1. PD in AKI
A ‘dispassionate’ Re-appraisal
Dr Sanjay Maitra
MD,DM(PGI,Chd),Clin.Fellowship Toronto Univ.
Sr.Consultant Nephrologist,Apollo Health City, Hyderabad
2.
3.
4.
5. In 2008 there were about 196,000 P.D. pts. worldwide (11% of total)
59 % were from developing and 41% from developed countries
PD prevalence increased 2.5 times in developing countries during the
period
The proportion of patients treated with PD declined in developed
countries but remained stable in developing countries
6. PD incidence rates are on the rise in US as compared to HD
During 2012 the Annual Mortality Rates for PD & HD similar
7.
8. Current Dialysis scenario in INDIA
Hemodialysis -82,000 pts
Perit. Dialysis -9,000
APD -700
Major PD centres ,India
SGPGI, Lucknow
CMC ,Vellore
PGIMER,Chandigarh
AIIMS,Delhi
NIMS, Hyderabad
MCH,Calicut
RIMS, Imphal
Ganga Ram Hosp,Delhi
Frontline Hospital
International Hosp,Gauhati
9. Role of PD in AKI
Complimentary not competitive
10. Advantages of PD
Widely available and technically easy
Particularly useful in isolated and remote areas
After natural calamities and in battle areas
Costs less than CRRT and Slow continuous dialysis
Fluid removal rather easy in haemodynamically
unstable patients
Gentler form of dialysis, no dialysis-disequilibrium
Gradual correction of acid-base and electrolyte disturbances
11. Advantages of PD
PD access placement is easier , particularly in children
PD very useful modality, particularly in small children
No need for arterial or venepuncture or anticoagulation
Highly biocompatible technique
Better and faster recovery from AKI is reported
May help remove cytokines in patients with Sepsis
PD well suited for hypotensive patients
Dextrose in PD solutions may provide nutrition
Intraperitoneal medication administration possible
12. Renal indications of PD in AKI
RRT in the treatment of children
Hemodynamically unstable patients
Presence of bleeding diathesis or haemorrhagic
conditions
Making vascular access or use of anti-coagulants difficult
Patients with difficult vascular access placement
Removal of high molecular weight toxins(10KD)
13. Non-Renal indications of PD
in AKI
Acute Pancreatitis
Clinically significant hypothermia or hyperthermia
Refractory heart failure
Liver failure
Infusion of drugs and nutrients as supportive
therapy in critically ill patients
14. Contraindications to Acute PD
Recent abdominal surgery
Pleuro- peritoneal connections
Severe respiratory failure
Life threatening hyperkalaemia
Extremely hypercatabolic state
Severe volume overload in a patient not on ventilator
15. Contraindications to Acute PD
Severe Gastro-oesophageal reflux disease
Low peritoneal clearance
Faecal or fungal peritonitis
Abdominal wall cellulitis
AKI in pregnancy
16. Current Dialysis scenario in INDIA
Hemodialysis -82,000 pts
Perit. Dialysis -9,000
APD -700
Major PD centres ,India
SGPGI, Lucknow
CMC ,Vellore
PGIMER,Chandigarh
AIIMS,Delhi
NIMS, Hyderabad
MCH,Calicut
RIMS, Imphal
Ganga Ram Hosp,Delhi
Frontline Hospital
International Hosp,Gauhati
17. The North-Eastern States
State Popln. Dia.cntr Nephr. HD
machines
HD
ssns
PD cntrs
Assam 3cr 20 15 200 6000 15
Manipur 27 lakh 8 5 3
Nagaland 23 lakh
7 3 2
Mizoram 11 lakh 5 2 3
Meghalaya 32 lakh 5 3
AP 12 lakh 1 1 1
Tripura 36 lakh 3 1
21. Stage Serum Creatinine Urine output
1 1.5-1.9 times baseline
Or
≥0.3mg/dl absolute increase
<0.5ml/kg/hr for 6-
12 hrs
2 2.0-2.9 times baseline <0.5ml/kg/hr for
≥12 hrs
3 3.0 times baseline
Or
↑ to ≥ 4.0 mg/dl
Or
Patients on Dialysis
Or
In patients<18yrs e-
GFR<35ml/min/1.73m2
<0.3ml/kg/hr for≥
24 hrs
Or
Anuria for≥ 12hrs
K-DIGO staging of AKI
22. Apprehensions about using PD
in AKI
Low Clearance of uremic toxins particularly in
Hypercatabolic and obese patients
Those on vasopressors and with splanchnic hypoperfusion
Potentially unpredictable fluid removal rates
Risk of peritonitis
Glucose absorption and hyperglycaemia
Excessive protein loss
Impaired diaphragmatic movement in ventilated patients
Causing decreased Functional Reserve Capacity
23. What does the evidence tell us about the
adequacy of PD in AKI?
