|
Complications of peritoneal dialysis
Contents:
List of
complications
[see other
common complications]
Infection : -Exit site
-Tunnel
Cuff extrusion
Malposition
Pain
Bleeding
Catheter obstruction
Visceral Perforation
Dialysate leak:-Pericathter
-Pleural
-Abdominal wall
-Genitalia
-Vaginal
Hernias :-Incisional
-Ventral
-Periumblical
-Catheter tract
-Inguinal
Back pain
Hypotension
Peripheral vascular insufficiency
Nutritional
- Hypoalbuminemia
-Obesity
-Hyperlipidemia
Peritoneal dialysate eosinophilia
Loss of peritoneal ultrafiltration or transport capacity
Top
Peritonitis
Peritonitis
is the most aggressive complication of chronic peritoneal dialysis, which
becomes the limiting factor in the success of this technique for many patients
POTENTIAL SOURCES OF PERITONITIS
EXOGENOUS
-
Primary connection site
-
Injection site for medication
-
The transfer set-catheter connection contamination
-
Poor hand washing
-
Defective tubing
-
Disconnection of dialysate circuit.
-
Exit and tunnel infection.
-
Frequent use of antibiotic predispose to fugal peritonitis
-
Others e.g. diarrhea, URTI, Contaminated hands
ENDOGENOUS
1-Acute visceral inflammation e.g. Appendicitis, Diverticulitis, Cholecystitis,
or Perforated bowel
.2-Septicemia
3-Bacteria residing female genital tract.
DIAGNOSTIC FEATURES OF PERITONITIS
-
Abdominal pain and bowel symptoms in 80% of
cases
-
Cloudy outflow
-
Fever (50%
-
Nausea (30%)
-
Diarrhea (7-10%)
-
Poor drainage
-
Loss of
ultrafiafiltration
-
Peritoneal fluid white blood cells count >
100/ml with >50 % polymorphonuclear leukocytes.
-
Gram stain positive for organism ~50% of time.
-
Culture positive in 95 % of cases.
·
Gram-positive pathogens:
65--75 %
Staphylococcus
epidermidis
Staphylococcus aurous
Streptococcus species
·
Gram-negative pathogens:
25--30 %
Enterobacteriaceae ( proteus, E Coli,
Klebsiella Enterobacter sp.)
Acinetobacter sp.
Pseudomonas sp.
·
Other pathogens
<5 %
Fungal
----Nocardia -------Asppergillus----Actinomycosis
TB & nonTB mycobacterium
·
Culture negative
: 5 %
Complications of peritonitis:
-
Catheter removal
-
Loss of ultrafiltration
-
Deterioration
of nutritional status
-
Ileus
-
Adhesions of peritoneal membrane.
-
Fungal peritonitis
-
Death
Prevention of peritonitis
-
Careful selection of patients
-
Adequate patient education and training
-
Treatment of constipation
-
Avoid exogenous sources of peritonitis
-
Treatment of staphylococcus aurous nasal
carriers.
-
Avoid unnecessary use of antibiotic.
Initial
Clinical Evaluation of Patient with Suspected Peritoneal Dialysis-Related
Peritonitis
- Symptoms: cloudy fluid and
abdominal pain
- Do cell count and
differential
- Gram stain and culture on
initial drainage
- Initiate empiric therapy
- Choice of final therapy
should always be guided by antibiotic sensitivities
Antibiotic therapy
ISPD
Guidelines/Recommendations
ADULT PERITONEAL
DIALYSIS-RELATED PERITONITIS TREATMENT RECOMMENDATIONS: 2000 Update
|
|
Residual urine output |
|
Antibiotic |
< 100
mL/day |
> 100
mL/day |
|
Cefazolin or cephalothin |
1 g/bag,
q.d. |
20 mg/kg
BW/bag, q.d. |
|
|
or |
|
|
|
15 mg/kg
BW/bag, q.d. |
|
|
Ceftazidime |
1 g/bag,
q.d. |
20 mg/kg
BW/bag, q.d. |
|
Gentamicin, tobramycin, netilmycin |
0.6 mg/kg
BW/bag, q.d. |
Not
recommended |
|
Amikacin |
2 mg/kg
BW/bag, q.d. |
Not
recommended |
q.d.
