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Saudi clinical guidelines for peritoneal dialysis 2014 I SAUDI CLINICAL GUIDELINES FOR PERITONEAL DIALYSIS 2014 Council of Health Services
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SAUDI CLINICAL
GUIDELINES FOR
PERITONEAL DIALYSIS
2014
Saudi Medical Guidelines for Peritoneal Dialysis
Council of Health Services
Saudi clinical guidelines for peritoneal dialysis 2014

||
TABLE OF CONTENTS :
- CONTRIBUTING AUTHORS
- PREFACE by Mohammed Almaghrabi,MD
- INTRODUCTION by Ayman Karkar,MD
PART 1 ADULT PERITONEAL DIALYSIS CLINICAL GUIDELIENES
Chapter1 peritoneal adequacy and prescription in adult....2
By Adnan Alfi,MD
Chapter 2 Guidelines for Peritoneal Dialysis solutions....8
By Adnan Alfi,MD
Chapter 3 Peritoneal Dialysis related Care and standards in adult....11
By Abdullah Alhwiesh,MD
Chapter4 nutrition in adult patients on peritoneal dialysis....21
By Lutfi Alkorbi,MD
Chapter 5 Peritoneal Dialysis Related Infections....25
By Mohammed Alsunaid,MD
Chapter 6 Noninfectious Complications in adult Peritoneal Dialysis....33
By Abdulkareem AL- suwaida,MD
PART 2 PEDIATRIC PERITONEAL DIALYSIS CLINICAL GUIDELINES
Chapter 7 Pediatric Peritoneal Dialysis Prescription And Adequacy....40
By Majed Aloufi,MD
Chapter 8 PD Catheter Standard Care In Children....46
By Abdullah Al Zulfah, MD
Chapter 9 Nutrition And Pediatric Peritoneal Dialysis....48
By Jameela Kari,MD
Chapter 10 Infectious Complications Of Peritoneal Dialysis....51
By Khalid Alhasan,MD
Chapter 11 Non Infectious Complications In Children....56
By Mohammed Almaghrabi,MD
Chapter 12 Peritoneal Dialysis For Acute Kidney Injury In Children....60
By Abdulhadi Altalhi,MD
PART 3 PERITONEAL DIALYSIS UNIT
Chapter 13 Peritoneal Dialysis Unit setting and standards....62
By Ayman Karkar,MD
INDEX....71
Saudi clinical guidelines for peritoneal dialysis 2014

III
MEDICAL ABBREVIATIONS
<table><tr><td>ACEIs</td><td>Angiotensin Converting-Enzyme Inhibitors</td></tr><tr><td>AKI</td><td>Acute Kidney Injury</td></tr><tr><td>APD</td><td>Automated Peritoneal Dialysis</td></tr><tr><td>ARBs</td><td>Angiotensin Receptor Blockers</td></tr><tr><td>BMI</td><td>Body Mass Index</td></tr><tr><td>BP</td><td>Blood Pressure</td></tr><tr><td>BSA</td><td>Body Surface Area</td></tr><tr><td>BUN</td><td>Blood Urea Nitrogen</td></tr><tr><td>CAPD</td><td>Continuous Ambulatory Peritoneal Dialysis</td></tr><tr><td>Ccr</td><td>Creatinine clearance in liters</td></tr><tr><td>CKD</td><td>Chronic kidney Disease</td></tr><tr><td>CQI</td><td>Continuous Quality Improvement</td></tr><tr><td>CT</td><td>Computed Tomography</td></tr><tr><td>DEI</td><td>Dietary Energy Intake</td></tr><tr><td>D / P</td><td>Dialysate : Plasma</td></tr><tr><td>DPI</td><td>Dietary Protein Intake</td></tr><tr><td>DRI</td><td>Dietary Reference Intake</td></tr><tr><td>EER</td><td>Estimated Energy Requirements</td></tr><tr><td>eGFR</td><td>estimated Glomerular Filtration Rate</td></tr><tr><td>ERBP</td><td>European Renal Best Practice</td></tr><tr><td>ES</td><td>Exit Site</td></tr><tr><td>ESI</td><td>Exit Site Infection</td></tr><tr><td>ESRD</td><td>End -Stage Renal Disease</td></tr><tr><td>ESP</td><td>Encapsulated Sclerosing Peritonitis</td></tr><tr><td>GDP</td><td>Glucose Degradation Products</td></tr><tr><td>GFR</td><td>Glomerular Filtration Rate</td></tr><tr><td>HD</td><td>Hemodialysis</td></tr><tr><td>IP</td><td>Intra-Peritoneal</td></tr><tr><td>IPP</td><td>Intra-Peritoneal Pressure</td></tr><tr><td>ISPD</td><td>International Society of Peritoneal Dialysis</td></tr><tr><td>ISRNM</td><td>International Society of Renal Nutrition and Metabolism</td></tr><tr><td>KDIGO</td><td>Kidney Disease Improving Global Outcomes</td></tr><tr><td>KDOQI</td><td>Kidney Disease Outcomes Quality Initiative (THE NATIONAL KIDNEY FOUNDATION)</td></tr><tr><td>KUB - X ray</td><td>Kidney, Urinary tract , Bladder - X ray</td></tr></table>
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IV
<table><tr><td>MAMC</td><td>Mid-Arm Muscle Circumference</td></tr><tr><td>MDH</td><td>Maximum Duration of Haemodialysis</td></tr><tr><td>MRI</td><td>Magnetic Resonance Imaging</td></tr><tr><td>MRSA</td><td>Methicillin-Resistant Staphylococcus Aureus</td></tr><tr><td>NICE guidance</td><td>National Institute for Health and Care Excellence guidance</td></tr><tr><td>NIPD</td><td>Nocturnal intermittent peritoneal dialysis</td></tr><tr><td>NSAIDs</td><td>Non-Steroidal Anti-Inflammatory Drugs</td></tr><tr><td>PCR</td><td>Protein Catabolic Rate</td></tr><tr><td>PD</td><td>Peritoneal Dialysis</td></tr><tr><td>PDF</td><td>Peritoneal Dialysate Fluid</td></tr><tr><td>PET</td><td>Peritoneal Equilibration Test</td></tr><tr><td>PEW</td><td>Protein Energy Wasting</td></tr><tr><td>PNA</td><td>Protein equivalent of total Nitrogen Appearance</td></tr><tr><td>PRSL</td><td>Potential Renal Solute Load</td></tr><tr><td>QI</td><td>Quality improvement</td></tr><tr><td>RCT evidence</td><td>The Randomized Controlled Trial evidence</td></tr><tr><td>RRF</td><td>Residual renal function</td></tr><tr><td>RRT</td><td>Renal replacement Therapy</td></tr><tr><td>SDS</td><td>Standard Deviation Score</td></tr><tr><td>SEP</td><td>Sclerosing Encapsulating Peritonitis</td></tr><tr><td>SGA</td><td>Subjective Global Assessment</td></tr><tr><td>SIGN</td><td>International Sign Association</td></tr><tr><td>TI</td><td>Tunnel Infection</td></tr><tr><td>UF</td><td>Ultra-Filtration</td></tr><tr><td>UFF</td><td>Ultra-Filtration Failure</td></tr><tr><td>UF volume</td><td>Urine fluid volume</td></tr><tr><td>WBC</td><td>White Blood Corpuscles</td></tr></table>
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V
CONTRIBUTING AUTHORS
ABDULLAH ALHWIESH,MD
Professor of internal Medicine and Nephrology, Dammam University, Dammam, Saudi Arabia
ABDULLAH AL ZULFAH,MD
Consultant Pediatric Nephrologist, King Abdulaziz Medical city, Riyadh, Saudi Arabia
ABDULKAREEM AL-SUWAIDA,MD
Consultant Nephrologist, King Saud University, Riyadh, Saudi Arabia
ABDULHADI ALTALHI,MD
consultant pediatric nephrologist, King Saud medical city, Riyadh, Saudi Arabia
ADNAN ALFI,MD
Consultant Nephrologist, Ministry of health, Jeddah, Saudi Arabia
AQEEL ALGHAMDI,MD
Consultant Pediatric Nephrologist, Ministry of health, Saudi Arabia
AYMAN KARKAR,MD
Consultant Nephrologist, Ministry of health, Dammam, Saudi Arabia
JAMEELA KARI,MD
Professor of Pediatrics, Consultant pediatric Nephrologist, King abdulaziz University, Jeddah, Saudi Arabia
KHALID ALHASAN,MD
Consultant Pediatric Nephrologist, King Saud University, Riyadh, Saudi Arabia
LUTFI ALKORBI, MD
Consultant Nephrologist, King Faisal Specialist Hospital, Riyadh, Saudi Arabia
MAJED ALOUFI,MD
