capd pelatihan, 15 april 2011.ppt
TRANSCRIPT
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Divisi GinjalHipertensiBag / SMF Ilmu Penyakit DalamFK UNUD / RSUP Sanglah Denpasar
Yenny Kandarini
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Integrated Treatment of ESRD
HEMODIALYSIS CAPD
KIDNEY TRANSPLANTATION
RRT
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DI LYSIS
Is the process of cleansing or filtering the blood
Intermittent Peritoneal Dialysis
Dialysis
Hemodialysis
Peritoneal dialysis
PeritonealDialysis
Automated Peritoneal Dialysis
Tidal Peritoneal Dialysis
Continuous Ambulatory
Peritoneal Dialysis (CAPD)
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1975 CAPD developed by Moncrief & Popovich
1978 Oreopoulus et al pioneered collapsible plasticcontainers for dialysat & titanium connector
1980 Buocristiani-Y set, Bazzota-double bag- applied
drainage before fill concept, straight & disconnectsystem available
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0
20
40
60
80
100
120
81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97
(000's)
Years
115,000 Patients
1993 - 1997
7.3% Annual Growth
Source: 1997 Baxter Patient Report
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Definition
PD is a process during which the peritoneal cavity
acts as the reservoir for dialysis fluid and theperitoneum serves as the semi permeable
membrane across which excess body fluid and
solutes including uraemic toxins, are removed.
(Gutch, Stoner & Corea 1999)
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ontinuous
mbulatory
eritoneal
ialysis
Proses dialisis tidak berhenti, secaraberkesinambungan membersihkan darah,
24 jam se-hari, setiap hari
Bebas bergerak, tidak berhubungan dengan
mesin
Menggunakan rongga peritoneum yang bekerjasebagai filter untuk mengeluarkan sisametabolisme dan cairan dari darah
Menyaring dan membuang cairan berlebihserta sisa metabolisme tubuh.
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Physiology ofPeritoneal Dialysis
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The peritoneum is a serosal membrane
that lines the peritoneal cavity
Thin Semipermiable
Large surface area (0,55 m2)
Divide into 2 parts: Parietal peritoneum (20% area)
Visceral peritoneum (80% area)
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Contains 100 ml or less of fluid
Adult can tolerate 2 L or more fluid without
pain or alteration to the respiratory function Male: peritoneal cavity is closed
Female: peritoneal cavity is continuous with
the Fallopian tubes. Rarely PD fluid become blood-stained during a
menstrual period
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Total peritoneal blood supply isestimated to be 60100 mL/min.
Only 25% of the peritoneal capillaries areperfused
The number of perfused peritonealcapillaries is the most important
determinant of peritoneal solute andwater transport, rather than the totalanatomical surface area.
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PD utilities the peritoneal membrane as a natural dialysis
filter.
A PD catheter inserted surgically into the peritonealcavity
PD solution is infused into the peritoneal cavity via the
catheter and remain there for up to 6-10 hours, during
which time uraemic toxins and fluid are removed by
diffusion and UF across the peritoneal membrane
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Time on dialysis
Blood flow
Peritoneal surface area Membrane permeability
Peritoneal lymphatics
Ultra filtration Transfer of fluid
Jeremy Levy et al, Oxford Handbook of Dialysis, 2003
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Definition
Selective diffusion- movement of solutes
from area of high solute concentration to an
area of low solute concentration across a
semi-permeable membrane. Driving Force - Concentration gradient
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Initial Final
Solutes flux
Driving force: concentration
gradient
The transport rate of small solutes is higher than that of
large solutes. Small solutes diffuse faster than large solutes
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Diffusion
Solute
removal
Dwell Time
Increasing solute size
Diffusion
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Definition Osmosis- movement of water from an area of
high water concentration to an area of low waterconcentration across a semi-permeable
membrane.
Or the movement of water from an area of low solute
concentration to an area of high solute concentration.
Driving force - concentration gradient
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Osmosis occurs between two solutions separated by a
membrane which is non-permeable (or partially
permeable) to the solutes
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Definition
The movement of solutes with a water-flow,
"solvent drag", e.g. the movement of membrane-
permeable solutes with water.
