see also: [[haemodialysis]], [[Spontaneous Bacterial Peritonitis|SBP]] see: [Dunn Peritoneal dialysis](x-devonthink-item://54C85B3E-4419-4325-BA89-7484779CC8F6), [Tintinalli - peritoneal dialysis](x-devonthink-item://9B938A9E-3DC9-4EB2-80E1-2F7117F943E8?page=14&start=4833&length=19&search=PERITONEAL%20DIALYSIS) > **Key historical elements for peritoneal dialysis patients** > - cause of end-stage renal disease > - type of peritoneal dialysis (continuous ambulatory peritoneal dialysis vs. continuous cyclic peritoneal dialysis) > - PD parameters: concentration, number of exchanges/day > - recent complications > - baseline weight, lab values, vital signs > - symptoms of uraemia > - retention of native kidneys? > - still producing urine? > **Clinical exam in ED** > - abdo: inspect for hernia, auscultate bowel sounds, test for rebound tenderness > - peritoneal catheter: exam surrounding skin, palpation of tunnel ## Principles for dialysis and ultrafiltration to occur, need 3 main components: - access -- indwelling catheter long-term tunneled tube with fenestrated pigtailed end - blood flow -- supplied by mesenteric circulation - a diffusion membrane -- peritoneum, a thin membrane of mesothlilal cells - dialysate **Techniques** PD can be accomplished in an acute setting, over the long term via exchanges of solution throughout the day (*continuous ambulatory PD*), or through multiple exchanges at night while the patient sleeps (*continuous cyclic PD*). also *intermittent peritoneal dialysis* 3x/week for 10-12 hours overnight. *prescription* - dialysate concentration -- usually bicarb-buffered dextrose solution - exchange volume usually 2L - inflow time -- time to fill peritoneal cavity, usually 15-30 min - dwell time -- period for which exchange vol remains in peritoneal cavity. btwn 30-90 min - outflow time -- gravity dependent drainage of dialsate fluid - number of exchanges -- determined by effluent rate. the more effluent per day you want to remove (greater clearance), more exchanges you need. stable ESRD pt on PD will have 4-6 exchanges per day, total daily effluent 8-10 L ## potential indications for PD - children - severe cardiovascular instability - severely coagulopathic pts - difficult vascular access - existing ascites - some residual renal function ## benefits - anticoagulation not required - haemodynamically better tolerated - decreased risk of dialysis disequilibrium syndrome - pt can remain ambulant while intermittent PD in progress ## disadvantages - difficult catheter placement - shocked pts have poorer peritoneal flow, lower efficiency of dialysis via peritoneal membrane - required intact peritoneal cavity (not available ot pts with recent abdo surgery) - not a good choice where quick removal of solute or fluids required (eg hyper K or pulm oedema) - large vol PD can result in resp compromise by pushing on the diaphragm from below ## Complications **catheter-related** - haematoma in pericatheter tract - intra-abdominal bleeding - perforation of a viscous (CXR free gas may be just from PD; > 5mm suggests perforation) - dialysate leakage around the catheter - dissection of fluid into abdominal wall - obstruction of inflow / outflow - [[Spontaneous Bacterial Peritonitis]] **pulmonary** - pulmonary oedema (BNP always elevated in chronic renal failure so not helpful in determining acuity) - atelectasis - pleural effusion - pneumonia **metabolic** - protein loss / hypoalbuminaemia - hyperglycaemia - post-dialysis metabolic alkalosis **other** - hypotension - abdo and inguinal hernias ## Peritonitis from peritoneal dialysis - specimen (macroscopically cloudy), gram stain, and culture *causes* - staph epidermidis - S aureus - enterobacteria - pseudomonas **signs of non-peritoneal dialysis related peritonitis may all be absent:** - anorexia - nausea - fever - abdo pain **diagnosis** - peritoneal fluid WCC > 100/cm3 and > 50% polymorphs (lower threshold than SBP in cirrhosis ) - (note it is > 250 in non PD-related peritonitis) **Treatment** - intraperitoneal if systemically well - gent 0.6mg/kg up to 50 mg added to 1 bag of dialysis fluid per day - cefazolin 15mg/kg added to 1 bag of dialysis fluid per day - replace cef1 with vanc 15-40 mg/kg up to 2 g if MRSA - 14-21 days - intraperitoneal + IV if sepsis