Consultant pediatric Nephrologist, Prince Sultan Medical Military city, Riyadh, Saudi Arabia
MOHAMMED AL MAGHRABI,MD
Consultant pediatric Nephrologist, King Fahad Specialist Hospital, Dammam, Saudi Arabia
MOHAMMED ALSUNAID,MD
Consultant Nephrologist, King Faisal Specialist Hospital, Riyadh, Saudi Arabia
Saudi clinical guidelines for peritoneal dialysis 2014

VI
PREFACE
This clinical reference is intended for health care professionals who are managing peritoneal dialysis patients. It is a small book that summaries up to date peritoneal dialysis clinical guidelines for both adults and pediatrics.
The organization of the book reflects coverage of contents to the clinical aspects.
Part 1 provides up to date clinical guidelines for management of adult peritoneal dialysis.
Part 2 focuses on clinical guidelines for pediatric peritoneal dialysis while part 3 outlines major peritoneal dialysis unit setting and standards.
guidelines objectives:
- To uniform the standard of care for patients on peritoneal dialysis nationwide.
- To establish quality care measures in peritoneal dialysis management for health care providers nationwide.
- To provide summary of recommendations in different clinical aspects for peritoneal dialysis patients serving as quick guide for healthcare giver.
guidelines scope:
- Summary of recommendations in different clinical aspects for peritoneal dialysis management. detailed rationales and literatures review topics are excluded
- Clinical guidelines for both adult and pediatric patients.
- Core guidelines related to PD .clinical aspects like anemia, cardiovascular diseases and bone diseases are excluded
- Outline of major PD unit setting standards. Detailed unit space specifications are excluded
- providing suggested reading in each chapter rather than detailed references helping toward more concise guidelines.
guidelines developer:
The developer of this guidelines is the national program of renal diseases, council of health services in Saudi Arabia.
How these guidelines were developed:
These are adopted clinical guidelines from best up to date available clinical evidence in the field of peritoneal dialysis management which have been developed through tow assigned committee groups (adult and pediatric) compose of senior nephrologists from various health sectors in Saudi Arabia.
Saudi clinical guidelines for peritoneal dialysis 2014

VII
INTRODUCTION
Peritoneal dialysis (PD), hemodialysis (HD) and kidney transplantation constitute an integral renal replacement therapy program, where end-stage renal disease (ESRD) patients can be shifted to one or more of these treatment modalities according to their assessment and prescription and/or when one of these modalities fails to satisfy its needs. Peritoneal dialysis has been well established as a first choice renal replacement therapy (RRT) modality with higher survival rate, especially in the first few years of treating ESRD patients. Peritoneal dialysis, and in particular when there are no contraindications, can be an excellent initial choice and first treatment option.
Recent studies have shown that when compared to HD, PD is associated with equivalent or better survival especially among non-diabetic and younger diabetic patients, where PD has an equal or lower mortality rate during the first 1-2 years of therapy. In addition, PD has the benefits of preserving residual renal function, delaying the need for vascular access and helping patients with multiple vascular access failure, a better option for older age groups especially those with cardiovascular disease and in promoting self-care and helping patients who are in need of more freedom. In fact, PD has become an attractive modality of renal replacement therapy following the recent availability of new PD solutions such as icodextrin and amino-acid-based and biocompatible PD fluids. The advance in PD technology, and in particular the better connecting systems with significant reduction in peritonitis rate and the improved technology of new generation of automated cycler dialysis machines enhanced PD utilization. Studies from the United Kingdom and more recent studies from Netherlands, Belgium and New Haven study have documented that if patients are given informed choice of dialysis treatment, 40-60% will choose PD modality. In addition, when comparing patient satisfaction with modality of HD versus PD as in CHOICE study, patients on PD therapy were more satisfied. Furthermore, patients on PD modality from New Haven study were not only more satisfied with their care, but they also felt with less significant impact of PD on their lives. Finally, one of the advances of PD has been the introduction of automated peritoneal dialysis (APD) technique and compact easy to use cyclers with many advantages.
Despite the multiple benefits and advantages, there has been a slow progress or decline in PD utilization in several countries. The major reasons include (1) insufficient or lack of focus on patients' education and training and encouragement and support, especially for anxious and unwell patients who might be nervous about participating in their own treatment, (2) lack or inadequate training of nursing staff and nephrologists in PD therapy, (3) insufficient encouragement and support of medical and nursing staff to guide patients to chose or implement PD modality as a possible first choice therapy, (4) lack or insufficient appreciation of the concept of “integrated renal replacement therapy (RRT) program”, and (5) inadequate preparation or lack of a proper set up of an independent PD unit.
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VIII
The success and continuity of a PD program relies on different factors including enthusiasm and commitment of the PD team, continuous training program for medical and nursing staff, structured educational program for pre-dialysis chronic kidney disease (CKD) patients, application of continuously updated policies and procedures and continuous evaluation and assessment of the applied program. Actually, implementation of these major steps should not only lay the foundation for solid PD program, but also should help in providing and maintaining adequate and unified standard technical PD performance and successful continuity of the program. This approach should be reflected on extended patient's PD treatment years, as an initial option of RRT, preservation of residual renal function, better preparation of kidney transplantation, delaying or avoidance of HD with vascular access problems, enjoying social life and more freedom together with least technical, infectious and non-infectious complications.
