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Peritonial Dialysis

Drajad priyono

Modalities of renal replacement therapy

Interchangeable, depends on residual renal Ramesh
function
Khanna & Karl D. Nolph

Peritoneal dialysis –
introduction
• method of RRT for 100.000 patients worldwide
• complementary to hemodialysis
Principles:
• peritoneum (capillary endothelium, matrix,
mesothelium) = semipermeable dialysis membrane
through which fluid and solute move from blood to
dialysis solution via diffusion and convection
• effective peritoneal surface area = perfused
capillaries closed to peritoneum (↓ in peritonitis)
• ultrafiltration (movement of water) enabled by
osmotic gradient generated by glucose or glucose
polymers (isodextrin)

Principles of peritoneal dialysis

Scheme of peritoneal solute transport by diffusion through the pores of capillary wall .

Model of transport . Nolph .3 sorts of pores Ramesh Khanna & Karl D.

5 mmol/l Cl 100 mmol/l lactate 35 mmol/l ev. lactate/bicarbonate glukose 1.25 g/dl osmolarity 347-486 pH 5.36-4. Composition of standard peritoneal dialysis solution Na 132 mmol/l Ca 1.2 GDP (degradation products of glucose) Ramesh Khanna & Karl D.25mmol/l Mg 0. Nolph .

Urea concentration in dialysate. rate of equalization of solute concentration depends on molecular size of solute .

Concentration of Creatinin in dialysate equilibrium of concentrations between dialysate and blood is slower than for urea .

punction or laparotomy (total anesthesy) • PD is started 3 weeks following the impantation of catheter . Peritoneal catheter • implanted via laparoscopy.

Types of peritoneal catheters .

better maintenance of residual renal function . Why to start with PD ? 1.

no difference in 2 year and 5 year mortality vs. HD (study NECOSAD) • saves vascular access • preferred for children (APD) • modality choice is a lifestyle issue . Why to start with PD ? • clinical outcomes comparable to HD.

peritoneal fibrosis and adhesions following intraabdominal operations 2. Nolph . Indication / Contraindications of PD 80% of patients have no contra-indication to any of the dialysis methods and may choose according to their life style between HD a PD Absolute contra-indications of PD: 1.inflammatory gut diseases Ramesh Khanna & Karl D.

Relative contraindications of PD • pleuro-peritoneal * diverticulosis leakage • colostomy • hernias • obesity • significant loin pain • blindness • big polycystic kidneys • severe deformant arthritis • psychosis • significant decrease of lung functions .

CAPD – continual ambulatory peritoneal dialysis • manual exchanges .

NIPD – night intermitent peritoneal dialysis (cycler) .

CCPD – continual cyclic PD .

CAPD vs. takes 5 hours • involves doing a CAPD exchange using a 2. CCPD) • performed in hospital.s. Assessement of PD adequacy PET (peritoneal equilibrium test) 1 • determines quick or slow passage of toxins from the blood into the dialysis fluid • ‘high-fast transporters’ v.27% G. samples of PD fluid and blood are taken at set times . ‘low-slow transporters’ • helps to decide about the PD scheme (dwell duration and intervals.

short dwells – APD Average OK OK CAPD or APD Slow Slow Good CAPD. 5 exchanges daily + 1 exchange at night .PET (peritoneal equilibration test) 2 Transporter Waste Water Best type of removal removal PD High Fast Poor Frequent exchanges.

Interpretation of peritonal equilibration test ?? .

Nolph .Results of baseline PET Ramesh Khanna & Karl D.

Choice of PD scheme depends of BSA and type of transport .

Assessement of peritoneal function 1. dicrease of Na in dialysis fluid after 60 minutes using 3.8% G (test of aquaporines) . weekly clearance of creatinine and urea 3.peritoneal equilibration test (type of transport and ultrafiltration after 4 hours) 2. daily UF 4. PET.

Ratio D/P for Na, upper curve – 1,27% glucose,
lower curve - 3,86% G (initial drop due to transcellular
UF of water through aquaporins)

Ultrafiltration during PD
Depends on:
- type of transporter – low transporters have better UF
- concentration and type of osmotic agent in PD fluid:
1. Fluids with glucosis (1,27%, 2,5% a 3,8% ), higher
concentration – higher osmotic pressure and UF
2. Fluid with icodextrin (Extraneal) = glucose polymer with
a large molecule, resorbs only 10-20%, offers longtime
UF, suitable for long night exchanges, 8-12 hours)
- time between exchanges, using glucose-based fluids,
maximal UF obtained after 2-3 hours, using longer
spaces UF dicreases.

