Peritoneal Dialysis on Acute Kidney Injury.pptx

pejari indikasi peritonela dilaiis pada aki

1. Peritoneal Dialysis as Acute Kidney Injury Treatment Option based on ISPD Guidelines Astried Indrasari

2. ACUTE KIDNEY INJURY Smoyer WE et al. Kidney Int 2016; 89(2): 254–256.

3. AKI Treatment Vinsonneau et al.. Lancet 2006; 368: 379–385 Parapiboon W. Perit Dial Int 2020; 40(4): 359–362

4. Is PD a suitable modality for treating AKI? Peritoneal dialysis (PD) should be considered a suitable modality for treatment of acute kidney injury (AKI) in all settings (1B).

5. Metabolic control,   mortality rate  (58 and 53%), and renal function recovery (28 and 26%) were similar in both groups, whereas HVPD was associated with a significantly shorter time to the recovery of renal function.  The survival at 28 days was significantly better in the patients treated with TPD when compared to CVVHDF (69.8% vs. 46.8%,  P  < 0.01). Infectious complications were significantly less ( P  < 0.01) in the TPD group (9.5%) when compared to the CVVHDF group (17.7%). Recovery of kidney function (60.3% vs. 35.5%), median time to resolution of AKI and the median duration of ICU stay of 9 days (7–11) vs. 19 days (13–20) were all in favor of TPD ( P  < 0.01). This study suggests that there are better outcomes with TPD compared to CRRT in the treatment of critically ill patients with AKI.

6. There is currently no evidence to suggest significant differences in mortality between peritoneal dialysis and extracorporeal blood purification in AKI. 

7. Based on moderate (mortality, recovery of kidney function), low (infectious complications), or very low certainty evidence (correction of acidosis) there is probably little or no difference between PD and extracorporeal therapy for treating AKI. Fluid removal (low certainty) and weekly delivered Kt/V (very low certainty) may be higher with extracorporeal therapy.

8. Access and fluid delivery for acute PD in adults Wong SN.Arch Dis Child 1988; 63(7): 827–831

9. Crabtree JH et al. Perit Dial Int 2019; 39(5): 414–436.

10. Advantages and disadvantages of flexible, rigid and other peritoneal access Crabtree JH et al. Perit Dial Int 2019; 39(5): 414–436.

11. Method of insertion

12. catheter implantation techniques Crabtree JH et al. Perit Dial Int 2019; 39(5): 414–436 .

13. Method of insertion effective PD is a catheter which allows rapid inflow and outflow of fluid to minimise drain and fill time and maximise the dialysate dwell time and contact of the dialysate with the peritoneal membrane Preparation of the patient prior to insertion of the catheter will assist achieving optimal outcomes. Examples include bowel preparation using either oral or rectal solutions prescribed for colonoscopy and ensuring the bladder is catheterised

14. Results:  Thirteen studies with a total of 2,681 subjects met the inclusion criteria. There was no significant difference in 1-year catheter survival in percutaneous vs surgical PD catheter placement (relative risk [RR] = 0.81; 95% confidence interval [CI]: 0.59-1.11, p = 0.19). Catheter dysfunction also did not differ significantly between the groups (pooled odds ratio [OR] = 0.86; 95% CI: 0.57-1.29, p = 0.46). The prevalence of peritoneal fluid leak also was similar for percutaneous and surgical groups (OR = 1.10; 95% CI: 0.58-2.09, p = 0.77). However, there was a significant lower incidence of peritonitis among those with percutaneous placement (incidence rate ratio [IRR] = 0.77; 95% CI: 0.62-0.96, p = 0.02

15. Prophylactic antibiotics

16. Prophylactic antibiotics There are four randomised , controlled trials on the use of perioperative intravenous cefuroxime,gentamicin vancomycin and cefazolin as compared to no treatment  The overall benefit of prophylactic was confirmed Although first-generation cephalosporin may be slightly less effective than vancomycin, the former is still commonly used because of the concern regarding vancomycin resistance. The decision of which antibiotic to use is dependent on local bacterial sensitivities, timing of the procedure and availability.

17. Tidal PD a small volume of fluid is left in the abdomen at all times which may reduce mechanical complications and pain associated with complete fluid drainage It may have a benefit in critically ill patients in that there is always some fluid in contact with the peritoneum, and therefore large molecular weight toxins formed as part of the inflammatory process may be cleared better This has been demonstrated most dramatically for higher dialysate flow rates

18. Peritoneal dialysis solutions for acute PD Bai ZG et al. Cochrane Database Syst Rev 2014; (7): CD007034

19. Commercial versus locally mixed solutions Palmer D et al. Perit Dial Int 2018; 38(3): 246–250 McCulloch. PeritDial Int 2020; 40(5): 441–445

20. Suggestions for the preparation of locally mixed peritoneal dialysis fluids

21.  Prescribing and achieving adequate clearance in acute PD 4.1) Targeting a weekly  K   t / V   urea  of 3.5 provides outcomes comparable to that of daily HD in critically ill patients; targeting higher doses does not improve outcomes  (1B) . This dose may not be necessary for most patients with AKI and targeting a weekly  K   t / V  of 2.2 has been shown to be equivalent to higher doses  (1B) . Tidal automated PD (APD) using 25 L with 70% tidal volume per 24 h shows equivalent survival to continuous venovenous haemodiafiltration with an effluent dose of 23 mL/kg/h  (1C) . (4.2) Cycle times should be dictated by the clinical circumstances. Short cycle times (1–2 h) are likely to more rapidly correct uraemia , hyperkalaemia , fluid overload and/or metabolic acidosis; however, they may be increased to 4–6 hourly once the above are controlled to reduce costs and facilitate clearance of larger sized solutes  (2C) . (4.3) The concentration of dextrose should be increased and cycle time reduced to 2 hourly when fluid overload is evident. Once the patient is euvolemic, the dextrose concentration and cycle time should be adjusted to ensure a neutral fluid balance  (1C) . (4.4) Where resources permit, creatinine, urea, potassium and bicarbonate levels should be measured daily; 24 h  K   t / V   urea  and creatinine clearance measurement is recommended to assess adequacy when clinically indicated  (practice point) . (4.5) Interruption of dialysis should be considered once the patient is passing >1 L of urine/24 h and there is a spontaneous reduction in creatinine  (practice point) .

22. Recommendations for clinical practice

23. management of adult patients requiring peritoneal dialysis to treat AKI

24. Managing Complications In PD For AKI

25. Peritonitis Li PK-T et al. Perit Dial Int J Int Soc Perit Dial 2016; 36(5): 481–508 Ballinger AE et al. Cochrane Database Syst Rev 2014; (4): CD005284.

26. mechanical complications Ponce D, et al. Clin J Am Soc Nephrol 2012; 7(6): 887–894. 7 Vijt D et al. EDTNA ERCA J 2004; 30(2): 91–96 Zorzanello MM. Nephrol Nurs J 2004; 31(5): 534–537.

27. The least invasive method of correction via catheter repositioning is with the use of fluoroscopy and a flexible guidewire to manipulate the catheter into the correct position if fluoroscopy is unavailable or unsuccessful, then surgical options need to be entertained.

28. Leakage HerbrigK etal . Nephrol Dial Transpl 2006; 21: 2037–2038.