pd intervention-1

PD administration program

Dr. Hamed Ezzat El-Eraky

Nephrology Specialist

Mansoura International Hospital

Kidney Function

Execratory function

REGULATORY FUNCTION

FORMATION & ACTIVATION OF CERTAIN HORMONES & VITAMINS

CHRONIC KIDNEY DISEASE IS A GENERAL TERM FOR HETEROGENEOUS DISORDERS AFFECTING THE STRUCTURE AND FUNCTION OF THE KIDNEY.

KIDNEY FAILURE IS DEFINED AS A GFR OF LESS THAN 15 ML/MIN PER 1·73 M², OR THE NEED FOR TREATMENT WITH DIALYSIS OR TRANSPLANTATION.

Symptoms & Signs Of Renal Failure

1- Accumulation Of Waste Products (Urea, K, Po4,..)

2- Accumulation Of Salt & Water ( HTN, L.L. Edema,

Dyspnea,…)

3- Acidosis

4- Hormones & Vitamins Defiancy( Anemia, Itching,

Bonache, Deformity, HTN, Anasarca)

The right modality at the right

time.

Complementary Not

Competitive

MULTIDISCPLINARY TEAM

•Pharmacist •Social worker

•PD nurse •Ward nurse

Dietitian nephrologist

Tx team Access team

0

50

100

150

200

250

300

350

400

UAE KSA Morocco Oman Qater Egypt Algeria

INDICATION OF PD:- UNAVAILABLE HD- HYPOTENSION- ACCESS FAILURE- DIABETIC PATIENT- ISCHEMIC HEART DISEASE- HEART FAILURE- BLEEDING TENDENCY- FEAR OF BLOOD- ACTIVE PERSONS- INFANT BELOW 12 YEARS

- Peritoneal adhesion due to previous

operation or inflammation

- Hernia

- Poor vision

- Psychiatric disorders

- COPD & asthma

- Morbid obesity

CONTRAINDICATION OF PD

Patient selection- AGE- GENERAL CONDITION- PERSONALITY- RENAL FUNCTION

• It’s an internal process inside the body in which Dialysis fluid is introduced to the peritoneal cavity through a catheter placed in the lower part of the abdomen.

• peritoneum serves as the dialysis membrane. The peritoneal cavity can often hold more then 3 liters, but in clinical practice only 1.5 – 2.5L of fluid are used.

• Solutes are transported across the membrane by diffusion.

• Fluid is removed by ultrafiltration driven by an osmotic pressure gradient.

Peritoneal catheters

Peritoneal fluid

Osmotic agent , Electrolytes , Acid – Base buffer

Osmotic agent

Glucose :Glucose was the only osmotic agent

available until 1990.

It is not directly toxic, effective andinexpensive available in con. 1.36%1.5% 2.5% and 4.25% with highglucose concentration is used foreffective UF

ElectrolytesSodium (Na)

Na conc. In P.D. Solution is bet 130 – 137 mEq/L.Potassium (K)

K can in available solution from (0 to 2 mEq/L).In hyperkalemic patient K free solution used to maximize Kremoval .To avoid hypokalemia add 1 to 4 mEq/L.

Calcium (Ca+)Ca level in the dialysate solution varies from 0 to 1.75 mmol/L.Ca level 1.0 to 1.25 mmol/L lead to adequate Ca balance & Phcontrol with oral Ca binder.Low Ca dialysate (0.6 – 1 mmol/L) is used in severhyperparathyroidism .

MagnesiumMg. in P.D. Solution at concentration varies from 0.25 to 0.75mmol/l may be associated with hypermagnesiumia,

Acid – Base buffer

The buffer composition of available P.D.

solutions can be divided into three

categories.

• Non bicarbonate buffers

• Bicarbonate / lactate combination buffers

• Bicarbonate buffers

PRINCIPLES OF PD EXCHANGES

Dialysis fluid is introduced to the peritoneal cavity through a catheter placed in the lower part of the abdomen.

peritoneum serves as the dialysis membrane. The peritoneal cavity can often hold more then 3 litres, but in clinical practice only 1.5 – 2.5L of fluid are used.

Solutes are transported across the membrane by diffusion.

Fluid is removed by ultrafiltration driven by an osmotic pressure gradient.

CAPD (Continuous Ambulatory Peritoneal

Dialysis)

APD (Automated Peritoneal Dialysis)

CCPD (Continuous Cycling Peritoneal Dialysis)

IPD (Intermittent Peritoneal Dialysis)

NIPD (Nocturnal Intermittent Peritoneal

Dialysis)

TPD (Tidal Peritoneal Dialysis)

Types of Chronic Peritoneal Dialysis

1. Fill Phase

(<15 minutes)

* Disconnect

2. Dwell phase

(4-8 hours)

3.Drain phase

(<20 minutes)

CAPD

Preservation of RRF

Higher Hb concentration

Less risk of acquiring blood

borne infections e.g. HCV

Better quality of life

It allows expansion with

limited resources

Lower staff / patient ratio

saves vascular access

preferred for children

ADVANTAGES OF PD

Complications of PD therapy

infectious Non infectious

Peritonitis TunnelExit site

Acute Chronic

peritonitis

• It is the major complication of PD and remains the main reason for switching patient to HD .

