renal replacement

7/31/2019 Renal Replacement

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Renal Replacement TherapyPeritoneal dialysis


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Renal Replacement Therapy(1997)

Hemodialysis

(53.3%)

Peritoneal Dialysis

(17.1%)

Renal Transplantation

(29.5%)

Etiologic Disease : DM(34%)> CGN(20.8%) > Hypertension(15.7%)

Total 20,244 patients

Korea Journal of Nephrology (1999)


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Peritoneal Dialysis

Solute and water transport via peritoneal

membrane

Solute movement via diffusion + convection

Less problems of bio-incompatibility

Loss of protein(10g/day) and middle

molecules


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Advantages of Peritoneal

Dialysis Better preservation of residual renal

function

Cardio protective effect Less freq. severe arrythmia(33% vs. 4%)

Higher employment

Less prevalent anti-HCV/HBV Better survival after kidney transplantation

More economic


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II. Apparatus of PD


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1. Conventional PD solution Glucose based solutions with lactate as

buffer

High conc. Of glucose and lactate Safe, effective and cheap

Easily metabolized

Low pH

Hyperosmolality

A variety of GDPs formed during heatsterilization


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Component of conventional

PD solutions Glucose(13.6mg/ml, 22.7mg/ml, 38.6mg/ml)

Sodium 132mmol/L

Potassium 0mmol/L

Calcium 1.25-1.75mmol/L

Magnesium 0.25-0.75mmol/L

Chloride 102mmol/L Lactate 35-40mmol/L

pH 5.0-5.5


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Critics about conventional PD

solutions1. Negative influence to peritoneal cell function :

phagocytosis, intracellular killing, and LT, cytokineand prostaglandin production

2. Dilution of 2L of dialysis solution in itself

3. High concentration of glucose

4. High concentration of lactate

5. Poor biocompatibilityPain during inflow


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2. Tenckhoff catheter


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3. Peritosol Bag


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4. Modes of Peritoneal Dialysis

Continuous ambulatory PD (CAPD)

Continuous Cycler-assisted PD (CCPD)

Nightly PD (NPD)

Intermittent PD (IPD)

Tidal PD


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CAPD

CCPD

NPD


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Automated PD

CCPD NPD


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III. Care of the PD Patients duringthe Perioperative & Break-in Period


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Preop Preparation(1)

Exit hole belt line

size and shape of abdomen, op

scar belt line-- 2cm above the skin

fold

Laterally or downward, 2cm

distant from location of superfcuff


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Colon study

Screening of colonic diverticulum

S-S enema :

Empty the bladder

Skin prep: neet cream Cefazolin 1g iv 1hr before catheter

insertion

Preop Preparation(2)


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Immediate Postop Procedure

Tip KUB

True pelvis

Flushing:heparinized saline500~1500mL until

clear Suture at the exit

site: should beavoided

Cefazolin 1g iv q

24h for 2 days2) Flushing


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Break-in Period Catheter Routine catheter use

Leakage 2~4.

absolute bed rest

Straining Omental adhesion- heparinized saline-

flush


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During 2~14 days flush, in-out exchange

Least exit treatmentis the best

Routine: Alaxyl 1P bid PO

PRN) Dulcorax 2cap supp / Glycerin enema

KUB f/u: 3, 7, 14


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Recommended Orders

Preop evaluation Colon study

During NPO,

hydration withD5W 1L + 2MNaCl 80cc 20gtt

e , BUN/Cr f/u

after enema

P/E

Belt line ?

Op scar ?

Location of exithole ?


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Preop -1 day

Get permission

Take a shower

S-S enema

Visit PD unit and

determine beltline

Recommended Orders

Preop preparation

NPO

D5W 1L iv 20gtt Cefazolin 1g iv on

call

Skin prep with neet

cream Empty bladder

Pain killer: Demerol


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Intraop

KUB

Flushing500~1000mL withheparinized salineuntil clear

Avoid suture atthe exit

Recommended Orders

Postop

Absolute bed rest !

