Use of peritoneal dialysis for the treatment of acute renal failure

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Use of peritoneal dialysis for the treatment of
acute renal failure

• Ri ???
• May 1, 2006

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Commonly Used Definitions of ARF

• An increase in serum creatinine of gt0.5 mg/dL
  over the base-line value in lt2 wks
• An increase in serum creatinine gt20 if baseline
  serum creatinine gt2.5 mg/dL
• A reduction in the calculated creatinine
  clearance of 50 percent

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Introduction

• The management of the patient with ARF requires
  meticulous attention to fluid, acid-base, and
  electrolyte balance as well as the removal of
  uremic toxins.
• PD is an overlooked procedure for dialytic
  support in acute renal failure, being primarily
  used for the treatment of patients with ESRD.
• Acute PD remains a viable option for the
  treatment of selected patients with ARF,
  particularly those who are hemodynamically
  compromised or have severe coagulation
  abnormalities

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Advantages of PD (I)

• It is widely available and technically easy to
  perform.
• Large amounts of fluid can be removed in
  hemodynamically unstable patients this fluid
  removal may also permit the administration of
  parenteral nutrition.
• Disequilibrium syndrome is not precipitated
  because of slow solute removal.

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Advantages of PD (II)

• Gradual correction of acid-base and electrolyte
  imbalance may be performed.
• PD access placement is relatively easy,
  particularly in children.
• Arterial or venous puncture and anticoagulation
  are not required.
• Dosing is easy, particularly in children.

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Practicality of PD

• Acute PD is widely available and can be provided
  without significant inconvenience in any
  hospital.
• The procedure is relatively simple, can be
  performed by trained intensive care unit (ICU)
  nursing staff.

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Hemodynamic Stability

• The continuous nature of acute PD involves the
  slow removal of solutes (eg, urea) and fluid. It
  is therefore desirable in hemodynamically
  unstable patients because large amounts of fluid
  can be removed over a prolonged period of time.

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Slow Correction of Metabolic Imbalances

• Acute PD enables continuous correction of
  acid-base status and electrolyte imbalance and
  the gradual removal of nitrogenous waste
  products.
• The slow removal of uremic toxins with acute PD
  is not associated with the development of the
  disequilibrium syndrome.

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Easy Access Placement (I)

• Acute PD access can be achieved without serious
  difficulty by inserting a semirigid catheter or
  by placing a Tenckhoff catheter.
• The semirigid catheter insertion can be performed
  at the bedside by a nephrologist or surgeon.

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Easy Access Placement (II)

• The Tenckhoff catheter is usually placed in the
  operating room by a surgeon this flexible
  catheter is more comfortable for the patient who
  is moving around in bed and operative insertion
  avoids the occasional development of intestinal
  perforation with percutaneous insertion.

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Systemic Anticoagulation Not Required (Excellent
Candidates for Acute PD)

• Those with a bleeding diathesis
• Patients in the immediate postoperative period
• Trauma patients
• Patients with intracerebral hemorrhage

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Hyperalimentation

• The use of hypertonic glucose PD solutions
  provides additional calories which is a benefit
  in malnourished patients.

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Tolerated in Children

• Acute PD has been frequently utilized and is the
  preferred form of therapy for dialysis children
  with ARF.
• The technique is convenient, relatively simple,
  and safe to perform in children, particularly
  since peritoneal access is easily obtained.
• Acute PD circumvents the need for arterial or
  venous puncture, both of which are difficult in
  children.

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Absolute Indication for Acute PD

• The need for dialysis and the inability to
  perform any other renal replacement technique

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Relative Indications for Acute PD

• Hemodynamically unstable patients
• The presence of a bleeding diathesis or
  hemorrhagic conditions
• Difficulty in obtaining blood access
• Removal of high molecular weight toxins (gt10 kD)
• Heart failure refractory to medical management

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Contraindications for Acute PD (I)

• Recent abdominal and/or cardiothoracic surgery
• Diaphragmatic peritoneal-pleural connections
• Severe respiratory failure
• Life-threatening hyperkalemia
• Severe volume overload in a patient not on a
  ventilator

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Contraindications for Acute PD (II)

• Severe gastroesophageal reflux disease
• Ongoing peritonitis
• Abdominal wall cellulitis
• Acute renal failure in pregnancy

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Mechanical Complications of Acute PD

• Abdominal pain or discomfort
• Intraabdominal hemorrhage
• Leakage
• Bowel perforation

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Infectious Complications of Acute PD

• Infectious complications are common, particularly
  peritonitis. The incidence of peritonitis can be
  significantly decreased by maintaining sterile
  precautions during the placement of acute PD
  catheters and by preventing contamination during
  exchanges.