= once/day; BW = body weight
|
Top
|
|
CAPD intermittent dosing (once/day) |
CAPD continuous dosing (per liter exchange) |
|
Drug |
Anuric |
Non anuric |
Anuric |
Nonanuric |
|
Aminoglycosides |
|
|
|
|
|
Amikacin |
2 mg/kg |
Increase all |
MD 24 mg |
Increase all
MD by 25%
|
|
Gentamicin |
0.6 mg/kg |
doses by 25% |
MD 8 mg |
|
Netilmicin |
0.6 mg/kg |
|
MD 8 mg
|
|
Tobramycin |
0.6 mg/kg |
|
MD 8 mg
|
|
Cephalosporins |
|
|
|
All LD same
as anuric |
|
Cefazolin |
15 mg/kg |
20 mg/kg |
LD 500 mg, MD
125 mg |
MD increase
by 25% |
|
Cephalothin |
15 mg/kg |
ND |
LD 500 mg, MD
125 mg |
MD, ND
|
|
Cephradine |
15 mg/kg |
ND |
LD 500 mg, MD
125 mg |
MD, ND
|
|
Cephalexin |
500 mg p.o.,
q.i.d. |
ND |
As
intermittent |
MD, ND
|
|
Cefuroxime |
400 mg
p.o./IV, q.d. |
ND |
LD 200 mg, MD
100_200 mg |
MD, ND
|
|
Ceftazidime |
1000_1500 mg |
ND |
LD 250 mg, MD
125 mg |
MD, ND
|
|
Ceftizoxime |
1000 mg |
ND |
LD 250 mg, MD
125 mg |
MD, ND
|
|
Penicillins |
|
|
|
All LD same
as anuric |
|
Piperacillin |
4000 mg IV,
b.i.d. |
ND |
LD 4 g IV, MD
250 mg |
MD, ND
|
|
Ampicillin |
250_500 mg
p.o., b.i.d. |
ND |
MD 125 or
250_500 mg p.o., b.i.d. |
MD, ND
|
|
Dicloxacillin |
250_500 mg
p.o., q.i.d. |
ND |
250_500 mg
p.o., q.i.d. |
MD, ND
|
|
Oxacillin |
ND |
ND |
MD 125 mg |
MD, ND
|
|
Nafcillin |
ND |
No change |
MD 125 mg |
MD, no change
|
|
Amoxicillin |
ND |
ND |
LD 250_500
mg, MD 50 mg |
MD, ND
|
|
Penicillin G |
ND |
ND |
LD 50 000
U, MD 25 000 U |
MD, ND
|
|
Quinolones |
|
|
|
|
|
Ciprofloxacin |
500 mg p.o.,
b.i.d. |
ND |
LD 50 mg, MD
25 mg |
ND
|
|
Ofloxacin |
400 mg p.o.,
then 200 mg p.o., q.d. |
ND |
As
intermittent |
ND
|
|
Others |
|
|
|
|
|
Vancomycin |
15_30 mg/kg
q.5_7 d |
Increase
doses by 25% |
MD 30_50 mg/L |
Increase MD
by 25% |
|
Teicoplanin |
400 mg IP,
b.i.d. |
ND |
LD 400 mg, MD
40 mgb |
ND
|
|
Aztreonam |
ND |
ND |
LD 1000 mg,
MD 250 mg |
ND
|
|
Clindamycin |
ND |
ND |
LD 300 mg, MD
150 mg |
ND
|
|
Metronidazole |
250 mg p.o.,
b.i.d. |
ND |
As
intermittent |
ND
|
|
Rifampin |
300 mg p.o.,
b.i.d. |
ND |
As
intermittent |
ND
|
|
Antifungals |
|
|
|
All LD same
as anuric |
|
Amphotericin |
NA |
NA |
MD 1.5 mg |
NA
|
|
Flucytosine |
2 g LD, then
1 g q.d., p.o. |
ND |
As
intermittent |
ND
|
|
Fluconazole |
200 mg q.d. |
ND |
As
intermittent |
ND
|
|
Itraconazole |
100 mg q.12
hr |
100 mg q.12
hr |
100 mg q.12
hr |
100 mg q.12
hr |
|
Antituberculus |
Isoniazid 300
mg p.o., q.d. |
ND |
As
intermittent |
ND
|
|
|
+ rifampin
600 mg p.o., q.d. |
|
|
|
|
|
+
pyrazinamide 1.5 g p.o., q.d. |
|
|
|
|
|
+ pyridoxine
100 mg/d |
|
|
|
|
Combinations |
|
|
|
