Ni Made HustriniDivisi Ginjal Hipertensi, Departemen Ilmu Penyakit Dalam

FKUI/RSCM - Jakarta

PENENTUAN REGIMEN PD

Contoh Kasus

Laki-laki, 28 tahun

CKD stage 5

Etiologi PGTA: MPGN

eGFR 6 ml/mnt/1,73m2

Diuresis 800 ml/24 jam. BB 60 kg

Dirujuk ke Poli PD untuk TPG

Apa yang perlu dilakukan

pertama kali?

KAJIKAJI

• Kondisi sosial ekonomi

• Kondisi klinis, kebutuhan pasien

• Karakteristik pasien

INISIASIINISIASI• APD vs CAPD

• Paparan glukosa minimal

MONITORMONITOR• PET

• Parameter klinis

• Luaran PD

1). Menentukan Modalitas PD

CAPD

APD

1). Menentukan Modalitas PDCAPD APD

Teknik lebih sederhana Teknik kompleks

Penggantian cairan 4xsehari Penggantian cairan 1-2xsehari

Risiko peritonitis +++ Risiko peritonitis +

Burnout +++ Burnout +

Manfaat untuk menjaga keseimbangan

cairan +

Manfaat untuk menjaga keseimbangan

cairan +++

Sodium sieving +++ Sodium sieving +

Biaya lebih murah Biaya mahal

Tidak perlu mesin Perlu mesin khusus

Kehilangan RKF + Kehilangan RKF +++

Kehilangan protein + Kehilangan protein +++

Baik untuk pasien:

- Gangguan penglihatan

- Pasien bekerja/caregiver

- High transporter

- Overload cairan

- ↑ Tekanan intrabdomen

2). Membuat Preskripsi Awal PD

Prinsip Preskripsi PD

• klirens solut

• status cairan

UrgensiUrgensi

• Medis

• Sosial

CAPD vs APDCAPD vs APD

• Tekanan intraabdomen

• Klirens solut dan UF

VolumeVolume

• Klirens solut dan UF

• Lifestyle

Jumlah Pergantian Cairan - Dwell TimeJumlah Pergantian Cairan - Dwell Time

• Paparan glukosa rendah

• Glucose sparing

Tonisitas dan Jenis CairanTonisitas dan Jenis Cairan

3). Incremental PD (iPD)

Merupakan metode PD yang dilakukan pada pasien

yang masih memiliki fungsi ginjal sisa (RKF) untuk

mencapai target klirens solut diawali dengan

melakukan preskripsi dosis PD terendah.

eGFR 4-5 ml/menit/1,73 m2

3). Incremental PD (iPD)

Metode:

1) preskripsi dengan total volume cairan terendah (misalnya

hanya dua atau tiga kali penggantian cairan per hari pada

CAPD);

2) hanya melakukan PD setengah hari (misalnya nocturnal APD

dengan dry day);

3) melakukan PD kurang dari 7 hari dalam seminggu.

Strategi untuk Mencapai Target

UF dan Klirens Solut

Target UF Target Klirens Solut

Tingkatkan volume dwell Tingkatkan lama PD

Icodextrin Icodextrin

Perpendek lama dwell Naikkan volume dwell

Perbanyak pergantian cairan Perpendek lama dwell

Naikkan tonisitas cairan (2,5%) Naikkan pergantian cairan

Contoh Preskripsi Awal CAPD

• 1,5%

• Icodextrin (UF atau long dwell)TonisitasTonisitas

• <50 kg: 1,5 L

• 50-70 kg: 1,8 L

• >70 kg: 2L (125 ml/kg/hari)

Volume dwellVolume dwell

• 4x jika RKF rendah

• 3x jika RKF baik

Jumlah pergantian

cairan

Jumlah pergantian

cairan

• Lifestyle

• Klirens solut dan UFDwell timeDwell time

Contoh Preskripsi Awal APD

•1,5%TonisitasTonisitas

• 10 jam

• sesuaikan dg lifestyleWaktu terapiWaktu terapi

• 5x siklus

• Rerata dwell time 1,5 jamJumlah pergantian cairanJumlah pergantian cairan

• Total 10 L

• Fill volume 1,8L

• Last fill & RKF

• Klirens solut dan UF

Volume cairanVolume cairan

Kembali ke Kasus….