Alaxyl 1P bid POstart

PRN) order forconstipation:Dulcorax 2capsupp and/or G-enema

PRN) if cough (+),give antitussive


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Postop 1day

ABR !

Cefazolin 1g iv q

24h for 2 days Alaxyl 1P bid PO

PRN) order forconstipation and

coughDressing change

Flushing withheparinized

solution

Postop 2~3 days

ABR !

Alaxyl 1P bid PO

PRN) order forconstipation andcough

No manipulation of

catheter KUB at 3th day

Education

Check dressing

gauze

Recommended Orders

Italic: by PD


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Postop 4days ~ 2wk Ambulation

Alaxyl 1P bid PO

PRN) order for constipation and cough

No manipulation of catheter

KUB at 1wk and 2wk

Education

Check dressing gauze

Dressing change & flushing at 1wk and 2wk

OB S/C at exit site at 1wk

Recommended Orders

Italic: by PD

nurse


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Discharge at 1wk or 2wk

Daily visit to PD unit room foreducation

Start indwell at 2wk

1000~1200mL increase 100ml per day

Recommended Orders


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IV. Adequacy of PD


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Clinical and laboratory indices ofadequate peritoneal dialysis

Clinical

Patient Feels Well.

Blood Pressure Well Controlled.

Stable Lean Body Mass

Good Fluid Balance

Absence of uremic symptoms

(anorexia, loss of taste, insomnia,asthenia, etc)

Laboratory

SCr


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Uremic Sx No ofexchange

Overall small MW clearance ismost closely related to uremic

toxicity

Why weekly Kt/V and CrCl ?

CANUSA study

680 CAPD patients

weekly Kt/V 0.1 = 5% patient survival CrCl 5 L/1.73m2/wk = 7% patient survival No evidence of a plateau effect over the range of the

clearance

Kt/V = 2.1 Predicted 2-yr survival 78% CrCl = 70

L/1.73m2


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MinimalRecommendations

for PD DoseDOQI

CAPD CCPD NIPD

Kt/V per wk 2.0 2.1 2.2CrCl per wk 60 63 66

Canadian Society of Nephrology

High/HA Low/LA

Kt/V per wk 2.0 2.0

CrCl per wk 60 50


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Peritoneal Kt = DUN / BUN x PD drain vol -- (2)

Renal Kt = UUN / BUN x 24H Urine vol -- (3)

Weekly Kt = { (2) + (3) } x 7 -- (4) Kt / V = (4) / (1)

Peritoneal Clcr = Dcr / Pcr x PD drain vol -- (5)

Renal Clcr = { ( Ucr/Pcr + UUN/BUN) / 2 } x 24h UV -- (6) Weekly Clcr = { (5) + (6) } x 7 x ( 1.73 / BSA )

Weekly Kt/V & CrCl


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1. Drain for at least 20min, ideally after an 8- to 12-hourovernight dwell using 2L of 2.5% dextrose solution

2. Weigh 2-L bag of warmed 2.5% dextrose solution

3. Infuse over 10min(at a rate of 200 ml/min). After each400-ml infused, roll the patient from side to side.

4. Indwell for 4 hours. Ambulatory during dwell time.

5. Drain over 20 min.6. After drainage, the bag is again weighed.

PET: Protocol


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Blood sample: 0,2,4 hour

Dialysate sample:

200 ml of dialysis solution is drained into the bag,mixed well, a 10 ml sample is taken, and theremaining 190 ml is reinfused back

after 2 and 4 hours, another sample is taken.

