PERITONEAL DIALYSIS. Frequently Asked Questions

Transcription

1 PERITONEAL DIALYSIS Frequently Asked Questions How will I know if PD is working well? What Problems can happen on PD? What medicines will I need to take? Will I need to be on a special diet or fluid restriction?

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3 How will I know if PD is working well? Most people, who have been on PD for a few weeks, start to feel quite well again. When you first start PD you may still be passing urine and this will help clear some waste and fluid from your body. Over the first two years on PD your urine output may decline, and your PD prescription may need to be changed. Symptoms such as feeling weak and tired, nausea and lack of appetite may be a sign that you are not receiving enough dialysis. A number of different blood and PD fluid tests can be carried out to assess how well your dialysis is working. What tests will I need to check how well my PD is working? People on PD need to have regular blood tests. Blood tests can tell how well PD is working, how well nourished you are, the state of your bones, how acid your blood is as well as your blood count, and iron level. The substances measured include: Creatinine: Potassium: Urea: Phosphate: Glucose: Bicarbonate: Albumin: This is the waste produced by muscles. A high creatinine level is not harmful, but it is an indicator of other waste in the blood. For an average sized person on PD the target level is below 800 mmols/l. This mineral is normally present in the blood. If the level gets too high or low it can cause the heart to stop. The normal level is mmols/l. Crisis levels are less than 2 or greater than 8, but most Kidney Units prefer you to have a large safety margin! Urea is produced when the food we eat is broken down. The normal level is mmols/l, but in dialysis patients a realistic target to aim for is a urea level of less than 25mmols/l. A high urea level will ften cause sickness. Phosphate is one of the substances in the blood necessary to keep bones healthy. The normal level is mmols/l. The target level on dialysis is less than 1.8 mmols. A high level can cause itching and bone disease. Diet and phosphate binders can help to control the level. The normal level of blood glucose is mmols/l. For diabetics on PD the high glucose in the PD fluid (needed to remove fluid) can cause problems. If patients absorb a lot of glucose from the PD fluid they may put on body weight. This is a measure of the acidity of the blood. If the blood bicarbonate level is low, this means the blood is too acid, and can cause weakness and fatigue. The normal level of bicarbonate in the blood is mmol/l. If the level is lower than normal, the amount of PD may need to be increased to reduce the acid level in the blood, or a bicarbonate supplement may be needed. This is a type of protein, and is an indicator of how well nourished 1

4 Calcium: Haemoglobin: Ferritin: PFT: a person is. The normal level is grams/l. The target level is around 35 grams/l but this varies between Units, as Hospitals use different methods to measure albumin. This mineral is needed to keep bones healthy. The normal level of calcium in the blood is mmol/l. Haemoglobin, or Hb as it is known, is the substance in the blood that carries oxygen around the body. The normal level is g/dl in women, and in men. A low Hb is called anaemia. The target level for people on PD is around 11-12g/dl. Iron supplements and EPO are common treatments for anaemia. Iron is needed to produce red blood cells, and a guide to how much iron is in the body is to do a blood test for ferritin. The target level for ferritin in the blood is above 200 mg/l. A Peritoneal Function Test. In some Units people are asked to collect all the PD fluid that they drain out, along with all the urine they pass in a 24-hour period. The fluid is sampled, tested, and the amount of waste cleared by PD, and by the kidneys (if the person passes urine) is then calculated. This is known as a Peritoneal Function Test (PFT) or Adequacy Test. What are the signs/symptoms of PD not working well? When people are not getting enough dialysis, they are sometimes referred to as under-dialysed. The main symptoms are tiredness, feeling weak, and going off food. However, these symptoms can also be due to other things such as: Anaemia (a low blood count) Stomach Ulcer Constipation A high level of urea in the blood can cause nausea and lack of appetite, leading to a loss of body weight or muscle size. What will happen if my results show my PD is not working well? A number of options can be considered to improve a person s PD. These include: Increasing the volume of the PD bags Doing an extra exchange during the day, or at night with a machine. Using special PD fluid such as Icodextrin. Changing from CAPD to APD. Increasing the time on APD, changing the number of exchanges, or the time each bag remains in the abdomen, or doing additional daytime exchanges. But, sometimes changing the type of PD, the volume or number of bags used, will not 2