Laki-laki, 28 tahun

CKD stage 5

Etiologi PGTA: MPGN

eGFR 6 ml/mnt/1,73m2

Diuresis 800 ml/24 jam. BB 60 kg

Dirujuk ke Poli PD untuk TPG

CAPD

Resep:

- Glu 1,5%, vol. 2 liter

- 3x pergantian cairan

- Dwell time 4-6 jam

CAPD

Resep:

- Glu 1,5%, vol. 2 liter

- 3x pergantian cairan

- Dwell time 4-6 jam

4). Peritoneal Equilibration Test (PET)

High

High Avg

Low Avg

Low

Implikasi Klinis PET

High Transporter Low Transporter

UF jelek UF baik

Klirens baik Klirens jelek

Rejimen:

- Maksimalkan UF (dwell

cepat APD)

Rejimen:

- Maksimalkan klirens

(dwell lama CAPD)

5). Adekuasi PD

Kriteria klinis Kriteria Lab

Ada: Tidak Ada: ELektrolit normal

Kreatinin

- <20 mg/dl (LBM >)

- <15 mg/dl (LBM <)

Hb 10-12 g/dl

Albumin 4

Keseimbangan Ca/P

- Klinis baik

- Merasa sehat

- TD terkontrol

- Nutrisi baik

- Status

fungsional baik

- Anoreksia

- Asthenia

- Dysgeusia

- Muntah

- Insomnia

- Mual

Guideline ISPD: Kt/V mingguan 1,7

Kesimpulan

Lakukan pengkajian:

Kondisi klinis

Lifestyle, sosial

Prinsip preskripsi awal PD:

Mencapai target klinis dan biokimia

Status fungsional

Dosis dialisis terendah dan paparan glukosa terendah

Monitoring preskripsi PD:

Profil klinis dan biokimia

PET dan adekuasi PD

KOMPLIKASI PD

1. Infeksi exit site (ESI) = infeksi kulit

tempat kateter keluar dari

abdomen.

2. Infeksi Tunnel = infeksi daerah

subkutan dimana kateter melewati

dinding abdomen.

3. Peritonitis = infeksi membran

peritoneum dan cairan dialisat

• infeksi dapat berasal dari kateter

• dialisat merupakan media

pertumbuhan kuman

KOMPLIKASI INFEKSI

Contoh Kasus

Laki-laki, 31 tahun

CKD stage 5

Etiologi PGTA: IgAN

CAPD 1,5 tahun

Keluhan: nyeri perut sejak tadi malam

Demam disangkal

Analisis Cairan Dialisat

Makroskopik:

Warna Tidak berwarna

Kejernihan Agak keruh

Bekuan Negatif

pH 7,9

Mikroskopik:

Jumlah sel 2383 sel/uL

Hitung Jenis:

PMN 2272 sel/uL (95,3%)

MN 111 sel/uL (4,7%)

Kimia:

Glukosa cairan 511 mg/dl

Glukosa serum 110 mg/dl

Ureum cairan 51 mg/dl

Ureum serum 64 mg/dl

Kreatinin cairan 8,34 mg/dl

Kreatinin serum 11,1 mg/dl

Kesan Infeksi dd/ Inflamasi

Diagnosis Peritonitis

Minimal dua (2) dari kriteria dibawah ini:

1. Gejala klinis peritonitis: nyeri perut dan/atau

cairan dialisat keruh

2. Jumlah hitung sel darah putih cairan dialisat

>100/uL atau >0,1x109/L (setelah dwell time

minimal 2 jam), dengan PMN >50%

3. Kultur cairan dialisat positif

Perit Dial Int. 2016;36:481-508

Diagnosis banding cairan

dialisat yang keruh

487

PDI SEPTEMBER 2016 - VOL. 36, NO. 5 ISPD PERITONITIS RECOMMENDATIONS: 2016 UPDATE

diarrhea. In addition, the patient should be questioned about

past history of peritonitis and ESI.

On physical examination, abdominal tenderness is typi-

cally generalized and is occasionally associated with rebound.

Localized pain or tenderness should raise the suspicion of an

underlying surgical pathology. Physical examination should

also include a careful inspection of the catheter tunnel and

exit site. Any discharge from the exit site should be cultured.

The degree of abdominal pain and tenderness are important

factors in deciding whether a patient requires hospital admis-

sion. In general, patients with minimal pain could be treated

on an outpatient basis with intraperitoneal (IP) antibiotic

therapy if this can be arranged. Follow-up within 3 days is

advisable to confirm resolution and appropriateness of the

antibiotic choice.

When peritonitis is suspected, dialysis effluent should

be drained, carefully inspected, and sent for cell count with

differential, Gram stain, and culture (207). An effluent cell

count with white blood cells (WBC) > 100/μL (after a dwell

time of at least 2 hours), with > 50% PMN, is highly sugges-

tive of peritonitis (208). Abdominal X ray is generally not

necessary. Peripheral blood culture is usually not necessary

but should be obtained if the patient is clinically septic. To

prevent delay in treatment, antibiotic therapy (see below)

should be initiated once the appropriate dialysis effluent speci-

mens have been collected, without waiting for the results of

laboratory testing.