Ultrafiltration in different types of PD
solutions

Criteria of PD adequacy

granulation) • peritonitis (turbid dialysate. life threatening complication. leading to intestinal obstruction) . Complications of PD 1 Infectious: • exit-site inflammation (flare. abdominal pain. fever) Non-infectious: • hernias • hydrothorax • sclerosing encapsulating peritonitis (rare. peritoneum is massively thickened and calcificated. suppurative secretion. mostly after ≥ 6 years on PD.

mesotelial damage. . vasculopathy and neo-angiogenesis) leading to loss of UF capacity – reason for PD cessation in 24% of all patients. Complications of PD 2 Non-infectious: • Leakage of dialysate along the peritoneal catheter • Drainage failure of dialysate (dislocation or catheter obstruction by fibrin) • Morphologic changes of peritoneum following long- lasting PD (peritoneal fibrisis. and in 51% of patients treated above 6 years.

leading to high (fast) type of transport including fast loss of osmotic glucose pressure • Decreased function of aquaporins • High lymfatic absorption . Causes of UF failure • Large vascular surface of peritoneum (due to neo-angiogenesis. vasodilation).

peritoneum (omentum) .1-before starting PD.Morphologic changes of peritoneum due to PD (1) Obr. norm.

submesotelial fibrosis and neo-angiogenesis (enlargement of vascular surface of peritoneum) .Morphologic changes of peritoneum due to PD (2) Obr.2-after 3 years of PD.

mycobacterial (1%). Peritonitis • Clinical features: cloudy PD effluent. fungal (3%). culture negative. Gram – (incl. antibiotic treatment failure. Pseudomonas) in 25%. metronidazole) • Goal: < peritonitis / 18 months . 14-21 days : Gram + cocci: Vankomycin / cephalosporin. S. vomiting. acute and chronic UF failure • Treatment for. CRP. • Laboratory: leucocytosis. abdominal pain. nausea. PD fluid culture • Bacteriology: Gram + cocci (incl. allergic (Icodextrin) • Complications: relapses. Gram -: aminoglycoside / cephalosporin III. Generation (+ antimycotics.aureus) in 75%. > 100wbc/ mm3.

aeruginosa) • beware central obesity . Ps. From PD gudelines (ISPD) • biocompatible PD solutions .normal pH. obtain UF above 750 ml/day • peritonitis and exit-site infection rates.aureus. regular revision of technique • invasive procedures cover by ATB prophylaxis • topical ATB administration if needed (S. low concentration of glucose • insertion of PD catheter – 10 days-6 weeks before RRT • urea / creatinine clearance measured every 6 months • PET: 6 weeks after commencing treatment + annually • avoid routine use of high glucose concentrations )use of icodextrin. aminoacids instead) • preserve residual diuresis.

Kidney Int. 2Vardhan. 2003. 2003. et al.64(suppl 88):S94-S99. et al. . Kidney Int.64(suppl 88):S114-S123. Perspectives .New dialysis solutions protect peritoneal membrane Physioneal1 Extraneal2 •  GDPs and AGEs • Isosmolar to plasma •  Lactate • No glucose exposure • Physiologic pH and pCO2 •  GDPs and AGEs •  Membrane and immune cell •  Membrane and immune cell function function Nutrineal2 • No glucose exposure • No GDPs or AGEs •  Membrane and immune cell function 1Skoufos.

control of fluid status  Appetite  Dyslipidemia  Patient acceptance  Quality of life No  UF  Time on PD Nutrineal  Glucose load  Glycemic control  Protein intake. et al. . Clinical advantages of new dialysis solutions Physioneal Extraneal  Infusion pain  Glucose load  Peritonitis  Glycemic control  Glycemic control  UF.64(suppl 88):S114-S123. nutritional status Pecoits-Filho. 2003. 2003. Kidney Int.64(suppl 88):S100-S104. Kidney Int. et al. Vardhan.

36% 1.5 L 2.36% Nutrineal 1. violet) do not lead to glucose absorbtion. Solutions based on another osmotic agent (blue. so decrease total daily glucose load).36% 3.5 L 2 Physioneal 2.5 L 2.5 L 2.36% Extraneal .5 L 1.5 L 2.5 L Physioneal Physioneal Physioneal Physioneal 1. Glucose absorbed = 159 g/day 1 2.36% 1. Absorbtion of glucose from peritoneal solutions 1.5 L Physioneal 2. Solutions containing glucose (green) lead to significant glucose absorbtion 2.86% Glucose absorbed = 50 g/day 2.

Thank you .

CCPD • Assessement of PD adequacy. Peritoneal dialysis . ultrafiltration • Assessement of peritoneal function • Complications • Perspectives – new dialysis solutions .outline • Principles of PD • PD solutions • PD catheter • Indication / contraindication of PD • PD schemes : CAPD.

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Ideal)PD)access ! Minimal)trauma)/)pain ! Rapid)fluid)infusion)without)pain ! Allow)complete)drain ! Maintain)stable)position)without)extrusion)of) deep)and)superficial)cuffs ! Allow)PD)therapy)for)many)years) 2 Saturday. March 30. 13 .