Therapy Modality: Continuous Ambulatory Peritoneal Dialysis ( CAPD )

1. Therapy Modality:Continuous Ambulatory Peritoneal Dialysis (CAPD) Renal Division Baxter Healthcare

2. CAPD - basic prescription • Manual therapy • Prescription volumes standardised 1,500ml, 2000ml, 2500ml, 3000ml solution bags • 6-8 hour dwell period each night (depends on type of membrane) • 4-5 day exchanges (with optional night dwell), 7 days a week • 3-5 hr dwell per day exchange

3. CAPD Exchange Procedure 1.Fill phase (<10 Minutes)

4. CAPD Exchange Procedure 2. Dwell phase (4-8 hours) 3. Drain phase (<20 minutes)

5. CAPD CAPD Continuous Therapy Volume Benefits Limitations 24 0 Time • Optimum dialysis for low permeability • Can be performed anywhere • High transporters will have poor UF • 4 x exchanges per day • IP pressure with large volumes Ambulatory Anywhere 4 - 5 Exchanges Long Dwells

6. Procedural Modifications- increasing UF 1 2 3

7. Procedural Modification - fill volume

8. Procedural Modification- no. of exchanges

9. PD Technique Survival Kawaguchi PDI 1999;19 (supp 2):S327 Years %

10. PD Technique Survival Kawaguchi PDI 1999;19 (supp 2):S327 • Reasons for withdrawal - Loss of UF - Inadequate dialysis - Peritonitis - Patient choice/psychological (‘burn-out’)

11. CAPD Outcome - Japan Kawaguchi PDI 1999;19 (suppl 3):S9 • 235 patients analysed between 1980 - 1997 • Average survival was 5.8 years • 142 patients changed dialysis therapy • Causes - loss of UF (23%) - inadequate dialysis (16%) - peritonitis (14%) • Peritonitis rate was very good - 1 episode/54 patient months

12. Causes of Technique Failure in Long-term PD 14% 5% 36% 20% 25%

13. CAPD Systems AIM: Safety, Simplicity, Comfort & Convenience Requirements: • Minimise risk of touch contamination • Maximise Flush efficiency • Inactivate organisms at patient connector if touch contamination occurred. • Proven and reliable connectology • Increased inactivation of organisms at the patient connection if a touch contamination occurs • Easy to learn and use system for all patients

14. 1 in 1 1 in 51 in 10 1 in 151 in 201 in 25 1 in 30 1 in 35 1 in 40 78 79 80 81 82 83 84 85 86 87 88 89 90 95 2000 Improvements in PD Connectology Gokal R., Nolph K.: Textbook of PD: 1-15, 1994. 1977-80 Data: Nolph & Sorkin, U. Missions1980-87 Data: CAPD Registry, USA1987-90 Data: Anecodotal reports, Europe/USA Infections (Per Patient Months) 1979: Monthly Tubing Change Titanium Adapter 1980: New Spike CAPD Set 1985: Extended Life Transfer Set, BDP 1986: UVXD 1986: APD-PAC X 1987: Y Set 1988: TwinBag - Europe 1989: UV-Flash, Pac Xtra 1990: PD Ultra Bag 1995: Homechoice 2000: Homechoice PRO

15. Peritonitis – Y-setSystems Holly AJKD 1994 > Peritonitis rates have improved over the years Straight line Y-set Staph epid. 0.34 0.17 Staph aureus 0.15 0.13 Gram -ve 0.12 0.10 Fungal 0.02 0.01 Peritonitis rate episodes/pt month disconnect O-set titaneum Plastic bags Glass bottles

16. Sources of Contamination Routes of entry

17. Safety: Reduced risk of organisms entering the PD system if touch contamination occurs Kubey W., et al., Blood Purification; 2000, 19(1). Twinbag connectology allows significantly (p<0.0001) fewer bacteria to be transferred into the fluid path. A recessed luer is of particular importance. Non-Recessed luer Recessed luer

18. CAPD Connectology: Reduced risk Kubey W., et al., Blood Purification; 2000, 19(1). The short distance between the Y-Junction and the patient connection ensures effective removal of bacterial contamination from the patient line should connection failure occur.