The WBC count in the effluent depends in part on the length

of the dwell. For patients on APD with rapid cycle treatment,

the clinician should use the percentage of PMN rather than the

absolute WBC count to diagnose peritonitis, and a proportion

above 50% PMN is strong evidence of peritonitis, even if the

absolute WBC count is less than 100/μL (208). On the other

hand, APD patients without a daytime exchange who present

with abdominal pain during the daytime may have no effluent

to drain. In this case, 1 L of dialysis solution should be infused,

dwelled for 1 to 2 hours, and then drained for inspection and

laboratory testing.

Some PD patients live far away from medical facilities and

cannot be seen expeditiously after the onset of symptoms.

Since prompt initiation of therapy for peritonitis is critical,

this necessitates reliance on immediate patient reporting of

symptoms to the center, and then initiating IP antibiotics in

the home setting. Such an approach requires that the patients

be trained in this technique and that antibiotics be kept at

home. Whenever possible, cultures should be obtained either

at a local facility or by having blood culture bottles kept at

home for use. However, it is important that no one accesses

the PD catheter without the appropriate training or equipment,

which is often the case in smaller emergency departments. In

this case the patient can drain his/ her abdomen and provide

the cloudy effluent for culture. Alternatively, the patient may

place the cloudy effluent bag in the refrigerator until they

can bring the sample to their PD center. The benefit of self-

initiated treatment, however, should be carefully balanced

against the potential problems of over-diagnosis and habitual

misuse of antibiotics.

Identification of Causative Organism

•Werecommendthattheblood-culturebottlebethepre-

ferred technique for bacterial culture of PD effluent (1C) .

•Wesuggestthatsamplingandculturemethodsbereviewed

and improved if more than 15% of peritonitis episodes are

culture-negative (2C) .

Gram stain of the PD effluent should be performed even

though the result is often negative (209). The yield on the Gram

stain is increased if it is performed on centrifuged specimens.

An appropriate method of culturing PD effluent is the most

important step in establishing the causative organism. In some

specialized centers, one could achieve less than 10% rate of

culture negative peritonitis. Identification of the organism and

subsequent antibiotic sensitivities help to guide the choice

of antibiotic, and the type of organism often indicates the

possible source of infection. Bedside inoculation of 5 – 10 mL

effluent in 2 (aerobic and anaerobic) blood-culture bottles

has a reasonable sensitivity, and the culture-negative rate is

typically around 10 – 20%. (210,211). The yield of peritoneal

fluid culture is enhanced by inoculating the fluid directly into

rapid blood-culture bottle kits (e.g. BACTEC, Kent, UK; Septi-

Chek, Roche Diagnostics, Basel, Switzerland; BacT/ Alert,

Biomerieux, Inc., Basingstoke, UK), centrifuging PD fluid

and culturing the pellet, or the lysis centrifugation technique

compared to inoculation into standard blood-culture bottles.

Specifically, centrifugation of 50 mL PD effluent at 3,000 g

for 15 minutes, followed by resuspension of the sediment in

3 – 5 mL supernatant and inoculation on solid culture media

or standard blood-culture media, increases the yield by 5 to

10 times but is more cumbersome (212,213). The combination

of water lysis, Tween-80 blood agar and Triton-X treatment of

the PD effluent is also a sensitive culture method (214). The

specimens should arrive at the laboratory within 6 hours. If

immediate delivery to the laboratory is not possible, the inocu-

lated culture bottles should ideally be incubated at 37°C. The

solid media should be incubated in aerobic, microaerophilic,

and anaerobic environments.

The speed with which bacteriological diagnosis can be

established is very important. Concentration methods do not

TABLE 4

Differential Diagnosis of Cloudy Effluent

•Culture-positiveinfectiousperitonitis

•Infectiousperitonitiswithsterilecultures

•Chemicalperitonitis

•Calciumchannelblockers

•Eosinophiliaoftheeffluent

•Hemoperitoneum

•Malignancy(rare)

•Chylouseffluent(rare)

•Specimentakenfrom“dry”abdomen

This single copy is for your personal, non-commercial use only.