Calculate D/P creatitine at 2 and 4 hours

D/D0 glucose at 2 and 4 hours

the volume of UF in the drainagebag

PET: Sampling


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Low transporters low D/P Cr; high D/Do glucose and good net UF

long, high-volume dwells

High transporters highest D/P Cr ; low D/Do glucose and low net UF

more frequent short-duration dwells

higher dialysate protein losses Average transporters

PD prescriptions that most suits their lifestyle

Recommended Prescriptions


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V. CAPD-related Peritonitis


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0

40

80

120

160

180

0 1Y 2Y 3Y 4Y 5Y

No

CAPD

TPL

HD

FU loss

Death

Fig.4 Status of CAPD Patients During the Course of Follow-up

(, 1999)


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Cause of Death

, 1999

29 death/1992 - 1997


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Cause of Technical Failure24 HD transfer/1992 - 1997


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Initial Clinical Evaluation of Patient withSuspected Peritoneal Dialysis-Related Peritonitis

Symptoms: cloudy fluid and abdominal pain

Do cell count and differential

Gram stain and culture on initial drainage

Initiate empiric therapy

Choice of final therapy should always be

guided by anti-biotic sensitivities


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Specimen Processing

Culture should be taken as early as possiblefrom suspected case of peritonitis: the firstcloudy fluid sample is the best specimen

Large volumes(>50mL) should be cultured orconcentrated to maximize bacterial recoveryrate(3,000g x 15min)

Washing the specimen sediment with sterile

saline or using antibiotic-removing/neutralizing resin has been shown toimprove the sensitivity

Identification and sensitivity testing should be

done as soon as possible


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(I)


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ISPD 2000 Guideline for Empiric Therapy

Cloudy Fluid / Abdominal Pain/ Unexpected Fever

Cell count, diff / Gram stain

/ Culture

Empiric TherapyCefazolin + Aminoglycoside

Vs Cefazolin + ceftazidime

Gram (+) Culture (-)Gram(-) Yeast

0 Hours

24 Hours

Gram staining

AdequateCulture

AdequateAntibiotics


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Aminoglycoside vs Ceftazidime

Aminoglycoside High % of sensitive organisms

Enterococci will require aminoglycoside

Synergistic effect on streptococcal andstaphylococcal infection

Ceftazidime Preserve residual renal function Resistance to ceftazidime result from point

mutation within genes that encode plasmidmediated enzyme


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Empiric Therapy for CAPD Peritonitis

Cefazolin Clindamycin Ceftazidime Aminoglycoside

With Residual Renal Fx

Without Residual Renal Fx

1g/bagqd

1g/bagqd

0.6mg/Kg/bagqd

600mg/bagIn each bag


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Recommandation for Vancomycin Use

Should not be used for primary therapy ofperitonitis

Except MRSA

lactam resistant organism

Serious gram(+) infection in pts allergic topenicillin

C. difficile enterocolitis that is not responding tometronidazole


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Using Vancomycin in CAPD

Peritonits Long term exposure should be avoided

Drug level monitoring Prevent level from falling into sub-

therapeutic range, especially in patientswith residual renal function

Other choice?


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Residual urine outputAntibiotic < 100 mL/day > 100 mL/day

Cefazolin or cephalothin

1 g/bag, q.d.

or15 mg/kg B/W/bag, q.d. 20 mg/kg BW/bag, q.d.

Ceftazidime 1 g/bag, q.d. 20 mg/kg BW/bag, q.d.

Gentamicin,tobramycin,

netilmycin 0.6 mg/kg BW/bag, q.d. Not recommended

Amikacin 2 mg/kg BW/bag, q.d. Not recommended

Empiric Initial Therapy for PeritonealDialysis-Related Peritonitis, Stratified for

Residual Urine Volume


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G(-) on Culture

Single G(-) Pseudomonas/ Xanthomonas Multiple &/ Anaerobes

Adjustantibiotics

Clinical Improvement

Continue continuous AGStop Cefa

Add Anti-psudomonas Antib.

?Surg. InterventionAdd Metronidazole

Yes No

14 days 21 days 21 days

Re-evaluationIf culture(+): Remove catheterIf exit infection(+): Remove catheter

96 hrsContinueTreatment


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Summary

Adequate Bacteriological W/U

Prompt Emperical Tx Adequate selection for Empiric antibiotics

renal replacement

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