Overview of peritoneal dialysis
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Overview of peritoneal dialysis

Overview of peritoneal dialysis

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  • Ultra-small or transcellular pores (4-6 A) are water channels or aquaporin-1.  They are numerous and resemble the water channels present in red blood cells and renal proximal tubules.  They transport water only (sieving) and are present in the endothelial cells of the peritoneal capillaries.  <br />
  • Sodium concentration in dialysate as a function of dwell time t. Dashed lines, clinical data (means ± SD); solid lines, model results. <br />
  • Intraperitoneal volume of dialysate (left) and glucose concentration in dialysate (right) as a function of dwell time t. Dashed lines, clinical data (means ± SD); solid lines, model results. <br />

Overview of peritoneal dialysis Overview of peritoneal dialysis Presentation Transcript

  • Overview of Peritoneal DialysisOverview of Peritoneal Dialysis Piti Niyomsirivanich, MD. Cardiology Fellowship of Maharat Nakhon Ratchasima Hospital
  • Peritoneal DialysisPeritoneal Dialysis water Urea/Cr E’lyte Urea/Cr E’lyte Ultrafiltration Diffusion plasma dialysate
  • Anatomy & PhysiologyAnatomy & Physiology • 3 Pore Model
  • •Ultra-small or transcellular pores (0.4-0.6 nm.) • Exist in small numbers and constitute 1-2 % of all pores •Transport water only (sieving) :aquaporin-1(water channel) Michael F. FlessnerAm J Physiol Renal Physiol 288: F433–F442, 2005 Free water
  • •Small pores (4.0-6.0 nm.) • Exist in large numbers and constitute 95% of all pores •transport small solutes and water: interendothelial cleft Michael F. FlessnerAm J Physiol Renal Physiol 288: F433–F442, 2005 Small solute e.g. Na ,K , Cr
  • •Large pores (20-24 nm) •Exist in small numbers and constitute < 3% of all pores •Transport macromolecules and anatomically large clefts between endothelial cells : convection Michael F. FlessnerAm J Physiol Renal Physiol 288: F433–F442, 2005 albumin
  • Distributive Model
  • • Ultrafiltration – Oncotic pressure gradient – Hydrostatic pressure gradient • Diffusion – The concentration gradiant – Effective peritoneal surface area – Intrinsic peritoneal membrane resistance – Molecular weight of the solute • Fluid Reabsorption – Occurs via the lymphatics  constant rate 1 ml/min
  • Sodium concentration in dialysate as a function of dwell time t. Stachowska-Pietka J et al. Am J Physiol Renal Physiol 2012;302:F1331-F1341 ©2012 by American Physiological Society
  • Intraperitoneal volume of dialysate as a function of dwell time t. Stachowska-Pietka J et al. Am J Physiol Renal Physiol 2012;302:F1331-F1341 ©2012 by American Physiological Society
  • Peritoneal Equilibration TestPeritoneal Equilibration Test • PET : การทดสอบประสิทธิภาพของเยื่อบุช่อง ท้องในการยอมให้สารผ่าน โดยเปรียบ เทียบความเข้มข้นของสาร ณ เวลาหนึ่ง • Concept : การดึงของเสียการดึงของเสีย : Bun, Cr, uremic toxin, K, P, Na : สัดส่วนความเข้มข้นของสารนั้น ในนำ้ายาที่ ปล่อยออก : Dสารนั้น ต่อความเข้มข้นของสารนั้น ในเลือด : Pสาร นั้น
  • Peritoneal Equilibration TestPeritoneal Equilibration Test > 0.81 < 0.5 ดูเรื่องการดึงนำ้า (UF) ดูเรื่องการแพร่ของ solute
  • PET High Transporter Low Transporter Less UF More UF High Solute Transport Low Solute Transport
  • PD Technique & PrescriptionPD Technique & Prescription
  • Peritoneal Equilibration TestPeritoneal Equilibration Test PET Prescription High Transporter Short dwell time Increase cycle High Average NIPD/CAPD Low Average High dose CAPD/CCPD Low High dose CCPD+RRF Switch to HD without RRF
  • PD SolutionPD Solution • PDF Conc. : 1.5 % , 2.5%, 4.25% Dextrose • Electrolyte – Na (132 mEq/L) / Mg (0.5) / Cl (96) – NaCl 538 mg/dL Sodium-lactate 448 mg/dL CaCl 25.7mg/dL MgCl 5.08 mg/dL – Lactate (40)  Bicarbonate • pH : 5.2 (4-6.5) • Osmole : 346 • New Solution : 7.5% Icodextrin (Glucose Polymer)
  • Peritoneal access device • Tenchoff catheter
  • • Straight bag system • Y-set • Double bag system – Connect – Drain – Flush – Fill – Disconnect
  • PD Technique & PrescriptionPD Technique & Prescription
  • Automate PD
  • Dialysis related peritonitisDialysis related peritonitis • Diagnosis (2 of 3)Diagnosis (2 of 3) 1. Clinical : Fever, Abdominal pain, Cloudy dialysate 2. PDF cell diff/cell count : WBC ≥ 100 (PMN ≥ 50%), in dwell time for 4 hr 3. PDF Culture : Positive
  • Investigation CBC Elyte , BUN , Cr , alb H/C CXR Film KUB PDF fluid : cell diff , cell count , culture gram stain (for Dx fungal infection)
  • Route of InfectionRoute of Infection • Transluminal  Hx Touch contamination • Periluminal  exit site infection, tunnel infection ? • Transmural  diarrhea ? Constipation ? • Transvaginal  leukorrhea , PID ? • Hematogenous  other source of infection
  • DDx. In Cloudy DialysateDDx. In Cloudy Dialysate 1. Culture-positive infectious peritonitis 2. Culture-negative Infectious peritonitis 3. Chemical peritonitis 4. Eosinophilia of the effluent 5. Hemoperitoneum 6. Malignancy (rare) 7. Chylous effluent (rare) 8. First drainage after break in period
