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Overview of peritoneal dialysis
1. Overview of Peritoneal DialysisOverview of Peritoneal Dialysis
Piti Niyomsirivanich, MD.
Cardiology Fellowship of Maharat Nakhon Ratchasima Hospital
4. •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
5. •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
6. •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
16. Peritoneal Equilibration TestPeritoneal Equilibration Test
PET Prescription
High
Transporter
Short dwell time
Increase cycle
High Average NIPD/CAPD
Low Average High dose CAPD/CCPD
Low High dose CCPD+RRF
Switch to HD without RRF
23. Dialysis related peritonitisDialysis related peritonitis
• Diagnosis (2 of 3)Diagnosis (2 of 3)
1. Clinical : Fever, Abdominal pain,
Cloudy dialysate
2. PDF cell diff/cell count : WBC ≥ 100
(PMN ≥ 50%), in dwell time for 4 hr
3. PDF Culture : Positive
24. Investigation
CBC
Elyte , BUN , Cr , alb
H/C
CXR
Film KUB
PDF fluid : cell diff , cell count , culture
gram stain (for Dx fungal infection)
25. 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
26. DDx. In Cloudy DialysateDDx. In Cloudy Dialysate
1. Culture-positive infectious peritonitis
2. Culture-negative Infectious peritonitis
3. Chemical peritonitis
4. Eosinophilia of the effluent
5. Hemoperitoneum
6. Malignancy (rare)
7. Chylous effluent (rare)
8. First drainage after break in period
29. • หลักการให้ 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
30. • 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 SepsisIn Clinical Severe Sepsis
Cefazolin + Cetazidime i.p. and i.v. Loading dose
Then if clinical improve only i.p. route
PD related peritonitisPD related peritonitis
31.
32. 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 tunnel
Clinical improvement
& evaluate exit site and tunnel
No clinical improvement
Reculture and evaluate
No clinical improvement
Reculture 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 infection
Off catheter
Exit site or tunnel infection
Off catheter
clinical improvement
Continue antibiotics
clinical improvement
Continue antibiotics
33.
34.
35.
36.
37.
38.
39. 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 tunnel
Clinical improvement
& evaluate exit site and tunnel
No clinical improvement
Reculture and evaluate
No clinical improvement
Reculture 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 infection
Off catheter
Exit site or tunnel infection
Off catheter
clinical improvement
Continue antibiotics
clinical improvement
Continue antibiotics
40. < 4 weeks , different organism
< 4 weeks , same organism
> 4 weeks , same organism
43. Equivocal exit site infections
purulent or bloody
drainage is only
present in the sinus
and cannot be
expressed outside.
44. 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.
45. Chronic infection
ent 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
Granulation tissue is
typically present
both externally and
in the sinus of the
exit site in chronic
infections.
47. ESI Scoring System
0 point 1 point 2 points
Swelling 0 < 0.5 cm > 0.5 cm
Crust 0 < 0.5 cm > 0.5 cm
Redness 0 < 0.5 cm > 0.5 cm
Pain 0 Slight Severe
drainage 0 Serous Purulent
Score = or > 4 : ESI ; purulent drainage ESI
Score < 4 may or may not represent ESI
48.
49.
50. 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 ?
51. 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
Ultra-small or transcellular pores (4-6 A) are water channels or aquaporin-1. They are numerous and resemble the water channels present in red blood cells and renal proximal tubules. They transport water only (sieving) and are present in the endothelial cells of the peritoneal capillaries.
Sodium concentration in dialysate as a function of dwell time t. Dashed lines, clinical data (means ± SD); solid lines, model results.
Intraperitoneal volume of dialysate (left) and glucose concentration in dialysate (right) as a function of dwell time t. Dashed lines, clinical data (means ± SD); solid lines, model results.