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“ Volume management in PD patient” นพ.กมล โฆษิตรังสิกุล
โรงพยาบาลมหาราชนครศรีธรรมราช
REASONS FOR DISCONTINUATION
HEAD TO TOE
Brain
Mouth
Abdomen
Legs
FLUID OVERLOAD
Common in contemporary PD populations and has been associated with adverse clinical outcomes
hypertension
left ventricular hypertrophy
congestive heart failure
hospitalization
APPROACH FOR FLUID OVERLOAD
salt & water intake
blood glucose control
cardiac status
change in RRF
adherence to prescription
appropriateness of prescription
mechanical complication
change in peritoneal membrane function
FLUID ASSESSMENT TOOLS
• Bioelectrical impedance analysis (BIA)
• Tracer dilution technique (Deuterium oxide, Sodium bromide)
• Dual-energy x-ray absorptiometry (DEXA)
• Biochemical markers( Cardiac natriuretic peptides level)
• Cardiothoracic ratio (CTR) & Vascular pedicle width(VPW)
• Inferior vena cava diameter (IVCD)
• Clinical syndrome( BP, Edema)
TOOLS TO EVALUATE
G. Woodrow, Perit Dial Int 2007; 27(S2):S143–S147
Body weight alterations
Daily weighing by patients is a routine part of PD management, and weighing is valuable in detecting changes in body fluid content.
FLUID BALANCE
The most appropriate way to control fluid balance in diabetic PD patients should be control of dietary salt and fluid intake.
Lei Quan, Perit Dial Int 2006; 26:95–100
PHYSIOLOGY OF VOLUME CONTROL
Input Output
สิริภา ช้างศิริกุลชัย, 2007 Update on CAPD, P111
PHYSIOLOGY OF VOLUME CONTROL
Input Salt
Fluid
SALT INTAKE IN PD
Blake G.,Perit Dial Int 2011;31:224
SALT INTAKE IN PD
• Sodium intake should be restricted to 65 mmol (1500 mg) or less daily in patients with hypervolemia (grade C).
Blake G.,Perit Dial Int 2011;31:224
WATER MEASUREMENT
FLUID
Visible fluid
Invisible fluid
VISIBLE FLUID
น้ำสำหรับทานยา
น้ำดื่มแก้กระหาย
น้ำแข็งอมแก้คอแห้ง
INTRAVENOUS MEDICATION
PERITONEAL MEMBRANE
The total surface of interchange of the peritoneal cavity is approximately 1 m2.
PERITONEAL MEMBRANE
FLUID ABSORPTION
• Via Lymphatic ducts & Tissue absorption
• Usually occurs in a fixed rate (0.2-1 ml/min)
• Affected by posture associated intra-abdominal pressure
ULTRAFILTRATION CURVE
PERITONEAL MEMBRANE
Unlike liquids and most solutes, larger particles are eliminated through the larger orifices that exist between the specialized mesothelial cells that cover the lymphatic conduits on the diaphragmatic surface of the peritoneal cavity. These intracellular orifices correspond to fenestrations of the basal membrane, and together serve as conduits of the peritoneal cavity to the underlying lymphatic drainage system of the diaphragm, called “lakes” or “lagoons.” The reabsorption of particles or bacteria is only possible in the subdiaphragmatic peritoneal surface through numerous stomas or intracellular lagoons, to which a network of lymphatic vessels flows into the diaphragmatic lacunas. These lacunas have a diameter of 8 to 12 microns, subject to variations depending on the diaphragmatic movements and the changes of thoraco- abdominal pressure. Smaller particles, such as bacteria that by general are approximately 2 microns in diameter, are readily absorbed through diaphragmatic lacunes into the thoracic duct. Intra-peritoneal fluid and exudates circulate constantly in the cavity toward the decanting zones via gravity, and toward the subphrenic spaces by the suction caused by diaphragmatic contraction. This works like a suction pump. It accelerates the flow during inspiration, and diminishes or restrains it during expiration, and it is probably the most important mechanism in charge of the “defensive” cleansing of the peritoneum [1,4].
