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Renal Replacement Therapy Peritoneal dialysis I. Introduction of PD.

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Presentation on theme: "Renal Replacement Therapy Peritoneal dialysis I. Introduction of PD."— Presentation transcript:

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2 Renal Replacement Therapy Peritoneal dialysis

3 I. Introduction of PD

4 Renal Replacement Therapy(1997) Hemodialysis (53.3%) Peritoneal Dialysis (17.1%) Renal Transplantation (29.5%) Etiologic Disease : DM(34%)> CGN(20.8%) > Hypertension(15.7%) Total 20,244 patients Korea Journal of Nephrology (1999)

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6 Peritoneal Dialysis Solute and water transport via peritoneal membrane Solute movement via diffusion + convection Less problems of bio-incompatibility Loss of protein(10g/day) and middle molecules

7 Advantages of Peritoneal Dialysis Better preservation of residual renal function Cardio protective effect Less freq. severe arrythmia(33% vs. 4%) Higher employment Less prevalent anti-HCV/HBV Better survival after kidney transplantation More economic

8 II. Apparatus of PD

9 1. Conventional PD solution Glucose based solutions with lactate as buffer High conc. Of glucose and lactate Safe, effective and cheap Easily metabolized Low pH Hyperosmolality A variety of GDPs formed during heat sterilization

10 Component of conventional PD solutions Glucose(13.6mg/ml, 22.7mg/ml, 38.6mg/ml) Sodium 132mmol/L Potassium 0mmol/L Calcium mmol/L Magnesium mmol/L Chloride 102mmol/L Lactate 35-40mmol/L pH

11 Critics about conventional PD solutions 1. Negative influence to peritoneal cell function : phagocytosis, intracellular killing, and LT, cytokine and prostaglandin production 2. Dilution of 2L of dialysis solution in itself 3. High concentration of glucose 4. High concentration of lactate 5. Poor biocompatibility Pain during inflow

12 2. Tenckhoff catheter

13 3. Peritosol Bag

14 4. Modes of Peritoneal Dialysis Continuous ambulatory PD (CAPD) Continuous Cycler-assisted PD (CCPD) Nightly PD (NPD) Intermittent PD (IPD) Tidal PD

15 CAPD CCPD NPD

16 Automated PD CCPDNPD

17 III. Care of the PD Patients during the Perioperative & Break-in Period

18 Preop Preparation(1) Exit hole belt line size and shape of abdomen, op scar belt line-- 2cm above the skin fold Laterally or downward, 2cm distant from location of superf cuff

19 Colon study Screening of colonic diverticulum S-S enema : Empty the bladder Skin prep: neet cream Cefazolin 1g iv 1hr before catheter insertion Preop Preparation(2)

20 Immediate Postop Procedure Tip KUB True pelvis Flushing: heparinized saline 500~1500mL until clear Suture at the exit site: should be avoided Cefazolin 1g iv q 24h for 2 days 2) Flushing

21 Break-in Period Catheter Routine catheter use Leakage 2~4. absolute bed rest Straining Omental adhesion- heparinized saline- flush

22 During 2~14 days flush, in-out exchange Least exit treatment is the best Routine: Alaxyl 1P bid PO PRN) Dulcorax 2cap supp / Glycerin enema KUB f/u: 3, 7, 14

23 Recommended Orders Preop evaluation Colon study During NPO, hydration with D5W 1L + 2M NaCl 80cc 20gtt e, BUN/Cr f/u after enema P/E Belt line ? Op scar ? Location of exit hole ?

24 Preop -1 day Get permission Take a shower S-S enema Visit PD unit and determine belt line Recommended Orders Preop preparation NPO D5W 1L iv 20gtt Cefazolin 1g iv on call Skin prep with neet cream Empty bladder Pain killer: Demerol

25 Intraop KUB Flushing 500~1000mL with heparinized saline until clear Avoid suture at the exit Recommended Orders Postop Absolute bed rest ! Alaxyl 1P bid PO start PRN) order for constipation: Dulcorax 2cap supp and/or G- enema PRN) if cough (+), give antitussive

26 Postop 1day ABR ! Cefazolin 1g iv q 24h for 2 days Alaxyl 1P bid PO PRN) order for constipation and cough Dressing change Flushing with heparinized solution Postop 2~3 days ABR ! Alaxyl 1P bid PO PRN) order for constipation and cough No manipulation of catheter KUB at 3th day Education Check dressing gauze Recommended Orders Italic: by PD nurse

27 Postop 4days ~ 2wk Ambulation Alaxyl 1P bid PO PRN) order for constipation and cough No manipulation of catheter KUB at 1wk and 2wk Education Check dressing gauze Dressing change & flushing at 1wk and 2wk OB S/C at exit site at 1wk Recommended Orders Italic: by PD nurse

28 Discharge at 1wk or 2wk Daily visit to PD unit room for education Start indwell at 2wk 1000~1200mL increase 100ml per day Recommended Orders

29 IV. Adequacy of PD

30 Clinical and laboratory indices of adequate peritoneal dialysis

31 Uremic Sx No of exchange Overall small MW clearance is most closely related to uremic toxicity Why weekly Kt/V and CrCl ? CANUSA study 680 CAPD patients weekly Kt/V 0.1 = 5% patient survival CrCl 5 L/1.73m 2 /wk = 7% patient survival No evidence of a plateau effect over the range of the clearance Kt/V = 2.1 Predicted 2-yr survival 78% CrCl = 70 L/1.73m 2