All LD same
as anuric |
|
Ampicillin/sulbactam |
2 g q.12 hr |
ND |
LD 1000 mg,
MD 100 mg |
ND
|
|
Trimeth/sulfamethox |
320/1600 mg
p.o., q.1_2 days |
ND |
LD 320/1600
mg p.o., MD 80/400 mg p.o. |
ND
|
MD = maintenance dose; LD =
loading dose; ND = no data; p.o. = oral; q.i.d. = four times per day; IV =
intravenous; q.d. = once per day; b.i.d. = twice per day; IP =
intraperitoneally; NA = not applicable.
CAPD patients with residual
renal function may require increased doses or more frequent dosing,
especially when using intermittent regimens. For penicillins: "No change" is
for those predominantly hepatically metabolized, or hepatically metabolized
and renally excreted; "ND" means no data, but these are predominantly
renally excreted, therefore probably an increase in dose by 25% is
warranted; "NA" = not applicable, that is, drug is extensively metabolized
and therefore there should be no difference in dosing between anuric and
nonanuric patients. Anuric = <100 mL urine/24 hours; nonanuric = >100 mL/24
hours. These data for CAPD only. |
a
The route of administration is IP unless otherwise specified. The
pharmacokinetic data and proposed dosage regimens presented here are based
on published literature reviewed through January 2000, or established
clinical practice. There is no evidence that mixing different antibiotics in
dialysis fluid (except for aminoglycosides and penicillins) is deleterious
to the drugs or patients. Do not use the same syringe to mix antibiotics.
|
b
This is in each bag × 7 days, then in 2 bags/day × 7 days, and then in
1 bag/day × 7 days.
|
Top
|
Enterococcus |
Staphylococcus aureus |
Other gram-positive organism
(Coagulase-negative staphylococcus)
|
|
At 24 to 48
hours |
|
Stop cephalosporins |
Stop
ceftazidime or aminoglycoside |
Stop
ceftazidime or aminoglycoside |
|
Start ampicillin 125 mg/L/bag |
Continue
cephalosporin |
Continue
cephalosporin |
|
Consider adding aminoglycoside |
Add
rifampin 600 mg/day, oral |
|
|
If ampicillin-resistant, start |
If MRSA,
start vancomycin |
If MRSE and
clinically not |
|
vancomycin or clindamycin |
or
clindamycin |
responding,
start vancomycin |
|
If VRE, consider quinupristin/dalfopristin |
|
or
clindamycin |
|
Duration of therapy |
|
14 days |
21 days |
14 days
|
|
At 96 hours |
|
If no improvement, reculture and evaluate for exit-site or
tunnel infection, catheter colonization, etc. |
|
Choice of final therapy should always be guided by
antibiotic sensitivities. |
VRE = vancomycin-resistant
enterococcus; MRSA = methicillin-resistant S. aureus; MRSE =
methicillin-resistant enterococcus.
