PD prescription

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PD prescription

  1. 1. Peritoneal Dialysis Prescription & Adequatcy Piti Niyomsirivanich,MD.
  2. 2. • Peritoneal dialysis prescription – Acute • Introduction • Peritoneal Catheter • Use of automate cycler • Prescribing acute peritoneal dialysis • Complications
  3. 3. • Chronic • Choice of PD treatment modality – Modalities of PD therapy CAPD , APD ,hybrid – CAPD or PD ? • Choice of prescription – Clearance targets – Measurement of clearance – Determinants of clearance – prescription • Nutritional issues in PD
  4. 4. Acute peritoneal dialysis presciption
  5. 5. • Peritoneal dialysis prescription – Acute • Introduction • Peritoneal Catheter • Use of automate cycler • Prescribing acute peritoneal dialysis • Complications
  6. 6. Introduction• Acute Peritoneal Dialysis – Nonvascular alternative for dialysis – Acutely less efficient than conventional hemodialysis
  7. 7. Adventage / DisadventageAdventage Disadventage •Technically simpler than that of •Less efficient than hemodialysis hemodialysis (flash pulmonary edema , drug •Doesn’t require highly trained overdose , acidosis ,hyperkalemia , personnel or expensive, complex catabolic patient) equipment •Protein loss  malnourished •Can be instituted quickly •Hyperglycemia •Avoids the potential problems related to vascular hemorrhage , air embolism •Serious morbidity (30%) and , thrombosis , infection mortality (5%) attributed Acute PD •Lower likelyhood of hypotensive and HD are similar episodes
  8. 8. Indications• Acute renal failure• Benefit in volume overload with cardiovascular compromise• Hypothermia• Hemorrhagic pancreatitis• Most beneficial in Rx of hemodynamically unstable
  9. 9. Contraindications• Recent surgery requiring abdominal drains• Known fecal or fungal peritonitis• Pleuroperitoneal fistula• Relative contraindication – Severe hypercatabolic states – Abdominal wall cellulitis – Adynamic ileus – Presence of abdominal adhesions or fibrosis – New aortic prosthesis
  10. 10. • Peritoneal dialysis prescription – Acute • Introduction • Peritoneal Catheter • Use of automate cycler • Prescribing acute peritoneal dialysis • Complications
  11. 11. Peritoneal catheter• Pts. With – multiorgan system failure Can be anticipated – Prolong period of renal failure• initial insertion of a Tenckhoff catheter (preferred > uncuffed temporary catheter) is recommended
  12. 12. • Peritoneal dialysis prescription – Acute • Introduction • Peritoneal Catheter • Use of automate cycler • Prescribing acute peritoneal dialysis • Complications
  13. 13. Use of automated cyclers• Traditionally been done using manual exchanged• Automated cyclers are being used instead – Saving nursing time (30-60 minutes exchange time)
  14. 14. • Peritoneal dialysis prescription – Acute • Introduction • Peritoneal Catheter • Use of automate cycler • Prescribing acute peritoneal dialysis • Complications
  15. 15. Prescribing acute peritoneal dialysis• A: Session length – In the setting of acute renal failure (catabolic , oliguric ), continuous removal of fluids and solutes is required – Need for hourly exchange on a continuous basis for days or weeks – Order for One day
  16. 16. Standard order for 1 day
  17. 17. Exchange volume• Average-sized adult can usually tolerate 2L exchanges – Those with abdominal wall or inguinal hernias, the exchange volume should be reduced• Some may prefer start with smaller volumes(1- 1.5 L) for the first few exchanges• The larger volume is , the greater the clearance and UF rates
  18. 18. Exchange time – Inflow 15 – dwell 30 - drain 15 – 1 hr.• Inflow time – Gravity – 10 min. – Prolonged • Kinking • Inflow resistance• Inflow pain due to acidic , hypertonic solution
  19. 19. Exchange time• Dwell period• Standard dwell period – Usual dwell time is 30 min – 2L per exchage 48 L per day – [Urea] in drained dialysate will be 50-60% of plasma• More stable patients – If Not extremely hypercatabolic state •  longer dwell time 1.5-5 hrs – At 5 hrs [UREA] dialysate = [UREA]plasma
  20. 20. Exchange time• Outflow time – Gravity – 20-30 min – Depend on • Total volume • Resistance to outflow • Height • 1st exchange • Outflow obstruction • Outflow pain
  21. 21. CEPD (Continouous equilibration peritoneal dialysis)• Alternative approach• Modified version of CAPD• Standard manual exchange every 3 to 6 hours• Adventage – Simplicity – Lower cost – Less labor-intense• Disadventage – Clearance are less – Not be adequate in more catabolic patient
  22. 22. Choosing the dialysis solution• 1.5% dextrose – Sufficient to remove 50-150 of fluid per hour (2L ,60min exchange time) – UF rate 1.2-3.6 L/day• 4.25% dextrose – UF 300-400 ml/hr – Acquired for treatment of CHF
  23. 23. Effect of peritonitis• During peritonitis – Enhanced absorption of glucose – Rapidly reducing the osmotic gradient – Maintaining the efficiency of UF • reduced exchange time • More hypertonic exchange
