Presentation on theme: "Dr. Leonid Feldman Nephrology and Hypertension Division Assaf Harofeh Medical Center November, 2007 Peritoneal Dialysis."— Presentation transcript:
Dr. Leonid Feldman Nephrology and Hypertension Division Assaf Harofeh Medical Center November, 2007 Peritoneal Dialysis
AJKD 2002:39:S32 3.3
Three options for renal replacement therapy
Criteria for initiation of chronic dialysis Uremic syndrome Hyperkalemia Volume expansion Metabolic acidosis Bleeding diathesis CrCl ≤ 10 ml/min resistant to conservative therapy
What is peritoneal dialysis? PD involves the transport of solutes and water across a “membrane” that separates two fluid- containing compartments: 1.blood in the peritoneal capillaries 2.dialysis solution in the peritoneal cavity
Peritoneal Transport Tree Distinct Processes: Diffusion Ultrafiltration ( Convection ) Fluid Absorption
Peritoneal Transport Two Clinical Endpoints: Clearance Fluid Removal
Cycler: performs four or five exchanges overnight, while patient sleep
Two double-cuff Tenckhoff peritoneal catheters: standard (A), curled (B).
Paradox of UF with glucose-based solutions: small pore radius A, glucose molecule 2-3A How does glucose exerts it’s osmotic gradient?
Directed primarily at small solutes clearance Use of 2.5% dextrose – osmotic drive not optimal Normal ranges for UF volume for each transport category - not fully defined Standard PET Peritoneal Equilibration Test
Prognosis and transport type What happens with our high transporters?
The high transporters in the beginning have reduced patient survival Wang, NDT 1998
Adequate dose of peritoneal dialysis Weekly Kt/V ≥ Creatinine clearence ≥ L/week K – urea clearence, L of blood/hour t – time, hours V – volume of Urea distribution
Complications of peritoneal dialysis Peritonitis and Exit site infections Catheter problems (malfunction, leak) Fluid overload Hyperglycemia Hyper- and hyponatremia Hypoalbuminemia Hernias
Exit site infection
Sclerosing encapsulating peritonitis. Abdominal CT scan of a patient with sclerosing encapsulating peritonitis. The thickened peritoneum is clearly visible
Patients on dialysis in Israel Total dialysis HD PD 497 pts.–26% 545 pts.–23% 376 pts. – 8%
Percent distribution of prevalent dialysis patients, by modality, USRDS 2006
Composition of Peritoneal Dialysis Solution 4.25%2.5%1.5% * * * Sodium(mEq/L) Potassium (mEq/L) Chloride (mEq/L) Calcium (mEq/L) Magnesium(mEq/L) Lactate (mEq/L) Glucose (mg/dL) pH Osmolality (mosm/kg) *Low Ca has 2.5 mEq/L
Blood vessels in the parietal peritoneum. Transverse sections of peritoneal arterioles (a) normal, (b) vasculopathy in a patient on PD; the vascular lumen is occluded by connective tissue containing fine calcific stippling (toluidine blue)
Peritonitis Empiric Treatment IP Cefazoline (15 mg/kg/d) + Ceftazidime (1g/d) Once culture results and sensitivities are known, antibiotic therapy should be adjusted as appropriate