|
Top
|
Single
gram-negative organism
|
Adjust
antibiotics to sensitivity |
14 days
|
|
< 100 mL urine, aminoglycoside |
|
> 100 mL urine, ceftazidime |
|
Pseudomonas/stenotrophomonas
|
Continue
ceftazidime and add |
21 days
|
|
< 100 mL urine, aminoglycoside (see Empiric Therapy,
Table 2) |
|
> 100 mL urine, ciprofloxacin 500 mg, p.o. b.i.d. |
|
or piperacillin 4 g IV q.12 hours |
|
or sulfamethoxazole/trimethoprim 1_2 DS/day |
|
or aztreonam load 1 g/L; maintenance dose 250 mg/L IP/bag |
|
Multiple
gram-negatives and/or anaerobes
|
Continue
cefazolin and ceftazidime and add |
21 days
|
|
metronidazole, 500 mg q.8 hours, p.o., IV, or rectally |
|
If no
change in clinical status, consider surgical intervention |
IV = intravenously; DS =
double strength; IP = intraperitoneally.
|
Top
|
Continue initial therapy
If clinical improvement
|
|
Duration of
therapy |
|
Discontinue
ceftazidime or aminoglycoside
Continue
cephalosporin |
14 days
|
|
If no clinical improvement at 96 hours |
Repeat cell
count, Gram stain, and culture |
|
|
If culture positive, adjust therapy accordingly |
14 days
|
|
If culture negative, continue antibiotics, consider
infrequent pathogens and/or catheter removal |
14 days
|
Top
|
At 24 to 48 hours
|
|
Flucytosine
and
Fluconazole |
Loading
dose 2 g p.o.; maintenance dose 1 g p.o. |
|
|
|
200 mg,
p.o., or intraperitoneally, daily |
|
If organism is resistant, consider itraconozole
|
|
At 4 to 7 days |
|
If clinical improvement, duration of therapy 4_6 weeks
|
|
If no clinical improvement, remove catheter and continue
therapy for 7 days after catheter removal |
Relapsing peritonitis
ISPD
Guidelines/Recommendations
ADULT PERITONEAL
DIALYSIS-RELATED PERITONITIS TREATMENT RECOMMENDATIONS: 2000 Update
Definition
Relapsing peritonitis is defined
arbitrarily as another episode of peritonitis caused by the same genus/species
that caused the immediately preceding episode and occurs within 4 weeks of
completion of the antibiotic course.
Presentation
Clinically,
these patients will have signs and symptoms similar to those described in
patients with sporadic peritonitis.
Treatment
In the presence of coagulase-positive
staphylococcus infection, a search for an occult tunnel infection should
be made.
Coagulase-positive or
-negative staphylococci should be treated with cephalosporins and rifampin
for approximately 4 weeks.
MRSA or S. epidermidis,
clindamycin or vancomycin should be considered for therapy
If enterococci are recultured,
ampicillin and an aminoglycoside should be used in the recommended doses.
Consideration should also be given to the possibility of an intra-abdominal
abscess.
If no clinical response is
noted after 96 hours of therapy for relapsing peritonitis, catheter removal is
indicated. If the patient responds clinically, but subsequently relapses
an additional time, catheter removal and replacement are recommended.
In relapsing peritonitis caused
by gram-negative organisms, one should evaluate clinically for an
intra-abdominal abscess. Catheter removal and surgical exploration should be
strongly considered in these patients. Treatment with ceftazidime or an
aminoglycoside alone can be used once culture results are known. If pseudomonas
or stenotrophomonas organisms are identified again on culture, the catheter
should be removed. Finally, in those patients with relapsing peritonitis,
short-term interruption of PD may be of value; however, the availability of
supportive hemodialysis will dictate whether this option can be considered.
Reference:
ISPD
Guidelines/Recommendations
ADULT PERITONEAL
DIALYSIS-RELATED PERITONITIS TREATMENT RECOMMENDATIONS: 2000 Update
William F. Keane,1 George R.
