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PD prescription

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  • 1. Peritoneal Dialysis Prescription & Adequatcy Piti Niyomsirivanich,MD.
  • 2. • Peritoneal dialysis prescription – Acute • Introduction • Peritoneal Catheter • Use of automate cycler • Prescribing acute peritoneal dialysis • Complications
  • 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. Acute peritoneal dialysis presciption
  • 5. • Peritoneal dialysis prescription – Acute • Introduction • Peritoneal Catheter • Use of automate cycler • Prescribing acute peritoneal dialysis • Complications
  • 6. Introduction• Acute Peritoneal Dialysis – Nonvascular alternative for dialysis – Acutely less efficient than conventional hemodialysis
  • 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. Indications• Acute renal failure• Benefit in volume overload with cardiovascular compromise• Hypothermia• Hemorrhagic pancreatitis• Most beneficial in Rx of hemodynamically unstable
  • 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. • Peritoneal dialysis prescription – Acute • Introduction • Peritoneal Catheter • Use of automate cycler • Prescribing acute peritoneal dialysis • Complications
  • 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. • Peritoneal dialysis prescription – Acute • Introduction • Peritoneal Catheter • Use of automate cycler • Prescribing acute peritoneal dialysis • Complications
  • 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. • Peritoneal dialysis prescription – Acute • Introduction • Peritoneal Catheter • Use of automate cycler • Prescribing acute peritoneal dialysis • Complications
  • 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. Standard order for 1 day
  • 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. 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. 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. Exchange time• Outflow time – Gravity – 20-30 min – Depend on • Total volume • Resistance to outflow • Height • 1st exchange • Outflow obstruction • Outflow pain
  • 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. 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. 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. 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. Insulin
  • 26. • Antibiotics – Intraperitoneal administration
  • 27. Monitoring fluid balance
  • 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. • Peritoneal dialysis prescription – Acute • Introduction • Peritoneal Catheter • Use of automate cycler • Prescribing acute peritoneal dialysis • Complications
  • 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. 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. Adequacy of Peritoneal Dialysis and Chronic Peritoneal Dialysis Prescription
  • 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. • Choice of modality – CAPD – APD – Variant of APD : CCPD , NIPD – hybrid• Selection based on – Clearance – UF – Nutritional requirement
  • 35. DiagrammaticRepresentation of various continuous ambulatory peritoneal dialysis and automate peritoneal dialysis
  • 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. 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. • 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. • 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. 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. • Risk of peritonitis – Decade ago • APD showed less peritonitis • But APD techinique improved now• Relative cost
  • 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. 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. • 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. 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. • 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. 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. • Body size – Large body size  harder to achieve clearance• Prescription – Change – Focus on lifestyle factors
  • 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. 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. 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. 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. 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. 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. 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. 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. 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. • 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. • 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. 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. • Caloric intake – = dietary intake + glucose absorbed – 35 kcal/kg/day – 10-30% come from glucose (depend on tonicity)
  • 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. Serum albumin• Strongest predictors of patient survival on PD• Influences – dialysate albumin losses – Inflammation – More than dietary protein intake
  • 64. Subject global assessment• Simple clinical tool• Predict patient outcome• KDOQI , Canadian Society
  • 65. Creatinine excretion• 24 hr urine and dialysate collections
  • 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