11 peritoneal dialysis

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  • 1. Peritoneal dialysis
    • Jana Fialov
    • Martina Peiskerov
    • Klinika nefrologie 1. LF a VFN
    • Praha
    • 10/2007
  • 2. Ramesh Khanna & Karl D. Nolph Modalities of renal replacement therapy Interchangeable, depends on residual renal function
  • 3. Peritoneal dialysis - outline
    • Principles of PD
    • PD solutions
    • PD catheter
    • Indication / contraindication of PD
    • PD schemes : CAPD, CCPD
    • Assessement of PD adequacy, ultrafiltration
    • Assessement of peritoneal function
    • Complications
    • Perspectives new dialysis solutions
  • 4. Peritoneal dialysis introduction
    • method of RRT for 100.000 patients worldwide
    • complementary to hemodialysis
    • Principles:
    • peritoneum (capillary endothelium, matrix, mesothelium) = semipermeable dialysis membrane through which fluid and solute move from blood to dialysis solution via diffusion and convection
    • effective peritoneal surface area = perfused capillaries closed to peritoneum ( in peritonitis)
    • ultrafiltration (movement of water) enabled by osmotic gradient generated by glucose or glucose polymers (isodextrin)
  • 5. Principles of peritoneal dialysis
  • 6. Scheme of peritoneal solute transport by diffusion through the pores of capillary wall
  • 7. Ramesh Khanna & Karl D. Nolph Model of transport - 3 sorts of pores
  • 8. Ramesh Khanna & Karl D. Nolph Na 132 mmol/l Ca 1,25mmol/l Mg 0,5 mmol/l Cl 100 mmol/l lactate 35 mmol/l ev. lactate/bicarbonate glukose 1,36-4,25 g/dl osmolarity 347-486 pH 5,2 GDP (degradation products of glucose) Composition of standard peritoneal dialysis solution
  • 9. Urea concentration in dialysate , rate of equalization of solute concentration depends on molecular size of solute
  • 10. Concentration of Creatinin in dialysate equilibrium of concentrations between dialysate and blood is slower than for urea
  • 11. Peritoneal catheter
    • implanted via laparoscopy, punction or laparotomy (total anesthesy)
    • PD is started 3 weeks following the impantation of catheter
  • 12. Types of peritoneal catheters
  • 13. Why to start with PD ? 1. better maintenance of residual renal function
  • 14. Why to start with PD ?
    • clinical outcomes comparable to HD, no difference in 2 year and 5 year mortality vs. HD (study NECOSAD)
    • saves vascular access
    • preferred for children (APD)
    • modality choice is a lifestyle issue
  • 15. Ramesh Khanna & Karl D. Nolph 80% of patients have no contra-indication to any of the dialysis methods and may choose according to their life style between HD a PD Absolute contra-indications of PD: 1.peritoneal fibrosis and adhesions following intraabdominal operations 2.inflammatory gut diseases Indication / Contraindications of PD
  • 16.
    • pleuro-peritoneal leakage
    • hernias
    • significant loin pain
    • big polycystic kidneys
    Relative contraindications of PD
    • severe deformant arthritis
    • psychosis
    • significant decrease of lung functions
    • * diverticulosis
    • colostomy
    • obesity
    • blindness
  • 17. CAPD continual ambulatory peritoneal dialysis
    • manual exchanges
  • 18. NIPD night intermitent peritoneal dialysis (cycler)
  • 19. CCPD continual cyclic PD
  • 20. Assessement of PD adequacy PET (peritoneal equilibrium test) 1
    • determines quick or slow passage of toxins from the blood into the dialysis fluid
    • high-fast transporters v.s. low-slow transporters
    • helps to decide about the PD scheme (dwell duration and intervals, CAPD vs. CCPD)
    • performed in hospital, takes 5 hours
    • involves doing a CAPD exchange using a 2.27% G, samples of PD fluid and blood are taken at set times
  • 21. PET (peritoneal equilibration test) 2 CAPD, 5 exchanges daily + 1 exchange at night Good Slow Slow CAPD or APD OK OK Average Frequent exchanges, short dwells APD Poor Fast High Best type of PD Water removal Waste removal Transporter
  • 22. Interpretation of peritonal equilibration test ??
  • 23. Ramesh Khanna & Karl D. Nolph Results of baseline PET
  • 24. Choice of PD scheme depends of BSA and type of transport
  • 25.
    • PET- peritoneal equilibration test (type of transport and ultrafiltration after 4 hours)
    • weekly clearance of creatinine and urea
    • daily UF
    • dicrease of Na in dialysis fluid after 60 minutes using 3,8% G (test of aquaporines)
    Assessement of peritoneal function
  • 26. Ratio D/P for Na , upper curve 1,27% glucose, lower curve - 3,86% G (initial drop due to transcellular UF of water through aquaporins)
  • 27.
    • Depends on:
    • - type of transporter low transporters have better UF
    • - concentration and type of osmotic agent in PD fluid:
    • Fluids with glucosis (1,27%, 2,5% a 3,8% ), higher concentration higher osmotic pressure and UF
    • Fluid with icodextrin (Extraneal) = glucose polymer with a large molecule, resorbs only 10-20%, offers longtime UF, suitable for long night exchanges, 8-12 hours)
    • - time between exchanges, using glucose-based fluids, maximal UF obtained after 2-3 hours, using longer spaces UF dicreases.
    Ultrafiltration during PD
  • 28. Ultrafiltration in different types of PD solutions
  • 29. Criteria of PD adequacy
  • 30.
    • Infectious:
    • exit-site inflammation (flare, suppurative secretion,
    • granulation)
    • peritonitis (turbid dialysate, abdominal pain, fever)
    • Non-infectious:
    • hernias
    • hydrothorax
    • sclerosing encapsulating peritonitis (rare, life threatening complication, mostly after 6 years on PD, peritoneum is massively thickened and calcificated, leading to intestinal obstruction)
    Complications of PD 1
  • 31.
    • Non-infectious:
    • Leakage of dialysate along the peritoneal catheter
    • Drainage failure of dialysate (dislocation or catheter obstruction by fibrin)
    • Morphologic changes of peritoneum following long-lasting PD (peritoneal fibrisis, mesotelial damage, vasculopathy and neo-angiogenesis) leading to loss of UF capacity reason for PD cessation in 24% of all patients, and in 51% of patients treated above 6 years.
    Complications of PD 2
  • 32.
    • Large vascular surface of peritoneum (due to neo-angiogenesis, vasodilation), leading to high (fast) type of transport including fast loss of osmotic glucose pressure
    • Decreased function of aquaporins
    • High lymfatic absorption
    Causes of UF failure
  • 33. Morphologic changes of peritoneum due to PD