Bailie,2 Elizabeth Boeschoten,3 Ram Gokal,4
Thomas A. Golper,5 Clifford J. Holmes,6 Yoshindo
Kawaguchi,7 Beth Piraino,8 Miguel Riella,9
Stephen Vas10
Department of
Medicine,1 Hennepin County Medical Center, University of Minnesota
Medical School, Minneapolis, Minnesota; Albany College of Pharmacy,2
Albany, New York, U.S.A.; Department of Peritoneal Dialysis,3
Academic Medical Center, Amsterdam, The Netherlands; Manchester Royal Infirmary,4
Manchester, United Kingdom; Vanderbilt University Medical Center,5
Nashville, Tennessee; Baxter Healthcare Corporation,6 McGaw Park,
Illinois, U.S.A.; Renal Division,7 Jikeikai University, School of
Medicine, Tokyo, Japan; University of Pittsburgh Medical Center,8
Pittsburgh, Pennsylvania, U.S.A.; Renal Division,9 Department of
Medicine, Evangelic School of Medicine, Curitiba Parana, Brazil; University of
Toronto,10 Toronto Hospital, Toronto, Ontario, Canada
Top
Tunnel infection
Peritonitis that fails to response to
appropriate antibiotic therapy
Mycobacterium
peritonitis
Fungal peritonitis
Fecal
peritonitis
Top
Flow chart for diagnosis and
management of exit-site infections is shown
|
Symptom |
Possible Cause
|
Treatment |
|
Pain on inflow
|
Low dialysate pH
Catheter tip irritation |
Add bicarbonate to dialysate
Observation |
|
Pain during dwell
|
Over distention of the abdomen |
Longer drain time
Decrease exchange volume |
|
Pain following dialysis
|
Peritonitis
Free abdominal air |
Antibiotic
Recumbent position
None |
|
Constant pain |
|
|
|
Diffuse |
Peritonitis
Abdominal
pathology |
Antibiotic
Diagnosis
and treatment |
|
Pelvic area |
Perineal, rectal, bladder irritation by
catheter tip |
Observation; consider catheter replacement |
|
Shoulder pain |
Air under diaphragm |
Recumbent position
None |
PERITONEAL
IRRITATION:
When, catheters are newly placed, some patient
experience pain in the perineum, rectum, or genitalia, which is probably due to
irritation by the catheters tip. Such pain is usually self-limited and
disappears within 1 week. In some patient, this persists continuously and
intensified when the peritoneal cavity is drained of fluid. In such cases the
catheter may be too long for the patient, causing continuous irritation by
pressing against pelvic structures. Late development of transvisceral erosion
may occur, necessitating at least a temporary interruption of chronic peritoneal
dialysis and catheters removal.
Top
Sites of dialysate leakage:
1-Pericatheter
2-Pleural
3-Abdominal wall
4-Genitalia
5-Vaginal
Pericatheter
Leak
Pericatheter is the most frequent
site of dialysate leak.Usualy occurs within the first two weeks of catheter
placement. Occasionally leakage will occur along catheter tract after months
suggesting:
1-Delayed
adherence of the catheter cuffs.
2-Traumatic
injury to the catheter, resulting in patency around the cuffs
·
Pericatheter
dialysate leak, frequently associated with :
1-Overdistension of the peritoneal cavity with fluid.
2-Increased
intraperitoneal pressure, e.g. in chronic cough and constipation
·
Leakage around a
patent internal catheter cuff will lead to dissection of the fluid into the
subcutaneous tissue. Patients are presenting as a bulge over the anterior or
lateral abdominal wall, edema, weight gain, and diminished outflow volume.
·
In general, it is
frequent in CAPD than in IPD or CCPD because of diminished intraperitoneal
pressure during recumbence. The risk is increased, if CAPD schedule is begun
soon after catheter insertion.
Management of Pericatheter
leak:
1-Prophylactic measures:
a-Use small exchange volume for several days to a week after Catheter placement to allow healing
of the tunnel
b-The use of hypertonic dialysate should
be minimized with new
catheters to reduce the volume of ultafiltrate
c-Instruct the patient (in CAPD) to
drain all the fluid completely at each exchange.
2-Temporarily discontinue peritoneal dialysis for 2-3 weeks and then cautiously
resume peritoneal dialysis.
3-Treat the predisposing factors; constipation, cough, and avoids hypertonic
dialysate on resuming dialysis
4-Catheter replacement.
