Hand out - volume management in pd patient

“ 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