Renal Replacement
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Transcript of Renal Replacement
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Renal Replacement TherapyPeritoneal dialysis
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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)
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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
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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
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II. Apparatus of PD
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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 heatsterilization
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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
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Critics about conventional PD
solutions1. Negative influence to peritoneal cell function :
phagocytosis, intracellular killing, and LT, cytokineand prostaglandin production
2. Dilution of 2L of dialysis solution in itself
3. High concentration of glucose
4. High concentration of lactate
5. Poor biocompatibilityPain during inflow
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2. Tenckhoff catheter
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3. Peritosol Bag
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4. Modes of Peritoneal Dialysis
Continuous ambulatory PD (CAPD)
Continuous Cycler-assisted PD (CCPD)
Nightly PD (NPD)
Intermittent PD (IPD)
Tidal PD
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CAPD
CCPD
NPD
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Automated PD
CCPD NPD
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III. Care of the PD Patients duringthe Perioperative & Break-in Period
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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 superfcuff
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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)
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Immediate Postop Procedure
Tip KUB
True pelvis
Flushing:heparinized saline500~1500mL until
clear Suture at the exit
site: should beavoided
Cefazolin 1g iv q
24h for 2 days2) Flushing
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Break-in Period Catheter Routine catheter use
Leakage 2~4.
absolute bed rest
Straining Omental adhesion- heparinized saline-
flush
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During 2~14 days flush, in-out exchange
Least exit treatmentis the best
Routine: Alaxyl 1P bid PO
PRN) Dulcorax 2cap supp / Glycerin enema
KUB f/u: 3, 7, 14
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Recommended Orders
Preop evaluation Colon study
During NPO,
hydration withD5W 1L + 2MNaCl 80cc 20gtt
e , BUN/Cr f/u
after enema
P/E
Belt line ?
Op scar ?
Location of exithole ?
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Preop -1 day
Get permission
Take a shower
S-S enema
Visit PD unit and
determine beltline
Recommended Orders
Preop preparation
NPO
D5W 1L iv 20gtt Cefazolin 1g iv on
call
Skin prep with neet
cream Empty bladder
Pain killer: Demerol
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Intraop
KUB
Flushing500~1000mL withheparinized salineuntil clear
Avoid suture atthe exit
Recommended Orders
Postop
Absolute bed rest !
Alaxyl 1P bid POstart
PRN) order forconstipation:Dulcorax 2capsupp and/or G-enema
PRN) if cough (+),give antitussive
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Postop 1day
ABR !
Cefazolin 1g iv q
24h for 2 days Alaxyl 1P bid PO
PRN) order forconstipation and
coughDressing change
Flushing withheparinized
solution
Postop 2~3 days
ABR !
Alaxyl 1P bid PO
PRN) order forconstipation andcough
No manipulation of
catheter KUB at 3th day
Education
Check dressing
gauze
Recommended Orders
Italic: by PD
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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
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Discharge at 1wk or 2wk
Daily visit to PD unit room foreducation
Start indwell at 2wk
1000~1200mL increase 100ml per day
Recommended Orders
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IV. Adequacy of PD
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Clinical and laboratory indices ofadequate 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
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Uremic Sx No ofexchange
Overall small MW clearance ismost 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
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MinimalRecommendations
for PD DoseDOQI
CAPD CCPD NIPD
Kt/V per wk 2.0 2.1 2.2CrCl 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
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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
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1. Drain for at least 20min, ideally after an 8- to 12-hourovernight 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 each400-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
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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 theremaining 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 drainagebag
PET: Sampling
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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
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V. CAPD-related Peritonitis
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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)
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Cause of Death
, 1999
29 death/1992 - 1997
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Cause of Technical Failure24 HD transfer/1992 - 1997
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Initial Clinical Evaluation of Patient withSuspected 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
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Specimen Processing
Culture should be taken as early as possiblefrom suspected case of peritonitis: the firstcloudy fluid sample is the best specimen
Large volumes(>50mL) should be cultured orconcentrated to maximize bacterial recoveryrate(3,000g x 15min)
Washing the specimen sediment with sterile
saline or using antibiotic-removing/neutralizing resin has been shown toimprove the sensitivity
Identification and sensitivity testing should be
done as soon as possible
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(I)
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ISPD 2000 Guideline for Empiric Therapy
Cloudy Fluid / Abdominal Pain/ Unexpected Fever
Cell count, diff / Gram stain
/ Culture
Empiric TherapyCefazolin + Aminoglycoside
Vs Cefazolin + ceftazidime
Gram (+) Culture (-)Gram(-) Yeast
0 Hours
24 Hours
Gram staining
AdequateCulture
AdequateAntibiotics
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Aminoglycoside vs Ceftazidime
Aminoglycoside High % of sensitive organisms
Enterococci will require aminoglycoside
Synergistic effect on streptococcal andstaphylococcal infection
Ceftazidime Preserve residual renal function Resistance to ceftazidime result from point
mutation within genes that encode plasmidmediated enzyme
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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
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Recommandation for Vancomycin Use
Should not be used for primary therapy ofperitonitis
Except MRSA
lactam resistant organism
Serious gram(+) infection in pts allergic topenicillin
C. difficile enterocolitis that is not responding tometronidazole
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Using Vancomycin in CAPD
Peritonits Long term exposure should be avoided
Drug level monitoring Prevent level from falling into sub-
therapeutic range, especially in patientswith residual renal function
Other choice?
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Residual urine outputAntibiotic < 100 mL/day > 100 mL/day
Cefazolin or cephalothin
1 g/bag, q.d.
or15 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 PeritonealDialysis-Related Peritonitis, Stratified for
Residual Urine Volume
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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 hrsContinueTreatment
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Summary
Adequate Bacteriological W/U
Prompt Emperical Tx Adequate selection for Empiric antibiotics