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Peritoneal dialysis

Peritoneal dialysis. Dr Ejaz Ahmed. Barrier to transport. Mesothelium Does not hinder transport Interstitium Hinders transport to some extent Endothelium Main barrier. Peritoneal transport principles. Diffusion Depends on concentration gradient Convection(filtration)

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Peritoneal dialysis

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  1. Peritoneal dialysis Dr Ejaz Ahmed

  2. Barrier to transport • Mesothelium • Does not hinder transport • Interstitium • Hinders transport to some extent • Endothelium • Main barrier

  3. Peritoneal transport principles Diffusion Depends on concentration gradient Convection(filtration) Depends on hydrostatic pressure and osmotic pressure

  4. Diffusion • Dr=p×a×c • Dr=diffusion rate • P=solute permeability • A=area of membrane • C=concentration gradient

  5. Ultrafiltration • UFr=p×a×(Hp+Op) • UFr=ultrafiltration rate • P=permeability of water • A=surface area • Hp=hydrostatic pressure gradient • Op=osmotic pressure gradient

  6. Material of catheter • Silicone rubber • Milky white material • Polyurethane • Clear material

  7. Catheter design • Three portions • Intraperitoneal • Extraperitoneal • External • Cuffs • Dacron material • One or two

  8. Placement of catheter • Open surgical placement • Peritoneoscopic placement • Blind placement

  9. Proper location of catheter • Intraperitoneal portion • Directed towards pelvis • Cuff • Deep: within medial or lateral border of rectus sheath • Superficial: about 2 cms from skin exit

  10. Composition of peritoneal dialysis fluid

  11. Osmotic agents • Low molecular weight • Glucose- 1.5%,2.5%,4.25% • Glycerol • Amino acids • High molecular weight • Albumin • Glucose polymer • peptides

  12. Clearance Theoretical concept “Volume of plasma from which all the substance has been removed and excreted into the urine per unit time” Amount excreted = Urine volume x urine concentration Excretion rate = Urine volume x urine concentration Time

  13. Clearance Example Clearance of a substance x Excretion rate = 100 mg/ml x 1 ml = 100 mg/min 1 minute Concentration of substance x in plasma = 1 mg/ml Amount of plasma cleared per minute = 100 mg/min = 100 ml 1 mg/ml Clearance = U x V T x P

  14. Principles of Clearance

  15. Principles of Clearance

  16. Clearance of Inulin

  17. Small solute clearance • Urea clearance (Kt/V) • Normalised to total body water • Creatinine clearance (CrCl) • Normalised to body surface area

  18. Total clearance • Sum of • Residual renal clearance • Peritoneal dialysis clearance

  19. Method of calculating dialysate clearance of urea • 24 hr collection of peritoneal dialysate effluent • Measure urea concentration in dialysate • Estimate total urea content • Urea concentration × volume of effluent • Calculate clearance • Kt = Urea content in dialysate Serum urea level

  20. Method of calculating renal clearance of urea • Collect 24 hr urine • Measure urea concentration in urine • Estimate total urea content • Urea concentration × urine volume • Calculate renal clearence of urea • Kt = Urea content in urine serum urea level

  21. Total and normalised clearance • Total clearance • Dialysate clearance + renal clearance • Normalised clearance (Kt/V) • Dialysate clearance + renal clearance Total body water

  22. Calculate clearance • A 50 yr old man weighing 66 Kg has no urine output. He is on CAPD with four 2.5 L exchanges daily. His blood urea is 160 mg/dl and dialysate urea concentration of 24 hr collection is 140 mg/dl.calculate his daily clearance

  23. Complications of peritoneal dialysis • Mechanical complication of catheter • Catheter obstruction/inadequate drain • Perforation and laceration of organs • Peritoneal catheter leaks • Infectious complications • Exit site infection • Peritonitis

  24. Clinical presentation of peritonitis(percentages)

  25. Route of entry for peritonitis • Touch contamination • Catheter related • Enteric • Haematogenous • Gynaecological

  26. Organisms causing peritonitis • Gram-positive • Staphylococcus epidermidis • Staphylococcus aureus • Streptococcus • Enterococcus • Gram-negative • Fungal • Mycobacterial

  27. Differential diagnosis of cloudy effluent Infectious peritonitis Eosinophilic peritonitis Sclerosing peritonitis Chylous ascites Malignant ascites Pancreatitis Chemical peritonitis

  28. Treatment of peritonitis • Antibiotics • Intraperitoneal route • Continuous • Intermitent • Intravenous route • Pain control

  29. Outcome and sequelae • Resolution-60-90% • Abscess formation-1% • Transfer to hemodialysis(technique failure)-30% • Sclerosing peritonitis-1-2% • Death-1-6%

  30. Types of peritoneal dialysis • Manual • CAPD-Continuous ambulatory peritoneal dialysis • Automated • CCPD-Continuous cyclic peritoneal dialysis • NIPD-Nocturnal intermittent peritoneal dialysis • TDP-Tidal peritoneal dialysis

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