Nephrology handbook

Question 1

What Hx taking for hyperK and need to rule out?
How do you manage hyperkalemia?

Answer 1

• Exclude pseudo-hyperkalaemia e.g. haemolysis in blood specimen, esp. in those with relatively normal renal function;
• Beware of increase K release from cells/ tissue breakdown and transcellular shift (acidosis)
• Check drug history e.g. K supplement, NSAID, ACEI/ ARB, K- sparing diuretic
  Ix: repeat RFT CO2 Cl-, ECG
  For urgent cases:
  1. 10% Calcium gluconate 10 mL or calcium chloride 5–10 ml IV over 2–3 minutes with cardiac monitoring; repeat if no effect in 5 minutes (onset:1–3 min; duration: 30–60 min ). If digoxin toxicity is suspected, omit calcium gluconate infusion.
  2. Dextrose-insulin infusion: give 250 mL D10 or 50 mL D50 with 8–10 units Actrapid HM over 30 minutes; repeat every 4–6 hours if necessary (onset: 30 minutes; duration: 4–6 hours ).
  3. Sodium bicarbonate 8.4% 100–150 mL over 30–60 min; to be given after calcium infusion in separate IV line; watch out for fluid overload (onset: 5–10 minutes; duration: 2 hours).
  4. Resonium C / A: 15–50 g orally Q 4–6 hrs or as retention enema; may be given in 100–200 mL 10% mannitol as laxative; one gram of resonium will bind 1 mmol of K. (onset: 1–2 hours; duration: 4–6 hours).
  5. Salbutamol 10–20 mg in 3 mL NS by nebulizer (onset: 15–30 minutes; duration: 2–3 hours).
  6. Diuretics: furosemide 40–80 mg IV bolus.
  7. Emergency haemodialysis or peritoneal dialysis.

Question 2

What is the Ix and Rx for chronic hyperkalemia cases?

Answer 2

Ix:

Detailed drug history
Consider checking cortisol, plasma renin activity, serum aldosterone

Rx:
1. Low K diet (< 2 g/day).
2. Diuretics: furosemide / thiazide
3. Correct acidosis with sodium bicarbonate 300-900 mg TDS (~10– 30 mmoles/day).
4. Fludrocortisone 0.1–0.2 mg daily (for Type IV RTA).

Question 3

What are the causes of hypercalcemia and how to calculate it?

Answer 3

• Common cause: hyperparathyroidism, hypercalcaemia of
  malignancy, drug-induced (vit D/ calcium supplement, thiazide
  diuretics, vit A)
• Commonly associated with dehydration
• Calculated corrected serum calcium level based on serum albumin concentration
• Corrected calcium = 0.02 * (40 g/L – patient’s albumin (g/L)) + serum Ca

Question 4

What is the Ix and Rx for hypercalcemia?

Answer 4

Ix: Check ionized calcium, PO4, RFT, PTH, Vit D, thyroid function, 24h urine x calcium or fractional excretion of Ca. ECG
Rx:
1. Off calcium / vitamin D supplement if any.
2. Volume repletion with NS at 100–500 mL/hr infusion (Guided by
CVP / urine output); start furosemide after rehydration 20–40 mg IV Q4–12H; aim at a urine output of ~ 200 mL/h; close monitoring of Na K Ca Mg level and fluid status.
3. Pamidronate IV 30–90 mg (with reference to patient’s renal function) in 250–500 mL NS infused over 4-6 hrs. Maximum effect is not seen for several days; repeat another dose after a minimum of 7 days if necessary.
4. Zoledronate IV 4 mg infusion over 15 min (maximal effect at 72 hours)
5. Salmon calcitonin 4 units/kg IM/SC Q12H; Calcium level begins to fall within 2–3 hours; tachyphylaxis occurred within 2–3 days.
6. Hydrocortisone 50 mg IV Q8H then prednisolone 40–60 mg daily (onset: 3–5 days; useful in haematological malignancy, vitamin D intoxication, granulomatous condition)
7. Haemodialysis with zero or low Ca dialysate
8. Newer treatment: Denosumab / Cinacalcet

Question 5

How to confirm true hyponatremia and what investigations to be done?