For permission to reprint multiple copies or to order presentation-ready

copies for distribution, contact Multimed Inc. at marketing@multi-med.com

by g

uest o

n A

pril 5

, 2018

http

://ww

w.p

dico

nnect.co

m/

Do

wnlo

aded

from

Perit Dial Int. 2016;36:481-508

Penyebab Infeksi Tersering pada

PD

1. Komplikasi kateter

kontaminasi saat pergantian cairan (penyebab

peritonitis terbanyak)

penyembuhan luka yang jelek pasca insersi

kateter

trauma

perawatan exit site yang tidak tepat

Penyebab Infeksi Tersering pada

PD

2. Konstipasi

3. Infeksi abdomen atau saluran genitouri atau

tindakan invasif

perpindahan bakteri kedalam kavum

abdomen/dialisat

4. Operasi gigi

bakteremia

5. Hipokalemia

konstipasi

perpindahan bakteri dari saluran cerna dialisat

PERITONITIS

Peritonitis sering terjadi dan penyebab kesakitan

yang bermakna

penyebab kematian pasien PD hingga 15%

penyebab utama membrane failure

Peritonitis dapat dicegah

1. training pasien

2. pencegahan kontaminasi

3. antibiotik profilaksis

4. menghindari konstipasi

Tatalaksana Awal Peritonitis

Perit Dial Int. 2016;36:481-508

Clinical evaluation.

Examine exit site and catheter and catheter tunnel.

Collect PD fluid for cell count, differential count, Gram stain, and

bacterial culture.

Start IP antibiotics as soon as possible

Allow to dwell for at least 6 hours

Empirical Gram-positive and Gram-negative coverage

based on patient history and center sensitivity patterns

Gram-positive coverage:

First-generation cephalosporin or

Vancomycin

Gram-negative coverage:

Third-generation cephalosporin or

Aminoglycoside

Consider adjuvant treatment: pain control, IP heparin, anti-fungal prophylaxis.

Education and assess IP injection technique.

Ensure follow-up arrangements.

Management algorithm for gram-positive cocci

identified in dialysis effluent

Perit Dial Int. 2016;36:481-508

492

LI et al. SEPTEMBER 2016 - VOL. 36, NO. 5 PDI

removal. Temporary use of icodextrin solution may prevent

fluid overload in PD patients with acute peritonitis (342).

Because of rapid glucose absorption, glycemic control may

worsen in diabetic patients. Blood glucose monitoring with

appropriate adjustments of insulin dosage may be needed.

Protein loss during peritonitis is also increased. Screening for

malnutrition should be undertaken in patients with prolonged

peritoneal inflammation.

SUBSEQUENT MANAGEMENT OF PERITONITIS

•Werecommendthatantibiotictherapybeadjustedto

narrow-spectrum agents, as appropriate, once culture

results and sensitivities are known. (1C) .

The management algorithms for gram-positive cocci and

gram-negative bacilli identified in dialysis effluent are sum-

marized in Figures 2 and 3, respectively. Within 48 hours of

initiating therapy, most patients with PD-related peritonitis

will show considerable clinical improvement. The effluent

should be visually inspected regularly to determine whether

clearing is occurring. If there is no improvement after 48

hours, cell counts and repeat cultures should be performed. In

addition, monitoring of WBC count in PD effluent may predict

treatment response. A retrospective study showed that dialysis

effluentWBCcount1,090/mm3 on day 3 was an independent

prognostic marker for treatment failure (343).

Refractory Peritonitis

•WerecommendthatthePDcatheterberemovedpromptlyin

refractory peritonitis episodes, defined as failure of the PD

effluent to clear up after 5 days of appropriate antibiotics

(1C) .

After initiation of antibiotic treatment, there is usually clini-

cal improvement in 72 hours. Refractory peritonitis is defined

as failure of the PD effluent to clear up after 5 days of appro-

priate antibiotics (Table 7). Catheter removal is indicated in

case of refractory peritonitis, or earlier if the patient ’s clinical

condition is deteriorating, in order to preserve the peritoneum

for future PD as well as preventing morbidity and mortality.

Prolonged attempts to treat refractory peritonitis by antibi-

otics without catheter removal are associated with extended

hospital stay, peritoneal membrane damage, increased risk of

fungal peritonitis, and excessive mortality (344).

Figure 2 — Management algorithm for gram-positive cocci identif ied in dialysis effluent.

Gram-positive cocci on culture

Assess clinical improvement, repeat dialysis efflu

e

nt cel l count and cul tur e at days 3- 5

Clinical improvement:continue antibiotics;

re-evaluate for occult exit-site or tunnel infection

coagulase-negative

staphylococci

treat for 14 days

Peritonitis resolves but persistentexit-site or tunnel infection

consider simultaneouscatheter removal and re-insertion

screen forS. aureus carrier;treat for 21 days

S. aureus Enterococci

treat for 21 days treat for 14 days

otherstreptococci

No clinical improvement:re-culture and evaluate

No clinical improvement by 5 days onappropriate antibiotics: remove catheter

Continue gram-positive coverage based on sensitivities.If enterococci, adjust coverage to vancomycin or other appropriate agents.

If methicillin resistant, adjust coverage to vancomycin or other appropriate agents.

This single copy is for your personal, non-commercial use only.

