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