Transition from Haemodialysis to Peritoneal Dialysis in an ESRD Patient | Case study

The nephrology and renal transplantation experts’ team from PACE Hospitals successfully performed peritoneal dialysis catheter insertion in a 68-year- old adult male patient with chronic kidney disease, stage-V (End stage renal disease).

A 68- year-old adult male with chronic kidney disease stage-V, on haemodialysis (procedure of cleaning blood using dialysis machine and a special filter called dialyzer) was referred to PACE Hospitals, Hyderabad for peritoneal dialysis catheter insertion (A treatment procedure that filters blood inside the body using the lining of the abdomen).

Medical history and Diagnosis

Upon profound examination, it was realized that the patient is a known case of chronic kidney disease stage-V (end stage chronic kidney disease) along with other co-morbidities like diabetes mellitus type II, hypertension, and coronary artery disease. The patient has been on haemodialysis as a complementary treatment method of renal replacement therapy (kidney transplantation). Delving more about his dialysis plan, it is understood that he has been subjected to haemodialysis weekly once through internal jugular vein permcath, at a hospital facility.

After considering the patient related health determinants, and lifestyle, Consultant Nephrologist and Renal Transplant Physician, Dr. A Kishore Kumar, Senior Consultant Urologist & Renal Transplant Surgeon, Dr. Vishwambhar Nath, Consultant Laparoscopic Urologists, Dr. Abhik Debnath and Dr. K Ravichandra from PACE Hospitals have ascertained to switch the patient from haemodialysis-hospital facility to peritoneal dialysis by catheter insertion.

Preparation for the procedure

The patient was admitted for peritoneal dialysis catheter insertion. Baseline investigations like complete blood picture, serum electrolytes, creatinine, liver function tests were done. Ultrasonogram (USG) abdomen is performed to rule out any intra-abdominal mass. The imaging test did not reveal any such mass or adhesions. The patient was given a single dose of glycopeptide antibiotic before performing the procedure.

Procedure

Peritoneal dialysis catheter insertion was done in operation theater under fluoroscopy (a technique used to differentiate between tissues and helps in the accuracy of a procedure) and local anesthesia. The abdomen was draped and cleaned with Betadine, and amino amide class local anesthesia was given 2cm below the umbilicus. A 2 cm incision was made on the skin below the umbilicus and tissues were separated until rectus sheath was exposed. With an intravenous needle, the linea alba was pricked, and the peritoneal cavity was entered. Upon having access to the peritoneal cavity, 500 ml of normal saline was instilled. The position of the needle was confirmed to be in the peritoneum with the help of contrast fluoroscopy. A Guide wire was inserted under guidance and the peritoneal dialysis catheter was inserted with a peel away sheath. Flow was checked, and a tunnel was created for exit on the left side of the abdomen, with the exit facing inferolateral below the belt line. The inner cuff of the peritoneal dialysis catheter was secured to rectus sheath and subcutaneous tissue was closed with absorbable sutures and skin was closed with proline. Dressing was done after achieving hemostasis. 

Aftermath

The patient was shifted to the intensive care unit and observed post procedure. He underwent one session of haemodialysis with permcath. Next day the dressing was changed from the peritoneal dialysis catheter as it was soaked up with seepage of blood. He had a temperature of 99.8O F once and no further episodes of fever. Glycopeptide antibiotic was advised but patient developed reactions of tachypnea (rapid breathing) and shortness of breath, Then the antibiotic is discontinued and given antihistamines with steroids to improve the symptoms after injection. Erythropoiesis stimulating agents (helps in red blood cells production) are given to handle anemia of chronic kidney disease. He was discharged in stable condition, with advice to review after 5 days for dialysis and peritoneal dialysis catheter flushing.

The patient is prescribed with antihypertensive drugs, diuretics, vasodilators, anti-platelets, and antipyretic medications. He was advised not to soak the peritoneal dialysis catheter dressing for 2 weeks. Water intake should be restricted to less than 1000ml per day, whereas salt intake should not be more than 5 grams/ day. Blood glucose levels should be monitored regularly.

The patient was instructed to contact PACE Hospitals in case of any emergency or development of symptoms like fever, abdominal pain, or vomiting. Dr. Kishore Kumar at PACE Hospitals recommended the patient to follow up after five days in the outpatient ward.

Switch in dialysis procedure: All you should know about!

Dialysis is a procedure to remove waste products and can be performed using various techniques like haemodialysis, peritoneal dialysis etc.

Haemodialysis cleanses the blood using a dialysis machine and a special filter called dialyzer (often called artificial kidney). On the contrary, peritoneal dialysis is the treatment procedure that filters blood inside the body using the lining of abdomen. Though the goal of both dialysis techniques remains similar, they carry their own advantages over the other technique.

Switching from one type of dialysis to another is common in patients with end stage renal disease (ESRD). Based on the patient’s lifestyle, some of the patients prefer to treat themselves at home, which is where peritoneal dialysis is done, and few patients would like to have professionals treat them at a hospital setup, where haemodialysis is done. In some cases, patients consider switching dialysis type due to technique failure (vascular access blockage/ infection) or medical reasons. Peritoneal dialysis is more effective in maintaining the haemodynamic stability for end stage renal disease patients, reducing blood pressure level, improving the clearance rate of molecular substances, and protecting the renal function of patients compared to haemodialysis, thereby improving the quality of life of the patient.

Department of Nephrology