For permission to reprint multiple copies or to order presentation-ready

copies for distribution, contact Multimed Inc. at marketing@multi-med.com

by g

uest o

n A

pril 5

, 20

18

http

://ww

w.p

dico

nn

ect.com

/D

ow

nlo

aded

from

Management algorithm for gram-negative bacilli

or mixed bacterial growth

Perit Dial Int. 2016;36:481-508

493

PDI SEPTEMBER 2016 - VOL. 36, NO. 5 ISPD PERITONITIS RECOMMENDATIONS: 2016 UPDATE

Relapsing, Recurrent, and Repeat Peritonitis

•Werecommendthattimelycatheterremovalbeconsidered

for relapsing, recurrent, or repeat peritonitis episodes (1C) .

The definitions of relapsing, recurrent, and repeat perito-

nitis are summarized in Table 7. Retrospective studies showed

that relapsing, recurrent, and repeat peritonitis episodes are

caused by different species of bacteria and probably represent

distinct clinical entities (166,345–347). When compared to

non-relapsing episodes, relapsing ones are associated with a

lower rate of cure, more ultrafiltration problems, and higher

rate of technique failure (166,348). Recurrent peritonitis epi-

sodes had a worse prognosis than relapsing ones (166,345).

A recent study suggested that bacterial DNA fragment levels

in PD effluent are significantly higher 5 days before and on

the date of completion of antibiotics amongst patients who

subsequently develop relapsing or recurrent peritonitis (349).

Another study suggests that effluent white cell count and leu-

kocyte strip test at the time of stopping antibiotics may also

predict relapse (350). However, further studies are needed to

validate these results and confirm their clinical utility.

Coagulase-Negative Staphylococcus

•Wesuggestthatcoagulase-negativestaphylococcigenerally

be treated with IP cephalosporins or vancomycin, accord-

ing to antimicrobial susceptibility, for a period of 2 weeks.

(2C) .

Coagulase-negative Staphylococcus peritonitis episodes,

especially those caused by S. epidermidis, are mostly due

to touch contamination. Many patients with S. epidermidis

peritonitis have mild clinical symptoms and respond well to

treatment as outpat ients (351–353). In some centers,

the prevalence of methicillin resistance is now very high

(354,355), and vancomycin may have to be considered as

empirical therapy. Even for methicillin-sensit ive strains,

it is important to avoid inadequate IP antibiotic levels,

which may lead to relapsing peritonitis. For this reason,

continuous dosing of IP f irst-generation cephalosporins is

preferable to intermittent dosing. Effective antibiotic treat-

ment for 2 weeks is generally suf f icient (351–354). The

patient ’s exchange technique should be reviewed to prevent

another episode.

Figure 3 — Management algorithm for gram-negative bacilli or mixed bacterial growth identif ied in dialysis effluent.

* Trimethoprim/ sulfamethoxazole is preferred for Stenotrophomonas species.

Gram-negative bacilli or mixed bacterial growth on culture

Continue gram-negative coverage based on sensitivities.Consider switching to 3rd or 4th generation cephalosporine.

Assess clinical improvement, repeat dialysis efflu

e

nt cel l count and cul tur e at days 3- 5

Clinical improvement:continue antibiotics

Pseudomonas orStenotrophomonas

species

give 2 effective antibioticsbased on sensitivity*;

re-evaluate exit site and tunnel

treat for 21-28 days

Peritonitis resolves but persistentexit-site or tunnel infection

consider simultaneouscatheter removal and re-insertion

treat for 21 days treat for 21 days

other gram-negative bacilli

No clinical improvement:re-culture and evaluate

No clinical improvement by 5 days onappropriate antibiotics: remove catheter

mixed gram-negative or gram-negative + gram-positive organisms

consider surgical problem;in addition to gram-negative

coverage, consider metronidazoleand ampicillin/vancomycin

This single copy is for your personal, non-commercial use only.

For permission to reprint multiple copies or to order presentation-ready

copies for distribution, contact Multimed Inc. at marketing@multi-med.com

by g

uest o

n A

pril 5

, 201

8http

://ww

w.p

dico

nnect.co

m/

Dow

nlo

aded

from

Indikasi Pencabutan Kateter

497

PDI SEPTEMBER 2016 - VOL. 36, NO. 5 ISPD PERITONITIS RECOMMENDATIONS: 2016 UPDATE

The treatment protocol should be based on general proto-

cols for treatment of tuberculosis but is often started with 4

drugs: rifampicin, isoniazid, pyrazinamide, and ofloxacin. A

previous study showed that rifampicin levels in PD effluent are

often low (407). Intraperitoneal rifampicin treatment has been

advocated but is not available in many countries. In general,

pyrazinamide and ofloxacin could be stopped after 2 months,

while rifampicin and isoniazid should be continued for a total

of 12 to 18 months (407–413). Pyridoxine (50 to 100 mg/ day)

should be given to avoid isoniazid-induced neurotoxicity. On

the other hand, long-term use of pyridoxine at a higher dose

(e.g. 200 mg daily) is in itself associated with neuropathy and

should be avoided. Streptomycin, even in reduced doses, may

cause ototoxicity after prolonged use and should be avoided.