Answer 5

• Rule out pseudohyponatraemia and hyperosmolar hyponatraemia (Check glucose, lipid, immunoglobulin level).
• Check history of prostatic surgery/uterine surgery
• Check medication history (thiazide, anti-depressants)
  Ix: RFT, serum/urine osmolality, spot urine [Na], cortisol, thyroid function

Question 6

What are the causes and Rx of isovolemia hyponatremia?

Answer 6

Isovolaemia:
- urine Na >20 mmol/L and urine osmo >100 mOsm/L: SIADH,
hypothyroid, Addison’s disease
- urine Na <10 mmol/L and urine osmo <100 mOsm/L: water
intoxication, primary polydipsia, beer potomania
Rx:
- Restrict water intake < 1000 mL per day for SIADH (Calculate the {urine [Na] + urine [K]/ serum [Na]} ratio; free water loss if ratio < 1)
- Treat the underlying cause; discontinue culprit medication
- NaCl oral supplement ± Frusemide
- Correction of hypokalaemia
- Increase dietary solute load

Question 7

What is the management of acute symptomatic hyponatremia?

Answer 7

• Consult ICU
• Very cautiously give IV hypertonic saline (100 ml 3% hypertonic
  saline (513 mmol/L) over 20 min or 50 mL 5.85% NaCl (1000 mmol/L) over 30 min
• Repeat if necessary until [Na] increase by 4–6 mmol/L or improvement in symptoms
• For patients with severe symptoms, [Na] should be corrected 1–2 mmol/L/hr for 3–4 hours
• Correction should not be > 8–12 mmol/L/24hr to avoid central pontine myelinolysis
• Adrogue formula: Change in serum Na with 1L of infusate =
  [(Infusate Na + infusate K) – (serum Na)] / (TBW+1)

Question 8

What are the causes and Rx of hypovolemic hyponatremia?

Answer 8

• urine Na <10 mmol/L: diarrhoea, vomiting, third space fluid loss,
  dehydration, remote diuretic use
• urine Na >20 mmol/L: diuretics, adrenal insufficiency, salt
  wasting, bicarbonaturia
  Rx:
• Use isotonic saline (NS) 500 mL/hr till BP normal then replace the sodium deficit with saline/ Na supplement
• Rate of correction should not be > 8–12 mmol/L over 24 hrs (Beware of rapid increase in [Na] after restoration to euvolaemic state)
• Sodium deficit: Na+ requirement (mmol)
  = total body water (0.6BW)(desired Na+–serum Na+)

Question 9

What are the causes and Rx of hypervolemic hyponatremia?

Answer 9

(urine Na <10 mmol/L: CHF, cirrhosis; urine Na >20 mmol/L: renal failure)
Rx:
- Treat the underlying cause
- Restrict water intake <1000 mL per day
- Furosemide 40–80 mg IV / 20–500 mg PO daily

Question 10

What is the sodium concentration of commonly used IV fluid?

Answer 10

Question 11

What are the causes for high anion gap metabolic acidosis?

Answer 11

MULEPAK-P
M=methanol, U=uraemia, L=lactic acidosis,
E=ethylene glycol P=paraldehyde, A=aspirin, K=ketosis, P=pyroglutamic acid (panadol)

Question 12

What are the causes for normal anion gap metabolic acidosis?

Answer 12

USED CAR
U=ureteroenterostomy, S=saline infusion, E=endocrinology e.g.: Addison, D=diarrhoea, C=carbonic anhydrase inhibitor, A=ammonium chloride, R=renal tubular acidosis (SJE, RA, SLE, PBC)

Question 13

What are prerenal causes of renal failure?

Answer 13

Hypotension, effective volume depletion e.g. dehydration, cirrhosis, congestive heart failure, sepsis, 3rd space sequestration

Question 14

What are postrenal causes of renal failure?

Answer 14

Urinary obstruction, stones, urethral obstruction, BPH

Question 15

What are renal causes of renal failure?

Answer 15

Rapidly progressive glomerulonephritis, vasculitis, acute tubular necrosis, tubulointerstitial nephritis, etc.

Question 16

What are the Ix for renal failure?

