The treatment of one patient with acute kidney failure (acute kidney injury) needs strict attention to body fluids, acid/base, and electrolytes
Peritoneal dialysis in treatment of acute kidney failure.
The treatment of one patient with acute kidney
failure (called also acute kidney injury) needs strict attention to body
fluids, acid/base, and electrolyte (sodium, potassium, etc..), in addition to
removing the accumulated uremic toxins. Despite this type of dialysis has been
overlooked in the management of patients in need for dialytic support, acute
peritoneal dialysis remains a vital choice dedicated for management of acute
kidney failure. Examples of cases that peritoneal dialysis is preferred may
include:
1)
Patients with
unstable hemodynamic states (low blood pressure with weak heart power and poor
circulation).
2)
Abnormal blood
coagulation profile (bleeding tendency).
3)
Lack of other
dialysis options (difficulty in hemodialysis).
In comparison to other dialysis modalities,
peritoneal dialysis owns many advantages as renal replacement therapy (modality
that replace the kidney function). These advantage may include the following:
1)
It is widely available,
2)
Easily performed.
3)
Easy access placement.
4)
The possibility of removal of large amounts of
fluids that is particularly beneficial in hemodynamically unstable (low blood
pressure and poor circulation) cases.
5)
Smooth and very gradual normalization of
acid-base and electrolyte disturbances.
6)
Administration of anticoagulating medications
is not required, and
7)
It is highly biocompatible (in accordance with
the normal body physiology).
Types
Application of peritoneal dialysis in acute
renal failure has a variety of indications and contraindications that is mostly
relative ones. On the other hand, this technique can be performed in
intermittent or in continuous manner according to the required amount of fluid
and solute removal. Peritoneal dialysis can be also performed manually or via a
dedicated machine (automated equipment).
Staff
As regard the personnel, staff nurse can manage
the peritoneal dialysis procedures. However, the use of an automated device or
cycler greatly decreases the need for a continuous nurse supervision. However,
the prescription of a standardized peritoneal dialysis session may include the
following details:
1)
The duration of the peritoneal dialysis
session,
2)
Component of the dialysate fluid,
3)
Amount of the exchange volume,
4)
Durations of the Inflow and outflow (drained
fluid) periods,
5)
Duration of the dwell timing,
6)
Number of exchange cycles,
7)
Added medications to the dialysate fluid, and
8)
How to monitor fluid balance.
Complications
Acute peritoneal
dialysis may be complicated by a list of complications, some of them are
devastating but may are controllable.
Mechanical complications
Mechanical complications are mostly not serious and not life
threatening, but they may affect dialysis adequacy. They include:
1) Abdominal pain or discomfort: Mild
abdominal discomfort is commonly seen and is usually related to abdominal
distention. On the other hand, moderate/severe pain may be attributed to a
catheter-related complications or infection and needs work up.
2) Intra-abdominal hemorrhage:
3) Mild
bleeding is frequently observed and may be noticed with catheter placement. However,
severe abdominal bleeding can be observed with semi-rigid catheters in
particular.
4) Leakage: Leakage around the PD catheter site is a commonly observed,
which can be improved by decreasing the exchange volume during the first 24
hours. Certain cases, however, may need temporary hold of the peritoneal
dialysis. Of note, large bowel evacuation can alleviate this problem.
5) Inadequate drainage: Incomplete
drainage is usually related to diminished bowel motility. Bowel cathartics can
enhance drainage in most cases, while catheter manipulation may be another
solution.
6) Bowel perforation: Perforated bowl can be observed, especially with the placement of
semi-rigid acute catheters. Clinically, patient can present with intense
abdominal pain, blood-colored peritoneal drainage, intra-abdominal bleeding, and
may be shock in severe cases. Fecal matter may be noticed
in the effluent drain. Treatment may include cessation of the acute peritoneal
dialysis session, removing the catheter, intravenous antibiotics, and surgical bowel
repair.
Infectious
complications
Infectious complications are commonly seen in
these patients, peritonitis (inflammation of the peritoneal membrane) in
particular. Prevalence of peritonitis can be greatly diminished by maintaining strict
sterile precautions during catheter placement and by avoiding contamination expected
with frequent exchanges. Dialysate leakage may be associated with increased incidence
of peritonitis. Moreover, abscess developed
in the puncture site can complicate the bedside placement of acute peritoneal catheters,
particularly if meticulous alertness is not driven to sterile technique.
Pulmonary complications
1) Basal atelectasis and pneumonia:
2) Lung
collapse and pneumonia can develop from the rise in intra-abdominal pressure that
is usually observed with acute peritoneal therapies. Moreover, the elevated
intra-abdominal pressure may induce inadequate lung inflation with stagnant
secretions.
3) Pleural effusion:
4) Fluid movement into the thoracic cavity, hydrothorax, can develop through
a defect in the diaphragm or via diaphragmatic lymphatic system. A right sided
effusion is most common. Decreasing intra-abdominal pressure by lowering
exchange volumes and performing acute PD in a supine position may help in most
situations. Pleurodesis (injection of certain medications into the pleural
cavity) usually not required.
5) Aspiration:
6) The
elevated intraperitoneal pressure may predispose peritoneal patients to (GERD) gastroesophageal
reflux disease and increased risk of aspiration.
Cardiovascular complications
1)
Hypovolemia: Intense
ultrafiltration or diaphragmatic rise owing to the higher intra-abdominal
pressure (hat result in venous return decline) can decrease the proper tissue
perfusion owing to inadequately filled heart.
2) Cardiac arrhythmias: Cardiac arrhythmias are common, due most
frequently to electrolyte and metabolic alterations, or diaphragm elevation.
3) Metabolic complications: Metabolic complications are commonly
observed and usually preventable.
4) Hyperglycemia: Hyperglycemia may occur due to high glucose content of the dialysate
fluid.
5) Hypoglycemia: Hypoglycemia may develop after cessation of peritoneal
dialysis.
6) Hypernatremia:
7) Hypernatremia
may be developed via the loss of free water in the dialysate fluid when
hypertonic exchanges (with high osmotic pressure) are frequently used. Sodium may
diffuse down its diffusion gradient from blood to dialysate through the small
intercellular "pores." Hypernatremia is best corrected by increasing
the length of the exchanges so that proper diffusion can occur and/or the use of less hypertonic (more concentrated) fluid.
Low sodium content dialysate are currently not available.
8) Hypokalemia: hypokalemia may ensue because standard PD solutions do not contain
any potassium. It can be corrected by addition of potassium salts to the
dialysate fluid.
9) Protein losses: Protein losses occur through the drained dialysate that may
exceed 5 gram per day. This complication may be intensified
by aggressive ultrafiltration and infectious episodes.
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