Nephrology Elective Course - Renal Replacement Therapy PDF

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[email protected] [email protected] [email protected] Nephrology Elective Course Renal Replacement Therapy Contents Topic ‫ﻃﻪ ﺍﺣﻤﺪ ﻃﻪ ﻓﻬﻤﻰ ﺍﻟﻌﺮﺟﻪ‬ Renal replacement therapy (indications, patient preparation, modalities choice) Hemodialysis (principles, hemodialysis access, dialysate and dialyzer) Hemodialysis (procedure, adequacy Hemodialysis complications Continuous Renal Replacement Therapy (modalities, indications, complications) 2024/2025 2024/2025 2024/2025 Peritoneal dialysis (principles, modalities, PD fluids) Peritoneal dialysis (procedure, adequacy and complications) Kidney transplantation; basic concepts  [email protected] [email protected] [email protected] Renal Replacement therapy Different modalities of RRT (Transplantation, Dialysis) ‫ﻃﻪ ﺍﺣﻤﺪ ﻃﻪ ﻓﻬﻤﻰ ﺍﻟﻌﺮﺟﻪ‬ Dialysis Options 2024/2025 2024/2025 2024/2025 Extracorporeal:  Intermittent Hemodialysis Slow Low efficiency Dialysis (SLED)  Continuous Hemofiltration CAVH, SCUF, CVVH, CAVHDF, CVVHDF Intracorporeal:  Peritoneal Dialysis  [email protected] [email protected] [email protected] CRRT Modalities  SCUF- Slow Continuous Ultra filtration (Ultra filtration)  CVVH- Continuous Veno-Venous Hemofiltration (Convection)  CVVHD- Continuous Veno-Venous Hemodialysis (Diffusion)  CVVHDF- Continuous Veno-Venous Hemodiafiltration (Diffusion and Convection) Hemodialysis Extracorporeal therapy:  Acute Intermittent Hemodialysis  CRRT ‫ﻃﻪ ﺍﺣﻤﺪ ﻃﻪ ﻓﻬﻤﻰ ﺍﻟﻌﺮﺟﻪ‬ 2024/2025 2024/2025 2024/2025 Dialyzer Dialysis through  [email protected] [email protected] [email protected] permcath Synthetic Graft ‫ﻃﻪ ﺍﺣﻤﺪ ﻃﻪ ﻓﻬﻤﻰ ﺍﻟﻌﺮﺟﻪ‬ Dialysis through synthetic graft Indication 2024/2025 of dialysis 2024/2025 2024/2025  Hyperkalemia  Metabolic acidosis  Fluid overload (recurrent CHF admissions)  Uremic pericarditis (rub)  Other nonspecific uremic symptoms: anorexia and nausea, impaired nutritional status, increased sleepiness, and decreased energy level, attention, and cognitive tasking  eGFR less 10-15 ml per min Interviewing with the patients and families to explain when to start and choose appropriate modality Making decisions Most people will require more than one treatment over their lives, so good to learn about all the options What are the possible treatment options? What do you know about these options?  [email protected] [email protected] [email protected] Possible kidney treatment options What is important for you to feel that you are having a good life? Flexible schedule? Independence/control? Commitments (e.g., work, family)? Fewer diet and fluid restrictions? Activity level? Lifestyle changes Active role in your care? ‫ﻃﻪ ﺍﺣﻤﺪ ﻃﻪ ﻓﻬﻤﻰ ﺍﻟﻌﺮﺟﻪ‬ Communicate with colleagues in different departments  Nephrologist  Advanced Practitioner  Nephrology Nurse  Renal Dietitian  Nephrology Social Worker  Biomedical Technician  Vascular Access Care Team: 2024/2025 - (The vascular access surgeon OR The 2024/2025 2024/2025 radiologist) Select appropriate dialysis modality (peritoneal and hemodialysis) In-center hemodialysis Patient and patient family do not need to participate in delivery dialysis. – Good for patients who are not independent and lack support system. Allows for adherence with treatments and administration of parenteral medications (erythropoietin and vitamin D analogues). Outcomes – High mortality rate. – Infections are frequent and increased mortality. Quality of Life – Inflexible schedule. – Most patients have hypertension requiring medications. – Travel to dialysis and planning a vacation is difficult. – Inability to work. – Post dialysis fatigue. – Decreased cognitive function/sense of well-being.  [email protected] [email protected] [email protected] Renal Transplantation It is the best modality of renal replacement therapy for the patient specially in young active individuals. Good quality of life. It may be living related or unrelated donner. OR Cadaveric donner. Problems with immunosuppression & graft rejection. Referral and Education for Patients with Progressive CKD Refer patients early, when eGFR < 30 ml/min/1.73 m2 Education about types of renal replacement therapy: Hemodialysis (vascular access +++) ‫ﻃﻪ ﺍﺣﻤﺪ ﻃﻪ ﻓﻬﻤﻰ ﺍﻟﻌﺮﺟﻪ‬ Peritoneal Dialysis (QOL advantage +++) Kidney Transplantation Refer when eGFR < 20 ml/min/1.73 m2 Living kidney transplant (family, friends) Build time on list before dialysis initiation Even transplant before dialysis initiation (pre-emptive) Advantages 2024/2025 of Timely Referral in Patients with Progressive CKD 2024/2025 2024/2025 Improves patient preparation for RRT Greater use of permanent vascular access Avoidance of emergent hemodialysis initiation Greater utilization of transplantation Management of medications which may help to delay the need for RRT Early Vaccination for Hepatitis B: Too Often Forgotten! Patients with ESRD have  response to vaccination. (Secondary to general suppression of immune system). Other Considerations for Vaccination in Patients with Progressive CKD Influenza vaccine annually, unless contraindicated. Polyvalent pneumococcal vaccine: eGFR 3.5g/L. Normalized protein due to high catabolic rate >1.0g/kg/day. Hemoglobin targets Keep HB level between 10-11 gm/dl. Target for other morbidity Control blood pressure by reach ideal dry weight. Control mineral bone disease by medications and dialysis. Correction of acidosis 2024/2025 2024/2025 2024/2025  [email protected] [email protected] [email protected] Complications of hemodialysis ‫ﻃﻪ ﺍﺣﻤﺪ ﻃﻪ ﻓﻬﻤﻰ ﺍﻟﻌﺮﺟﻪ‬ Patient complications 1-Intradialytic hypotension Definitions for IDH: Systolic BP less than 90 mm Hg. A fall in systolic BP of 20 or 30 mm Hg from predialysis pressure Causes of Intradialytic Hypotension 2024/2025 2024/2025 2024/2025 1) Volume-related a. Large weight gain (high ultrafiltration rate) b. Short weekly dialysis time (high ultrafiltration rate) c. Excessively low target (“dry”) weight 2) Inadequate vasoconstriction a. Autonomic neuropathy b. Antihypertensive medications c. Eating during treatment d. Anemia 3) Cardiac factors a. Diastolic dysfunction a. Pericardial tamponade b. Myocardial infarction  [email protected] [email protected] [email protected] 4) uncommon factors a. Occult hemorrhage b. Septicemia c. Dialyzer reaction d. Hemolysis e. Air embolism Treatment of IDH  Review dietary sodium intake.  Do not give food or glucose orally during, or immediately preceding, dialysis to hypotension prone patients.  Fluid intake should be 13 mL / kg per hour.  Consider raising the patient’s target weight.  In refractory cases, consider a trial of higher (140–145 mM) dialysis sodium. 2-Cramping Painful muscle spasms (usually in extremities) 2024/2025 Causes 2024/2025 2024/2025 Excessive ultrafiltration Intradialytic hypotension Electrolyte-mineral disturbances (Hypomagnesemia - Hypocalcemia - Predialysis hypokalemia) Treatment of Muscle Cramps Treat the symptoms: – Normal saline bolus – Reduce UFR – Massage or apply opposing force – Assess dry weight Prevention: – Assess for accurate target weight –Sodium modelling –Carnitine  [email protected] [email protected] [email protected] 3-Disequilibrium Syndrome ‫ﻃﻪ ﺍﺣﻤﺪ ﻃﻪ ﻓﻬﻤﻰ ﺍﻟﻌﺮﺟﻪ‬ Causes - Fluid shift into the brain due to removal of wastes from the blood stream causing cerebral edema - Rapid changes in serum electrolytes, especially in new patients Treatment Treat the symptoms: – Monitor new patients carefully for hypertension – Decrease 2024/2025 blood flow rate 2024/2025 2024/2025 – Treat nausea , vomiting and headache – Be alert for restlessness, speech/mental changes Prevention: – Assess new patients electrolyte levels – Use a smaller dialyzer, lower BFR and shorter dialysis time for first few treatments 4-Nausea and Vomiting Causes: –Hypotension –Uremia –Disequilibrium Syndrome Treatment the symptoms: –Hypotension = NS bolus  [email protected] [email protected] [email protected] Prevention –Uremic patient or one with Disequilibrium Syndrome require careful pre-assessment and monitoring during the initial treatments. 