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Peritoneal dialysis Dr Ejaz Ahmed. Barrier to transport Mesothelium –Does not hinder transport Interstitium –Hinders transport to some extent.

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Presentation on theme: "Peritoneal dialysis Dr Ejaz Ahmed. Barrier to transport Mesothelium –Does not hinder transport Interstitium –Hinders transport to some extent."— Presentation transcript:

1 Peritoneal dialysis Dr Ejaz Ahmed

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6 Barrier to transport Mesothelium –Does not hinder transport Interstitium –Hinders transport to some extent Endothelium –Main barrier

7 Peritoneal transport principles Diffusion –Depends on concentration gradient Convection(filtration) –Depends on hydrostatic pressure and osmotic pressure

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9 Diffusion Dr=p×a×c Dr=diffusion rate P=solute permeability A=area of membrane C=concentration gradient

10 Ultrafiltration UFr=p×a×(Hp+Op) –UFr=ultrafiltration rate –P=permeability of water –A=surface area –Hp=hydrostatic pressure gradient –Op=osmotic pressure gradient

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14 Material of catheter Silicone rubber –Milky white material Polyurethane –Clear material

15 Catheter design Three portions –Intraperitoneal –Extraperitoneal –External Cuffs –Dacron material –One or two

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17 Placement of catheter Open surgical placement Peritoneoscopic placement Blind placement

18 Proper location of catheter Intraperitoneal portion –Directed towards pelvis Cuff –Deep: within medial or lateral border of rectus sheath –Superficial: about 2 cms from skin exit

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20 Sodium(mmol/L) Potasium(mmol/L)0-2 Calcium(mmol/L) Magnesium(mmol/L) Chloride(mmol/L) Lactate(mmol/L)35-40 Bicarbonate(mmol/L)34 Bicarbonate/lactate25/15 Glucose(g/dl) lcodextrin(g/dl)7.5 Amino acids(g/dl)1.1 Composition of peritoneal dialysis fluid

21 Osmotic agents Low molecular weight –Glucose- 1.5%,2.5%,4.25% –Glycerol –Amino acids High molecular weight –Albumin –Glucose polymer –peptides

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28 Clearance Theoretical concept “Volume of plasma from which all the substance has been removed and excreted into the urine per unit time” Amount excreted = Urine volume x urine concentration Excretion rate = Urine volume x urine concentration Time

29 Clearance Example Clearance of a substance x Excretion rate = 100 mg/ml x 1 ml = 100 mg/min 1 minute Concentration of substance x in plasma = 1 mg/ml Amount of plasma cleared per minute = 100 mg/min = 100 ml 1 mg/ml Clearance = U x V T x P

30 Principles of Clearance

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32 Clearance of Inulin

33 Substance (L/wk) kidney H D standard H D High flux CAPD Urea Vit B Inulin β2 Microg

34 Small solute clearance Urea clearance (Kt/V) –Normalised to total body water Creatinine clearance (CrCl) –Normalised to body surface area

35 Total clearance Sum of –Residual renal clearance –Peritoneal dialysis clearance

36 Method of calculating dialysate clearance of urea 24 hr collection of peritoneal dialysate effluent Measure urea concentration in dialysate Estimate total urea content –Urea concentration × volume of effluent Calculate clearance –Kt = Urea content in dialysate Serum urea level

37 Method of calculating renal clearance of urea Collect 24 hr urine Measure urea concentration in urine Estimate total urea content –Urea concentration × urine volume Calculate renal clearence of urea –Kt = Urea content in urine serum urea level

38 Total and normalised clearance Total clearance –Dialysate clearance + renal clearance Normalised clearance (Kt/V) –Dialysate clearance + renal clearance Total body water

39 Calculate clearance A 50 yr old man weighing 66 Kg has no urine output. He is on CAPD with four 2.5 L exchanges daily. His blood urea is 160 mg/dl and dialysate urea concentration of 24 hr collection is 140 mg/dl.calculate his daily clearance

40 Complications of peritoneal dialysis Mechanical complication of catheter –Catheter obstruction/inadequate drain –Perforation and laceration of organs –Peritoneal catheter leaks Infectious complications –Exit site infection –Peritonitis

41 Clinical presentation of peritonitis (percentages) Cloudy fluid Abdominal pain67-97 Abdominal tenderness62-79 Fever34-36 Chills18-23 Nausea30-35 Vomiting25-30 Diarrhoea7-15

42 Route of entry for peritonitis Touch contamination Catheter related Enteric Haematogenous Gynaecological

43 Organisms causing peritonitis Gram-positive –Staphylococcus epidermidis –Staphylococcus aureus –Streptococcus –Enterococcus Gram-negative Fungal Mycobacterial

44 Differential diagnosis of cloudy effluent Infectious peritonitis Eosinophilic peritonitis Sclerosing peritonitis Chylous ascites Malignant ascites Pancreatitis Chemical peritonitis

45 Treatment of peritonitis Antibiotics –Intraperitoneal route Continuous Intermitent –Intravenous route Pain control

46 Outcome and sequelae Resolution-60-90% Abscess formation-1% Transfer to hemodialysis(technique failure)-30% Sclerosing peritonitis-1-2% Death-1-6%

47 Types of peritoneal dialysis Manual –CAPD-Continuous ambulatory peritoneal dialysis Automated –CCPD-Continuous cyclic peritoneal dialysis –NIPD-Nocturnal intermittent peritoneal dialysis –TDP-Tidal peritoneal dialysis

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49 TYPE Day exchange Night exchange Volume of exchange CAPD CCPD NIPD TDP

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51 Peritoneal transport assessment PET test –Concentration of creatinine in dialysis solution at four hrs –Concentration of creatinine in plasma at same time –Ratio of dialysate creatinine to plasma creatinine is calculated –Subject is classified into different transporter group

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56 Improving outcomes: equal or better survival in first 2–3 years Better preservation of RRF versus HD Higher haemoglobin levels; less erythropoietin use Preservation of vascular access for HD Provides continuous UF for improved blood pressure and volume control Better outcomes post-transplant Less risk of acquiring blood borne virus (hepatitis C) Patient benefits including more flexible holidays and travel and higher employment rates; better quality of life than maintenance HD Ability to expand patient numbers in a dialysis centre with limited need for resources and major capital investments Lower staff to patient ratio than maintenance HD Less costly than maintenance HD

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