CAPD : pemilihan pasien,persiapan

dan insersi kateter

Atma Gunawan

Consultant Nephrologist

RSSA Malang

Pilihan terapi pengganti gagal ginjal

Pilihan terapi pengganti gagal ginjal

CAPD (continous ambulatory peritoneal dialysis)

CAPD

Osmosis :

APD (automated peritoneal dialysis)

Distribusi HD, PD dan home HD

Briggs et al. International Variations in Peritoneal Dialysis Utilization and Implications for PracticeAJKD. July 2019Volume 74, Issue 1,

Pages 101–110

Data IRR Jan 2018:

CAPD 2%

HD 98%

PLB

CAPD Data per Des 2018

15

45 17

40

21

9

21

70

68

78

22

16

13

CAPD Px

Mapping

75

30

57

360

54

88

179

496

22

46

Solo

61

202

RSSA

Malang

ESRD ’S PATIENT (SEPT 2017)

Haemodialysis

CAPD

Renal Transplant

N = 688 (70%)

N = 296 (30%

N = 15 (1.5%)

PD candidate population

• All patients initiated on dialysis with a

diagnosis of ESRD .

• Acute kidney injury.

• All patients with a failed graft requiring

dialysis.

• CHF resisten diuretik

• Liver cirrhosis with ascites permagna

• ESRD children < 20 kg

Surgical Contraindications to CAPD

• Absolute :

- severe peritoneal adhesions

- inflammatory bowel disease

- sepsis of anterior abdominal wall

- large unrepairable hernia of abdominal wall

• Relative :

- previous extensive pelvic or low abdominal surgery

- colostomy or ileostomy

- bleeding tendency

- post peritonitis

Benefit on PD ?

• Survival awal lebih baik

• Biaya lebih murah

• Preservasi RRF

• Logistik !

• Risiko hepatitis lebih rendah

• Clearance terhadap toxin makromolekul lebih baik

Data harapan hidup

Study CAPD Hemodialisis Kidney transplant

Renal registry report 20091 year survival

94.5% 87.3% 97.9% *

Huanag et al 200810 year survivar

35% 33.8% 86% *

Peritoneal Dialysis: Peritoneal Dialysis in the Treatment of Stage 5 Chronic Kidney Disease.NICE Clinical Guidelines, No. 125.Centre for Clinical Practice at NICE (UK).London: National Institute for Health and Clinical Excellence (UK); 2011 Jul.

* Ojo Ao, Kidney Int. 2000 Jan;57(1):307-13

Perbandingan biaya (mandiri)

Biaya 1x HD = Rp 879.000,-

Biaya HD perbulan (12x) =

Rp 10.548.000.-

NB; InaCBGs HD RSUD tipe

B

120 kantong CAPD bag

perbulan = Rp 7.500.000

Transplantasi ginjal RSUD

tipe A Rp 415.365.800 +

obat RP 50 jt satu tahun

pertama

Pembiayaan Mandiri 1 Pasien gagal ginjal kronik/ESRD

TahunKe-

KumulatifBiaya Hemodialisa

KumulatifBiaya C A P D

Kumulatif BiayaTransplantasi ginjal

1 93.600.000 79.200.000 300.000.000

2 187.200.000 158.400.000 330.000.000

3 280.800.000 237.600.000 360.000.000

4 374.400.000 316.800.000 390.000.000

5 468.000.000 396.000.000 410.000.000

6 561.600.000 475.200.000 440.000.000

7 655.200.000 554.400.000 470.000.000

8 936.000.000 633.600.000 500.000.000

9 1.029.600.000 712.800.000 530.000.000

10 1.123.200.000 792.000.000 560.000.000

HD = 1 pasien x 12/bulan x 650.000, CAPD 12 x 6.600.000, Renal transplant : biaya op 250.000.000, thn 1 obat 50 jt, tahun ke dua dan seterusnya obat 30 jt per tahun (RSSA)

HD 12x/bl ; CAPD 4 bag/hari

Clearance by normal kidneys HD and CAPD

Cle

aran

ce (

L/w

k)

0

200

400

600

800

1000

Kidney Hd CAPD

MW

Inulin 5200

Creatinine 113

Urea 60

Risiko hepatitis B

Keuntungan segi logistik

• HD : 1 nurse per 3 pasien

PD : 1 nurse per 50 pasien

• Rasio kebutuhan bangunan terhadap pasien sangat kecil !

