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PERITONEAL DIALYSIS

Q.650. What are the general complications of P.D.?

 PERITONEAL DIALYSIS

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Q.650. What are the general complications of P.D.?

   A. Complications” of P.D.:

         1. Abdominal (Paraumblical hernia). (🠝IAP).  👀

         2. Vaginal hernia.

         3. Rectal prolapse.

         4. Scrotal swelling 🠞Patent processus vaginalis 🠞Scrotal Dzt leak.

         5. Pleuro-pritoneal leak.

         6. Lumber lordosis.                

         7. Inflow pain 🠞Clamp the line to reduce flow.

         8. Isolation Depression (Lonely hours).  😌      

         9. Decreased appetite due to:        

                                         i.    Increased abdominal fullness

                                        ii.    Decreaed DX. Adequacy.

                                       iii.    Loss of “nutrient” é Dzt.

         10. Hemo🩸Pr.: é menses in (open “processus vaginalis🠞Cath. clot block). 

Q.651.What is SEP.? How to manage? 

A. SEP. (Sclerosing Encapsulating Pertonitis): ch.ch. by [extensive intra-Pr. fibrosis  + encasement of bowel loops + progressive loss of U.F.]🠞fluid retention & edema. Etiology: {not clear but may be: prior sev. peritonitis, acetate DZt. buffer, a reaction to foreign ag. e.g. plasticizers fr. cth., B.B., premature withdrawal fr. P.D. & extended dur. of P.D.}.

Sn & Sm of SEP : [abdominal pain, nausea, loss of appetite, constipation, drr., abd. mass, ascites, wt. loss, vomiting & fatigue].

Dgx. SEP: by CT🠞[Pr. calcification, bowel thickening, bowel tethering, and bowel dilatation]. Confirmation: by laparotomy and/or laparoscopy. (rarely used).

ttt. SEP: Stop P.D. & transfer to H.DX. (although it may develop or worsen after stopping PD), bowel rest + TPN & (may be) im/m. therapy and/or surgery.

Q.652. What are the possible mechanisms of solute clearance and U.F. in P.D?

A. Pr. barrier 👌has 3 layers :[Pr. mesothelium, interstitium & cpll. endothelium]. According to the 3-pore model of solute transport, cpll. endothelium contains 👌3 different-sized pores which’re size-selective in restricting solute transport. Aqua-porin-1 is the smallest sized pore and is responsible for 40 % of free water transport across Pr. membrane. Transport of different solutes is based on diffusion & convection. Trans-cpll. U.F. rate is determined by: [net pressure gradient & by Pr. membrane ch.ch. & by Starling’s law. Both crystalloids and/or colloid based Dx. solutions cn be used to provide the required osmotic or oncotic gradients. Rate of solute transport varies between individuals, which may hv therapeutic implications for Dx. adequacy as well as fluid overload.

U.F. failure occur due] alterations in vascular surface area (larger vasccular surface area 8more pores available for transport), which🠞Rapid loss of gluc. gradient across the membrane & fluid retention. Selective loss of aquaporin-1 function. & other f. can🠞U.F. failure, which can be determined by sp. studies on Pr. membrane.

Q.653. How to evaluate hypervolemia in P.D. patients? 

A.Volume overload in PD is mostly due to preventable/treatable causes, which incl.:[excessive sod. or water intake, too little sod. or water removal, or a new comorbid dis.]. Causes of 🠝salt & water intake incl.:[noncompliance é dietary restrictions & absorption of fluid dur. dwells caused by failure of PD prescription 🠞adequate osmotic (or oncotic) stimulus for U.F.]. Causes of insuff. salt & water removal incl.:[prescription failure to provide adequate osmotic (or oncotic) stimulus for U.F., failure of Pr membrane to resp. to osmotic stimulus & loss of Kru].

Comorbid disease:[new CVS event or worsening of heart disease, hypoalbuminemia &🠞oncotic pressure or mech. or anatomical problem]. Evaluation of volume overloaded incl.:[history & physical exam., fill & drain test, PET & radiogr. studies]. History: excl. CVS dis., determining loss of body mas & adherence é DX. prescription or salt & water intake. Exam. incl.:[exit site for fluid(dextrose +ve on dipstick), pres. of hernias, especially in pericth., genital, inguinal & femoral areas & distribution of retained fluid: generalized, unilateral, or localized. Mechanical or anatomical problems may be quickly excl. by performing a quick two liter "fill & drain" to determine nature & rate of Dzt flow. Fibrin clots, difficulty é inflow, or incomplete or positional drainage may be obs.. PET test allows ch.ch. of Pr. transport, U.F. capacity & pres. of sodium sieving or change fr. prior PET tests.

Radiographic evaluation: used é cth. malposition or Dzt. leak. A flat plate of the abdomen us. used to evaluate cth placement & positioning & may reveal constipation. Lateral film may excl. rotation or kink in S.C. part. Abd. CT é intraPr. contrast or MRI without contrast usually used to excl. Dzt leak. Gadolinium-based imaging should be avoided. Dzt. prescription & U.F. should be reviewed monthly. Routine monitoring of all ptns should incl.:[ur. volume & overnight drain vol. (CAPD) or daytime drain vol.(APD)]. Baseline PET should be done é initiation of Dx. & repeated if indicated. Measures to help prevent overload includ: [diuretics, avoid nephrotoxic ag., monthly dietary counseling, enhancing compliance, optimizing s. glucose control (to maximize osmotic gradients) & matching dwell time to transport type].

Q.654. What are the noninfectious complications of P.D. catheters? 

Erosion of cth. cuff thr. the skin may be a sequela of exit-site infection or excessive superficial cuff placement. Conservative ttt may be attempted if there’s no evidence of infection. Cuff shaving or cth. removal may be required in presence of infection. Intestinal perforation can occur at time of cth. implantation due to direct injury, or weeks to m.s after placement due to bowel erosion. It’s life-threatening & shd requires a high index of suspicion & urgent 🔔 attention. Clues of perforation 🠞feculent or bloody Dzt, Dzt retention, drr. occ. after Dzt. instillation, or G.-ve peritonitis. Thpy: [cessation of P.D., cth. removal, i.v. A.B. & bowel repair.] .


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