Imad Ahmed MD

Renal Associates of West Michigan

Facts:

- Medicare funded program

- Cost

- Significant mortality and morbidity

- Reduced quality of life

- Shrinking donor pool

ESRD

CAUSES

- DM

- Hypertension

- Chronic GN

- Vascular disease

- Nephrotoxins

ESRD

WHEN TO START RRT

- Relative Indications

- Nutritional status

- Fatigue

- GI symptoms

- Absolute Indications

- Hyperkalemia

- Fluid overload

- Metabolic acidosis

- Uremia

ESRD

Absolute Indications to initiate RRT

- Pericarditis

- Encephalopathy

ESRD

IHD

Home HD

PD

Renal transplant

Conservative care and palliative care

Modalities

93% IHD

7% Peritoneal dialysis

<1% Home HD

2010 – 5000 – 6000 patients on home HD

HOME DIALYSIS

Reasons for decline in home therapies

- Direct supervision by a nurse

- Increasing elderly population

- Sick patients

- Increase in number of outpatient dialysis units / for profit units

- Lack of patient motivation

- Family motivation

- Training of nephrology fellows and practicing physicians

- Shortage of staff

Home Dialysis

TYPES

- APD

- CAPD

- IPD

- TPD

- CFPD

- Classic IPD

Peritoneal Dialysis

Selection of patients

- Transport characteristics

- Life style choices

- BSA

- Large / anuric pt

CAPD & APD

Selected Clinical outcomes

Incidence of technique failure

Mortality

Kt/V

RKF ( urine volume > 100 ml/day)

CAPD vs APD

Glucose containing - GDP’s Amino acid containing Xylitol containing Glycerol containing Acetate Sol Low Ca++ Solutions Icodextrin Additives : Abx , heparin , KCL and Insulin

Available Solutions

Extremely Important

Preserve and protect it

Nephrotoxins

Gadolinium exposure

Residual Kidney function

Excess body fluid and mortality Kt/V correlates inversely with volume Lower serum albumin Greater fluid removal – predictor of improved relative risk of

death Peritoneal membrane failure vs other issues - Dietary habits - Loss of RKF - Prescription - Diuretics OSA and nocturnal PD.

Fluid Balance with PD

Severe cardiomyopathy

Autonomic dysfunction

Poor vascular access

Bridge to renal transplant and cardiac transplant.

Chronic hypotension

Acute CVA

Preferred therapy for infants and young children

PD vs HD

Abdominal hernias

Extensive adhesions , memb fibrosis , malignancy

Colostomy , Ileostomy , nephrostomy ir ileal conduit

Chronic backache/ disc disease

Psychological and social issues

Severe diverticular disease of colon

Severe neurologic disease , movement disorder

Severe arthritis

Severe COPD

Severe malnutrition

Contraindications to Peritoneal dialysis

Infectious

- Peritonitis

- Exit site infection

- Tunnel infection

Complications of PD

Primary

Secondary

- Hx of constipation

- Diarrhea

- Hernia

PERITONITIS

Signs & Symptoms

- Abd pain 79 – 88%

- Fever > 37.5

- N/V 31 – 51 %

- Cloudy effluent 84%

- Hypotension

- Tender hernia site

- Exit site tenderness , discharge or tunnel tenderness

PERITONITIS

Cloudy fluid ( WBC > 100)

Absence of cloudy fluid ( APD/CCPD)

Severe abd pain – certain organisms

Stool in bag/dialysate

PERITONITIS

LABS:

- WBC count > 100

- 10 % pts have less than 100/mm3

- 50% PMN’s

- Neutropenic and txp patients

- Predominance of lymphocytes

- High eosinophils , > 10 %

- High amylase and lipase level

- Organisms – Gram + - Coag neg staph vs bacteroides.

PERITONITIS

Management

- Hypotensive

- Hemodynamically stable

- Initiate Abx ASAP

- Gram + ( coag – staph , staph aureus and enterococcus)

- Gram – ( Bowel , skin , urinary tract , contaminated water and animal contact). Ecoli , campylobacter and pseudomonas.

PERITONITIS

Fungal

- Immunocompromised

- Abx use

PERITONITIS

Management

- Pain control

- Heparin

- Longer dwells?

- Antibiotics – Empiric ? Use of aminoglycosides.

- Cephalosporin allergy – Aztreonam

- Duration of antibiotics

- Vancomycin dosing.

- Stopping PD for 2 days?

PERITONITIS

Catheter removal:

- Relapsing peritonitis – Same species within 4 weeks

- Refractory peritonitis – No response to abx within 5 days.

- Refractory catheter infections.

- Fungal peritonitis

- Pseudomonas – Removal + 2 abx for 3 weeks.

- Fecal peritonitis

- When to place new catheter ?

PERITONITIS

Non infectious:

- GERD

- Back pain

- Delayed gastric emptying

- Pleural effusion

- Hemoperitoneum

- Inflow pain

- Electrolyte abnormalities

- Catheter malposition

Complications of PD

Inflow or infusion pain

- Transient

- Acidic PH of dialysate

- Catheter position

- Management - Sod bicarb injection

- Infusion rate

- 1% lidocaine inj

- Tidal vol

Complications of PD

Hemo – peritoneum

- Menstrual bleeding

- Anticoagulation

- ADPKD

- Catheter manipulation

- Renal tumors

- Sclerosing peritonitis

Complications of PD

Management of bloody dialysate

- Reassurance

- Imaging and ER evaluation

- Heparin

- Coag profile

- Frequent exchanges

Complications of PD

Management of delayed gastric emptying

- Reduce intra abd pressure

- Motility drugs

Pleuro – peritoneal leak

- Pleural effusion – bil ( Vol overload , CHF )

- One side effusion – No edema , CHF

- Diaphragmatic hernias , neg intra thoracic pressure

- 1.6 – 10 %

- More common in women

Complications of PD

- Asymptomatic

- Loss of UF

- Neg drain

- Right sided

- Dyspnea

Pleuro – Peritoneal leak

Management

- Thoracentesis

- Drain peritoneal cavity

- Avoiding supine dwells

- Intermittent PD

- Resolve spontaneously

- Stopping PD

- Chemical pleurodesis , surgical repair of defect

Pleuro – Peritoneal leak

Why PD?

Residual kidney function

Middle molecule clearance

Nutrition

Quality of life

Vascular access

Bridge to renal and / or cardiac transplant

Low cost

The future?

Why PD?

FDA approval

5 KG Wt

Wearable Kidney