Download - Overview of peritoneal dialysis
Overview of Peritoneal DialysisOverview of Peritoneal Dialysis
Piti Niyomsirivanich, MD.Cardiology Fellowship of Maharat Nakhon Ratchasima Hospital
Peritoneal DialysisPeritoneal Dialysis
water
Urea/CrE’lyte
Urea/CrE’lyte
Ultrafiltration
Diffusion
plasma dialysate
Anatomy & PhysiologyAnatomy & Physiology
• 3 Pore Model
•Ultra-small or transcellular pores (0.4-0.6 nm.)• Exist in small numbers and constitute 1-2 % of all pores•Transport water only (sieving) :aquaporin-1(water channel)
Michael F. FlessnerAm J Physiol Renal Physiol 288: F433–F442, 2005
Free water
•Small pores (4.0-6.0 nm.)• Exist in large numbers and constitute 95% of all pores•transport small solutes and water: interendothelial cleft
Michael F. FlessnerAm J Physiol Renal Physiol 288: F433–F442, 2005
Small solute e.g. Na ,K , Cr
•Large pores (20-24 nm) •Exist in small numbers and constitute < 3% of all pores•Transport macromolecules and anatomically large clefts between endothelial cells : convection
Michael F. FlessnerAm J Physiol Renal Physiol 288: F433–F442, 2005
albumin
Distributive Model
• Ultrafiltration– Oncotic pressure gradient– Hydrostatic pressure gradient
• Diffusion– The concentration gradiant– Effective peritoneal surface area– Intrinsic peritoneal membrane resistance– Molecular weight of the solute
• Fluid Reabsorption– Occurs via the lymphatics constant rate 1 ml/min
Sodium concentration in dialysate as a function of dwell time t.
Stachowska-Pietka J et al. Am J Physiol Renal Physiol 2012;302:F1331-F1341
©2012 by American Physiological Society
Intraperitoneal volume of dialysate as a function of dwell time t.
Stachowska-Pietka J et al. Am J Physiol Renal Physiol 2012;302:F1331-F1341
©2012 by American Physiological Society
Peritoneal Equilibration TestPeritoneal Equilibration Test
• PET : การทดสอบประส�ทธิ�ภาพของเยื่��อบ�ช่�องท�องในการยื่อมให้�สารผ่�าน โดยื่เปร ยื่บเท ยื่บความเข�มข�นของสาร ณ เวลาห้น%�ง
• Concept : การด%งของเส ยื่การด%งของเส ยื่ : Bun, Cr, uremic toxin, K, P, Na : ส&ดส�วนความเข�มข�นของสารน&'น ในน('ายื่าท �ปล�อยื่
ออก : Dสารน&'น
ต่�อความเข�มข�นของสารน&'น ในเล�อด : Pสารน&'น
= D/Pสารน&'น
Peritoneal Equilibration TestPeritoneal Equilibration Test
> 0.81
< 0.5
ดู�เรื่��องการื่ดู�งน้ำ �า (UF) ดู�เรื่��องการื่แพรื่�ของ solute
PET
High Transporter Low Transporter
Less UF More UF
High Solute Transport Low Solute Transport
PD Technique & PrescriptionPD Technique & Prescription
Peritoneal Equilibration TestPeritoneal Equilibration Test
PET PrescriptionHigh
TransporterShort dwell time
Increase cycle
High Average NIPD/CAPD
Low Average High dose CAPD/CCPD
Low High dose CCPD+RRFSwitch to HD without RRF
PD SolutionPD Solution
• PDF Conc. : 1.5 % , 2.5%, 4.25% Dextrose• Electrolyte
– Na (132 mEq/L) / Mg (0.5) / Cl (96) – NaCl 538 mg/dL Sodium-lactate 448 mg/dL
CaCl 25.7mg/dL MgCl 5.08 mg/dL – Lactate (40) Bicarbonate
• pH : 5.2 (4-6.5)• Osmole : 346 • New Solution : 7.5% Icodextrin
(Glucose Polymer)
Peritoneal access device
• Tenchoff catheter
• Straight bag system• Y-set• Double bag system
– Connect– Drain– Flush– Fill– Disconnect
PD Technique & PrescriptionPD Technique & Prescription
Automate PD
Dialysis related peritonitisDialysis related peritonitis
• Diagnosis (2 of 3)Diagnosis (2 of 3)1. Clinical : Fever, Abdominal pain,
Cloudy dialysate2. PDF cell diff/cell count : WBC ≥ 100
(PMN ≥ 50%), in dwell time for 4 hr3. PDF Culture : Positive
Investigation
CBCElyte , BUN , Cr , alb H/CCXRFilm KUB
PDF fluid : cell diff , cell count , culture gram stain (for Dx fungal infection)
Route of InfectionRoute of Infection
• Transluminal Hx Touch contamination
• Periluminal exit site infection, tunnel infection ?
• Transmural diarrhea ? Constipation ?
• Transvaginal leukorrhea , PID ?