5-Discontinue peritoneal dialysis and transfer the patient to hemodialysis on
permanent basis
Top
Mechanical dysfunction of peritoneal catheter is most frequently a one-way
outflow obstruction. It is detected when the drainage volume is less than
the inflow volume .It caused by catheter malposition , partial occlusion
by fibrin , catheter encasement by omentum ,-bowel- fibrous tissue and
loculation of peritoneal cavity ...etc.Patient with recurrent peritonitis,
particularly when it is not promptly diagnosed and treated ,may develop gradual
fibrosis around the catheter, which limits mechanical exchange of dialysate.
Typical causes and approaches to treatment are shown in the following table:
|
Problem |
Possible Causes |
Treatment |
|
Poor Dialysate Inflow |
Fibrin / Clot obstruction |
Flush the catheter
Add Heparin (500/l)
Urokinase/streptokinase |
|
Poor Catheter Position |
Laxatives, Reposition or Replace the
Catheter |
|
Kinked External Tubing |
Examine the tubing system
.and Correct |
|
Poor Dialysate Outflow |
Kinked External Tubing |
Examine the tubing
system .and Correct |
|
Malposition of the Catheter |
Laxatives-
Reposition or Replace the
Catheter |
|
Air in line |
Flush line |
|
Fibrin Obstruction |
Heparinized Saline
Urokinase-streptokinase |
|
Catheter Encasement by: Bowel- Omentum,
fibrous tissue |
Replace the Catheter Catheter Stripping,
Omentectomy |
|
Peritonitis
|
Treat Peritonitis |
Use of Thrombolytic Agents:
Urokinase:
1-Dilute 5000 IU in 40-50 ml of 0.9 % saline.
2-Inject the total volume into the peritoneal
catheter.
3-Clamp the catheter ,and wait for 2 hours,
then asses the drainage.
4-Repeat once if needed.
Streptokinase
1-Test for Allergy ;
a-Scratch the skin with
needle then place a drop o a 100 IU/ml over the scratch , and observe for 15
minutes.
b- If no wheal and flare
inject 0.1 ml of the same solution intradermally, if no wheal and flare appear, then
allergy is unlikely .
2--Dilute 750,000 IU in 40-50 ml of 0.9 %
saline
3-Inject the total volume into the peritoneal catheter.
4-Clamp the catheter ,and wait for 2 hours, then asses the drainage.
5-Repeat once if needed
Top
|
Complication |
Cause |
Diagnosis |
Intervention |
|
Fibrin Formation |
Formed in response to inflammation due to
decreased fibrinolysis of fibrinogen e.g. in peritonitis |
Whitish strands /clots seen in effluent or
catheter .It may lead to obstruction if not treated. |
Heparin added to dialysate to prevent fibrin
production and adhesion formation. Urokinase or Streptokinase is used in
severe cases |
|
Hemoperitonium |
Trauma, Menstruating women, Ovulation,
Ovarian cysts, Peritonitis, Post colonoscopy or enema, ? endometriosis. |
Blood effluent, 2 ml /L will result in
blood-tinged effluent, Hematocrit of 5%,indicative of major bleeding. |
In-and-out flushes with room temperature
dialysate (vasoconstriction); Addition of heparin to prevent obstruction. |
|
Air in Peritoneum |
Loose connections. Air in the system |
Shoulder pain; peritoneal eosinophilia |
Tighten the connections Drain the peritoneal
cavity in knee-chest position or trendelenburge. May need to resolve over
time. |
|
Hernias [in 5% of patients on CAPD] |
Increased intraabdominal pressure due to the
presence of dialysate in peritoneum, specially in patients with congenital
or acquired defects; previous abdominal surgeries. |
Swelling in inguinal, ventral incisional,
umbilical area, non painful, reducible.
Some cause intestinal obstruction. |
IPD,CCPD with minimal or no dwell; Decreased
exchange volume; Surgical repair |
|
Scrotal or [labial] edema [not uncommon] |
Inguinal hernia(66%) Dialysate leak from
catheter tracts(17%), Fluid retention due to high peritoneal membrane
permeability and UF failure (24%), Combined causes (7%) |
Scrotal swelling usually bilateral] ,penile
edema, weight gain, palpable hernia, poor dialysate outflow.
