Q.641. How to estimate the adequacy of peritoneal dialysis?
PERITONEAL DIALYSIS
Q.641. How to estimate the adequacy of peritoneal dialysis?
The recmm. minimal delivered total Ssc of Kt/Vurea shd be at least 1.7/w. for CAPD. Measures preserving Kru is recommended. The minimal delivered total Ssc recomm. in the new guidelines are correct based on current evidence.
A requirement for higher values may be most applicable in U.S., a country in which higher adequacy goals may be necessary for a relatively older & sicker ptn..In addition, higher values may be necessary in those eating more protein who may have a metabolic need for relatively higher Ssc rates. In U.S., target doses sufficiently above minimum threshold to ensure minimum level of DX. dose , delivered to all ptn. target Kt/Vurea = 1.8/w..
Automated P.D.: No prospective trials available & looking at relative risk of death in relationship to dose in APD . The 2006 K/DOQI work group: the higher targets previously recommended are not required é APD. Minimal dose of Kt/V urea should be 1.7/w. for APD. Once ptn is anuric , he should undergo 24 h./d. PD to optimize middle molecular wt solute clearance. This’s because randomized trials hv only evaluated 24 h./d. PD. Calculation of solute clearance: Weekly Kt/Vurea cn be estimated fr. the foll.: daily Pr. urea clearance (Kt)= sum of product of all drain volume (Pr.+ Kru) + ratio of urea conc. in the drained Dzt or urine to tht in pl. (D/P urea). If there’s significant Kru (residual kidney vol.:>100 mL/d.), both Pr. & residual R. components of Ssc are used in calculation.
Fluid balance:🠝 body fluid ⮞🠝 M.R. in P.D.. Fluid overload shd be evaluated & adjust P.D. prescription. To improve vol. status: [🠋dietary sod.; loop diuretics é signif. Kru; and/or change U.F. profile of long dwell or use aother osmotic agents].
Q.642. What are the problems with solute clearance & U.F. in continuous P.D.?
(1) Inadequate solute clearance:= [increased BUN & pl. cr. or app. of
uremic Sms despite seemingly successful PD]. It may be caused by poor
compliance, high protein intake
or hypercatabolic state, or 🠋intrinsic
P.M. permeability. These causes cn be distinguished by PET.
Initial ttt ⮞ more intensive DX.,
achieved by 🠝 volume of inflow Dzt/exchange.
If failed ⮞ transfer to H.DX..
(2)
Impaired U.F.:
ch.ch. by persistently low drain vol. after 4 h. of dwell. It’s
caused by 🠝 Pr. solute transport, wch
may be transient, due to Ac. peritonitis, or sustained,
often due to repeated episodes of peritonitis. Ptn é 🠋 U.F. may be ttted by shortening
dwell time, or by using more freq. hypertonic exchanges. Other
options: instillation of icodextrin Dzt., or use of diuretics
in ptn. é Kru. Occ. ptn é U.F. failure may
require maintenance H.DX. via temporary C.V. cath..
Combination of N. or low solute transport & low drain volumes sugg. Pr. cth. malfunction, extra-Pr. Dzt. leakage, enhanced absorption by Pr. lymphatics or 🠋 in U.F. Co.. A dcr. U.F. Co. is rare, and may occur in conjunction é SEP.
Q.643. How to increase K/t.V. in P.D. patients?
(1) 🠝 No. of dwells. (Dwell = Exchange frequency).
(2) 🠝 Size of dwells.
Q.644. What is Quantum? !
What
is Adequest? !
A. Adequest: a formula developed by Baxter for evaluation of P.D adequacy.
Q.645. What is PET (Peritoneal equilibration test)?
2) High Average.
3) Low Average.
4) Low transporter.
Q.647. How frequent are abdominal hernias occurring in continuous P.D.?
Measures taken pre- &
post-operative to 🠟 risk of hernia & Dzt. leaks incl.: evaluation
& repair of existing hernias, the location & procedures used for P.D.
cth. Placement & methods to 🠟
intra-abd. pressure in post-op. period. Ptns developed hernia after initiation of PD
shd undergo elective repair. Use of a polypropylene
mesh prosthesis 🠞🠟risk
of post-op. hernia. Low-vol.
supine P.D. can be resumed several d.s after repair. TTT of
Dzt. leak varies in ptn. é or
without associated hernia. ttt of an uncomplc. Dzt. leak (é
no associated hernia) cn initially be ttt.ed by temporarily stopping
PD, changing to low vol., supine, or dry day PD, or by short
term transfer to HDX. ttt of recurrent leaks depends on location &
etiology of the leak.
Q.648. what is the role of P.D. in treatment of acute kidney injury (ARF)?
Q.649. What are
the complications associated with acute PD?
A. Acute P.D.
complcation, some are serious, life-threatening, many are preventable:
I. Mech. complications: Mostly
not serious, but may ⮞🠟DX.
Efficiency, which including.:
1) Abdominal Pain/discomfort: Mild abd. pain/discomfort is common & us.
2ndry to abdominal distention. Moderate/sev. pain us. due to cth.-related complc. or infc. .
2) Intraabd. hge: Mild bleeding is frequent & can be obs. é cth. placement. However, severe
intraabd-ominal hge hs bn rep. fr. cth., partic. semirigid Ac. cth.
3) Leakage:
is common & ttt.: 🠟 exchange vol. for 1st 24 h. Temporary cessation of PD may be necessary & bowel evacuation cn mitigate the
problem.
4) Inadequate drainage: usually due to 🠟 bowel motility. Bowel cathartics⮞ improve drainage, while manipulation of
cth. may occasionally be necessary.
5) Bowel perforation: Observed é
semirigid Ac PD cth.⮞Severe abdominal pain, blood-tinged Pr. effluent, intraabd. hge & (rarely) shock.
Bowel/fecal material can be noted é effluent Dzt., ttt.: [Cessation of PD.,
cath. removal, i.v. A.B. & bowel repair].
II.
Infc. complic.: Common,
esp. peritonitis, which can be significant dcrease by maintaining sterile
precautions during cth. placement & preventing contamination during ex-changes.
Leaking Dzt predisposes to peritonitis. Puncture site
abscess can result from bedside placement of Ac. PD cth., esp. missed
attention to sterile technique.
III. “Pulmonary” complications:
1) Basal
atelectasis & pneumonia: cn result from 🠉 IAP associated é
Ac. PD.⮞ inadequate
lung expansion & stasis of secretions.
2) Pl.
effusion: fluid migration 👉 to thoracic cavity, hydrothorax, cn occ. é diaphragmtic defect or its lymphatics ⮞ Rt.
sided eff.(most
common). 🠟 IAP by🠟exchange vol. & using supine position wil
help. Pleurodesis rarely required.
3) Aspiration : 🠉intraPr. pressure predisposes to GERD ⮞🠉risk of aspiration.
IV.
CVS. complications:
1. Hypovolemia: due to excessive U.F.
2. Cardiac
arrhythmias:
due mostly to electrolyte
& metabolic disturbances, or diaphragmatic elevation.
V.
Metabolic complications:
1) Hyperglycemia.
2) Hypernatremia.
3) Hypoglycemia.
4) Hypokalemia: Standard PD solutions do not
contain K+, add K+
to Dzt.
VI. Protein loss: May exceed 5 g/d.. which
incr. by aggressive U.F. & infection.
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