CAPD pelatihan, 15 april 2011.ppt

8/11/2019 CAPD pelatihan, 15 april 2011.ppt

1/66

Divisi GinjalHipertensiBag / SMF Ilmu Penyakit DalamFK UNUD / RSUP Sanglah Denpasar

Yenny Kandarini


2/66

Integrated Treatment of ESRD

HEMODIALYSIS CAPD

KIDNEY TRANSPLANTATION

RRT


3/66

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)


4/66

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


5/66

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


6/66


7/66

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)


8/66

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.


9/66


10/66


11/66

Physiology ofPeritoneal Dialysis


12/66

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)


13/66

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


14/66

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.


15/66

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


16/66

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


17/66

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


18/66

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


19/66

Diffusion

Solute

removal

Dwell Time

Increasing solute size

Diffusion


20/66

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


21/66

Osmosis occurs between two solutions separated by a

membrane which is non-permeable (or partially

permeable) to the solutes


22/66

Definition

The movement of solutes with a water-flow,

"solvent drag", e.g. the movement of membrane-

permeable solutes with water.


23/66

Start of DialysisFluid removal by

osmosis include

solutes removed by

convection


24/66

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


25/66

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


26/66

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


27/66


28/66

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


29/66

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


30/66

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


31/66

Relative contraindications to PD

Imminent living-related transplantation

Impending/recent major abdominal surgery

Lack of an appropriate caregiver


32/66

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


33/66

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


34/66

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


35/66


36/66

Gram-positive (50%)

Gram-negative,non pseudomonas

Pseudomonas

Fungal (2%)

Tuberculosis Biofilm

(15%)


37/66

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


38/66

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)


39/66


40/66

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


41/66

Tunnel Infection

F i l f h i l h


42/66

Functional parts of the peritoneal catheter


43/66


44/66

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


45/66

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%


46/66

CAPD

0

500

1000

1500

2000

2500

Time (24 hour clock)

Volume


47/66


48/66

Spent dialysate is drained out.

This process takes approximately 10-20 minutes


49/66

Fresh dialysate is flushed from the fresh solution bag

into the drain bag.

This process takes approximately 5 seconds


50/66

Fresh dialysate is infused into the peritoneal cavity.

This takes 8-10 minutes


51/66

O

Dialysate remains in the peritoneal cavity for 48 hours

During this time waste products and excess fluid is removed


52/66

Ultra Bag Disconnect System

Andy -Twin Bag Disconnectsystem

CAPD system in Indonesia

Initiation to CAPD


53/66

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


54/66

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


55/66

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


56/66

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


57/66

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.


58/66


59/66


60/66


61/66


62/66


63/66


64/66


65/66


66/66

CAPD pelatihan, 15 april 2011.ppt

Documents

Transcript of CAPD pelatihan, 15 april 2011.ppt