32 Minimal Recommendations for PD Dose DOQI CAPDCCPDNIPD Kt/V per wk CrCl per wk Canadian Society of Nephrology High/HALow/LA Kt/V per wk CrCl per wk 60 50

33 Peritoneal Kt = DUN / BUN x PD drain vol -- (2) Renal Kt = UUN / BUN x 24H Urine vol -- (3) Weekly Kt = { (2) + (3) } x 7 -- (4) Kt / V = (4) / (1) Peritoneal Clcr = Dcr / Pcr x PD drain vol -- (5) Renal Clcr = { ( Ucr/Pcr + UUN/BUN) / 2 } x 24h UV -- (6) Weekly Clcr = { (5) + (6) } x 7 x ( 1.73 / BSA ) Weekly Kt/V & CrCl

34 1. Drain for at least 20min, ideally after an 8- to 12-hour overnight dwell using 2L of 2.5% dextrose solution 2. Weigh 2-L bag of warmed 2.5% dextrose solution 3. Infuse over 10min(at a rate of 200 ml/min). After each 400-ml infused, roll the patient from side to side. 4. Indwell for 4 hours. Ambulatory during dwell time. 5. Drain over 20 min. 6. After drainage, the bag is again weighed. PET: Protocol

35 Blood sample: 0,2,4 hour Dialysate sample: 200 ml of dialysis solution is drained into the bag, mixed well, a 10 ml sample is taken, and the remaining 190 ml is reinfused back after 2 and 4 hours, another sample is taken. Calculate D/P creatitine at 2 and 4 hours D/D 0 glucose at 2 and 4 hours the volume of UF in the drainage bag PET: Sampling

36 Low transporters low D/P Cr; high D/Do glucose and good net UF long, high-volume dwells High transporters highest D/P Cr ; low D/Do glucose and low net UF more frequent short-duration dwells higher dialysate protein losses Average transporters PD prescriptions that most suits their lifestyle Recommended Prescriptions

37 V. CAPD-related Peritonitis

38 Y2Y3Y4Y 5Y No CAPD TPL HD FU loss Death Fig.4 Status of CAPD Patients During the Course of Follow- up (, 1999)

39 Cause of Death, death/

40 Cause of Technical Failure 24 HD transfer/

41 Initial Clinical Evaluation of Patient with Suspected Peritoneal Dialysis-Related Peritonitis Symptoms: cloudy fluid and abdominal pain Do cell count and differential Gram stain and culture on initial drainage Initiate empiric therapy Choice of final therapy should always be guided by anti-biotic sensitivities

42 Specimen Processing Culture should be taken as early as possible from suspected case of peritonitis: the first cloudy fluid sample is the best specimen Large volumes(>50mL) should be cultured or concentrated to maximize bacterial recovery rate(3,000g x 15min) Washing the specimen sediment with sterile saline or using antibiotic-removing /neutralizing resin has been shown to improve the sensitivity Identification and sensitivity testing should be done as soon as possible

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44 ISPD 2000 Guideline for Empiric Therapy Cloudy Fluid / Abdominal Pain / Unexpected Fever Cell count, diff / Gram stain / Culture Empiric Therapy Cefazolin + Aminoglycoside Vs Cefazolin + ceftazidime Gram (+)Culture (-)Gram(-)Yeast 0 Hours 24 Hours Gram staining Adequate Culture Adequate Antibiotics

45 Aminoglycoside vs Ceftazidime Aminoglycoside High % of sensitive organisms Enterococci will require aminoglycoside Synergistic effect on streptococcal and staphylococcal infection Ceftazidime Preserve residual renal function Resistance to ceftazidime result from point mutation within genes that encode plasmid mediated enzyme

46 Empiric Therapy for CAPD Peritonitis CefazolinClindamycinCeftazidimeAminoglycoside With Residual Renal Fx Without Residual Renal Fx 1g/bag qd 1g/bag qd 0.6mg/Kg/bag qd 600mg/bag In each bag

47 Recommandation for Vancomycin Use Should not be used for primary therapy of peritonitis Except MRSA lactam resistant organism Serious gram(+) infection in pts allergic to penicillin C. difficile enterocolitis that is not responding to metronidazole

48 Using Vancomycin in CAPD Peritonits Long term exposure should be avoided Drug level monitoring Prevent level from falling into sub- therapeutic range, especially in patients with residual renal function Other choice?

49 Empiric Initial Therapy for Peritoneal Dialysis-Related Peritonitis, Stratified for Residual Urine Volume

50 G(-) on Culture Single G(-) Pseudomonas/ XanthomonasMultiple &/ Anaerobes Adjust antibiotics Clinical Improvement Continue continuous AG Stop Cefa Add Anti-psudomonas Antib. ?Surg. Intervention Add Metronidazole YesNo 14 days21 days Re-evaluation If culture(+): Remove catheter If exit infection(+): Remove catheter 96 hrs Continue Treatment

51 Summary Adequate Bacteriological W/U Prompt Emperical Tx Adequate selection for Empiric antibiotics


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