Saudi clinical guidelines for peritoneal dialysis 2014

PART 1
ADULT PERITONEAL DIALYSIS CLINICAL GUIDELINES
Saudi clinical guidelines for peritoneal dialysis 2014

PART 1. ADULT PERITONEAL DIALYSIS CLINICAL GUIDELINES
CHAPTER 1 GUIDELINES FOR ADEQUACY OF PERITONEAL DIALYSIS
GUIDELINE (1) ADEQUACY OF PERITONEAL DIALYSIS
GUIDELINE (2) RESIDUAL RENAL FUNCTION
GUIDELINE (3) PERITONEAL MEMBRANE TRANSPORT CHARACTERISTICS
GUIDELINE (4) MEASURES OF PD DOSE AND SOLUTE CLEARANCE
GUIDELINE (5) FREQUENCY OF MEASUREMENTOF DELIVERED PD DOSE AND TOTAL SOLUTE CLEARANCE
GUIDELINE (6) METHODS OF MEASUREMENT OF DELIVERED DOSE OF PD
GUIDELINE (7) TARGETS FOR SOLUTE CLEARANCE
GUIDELINE (8) FAILURE TO ACHIEVE PRESCRIBED PD DOSE
GUIDELINE (9) PERITONEAL DIALYSIS PRESCRIPTION
GUIDELINE (10) MAINTENANCE OF EUVOLEMIA
GUIDELINE (11) NUTRITION IN PD
GUIDELINE (12) QUALITY IMPROVEMENT PROGRAMS
GUIDELINE (1) : ADEQUACY OF PERITONEAL DIALYSIS
1.1 Adequacy of peritoneal dialysis (PD) should be a concept and not a number and should include clinical assessment of laboratory results, peritoneal and renal clearances, hydration status, appetite and nutritional status, energy level, quality of life, hemoglobin concentration, responsiveness to erythropoietin therapy, electrolytes and acid–base balance, calcium phosphate homeostasis, and blood pressure control.
GUIDELINE (2) : RESIDUAL RENAL FUNCTION
2.1 Frequency of measurement:
2.1.1 Residual renal function (RRF), which represents the function of the native kidneys or the in situ kidney allograft, should be measured at initiation of PD therapy and then every 2 months in the first 6 months, then the measurement to be every 4 months.
2.1.2 More frequent measurement at the following times:
2.1.2.1 Patients who rely significantly on residual renal function to achieve the minimal target level of small solute clearance, RRF should be monitored regularly and at an appropriate frequency (every 1 – 2 months)
2.1.2.2 Substantial decline in urine output.
2.1.2.3 Unexplained fluid overload.
2.1.2.4 With major change of clinical status (eg, hospitalization or weight loss) or biochemical evidence of worsening uremia.
2.1.2.5 Within 4 weeks of any alteration in PD prescription.
2.2 Measures of RRF should be estimated by using 24-hour urine collection and should also be expressed as glomerular filtration rate (GFR) in milliliters per minute.
2.3 RRF should be considered insignificant if urine volume in a 24-hour collection period is \( \leq \) 100 mL or GFR < 2ml/min.
2.4 Preservation of RRF
2.4.1 Health care team in every dialysis facility should strive to preserve RRF.
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PART 1. ADULT PERITONEAL DIALYSIS CLINICAL GUIDELINES
BP should be controlled to less than 140/90 mmHg provided that this is not associated with signs and symptoms of postural hypotension or volume depletion.
2.4.3 Angiotensin converting-enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) should be strongly considered, unless contraindicated, in all PD patients with significant urine output.
2.4.4 Strong consideration should be given to the use of high-dose oral furosemide (up to 250 mg bd) and oral metolazone (up to 5 mg bd) in all PD patients with significant (>100 mL daily) urine output, provided that this is not associated with signs and symptoms of postural hypotension or volume depletion.
2.4.5 Avoidance of potential insults to residual renal function which include avoidance the use of nephrotoxic drugs like aminoglycosides and NSAIDs, avoidance or judicious use of radiographic contrast dye, prevention of episodes of hypotension and volume depletion, and finally prevention and proper control of hypercalcemia and proteinuria.
GUIDELINE (3) : PERITONEAL MEMBRANE TRANSPORT CHARACTERISTICS
3.1 Peritoneal membrane transport characteristics should be monitored for all PD patients using peritoneal equilibration test (PET).
3.1.1 Standard PET is the traditional test used for assessment of peritoneal membrane transport characteristics. It is standardized both procedurally and interpretably.
3.1.2 Fast PET is a simplified standard PET test which is easier, practical and faster and can be used as screening tool to evaluate changes in peritoneal membrane functions in patients that have previously undergone standard PET.
3.1.3 Modified PET is performed to evaluate ultrafiltration failure.
3.2 Baseline peritoneal membrane transport characteristics should be established 4 weeks after initiating a daily PD therapy but no earlier, and to be repeated routinely every 6-12 months.
3.3 More frequent monitoring should be done if clinically indicated:
3.3.1 Presence of unexplained volume overload.
3.3.2 Decreasing drain volume in overnight dwell in CAPD and in daytime dwell in APD.
3.3.3 Increasing clinical need of hypertonic dialysate dwells to maintain drain volume.
3.3.4 Worsening hypertension.
3.3.5 Change in measured peritoneal solute removal (Kt/V \( _{urea} \) ).
3.3.6 Unexplained signs and symptoms of uremia.
3.4 All measurements of peritoneal transport characteristics should be obtained when the patient is clinically stable and at least 1 month after resolution of an episode of peritonitis.
3.5 Icodextrin should not be used in the preceding exchange before a PET as it increases the dialysate:plasma (D/P) creatinine ratio.
3.6 PD patients should be categorized according to their peritoneal membrane transport characteristics and PD modality and prescription to be modified accordingly.
GUIDELINE (4) : MEASURES OF PD DOSE AND SOLUTE CLEARANCE
Saudi clinical guidelines for peritoneal dialysis 2014

PART 1. ADULT PERITONEAL DIALYSIS CLINICAL GUIDELINES
4.1 Delivered PD dose and small solute clearances in peritoneal dialysis should be measured by total weekly \( Kt/V_{urea} \) and total weekly creatinine clearance:
4.1.1 Total (peritoneal plus renal) weekly \( Kt/V_{urea} \) which defined as urea clearances [Kt, (L/week)] normalized to total body water [V, (L)], is based on a 24-hour collection of urine (kidney \( Kt/V_{urea} \) ; if urine volume >100 mL/day) and a 24-hour collection of effluent for PD including the ultrafiltration with the infused dialysate volume (peritoneal \( Kt/V_{urea} \) ).
4.1.2 Total (peritoneal plus renal) weekly creatinine clearance in liters (Ccr) normalized to \( 1.73 \, m^{2} \) body surface area (BSA), is based on 24-hour collection of urine (if urine volume > 100ml/day) and estimation of the average of urea and creatinine clearance (renal \( C_{Cr} \) ) and 24-hour collection of effluent for PD including the ultrafiltration with the infused dialysate volume (peritoneal \( C_{Cr} \) ).
