PERITONEAL DIALYSIS: PHYSIOLOGY

WHAT ?
Uses dialysis fluid infused into the peritoneal cavity and a system of biological membranesthe peritoneal barrier for this purpose.

Solutes and fluids are exchanged between the capillary blood and the intraperitoneal fluid through a biologic membrane, the peritoneum.

HISTORY

Ganter performed first PD in humans in 1923.

the first successful treatment of acute renal failure using peritoneal irrigation was described more than 20 years later by Fine, Frank, and Seligman in 1946.

In 1950, Odel and coworkers reviewed the experience with the first 100 patients treated with intermittent PD, from 1923 to 1948 and concluded that this therapy should be restricted to patients with reversible acute renal failure
With the introduction of Tenckhoff catheter in 1968, and the portable/wearable equilibrium dialysis technique in 1976, PD became a viable renal replacement therapy for the long-term treatment of patients with ESRD

CAPD originated in Austin, Texas, in 1975, when Robert Popovich and Jack Moncrief discussed ways to dialyze a patient who was unable to undergo hemodialysis

PERITONEAL ANATOMY

Wrapped tightly around.

Surface area of 1-2 sq m Visceral % 80 Sup Mesenteric artery Portal vein Parietal 20 Lumbar, intercostal,epi gastric IVC

Blood supply

Venous drainage

Parietal peritoneum is more important in PD Remember: functional area is important compared to total peritoneal surface area. The functional area relates to the surface area of the capillaries in the peritoneal interstitium, the capillary density, and the spatial arrangement of these capillaries.

HISTOLOGY

Surface lined by mesothelium Covered with thin layer of peritoneal fluid 5 micro meter. Beneath the mesothelium lies the interstitial tissue, comprising of an amorphous ground substance or gel like extracellular matrix interlaced with collagenous, reticular, and elastic fibers; adipocytes, fibroblasts, and granular material and containing blood capillaries, nerves, and lymphatic vessels.

MODELS OF PERITONEAL TRANSPORT

3 pore model Distributed model.

3 pore model

Peritoneal capillary is critical barrier to peritoneal transport. Pores of different size mediate the transfer of solutes and water.

DISTRIBUTED MODEL

Emphasizes the importance of distribution of capillaries in the peritoneal membrane. Transport is dependent on surface area of the capillaries. The distance of each capillary from the mesothelium determines its relative contribution

PHYSIOLOGY OF PERITONEAL TRANSPORT

Diffusion Ultrafiltration Fluid absorption

DIFFUSION

Factors influencing diffusion

Concentration gradient Effective peritoneal surface area Intrinsic peritoneal membrane resistance Molecular weight of the solute concerned.

Factors influencing diffusion

Concentration gradient: Larger the gradient,

more efficient the dialysis. Maximum at start of dialysis dwell gradually decreases during the course of dwell. counteracted by : More frequent exchanges Increasing dwell volume

Effective peritoneal surface area: area of peritoneal surface that is sufficiently close to capillaries to play a role in transport. Increased by using larger fill volumes.

INTRINSIC PERITONEAL MEMBRANE RESISTANCE: may reflect Differences in number of pores per unit surface area of capillary available for peritoneal transport Distance across the interstitium of these capillaries from the mesothelium.

ULTRAFILTRATION

FACTORS INFLUENCING UF:

Concentration gradient for the osmotic agent. Effective peritoneal surface area. Density of small and ultra pores in capillaries Reflection coefficient for the osmotic agent Measures how effectively the osmotic agent diffuses out of dialysis solution into the peritoneal capillaries. Between 0 and 1 Glucose : 0.03, icodextrin 1

HYDROSTATIC PRESSURE GRADIENT:

Capillary pressure : 20 mm Hg Intraperitoneal pressure : 7 mm Hg

Greater in well hydrated pts, lower in dehydration. Intraperitoneal pressure increased with standing/sitting and with large dwell volume.

Oncotic pressure gradient.: UF high in hypoalbuminemia.

FLUID ABSORPTION

1-2 ml per min Via lymphatics 0.2-0.4 ml per min Rest absorbed across the parietal peritoneum into surrounding tissues.

Clinical assessment of peritoneal transport

The net removal of solutes and fluid during PD can be measured by evaluating the drained dialysate. the concentrations of urea and creatinine are measured in dialysate and plasma. The dialysate to plasma concentration ratios (D/P) of either of these solutes multiplied by the daily drain volume gives the 24-hour clearance. Weekly creatinine and urea clearances are obtained by multiplying these figures by 7.

Peritoneal Equilibration Test

Yields approximate estimations of the rate of peritoneal transport of small solutes and of UF capacity

HIGH TRANSPORTERS

Have relatively large effective peritoneal surface area or high intrinsic membrane permeaility.
Achieve most rapid and complete equilibration for creatinine and urea.

HIGH TRANSPORTERS

Rapidly loose their osmotic grdient for UF. High D/P Cr, Ur, Na Low D/Do Glucose. Rapidly loose protein.

LOW TRANSPORTERS

Low membrane permeability, and small effective peritoneal surface area. Have slower and less complete equilibration for urea and creatinine. Low D/P cr, Ur, Na High D/Do Glucose and high UF.

Clinical implications
Peritoneal membrane transport classification 1. Choose peritoneal dialysis regimen. 2. Monitor peritoneal membrane function. 3. Diagnose acute membrane injury. 4. Diagnose causes of inadequate ultrafiltration. 5. Diagnose causes of inadequate solute clearance. 6. Estimate dialysate to plasma ratio of a solute at time t. 7. Diagnose early ultrafiltration failure. 8. Predict dialysis dose.

Diagnosing UF failure: D/P Na ratio

Why to start with PD ?

1. better maintenance of residual renal function

Why to start with PD ?

clinical outcomes comparable to HD, no difference in 2 year and 5 year mortality vs. HD (study NECOSAD) saves vascular access preferred for children (APD)

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