusion not related to constipation is most likely related to adhesions, omental wrapping, or epiploic appendices, and would require surgical or laparoscopic intervention and correction.

Injection of catheters with sterile contrast by radiology can facilitate diagnosis. Inability to resolve these issues with the existing or new Peritoneal Dialysis catheter would be an indication for transfer to HD.

The presence of fibrin or blood occluding a Peritoneal Dialysis catheter at times can be signaled by the appearance of these substances in the Peritoneal Dialysis catheter or effluent.

Heparin should be added in a concentration of 500 to 2000 U/L to each dialysate exchange and continued for at least 24 to 48 hours after the effluent is clear.

A catheter obstructed with blood or fibrin can be treated with push–pull infusion of dialysate or sterile saline under moderate pressure with a 50-mL syringe.

The procedure should be discontinued if the patient has any pain or cramping.

Alternatively there are several anecdotal reports of success utilizing different regimens of tissue plasminogen activator (tPA) infused with sterile saline or sterile water into the Peritoneal Dialysis catheter.

No controlled studies demonstrate the safety or efficacy of this methodology, however.

Continuous ambulatory peritoneal dialysis (CAPD) is used to treat end-stage renal failure in an increasing number of patients.

CAPD has an advantage over hemodialysis in that it allows patients greater freedom to perform daily activities; it also provides other clinical benefits.

However, the long-term effectiveness of CAPD is limited by complications, which have various causes.

Complications with an infectious cause include bacterial peritonitis, tuberculous peritonitis, and infections of the catheter exit site and tunnel.

Noninfectious complications include catheter dysfunction, dialysate leakage, hernias, and sclerosing encapsulating peritonitis.

Many imaging modalities-radiography, ultrasonography, peritoneal scintigraphy, computed tomography (CT), and magnetic resonance (MR) imaging-are useful for characterizing these complications. CT peritoneography and MR peritoneography are techniques specifically suited to this purpose.

Imaging plays a critical role in ensuring that complications are detected early and managed appropriately.

Despite the evidence in favor of Peritoneal Dialysis, there is still a growing concern about Peritoneal Dialysis technique failure, which is estimated to happen in about 40% of patients in the first year of Peritoneal Dialysis and is usually caused by recurrent or refractory peritonitis, ultrafiltration failure, and inadequate dialysis.

What is a Peritoneal dialysis?

Peritoneal dialysis (PD) is a home-based renal replacement therapy for patients with end-stage kidney disease, offering a degree of autonomy and flexibility of lifestyle.

After the placement of a catheter into the peritoneal cavity under either general or local anaesthetic, the patient is instructed how to perform dialysis exchanges during which dialysate is instilled into the peritoneal cavity.

Starting dialysis with a Peritoneal Dialysis Catheter is preferable to an HDC in terms of patient morbidity, mortality, and cost.

It has also been shown in large observational retrospective studies that there is a survival advantage for PD over HD in the first 1 to 3 years of dialysis.

The 2013 Annual Data Report from the United States Renal Data System also shows a significantly improved adjusted probability of 5-year survival with PD compared to HD.

This early survival, for the most part, may be explained by selection bias because healthier patients may be more likely to choose PD as their modality.

Patients with comorbid conditions tend to start HD after an acute illness and have high early mortality that is wrongly attributed to their HD modality.

These exchanges can either be performed manually (continuous ambulatory or CAPD), or using a machine (automated or APD). 

There are two ways to perform peritoneal dialysis, Continuous-Cycler Assisted Peritoneal Dialysis (CCPD) and Continuous Ambulatory Peritoneal Dialysis (CAPD), which are outlined below.  

Continuous Cycling Peritoneal Dialysis

Continuous cycling peritoneal dialysis (CCPD) is a method of performing peritoneal dialysis exchanges using a machine called a cycler during your sleeping hours. Generally, three to five exchanges are done each night. There is an option to drain directly to your toilet or a drain or into drain bags that you would empty when you wake up in the morning. This program frees up your daytime hours. Each nightly session lasts at least eight to ten hours.  Some programs leave you with a set amount of dialysate at the end of your treatment that will dwell during the day.

Continuous Ambulatory Peritoneal Dialysis

Continuous ambulatory peritoneal dialysis (CAPD) is a method of performing peritoneal dialysis exchanges using gravity to drain and fill your peritoneal membrane with solutions four times each day, spaced evenly throughout the day. It usually takes about 30 minutes to complete an exchange. The exchanges can be done in a clean environment, and you are free to be active during each dwell.

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