Exclude ultrafiltration failure PET]
CT with contrast, peritoneal scintigraphy |
Treat the cause. |
|
Pleural leak
[Hydrothorax] |
Congenital defect in the diaphragm
Excessive use of hypertonic dialysate
Develop within hours or days [may be delayed
up to several months] after initiating PD |
Shortness of breath, Decreased dialysate
outflow volume. Signs of right sided pleural effusion.
Pleural fluid have high glucose and low
protein. It can be documented by utilizing radionuclide imaging.
|
Avoid hypertonic dialysate
Stop peritoneal dialysis temporarily.
Change the patient to CCPD NIPD,or HD
schedule |
|
Backache |
Alteration of body posture resulting from
the presence of dialysate in the abdomen |
Low back pain , Common in CAPD
|
Using low volume exchange for day time,--
Change to CCPD schedule, |
|
Obesity |
Results from absorption of calories from
dialysate glucose [~ 600calories/day in CAPD]. |
Significant weight gain ,
20% increase of body weight after 5 years on
CAPD |
Restriction of the usage of hypertonic
dialysate. Diet education to reduce calories intake.
Use of dialysate containing nonglucose
osmotic agents |
|
Hyperlipidemia |
Absorption of glucose from dialysate. |
Hypertriglycridmia, Hypercholesterolemia;
HDL
Coronary artery disease |
Diet education, Exercise, Use of nonglucose
osmotic agents dialysate, Drugs (e.g. Lovastatin). |
|
Protein loss |
Proteins are lost through the dialysate. |
Protein loss =9-10 g/d with CAPD
12-15 g/d with IPD
Hypoproteinemia
Hypoalbuminemia - Compromised immunity |
Diet : 1.5 g/kg/day + total 35 kcal/kg/day |
|
Orthostatic hypotension |
Extracellular volume depletion due to
excessive ultrafiltration with inadequate dietary and volume intake
Hypoproteinemia
Autonomic insufficiency |
Symptomatic postural hypotension |
Increase salt and water intake.
Salt tablets 50-150 mEq/day.
Dialysis instruction. |
|
Peritoneal Dialysate Eosinophilia |
Unknown, Occurs in patient shortly after
dialysis |
Cloudy effluent, Elevated leukocyte
containing 40-95% eosinophils, low IgE, normal protein without evidence of
peritonitis |
Self limited
Careful monitoring to exclude bacterial
peritonitis |
|
Peritoneal Dialysis Failure :
|
Loss of ultrafiltration
due to
Acute and Recurrent Peritonitis
Extensive adhesion due abdominal surgery or
inflammatory process
Idiopathic (over several years) |
Increase the need for hypertonic sol
Fluid retention
Solute removal is intact [in type 1]
Solute removal is reduced [in type 2] |
Resting the membrane
Eliminating long dwell exchange
CAPD -do frequent exchanges
CCPD -additional exchanges
at day time
Reducing cycle time
Switch CAPD to
CCPD
CCPD
to NIPD |
|
|
Loculation of peritoneal cavity
Due to Fibrosis
Adhesions
From inflammation |
Sensation of distension.
Inability to tolerate previously used
dialysate volume.
Poor dialysate outflow
Poor catheter function |
Hemodialysis |
|
|
Peritoneal sclerosis
Unknown
Recurrent peritonitis in many cases
Chemical irritation
Disinfectant: e.g.chlorohexidine
Tubes and connections:
e.g.plasticizers |
Nausea, vomiting [Uremia]
Malabsorption [weight loss]
Abdominal pain
Abdominal mass or ascites
Bowel obstruction
Patient has thick firm grayish-white fibrous
tissue covering the viscera. |
Laxatives
Avoid barium administration [prevent bowel
obstruction]
Hemodialysis |
|
Catheter cuff Extrusion and Erosion |
Positioning of the distal cuff too
superficially or the tunnel is to short. Erosion is frequent in individuals
who are thin and lack of adequate fat tissue. |
Gradual extrusion of the distal cuff through
the catheter exit site |
Removal of the cuff to prevent retraction
with the catheter in place provided infection does not develop.
Catheter replacement. |
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