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Pulmonary Complications of Acute PD

• Basal atelectasis and pneumonia
• Pleural effusion
• Aspiration

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Cardiovascular Complications of Acute PD

• Reduced cardiac output
• Cardiac arrhythmias

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Metabolic complications of Acute PD

• Hyperglycemia
• Hypernatremia
• Hypokalemia
• Protein losses

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Effect on Mortality

• A paucity of data exists concerning the effect on
  mortality of PD versus intermittent hemodialysis
  or continuous renal replacement therapies other
  than PD in patients with acute renal failure.
• Most studies have shown that the mortality and
  incidence of renal recovery with acute PD was at
  least comparable to hemodialysis.

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An Original Article from NEJM (I)

• Hemofiltration and Peritoneal Dialysis in
  Infection-Associated Acute Renal Failure in
  Vietnam Volume 347895-902 Sep 19, 2002
• The primary objective of the study was to assess
  the efficacy, safety, practicality, and cost of
  short-term peritoneal dialysis as compared with
  pumped venovenous hemofiltration in a
  well-equipped hospital in a developing country.

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An Original Article from NEJM (II)

• The primary end point was the rapidity of
  resolution of metabolic abnormalities, indicated
  by the rates of change in and normalization of
  the venous plasma creatinine concentration and
  arterial plasma pH.
• Mortality and the cost of treatment were
  secondary end points.
• Patients had either severe falciparum malaria or
  sepsis-related acute renal failure.

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Results

• Between 1993 and 1998, 70 patients entered the
  study.
• There was no significant difference in any of the
  base-line variables between the groups (36
  patients assigned to peritoneal dialysis and 34
  to hemofiltration).
• Falciparum malaria was the underlying cause of
  acute renal failure in 48 patients (69 percent).
  The other 22 patients all had presumed bacterial
  sepsis.

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Correction of Metabolic Abnormalities

• Plasma Cre declined more than twice as rapidly
  in the group assigned to hemofiltration.
• The rate of resolution of acidosis was
  considerably faster and normalization more
  complete in the group assigned to hemofiltration.
• A significantly higher proportion of patients
  assigned to hemofiltration had a normal pH and
  base deficit at the end of the session of
  renal-replacement therapy.

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Mortality

• There were 17 deaths (47 percent) in the group
  assigned to peritoneal dialysis as compared with
  5 (15 percent) in the group assigned to
  hemofiltration (relative risk, 3.2 95 percent
  confidence interval, 1.3 to 7.7 P0.005).
• In a logistic-regression model including
  underlying disease (malaria or bacterial sepsis)
  and the presence or absence of jaundice as
  explanatory variables, peritoneal dialysis was
  significantly associated with death (odds ratio,
  5.1 95 percent confidence interval, 1.6 to 16).

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Economic Implications

• PD the mean costs per survivor were 3,000 (95
  percent confidence interval, 2,210 to 3,790)
• Hemofiltration 1,340 (95 percent confidence
  interval, 1,130 to 1,560)

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Peritoneal Dialysis in Acute Renal Failure Why
the Bad Outcome? (I)

• An editorial in the same issue of NEJM
• Given that increased adequacy of solute removal
  has been linked to better outcomes in patients
  with acute renal failure who are receiving either
  hemodialysis or venovenous hemofiltration, part
  of the survival benefit of hemofiltration in this
  study was probably due to better toxin removal.

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Peritoneal Dialysis in Acute Renal Failure Why
the Bad Outcome? (II)

• Whereas venovenous hemofiltration was conducted
  with more or less state-of-the-art methods, the
  peritoneal-dialysis techniques employed were not
  optimal rigid, rather than flexible, catheters
  were used, and dialysate bags were hung and
  changed manually, rather than with the use of a
  cycler.
• The peritoneal dialysate was made in the hospital
  pharmacy (not commercial).

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Peritoneal Dialysis in Acute Renal Failure Why
the Bad Outcome? (III)

• High osmolality of peritoneal-dialysis fluid and
  high glucose levels have been linked to stunning
  and dysfunction of leukocytes.
• High splanchnic-blood glucose levels may
  stimulate the growth of the erythrocytic stage of
  malaria organisms in the liver.

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Peritoneal Dialysis in Acute Renal Failure Why
the Bad Outcome? (IV)

• Whatever the explanation for the findings, the
  results are of great practical importance to
  nephrologists treating patients who have acute
  renal failure associated with malaria or sepsis,
  since the authors suggest that peritoneal
  dialysis should not be used.
• Another lesson to be learned is that we must also
  determine whether there are technique-specific
  factors that affect outcome.

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Thanks for your attention