This document discusses prescribing acute and chronic peritoneal dialysis. For acute PD, it recommends using a Tenckhoff catheter and automated cyclers. Exchanges should be hourly with 2L volumes. Clearance is monitored using BUN levels and D:P ratios. Complications include abdominal distention and peritonitis. For chronic PD, clearance targets are a Kt/V of 1.7 per week. Prescriptions are based on residual renal function, transporter status, and body size. CAPD and APD are both options depending on lifestyle. Clearance can be increased by optimizing exchange volumes, frequency, and solution tonicity.
A detailed description of diagnosing and managing peritonitis and catheter-related infections in peritoneal dialysis patients.
A practical guide for Nephrologists and health care professionals.
A detailed description of diagnosing and managing peritonitis and catheter-related infections in peritoneal dialysis patients.
A practical guide for Nephrologists and health care professionals.
Renal Replacement Therapy: modes and evidenceMohd Saif Khan
Renal replacement therapy is a supportive care often required in critically ill patients who develop acute renal failure and its complications. Complexity arises when such patients become hemodynamically unstable and pose special challenge to critical care clinicians in ICU to carefully choose dialytic modality to tackle volume and solute overload. This presentation is about short description of modalities of RRT and current evidence regarding initiation, dose and type of modality.
A very simple yet comprehensive presentation to understand the concept of CRRT and its implementation in Intensive Care Unit. Intended for the very beginners in ICU. After going through the presentation you will be able to say "Now I know it!"
Continuous renal replacement therapy is a recently introduced modality for renal replacement therapy in hemodynamic unstable patients with AKI in ICU
THIS lecture was represented in Mansoura international hemodialysis course
Renal Replacement Therapy: modes and evidenceMohd Saif Khan
Renal replacement therapy is a supportive care often required in critically ill patients who develop acute renal failure and its complications. Complexity arises when such patients become hemodynamically unstable and pose special challenge to critical care clinicians in ICU to carefully choose dialytic modality to tackle volume and solute overload. This presentation is about short description of modalities of RRT and current evidence regarding initiation, dose and type of modality.
A very simple yet comprehensive presentation to understand the concept of CRRT and its implementation in Intensive Care Unit. Intended for the very beginners in ICU. After going through the presentation you will be able to say "Now I know it!"
Continuous renal replacement therapy is a recently introduced modality for renal replacement therapy in hemodynamic unstable patients with AKI in ICU
THIS lecture was represented in Mansoura international hemodialysis course
Peritoneal dialysis by Dr. Basil TumainiBasil Tumaini
Peritoneal dialysis by Dr. Basil Tumaini, prepared for nephrology lecture during the residency in Internal medicine at Muhimbili University of Health and Allied Sciences
AKI in the ICU
Principles of RRT
Modes of RRT
Indications for RRT
Optimal timing: When to start
Optimal modality: What Modality and Where ??
Optimal dosing- How Much?
Summary and Conclusions
peritoneal dialysis, management of chronic renal failureSapana Shrestha
Peritoneal dialysis is a technique of dialysis in which solute and fluid exchange occurs between peritoneal capillary blood and dialysis solution in the peritoneal cavity via peritoneal layer with the help of peritoneal catheter.
خلاصه:
دیالیز صفاقی یکی از روش های درمانی جایگزین در کودکان با نارسایی مزمن و شدید کلیه می باشد . روش ساده ای است که بدون وابستگی به مرکز میتوان در منزل انجام داد و به فعالیتهای معمول ادامه داد. در این روش کاتتر دیالیز که تنکوف می باشد و معمولا انتهای پیچ خورده ای دارد و گردن خروجی ان به صورت خمیده می باشد به روش جراحی یا در کنار تخت بیمار کاتتر وارد شکم و به طرف پشت مثانه هدایت می شود. در کودکان به منظور جلوگیری ازانسداد کاتتر ، امنتکتومی صورت میگیرد. معمولا دوهفته بعد از کاتتر گذاری می توان دیالیز را شروع کرد. محلول دیالیز صفاقی خاصیت اسموتیک بالا دارد و عمدتا دارای قند بالا می باشد . قند موجود در مایع دیالیز کمک می کند تا آب و املاح براساس خاصیت اسموتیک از خون به حفره صفاق جابجا شوند، براساس خاصیت انتشار اوره و کراتینین ، فسفر و پتاسیم جابجا میشوند تا به تعادل برسند. حجم مایع دیالیز معمولا 1100 سی سی به ازای هر متر مربع در کودکان بالای یکسا ل و 600 سی سی به ازای هر متر مربع بدن در کودکان زیر یکسال می باشد. بهتر است دفعات تجویز مایع دیالیز با اندازه گیری تست تعادل پریتوئن صورت گیرد. به منظور جلوگیری از بروز فتق ویا نشت بهتر است حجم مایع تجویز شده با اندازه گیری فشارداخل شکم کنترل شود. وفشارداخل شکم کمتراز 18 سانتی متر آب نگهداشته شود. عوارض دیالیز صفاقی به عوارض عفونی ( پریتونیت ، عفونت محل خروج کاتتر و یا تونل) و حوادث غیر عفونی شامل بروز فتق ، نشت مایع دیالیز ، تجمع مایع د رفضای پریتونئال ، جابجایی کاتتر دیالیز صفاقی ، چسبندگی وانسداد ونهایتا فیبروز اسکلروزه پریتوئن می باشد. درکودکان توجه به دریافت مناسب کالری متناسب با سن برای رشد قدی و وزنی ضروری است.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
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Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
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New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
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NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
6. Introduction
• Acute Peritoneal Dialysis
– Nonvascular alternative for dialysis
– Acutely less efficient than conventional
hemodialysis
7. Adventage / Disadventage
Adventage 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
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
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)
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
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
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
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
37. 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
38. 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
39. • 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
40. • 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
41. 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)
42. • Risk of peritonitis
– Decade ago
• APD showed less peritonitis
• But APD techinique improved now
• Relative cost
43. • 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
44. 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
45.
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. 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
48. • 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
49. 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
50. • Body size
– Large body size harder to achieve clearance
• Prescription
– Change
– Focus on lifestyle factors
51. • 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
52. 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
– 45 lead to burn out (alt. night exchange)
• Increase the tonicity of dialysis solution
– Increase UF and clearance
53. 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
54. 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 cyclingtolerate
larger dwell volume
– 4X2.5 L per session is better than 5X2 L per session
55. 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
56. 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
57. 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
58. 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
59. 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
60. • 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
61. • 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
62. 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
63. • Caloric intake
– = dietary intake + glucose absorbed
– 35 kcal/kg/day
– 10-30% come from glucose (depend on tonicity)
64. 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
65. Serum albumin
• Strongest predictors of patient survival on PD
• Influences
– dialysate albumin losses
– Inflammation
– More than dietary protein intake