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Start of DialysisFluid removal by
osmosis include
solutes removed by
convection
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Lost into the dialysate Absorbed into the
circulation
Small molecules (e.g. urea,
creatinine)
Dextrose (if dextrose-containing
PD solution)
Some electrolytes (notably
potassium)Calcium
Protein (up to 510 g/d)
Amino acids, trace minerals,
hormones, drugs
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Glucose 1.5%, 2.3%, 4.25%
Sodium 134 mmol/l
Calcium 1 mmol/l, 1.75mmol/l
Magnesium 0.5 mmol/l
Chloride 102 mmol/l
Lactate 35 mmol/l
Note:- No potassium, no urea and no
creatinine
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After a two litre bag has dwelled for four
hours average ultrafiltration
1.5% 200 ml ultrafiltrate
2.3% 200 - 400 ml ultrafiltrate
4.25% 600 ml 800 ml ultrafiltrate
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Indications for PD in preference to HD
Very small/very young patients
Lack of vascular access
Contraindications to anticoagulation
Cardiovascular instability
Poorly controlled hypertension /
hypertensive cardiomiopathy (relative)
Lack of proximity to pediatric HD center (relative)
Desire for normal school attendance More liberal fluid intake
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Absolute
Abdominal wall stoma
high risk of peritonitis
Diaphragmatic fluid leak
peritoneal dialysis fluid causes
Adhesions
hinder flow of peritoneal dialysis fluid
Loss of peritoneal function or integrity
peritoneal dialysis not technically possible
Severe inflammatory bowel ds
Medical contraindications to peritoneal dialysis
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Medical contraindications to peritoneal dialysis
Relative
Large muscle mass-potentiallyinadequate dialysis
Obesity
difficulty with catheter insertion
Intestinal diseasepotential to initiate peritonitis
Respiratory disease
intolerance of splinting of diaphragm by intraperitoneal
fluidHernia
exacerbated by peritoneal dialysis fluid it not surgicallycorrectable
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Relative contraindications to PD
Imminent living-related transplantation
Impending/recent major abdominal surgery
Lack of an appropriate caregiver
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PERITONEAL DIALYSIS ADVANTAGES
Continuous dialysis
Self care dialysis
Home based dialysis
Simple to learn and perform
Minimal dietary restrictions
No needle puncture required
No blood access problems
Mobility during dialysis Ease of travel
Minimal cardiovascular stress
No blood loss
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PERITONE L DI LYSIS DIS DV NT GES
Peritonitis
Protein loss
Potential for elevated blood lipid (fat) andtriglyceride levels
Peritoneal catheter
Daily dialysis schedules
Possible weight gain
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o Systemic metabolic effects of glucose dialysateo Dyslipidemia
o Protein loss
o Hyponatremia / hypernatremia
o Hypokalemia / hyperkalemiao Hypocalcemia / hypercalcemia
o Hemoperitoneum
o Encapsulating peritoneal sclerosis
o Hydrothoraxo Hernia
o Abdominal and genital leaks
Noninfectious Complicationsof Peritoneal Dialysis
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Gram-positive (50%)
Gram-negative,non pseudomonas
Pseudomonas
Fungal (2%)
Tuberculosis Biofilm
(15%)
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External appearance of aperfect exit (magnified 4.5X)
Natural color, no scab, no
granulating tissue, no
redness, no drainage
Sinus appearance of perfectexitstrong and mature,
cover visible sinus
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cutely Infected
Exit
Painful Swollen
Red with erythema > 13
mm in diameter
Exuberant granulationtissue
Bleed easily upon touch
Visible around exit
and/or in visibly sinus
Drainage
Purulent and / or bloody
Wet exudates on dressing
Crust or scab around exit
(or in the sinus)
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Chronically Infected
Exit
Evolved from acute infection thatis unresolved for > 4 weeks
Signs of pain, swelling and
redness are absent
Granulation tissue : exuberant
around exit and/or sinus
Epithelium: absent or covers onlypart of sinus
Sometimes visible sinus and exit
appears normal
Drainage:
Purulent or bloody,
spontaneous or after pressureon sinus
Wet exudate on dressing
Crust or scab around the exit or
in the sinus
External cuff gets infected
T l I f i
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Tunnel Infection
F i l f h i l h
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Functional parts of the peritoneal catheter
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Symptoms:
- cloudy fluid; and/or- abdominal pain (79%); and/or- fever (53%)
Look for :CLOUDY BAGS
Stomach Pain Fever
Do your exchanges just as
you are taught
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Dialysate volume : 2 L for 4 cycle exchangeschedule :
08.00, 12.00, 16.00, 24.00
(before bed time) Ultrafiltration:
08.00, 12.00, 16.001.5%
24.002.5%
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CAPD
0
500
1000
1500
2000
2500
Time (24 hour clock)
Volume
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Spent dialysate is drained out.