GUIDELINE (5) : FREQUENCY OF MEASUREMENT OF DELIVERED PD DOSE AND TOTAL SOLUTE CLEARANCE
5.1 Within the first six months of PD initiation
5.1.1 Total weekly \( Kt/V_{urea} \) and total weekly \( C_{Cr} \) measurement should be measured one month after PD initiation and a every 3-4 months subsequently.
5.1.2 Measurements should not be performed sooner than 2 weeks of PD initiation.
5.2 More frequent measurements at the following times
5.2.1 With major change of clinical status (eg, hospitalization or weight loss) or biochemical evidence of worsening uremia.
5.2.2 Within 4 weeks of any alteration in PD prescription.
5.2.3 After 4 weeks of resolution of peritonitis.
5.3 Routine measurements of total Kt/Vurea and total creatinine clearance should be performed when the patient is clinically stable (eg, stable weight, BUN and creatinine concentrations).
5.4 Baseline total \( Kt/V_{urea} \) and total \( C_{Cr} \) should be established from the first 2-3 measurements.
GUIDELINE (6) :METHODS OF MEASUREMENT OF DELIVERED DOSE OF PD
6.1 Accurate measurement of total \( Kt/V_{urea} \) and total creatinine clearance ( \( C_{Cr} \) ) requires accurate collection and analysis of urine, dialysate, and serum in a way that yields reproducible and valid results.
6.2 Compliance with complete urine and dialysate collections is mandatory.
6.3 Serum sample preferred to be obtained according to modality:
6.3.1 For CAPD patients, the serum sample can be obtained at any convenient time.
6.3.2 For APD patients, the serum sample should be obtained at the midpoint of the daytime dwell or the midpoint of daytime empty period if patient on NIPD.
6.4 Total body water (V) should be estimated by either the Watson or Hume method in adults using actual body weight.
Saudi clinical guidelines for peritoneal dialysis 2014

PART 1. ADULT PERITONEAL DIALYSIS CLINICAL GUIDELINES
6.5 Body surface area (BSA) should be estimated by the DuBois and DuBois method, the Gehan and George method, or the Haycock method using actual body weight.
6.6 In malnutritioned patient the total body water and the BSA should be estimated based on his or her Ideal Body Weight.
GUIDELINE (7) : TARGETS FOR SOLUTE CLEARANCE
7.1 Adequacy targets for dialysis should include both solute removal and fluid removal.
7.2 Total (renal and peritoneal) weekly \( Kt/V_{urea} \) of 1.7 or a Total (renal and peritoneal) weekly creatinine clearance of 50L/1.73m \( ^{2} \) should be considered as minimal delivered dose.
7.3 The minimum peritoneal target for \( Kt/V_{urea} \) in anuric patients is a weekly value of 1.7.
7.4 The minimum peritoneal target for net ultrafiltration in anuric patients is 750 ml./day.
7.5 In APD patients, due to a more variable relationship between urea and creatinine clearance, an additional target of 45 L/week/1.73 m \( ^{2} \) for creatinine clearance is recommended.
GUIDELINE (8) : FAILURE TO ACHIEVE PRESCRIBED PD DOSE
8.1 Patient related causes of failure to achieve prescribed PD dose should be identified and corrected with special consideration to incompliance of patients to prescribed dose, lack of understanding of importance of adherence to full prescription and errors of sampling and collection.
8.2 Staff related causes of failure to achieve prescribed PD dose should be identified and corrected with special consideration to errors in patient selection, errors in prescription, inadequate monitoring of delivered dose and inadequate patient education.
8.3 Estimation of total daily creatinine excretion in urine and dialysate that differs from the baseline rate (as determined during the first 6 months by \( >15\% \) should prompt an investigation for noncompliance, improper collection of drained dialysate and/or urine, or altered peritoneal transport function.
GUIDELINE (9) : PERITONEAL DIALYSIS PRESCRIPTION
9.1 The peritoneal dialysis prescription should take into consideration patient's body surface area (BSA), peritoneal membrane permeability properties, and amount of RRF. Also the patient's schedule and quality of life should be taken into account.
9.2 For continuous ambulatory PD (CAPD), the usual starting prescription need not to exceed daily 4 exchanges of 2 liters fill volume. Lower volumes or fewer exchanges than \( 4 \times 2 \) L daily can be used for smaller individuals or for those with significant RRF.
9.3 For automated peritoneal dialysis (APD), the initial prescription should be 3-5 cycler exchanges of 2 liters fill volume and the time on the cycler should range between 7 to 10 h. Lower fill volumes than 2 liters can be used for smaller individuals or for those with significant RRF.
9.4 PD prescription should be modified subsequently according to clinical status of the patients and periodic assessment of membrane characteristics and solute adequacy tests.
Saudi clinical guidelines for peritoneal dialysis 2014

PART 1. ADULT PERITONEAL DIALYSIS CLINICAL GUIDELINES
9.5 To optimize middle-molecule clearance in patients who have minimal RRF, the PD prescription should preferentially include dwells for the majority of the 24-hour day. This is recommended even if small molecule clearance is above target without the longer dwell.
9.6 To optimize small-solute clearance, the instilled fill volume per exchange should first be increased before increasing the number of exchanges per day. The exchange volume of the supine exchange(s) should be increased first because this position has the lowest intra- abdominal pressure.
9.7 Anuric patients should not be offered less than 24-h dialysis.
9.8 To optimize the fill volume, the PD prescription should be personalized taking into account the following key points
9.8.1 Body surface area; the classic fill volume of 2 liter per exchange in standard adult person can be expressed as 1200ml/m2 and should be beneficial in patients with small BSA. The optimal fill volume in an adult is 1400-1600mL/m2.
9.8.2 Intraperitoneal pressure (IPP); an increase in fill volume of 500 mL (increasing IPP by 1 cmH2O in supine position) increases the net fluid absorption rate by about 35 mL per hour.
9.9 Compliance of the patients with prescriptions must be verified periodically.
9.10 The patient's record of PD effluent volume should be reviewed monthly, with particular attention to the drain volume from the overnight dwell(s) of CAPD and the daytime dwell(s) of APD.
GUIDELINE (10) : MAINTENANCE OF EUVOLEMIA
10.1 All PD patients should have established dry weight within the first 30 days of PD initiation, and should be monitored regularly for consistent achievement of this dry weight and volume status every 1-3 months or more frequently according to clinical stability.
10.2 Net daily peritoneal UF volume of <750 mL in anuric patients or <250 mL in patients with RRF should be an indication for careful evaluation of volume status focusing on salt and water intake, blood glucose control in diabetic patients, cardiac status, changes in RRF, appropriateness and adherence to the PD prescription, mechanical complications and change in peritoneal membrane function.
10.3 If membrane failure is suspected, assessment with a modified (4.25% dextrose) PET is warranted. A peritoneal UF volume of less than 400 mL over 4 hours with a 4.25% dextrose PET is a good indicator of UF failure, after excluding other causes eg, Leak or Catheter Dysfunctions.