5-Headache Causes: –Hypertension –Inaccurate dry weight with too much fluid removed –Rapid fluid or electrolyte shift –Disequilibrium Syndrome –Anxiety/nervous tension ‫ﻃﻪ ﺍﺣﻤﺪ ﻃﻪ ﻓﻬﻤﻰ ﺍﻟﻌﺮﺟﻪ‬ Treat the symptoms –Unit policy for analgesics –Hypertension: BP assessment –Hypotension –NS bolus Prevention: –identify the cause and then prevent it in the future 6-Chest 2024/2025 Pain 2024/2025 2024/2025 Causes Ischemia to heart muscle (Coronary Artery Disease) Anemia Hypotension from fluid depletion Hypovolemia Blood flow rate increased too rapidly on patient with known cardiac disease Treatment Treat the cause Accurate fluid removal and weight assessment 7-Itching Causes: –Dry skin –Secondary hyperparathyroidism –Abnormal levels of calcium, magnesium and phosphorus in tissues  [email protected] [email protected] [email protected] –Allergies –Uremia with an elevated BUN Treatment: –Adequate dialysis to regulate electrolyte levels –Lotions or medications for dry skin/allergies Prevention: –Control of uremia and secondary hyperparathyroidism –Adequate dialysis to regulate electrolyte levels 8-Chills and Fever ‫ﻃﻪ ﺍﺣﻤﺪ ﻃﻪ ﻓﻬﻤﻰ ﺍﻟﻌﺮﺟﻪ‬ Causes: Infection or septicemia Vascular access Respiratory illness Cold dialysate or malfunctioning thermostat Patient has shaking/shivering without fever Pyrogenic reaction 2024/2025 2024/2025 2024/2025 9-Hypertension Causes: –Fluid overload –Non-compliance with blood pressure medications –Anxiety –Renin overproduction Treatment –Review medications of BP –Assessment of target weight and fluid removal goal  [email protected] [email protected] [email protected] Technical complications 1-Clotting in the Extracorporeal Circuit Formation of blood clots in the dialyzer and blood lines Causes: –Inadequate anticoagulation –Low blood flow rate –Air in blood lines Treatment: –Anticoagulation ‫ﻃﻪ ﺍﺣﻤﺪ ﻃﻪ ﻓﻬﻤﻰ ﺍﻟﻌﺮﺟﻪ‬ –Vascular access CVC problems 2-Exsanguination Extreme blood loss Causes: –Rupture of access (at anastomosis or aneurysm) –Needles dislodging from access 2024/2025 2024/2025 2024/2025 –Blood line separation –Crack in dialyzer casing/Rupture of dialyzer –Loose dialyzer caps/connections Treatment Identify the source of blood loss Stop dialysis –Return blood if possible (not contaminated system) Treat the symptoms: –Normal saline to support blood pressure –Oxygen for shortness of breath Other Technical Complications 1. Hemolysis 2. Air Embolism 3. Dialyzer reactions  [email protected] [email protected] [email protected] Vascular access complications 1. Infections 2. AV graft/fistula thrombosis or stenosis 3. Aneurysmal formation and/or bacterial infection weaken the vessel wall, increasing the risk for bleeding 4. Bleeding occurs post HD after catheter is disconnected from AV access site ‫ﻃﻪ ﺍﺣﻤﺪ ﻃﻪ ﻓﻬﻤﻰ ﺍﻟﻌﺮﺟﻪ‬ 2024/2025 2024/2025 2024/2025  [email protected] [email protected] [email protected] Continuous Renal Replacement Therapy (CRRT) Background Renal replacement therapy (RRT) includes: Dialysis: o Hemodialysis (HD); intermittent hemodialysis (iHD) or continuous renal replacement therapy (CRRT) modalities o Peritoneal dialysis (PD) Transplantation ‫ﻃﻪ ﺍﺣﻤﺪ ﻃﻪ ﻓﻬﻤﻰ ﺍﻟﻌﺮﺟﻪ‬ Acute kidney injury (AKI) is a common complication in critically ill patients. It is associated with substantial morbidity and risk of death. Approximately 5% to 10% of patients with AKI require renal replacement therapy (RRT) during their hospital stay, with mortality rates of 30% to 70%. CRRT is especially useful for critically ill patients with multiple co-morbidities and hemodynamic instability. Definition 2024/2025 2024/2025 2024/2025 Continuous renal replacement therapy (CRRT) is an extracorporeal blood purification therapy intended to substitute for impaired renal function over an extended period of time and applied for or aimed at being applied for 24 hours a day. Transport mechanisms Certain transport mechanisms are utilized during dialysis to move fluid and solutes through the semi-permeable membrane. These mechanisms include: Diffusion Osmosis Convection Ultrafiltration Adsorption Diffusion  [email protected] [email protected] [email protected] Removal of small molecules by diffusion through the addition of dialysate to the fluid side of the filter. Dialysate is used to create a concentration gradient across a semi permeable membrane. Osmosis Movement of fluid across a semipermeable membrane from an area of lower solute concentration to an area of higher solute concentration. Ultrafiltration The