POSTURE & INTRA-ABDOMINAL PRESSURE
Intra abdominal pressure (cm H 2 O)
Exchange volume (ml/kg)
Sitting
Upright
Supine
Via Lymphatic ducts & Tissue absorptionUsually occurs in a fixed rate (0.2-1 ml/min)Affected by posture associated intra-abdominal pressure Supine < Standing < Sitting
PERITONEAL EQUILIBRATION TEST
Evaluation of peritoneal membrane function test ( modified PET)
modified PET -4.25%
High Low HA/LA
• Idiopathic
• Peritonitis
• Peritoneal membrane change
Adhesion
< 5 mEq/L
Sodium dipping
>5 mEq/L
Aquaporin deficiency
Increase Lymphatic absorption
จิรายุทธ จันทร์มา, 2008 Optimal Care on CAPD in Thailand, P125
UF FAILURE
Blake G.,Perit Dial Int 2011;31:224
ABDOMEN
FLUIDS MANAGEMENT
Kidney International 20002 (62) Supplement 81: S8-S16
DIFFERENT MODE OF PD
DIALYSIS FLUID : OSMOLARITY
1.5% dextrose : 346 mOsm/L
2.5% dextrose : 396 mOsm/L (hypertonic)
4.25% dextrose : 485 mOsm/L (hypertonic)
7.5 % icodextrin (Extraneal) : 282-286 mOsm/L
http://www.baxter.com/downloads/patients_and_caregivers/products/dianeal_ultrapd2.pdf
http://www.baxter.com/downloads/patients_and_caregivers/products/extraneal_pi.pdf
ULTRAFILTRATION
1.5% Glucose 2000 ml
Max UF 330 + 187 ml
Time to max UF 140 + 48 min (2.3 hr)
4.25% Glucose 2000 ml
Max UF 1028 + 258 ml
Time to max UF 247 + 61 min (4 hr)
ULTRAFILTRATION CURVE
ICODEXTRIN
ABDOMEN
PD RELATED PERITONITIS
Defined as the presence of at least 2 of the following conditions:
• Abdominal pain or tenderness
• Presence of white blood cells in peritoneal effluent in excess of 100 cells/mL, comprising at least 50% PMN
• Positive dialysate culture results
Perit Dial Int : July/August 2010 vol. 30 no. 4, 440-447
STABILITY OF DRUGS
Perit Dial Int 2009; 29:5–15
STABILITY OF SINGLE DRUGS IN PD SOLUTIONS IN PVC CONTAINER
Perit Dial Int 2009; 29:5–15
Perit Dial Int 2009; 29:5–15
STABILITY OF SINGLE DRUGS IN PD SOLUTIONS IN PVC CONTAINER
STABILITY OF DRUGS
PERITONITIS - APD
Ideally the patient should convert to a CAPD regime with the help of the nursing staff.
When the fluid has cleared, the patient may return to a more typical APD regimen (i.e. short nightly cycles and a prolonged daytime dwell).
If the daytime dwell contains antibiotics, this must be a full exchange (at least 6 hours).
LAPAROSCOPIC VIEW
ABDOMEN
PHYSIOLOGY OF VOLUME CONTROL
Output
• Urine (RRF)
• PD fluid ultrafiltration
สิริภา ช้างศิริกุลชัย, 2007 Update on CAPD, P111
Urine (RRF)
PD fluid ultrafiltration
CAREFUL EVALUATION OF VOLUME STATUS
Blake G.,Perit Dial Int 2011;31:224
• Low net daily peritoneal UF volume
• <750 mL in anuric patients
• <250 mL in patients with RRF
RESIDUAL RENAL FUNCTION
Marron B, Kidney Int 2008; 108:S42-51
HIGH-DOSE DIURETICS
Medcalf JF,et al.Kidney Int 2001; 59:1128–33.
• RCT conducted in incident 61 CAPD patients
• Furosemide 250 mg daily (plus metolazone 5 mg daily) followed for 12 months.
• Increase in urine output and urinary sodium excretion with no difference in the rate of loss of RRF.
• Thiazide diuretics alone are generally ineffective in promoting diuresis in PD patients.
LEGS