Q.630. What are the available types of P.D.?PERITONEAL DIALYSIS

 PERITONEAL DIALYSIS

 

Q.630.   What are the available types of P.D.?

A.  P.D.: 🠞 2   Non-A.P.D.    🠞

(1) Ac. P.D. = I.P.D. (intermittent P.D.). 30 كيس مرتين في الأسبوع 

(2) CAPD.

              🠞  4 A.P.D.:   🠞

(1) CCPD.

(2) INPD.

(3) TPD.                     سِيبْ شِوَيَّه.     

(4) Optimized P.D. ☕   . واحده زياده بالنهار مع الشاي 

  

Q.631. Describe the various types of P.D.? 

PD: continuous or intermittent. Continuous ambulatory P.D. (CAPD): multiple exch. dur. day (us. 3) foll. by overnight dwelling Modification: one nighttime exch. é exchange device, resulting in [2 overnight exchanges + 3 exchange during day]. Automated P.D.(APD): consist of continuous cycler P.D. (CCPD), nightly intermittent P.D. (NIPD) & tidal P.D. (TPD). CCPD: Long daytime dwell + several cycles overnight. Minority of those undergoing CCPD don’t have daytime dwell & others must hv daytime/mid-day exchange. Some intermittent techniques, e.g. nightly intermittent P.D. (NIPD) or intermittent P.D. (IPD), have ttt periods ("wet" abdomen) alternating é times durtion which Pr. cavity hs bn drained of Dzt ("dry" abdomen).Tidal P.D. (TPD): exchange in which Pr. cavity always contains at least some Dzt (1/2 full)🠞 incr. comfort  & facilitates drainage in some ptns. Ptn. may or may not have a day-time dwell.

Intermittent regimen typically utilize multiple short dwells & automated technology to operate at near maximum solute clearance rates. Of the intermittent techniques, TPD is infrequently used as it’s v. expensive (needs a large No. of Dzt) & technically difficult to perform. Incr. solute clearances hv also not bn confirmed. Most frequently, TPD is used to 🠋drainage problems in selected ptns. As recomm. in European Best Practice guidelines, it can also be used in those é inflow/outflow pain & in ptn.  é slow Pr. drainage. Continuous flow P.D. (CFPD): another technique in which two Pr. Cth. or one cth. é two ports provide continuous inflow & outflow of Dzt. Since Dzt is constantly refreshed, clearances similar to that obtained é daily HDX can be obtained. CFPD was 1^st  introduced decades ago, but was subsequently abandoned due to technical & financial limitations. There has been a renewed interest in this technique because of frequently inadequate clearances é other PD modalities & introduction of technical innovations that may make CFPD feasible.

Q.632. Compare CAPD vs APD as a P.D. modality? 

CAPD & APD seem to provide similar clinical outcomes incl. M.R. Both modalities 🠞 similar [mortality & hospitalization rates, risk of peritonitis, & fluid leaks]. APD may be associated é relatively more time for work & social 😉 activities. Relative effect of CAPD & APD on Kru is controversial. Observational study showed: higher risk of complete loss of R. function in 1^st y. associated é APD comp. to CAPD. However, no difference was detected in the systemic review é this study.

Q.633. Explain how to start P.D. prescription?

At the start of DX when ptn have some Kru , most ptns cd do any PD technique and us. able to achieve Kt/V & vol. control targets. However, once Kru  is negligible, modality choice may need to match Pr. transport ch.ch. to optimize solute clearance & U.F. It’s important to individualize ptn’s dwell times & vol., so that target dose of PD can be achieved. PD is considered adequate in most ptn if weekly total Kt/V for urea is at least 1.7 & if considering Cr. Cl.: weekly Cr. Cl.: at least 50-60 L/w./1.73 m2 B.S.A. (é some variation based upon transporter status) . Attainment of these goals must be documented & then monitored over time. It’s often necessary, to incr. ptn’s DX prescription (by🠉No. of exch. or dwell vol.) as Kru is lost or there’s a decrease in net permeability of Pr. membrane.

Q.634. What is the role of peritoneal equilibration test in P.D. prescription?

1^st step: determine Pr membrane transport ch. ch. using PET Based upon published norms. Dwell time is then matched to transport type in effort to🠉daily clearances & U.F. while 🠋 glucose absorption. Rapid transporters: Consider, the problem in "rapid" transporters of Cr. fr. blood to Dzt. They achieve almost total equilibration between pl. & Dzt for urea & cr. in few h.s. They’re also rapid absorbers of Dzt glucose🠊 removing the osmotic stimulus to U.F.. Net effect = they begin to absorb Dzt with glucose leading, after 2-3h. h., to dcrease in U.F. vol. & net solute clearance.(as the solutes tht hv diffused into Dzt are also absorbed back into systemic circulation).

In this setting, standard CAPD, which utilizes prolonged dwell times, might not produce sufficient fluid or solute removal. This would necessitate more frequent  hypertonic Dzt (2.5 or 4.25 % dextrose), potentially inducing hyperglycemia, hypertriglyceridemia, and/or wt gain fr. 🠉 glucose absorption, or icodextrin. A better alternative in many cases is multiple short dwells é standard Dzt as é NIPD. Slow transporters: Us. need long dwell times to adequately remove small solutes. U.F. is not a problem, since glucose is also slowly absorbed.

Q.635. What is the effect of residual renal function (Kru) on P.D. prescription?  

Ptns typically have some Kru when they’re started on maintenance DX. In this setting, it may not be as important to match dwell time é transporter type, since the urine volume can replace the need for U.F. & the minimal renal solute excretion augments that due to DX. However, as Kru gradually dcrease over time, matching of dwell time to transport type becomes increasingly important.