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Renal Replacement Therapy Peritoneal dialysis

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Presentation on theme: "Renal Replacement Therapy Peritoneal dialysis"— Presentation transcript:

1 Renal Replacement Therapy Peritoneal dialysis

2 I. Introduction of PD

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

4

5 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

6 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

7 II. Apparatus of PD

8 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 현재 사용되는 PD solution은 년대에 사용되던 PD solution과 큰 차이가 없었다. Osmolality 340, mOsm/kg정도

9 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

10 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 Whether the toxic effects of glucose per se on phagocytes and mesothelial cells seen in vitro are clinically relevant is still unknown, though ex vivo studies have shown impaired pahgocyte function after 30min of in vivo exposure to commercial dialysis fluid.

11 2. Tenckhoff catheter

12 3. Peritosol Bag

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

14 CAPD CCPD NPD

15 Automated PD CCPD NPD

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

17 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

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

19 Immediate Postop Procedure
Tip KUB True pelvis 내 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

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

21 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

22 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 ?

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

24 Recommended Orders Intraop Postop KUB
Flushing 500~1000mL with heparinized saline until clear Avoid suture at the exit 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

25 Recommended Orders Postop 1day ABR ! 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  Italic: by PD nurse

26 Recommended Orders 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  Italic: by PD nurse

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

28 IV. Adequacy of PD

29 Clinical and laboratory indices of
adequate peritoneal dialysis

30 Why weekly Kt/V and CrCl ?
 Uremic Sx  No of exchange Overall small MW clearance is most closely related to uremic toxicity CANUSA study 680 CAPD patients  weekly Kt/V 0.1 = 5%  patient survival  CrCl 5 L/1.73m2/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/1.73m2

31 Minimal Recommendations for PD Dose
DOQI CAPD CCPD NIPD Kt/V per wk CrCl per wk Canadian Society of Nephrology High/HA Low/LA Kt/V per wk CrCl per wk

32 Weekly Kt/V & CrCl Peritoneal Kt = DUN / BUN x PD drain vol -- (2)
Renal Kt = UUN / BUN x 24H Urine vol -- (3) Weekly Kt = { (2) + (3) } x (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 )

33 PET: Protocol 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.

34 PET: Sampling 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/D0 glucose at 2 and 4 hours the volume of UF in the drainage bag

35 Recommended Prescriptions
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

36 V. CAPD-related Peritonitis

37 No CAPD 180 160 120 80 40 1 Y 2 Y 3 Y 4 Y 5 Y Death FU loss TPL HD
1 Y 2 Y 3 Y 4 Y 5 Y Fig.4 Status of CAPD Patients During the Course of Follow-up (, 1999)

38 Cause of Death 29 death/ 양재석 등, 1999

39 Cause of Technical Failure
24 HD transfer/

40 Symptoms: cloudy fluid and abdominal pain
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 -For APD; 특히 stagnant fluid가 turbid한 것이 진단에 가장 많은 도움

41 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

42 복막염의 원인균(I) 적절한 균배양 검사의 중요성 다량의 투석액을(>50mL)
Centrifuge 농축시킨 다음(3,000g x 15 min) Sterile saline으로 세척 3-5mL의 saline에 resuspend해서 Blood culture bottle에 배양: 혐기성균 + 호기성 균을 동시에 배양

43 ISPD 2000 Guideline for Empiric Therapy
Cloudy Fluid / Abdominal Pain / Unexpected Fever Gram staining Adequate Culture Cell count, diff / Gram stain / Culture Adequate Antibiotics Empiric Therapy Cefazolin + Aminoglycoside Vs Cefazolin + ceftazidime 0 Hours Gram staining의 중요성 10mL을 원심분리 후에 검사하면 93%에서 양성 Gram staining 결과에 의존해서 항생제를 선택하면 안된다. 원인균을 예측할 수 있는 확률: G(+) 85%, G(-) 95% 신속하고 적절한 항생제의 선택 Cefazolin + aminoglycoside 만일 출구 감염이 pseudomonas나 S aureus면  해당균에 대한 항생제 만일 recurrent peritonitis면 대상 균에 대한 항생제 24 Hours Gram (+) Gram(-) Culture (-) Yeast

44 Aminoglycoside vs Ceftazidime
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 Ceftazidime covering G(+) and G(-) Ceftazidime adequate in view of the increasing incidence of gram negative peritonitis? Resistance to ceftazidime result from point mutation within genes that encode plasmid mediated enzyme Aminoglycoside as intiial and ± oral quinolone ?

45 Empiric Therapy for CAPD Peritonitis
Without Residual Renal Fx Cefazolin Clindamycin Ceftazidime Aminoglycoside 1g/bag qd 600mg/bag In each bag 1g/bag qd 0.6mg/Kg/bag qd With Residual Renal Fx

46 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

47 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?

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

49 Pseudomonas/ Xanthomonas
G(-) on Culture Single G(-) Pseudomonas/ Xanthomonas Multiple &/ Anaerobes Adjust antibiotics Continue continuous AG Stop Cefa Add Anti-psudomonas Antib. ?Surg. Intervention Add Metronidazole Clinical Improvement Yes No Continue Treatment Re-evaluation If culture(+): Remove catheter If exit infection(+): Remove catheter 96 hrs 14 days 21 days 21 days

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


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