Q.661 What are the recommendation related to placement and maintenance of P.D. catheter? peritoneal dialysis complications peritoneal dialysis

PERITONEAL DIALYSIS

 

Q.661 What are the recommendation related to placement and maintenance of P.D. catheter?                                        

A. Consistent “ease” bidirectional flow of Dzt. is 🠊 the main function of PD cth.. Cth.'s function depends upon:[design, implantation site & configuration of system used to perform DX. exchanges]. Most cth. are flexible tubes é multiple ports in distal (intraabd.) segment wch is ideally positioned freely in intraabd. pelvic area. Many types are available. Cth. used by PD program primarily depends upon preferences & experience of clinician , é some guidelines stating tht no sp. cth. is definitively better. However, double ✌ is preferred over single cth., it hs fewer complic. & longer time to 1^st peritonitis episode & longer survival.

Site of placement: paramedian or lateral abdominal rather thn midline. In some ptns, presternal cth. may be preferred. A downwardly-directed tunnel is preferred & prox. A.B. shd be given at time of placement. Choice of cth. technique depends upon preferences & expertise of surgeon or nephrologist inserting the cath.. No technique showed to be preferable overall, each method hs its benefits & S.E.

Q.662. How to prevent peritonitis in continuous P.D.?  

A. To limit the risk of peritonitis in PD. : All ptns must be taught  proper techniques to 🠋 risk of infection. A.B., e.g. cephalosporin, just prior to cth. placement to 🠋incidence of wound infc. & peritonitis is recommended.

Close attention👆 to cth. implantation technique is needed. Improper cth. placement predisposes to cth. infection. All ptns should use Y systems or cyclers & if cost is not an issue, Y & double bag systems are recommended to further decrease likelihood of contamination. Standard spike 💢 systems shd not be utilized. Ptn. é recurrent peritonitis, one needs to review their technique, rule out exit site or cth. biofilm problems, or consider possibility that ptn is a nasal carrier for S. aureus.

Q.663. What are the noninfectious complications of continuous P.D.? 

 

A. These complications occur é either CAPD or CCPD us. due to 🠝IAP resulting fr. pres. of Dzt into Pr. cavity 🠞 [GERD & delayed gastric emptying, back & abdominal pain & pl. effusion]. Other problems incl.[hemoPr., hypo-k+, & dys.Mg+]. GERD & delayed gastric emptying should be considered in well-dialyzed ptn C/O of n. & v., fullness & epigastric discomfort. Added to general measures, ttt of GERD in CAPD/CCPD may involve 🠋supine intra.Pr. fluid vol.. However, since achieving adequate DX. depends in large part on exchange vol., this strategy usyally require careful tailoring of DX. prescription to avoid inadequate Ssc.. A pleuroPr. leak should be considered in ptn. é pl. eff. (esp. Rt.-sided eff.) without other Sns of H.F.. Abdominal pain shd prompt consideration of peritonitis, cth. malfunc., or infusion pain fr. high dextrose or acidic Dzt. infusion pain may be ttt é intra-Pr. infusion of HCO3. Unlike HDX., hypoK+ is common in PD. Liberalization of dietary K+ & oral K+ suppl. can be needed.

Q.664. How to adjust iron balance in predialysis, P.D., & home HDX patients?

