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