Ethambutol is associated with a high risk of optic neuritis

in dialysis patients and must be used with appropriate dos-

age reduction. Previous reports suggest a dose of 15 mg/ kg

every 48 hours or thrice weekly for up to 2 months (414). The

optimal treatment for drug-resistant tuberculous peritonitis

remainsunknown.

Many patients respond to anti-tuberculous therapy without

catheter removal (407–413,415). However, it is important

to dif ferentiate patients with miliary tuberculosis, whose

peritonitis is part of the disseminated disease, from those

with isolated tuberculous peritonitis without extraperitoneal

infection, because the duration of anti-tuberculous therapy

is different.

Non-Tuberculous Mycobacterial Peritonitis

Data on peritonitis caused by non-tuberculous mycobacte-

ria are limited but may be increasing (21,416–422). It is not

uncommon for non-tuberculous mycobacteria to be misidenti-

fied as gram-positive diphtheroids. Over half of the isolates are

rapidly growing species, such as M. fortuitum and M. chelonae

(420), and often become positive on routine bacteriologic

cultures in 3 to 5 days. It has been postulated that extensive

use of topical gentamicin ointment for exit-site infection

may predispose patients to non-tuberculous mycobacterial

infection of the exit site (144). The treatment regimen for non-

tuberculous mycobacterial peritonitis is not well established

and requires individualized protocols based on susceptibility

testing. Catheter removal is usually necessary, and experience

with non-removal is limited (420–422). The type and duration

of antibiotic therapy are variable, and the optimal treatment

regimen is poorly defined and depends on species and drug

susceptibilities (416–422).

Catheter Removal and Re-Insertion

•WerecommendthatPDcathetersberemovedforrefractory,

relapsing, or fungal peritonitis unless there are clinical

contraindications (1C) .

•WesuggestthatitisappropriatetoconsiderreturntoPD

for many patients who have had their catheter removed for

refractory, relapsing, or fungal peritonitis (2C).

•Wesuggestthatifre-insertionofanewcatheterisattempt-

ed after a PD catheter is removed for refractory, relapsing,

or fungal peritonitis, it be performed at least 2 weeks after

catheter removal and complete resolution of peritoneal

symptoms (2D) .

Indications for catheter removal are summarized in Table 8.

For refractory peritonitis and fungal peritonitis, simultaneous

re-insertion of a new PD catheter is not recommended, and

patients should be put on temporary hemodialysis. Observa-

tional studies suggest that effective antibiotics should be

continued for at least 2 weeks after catheter removal for

refractory peritonitis (423,424).

After severe episodes of peritonitis, around 50% of patients

could potentially return to PD (423–425). An ANZDATA Registry

study demonstrated that return to PD after catheter removal

and temporary hemodialysis for peritonitis was not associated

with inferior patient-level clinical outcomes when compared

with other patients who either never required hemodialysis

transfer for peritonitis or who had permanent hemodialysis

transfer for peritonitis (426). Furthermore, subsequent peri-

tonitis-free, technique and patient survival following return

to PD were not associated with organism type or duration of

time from hemodialysis transfer to PD restart (426). There are

few data on the optimal duration between catheter removal for

peritonitis and re-insertion of a new catheter. Observational

studies suggest a minimum period of 2 to 3 weeks (423–425),

although some would recommend later re-insertion in cases

of fungal peritonitis (397,398). Re-insertion of a new catheter

should be done by laparoscopic or mini-laparotomy approach

so that adhesion can be directly visualized. Ultrafiltration

problems are common after return to PD (423,424). A small

proportion of patients with PD-related peritonitis develop

recurrent intra-abdominal collection that requires percuta-

neous drainage after catheter removal (427). The chance of

a successful return to PD is very low in this group of patients,

and direct conversion to long-term hemodialysis should be

considered (427).

FUTURE RESEARCH

There are some new antibiotics that, to the best of our

knowledge, have not been tried for the treatment of PD-related

peritonitis. For example, ceftaroline has good coverage of

TABLE 8

Indications for Catheter Removal

•Refractoryperitonitis

•Relapsingperitonitis

•Refractoryexit-siteandtunnelinfection

•Fungalperitonitis

•Catheterremovalmayalsobeconsideredfor

– repeat peritonitis

– mycobacterial peritonitis

– multiple enteric organisms

This single copy is for your personal, non-commercial use only.