This process takes approximately 10-20 minutes
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Fresh dialysate is flushed from the fresh solution bag
into the drain bag.
This process takes approximately 5 seconds
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Fresh dialysate is infused into the peritoneal cavity.
This takes 8-10 minutes
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O
Dialysate remains in the peritoneal cavity for 48 hours
During this time waste products and excess fluid is removed
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Ultra Bag Disconnect System
Andy -Twin Bag Disconnectsystem
CAPD system in Indonesia
Initiation to CAPD
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Implant catheter
Provide educational materials to caregivers, patients
Immediate PD required?
2-to 6-weeks healing period, then start dialysis with 4-
8 excahnges using 300 mL/m2BSA volume,* increase
fill volume to 1100 mL/m2BSA within 7-14 days
Start supine dialysis with 12-24 exchanges using
300 mL/m2BSA volume* for 7 days, increase fill
volume to 1100 mL/min2BSA within 14-21 days
Establish maximally tolerable fill volume by either repeated IPP measurements or clinical
judgment. Adjust to maximally tolerable fill volume
Initial prescription: 3 3-to 5-hour daytime + 1 9- to 12-hour nighttime cycles with macimally
tolerable fill volume (usually 1100 mL/m2BSA
Preformed PET, measure urinary and dialysate creatinine and urea clearances at the end of
training (preferably 4 weeks after start of PD
Use PD dosing tables or software (PD adequest or renalsoft PD Rx Management) to adjust PD
prescription
No Yes
* 200 mL/m2BSA during infancy
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Criteria of C PD adequacy
Total Kt / Vurea> 2.0/week
Total CrCI / 60 L/1.73 m2/week in high / high average
transporters, > 50 in low/low average transporters
Clearance associated with normal status for hydration,
electrolyte balance, blood pressure, growth, nutrition and
psychomotor development
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Outcome evaluation
Monthly assessment of growth and weight gain, head circumference
(infants); blood pressure, acid-base status, electrolytes, serum
creatinine, BUN, hemoglobin/hematocrit, serum albumin, record urine
output and daily ultra filtration
Serum ferritin, serum iron, total iron binding capacity (monthly until
stable, then every 2-3 months)
Every 3 months assessment of intact PTH, alakaline phosphatase
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Every 4 months assessment of 24-hour dialysate and urine collection for
CrcI, Kt/Vurea; possibly more frequent if prior assessment reveals failure
adequacy targets; school evaluation
Every months neurodevelopmental assessment in infants < 4 years of age
Consider annual:
Ambulatory blood pressure monitoring (ABPM), especially if casual
BP frequently borderline or discrepant from home measurements,
echocardiography
Hand and wrist X-ray (especially if intact PTH frequently outside
therapeutic range
Outcome evaluation
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Practice Points
Peritoneal dialysis should be considered in all
patients approaching ESRF
Planning for peritoneal dialysis is a multidisciplinary
process that should be instituted well before the
requirement for dialysis
Patients maintained on peritoneal dialysis should be
assessed regularly for the adequacy of solute
clearance and ultra filtration; inadequate dialysis is
associated with increased morbidity and mortality
Infective complications of peritoneal dialysis,
particularly peritonitis, must be identified and treated
promptly.
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