10.4 Management of hypervolemia
10.4.1 Sodium intake should be restricted to 65 mmol (1500 mg) or less daily in patients with hypervolemia.
10.4.2 In patients with RRF, high-dose diuretics (furosemide 250 mg twice daily(bd) with or without metolazone 5 mg bd increase sodium excretion and urine volume.
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10.4.3 Hypertonic 4.25% dextrose solution may be required to achieve euvolemia; however, sustained use of such solution is not desirable.
10.4.4 Icodextrin solution is preferred over glucose-based dialysate for long-duration (>8-hour) dwells.
10.4.5 PD 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.
10.4.6 Anuric patients who consistently achieve a daily ultrafiltration of less than 750 ml should be closely monitored and the benefits of modality switch should be considered.
10.5 Management of hypertension
10.5.1 Patients with hypertension should be assessed for hypervolemia and, if appropriate, treated as outlined in the guideline “10.4 management of hypervolemia”.
10.5.2 Target BP should be <140/90 mmHg.
10.5.3 ACEIs or ARBs should be the preferred antihypertensive agents; however, comorbid conditions should be taken into account when prescribing antihypertensive.
GUIDELINE (11) : NUTRITION IN PD
Nutritional support is an essential part for achieving target adequacy .full recommendations as per related chapter page
GUIDELINE (12) : QUALITY IMPROVEMENT PROGRAMS
12.1 Each PD facility should establish quality improvement programs with the goal of monitoring clinical outcomes and implementing programs that result in improvements in patient care.
12.2 Quality improvement programs should include representatives of all disciplines involved in the care of the PD patient, including physicians, midlevel practitioners, nurses, social workers, dietitians, and administrators.
12.3 Quality improvement (QI) domains that should be considered include the rates of peritonitis, exit site infection, technique failure, patient satisfaction, quality of life, catheter related problems and catheter survival. QI domains should be broadened to include standard therapeutic targets of adequacy measures, blood pressure and volume control, anemia and bone mineral metabolism management, lipid control, etc.
Saudi clinical guidelines for peritoneal dialysis 2014

PART 1. ADULT PERITONEAL DIALYSIS CLINICAL GUIDELINES
CHAPTER 2 GUIDELINES FOR PERITONEAL DIALYSIS SOLUTIONS
GUIDELINE (1) OSMOTIC AGENTS OF PERITONEAL DIALYSIS (PD) SOLUTIONS
GUIDELINE (2) BUFFER SYSTEM OF PD SOLUTIONS
GUIDELINE (3) ELECTROLYTE CONSTITUENTS OF PD SOLUTIONS
GUIDELINE (4) WARMING OF PD SOLUTIONS
GUIDELINE (1) : OSMOTIC AGENTS OF PERITONEAL DIALYSIS (PD) SOLUTIONS
1.1 Glucose is the standard osmotic agent for PD solutions. The lowest glucose concentration possible to achieve euvolemia should be used.
1.2 Amino acid-containing solution should be considered in malnourished patients to improve nutritional status. Amino acid solutions should only be administered once daily(4–6 h dwell) to avoid uremic symptoms and metabolic acidosis.
1.3 Poly-glucose solution which is commercially available as icodextrin 7.5%, containing glucose polymers and having an average molecular weight of 16200 Da, can be safely and effectively substituted for glucose-based dialysates in one long-dwell peritoneal dialysis exchange per day (up to 16 hours).
1.3.1 Icodextrin should be specifically considered in patients with symptomatic fluid overload and ultrafiltration failure, particularly in the settings of acute peritonitis, high transport characteristics, and diabetes mellitus.
1.3.2 Whenever possible, early and continued use of icodextrin should be considered.
1.3.3 With the use of icodextrin, the patients should be closely monitored for skin rashes, hyponatremia and accumulation of maltose and other saccharides which interfere with biochemical assays (e.g. glucose, amylase).
GUIDELINE (2) : BUFFER SYSTEM OF PD SOLUTIONS
2.1 Biocompatible PD solutions buffered with either lactate, bicarbonate or both and delivered in multi-chamber bag should be the first choice of PD solution.
2.2 Although, lactate is the standard buffer applied in conventional PD solution but lactate containing PD solution is bioincompatible and all normal cellular functions of resident peritoneal cells are impaired.
2.3 High buffer-containing solution should be used in patients with metabolic acidosis (venous serum bicarbonate <25mmol/l). However, the serum bicarbonate concentration should be monitored in order to avoid metabolic alkalosis (venous serum bicarbonate>29mmol/l).
GUIDELINE (3) : ELECTROLYTE CONSTITUENTS OF PD SOLUTIONS
3.1 Commercially available PD solutions contain 132-134 mEq/L(mmol/L) of sodium. PD solutions containing 115-126 mmol/l of sodium have shown promising results.
3.2 Potassium should not be included in PD solution.
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3.3 Commercially available PD solutions contain1–1.75mmol/l of calcium. Low calcium-containing solutions should be used in patients with hypercalcaemia. However, the serum calcium concentration should be monitored in order to avoid hypocalcaemia.
3.4 Commercially available PD solutions contain0.25–0.75mmol/l of magnesium. Low magnesium-containing solutions should be used in patients with hypoparathyroidism.
GUIDELINE (4) : WARMING OF PD SOLUTIONS
4.1 PD solutions should be warmed prior to inflow and should be used as soon as possible following heating.
4.2 Any of the following dry heating methods (heating pads, heating/warming cupboards, or manufacturer-supplied warming devices) can be used to warm PD solutions prior to infusion.
4.3 Measured solution temperature prior to inflow should be approximately 37 degrees C (+/- 0.5 degrees C). Solution temperature can be checked by folding the bag over an electronic thermometer probe.
4.4 Water baths should not be used for heating solutions due to the potential of water borne organism contamination to the system.
4.5 PD solution should appear clear in colour prior to infusion and the bag should be discarded if the solution appears brown following exposure to the heat source.
4.6 All staff, patients and caregivers should receive specialized training that is aimed at mitigating potential risk factors associated with warming of PD solutions such as hot spots and glucose degradation products (GDP) formation.
ADEQUACY OF PERITONEAL DIALYSIS SUGGESTED READINGS:
1. Agrawal A. & Nolph K.D. Management of high peritoneal transporters. Peritoneal Dialysis International 20: 160-165, 2000.
2. Blake PG, Bargman JM, Brimble KS, Davison SN, Hirsch D, McCormick BB, Suri RS, Taylor P, Zalunardo N, Tonelli M; Canadian Society of Nephrology Work Group on Adequacy of Peritoneal Dialysis: Clinical Practice Guidelines and Recommendations on Peritoneal Dialysis Adequacy 2011. Perit Dial Int 31: 218–239, 2011.
3. Daugirdas JT, Blake PG, Ing TS, Eds.: Handbook of Dialysis. 4th ed. New York, Lippincott Williams & Wilkins, 2006.
4. Dombros N, et al. European best practice guidelines for peritoneal dialysis. 8 Nutrition in peritoneal dialysis. Nephrol. Dial. Transplant. 2005;20(Suppl. 9):ix28–ix33.