For permission to reprint multiple copies or to order presentation-ready

copies for distribution, contact Multimed Inc. at marketing@multi-med.com

by

gu

est on

April 5

, 20

18

http

://ww

w.p

dico

nnect.co

m/

Do

wnlo

aded

from

Perit Dial Int. 2016;36:481-508

Kesimpulan

Peritonitis merupakan komplikasi infeksi

terbanyak pada PD dengan angka kematian

yang cukup tinggi.

Penyebab terbanyak peritonitis adalah

kontaminasi saat pergantian cairan dan

konstipasi.

Peritonitis dapat dicegah

Tatalaksana peritonitis sedini mungkin dengan

AB intraperitoneal dan selanjutnya sesuai hasil

kultur menentukan survival PD.

KOMPLIKASI NON INFEKSI

KASUS – GANGGUAN OUTFLOW

Laki-laki 54 tahun, dalam selama CAPD 3 tahun.

Keluhan: BB dan lingkar perut bertambah sjk 3 hari

yl.

Pasien memakai dianeal 2,5% 3x dan 1,5% 1x,

namun UF masih jelek dan waktu drain sangat

lama.

Cairan jernih.

Inflow lancar, namun outflow sangat lama.

500 ml pertama sekitar 30 menit, kemudian aliran

berhenti.

Apa yang akan Anda Lakukan?

A. Memiringkan pasien ke satu sisi dan

sebaliknya untuk melihat apakah outflow

membaik.

B. Bilas kateter dengan heparin

C. Transfer ke HD – PD dianggap gagal.

D. Berikan laksatif

1. KONSTIPASI

adalah penyebab

gangguan outflow

tersering

2. MIGRASI TIP KATETER

Migrasi Kateter

Diagnosis awal dengan foto polos

abdomen.

Jika kateter keluar dari pelvis:

trochar radiologi atau laparoskopi untuk

menarik kateter ke dalam pelvis.

reposisi laparoskopi.

Kembali ke kasus….

inflow tidak ada masalah outflow

lambat

dialisat jernih

BNO: tidak ada konstipasi dan kateter tidak

bermigrasi keatas.

langkah selanjutnya?

Kasus…...

Perawat mencoba flush kateter dengan

spuit.

Flush lancar namun sulit diaspirasi

Apa yang akan Anda lakukan

selanjutnya?

A. memberikan lagi urus-urus

B. flush dengan larutan NS-heparin

C. memberikan 1-2 L dialisat

D. injeksi tPA IP

E. transfer ke HD

3. SUMBATAN FIBRIN

Kembali lagi ke kasus…...

inflow tidak ada masalah, outflow lambat,

cairan jernih

BNO: tidak ada konstipasi, tidak ada migrasi

kateter

Ns sudah flush kateter dengan spuit, flush lancar

namun aspirasi susah

Fibrin negatif

langkah selanjutnya?

4. OMENTAL WRAP

Lebih banyak terjadi pada:

anak-anak

jika posisi tip kateter diluar pelvis

biasanya inflow baik namun outflow jelek

dapat dicegah dengan omentopeksi pada anak

dan orang dengan omentum yang ‘berlebih’

Perlu tindakan bedah:

omentektomi dengan/atau tanpa penggantian

kateter PD

Diagnosis Banding Gangguan

Outflow

konstipasi

migrasi tip kateter

sumbatan fibrin

adhesi/perlengketan

omental wrap

Lainnya….....???

Diagnosis Banding Gangguan

Outflow

1. konstipasi

2. migrasi tip kateter

3. adhesi/perlengketan

4. omental wrap

5. fibrin, klot, obstruksi eksternal (frangible,

transfer set)

6. bocor

PENINGKATAN TEKANAN INTRA-

ABDOMINAL

Hernia

Kebocoran perikateter, abdomen dan

genital

Hidrothoraks

Tn. C mengeluh ada benjolan

sejak 1 minggu

Laki-laki, 48 tahun dengan CKD stage 5 e.c DKD,

dalam CAPD (4x penggantian, 1.5% 3x dan 2.5% 1x,

@2L)

Satu tahun kemudian: baik

RRF 8 ml/menit

Saat kontrol, mengeluh benjolan muncul di ingunal

kiri.