  24. 24. Dialysis Solution additives• KCl – Hypokalemia  KCl 3-5 mEq/L can be added – Correction of acidosis K shift  hypokalemia• Heparin – Catheter obstruction due to fibrin – 1000 U/2 L• Insulin – Glucose absorbed from the dialysis solution
  25. 25. Insulin
  26. 26. • Antibiotics – Intraperitoneal administration
  27. 27. Monitoring fluid balance
  28. 28. Monitor Clearance• In general – BUN should maintain below 80 mg/dl – D:P ratio for urea • [BUN]dialysate : [BUN]plasma ratio • Multiplied by total daily dialysate volume urea daily clearance • Should be at least 10 ml/min • 20-30 ml/min in hypercatabolic patient
  29. 29. • Peritoneal dialysis prescription – Acute • Introduction • Peritoneal Catheter • Use of automate cycler • Prescribing acute peritoneal dialysis • Complications
  30. 30. Complications• Abdominal distention – Incomplete drainage• Peritonitis – 12% of cases – Occur within first 48 hrs – Gram +ve organisms (>50%) – Prolong used of Multiple antibiotics  fungus• Hypotention – Removal large amout of fluid
  31. 31. Complications• Hyperglycemia – IP insulin• Hypernatremia – UF generated in PD [Na] 70 mEq/L – Increased loss of water• Hypoalbuminemia – Protein loss 10-20 gm /day – Early oral or parenteral hyperalimentation should be instituted
  32. 32. Adequacy of Peritoneal Dialysis and Chronic Peritoneal Dialysis Prescription
  33. 33. • Chronic • Choice of PD treatment modality – Modalities of PD therapy CAPD , APD ,hybrid – CAPD or PD ? • Choice of prescription – Clearance targets – Measurement of clearance – Determinants of clearance – prescription • Nutritional issues in PD
  34. 34. • Choice of modality – CAPD – APD – Variant of APD : CCPD , NIPD – hybrid• Selection based on – Clearance – UF – Nutritional requirement
  35. 35. DiagrammaticRepresentation of various continuous ambulatory peritoneal dialysis and automate peritoneal dialysis
  36. 36. Modality of peritoneal dialysis therapy• CAPD – Low cost – Freedom from dialysis machinery – Continuous therapy and a steady physiologic state – Nomalization of blood pressure is possible in most patients. – Multiple procedural sessions – Can be done away from home – Episodes of peritonitis
  37. 37. Modality of peritoneal dialysis therapy• APD – CCPD • Continuous therapy • Need for cycler • Complications associated c a prolonged day dwell – Excessive resorption of dialysate » Icodextrin are useful in day dwell – NIPD • No dialysis fluid during day time • Suitable for patient with good residual renal function
  38. 38. • Hybrid forms of PD – CAPD with automated nocturnal exchange • A night exchange device – APD with additional exchange during the day• IPD – Almost extinct – Cycler in hospital 2-3 times weekly duration 12-24 hr
  39. 39. • Chronic • Choice of PD treatment modality – Modalities of PD therapy CAPD , APD ,hybrid – CAPD or PD ? • Choice of prescription – Clearance targets – Measurement of clearance – Determinants of clearance – prescription • Nutritional issues in PD
  40. 40. CAPD or APD• Based on – Lifestyle ,emplyment , place of residence comfort with the cycle technology and family and social support• Previously APD better than APD – Na Sieving • Risk of net fluid resorption with long day dwells • Led to concerns about Na removal with APD – Systolic hypertension with APD > CAPD (no randomized trial but generalizable)
  41. 41. • Risk of peritonitis – Decade ago • APD showed less peritonitis • But APD techinique improved now• Relative cost
  42. 42. • Chronic • Choice of PD treatment modality – Modalities of PD therapy CAPD , APD ,hybrid – CAPD or PD ? • Choice of prescription – Clearance targets – Measurement of clearance – Determinants of clearance – prescription • Nutritional issues in PD
  43. 43. Choice of a prescription• Clearance targets – ADEMEX study • 1000 CAPD patients – 4X2 L CAPD versus a high peritoneal clearance regimen – 2 years – Mean Kt/V 1.62 and 2.12 / wk A concensus target Kt/V for PD  1.7 /wks
  44. 44. • Chronic • Choice of PD treatment modality – Modalities of PD therapy CAPD , APD ,hybrid – CAPD or PD ? • Choice of prescription – Clearance targets – Measurement of clearance – Determinants of clearance – prescription • Nutritional issues in PD
  45. 45. Frequency of measurement• Within 1 month of initiation• And then q 4 months• Discordance between Kt/V and CrCl – APD • Cr has higher molecular weight than urea
  46. 46. • Chronic • Choice of PD treatment modality – Modalities of PD therapy CAPD , APD ,hybrid – CAPD or PD ? • Choice of prescription – Clearance targets – Measurement of clearance – Determinants of clearance – prescription • Nutritional issues in PD
  47. 47. Determinants of clearance• Residual renal function – Account for as much as 50% of total clearance – Preserved in patient on CAPD •  ACEI ,ARB • Avoid nephrotoxic agents i.e. aminoglycoside• Peritoneal transport status – PET • Low transporter  high volume ,long duration dwell – Low average – High average • High transporter  short duration dwell