  • Abnormal PD SolutionAbnormal PD Solution
  • • Rule out 2nd Peritonitis – Acute appendicitis – Ruptured viscus – Diverticulitis – Strangulated hernia • สงสัยเมื่อ ?? – Hx : ปวดท้องก่อนนำ้ำยำขุ่น / ปวดท้องแต่ นำ้ำยำไม่ขุ่น – P.E. : PR Exam, Localizing pain – Mixed organisms – Free air ???  CAPD < Automate PD PD related peritonitisPD related peritonitis
  • • หลักการให้ Antibiotic –Empiric antibiotics: • Cover Gram+ve & Gram-ve organisms • Center-specific selection of empiric therapy • History of sensitivities of organisms causing peritonitis –Gram +ve : 1st Cephalosporin –Gram -ve : 3rd Cephalosporin or Aminoglycoside PD related peritonitisPD related peritonitis
  • • Empiric regimen:Empiric regimen: Cefazolin 1 gm i.p. + Cetazidime 1 gm.i.p in PDF 2,000 ml ,dwell time ≥ 6 hours • In Clinical Severe SepsisIn Clinical Severe Sepsis Cefazolin + Cetazidime  i.p. and i.v. Loading dose Then if clinical improve  only i.p. route PD related peritonitisPD related peritonitis
  • Empirical antibioticEmpirical antibiotic Clinical Assessment on day 3-5Clinical Assessment on day 3-5 Microbes Isolated from culture ,Adjust antibioticsMicrobes Isolated from culture ,Adjust antibiotics Clinical improvement & evaluate exit site and tunnel Clinical improvement & evaluate exit site and tunnel No clinical improvement Reculture and evaluate No clinical improvement Reculture and evaluate No clinical improvement by day 5 after appropriate antibiotic : off catheter No clinical improvement by day 5 after appropriate antibiotic : off catheter Exit site or tunnel infection Off catheter Exit site or tunnel infection Off catheter clinical improvement Continue antibiotics clinical improvement Continue antibiotics
  • Empirical antibioticEmpirical antibiotic Clinical Assessment on day 3-5Clinical Assessment on day 3-5 Microbes Isolated from culture ,Adjust antibioticsMicrobes Isolated from culture ,Adjust antibiotics Clinical improvement & evaluate exit site and tunnel Clinical improvement & evaluate exit site and tunnel No clinical improvement Reculture and evaluate No clinical improvement Reculture and evaluate No clinical improvement by day 5 after appropriate antibiotic : off catheter No clinical improvement by day 5 after appropriate antibiotic : off catheter Exit site or tunnel infection Off catheter Exit site or tunnel infection Off catheter clinical improvement Continue antibiotics clinical improvement Continue antibiotics
  • < 4 weeks , different organism < 4 weeks , same organism > 4 weeks , same organism
  • Exit site Twardowski Score Perfect exit Good exit Equivocal exit Acute infection Chronic infection Exit trauma
  • Equivocal exit site infections purulent or bloody drainage is only present in the sinus and cannot be expressed outside.
  • Acute exit site infection characterized by redness, swelling and tenderness. The erythema is more than twice the diameter of the catheter and there is regression of the epithelium in the sinus.
  • Chronic infection ent both externally and in the sinus of the exit site in chronic infections. The exit is sometimes covered by a large, persistent crust or scab. There is usually no Granulation tissue is typically present both externally and in the sinus of the exit site in chronic infections.
  • Exit trauma
  • ESI Scoring System 0 point 1 point 2 points Swelling 0 < 0.5 cm > 0.5 cm Crust 0 < 0.5 cm > 0.5 cm Redness 0 < 0.5 cm > 0.5 cm Pain 0 Slight Severe drainage 0 Serous Purulent Score = or > 4 : ESI ; purulent drainage ESI Score < 4 may or may not represent ESI
  • UF failure 1.Compliance (oral Na , drug) ? 2.Cardiovascular cause ? 3.Evaluate residual renal function (nephrotoxic drug ) ? 4.Mechanic Failure ? a. Obstruction ,Entrapment , Malposition b. Hernia , leakage 5.Peritoneal Function ?
  • Evaluation • Hx – Cardiovascular disorder ? – Lean body mass – Salt and water – Residual renal function (nephrotoxic agent ?) • PE – Exit site leakage – Hernia pericatheter ,genital ,inguinal ,femoral area – Edema : generalized , unilateral , localized , decrease BS ,abdominal wall ,inguinal area , genitalia
  • Evaluation •Malposition of catheter •Pleural effusion •Asymetrical Abdominal bulging •Hernia
  • Fluid overload PE & Hx Rapid fill and drain , film KUB AP & lateral พบสาเหตุ Catheter malposition Leakage occlusion ไม่พบสาเหตุ PET Drain volume Drain volume ลดลง UF ลดลง D/P คงที่D/P ลดลง (low transport) D/P เพิ่ม (high transport) Drain volume D/P ไม่เปลี่ยนแปลง Decrease Residual renal Fn Sclerosing peritonitis Peritoneal fibrosis adhesion Increase lymphatic absorption Aquaporin deficiency Leakage malposition Recent peritonitis (30-60 mindelta5)
  • Treatment • Collect cause • Diuretics • 4.25%PDF <> 1.5%PDF • Increase frequency (high transporter)
  • General Care
  • General Care