Pemeriksaan Fisik Tn.C

Peningkatan Tekanan Intra-

Abdomen (TIAb)

Adanya dialisat didalam kavum peritoneum

akan meningkatkan TIAb

Peningkatan ini tergantung dari:

Volume dialisat yang masuk

Posisi pasien (duduk > berdiri > tidur)

Usia, indeks massa tubuh

Batuk, mengangkat beban, mengedan

Hernia Lainnya: Hernia Ventralis

Hernia Umbilicalis

Tatalaksana:

Inspeksi dan evaluasi perkiraan lokasi hernia

Konsultasi bedah:

Tidak selalu harus di-repair, namun cenderung

membesar, menyebabkan kebocoran dialisat

Risiko inkarserasi usus, peritonitis

Evaluasi kaitan dengan postur, aktivitas dan

cairan dialisat

Bisa dilakukan modifikasi PD (NIPD atau PD volume

kecil)

HERNIA

HERNIA

Tatalaksana:

Edukasi pasien tentang tanda-tanda inkarserasi

Repair bedah:

Dialisis perioperatif sangat tergantung dari fungsi

ginjal dan kondisi pasien

Tidak selalu harus transfer ke HD

Mulai kembali PD dengan volume kecil, posisi tidur,

tingkatkan volume setelah 2 minggu

Sesak Nafas yang Memberat

pada Pasien PD

Ny. S, 53 tahun dengan CKD stage 5 e.c DKD,

telah dilakukan insersi kateter PD.

1 minggu setelah inisiasi PD, pasien

menghubungi suster PD karena keluhan sesak

nafas yang memberat sejak 3 hari.

Tidak ada batuk/mengi/dahak.

Ada penambahan BB 1 kg dari target BBK.

Ny. S, 53 tahun

HIDROTHORAKS

Definisi: ditemukannya cairan dialisat didalam

kavum pleura.

Insiden: sekitar <5%

Patogenesis: perpindahan dialisat, akibat

peningkatan TIAb, dari peritoneum ke dalam

kavum pleura melalui defek diafragma yang

kongenital ataupun didapat

HIDROTHORAKS

Gejala/Tanda:

Dapat asimptomatik

Sesak nafas

Tidak membaik dengan dialisat konsentrasi

tinggi

UF <<

Efusi pleura kanan pada rontgen thoraks

PKD

HiDROTHORAKS

Diagnosis:

Thorakosentesis untuk mengurangi

simtom dan/atau untuk diagnostik

Analisis cairan pleura:

Transudat

Kadar glukosa tinggi (umumnya, namun

tidak selalu – icodextrin iodine: blue-

black)

Hitung sel bervariasi

HIDROTHORAKS

Diagnosis

Pemeriksaan radionuclide atau radiocontrast

Melihat pergerakan cairan dari peritoneum kedalam

rongga thoraks

Technetium-99m tagged macro-aggregated

albumin atau Tc-99 sulfur colloid

Methylene blue dye kedalam dialisat diikuti

thorakosentesis tidak dianjurkan!

Visualisasi langsung dengan thorakoskopi

(VATS)

HIDROTHORAKS

Tatalaksana:

Thorakosentesis jika diperlukan (pasien

mengeluh sangat sesak)

Stop PD

Hemodialisis sementara

Mesothelium dapat memperbaiki dirinya sendiri

dan menutup defek yang ada hanya dengan

mengistirahatkan PD (2-6 minggu)

HIDROTHORAKS

Tatalaksana:

Coba mulai PD dengan volume kecil (glukosa dialisat

dalam kavum pleura dapat berfungsi sebagai agen

sklerosis)

Monitor ketat tanda uremia!

Pleurodesis (talc, tetrasiklin, bleomisin, darah

autologus)

Repair operasi atau pleuroskopik (defek diafragma

diidentifikasi dan diberikan patch atau dijahit)

50% pasien berhasil direpair dan melanjutkan PD

Nn. T, 26 tahun dengan dialisat

kemerahan

HEMOPERITONEUM

Definisi:

Darah pada cairan dialisat

Gejala/Tanda:

Menakutkan!

Pikirkan penyebab “jinak” dan “serius”

HEMOPERITONEUM

Penyebab “jinak”:

Menstruasi

Ovulasi

Ruptur kista ginjal atau ovarium

Trauma

Koagulopati

HEMOPERITONEUM

Penyebab “serius”:

Iskemia usus

Kanker kolon

Pankreatitis

Encapsulating peritoneal sclerosis

Kanker saluran kemih

HEMOPERITONEUM

Tatalaksana:

Heparin IP untuk mencegah clotting pada

kateter

Bilas

Dialisat dijaga agar dalam suhu ruang

Evaluasi tergantung apakah gejala/tanda

mengarah ke tiper jinak/serius

**saat training, edukasi pasien perempuan untuk

kemungkinan komplikasi ini

Kesimpulan

Komplikasi non infeksi yang sering terjadi:

1. Gangguan outflow: konstipasi; migrasi tip

kateter; adhesi/perlengketan; omental wrap;

fibrin, klot, obstruksi eksternal (frangible,

transfer set); dan bocor.

2. Peningkatan tekanan intra abdomen: hernia;

kebocoran perikateter, abdomen dan genital;

hidrothoraks.

3. Hemoperitoneum