5. Fischbach M, Stefanidis CJ, Watson AR, European Paediatric Peritoneal Dialysis Working Group (2002) Guidelines by an ad hoc European committee on adequacy of the paediatric peritoneal dialysis prescription. Nephrol Dial Transplant 17:380–385.
6. Fouque D, Vennegoor M, ter Wee P et al. EPBG guideline on nutrition. Nephrol Dial Transplant 2007;22(Suppl 2): ii45–ii87.
7. Han SH, Han DS (2012) Nutrition in patients on peritoneal dialysis. Nat Rev Nephrol 8: 163–175. doi:10.1038/nrneph.2012.12.
8. Johnson D, Brown F, Lammi H, Walker R, Caring for Australians with Renal Impairment (CARI). The CARI guidelines. Dialysis adequacy (PD) guidelines. Nephrology (Carlton) 2005; 10 (Suppl 4): S81–S107.
9. Kathuria P, Twardowski ZJ. Automated Peritoneal Diálisis. En: Khanna R, Krediet RT, Eds. Nolph and Gokal's Textbook of Peritoneal Diálisis, third edition. Springer Science 2009.
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10. National Kidney Foundation. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for 2006 Updates: Hemodialysis Adequacy, Peritoneal Dialysis Adequacy and Vascular Access. Am J Kidney Dis 48:S1-S322, 2006 (suppl 1).
11. National Kidney Foundation: II. NKF-K/DOQI clinical practice guidelines for peritoneal dialysis adequacy: Update 2000. Am J Kidney Dis 37[Suppl 1]: S65–S136, 2001.
12. Rees L, Feather S, Shroff R. Peritoneal dialysis clinical practice guidelines for children and adolescents. http://www.bapn.org/assets/clinical_standards/BAPN%20PD%20Standards%20and%20Guidelines.pdf. Accepted January 2008
13. Woodrow G, Davies S. Clinical Practice Guidelines: Peritoneal Dialysis. UK Renal Association, 5 \( ^{th} \) Edition, 30 July 2010. www.renal.org/guidelines.
PD SOLUTIONS GUIDELINES SUGGESTED READINGS:
1. BC renal agency, peritoneal dialysis guidelines: Warming of peritoneal dialysis solution. http://www.bcrenalagency.ca/sites/default/files/documents/files/Warming%20Peritoneal%20Dialysis%20Solutions.pdf.
2. Chaudhary K and Khanna R. Biocompatible Peritoneal Dialysis Solutions: Do We Have One? Clin J Am Soc Nephrol. 2010 Apr;5(4):723-32. doi: 10.2215/CJN.05720809. Epub 2010 Jan 21.
3. Dombros N, Dratwa M, Feriani M, et al; EBPG Expert Group on Peritoneal Dialysis: European best practice guidelines for peritoneal dialysis. 5 Peritoneal dialysis solutions. Nephrol Dial Transplant. 2005 Dec;20Suppl 9:ix16-ix20.
4. Johnson DW, Agar J, Collins J, et al: Recommendations for the use of icodextrin in peritoneal dialysis patients. Nephrology (Carlton). 2003 Feb;8(1):1-7.
5. Schmitt CP, Bakkaloglu SA, Klaus G, Schröder C, Fischbach M; European Pediatric Dialysis Working Group. Solutions for peritoneal dialysis in children recommendations by the European Pediatric Dialysis Working Group. PediatrNephrol. 2011 Jul;26(7):1137-47. doi: 10.1007/s00467-011-1863-4. Epub 2011 Mar 31.
6. Schröder C.H. on behalf of the European Paediatric Peritoneal Dialysis Working Group: The Choice Of Dialysis Solutions In Pediatric Chronic Peritoneal Dialysis: Guidelines By An Ad Hoc European Committee. Perit Dial Int., Vol. 21, pp. 568–574.
7. Teitelbaum I and Burkart J. Peritoneal Dialysis. Am J Kidney Dis. 2003 Nov;42(5):1082-96. Review.
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CHAPTER 3 PD CATHETER RELATED CARE AND STANDARDS INADULT
GUIDELINE (1) THE ACCESS TEAM
GUIDELINE (2) TIMING AND COORDINATION OF REFERRAL AND SURGERY
GUIDELINE (3) IMPLANTATION PROTOCOL
GUIDELINE (4) THE IMPLANTATION TECHNIQUE
GUIDELINE (5) FACILITIES FOR PD CATHETER INSERTION
GUIDELINE (6) TRAINING FOR PD CATHETER INSERTION
GUIDELINE (7) AUDIT OF PD CATHETER INSERTION
The main function of a peritoneal dialysis catheter is to permit consistent bidirectional flow of dialysate without extraordinary effort or undue discomfort [1]. The catheter's function depends upon its design, implantation site, and the configuration of the system used to perform dialysis exchanges. Most catheters are flexible tubes with multiple ports in the distal (intraabdominal) segment which is ideally positioned freely in the intraabdominal pelvic area. The catheter's midportion is normally implanted within the wall of the abdomen via one to two Dacron velour cuffs. With double-cuffed catheters, the deep cuff is imbedded in the abdominal rectus muscle; the superficial cuff in both double cuff and single cuff catheters is placed subcutaneously approximately 2 cm from the catheter exit site on the abdominal wall.
TYPES OF CATHETERS
Many types of catheters are available for chronic peritoneal dialysis. The double cuff straight Tenckhoff catheter, a silicone catheter with a straight (as opposed to coiled) intra-abdominal portion is a commonly used catheter \( [1-3] \) . The Missouri Swan Neck catheter and the Toronto Western catheter have also been used extensively \( [4] \) . Regardless of type, overall catheter survival is approximately 88 percent at one year with removal rates of 15 percent per year \( [3,5,6] \) . The benefit of one catheter over another has not been conclusively demonstrated by prospective, randomized trials \( [3,5-9] \) . A systematic review published in 2004, for example, found no difference related to prevention of peritonitis with respect to straight versus coiled or single versus doubled cuffed catheters, although all cause mortality may be lower with straight catheters (RR of 0.26, 95% CI of 0.07 to 0.99) \( [7] \) .
A randomized prospective study of 132 patients found no difference in time to catheter malposition, catheter-associated infections, or overall catheter survival [10]. However, an unexplained finding on secondary outcome analysis in this study was that a significantly decreased time to technique failure was observed with the coiled catheter (1.4 versus 2.1 years). This was principally due to inadequate small-solute clearance. However, the authors report no difference in dialysis adequacy measures between the two groups, suggesting that study bias is responsible for the observed differenc
CONSIDERATIONS IN CATHETER PLACEMENT :
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Various factors require consideration when inserting a peritoneal dialysis catheter. These include the location of the exit site, use of prophylactic antibiotics, implantation technique, pre- and postoperative care of the catheter, and temporal needs for dialysis [19]. Exit site location — Most PD catheters are placed in a paramedian or lateral abdominal location rather than in the midline. This location allows for positioning of the catheter's deep cuff in or below the rectus muscle, thereby permitting better tissue ingrowth around the cuff due to the richer vascularization of muscle tissue. A paramedian location also provides better structural support for and a strong seal around the catheter, thereby minimizing the risk of peritoneal leak [1-3]. The incidence of peritonitis or exit-site/tunnel infections appears to be similar with midline or lateral insertions. Gentle dissection and careful exit-site construction resulting in the smallest possible hole for the exiting catheter is therefore desirable.