• Hematogenous other source of infection
DDx. In Cloudy DialysateDDx. In Cloudy Dialysate
1. Culture-positive infectious peritonitis2. Culture-negative Infectious peritonitis3. Chemical peritonitis4. Eosinophilia of the effluent5. Hemoperitoneum6. Malignancy (rare)7. Chylous effluent (rare)8. First drainage after break in period
Abnormal PD SolutionAbnormal PD Solution
• Rule out 2nd Peritonitis– Acute appendicitis– Ruptured viscus– Diverticulitis– Strangulated hernia
• สงส&ยื่เม��อ ??– Hx : ปวดท�องก�อนน('ายื่าข��น / ปวดท�องแต่�น('ายื่าไม�
ข��น– P.E. : PR Exam, Localizing pain– Mixed organisms– Free air ??? CAPD < Automate PD
PD related peritonitisPD related peritonitis
• ห้ล&กการให้� Antibiotic– Empiric antibiotics:
• Cover Gram+ve & Gram-ve organisms• Center-specific selection of empiric therapy• History of sensitivities of organisms causing
peritonitis
– Gram +ve : 1st Cephalosporin– Gram -ve : 3rd Cephalosporin or
Aminoglycoside
PD related peritonitisPD related peritonitis
• Empiric regimen:Empiric regimen: Cefazolin 1 gm i.p.
+ Cetazidime 1 gm.i.p in PDF 2,000 ml ,dwell time ≥ 6 hours• In Clinical Severe Sepsis In Clinical Severe Sepsis Cefazolin + Cetazidime i.p. and i.v. Loading doseThen if clinical improve only i.p. route
PD related peritonitisPD related peritonitis
Empirical antibioticEmpirical antibiotic
Clinical Assessment on day 3-5Clinical Assessment on day 3-5
Microbes Isolated from culture ,Adjust antibioticsMicrobes Isolated from culture ,Adjust antibiotics
Clinical improvement& evaluate exit site and tunnelClinical improvement& evaluate exit site and tunnel
No clinical improvementReculture and evaluateNo clinical improvementReculture and evaluate
No clinical improvement by day 5 after appropriate antibiotic
: off catheter
No clinical improvement by day 5 after appropriate antibiotic
: off catheter
Exit site or tunnel infectionOff catheterExit site or tunnel infectionOff catheter
clinical improvementContinue antibiotics clinical improvementContinue antibiotics
Empirical antibioticEmpirical antibiotic
Clinical Assessment on day 3-5Clinical Assessment on day 3-5
Microbes Isolated from culture ,Adjust antibioticsMicrobes Isolated from culture ,Adjust antibiotics
Clinical improvement& evaluate exit site and tunnelClinical improvement& evaluate exit site and tunnel
No clinical improvementReculture and evaluateNo clinical improvementReculture and evaluate
No clinical improvement by day 5 after appropriate antibiotic
: off catheter
No clinical improvement by day 5 after appropriate antibiotic
: off catheter
Exit site or tunnel infectionOff catheterExit site or tunnel infectionOff catheter
clinical improvementContinue antibiotics clinical improvementContinue antibiotics
< 4 weeks , different organism
< 4 weeks , same organism
> 4 weeks , same organism
Exit siteTwardowski Score
Perfect exitGood exitEquivocal exitAcute infectionChronic infectionExit trauma
Equivocal exit site infections
purulent or bloody drainage is only present in the sinus and cannot be expressed outside.
Acute exit site infection
characterized by redness, swelling and tenderness.
The erythema is more than twice the diameter of the catheter and there is regression of the epithelium in the sinus.
Chronic infection
Chronic exit site infection -. Granulation tissue is typically present both externally and in the sinus of the exit site in chronic infections. The exit is sometimes covered by a large, persistent crust or scab. There is usually no pain, redness or swelling and the skin is often hyper pigmented.
Granulation tissue is typically present both externally and in the sinus of the exit site in chronic infections.
Exit trauma
ESI Scoring System
0 point 1 point 2 pointsSwelling 0 < 0.5 cm > 0.5 cmCrust 0 < 0.5 cm > 0.5 cmRedness 0 < 0.5 cm > 0.5 cmPain 0 Slight Severedrainage 0 Serous Purulent
Score = or > 4 : ESI ; purulent drainage ESIScore < 4 may or may not represent ESI
UF failure
1.Compliance (oral Na , drug) ?2.Cardiovascular cause ?3.Evaluate residual renal function (nephrotoxic
drug ) ?4.Mechanic Failure ?
a. Obstruction ,Entrapment , Malposition b. Hernia , leakage
5.Peritoneal Function ?
Evaluation
• Hx– Cardiovascular disorder ?– Lean body mass– Salt and water– Residual renal function (nephrotoxic agent ?)
• PE– Exit site leakage– Hernia pericatheter ,genital ,inguinal ,femoral area– Edema : generalized , unilateral , localized , decrease
BS ,abdominal wall ,inguinal area , genitalia
Evaluation
•Malposition of catheter•Pleural effusion•Asymetrical Abdominal bulging•Hernia
Fluid overload
PE & Hx
Rapid fill and drain , film KUB AP & lateral
พบสาเหตุ�Catheter malposition
Leakageocclusion
ไม่�พบสาเหตุ�PET
Drain volume
Drain volume ลดูลง
UF ลดูลง
D/P คงที่ �D/P ลดูลง (low transport) D/P เพ!�ม่ (high transport)
Drain volume D/P ไม่�เปล �ยน้ำแปลง
Decrease Residual renal Fn
Sclerosing peritonitisPeritoneal fibrosis
adhesion
Increase lymphatic absorptionAquaporin deficiency
Leakagemalposition
Recent peritonitis
(30-60 mindelta5)
Treatment
• Collect cause
• Diuretics• 4.25%PDF <> 1.5%PDF • Increase frequency (high transporter)
General Care
General Care