24. Pooled Mortality was 39.3% in PD only group
In cohort studies comparing PD with EBP
the mortalities were comparable 58% vs 56.1%
In RCT the mortalities were no different
Primary outcomes :Mortality rates
Secondary outcomes : Length of stay
Kidney recovery & complications of PD
and EBP
One half of studies are from Asia –Pacific 4 are from Brazil, 3 are from Africa
Mean age of patients ranged from 29.1-75.6 yrs
Causes of AKI were Sepsis, Pre-renal,Cardiac failure,Post-surgery and
nephrotoxic agents
25. What did the RCT’s show?
Primary Outcomes
Two of the studies compared PD with CRRT
George and Phu
The third one compared PD with Intermittent HD
4th Study compared patients of AKI or CKD on PD or
intermittent HD
Only 8 of 40 were AKI
Pooled results from RCT showed no difference
26. What did the RCT’s show?
Secondary Outcomes
Rapid Recovery of Renal functions in AKI pts on PD
Doubtful , one study from Brazil found it to be true
Studies from India and Vietnam found the opposite
Study by Phu et al found the mortality rate to be nearly 3 times that
of CVVHD
Complications of PD
Most common is Peritonitis (40%)
Technique failure or catheter related problems
In 1 study only mentioned as 10%
Difficult to generalise because
Review spanned over 4 decades ,both PD and CRRT techniques have
changed
Epidemiology of AKI has also changed, Sicker ,older patients
28. Patients with AKI and MODS were randomly allotted to CVVHDF or CPD
25 patients in each group
Primary outcome ,Composite correction of uremia and fluids and electrolytes
Secondary outcomes, improvement of sensorium ,hemodynamic stability, cost ,
survival
Solute correction better in HD, acidosis better corrected with PD
Fluid overload better corrected with CVVHD
Mortality 84% in CVVHDF and 72% in PD group, PD was cheaper too
29. Prospective Randomised Controlled trial
Compared effect Of HVPD vs Daily HD on AKI patient survival
Total 120 patients ,60 in each arm ;age and severity matched
Primary end point hospital survival and renal function recovery
Secondary end point metabolic control
Weekly Kt/V in HVPD -3.6 , with DH 4.7
Mortality rates were comparable 58 and 53%, Renal recovery similar
Patients with HVPD had shorter time to recovery in renal function
30.
31. Prospective randomised cross-over trial
Pts with mild to moderately catabolic ARF
Assigned to CEPD or TPD and then changed over to the other
87 patients received 236 sessions of dialysis (118 each)
TPD had better clearances than CEPD
Normalised Creatinine clearances 68.5 vs 58.85
Kt/V 2.43 vs 1.80
Both were reasonable options for treating AKI
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33.