Sutures should never be placed at the catheter exit site. Suture material may act as a nidus for bacterial growth and increase the risk of catheter-related infection. Fibroblast ingrowth of the Dacron cuff is sufficient to anchor the catheter.
There is a paucity of data relating to the efficacy of prophylactic antibiotics before PD catheter implantation. The administration of an antibiotic just prior to peritoneal catheter placement may decrease the incidence of wound infection and peritonitis \( [24-29] \) . In the largest prospective study, 221 patients undergoing PD catheter placement were randomly assigned to vancomycin (1 gm given intravenously 12 hours prior to the procedure), cefazolin (1 gm given intravenously 3 hours prior to placement), or no antibiotics \( [28] \) . At two weeks, the incidence of peritonitis was significantly lower in those given antibiotics, particularly vancomycin (1, 7, and 12 percent for the vancomycin, cefazolin, and no treatment groups, respectively for suture material at the exit site. In a systematic review published in 2004, an analysis of four randomized prospective studies consisting of 335 patients (including the study just mentioned) found that the use of perioperative intravenous antibiotics, compared with no treatment, significantly reduced the risk of peritonitis within one month of surgery (RR of 0.35, 95% CI 0.15 to 0.80).
There are reports of a rise in the incidence of vancomycin resistant Enterococcus sp. As a result, the routine use of vancomycin for prophylaxis prior to catheter insertion is not recommended. Other antibiotics, such as a cephalosporin, should therefore be the first choice [30].
Implantation technique
Compared with an upwardly or horizontally-directed PD catheter tunnel, a downwardly-directed tunnel is preferred and recommended by International Guidelines since it may be associated with fewer catheter infections and fewer peritonitis episodes resulting from catheter or tunnel infections [17]. Catheters with a permanent bend (eg, Swan Neck catheter) naturally have a downwardly-directed tunnel because of the catheter's configuration. There are several basic methods of PD catheter insertion [1-3,20,32]
1- Percutaneous catheter insertion using seldomger
2- Percutaneous catheter insertion technique (simple, new and safe technique by dr alhwiesh with help of introducer and guide wire)(32)
3- Laparoscopy technique
4- Fluoroscopy technique
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5- Surgery technique either by a standard dissection or by a modification, such as the buried technique (Moncrief-Popovich) or using a presternally-located catheter
Percutaneous catheter insertion represents a bedside intervention predominantly performed by nephrologists. It requires only local anesthesia, sedation, and minimal transcutaneous access. Insertion of the PD catheter by the nephrologist has therefore been encouraged by several studies.[32] The ultimate goal is to provide timely and effective catheter insertion without an unduly long wait time or delay, during which potential candidates for PD may lose interest in the modality.
Several worldwide reports have suggested that insertion of PD catheters by nephrologists from centers with more experience in PD results in more effective control of infectious complications and peritoneal access creation (27,30.32). The practice of PD catheter insertion by nephrologists substantially contributed to better treatment outcomes.
Peritoneoscopy/laparoscopy — Peritoneoscopic catheter placement permits immediate use and, in experienced hands, is a relatively simple and quick procedure [3]. At one center, a significantly lower incidence of flow dysfunction was observed with such placement (particularly advanced laparoscopic techniques) compared with an open surgical procedure
Fluoroscopy — Percutaneous fluoroscopy-guided placement provides accurate placement with little waiting time and a relatively small incision. Limited data suggest that this approach provides similar outcomes compared with more invasive techniques. however, the incidence of late leakage appears to be increased.
Surgery — Surgical placement of catheters has the advantage of precise catheter placement with little risk of viscus perforation. Disadvantages are the longer time involved (including operating room scheduling), greater cost, and larger incision required.
The buried catheter technique differs from the standard surgical technique in that the entire catheter remains buried subcutaneously until it is ready to be used, usually four to six weeks after catheter placement \( [25] \) . At that time, the catheter is exteriorized. This method was developed to possibly reduce peritonitis and catheter infections by allowing complete sinus tract healing and fibroblast ingrowth into the cuff before local trauma to the exit site could occur.
Summary :
As with the choice of catheter, the technique used by a PD program depends upon the preferences and expertise of the surgeon or nephrologist inserting the catheter. Each method of insertion has its benefits and proponents, but no technique has been shown to be preferable overall \( [13] \) . A survey of surgical residency program directors showed that, although most programs included peritoneal dialysis catheter placement as a procedure taught to their trainees, most surgeons placed two or fewer than five catheters during their training \( [26] \) . Thus, experience in individual programs will dictate the technique and operators placing PD catheters
POSTOPERATIVE CATHETER CARE :
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Newly placed catheters are usually flushed with small volumes of dialysate (heparin may be added as 500 to 1000 units/L dialysate if fibrin or clots are evident) until the effluent is clear. The catheter is then capped and a dressing applied to the site. There are few controlled trials of optimal catheter care post-placement, but most suggest that the catheter site be covered with gauze dressing and remain undisturbed for several days [3]. The catheter should be immobilized with a dressing and/or tape to minimize trauma [3]. Infrequent dressing changes (eg, once/week) are probably sufficient for the first one to two weeks after implantation. It is important to minimize catheter movement and handling, since local trauma can increase the risk of bacterial colonization with subsequent infection. However, limited data suggest that if necessary, the catheter may be used immediately after placement without increasing the risk of infection. This was shown in a single center study in which 18 patients were started on in-center three times weekly peritoneal dialysis immediately after catheter placement [5]. Compared with 9 patients who waited two weeks prior to starting dialysis, urgent initiation was associated with no greater risk of peritonitis or exit site infection at three months.
To minimize the risk of fluid leak, it is preferable to wait at least 10 to 14 days after catheter insertion before beginning peritoneal dialysis. If PD is required less than 10 days following catheter placement, small volume exchanges (ie, less than 1500 mL) performed in the recumbent position only (eg, with a cycler or chronic ambulatory peritoneal dialysis with supine dwells only) can be performed with little risk of a significant leak.
Some may choose to "lock" the PD catheter during temporary cessation of PD in an attempt to avoid clotting of the PD catheter. Heparin can be used for this purpose in the same dosages used to lock hemodialysis catheters, as the heparin is not peritoneally absorbed. Others may elect not to lock the PD catheter as the risk of catheter occlusion during non-use is probably 1.