movement of fluid through a semi-permeable membrane driven by a pressure gradient (hydrostatic pressure). ‫ﻃﻪ ﺍﺣﻤﺪ ﻃﻪ ﻓﻬﻤﻰ ﺍﻟﻌﺮﺟﻪ‬ Convection The aim is to move solutes with fluid, referred to as a “solvent drag”. Plasma water and certain solutes depending on the molecular weight are forced across the membrane. This is especially useful for removal of solutes of middle and large molecular weights, and this needs replacement fluid. Adsorption Molecular adherence to the surface or interior of the membrane. Some molecules will attach to the membrane surface, while other molecules may 2024/2025 2024/2025 2024/2025 permeate the membrane, but become stuck within the fibers. It is believed that inflammatory mediators are effectively removed via adsorption. Requirements for CRRT A central double-lumen veno-venous hemodialysis catheter An extracorporeal circuit and a hemofilter A blood pump and a effluent pump. Dialysate and/or replacement pumps may be required. CRRT modalities These include: Slow Continous Ultrafiltration (SCUF): Continuous Venovenous Hemofiltration (CVVH) Continuous Venovenous Hemodialysis (CVVHD) Continuous Venovenous Hemodiafiltration (CVVHDF)  [email protected] [email protected] [email protected] Table 1and Table 2 show principle of each CRRT modality and the need for dialysate and/or replacement fluid for each modality. Table 1: CRRT modalities; transport mechanisms used in each modality. Modality Diffusion Convection Ultrafiltration SCUF - - + ‫ﻃﻪ ﺍﺣﻤﺪ ﻃﻪ ﻓﻬﻤﻰ ﺍﻟﻌﺮﺟﻪ‬ CVVH - + ± CVVHD + - ± CVVHDF + + ± Table 2: CRRT modalities; the need for replacement and/or dialysate solution in each modality. Modality Replacement solution Dialysate fluid 2024/2025 (Substitution fluid) 2024/2025 2024/2025 SCUF - - CVVH + - CVVHD - + CVVHDF + + Indications for initiation of CRRT Volume overload Metabolic acidosis Electrolyte abnormalities e.g. hyperkalemia, hyperphosphatemia. Uremic manifestations e.g. encephalopathy, pericarditis Persistent/progressive acute kidney injury Continuous renal replacement therapy or intermittent hemodialysis?  [email protected] [email protected] [email protected] As previously shown, indications for CRRT are the same general indications for dialysis initiated through conventional method; intermittent hemodialysis (iHD). However CRRT facilitates a gentle removal of even large volumes of fluid and an effective fluid status control during treatment. CRRT has the following advantages: Better in hemodynamically unstable patients including critically ill patients in intensive care units. Allows adequate parenteral nutrition. ‫ﻃﻪ ﺍﺣﻤﺪ ﻃﻪ ﻓﻬﻤﻰ ﺍﻟﻌﺮﺟﻪ‬ Less disequilibrium syndrome; a syndrome that results from rapid removal of urea. Data do not support the superiority of any particular mode of RRT in patients with AKI. In the majority of patients, selection of modality should therefore be based upon local expertise and availability of staff and equipment. Specific patients who would benefit from CRRT: Hemodynamically unstable patients 2024/2025 Patients with combined acute renal and hepatic failure 2024/2025 2024/2025 o Improved CV instability and intracranial pressure Acute brain injury o Decreased cerebral edema Advantages of CRRT over slow low efficacy dialysis CRRT provide better hemodynamic stability than slow low efficacy dialysis (SLED) depending on the high technology machine. SLED is lacking the principle of convection for the removal of large molecular toxins. Complications of CRRT Catheter-related complications including hemorrhage, pneumothorax, air embolism, venous thrombosis and venous stenosis. Extracorporeal circuit-related complications: o Allergic reaction to hemodialyzer/hemofilter or tubing o Circuit thrombosis o Hemolysis  [email protected] [email protected] [email protected] o Air embolism o Hypothermia o Hypotension Electrolyte disturbances: o Hypophosphatemia o Hypokalemia o Hypocalcemia o Hypomagnesemia Incorrect medication dosing ‫ﻃﻪ ﺍﺣﻤﺪ ﻃﻪ ﻓﻬﻤﻰ ﺍﻟﻌﺮﺟﻪ‬ Remember:  CRRT is a continuous modality of HD used especially in hemodynamically unstable patients with AKI.  It allows removal of larger amount of fluid over a prolonged period of time.  