Pros/cons & effectiveness of peritoneal dialysis

[Annaed119]

Please help!! I am an RN with experience in ER and PACU, but not in renal or dialysis. I have a very dear friend, a 62 y/o male, who has been fighting multiple myeloma for the last 3 years. He has exhausted all available forms of treatment for the myeloma with no remission and knows the myeloma is terminal. However, he has recently had complications of 2 episodes of acute renal failure; during the most recent episode about a week ago, his K+ jumped to 8.2!!! The doctors are now telling him he only has about 8% kidney function and he must decide whether or not to start dialysis or go home and wait to die from the kidney failure. Because of his myeloma, he is not a candidate for hemodialysis, so peritoneal dialysis is his only option. I have done a lot of research on this type of dialysis, so I understand the physiology and mechanics/skills needed to do this. My concerns are these:

1. I read in several resources that it takes about 2 weeks after insertion of the access catheter into the abdomen before dialysis can be started to allow scar tissue to develop around the site. Is this accurate?

2. If the above is accurate, will the peritoneal dialysis be able to make up for what will be nearly 4 weeks of only 8% kidney function? His BUN is already 5 times normal, his K+ is currently 4.5 and he is hypertensive. Is it even realistic to think he will live for another 4 weeks to start dialysis at this rate?

3. When the nephrologist first discussed the idea of peritoneal dialysis, he got my friend all excited about CCPD. My friend liked the idea of hooking up to the cycler at night and letting it take care of the exchanges while he slept. Now, my friend is being told that initially he would need to use CAPD.

If I understand what I have read correctly, there is about a 3 or 4 hour window of time that each bag of diasylate must be retained in the abdomen. This sounds like an all-day ordeal to me, sloshing around with an extra 2-3 liters of fluid in his abdomen and always needing to make sure he has his supplies with him. Is there any real quality of life with CAPD, or is it not this bad?

Any information about this is greatly appreciated. As an RN, I know that if I want the real "down and dirty" about something, go to another RN. I don't have enough experience in this field to be able to tell if the doctors are being straight with my friend or just telling him what they think he wants to hear. My friend knows the myeloma is going to kill him....he just wants quality time with his family while he can have it. He doesn't want his kids and grandkids to remember him as always feeling ill or not being able to do things because he is tied to a dialysis exchange schedule. Thank you so much!

[talaxandra]

First off, I'm sorry about your friend - this must be hard for you. My dialysis experience in in Australia, so there may be some differences in practice.

1) You're right about the wait time, give or take. Without time for tissue to adhere to the cuff, the patient's at increased risk of peritonitis. At my hospital the patient has a number of 500ml exchanges immediately post-op, to clear blood out of the peritoneal cavity, and then have an antibiotic dwell to reduce the risk of peritonitis, and then the Tenckhoff is left to rest.

2) I can't answer your second question, because most of our patients are able to have bridging haemo is the doctors are concerned about survival until the Tenckhoff is ready to be used. The only thing I can say is that his doctors must have taken this in to account, so if they think surgery is a valid option there must be some chance. Renal failure in MM is usually fairly insidious, so his body may be more tolerant to increased creatinine, urea and K+ than most people. Even with dialysis, many fully compliant end-stage renal patients have electrolytes that would have you freaking out if they were anyone else.

3) I understand your concern about day time dwells - it does sound uncomfortable and unpleasant. In the initial stages some patients have reported disomfort when full, but that's because the peritoneal cavity (which is a potential space) is unacustomed to the fluid; this doesn't last long. Because it's a potential space, which only expands to accomodate the infused fluid, it's not really slosshing around - it's more like amniotic fluid in a uterus than water in a half-full container. What is more common is patients who are used to being full reporting discomfort (an achey, crampy feeling usually) if they have to be empty for a prolonged period.

It sounds arduous, lugging supplies around everywhere you go, but in reality the patient away from home just needs somewhere clean to perform an exchange (with access to a sink, a bench, and a hook to hang a bag from), a Tenckhoff cap, and a warm place for the bag. Our patients have portable heater boxes with room for two bags, like a cooler. Our patients typically perform four exchanges a day; these are preferrably evenly spaced during the day, with the last exchange dwelling while they sleep. They can leave a six- or eight-hour break between excahnges if necessary, though we don't recommend this routinely.

The other changes (fluid and dietary restrictions, medications) seem more arduous to me, but that might be because I don't have renal failure, and I'm comfortable with the technique.

If your friend does decide to go ahead with renal replacement therapy he may be surprised at how much better he feels after a couple of weeks. Unlike haemo, peritoneal dialysis won't dramatically drop his blood pressure, reduce his haemoglobin, or exhaust him. It takes around fifteen to thirty minutes for most people to run an exchange out, and about half that to run it - aside from that, he should be free to go about as usual (but hopefully feeling better than he does now).

I hope this has helped. Good luck and best wishes.