The modified GRADE system defines both the strength of the recommendations of the guideline authors and the level of evidence upon which each of the recommendations is based. This grading system classifies expert recommendations as “strong” (Grade 1) or “weak” (Grade 2) based upon the balance between the benefits and risks, burden, and cost. The quality or level of evidence is designated as high (Grade A), moderate (Grade B), low (Grade C), or very low (Grade D) depending on factors such as study design, directness of evidence, and consistency of results. Grades of recommendation and quality of evidence may range from 1A to 2D. The GRADE system was developed by an international group of guideline developers and methodologists to maximize the usefulness of clinical practice guidelines in the management of typical patients (1–7). Most guideline organizations recognize the need for a standard grading scheme and the GRADE system has been adopted by many leading organizations, including NICE, SIGN, KDIGO, ERBP, and KDOQI, as well as UpToDate (8,9).
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GUIDELINE (1) : THE ACCESS TEAM
We recommend that each center should have a dedicated team involved in the implantation and care of peritoneal catheters. Rationale: The access team should comprise nurses, nephrologists, and surgeons who have experience in peritoneal dialysis (PD). Each member of the team should understand the importance to the patient of successful access placement and the need for attention to detail in the reduction of complications
GUIDELINE (2) : TIMING AND COORDINATION OF REFERRAL AND SURGERY
2.1 Timing and Coordination of Referral and Surgery : We suggest that, whenever possible, catheter insertion should be performed at least 2 weeks before starting PD. Small dialysate volumes in the supine position can be used if dialysis is required earlier. Rationale: There are two main patient groups requiring PD access:
1. Patients with progressive renal failure predicted to need dialysis: For these patients, access should be Coordinated from the chronic kidney disease low clearance clinic. The objective is placement of access sufficiently early to enable the patient to train for PD in a timely fashion while residual renal function is sufficient, and to avoid the need for temporary vascular access for hemodialysis if there are problems with catheter function. It is not recommended that patients commencing PD have an arteriovenous fistula formed unless there is a plan to transfer to hemodialysis within a few months or some clinical doubt regarding the viability of PD in a given patient beyond a few months.
2. Patients with stage 5 chronic kidney disease presenting as uremic emergencies [late referrals] For these patients there should be a pathway that allows the choice ofPD as a modality. This requires adequate patient education to be available to permit choice. The advantage of placing PD access in patients who have not had the opportunity to be prepared for renal replacement therapy is that the requirement for prolonged use of central venous access can be reduced. This has to be balanced against the potential for complications associated with the early use of PDcatheters (12).
GUIDELINE (3) : IMPLANTATION PROTOCOL
Implantation Protocol : We recommend that renal units should have clear protocols for perioperative catheter care, including the use of antibiotic prophylaxis. Rationale: The following points should be included in the perioperative catheter care protocol:
- Preoperative: checking for hernias and screening for methicillin-resistant Staphylococcus aureus (MRSA) and nasal carriage of S. aureus; identifying a catheter of a suitable length; marking the exit site with the patient sitting or standing.
- Pre-implantation: preparing the bowel with laxatives; ensuring bladder emptying; administering
prophylactic antibiotics; preparing surgical site according to NICE guidance (14).
- Post-procedure: flushing catheter and capping off using suitable dialysate; covering exit site with a
suitable nonocclusive dressing and, if possible, not disturbing for 5 – 10 days; immobilizing the catheter;
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discharging patient home with supply of aperients and advice on recognizing potential complications.
Once the catheter is placed and until healing is completed, the dressing changes should be done by a dialysis nurse using sterile technique. Administration of prophylactic antibiotics is recommended
to reduce the risk of catheter-site infection, peritonitis, and wound sepsis and there is randomized controlled trial (RCT) evidence for the use of vancomycin (15). The Cochrane Collaboration found four trials of intravenous antibiotics and found the evidence to be strong in preventing catheter insertion-associated early peritonitis but not tunnel or exit-site infection (16). This evidence is also reviewed in the ISPD peritonitis guidelines (17). The choice of antibiotic should be based upon local guidelines, with consideration given to efficacy, risks of selection of resistant organisms, and development of Clostridium difficile colitis.
GUIDELINES (4) : THE IMPLANTATION TECHNIQUE
4.1 The Implantation Technique : We recommend that local expertise at individual centers should govern the choice of method of PD catheter insertion.
4.2 The Implantation Technique : We recommend that each PD unit should have the ability to manipulate or reimplant PD catheters when necessary.
4.3 The Implantation Technique : We recommend that urgent removal of PD catheters should be available where necessary. Rationale: Catheter removal is indicated either acutely
in the case of PD peritonitis or as a planned procedure, for example, following renal transplantation or switch to hemodialysis. For the planned procedure, catheter removal can be performed as a day case. Under certain circumstances, simultaneous removal and replacement has been described for certain indications, for example, localized exit-site infection or during remission following relapsing peritonitis (18). This should not be done for tunnel infection or active peritonitis.
4.4 We recommend that timely surgical support should be available for the review of PD patients. Rationale: There is no RCT evidence to support one method of insertion over another; however, the method needs be determined by patient characteristics. For more complicated patients, including those with previous significant abdominal surgery, a technique that involves direct vision is necessary, such as laparoscopic or open insertion (19).
Peritoneal access surgery is generally considered part of the overall requirement for dialysis access and should include facilities for both catheter insertion and catheter removal. Data from the UK Renal Registry indicate that the incident renal replacement population was 113 per million of the population in 2004, with 20% starting on PD (11). About two thirds of catheter insertions in the UK are performed using the open surgical technique and the majority of the others are done using the medical percutaneous technique
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GUIDELINE (5) : FACILITIES FOR PD CATHETER INSERTION
5.1 Facilities for PD Catheter Insertion :We recommend that a dedicated area should be used for catheter insertion, with appropriate staffing, suction, oxygen, and patient monitoring facilities.
Rationale: The anesthetic requirement depends on the technique selected, which is influenced by the characteristics of the patient. Typically, for percutaneous or peritoneoscopic routes, sedation may be required (20). Conscious sedation needs to be managed according to local clinical governance procedures.
5.2 Facilities for PD Catheter Insertion
We suggest that no particular catheter type has been proven to be better than another Rationale: The Cochrane Review did not find any advantage for straight versus coiled catheters, single or
double cuff, median or lateral incision (21). However, a RCT reported improved primary catheter function (22) and improved PD technique survival for straight versus coiled catheters (23). A further RCT reported that coiled catheters might have higher migration rates than straight catheters (24). These data relate to relatively small studies and we would not advocate at this stage that centers with good outcomes change their choice of catheter type until more information is available. Although
subcutaneous burying of the catheter until use (Moncrief method) was not associated with a reduction
in infectious complications (25), its use may have advantages for the relationship between the timing of catheter insertion and the start of training.
5.3 Facilities for PD Catheter Insertion :
We suggest that a catheter of a suitable length should be used.
Rationale: It is good practice to make an assessment of the required length of the peritoneal catheter since a catheter of inappropriate length can lead to pain or impaired function (26,27). We draw attention to the publications by John Crabtree describing a method to determine the appropriate length for the PD catheter (27).
5.4 Facilities for PD Catheter Insertion :
We suggest that PD catheters 

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