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Renal Replacement TherapyPeritoneal dialysis
I. Introduction of PD
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)
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
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
II. Apparatus of PD
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 heat
sterilization
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
Critics about conventional PD solutions
1. Negative influence to peritoneal cell function : phagocytosis, intracellular killing, and LT, cytokine and prostaglandin production
2. Dilution of 2L of dialysis solution in itself
3. High concentration of glucose
4. High concentration of lactate
5. Poor biocompatibility Pain during inflow
2. Tenckhoff catheter
3. Peritosol Bag
4. Modes of Peritoneal Dialysis
Continuous ambulatory PD (CAPD)
Continuous Cycler-assisted PD (CCPD)
Nightly PD (NPD)
Intermittent PD (IPD)
Tidal PD
CAPD
CCPD
NPD
Automated PD
CCPD NPD
III. Care of the PD Patients during the Perioperative & Break-in Period
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 superf cuff
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)
Immediate Postop Procedure
Tip KUB True pelvis 내
Flushing: heparinized saline 500~1500mL until clear
Suture at the exit site: should be avoided
Cefazolin 1g iv q 24h for 2 days
2) Flushing
Break-in Period Catheter Routine catheter use
Leakage 2~4. absolute bed rest Straining Omental adhesion- heparinized saline-
flush
During 2~14 days flush, in-out exchange
“Least exit treatment is the best”
Routine: Alaxyl 1P bid PO PRN) Dulcorax 2cap supp / Glycerin enema KUB f/u: 3, 7, 14
Recommended OrdersPreop evaluation Colon study
During NPO, hydration with D5W 1L + 2M NaCl 80cc 20gtt
e’ , BUN/Cr f/u after enema
P/E Belt line ? Op scar ? Location of exit
hole ?
Preop -1 day Get permission Take a shower S-S enema Visit PD unit and
determine belt line
Recommended Orders
Preop preparation NPO D5W 1L iv 20gtt Cefazolin 1g iv on
call Skin prep with neet
cream Empty bladder Pain killer: Demerol
Intraop KUB Flushing
500~1000mL with heparinized saline until clear
Avoid suture at the exit
Recommended Orders
Postop Absolute bed rest ! Alaxyl 1P bid PO
start PRN) order for
constipation: Dulcorax 2cap supp and/or G-enema
PRN) if cough (+), give antitussive
Postop 1day ABR ! Cefazolin 1g iv q 24h
for 2 days Alaxyl 1P bid PO PRN) order for
constipation and cough
Dressing changeFlushing with
heparinized solution
Postop 2~3 days ABR ! Alaxyl 1P bid PO PRN) order for
constipation and cough No manipulation of
catheter KUB at 3th dayEducationCheck dressing gauze
Recommended Orders
Italic: by PD nurse
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
Discharge at 1wk or 2wk
Daily visit to PD unit room for education
Start indwell at 2wk 1000~1200mL increase 100ml per day
Recommended Orders
IV. Adequacy of PD
Clinical and laboratory indices of adequate 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<16-20 mg/dL(muscular person), <12-15 mg/dL(thin and lean person) Normal Serum Electrolytes (Ca, Phosphate, Mg) Satble Nerve Conduction Velocities Normal Serum Albumin Urea Kinetic Parameters (weekly Kt/V, (PCR)n)
Uremic Sx No of exchange
Overall small MW clearance is most 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
Minimal Recommendations for PD Dose
DOQI
CAPD CCPD NIPD
Kt/V per wk 2.0 2.1 2.2
CrCl 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
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
1. Drain for at least 20min, ideally after an 8- to 12-hour overnight 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 each 400-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
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 the remaining 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 drainage
bag
PET: Sampling
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
V. CAPD-related Peritonitis
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)
Cause of Death
양재석 등 , 1999
29 death/1992 - 1997
Cause of Technical Failure
Peritonitis67%
Unkown8%
Loss of theassistance
4%
UFfailure13%
Recurrent hernia4%
Metastatic Ca4%
24 HD transfer/1992 - 1997
Initial Clinical Evaluation of Patient with Suspected 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
Specimen Processing
Culture should be taken as early as possible from suspected case of peritonitis: the first cloudy fluid sample is the best specimen
Large volumes(>50mL) should be cultured or concentrated to maximize bacterial recovery rate(3,000g x 15min)
Washing the specimen sediment with sterile saline or using antibiotic-removing /neutralizing resin has been shown to improve the sensitivity
Identification and sensitivity testing should be done as soon as possible
복막염의 원인균 (I)
Mixed7%
No Growth39%
G(- )16%
G(+)36%
Tuberculosis0.4%
Fungus2%
ISPD 2000 Guideline for Empiric Therapy
Cloudy Fluid / Abdominal Pain/ Unexpected Fever
Cell count, diff / Gram stain/ Culture
Empiric TherapyCefazolin + AminoglycosideVs Cefazolin + ceftazidime
Gram (+) Culture (-)Gram(-) Yeast
0 Hours
24 Hours
Gram staining
Adequate Culture
Adequate Antibiotics
Aminoglycoside vs Ceftazidime
Aminoglycoside High % of sensitive organisms Enterococci will require aminoglycoside Synergistic effect on streptococcal and
staphylococcal infection
Ceftazidime Preserve residual renal function Resistance to ceftazidime result from point mutation
within genes that encode plasmid mediated enzyme
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
Recommandation for Vancomycin Use
Should not be used for primary therapy of peritonitis
Except MRSA lactam resistant organism Serious gram(+) infection in pts allergic to
penicillin C. difficile enterocolitis that is not responding to
metronidazole
Using Vancomycin in CAPD Peritonits
Long term exposure should be avoided Drug level monitoring
Prevent level from falling into sub-therapeutic range, especially in patients with residual renal function
Other choice?
Residual urine output Antibiotic < 100 mL/day > 100 mL/day
Cefazolin or cephalothin 1 g/bag, q.d.
or 15 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 Peritoneal Dialysis-Related Peritonitis, Stratified for Residual Urine Volume
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 hrsContinue
Treatment
Summary
• Adequate Bacteriological W/U• Prompt Emperical Tx• Adequate selection for Empiric antibiotics