5 be sufficient or be acceptable to the person, and the best option might be to change to haemodialysis. What problems can happen on PD? The occurrence of problems on PD and their severity can vary greatly between individuals. The 4 main areas in which problems can occur are listed below: 1. Psychological Problems Anxiety and Depression: As well as all the anxieties felt by most people at some time in their lives, kidney patients also have additional anxieties relating to their condition and their treatment. You will need to understand the reasons for your anxieties and any medical causes that can be treated. Having a better understanding often helps people to cope. It sometimes helps to share anxieties, and identify ways of coping. Many Units have a Renal Social Worker, a psychologist, or members of the Kidney Patient Association as well as doctors and nurses who will have experience of helping people to cope with their anxieties. People on dialysis are as prone to depression as anyone else. Occasionally people will need medical treatment for depression, but quite often, after a period of feeling low, people find ways of coping and adjusting to life on PD. Body image: Some people on PD do not like the way PD affects their appearance. The abdomen tends to get stretched by PD, giving it a rounded appearance. Young people in particular may be very conscious of their body shape, especially if they are slim. Keeping fit and doing exercises to strengthen the abdominal muscles will help. The PD catheter can also cause body image problems. People on PD have to come to terms with the fact that they now have a plastic tube permanently protruding from their abdomen. Some people find this very difficult to cope with, feeling that they have been mutilated. They may also worry that the catheter might put off a sexual partner. Some people make a joke or tell a funny story about why the catheter is there when showing it to someone for the first time. It is important to talk about your feelings with your partner, PD nurse or doctor who can refer you to someone who may be able to help you come to terms with your changed body image. People on PD may need to remind themselves, that people who really love them, will continue to do so, regardless of how they look. 2. Infections Peritonitis: This is an infection inside the tummy. The most common reason why people on PD get peritonitis is that they touch the connection between the bag of fluid and the catheter. However, even if PD exchanges are scrupulously clean, infection 3

6 can still enter the abdomen from the outside world through the catheter. People can expect to get on average less than one attack of peritonitis every year. So it is not that common. Indeed, some people never get it. On APD peritonitis is less likely to occur than on CAPD, probably because fewer catheter connections are required. A person will know when they have peritonitis because the dialysis fluid that drains out will be cloudy. This fluid is normally see-through. The signs and symptoms are usually one or more of the following: Cloudy bag Tummy pain Vomiting A raised temperature Peritonitis is treated by adding one or more antibiotics to the fresh dialysis fluid, and by antibiotic tablets. Patients are not usually admitted to hospital when they have peritonitis. Occasionally, a person may get several attacks of peritonitis in a row. The doctor may then decide that an operation to remove the old PD catheter, and put in a new one is needed straight away. Alternatively, the doctor may decide that it is better to delay replacing the catheter and to rest the abdomen by not using it for PD for a period of 4 to 6 weeks. If this happens, the person will usually need to have haemodialysis until PD is resumed. Peritonitis is usually caused by one of two types of bacteria: Staphylococcus epidermidis Staphylococcus aureus Both of the above infections are often known as staph infections. In rare but serious cases, peritonitis is caused by a fungus (usually a type called candida albicans). If peritonitis is caused by a fungus, it will be treated straight away by an operation to remove the PD catheter. Drugs are not very effective against fungi, but the problem soon goes away if the catheter is removed. The catheter can still be replaced at a later date. If a person has many bad attacks of peritonitis, PD may no longer be suitable for them. They will then have to change to haemodialysis as their long-term treatment. Exit Site and Tunnel Infections: This is an infection at the point where the PD catheter comes out through the skin. This causes a red tender area around the exit site, and when someone has this type of infection, squeezing around the exit site may produce some pus. 4

