renal replacement therapy 2 - isfahan university of ... · renal transplantation is the preferred...
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Renal replacement therapyperitoneal dialysis
Sh.Atabak
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Problems of ESRD patients in 20101. Fast growing number of ESRD patients
2. Astonishing ESRD cost
3. Sever shortage of financial resources
4. Sever shortage of donor organ
5. Chronic rejection as a main etiology in waiting lists
6. Ethical debates in using live unrelated donors
7. Suboptimal current outcomes
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RRT
If the patient is not of advanced age and is not afflicted with severe comorbid illness, renal transplantation is the preferred form of renal replacement therapy.
Living donor transplantation is preferred to cadaveric transplantation.
For the patient who awaits or who cannot undergo transplantation, either peritoneal dialysis or hemodialysis may be chosen.
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Integrated Care Approach “Start renal replacement therapy in
ESRD patients with PD, transfer them to HD when problems with PD occur, and
transplant them when the possibility exists”
Lameire N, et al, Seminar of Uro-Nephrology, (1999)
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Rational for a dialysis program in spite of
no waiting list for kidney Tx1) More than 15% of ESRD patients are not eligible for kidney transplantation (contrandications)
A : Malignancy B : Chronic Infection C : Sever exterarenal disease
Chronic liver disease Uncorrectable heart disease Chronic lung disease (difficult anesthesia) Sever peripheral vascular disease (Difficult anastomosis) (Limb viability)
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If medically suitable, PD should be the first option for RRT when a patient reaches ESRD (in the absence of a suitable live donor).
Coles GA. Et al. , What is the place of peritoneal dialysis in the integrated treatment of renal failure? KI, 54; 2234-2240,
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Types of PD
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MEA PD Variations (Adults) - 2001
Manual Systems (CAPD)
Automated Systems (APD)
29%
69%
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Advantages of PD Disadvantages of PD
➢Ease of performance Low efficiency ➢High safety margin Body image problem ➢Portability secondary to catheter ➢Availability Pulmonary compromise ➢Fewer dialysis-related Protein loss symptoms Metabolic Complications ➢No anticoagulation
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PD as the Initial Form of Renal Replacement Therapy
• Better initial survival • Preserves residual renal function • Effective blood pressure and volume control
• PD → Transplant:
• reduced risk of early acute renal failure
• Reduced risk of being infected by a blood borne virus
• Delays the use of HD blood access sites • Quality of life
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Relationship of Members of CAPD Family
Nurse
Patient
Doctor Family
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PredialysisWork assessment • Suitable area for
CAPD exchange • Educate management
& personnel staff • A Home Sister is
always available at Clinic
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Home Visit
What is it? Discussion Dialysis problems Health Status Social life Knowledge of Renal failure/treatment Liaison
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Nephrology Consultation
• Timely appointments • accessibility
• Available for discussion • by phone • by fax • for information/direction
• Communication patterns preferred • individualized
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Integrated ESRD Care
Residual Renal Function
Hemodialysis
Crea
tinine
Clear
ance
(ml/min) 20
15
10
5
0Time on Dialysis
Initiation of Dialysis
Peritoneal Dialysis
Transplant
PD
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• Peritoneal dialysis (PD) may be a useful technique in the treatment of patients with congestive heart failure, both with and without primary end-stage renal disease (ESRD)
CHF
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• CHF is a major and growing health program • 1% of all people above 40 years old have
HF • The prevalence doubled with each decades
of life, being around 10% over 70 years old. • 5% of all hospitalization is due to HF • Third cause of cardiovascular mortality.
A study in Spain
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• Fluid accumulation worsen the HF • Renal perfusion decreased and activation
of neurohurmonal induce glomeulosclerosis and tubulointerstitial fibrosis
Results of alteration
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• Some cytokine and humoral factors have been involved in the progression of HF.
• Some have myocardial depressant activity as ANP, tumor necrosis factor.
Middle molecule
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Presentation Plan
1.Type of catheters 2.Pre-operative care 3.Catheter placement 4. Immediate post-op. care 5.Chronic catheter care
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• Rapid rate of dialysate flow • Minimum or no - leaks - migration - exit and tunnel infections - peritonitis • Ease of insertion by all techniques • Long lasting • Inert material - durability - resistant to infection/biofilm - antimicrobial properties
Peritoneal Catheters
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انواع کاتتر
Straight Tenckhoff cath. 2 cuffs
Coiled 1 cuff
CoiledTenckhoff cath. 2 cuffs
Swan Neck Missouri 2 cuffs
Swan Neck Tenckhoff Permanent bend (180o ) between the 2 cuffs
Pre sternal 1 cuff
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Appropriate candidates
• Motivated ESRD patients • Patient’s family support, care givers,
etc. • Ability to understand and use sterile
techniques • Physical capability • Ideal candidate has no prior abdominal
procedures
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Catheter Placement
• Operator should be interested in outcome • Percutaneous, surgical or laparoscopic • Catheter tip must be in the true pelvis • Deep cuff in rectus muscle • Arcuate tunnel- downward position • No sutures at exit site • Check flow before closure
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Catheter Break-in
• Flush post-op with 500 ml to 1000 ml dialysate to check patency
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Catheter Insertion
PRE-IMPLANTATION PREPARATION
❖ Fully inform patient about the details of the procedure
❖ Pre-surgical assessment (e.g. hernias) ❖ Determination of exit-site ❖ Skin preparation ❖ Bowel preparation ❖ Prophylactic antibiotics
Evidences suggest that peri-op antibiotics diminish wound infection
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Catheter Implantation Techniques
RECOMMENDATIONS • Performing implantation competently, experienced
operator, having a planned manner, Care and attention to details are important
• Peritoneal entry - lateral or paramedian • Deep cuff - placed in musculature of anterior
abdominal wall or within posterior rectus fascia • Subcutaneous cuff - 2cm from exit-site • Catheter patency needs checking • Exit-site facing downward or laterally
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Immediate Post Operative Care
AIMS ❖ Minimizing bacterial colonisation ❖ Preventing trauma to exit-site and traction on cuffs ❖ Minimizing intra-abdominal pressure to prevent
leakage ❖ Several approaches for post operative care ❖ No evidence to support superiority of any single
method RECOMMENDATIONS ❖ Minimizing catheter movements ❖ Minimizing catheter handling until healing of wound
and tract for 3-4 weeks
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Post implantation Dialysis
RECOMMENDATIONS
• Flush catheter with small volumes (e.g. 500mL) until effluent becomes clear
• Starting CAPD depends on type of implantation technique - generally catheter should be capped for 2 weeks before starting PD
• PD in the interim should be
- intermittent - small volumes - gradual increase in volume - patient in a supine position
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CAPD Exchange Procedure
1. Fill phase (<10 Minutes)
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CAPD Exchange Procedure
2. Dwell phase (4-8 hours)
3. Drain phase (<20 minutes)
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