• Biaya transportasi sedikit

Methode Seldinger

technique

Peritoneuscopic Minilaparotomy Laparoscopic

Done by Nephrologist Nephrologist Surgeon/nephrolo

gist

Surgeon/nephrolo

gist

Setting Clean side-room Clean side-

room/operating

theater

Operating theater Operating theater

Anesthesia Local anesthesia Local/general

anesthesia

Local/general

anesthesia

General anesthes

Pros (i) Short learning

time

(ii) Low

complication rates

(i) Direct

visualization of

Peritoneum

(ii) Low leakage

rates

(i) Direct

visualization of

peritoneum

(ii) Allow purse-

string suture of

peritoneum

(iii) Low leakage

rates

(iV) Can

omentectomy

(i) Visualization of

intra-abdominal

structures

(ii) Allow

adjunctive

procedures for

example

Adhesiolysis,

omentopexy

Cons Relatively high

early

leakage rates

Short learning

time

Long learning time Long learning time (i) Very long

learning time

(ii) High cost

(iii) Specialized

equipment

needed

International Journal of Nephrology Volume 2013, Article ID 940106

Surgical versus percutaneous techniques for peritoneal

dialysis catheter placement: A meta-analysis of the

outcomes

Annals of Medicine and Surgery 10 (2016) 11-18

Incidence of overall mechanical and

infectious complication

Annals of Medicine and Surgery 10 (2016) 11-18

Who inserted PD catheter ?

KGH

Bedah umum

Bedah digestive

Bedah urologi

Competency of nephrologist consultant

Methode of insertion PD catheter

Methode of PD insertions by nephrologist

Methodes Hospital

Laparatomy RSSA (Malang) ; RSUD Zainul Abidin

(Banda Aceh)

Peritoneuscopic

Seldinger technique

RSSA (Malang)

RSSA (Malang) ; RSHS (Bandung),

RS Gatot Subroto (Jakarta) ; RSUP

M.Hoesin (Palembang)

• PD catheter inserted by nephrologist start on 2006.

• Started at Malang, by laparatomy methode

Site of insertion/deep cuff location

: surgical approach : peritoneus/laparoscopic

Catheter anatomy

Extra-Peritoneal

standard Tenckhoff

Swan neck

Cuff

double cuffs

single cuff

Intra-Peritoneal

straight

coiled tip

Types of PD catheter

Tenckhoff cateheter

Deep cuff location

• Deep cuff should be burried inside muscle or posterior fascia

PD catheter implantation by

laparatomy

Location of main wound and exit site

(laparotomy).

Skin incision, the subcutaneous tissue is

dissected till the reach of the anterior

rectus sheath

The rectus muscle is bluntly split

The posterior rectus sheath and the

peritoneumembran then identified and cut

open

Purse-string suture of the peritoneum

together with the posterior rectus sheath is

then applied

After the insertion of PDC with a malleable

stylet, the peritoneum and posterior rectus

sheath are closed with the purse-string

suture

The internal cuff is tightly tied above the

posterior rectus sheath and the

peritoneum, secured within the rectus

muscle

The anterior rectus sheath is then sutured

with a part of the PDC tunneled between

the anterior rectus sheath and the rectus

muscle.

The PDC is tunneled in the subcutaneous

layer, a downward pointing exit site

Open surgical repositioning and partial omentectomy

Ny. M, 68 y.o. Bad inflow and outflow.Catheter

migration. Repairing Sept 8,2007. RSSA

Kaplan–Meier plot of Tenckhoff catheter survival in

the present study. 2 yr sr 87,2 %

TENCKHOFF CATHETER

INSERTION BY 6

NEPHROLOGISTS:OPEN

DISSECTION TECHNIQUE in

Hongkong. N=250 (2005-2008)

Perit Dial Int 2010; 30:524-527

PD catheter implantation by

peritoneuscopic

Peritoneuscope

Site of insertion

Rectus abdominis muscle, and the mean distance from midline to LRA at the three levels

To avoid injury to IEA, trocars can be safely inserted 5.5 cm [mean + 1 standard deviation (SD)] away from the midline (or) slightly more than one-third of the distance

between the midline and a sagittal plane running through ASIS

Joy P et al. J Min Access Surg 2017;13:18-21

Make 3-5 cm long horizontal skin incision.

Perform blunt dissection with hemostats to the anterior surface of the rectus sheath.

Insert Quill® Catheter Guide Assembly at 20o - 30o angle toward coccyx into the

peritoneum

Insert Y-TEC® scope into cannula & lock together. Confirm location of

cannula (and scope) within the peritoneum.

Insufflate filtered room air (approximately 700—1200 cc, depending on

patient size

Re-insert scope

Examine peritoneum to find best location for catheter

Remove the cannula from the Quill® Guide with a slight twisting motion and

retraction of the cannula

Insert and dilate the Quill® Guide with the small and large dilator (goal is to

dilate rectus muscle).