• The rate should not be > 1 episode/18 patient-month or 0.67 episode / year at risk (ISPD guidelines)

clinical presentation of peritonitis

abdominal pain ( 80% )

fever ( 50%)

nausea ( 30% )

diarrhea ( 7-10% )

poor drainage

cloudy fluid or drainage

loss of UF function

Diagnosis of peritonitis

Based on the number of WBCs :100 wbc / mm3.

A gram stain should be done.

Bacteria are present in low concentrations in PD fluid.

positive culture, in the absence of WBCs usually

represent contamination

Culture negative ~ 20% of cases.

sterile culture: antibiotic, poor culture technique, early

sampling.

Initiate empiric therapy with Cefazolin or Cephalothin and OR Glycopeptide ( Vancomycin or Teicoplanin) and Ceftazidime

Initial therapy

Continuous dosing Intermitt. dosing

Cefazolin or cephalothin

250 mg/L load,then 125 mg/L in each exchange

15 mg/kg in a single exchange/day

Ceftazidime 250 mg/L load,then 125 mg/L /change 15 mg/kg in a single exchange /day

Vancomycin 500 mg/L load,then 30mg/L /change 30 mg/kg in a single exchange q 5-7 days

Teicoplanin 200 mg/L load,then 20mg/L /change 15 mg/kg in a single exchange q 5-7 d.

Maintenance therapyStaph. aureus Enterococcus strepto. Other gram +ve

Methicilin sensitive:continue cephalosporinDiscontiue ceftazidime and glycopeptide.Add rifampicin20mg/kg/day, orally.

Mehticillin resistant:Discontinue ceftazidimeContinue glycopeptide

Discontiue cephalosporin or glycopeptide and ceftazidime,startampicillin 125 mg/L.

Aminoglycoside may be added based on sensitivity result and patient response.

Vancomycin for ampicillin resitancscases

Methicillin sensitive:

Discontinue ceftazidime and glycopeptide, continue cephalosporin

Duration: 21 days 14 days 14 days

Single gram –ve /non Pseudomonas

pseudomonas Multiple organisms and /or anaerobe

Adjust antibiotics to sensitivity pattern.May continue ceftazidime

Discontinue cephalosporin or glycopeptide.Continue ceftazidime, add agent with activity against pseudomonas ( piperacillin,ciprofloxacin,aminoglycoside or aztreonam

Consider surgical intervention and add :

Metronidazole 15 mg/kg/day in divided doses (max. 1.5gm/day).

Duration: 14 days 21 days 21 days

Maintainance therapy

Non-infectious Complications of Peritoneal Dialysis

Mechanical complications Metabolic Disturbances

Early

Pain

Bleeding

Perforation of a viscera

Exit site leak

Late

Catheter – related complications

Pain

Bleeding

Catheter obstruction

Catheter cuff extrusion

Increased intra –peritoneal pressure

Fluid leak

Hernias

Low back pain

GERD

Alteration of diaphragmatic mechanics

Alteration of peritoneal transport

Peritoneal –membrane

related complications

Ultrafiltration Failure (UFF)

Encapsulating peritoneal Sclerosis

Hyperglycaemia Hyperlipidemia

Malnutrition Hypokalemia

Hypermagnesaemia

• Closed system

• Semi closed

• Open system

Failure of PD programCost Problems

• Limited number of patients

– Local production of peritoneal bags is not feasible except on a large scale >500 – 1000 pts [All bags are imported from western countries therefore, they are relatively very expensive ].!

– Manufacture of local bags will not be feasible due to limited number of patients.

– Difficulty in increasing the number of patients due to the high cost of CAPD

• Limited Resources

– Depending only on government subsidy

– Lack of a integrated insurance system

PD program in Mansoura

PD program in Nephrology Department Of New Mansoura General Hospital ( international ) is established about 6 years ago.

The service in our department introduced to the patient for free.

At 1st Its mainly depend on donation supported by

الجمعية االهلية المصرية لدعم الغسيل البريتونى

تونىالجمعية االهلية المصرية لدعم الغسيل البري

نفقة دولة

تأمين صحى

240 * 5.5 = 1320120 * 28 = 3360

monthly cost = 4680

240 * 12 = 2880120 * 50 = 6000

monthly cost = 8880

• Home visit

• Dialysis

• Monthly visit

• complication

• Patient selection

• Education

• Catheter insertion

• Wash

PREPARATION FOR PD

Patient selection

• From the start for cases of CKD either young age , cardiac or difficult access.

• Transformed from HD: mainly due to access failure or life style.