  48. 48. • Body size – Large body size  harder to achieve clearance• Prescription – Change – Focus on lifestyle factors
  49. 49. • Chronic • Choice of PD treatment modality – Modalities of PD therapy CAPD , APD ,hybrid – CAPD or PD ? • Choice of prescription – Clearance targets – Measurement of clearance – Determinants of clearance – prescription • Nutritional issues in PD
  50. 50. CAPD• Initial – 4x2 L or 4x2.5 in larger patients – Increase peritoneal Kt/V in CAPD • Increasing exchange volumes – Increase backpain – Abdominal distention – Shortness of breath • Increasing the frequency of daily exchange – Most CAPD pts. Do 4 exchange daily – 45 lead to burn out (alt. night exchange) • Increase the tonicity of dialysis solution – Increase UF and clearance
  51. 51. APD• 10-12 L daily (15 L in larger)• Good residual renal function  NIPD• High transporter  short day time/second dwell• Typical cycler time is 8-10 hrs – dwell volumes 2 L
  52. 52. Increase clearance of APD• Introduction of a day dwell – NIPD • Adding day dwell  increase Kt/V and CrCl by 25%-50% • Disadventage – In high transporter  increase net fluid resorption – Icodextrin or shortening day dwell• Increase dwell volumes on cycler – Because patients are supine during cyclingtolerate larger dwell volume – 4X2.5 L per session is better than 5X2 L per session
  53. 53. Increase clearance of APD• Time on cycler – The longer time ,the better clearance• Increasing frequency of cycles – More frequent cycle  increase clearance on APD – But More frequent cycle Dialysis time lost• Increasing dialysis solution tonicity – concern about glocose-related complications arise
  54. 54. Incremental versus maximal prescription• Incremental approach – Suitable when dialysis is being initiated early – 2-3 CAPD exchanges daily or a low-volume – Less costly and less onerous – Decrease total glucose exposure and risk of peritonitis – Require regular monitoring of resiual function • To ensure that the clearance achieved doesn’t below target levels
  55. 55. Empirical versus Modeled approach• Modeled approach• collecting patient anthropometric data , PET , residual renal function• Computer program uses the data to predict• Actual clearance still have to be measure• because discrepancy between actual and modeled
  56. 56. Empirical versus Modeled approach• Empirical approach – Physician uses knowledge of the patient’s size , residual renal function , and peritoneal transport status – And choose a resonable prescription – Advantage • Less trial and error • Earlier identification of an appropriate prescription
  57. 57. Prescription pitfalls in peritoneal dialysis• Loss of residual renal function – Not monitored closely enough• Noncompliance – No single test that identifies this problem – Serial measurement of 24-hr dialysate plus urinary Cr excretion• High serum creatinine despite good clearances – Kt/V > 1.7/wk but serum Cr > 12-15 – Non compliance – Kt/V high and CrCl low – Residual renal function fades away – Hight lean body mass
  58. 58. • Inappropriate switch form CAPD to APD – Particular in low transporter• Inadequate attention to fluid removal – Particular in high , high-average transporter and long dwells that result in net fluid resorption
  59. 59. • Chronic • Choice of PD treatment modality – Modalities of PD therapy CAPD , APD ,hybrid – CAPD or PD ? • Choice of prescription – Clearance targets – Measurement of clearance – Determinants of clearance – prescription • Nutritional issues in PD
  60. 60. Nutritional Issues in PD• nPNA – Normalized protein equivalent of nitrogen appearance – Include • Serum albumin • Subjective global assessment • Lean body mass – Measure 24 hr of dialysate and urine (intake output) – Bergstrom – Recommend 1.2 gm/kg/day
  61. 61. • Caloric intake – = dietary intake + glucose absorbed – 35 kcal/kg/day – 10-30% come from glucose (depend on tonicity)
  62. 62. Bergstrom formulas• 1) PNA (g per day)=20.1 + 7.5 UNA (g per day)or• 2) PNA (g per day)= 15.1 + 6.95 UNA + dialysate protein losses (g per day)• UNA = urinary nitrogen losses (g/day) + dialysiate urea nitrogen losses• 1) if dialysate protein losses are unknown• 2) if dialysate protein losses are known
  63. 63. Serum albumin• Strongest predictors of patient survival on PD• Influences – dialysate albumin losses – Inflammation – More than dietary protein intake
  64. 64. Subject global assessment• Simple clinical tool• Predict patient outcome• KDOQI , Canadian Society
  65. 65. Creatinine excretion• 24 hr urine and dialysate collections
  66. 66. Treatment of malnutrition• Dietitian support – Dietition to ensure adequate protein intake• Nutritional Supplement• Promotility agent – Gastric emptying is impaired• Anabolic steroid – 1 RCT ,Nandrolone 100 mg IM weekly for 6 months  improve lean body mass• Amino acid – amino acid based dwell

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