7 Some people get exit site infections regularly, whereas others may never get them. Keeping the catheter taped down to the skin will help reduce the likelihood of an exit site infection, especially when the catheter is new. Most Units advise people to put a clean dressing over their exit site each day, after they have showered. Exit site infections respond well to antibiotics, usually given either as tablets or creams. Sometimes, a single intravenous injection of an antibiotic called vancomycin is needed. There is usually no need to remove the PD catheter. Occasionally, an exit site infection spreads down the catheter tunnel (the route taken by the catheter through the tummy wall). This type of infection is called a tunnel infection. Antibiotics are not always effective when someone has a tunnel infection. An operation to remove the catheter will then be necessary. It may be possible to insert a new catheter at the same operation, but this will depend on how extensive the infection is (there is a risk that the new catheter could also get infected). 3. Catheter/Drain Problems Leak of PD fluid: In most people, the seal around the catheter exit site (where the catheter leaves the abdomen) works properly. PD fluid drains in and out of the abdomen through the tube without any leakage. However, in some people, the PD fluid leaks out around the catheter, wetting the dressing over the exit site. If a leaking catheter is rested (not used for dialysis) for 2 to 4 weeks, it will usually seal up again, and become watertight. Occasionally, however, a leak may recur even if the catheter is rested. It may then be necessary to have an operation to take out the leaking catheter. A new catheter, at a different site, is usually put in during the same operation. In some men on PD, fluid leaks into the scrotum, or into the vagina in women and causes swelling. If this type of leak occurs, PD must be stopped temporarily until the leak has healed. A test can be carried out to check the location and size of a leak, and whether surgery is needed to repair it. A special dye is put down the catheter and x-rays show where the dye goes - known as a peritonealogram. Drainage Problems: One of the most common problems with PD - especially when people first start PD is poor drainage of the dialysis fluid. The most common reason for poor drainage is constipation. If a person becomes constipated, the bowels press against the catheter and make the dialysis fluid drain very slowly. The fluid may also get trapped in pockets of bowel, preventing it from draining properly. So it is very important to avoid constipation, perhaps by taking regular laxatives. The PD catheter may become blocked with a substance called fibrin, which is a form of protein. It looks like tiny strands of cotton wool and is completely harmless. A patient may be able to clear the catheter simply by squeezing the tubing to dislodge 5

8 the fibrin. Alternatively, a nurse will be able to clear the catheter by injecting water, saline (a salt solution) or a de-clotting agent called heparin, down the catheter. This is a simple procedure and will not need an operation. Some patients have to inject a small quantity of heparin into a single bag each day (usually the overnight bag) to dissolve any fibrin that accumulates in the peritoneum and hence keep the catheter clear. Another reason for poor drainage is that the catheter is in the wrong position. Sometimes a displaced catheter will float back into the right position naturally. If this does not happen, then an operation may be required to correct the position of the catheter. Blood in PD fluid: Sometimes when PD fluid is drained out at the end of an exchange it may look slightly red or pinkish in colour. This happens if any of the small blood vessels in the peritoneum are broken. This can be caused by lifting something heavy or can happen while playing sport. In females, red or pink bags can occur during their period (menstruation). People are advised to contact their Unit if the bags don t clear up in a few days, or if the fluid in the bags look very bloody, and not just stained red or pink. 4. Physical Problems Fluid overload: The amount of used fluid that is drained out of the body after PD is about 1 to 1.5 litres per day more than the amount of fresh dialysis fluid that is put in. This extra fluid is in effect, the PD person s urine. It does not increase in quantity however much the patient drinks. This means that people on PD have to restrict their drinking to avoid problems due to fluid overload, particularly when they stop passing urine. Fluid overload leads to an increase in body weight, high blood pressure, swollen ankles and shortness of breath. Constipation: Many people on PD are prone to constipation. There are several reasons for this. People on PD (like many others who are not on dialysis!) do not have enough fibre (roughage) in their diet. Wholemeal or brown bread, fresh fruit and vegetables are good sources of fibre. Restrictions on fluid intake, certain fruit (patients on a potassium restriction), and decreased level of activity can all contribute to constipation. Constipation can cause problems with poor drainage of PD fluid. It is therefore important to avoid constipation, by taking regular laxatives, such as lactulose and senokot (senna). Hernia: A hernia occurs when a wall of muscle weakens and lets an organ or tissue out from inside. Hernias can cause difficulties for people on PD. If a person has a hernia before the PD catheter is put in, it can become more of a problem afterwards. The daily draining of PD fluid into and out of the abdomen can cause the hernia to become 6