It allows removal of middle to large molecular weight substances.  Modalities include SCUF, CVVH, CVVHD and CVVHDF.  Complications are related to catheter insertion, anticoagulant used and 2024/2025 electrolyte loss 2024/2025 2024/2025  [email protected] [email protected] [email protected] Peritoneal dialysis Principles of peritoneal dialysis: The peritoneum is used as the membrane through which fluid and dissolved substances are exchanged with the blood. It is used to remove excess fluid, correct electrolyte problems, and remove toxins in patients with kidney failure. Procedure: 1. Insertion of the peritoneal catheter 2. Hang out the dialysis solution 3. Open the valve allowing the fluid to pass into the peritoneum about 2-3 litters over ‫ﻃﻪ ﺍﺣﻤﺪ ﻃﻪ ﻓﻬﻤﻰ ﺍﻟﻌﺮﺟﻪ‬ 10 to 15 minutes, the total volume of fluid is called dwell 4. Leave the fluid in the peritoneal cavity about 4 to 6 hours then remove it during this period the waste substances are removed from the blood by diffusion to the dialysate fluid. 5. The process is repeated, this can occur automatically while the patient is sleeping (automated peritoneal dialysis, APD), or during the day by keeping two litres of fluid in the abdomen at all times, exchanging the fluids four to six times per day (continuous ambulatory peritoneal dialysis, CAPD), or done at the hospital over 24 hour while the patient is admitted. 2024/2025 2024/2025 2024/2025 Hang up Infusion  [email protected] [email protected] [email protected] Diffusion Drainage Advantages of PD Its portability, as the treatment is provided by the patient or caregiver, there is ‫ﻃﻪ ﺍﺣﻤﺪ ﻃﻪ ﻓﻬﻤﻰ ﺍﻟﻌﺮﺟﻪ‬ greater freedom to travel and independence from medical and nursing staff compared to HD. PD is a continuous therapy, constantly removes solutes and water, allowing for a less restrictive diet. PD also provides greater preservation of residual renal function 3. Disadvantages of PD PD should 2024/2025 be carried out daily. 2024/2025 2024/2025 The patient or caregiver is fully responsible for paying attention to their technique to prevent infectious complications. Structural changes in the peritoneal membrane can occur over time, which may compromise the effectiveness of the method. Contraindications to PD Absolute contraindications; Uncorrectable surgical conditions (e.g., extensive hernias, diaphragmatic hernias). Multiple peritoneal adhesions. Physical or mental inability to perform the method. Relative contraindications; The presence of recent abdominal vascular prostheses and ventriculoperitoneal shunts. Frequent episodes of diverticulitis. Inflammatory or ischemic intestinal disease, Morbid obesity. The peritoneum is a serous membrane with a surface of 1 to 2 m2 in adults and has two leaflets, the visceral and the parietal. The structure of the peritoneal membrane is composed of:  [email protected] [email protected] [email protected] A monolayer of mesothelial cells. The interstitium. Peritoneal capillaries. Visceral lymphatics. Effective peritoneal surface area: The functional area available for exchanging between blood and the dialysate 2 determined by the number of perfused capillaries. Capillaries represent the largest barrier to the transport of solutes and water. This transport can be explained by the three-pore model: ‫ﻃﻪ ﺍﺣﻤﺪ ﻃﻪ ﻓﻬﻤﻰ ﺍﻟﻌﺮﺟﻪ‬ Ultra-pores Small pores Large pores 1. The endothelial cells of peritoneal capillaries are permeable to water through Ultra- pores (transcellular pores or aquaporins) 4 nm radius. 2. Small pores are responsible for the transport of small solutes by diffusion and/ or convection 6. 2024/2025 2024/2025 2024/2025 3. Large pores (12 to 15 nm radius) are responsible for the passive transport of macromolecules, such as albumin. Solute diffusion Occurs by a concentration gradient, with solutes such as urea, creatinine and potassium moving from the plasma toward the dialysate, while other solutes, such as bicarbonate, move in the opposite direction. Convective transport Solute removal as a direct result of fluid movement into and out of the peritoneal cavity. Fluid removal occurs through the osmotic gradient created by the addition of osmotic agents to the dialysis solution. This hyperosmolar dialysate induces fluid removal from plasma, a process called ultrafiltration. The higher the ultrafiltration, the greater the convective transport of solutes. A small amount of absorption of liquids and solutes through the lymphatic path. The volume of ultrafiltration depends on; The glucose concentration in the dialysis solution.  [email protected] [email protected] [email protected] The period of permanence of the fluid in the peritoneal cavity (with longer permanence, transperitoneal absorption of glucose leads to a decreased concentration of glucose in the dialysate, decreasing the osmotic gradient). The individual characteristics of peritoneal membrane. PD ACCESS It is necessary to implant a catheter in the abdominal wall that will allow bidirectional flow of the dialysis solution. Catheters are constructed of silicone rubber. with multiple pores on its distal (intra-abdominal) portion, and it should ideally be positioned freely in the pelvic area. There are multiple catheter designs with different intraperitoneal configurations (straight or coiled), subcutaneous segments (straight or swan neck), and number of ‫ﻃﻪ ﺍﺣﻤﺪ ﻃﻪ ﻓﻬﻤﻰ ﺍﻟﻌﺮﺟﻪ‬ cuffs (1 or 2). The most used catheter is the Tenckhoff catheter, which has a straight configuration. The Tenckhoff catheter is laterally externalized through a hole called an exit point, and it has two Dacron cuffs. One of the cuffs is subcutaneous and 1 to 2 cm from the exit-site on the skin (external cuff), The other cuff is near the peritoneum. Between catheter implantation and the beginning of dialysis therapy, it is advisable to wait at least two weeks 7, a period called break-in, to prevent leakage of the pericatheter dialysate. Patients may require 2024/2025 initiation of dialysis therapy 2024/2025 immediately 2024/2025 after catheter implantation; in these situations, only small volume exchanges are made, preferably in the supine position. Types of PD treatment 1. Continuous Ambulatory Peritoneal Dialysis (CAPD): The peritoneal cavity is always filled with the dialysis solution (usually 2–2.5 L), and this fluid is changed 3–5 times a day at 4–8 hr intervals. in adults, according to the needs of each patient. This change is performed manually and occurs due to gravity through a system consisting of two bags connected by a Y-piece to the catheter. This two-bag system consists of an empty floor-standing bag to drain the solution from the peritoneal cavity (toxin saturated solution) and a fresh-solution bag that hangs on a stand at a height above catheter level to be infused immediately after draining the saturated solution. After this infusion, the patient disconnects the system and disposes it and is then free to perform activities until the next change. 2. Automated Peritoneal Dialysis (APD):  [email protected] [email protected] [email protected] Three to six changes are performed by an automatic cycler overnight while the patient is sleeping. APD can be of the following types: a. Intermittent Night Peritoneal Dialysis: ▪ Changes performed at night with the automatic cycler, and the peritoneal cavity remains without dialysis fluid during the day. Indicated for patients who have residual renal function. b. Continuous Cycling Peritoneal Dialysis: ▪ In addition to making the changes at night with the cycler, the patient maintains the dialysis solution within the peritoneal cavity during the day and may perform manual changes during the day. performed for patients who do not have ‫ﻃﻪ ﺍﺣﻤﺪ ﻃﻪ ﻓﻬﻤﻰ ﺍﻟﻌﺮﺟﻪ‬ residual renal function. PD SOLUTIONS Conventional Solutions The composition of PD solutions is divided into the osmotic agent, buffer, and electrolytes. Calcium (1.25-1.75 /2.5 or 3.5 mEq/L). Sodium 2024/2025 132-134 mEq/L. 2024/2025 2024/2025 Chlorine 95 to 102 mEq/L. Magnesium levels of (0.25 – 0.75 mM). Dextrose The osmotic agent used in conventional PD solutions and is available in 3 concentrations: 1.5%, 2.5%, and 4.25% (as glucose monohydrate). Heat sterilization of glucose leads to the generation of glucose degradation products (GDPs). Because fewer GDPs are generated when this heat sterilization occurs at a low PH. conventional PD solution use lactate as a buffer and have a pH of