A. Iron stores †must be assessed prior to starting iron therapy & non-R. causes of anemia shd be excluded. Evaluation of R. anemia must include:[RBCs indices, Retics, s. iron, TIBC, TSAT, s. ferritin & occult bld in stool]. “Absolute” iron def. is to be present when TSAT ≤20 % in CKD & s. ferritin ≤100 ng/mL in pre-DX. & P.D. ptns & ≤200 ng/mL in home HDX ptn.“Functional” iron def. is ch.ch. by pres. of adequate iron stores, but é relative inability to mobilize iron for erythropoiesis . Functional def. is ass. é  TSAT ≤20 % & 🠝ferritin (100-800 ng/mL or higher). However, TSAT & s. ferritin above these levels (20 % & 800 ng /mL, resp.) do not necessarily indicate tht further iron wd be without an EPO stimulating effect. Targeting HB. é range of 10-12 g/dL in CKD ttted é Epo is suggested. Thus, iron thpy & Epo are indicated in anemia due to CKD & H.B. <10 g/dL. Do NOT target HB. >13 g/dL. Ptn é anemia due to CKD & absolute iron deficiency (TSAT ≤20 % [for preDX., P.D., & home HDX] & ferritin ≤100 ng/mL [for preDX & P.D.] or ferritin ≤200 ng/mL [for home HDX.]), iron thpy prior to use of Epo is recommended. Anemia due to CKD & borderline iron indices, i.e TSAT ≤20 % (for preDx, P.D., & home HDX.) & ferritin between 100 & 500 ng/mL (for pre-DX & P.D.) or ferritin betw. 200 & 500 ng/mL (for home HDX.), oral iron thpy prior to Epo. is suggested. In such ptn., ttt é i.v. iron cn be considered but only if underlying infec. and/or cause of  inflmm. state have been excluded. Such ptn must be closely monitored for incr. ferritin & adverse effects of iron. We do not routinely give i.v. iron to ptn é ferritin > 500 ng/mL👆. Among preDX. & P.D., initial iron therapy é oral iron rather thn parenteral iron thpy is recommended.

Home HDX.: initial iron therapy é oral iron rather thn parenteral iron is suggested. Oral iron=200 mg/d. elemental iron. Due to simplicity & cost issues🠞 ferrous So4 325 mg (65 mg elemental iron/t.) t.i.d.. Among pre-DX., P.D. & home HDX., goals é initial iron therapy incl.:[🠝H.B. & 🠝TSAT> 20-25 % but <50 %]. In preDx. & P.D., aiming to maintain ferritin > 100 ng/mL but <500 ng/mL & for home HDX., aim to maintain ferritin>200 ng/mL but <500 ng/mL. Ptn.s receiving EPO 🠞 maintenance iron thpy . Among preDX & P.D.: goalsof maintenance iron to be TSAT betw. 20-50 % & s. ferritin between 100 & 500 ng/mL . In home HDX., it’s recommended: TSAT be maintained>20 % & s. ferritin> 200 ng/mL & TSAT < 50 % & s. ferritin <500 ng/mL. Iron indices are reevaluated after 1-2 m. of oral iron. If HB. doesn’t incr. to target (é modest Epo.), TSAT remains < 20 % for all ptn. , and/or s.ferritin still< 100 (for preDx & P.D.) or < 200 ng/mL (for HDX. Ptn.) ➳ parenteral iron shd be started. If parenteral iron initiated, ferric gluconate in sucrose cx or iron sucrose rather than iron 👽dextran is recommended, optimal reg. are unclear, but the following regimen are suggested :

300-400 mg iron sucrose, once/w. (or less often if necessary, i.e for ptn. convenience, etc.): 2-3 doses🠞total: 600-1000 mg, as needed. If not well tolerated, additional 200 mg can be used. 250 mg of ferric gluconate in sucrose cx can given once/ w. (or less often if necessary, ie é ptn. convenience, etc.) 3-4 doses, as needed. We don’t routinely give i.v iron é ferritin>500 ng/mL& anemia, alth. ptn. should be individualized. So, initial 🠝Epo. dose alone, without i.v. iron, may be considered if H.B. is <11 g/dL é Epo dose that’s not partic. high. If this’s not successful in raising H.B or further increase is desired 🠞judicious suppl. iron with or without further🠝 in Epo dose.   💋

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Q.665. What are the suggested modalities for diagnosis of abdominal & thoracic cavity defects in P.D. patients?            

A. Different diagnostic modalities can be used alone or in combination to diagnose abd. wall and/or thoracic defects in PD. Based on sensitivity, specificity & cost, we use & recommended CT peritoneography as initial diagnostic modality . It’s the most commonly used modality in U.S. & offers distinct adv. over plain CT scans.

Although MR peritoneography hs  similar sensitivity to CT pr. graphy in Dgx these defects, use of gadolinium in DX ptn.s has been ass. é 🠞 severe syndrome of nephrogenic systemic fibrosis. So, Gadolinium-based img. should be avoided  MR peritoneography using DX. fluid as a contrast medium may offer a valuable, cheap & user friendly alternative. However, further study in additional centers is required to validate its usefulness. Isotope scanning is principally used in allergic ptn. to iodinated contrast used in CT Pr.graphy.