9 bigger (and more painful). If nothing is done, the bowel can become stuck inside the hernia, thereby blocking the bowel. This will require an emergency operation. If an existing hernia is noticed by the surgeon during an operation to insert a PD catheter, it will be repaired during the same operation to prevent it causing problems in the future. If a hernia develops months or years after the catheter insertion, an operation is needed to repair it. Itching: The normal level of phosphate in the blood is 0.8 to 1.4 mmol/l. On PD, people sometimes have a raised blood phosphate level. It is thought that a high phosphate level causes itching. Blood phosphate levels can be controlled by taking phosphate binders, and reducing phosphate intake in the diet. Sometimes medications such as hydroxyzine or chlorpheniramine (piriton) are used to relieve itching until the blood phosphate level is reduced. Iron deficiency and anaemia can also cause itching. Pain and discomfort: Some people find PD is uncomfortable, or even painful, particularly when they first start treatment. Most people will get used to having fluid in their abdomen, but sometimes small people will be unable to tolerate more than litres of fluid. A feeling of fullness or of being bloated after eating is quite common. People with back problems may be unable to tolerate CAPD and switch to APD (using smaller volumes of fluid by day, and larger volumes when lying down at night) or haemodialysis. Cramp or Restless legs at night: Cramps and restless legs at night affect some people on PD. An imbalance in the levels of water and salt in the blood may be a factor in cramp. Stretching and massaging the limb can help. Quinine sulphate taken at bedtime helps prevent cramp. Restless leg syndrome (an irresistible urge to move the legs at night) can occur in kidney failure. It can be very stressful as it disrupts sleep, leading to tiredness during the day. A tablet called Clonazepam is sometimes used to treat this problem. It may also help the person to sleep. What medicines will I need to take? The most common types of medicines that patients on PD need to take are: Phosphate binders to reduce bone disease Iron, and Erythropoietin to reduce anaemia (low blood count) Anti-hypertensive medicines to control high blood pressure Laxatives to prevent constipation Phosphate binders When the kidneys are working properly they get rid of excess phosphate from the body. Phosphate, which is found in dairy products, nuts and meat, is needed to keep bones healthy. If phosphate levels become too high in kidney failure this can damage bones and blood vessels. Medications such as Calcium carbonate, Calcichew, or Alucaps, if 7

10 taken before meals can bind with phosphate in the food you eat so that the phosphate is not absorbed into the body and the level in the blood becomes lower. There are several different types of phosphate binder medication, your doctor and renal dietician will be able to discuss which one might suit you best. Iron and Erythropoietin Healthy kidneys produce a substance called Erythropoietin (known as EPO for short). EPO is used in the bone marrow to help produce red blood cells. Red blood cells carry oxygen around the body and, if the level is low, it is called anaemia. If EPO is injected into the body (using a small needle) this can help produce red blood cells. EPO is usually given 1-3 times a week. People on EPO will use up Iron quickly making red blood cells, and they may need an iron supplement. This can be given by tablet (eg Ferrous sulphate or Pregaday) or by injection. Anti-hypertensive medicines High blood pressure (hypertension) is fairly common in people with kidney problems. Blood pressure is affected by the amount of fluid in the body as well as the width of the vessels (arteries) that the blood flows through. It is therefore important for people on PD to control the level of fluid in their blood. This is done by balancing what fluid goes in with what comes out. Often one or more medications are needed to control blood pressure. Laxatives Constipation causes drainage problems on PD and it is therefore important to avoid becoming constipated. Lactulose is a liquid, which can be taken daily to prevent constipation: it works by softening the faeces in the bowel. Senokot (senna) can also be used daily to prevent constipation: it works by stimulating the bowel to move. Both drugs can cause stomach cramps in some people. It is important to let the pharmacist know that you are on dialysis if you are buying other laxatives, as some are not suitable for people with kidney failure. Will I need to be on a special diet or fluid restriction? Why are some foods restricted? Many people on PD are able to enjoy a normal diet without too many restrictions. This is because PD is a continuous form of dialysis, and waste from the food digested is continuously being removed. Dietary restrictions of certain foods are usually stricter in the period leading up to needing dialysis (pre dialysis patients). The foods that are sometimes restricted are those which are high in potassium, or phosphate. It is important to discuss your blood results with the doctor or dietician, before restricting your intake of potassium, phosphate, or calcium. If your blood levels are too low this can be harmful too. 8

11 The normal level of potassium in the blood is mmols/l. A very high or low level of potassium can cause the heart to stop. Your Dietician will advise you if you need to increase or decrease your potassium intake. Phosphate (normal level mmol/l) and calcium (normal level mmol/l) levels in the blood need to be kept around normal limits to help prevent bone disease or damage to blood vessels. A combination of diet, dialysis and drugs is usually the best way to keep calcium and phosphate levels normal. Why do I need to eat more protein? Protein is an essential nutrient, which enables the body to build muscles and repair itself. The main sources in the diet are meat, fish, dairy products, and pulses (such as beans and lentils). The normal level of a protein called albumin is around g/l. People on PD lose protein along with the waste they drain out when they do an exchange. Quite often people are advised to eat extra protein, and some people are prescribed drinks or powders that contain extra protein. it is important to discuss your blood test results with the doctor or dietician before changing your intake of protein. 9

12 The National Kidney Federation cannot accept responsibility for information provided. The above is for guidance only. Patients are advised to seek further information from their own doctor National Kidney Federation (NKF) All rights reserved Last Reviewed October 2017