Imad Ahmed MD. Renal Associates of West Michigan

Transcription

1 Imad Ahmed MD Renal Associates of West Michigan

2 ESRD Facts: - Medicare funded program - Cost - Significant mortality and morbidity - Reduced quality of life - Shrinking donor pool

3 ESRD CAUSES - DM - Hypertension - Chronic GN - Vascular disease - Nephrotoxins

4 WHEN TO START RRT - Relative Indications - Nutritional status - Fatigue - GI symptoms - Absolute Indications - Hyperkalemia - Fluid overload - Metabolic acidosis - Uremia ESRD

5 Absolute Indications to initiate RRT - Pericarditis - Encephalopathy ESRD

6 Modalities IHD Home HD PD Renal transplant Conservative care and palliative care

7 HOME DIALYSIS 93% IHD 7% Peritoneal dialysis <1% Home HD patients on home HD

8 Home Dialysis Reasons for decline in home therapies - Direct supervision by a nurse - Increasing elderly population - Sick patients - Increase in number of outpatient dialysis units / for profit units - Lack of patient motivation - Family motivation - Training of nephrology fellows and practicing physicians - Shortage of staff

9 Peritoneal Dialysis TYPES - APD - CAPD - IPD - TPD - CFPD - Classic IPD

10 CAPD & APD Selection of patients - Transport characteristics - Life style choices - BSA - Large / anuric pt

11 Selected Clinical outcomes Incidence of technique failure Mortality Kt/V CAPD vs APD RKF ( urine volume > 100 ml/day)

12 Available Solutions Glucose containing - GDP s Amino acid containing Xylitol containing Glycerol containing Acetate Sol Low Ca++ Solutions Icodextrin Additives : Abx, heparin, KCL and Insulin

13 Residual Kidney function Extremely Important Preserve and protect it Nephrotoxins Gadolinium exposure

14 Fluid Balance with PD Excess body fluid and mortality Kt/V correlates inversely with volume Lower serum albumin Greater fluid removal predictor of improved relative risk of death Peritoneal membrane failure vs other issues - Dietary habits - Loss of RKF - Prescription - Diuretics OSA and nocturnal PD.

15 PD vs HD Severe cardiomyopathy Autonomic dysfunction Poor vascular access Bridge to renal transplant and cardiac transplant. Chronic hypotension Acute CVA Preferred therapy for infants and young children

16 Contraindications to Peritoneal dialysis Abdominal hernias Extensive adhesions, memb fibrosis, malignancy Colostomy, Ileostomy, nephrostomy ir ileal conduit Chronic backache/ disc disease Psychological and social issues Severe diverticular disease of colon Severe neurologic disease, movement disorder Severe arthritis Severe COPD Severe malnutrition

17 Complications of PD Infectious - Peritonitis - Exit site infection - Tunnel infection

18 Primary Secondary - Hx of constipation - Diarrhea - Hernia PERITONITIS

19 PERITONITIS Signs & Symptoms - Abd pain 79 88% - Fever > N/V % - Cloudy effluent 84% - Hypotension - Tender hernia site - Exit site tenderness, discharge or tunnel tenderness

20 PERITONITIS Cloudy fluid ( WBC > 100) Absence of cloudy fluid ( APD/CCPD) Severe abd pain certain organisms Stool in bag/dialysate

21 PERITONITIS LABS: - WBC count > % pts have less than 100/mm3-50% PMN s - Neutropenic and txp patients - Predominance of lymphocytes - High eosinophils, > 10 % - High amylase and lipase level - Organisms Gram + - Coag neg staph vs bacteroides.

22 Management - Hypotensive - Hemodynamically stable - Initiate Abx ASAP PERITONITIS - Gram + ( coag staph, staph aureus and enterococcus) - Gram ( Bowel, skin, urinary tract, contaminated water and animal contact). Ecoli, campylobacter and pseudomonas.

23 PERITONITIS Fungal - Immunocompromised - Abx use

24 PERITONITIS Management - Pain control - Heparin - Longer dwells? - Antibiotics Empiric? Use of aminoglycosides. - Cephalosporin allergy Aztreonam - Duration of antibiotics - Vancomycin dosing. - Stopping PD for 2 days?

25 PERITONITIS Catheter removal: - Relapsing peritonitis Same species within 4 weeks - Refractory peritonitis No response to abx within 5 days. - Refractory catheter infections. - Fungal peritonitis - Pseudomonas Removal + 2 abx for 3 weeks. - Fecal peritonitis - When to place new catheter?

26 Complications of PD Non infectious: - GERD - Back pain - Delayed gastric emptying - Pleural effusion - Hemoperitoneum - Inflow pain - Electrolyte abnormalities - Catheter malposition

27 Complications of PD Inflow or infusion pain - Transient - Acidic PH of dialysate - Catheter position - Management - Sod bicarb injection - Infusion rate - 1% lidocaine inj - Tidal vol

28 Complications of PD Hemo peritoneum - Menstrual bleeding - Anticoagulation - ADPKD - Catheter manipulation - Renal tumors - Sclerosing peritonitis

29 Complications of PD Management of bloody dialysate - Reassurance - Imaging and ER evaluation - Heparin - Coag profile - Frequent exchanges

30 Complications of PD Management of delayed gastric emptying - Reduce intra abd pressure - Motility drugs Pleuro peritoneal leak - Pleural effusion bil ( Vol overload, CHF ) - One side effusion No edema, CHF - Diaphragmatic hernias, neg intra thoracic pressure % - More common in women

31 Pleuro Peritoneal leak - Asymptomatic - Loss of UF - Neg drain - Right sided - Dyspnea

32 Pleuro Peritoneal leak Management - Thoracentesis - Drain peritoneal cavity - Avoiding supine dwells - Intermittent PD - Resolve spontaneously - Stopping PD - Chemical pleurodesis, surgical repair of defect

33 Why PD?

34 Residual kidney function Middle molecule clearance Nutrition Quality of life Vascular access Bridge to renal and / or cardiac transplant Low cost The future? Why PD?

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36 Wearable Kidney FDA approval 5 KG Wt

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