imad ahmed md renal associates of west michigan...imad ahmed md renal associates of west michigan...
TRANSCRIPT
![Page 1: Imad Ahmed MD Renal Associates of West Michigan...Imad Ahmed MD Renal Associates of West Michigan Facts: - Medicare funded program - Cost - Significant mortality and morbidity - Reduced](https://reader034.vdocuments.mx/reader034/viewer/2022042710/5f5d3d4644d79052e8589ea8/html5/thumbnails/1.jpg)
Imad Ahmed MD
Renal Associates of West Michigan
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Facts:
- Medicare funded program
- Cost
- Significant mortality and morbidity
- Reduced quality of life
- Shrinking donor pool
ESRD
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CAUSES
- DM
- Hypertension
- Chronic GN
- Vascular disease
- Nephrotoxins
ESRD
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WHEN TO START RRT
- Relative Indications
- Nutritional status
- Fatigue
- GI symptoms
- Absolute Indications
- Hyperkalemia
- Fluid overload
- Metabolic acidosis
- Uremia
ESRD
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Absolute Indications to initiate RRT
- Pericarditis
- Encephalopathy
ESRD
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IHD
Home HD
PD
Renal transplant
Conservative care and palliative care
Modalities
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93% IHD
7% Peritoneal dialysis
<1% Home HD
2010 – 5000 – 6000 patients on home HD
HOME DIALYSIS
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Reasons for decline in home therapies
- Direct supervision by a nurse
- Increasing elderly population
- Sick patients
- Increase in number of outpatient dialysis units / for profit units
- Lack of patient motivation
- Family motivation
- Training of nephrology fellows and practicing physicians
- Shortage of staff
Home Dialysis
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TYPES
- APD
- CAPD
- IPD
- TPD
- CFPD
- Classic IPD
Peritoneal Dialysis
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Selection of patients
- Transport characteristics
- Life style choices
- BSA
- Large / anuric pt
CAPD & APD
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Selected Clinical outcomes
Incidence of technique failure
Mortality
Kt/V
RKF ( urine volume > 100 ml/day)
CAPD vs APD
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Glucose containing - GDP’s Amino acid containing Xylitol containing Glycerol containing Acetate Sol Low Ca++ Solutions Icodextrin Additives : Abx , heparin , KCL and Insulin
Available Solutions
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Extremely Important
Preserve and protect it
Nephrotoxins
Gadolinium exposure
Residual Kidney function
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Excess body fluid and mortality Kt/V correlates inversely with volume Lower serum albumin Greater fluid removal – predictor of improved relative risk of
death Peritoneal membrane failure vs other issues - Dietary habits - Loss of RKF - Prescription - Diuretics OSA and nocturnal PD.
Fluid Balance with PD
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Severe cardiomyopathy
Autonomic dysfunction
Poor vascular access
Bridge to renal transplant and cardiac transplant.
Chronic hypotension
Acute CVA
Preferred therapy for infants and young children
PD vs HD
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Abdominal hernias
Extensive adhesions , memb fibrosis , malignancy
Colostomy , Ileostomy , nephrostomy ir ileal conduit
Chronic backache/ disc disease
Psychological and social issues
Severe diverticular disease of colon
Severe neurologic disease , movement disorder
Severe arthritis
Severe COPD
Severe malnutrition
Contraindications to Peritoneal dialysis
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Infectious
- Peritonitis
- Exit site infection
- Tunnel infection
Complications of PD
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Primary
Secondary
- Hx of constipation
- Diarrhea
- Hernia
PERITONITIS
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Signs & Symptoms
- Abd pain 79 – 88%
- Fever > 37.5
- N/V 31 – 51 %
- Cloudy effluent 84%
- Hypotension
- Tender hernia site
- Exit site tenderness , discharge or tunnel tenderness
PERITONITIS
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Cloudy fluid ( WBC > 100)
Absence of cloudy fluid ( APD/CCPD)
Severe abd pain – certain organisms
Stool in bag/dialysate
PERITONITIS
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LABS:
- WBC count > 100
- 10 % pts have less than 100/mm3
- 50% PMN’s
- Neutropenic and txp patients
- Predominance of lymphocytes
- High eosinophils , > 10 %
- High amylase and lipase level
- Organisms – Gram + - Coag neg staph vs bacteroides.
PERITONITIS
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Management
- Hypotensive
- Hemodynamically stable
- Initiate Abx ASAP
- Gram + ( coag – staph , staph aureus and enterococcus)
- Gram – ( Bowel , skin , urinary tract , contaminated water and animal contact). Ecoli , campylobacter and pseudomonas.
PERITONITIS
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Fungal
- Immunocompromised
- Abx use
PERITONITIS
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Management
- Pain control
- Heparin
- Longer dwells?
- Antibiotics – Empiric ? Use of aminoglycosides.
- Cephalosporin allergy – Aztreonam
- Duration of antibiotics
- Vancomycin dosing.
- Stopping PD for 2 days?
PERITONITIS
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Catheter removal:
- Relapsing peritonitis – Same species within 4 weeks
- Refractory peritonitis – No response to abx within 5 days.
- Refractory catheter infections.
- Fungal peritonitis
- Pseudomonas – Removal + 2 abx for 3 weeks.
- Fecal peritonitis
- When to place new catheter ?
PERITONITIS
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Non infectious:
- GERD
- Back pain
- Delayed gastric emptying
- Pleural effusion
- Hemoperitoneum
- Inflow pain
- Electrolyte abnormalities
- Catheter malposition
Complications of PD
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Inflow or infusion pain
- Transient
- Acidic PH of dialysate
- Catheter position
- Management - Sod bicarb injection
- Infusion rate
- 1% lidocaine inj
- Tidal vol
Complications of PD
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Hemo – peritoneum
- Menstrual bleeding
- Anticoagulation
- ADPKD
- Catheter manipulation
- Renal tumors
- Sclerosing peritonitis
Complications of PD
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Management of bloody dialysate
- Reassurance
- Imaging and ER evaluation
- Heparin
- Coag profile
- Frequent exchanges
Complications of PD
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Management of delayed gastric emptying
- Reduce intra abd pressure
- Motility drugs
Pleuro – peritoneal leak
- Pleural effusion – bil ( Vol overload , CHF )
- One side effusion – No edema , CHF
- Diaphragmatic hernias , neg intra thoracic pressure
- 1.6 – 10 %
- More common in women
Complications of PD
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- Asymptomatic
- Loss of UF
- Neg drain
- Right sided
- Dyspnea
Pleuro – Peritoneal leak
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Management
- Thoracentesis
- Drain peritoneal cavity
- Avoiding supine dwells
- Intermittent PD
- Resolve spontaneously
- Stopping PD
- Chemical pleurodesis , surgical repair of defect
Pleuro – Peritoneal leak
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Why PD?
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Residual kidney function
Middle molecule clearance
Nutrition
Quality of life
Vascular access
Bridge to renal and / or cardiac transplant
Low cost
The future?
Why PD?
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FDA approval
5 KG Wt
Wearable Kidney
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