34. The usefulness of Urea Kinetic Modelling in AKI is debatable
Other than small solute clearance , no other parameter identified
One RCT from Brazil compared PD to daily HD and found no difference
Kt/V urea of 3.6±0.6 per week
Extrapolating from HD data std- Kt/V urea of 2.1 is considered adequate in
most
There are no targets for Middle Molecular weight substances
Ultrafiltration volume control remains difficult on PD
35. Techniques of PD used for AKI
Technique Description Clearance
Acute Intermittent
Peritoneal Dialysis(AIPD)
Fequent small exchanges with volumes
of 1-2 litres
Dialysate flow 2-6 ltrs /hr
Each session 16-20hrs,3times/wk
Urea Cl
8-12ml/min
Continuous Equilibrating
Peritoneal Dialysis (CEPD)
Long dwells of 2-6 hrs (like CAPD)
2 ltrs. dialysate volume
? Low small mol.clearance
Tidal Peritoneal Dialysis
(TPD)
Portion of Dialysate ,Tidal drain volume
is removed (1-1.5 ltrs)
Replaced by Tidal fill volume
Reserve volume remains in abd.
Urea Cl
15/ml/min
High Volume Peritoneal
dialysis (HVPD)
Continuous therapy proposed to increase
small solute clearance
Cycler based 18-48 exchanges /24hrs
2ltr exchanges. Total dial 36-70 ltrs /day
Continuous Flow peritoneal
Dialysis(CFPD)
2 accesses for inflow and outflow
Dialysis flows of 300ml/min achieves
good urea clearance
Urea Cl
30-35ml/min
40. Type of PD Catheter to be used
Flexible peritoneal catheters should be used wherever available
Tunneled catheters have lesser peritonitis and peri-catheter leaks
Prophylactic antibiotics prior to Tenckhoff catheter implantation
Closed fluid delivery system with Y connection preferable
In Low-resource areas spiking of bags and make-shift connections may
be used
41. Choice the technique
Depending on patient profile , available resources and local
expertise
PD catheter implantation by nephrologist is safe and to be
encouraged
Patient with midline scars and high risk of peritoneal
adhesions should avoid blind insertions
PD Insertion Techniques
42. Type of PD solution for acute PD
In patients with Shock or liver failure , bicarbonate based solutions
should be used, when not available lactate containing ones to be used
Commercially prepared solutions in collapsible bags are better,
If not, locally manufactured solutions under sterile conditions to be used
43. Components of Acute PD prescription
1.) Length of the dialysis session
2.) Dialysate composition
3) Exchange volume
4) Inflow and outflow periods
5) Dwell time
6) Number of exchanges
7)Additives
8) Monitoring of fluid balance
Objectives
When resources permit, target weekly Kt/V of 3.5,outcomes same as HD
For many patients a weekly Kt/V of 2.1 may be adequate
During initial 24 hrs of therapy, duration of cycle times needs adjustment
Short cycles to correct hyperkalemia ,metabolic acidosis and fluid
overload are necessary
Avoid Fluid overload
Drug levels ,particularly antibiotics to be monitored
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45.
46. Complications of PD in AKI
Peritonitis
Diagnosis may be challenging
Abdominal pain, cloudy effluent
PD fluid WBC >100cells/µL after 2 hours dwell, repeat daily
Leucocyte esterase 2+ on Urine dipstick
Treat clinically if in doubt
Antibiotics to be given I.P and with every exchange
Mechanical complications
Catheter malfunction , blockage ,displacement
Reported incidence between 7-10%
Protein loss
About 6- 12 gm/day in CAPD, upto 48 gms/day in Peritonitis
Brazilian study with HVPD found 4.2 ±6.1 gm/24 hr in AKI
Hyperglycaemia
Maintain eu -glycaemia
47. Summary
PD can be a useful option in treating patients of AKI in
low resource settings, far-flung areas or as part of
disaster management.
It is particularly useful in certain patient population like
small children or those with cardio-renal syndromes or
vascular access problems
PD, both manual and automated can provide reasonable
doses of dialysis in mild to moderately hyper-catabolic
patients
Cycler based therapies with a closed drainage system
have lesser degrees of peritonitis
48. Summary
Automated peritoneal Dialysis and newer PD solutions
have restricted use in developing countries mainly
because of cost and lack of infrastructure
Hyperglycaemia and protein loss in PD are not un
surmountable problems
Use of PD should be encouraged by the nephrology
community as well as the state policy makers in
developing countries
Patients of AKI here have less associated comorbidities and
are generally younger