Peritoneal Dialysis Flashcards
critical barrer for transport
peritoneal capillary
Aquaporin in peritoneum
AQP1
collectionof dialysate in modified PET
0, 120 and 240 minutes
purulent discharge +- erythema of skin
exit site infection
clinical inflammation and ultrasonographic evidence
tunnel infection
3-7 cycles 1.5-2L dwell over 9h at night
CCPD
incomprete drain of a portion of infused fluid before filling
Tidal PD
Target Kt/V in PD
1.7
PET results: D/P of 0.82-1.03
high transporter
D/P of 0.65-0.81
high average transporter
D/P of 0.5-0.64
low average transporter
D/P of 0.34 to 0.49
low transporter
which transporter good UF
low transporter
which transporter better clearance
high transporter
dose of cefazolin
LD 500 mg/L MD 125 mg/L
dose of vancomycin
LD 30 mg/kg MD 1.5 mg/kg/bag
dose of amikacin
LD 25 mg/L MD 12 mg/L
when to return to PD after peritonitis
2 weeks of catheter removal
bowel obstruction, encapsulation due to fibrosis, bloody ascites
encapsulating pertineal sclerosis
duration of draining
20-30 mins
fill duration
5-10 mins
surface are of peritoneum
1-2 m2
more important surface area
parietal
blood flow of peritoneum
50-100
sodium sieving only occurs at
ultrapores
greatest hydrostatic pressure in
sitting position
visceral peritoneum
80%
effective peritoneal surface area = peritoneal vascularity
Distributed Model
direction of external catheter
lateral and inferior
exit site in females
below umbilicus
exit site in males
above umbilicus
break in period
2-4 weeks
leakage at the skin exit site
pericatheter leak
most common cause of outflow failure
kinks
heparin to be placed when with fibrin
250-500 u/L
buffer in low gdp
bicarbonate
Adequate solute clearance, poor UF - transporter/pd modality
High transporter, APD
Inadequate solute clearance, very good UF - transporter/modality
Low transporter, capd
When to do pet?
4-8 weeks after initiation; Clinically stable and at least 1 month after resolution of an episode of peritonitis
evaluation of suspected ultrafiltration faioure
Modified PET
evidence that peritoneal membrane has lost its capability to remove uf
net uf less than 400 ml
when to measure kt/V in pd
Within 1st month after initiation, atleast once q4 months, 1
month after peritonitis episode
target kt/V in pd
1.7/week
target uf in pd
Target UF of 1L per day
erythema, edema and tenderness over the subcutaneous pathway of the catheter
Tunnel infection
exit site scoring system
swelling, crust, redness, pain, drainage
infection should be assumed with exit site score of
> =4
sufficient to indicate infection
purulent drainage
indications for catheter removal for exit site and tunnel infection
Pseudomonas aeruginosa infection, tunnel infection, exit site infection + peritonitis
antibiotic prophylaxis prior to colonoscopy and invasive gynecologic procedures
IV ampicillin + amino glycoside +/- metronidazole
antifungal prophylaxis when pd receive antibiotic courses
oral nystatin 500k u 4x/day or fluconazole 200 mg q48h throughout duration of antibx therapy
clinical presentation and dx of peritonitis
atleast 2 of the ff:
Clinical features + effluent > 100 mcgL for 2 hrs with > 50% pmn + positive dialysis effluent culture
duration from collection to lab
6 hours
gram positive coverage for pd peritonitis
First generation cephalosporin or vancomycin
Gram neg coverage
3rd gen ceph or aminoglycosides
initial dwell of antibx
6hrs
episode that occurs within 4 weeks of completion of therapy of a prior episode but with a different organism
recurrent
Episode that occurs within 4 weeks of completion of therapy of a prior episode with the same organism or one sterile episode
Relapsing
Episode that occurs more than 4 weeks after completion of therapy of a prior episode with the same organism
Repeat
failure of the effluent to clear after 5 days of appropriate antibiotics
refractory
Peritonitis on conjunction with an exit site or tunnel infection with the same organism or one sterile site
catheter related
Coag neg staph tx
IP cephalo or vanco x 2 weeks
Tx strep sp
ip ampicillin x 2 weeks
Enterococcus
Vanco x 3 weeks + aminoglycoside if severe
VRE
Ampicillin x 3 weeks
Staph aureus
Cephalo x 3 weeks (mssa), ip vanco x 3 weeks (mrsa)
Corynebacterium
Vanco x 3 weeks
pseudomonas
cephalo + amino or oral fluoro x 3 weeks
polymicrobial
Surgical eval
amino + 3rd gen/carbapenem + anaerobic coverage with metronidazole or clindamycin x 3 weeks
Fungal
Catheter removal + antifungal x 2-3 weeks after removal
flucytosine + amphotericin B
Tuberculous
HRZe x 4 months, HR x 12-18 mos
may consider return to pd later
refractory, relapsing, fungal
tx for culture negative peritonitis
discontinue gram neg coverage, continue cefaz or vanco for 2 weeks
blind insertion of pd catheter
seldinger technique
most widely used pd catheter
Tenckhoff catheter followed by swan neck
most widely used as osmotic agent
dextrose
physiologic concentratoon of Ca and pH in pd solution
2.5 meq/L
pH 5.4
administration of an effective dossage of dialysis solution, clinically asymptomatic patient
Adequate dialysis
dose capable of reducing mortality and morbidity, dose above which increase does not justify burdeb
Optimal dialysis
when to remove catheter
fungal peritonitis intraabdominal disease refractory tunnel and or exit site infection relapsing refractory
catheter removal and sinuktaneous placement of a new catheter is most successful
exit site or tunnel infection
relapsing infections once with normal effluent counts
success - infections that do not involve s. aureus, pseudomonas, mycobacteria or fungi
how to apply mupirocin in the nares
5 days a month
most common cause of uff, increase in peritoneal effective surface area
type 1 high transporter with uff
reduced small solute clearance and uf, decreased membrane surface area
low transporter with uff II
type 3 uff
uff with transport in the normal range