Insert the stylette into the catheter. Insert catheter (with stylette) through the

rectus muscle into location in the peritoneum

Advance catheter and Cuff Implantor® simultaneously 1 cm into the rectus

muscle. Retract the Quill® Guide and cuff implantor parallel with the catheter

Create tunneling : incision exite site, inserting tunnelor with

catheher to exite site

Perbandingan open surgery vs peritoneuskopi di RSSA

Open Surgery (n=108) Peritoneouscopy (n=64)

Usia (tahun) (p=0.053) 50±13.4 47±10.3

Jenis Kelamin (L/P) (p=0.331) 74/34 41/23

Lama CAPD (bulan) (p=0.548) 45±40.9 19±15.5

≤ 6 bulan 9(8.3%) 7(10.9%)

7-12 bulan 25(23.1%) 21(32.8%)

>12 bulan 74(68.5%) 36(56.3%)

Tingkat Pendidikan (p=0.001 )

≤ SD 25(23.1%) 34(53.1%)

SMP 27(25.0%) 8(12.5%)

SMA 37(34.3%) 12(18.8%)

≥ S1 19(17.6%) 10(15.6%)

Komplikasi non mekanik (p=0.015)

Perdarahan 5(4.6%) 2(3.1%)

Infeksi Exit Site 7(6.5%) 0

Peritonitis 4(3.7%) 0

Masalah Mekanik (p=0.182)

Malposisi 4(3.7%) 2(3.1%)

Kateter Tertekuk 0 1(1.6%)

Bocor 8(7.4%) 0

Outflow Failure 6(5.5%) 3(4.7%)

Outcome Catheter (p=0.947))

Meninggal 31(28.7) 18(28.1%)

Off Catheter 5(4.6%) 1(1.6%)

Peritonitis 9(8.3%) 8(12.5%)

LAPAROSCOPIC

(for catheter reposition)

OMENTOPEXY

Break in periode

• Time to start dwelling

• Depend on methode of insertion.

• Optimally 2 weeks post-operation.

• Peritoneuscopic : 1 week

Laparascopic : 10 days

Seldinger technique : 2 weeks

Laparotomi : 2 weeks

• However, peritoneal dialysis can be started within hours of

placement of a catheter if needed; using low-volume, supine

exchanges.

• The break-in period may need to be longer in patients in whom there

is concern about impairment in wound-healing (diabetes, on steroid).

Embeded catheter

(Moncrief and Popovich Technique)

Perawatan kateter PDpasca insersi

• Antibiotik profilaksis diberikan sebelum insersi kateter PD

• Dressing exite site dilakukan setiap minggu, sampai luka kering.

• Dressing tambahan dilakukan bila kasa basah atau berdarah.

• Belum boleh kena air selama luka belum kering.

• Mandi/shower boleh setelah luka kering (2-3 minggu post-op).

ISPD Guideline.Perit Dial Int 2012; 32:S29–S86 ; Oxford Univ. Hospital , NHS Found Trust

Perawatan kateter PDpasca insersi

Lakukan teknik aseptik, masker dan handschoen steril:

• Bersihkan luka sekitar exite site dengan kasa steril yang dibasahi cairan antiseptik.

• Kerak luka dibersihkan dengan kasa dibasahi NS.

• Gunakan kasa lain untuk membersihkan tubing kateter, dari arah tubuh keluar

• Gunakan kasa kering steril beberapa lapis untuk menutup luka. Lalu difiksasi

• Selang kateter difiksasi, sesuai posisinya, untuk mencegah pergerakan.

ISPD Guideline.Perit Dial Int 2012; 32:S29–S86

Perawatan kateter harian untuk pencegahan infeksi

• Setiap hari dioleskan antibiotik cream/zalf pada exite site.

• Exite site dibersihkan minimal 2x seminggu atau setiap selesai mandi/shower

• Bila terjadi exite site infection : bersihkan exite site setiap hari.

ISPD CATHETER-RELATED INFECTION RECOMMENDATIONS: 2017 UPDATE

Antibakteri Topical , Antiseptik, dan cairan antiseptik untuk pencegahan infeksi terkait kateter

• Povidone-iodine • Chlorhexidine solution • Amuchina solution/hypochlorite solution • Mupirocin cream • Gentamicin cream or ointment • Ciprofloxacin otologic solution • Antibacterial honey • Polysporin triple ointment • Polyhexanide

Ringkasan

• CAPD adalah pilihan terapi pengganti ginjal

yang mempunyai beberapa kelebihan

dibandingkan HD

• Metode insersi percutaneus memberikan hasil

lebih superior dibandingkan laparotomi

• Lama break in periode tergantung metode

insersi

• Dressing dan exite site care adalah penting

paska operasi