Answer 16

• CBP, RLFT, CO2, Cl, Ca, PO4, amylase, urate, LDH, arterial blood gas, CK;
• 24 hr urineNa K Cr, total protein;
  (*Assessment of creatinine clearance/eGFR in non-steady state is not reliable)
• Autoimmune markers: ANF, Anti-DsDNA, Anti ENA, C3/4, ANCA, anti-GBM,
• ASOT, cryoglobulin
• Ig pattern, Serum electrophoresis, urine electrophoresis
• Spot urine x TP/ Cr ratio, dysmorphic RBC, eosinophil;
• MSURM C/ST;
• HBsAg/Ab, anti HBc, anti-HCV (Urgent HBsAg and anti HCV if
  haemodialysis is anticipated)
• CXR, ECG
• Urgent KUB, USG kidneys

Question 17

How to identify the potential of a organ donor for renal transplant?

Answer 17

Definitie dx, irreversible CNS damage
Brain death is imminent
Put on mechanical ventilation
GCS 3-5/15
Both pupils fixed to light

Question 18

What is the exclusion criteria for renal transplant donor?

Answer 18

 Uncontrolled fulminant infection;
 Risk of transmission of disease caused by prions, including Creutzfeldt-Jakob disease, rapid progressive dementia or degenerative neurological disease;
 History of IV drug abuse;
 HIV +ve cases or has risk factors for HIV infection;
 Presence or previous history of malignant disease (except primary basal cell carcinoma, carcinoma in-situ of uterine cervix and some primary tumour of CNS)
 Unknown cause of death
 Victims of intoxication of toxic substance

Question 19

What is the aim of maintenance of organ perfusion of potential donor?

Answer 19

 Maintain SBP 100–140 mmHg, AR 60–120 bpm
 Maintain Mean BP > 80 mmHg
 Maintain CVP of 8–12 cm H2O
 Maintain hourly urine output ~100 ml
 Maintain intake and output balance and cover insensible loss
 Maintain SaO2 ≥ 95%
 Maintain body temperature >36°C

Question 20

What is management for potential renal donor?

Answer 20

a. Monitor BP, P, CVP, urine output, SaO2, ventilator status q1h, body temperature q2h
b. Monitor electrolytes, RLFT, Ca/PO4 q6–8h, H’stix q2–4h
c. Set two good IV lines, preferably one central line
d. Monitor BP:
- If persistently hypertensive (MBP >120 mmHg), start labetalol 5 mg IV over 1 min and repeat at 5 min intervals if necessary
- If persistently hypotensive (SBP ≤100 mmHg)
 Start fluid replacement by infusing crystalloid or colloid
 Add dopamine 2.5–10 micrograms/kg/min if BP persistently low despite adequate fluid replacement
 Add adrenaline (1– 60 micrograms/min) or noradrenaline (3–60 micrograms/min) infusion
 If BP persistently low: start hydrocortisone 100 mg stat & 100 mg q8h
e. Monitor urine output:
- If massive urine output (> 200 ml/hour)
 Control hyperglycaemia (H’stix > 12 mmol/L persistently) by Actrapid HM infusion at 2–6 units/hour
 Control diabetes insipidus (serum Na ≥150 mmol/L) by dDAVP 2–6 microgram IV q6–8h
 Control hypothermia (body temperature ≤35°C) by apply patient warming system
- If oliguric (hourly urine <30 ml)
 Check Foley patency
 Oliguria with low or normal CVP, start fluid replacement
 Oliguria with high CVP, start lasix 20–250 mg IVI
f. Add prophylactic antibiotics after blood culture if fever >38°C

Question 21

What is the routine arrangement in potential renal donor?

Answer 21

a. Inform transplant coordinator via hospital operator at any time
b. Interview family for grave prognosis, do not discuss organ donation with family until patient is confirmed brain death
c. Once the patient meets brain death criteria, arrange qualified personnel to perform brain stem death test.

Question 22

What are the Ix for hypokalemia?
What is important history assessment for hypoK?

Answer 22

RFT, total CO2 content, Cl-, Mg, TFT, cortisol
Simultaneous blood and urine x TTKG (transtubular K gradient) or 24h urine for K/urine K/Cr
Aldosterone renin ratio if confirmed urinary K loss (after correction of hypoK)
Check baseline ECG

Check drug history especially diuretic therapy
Usually associated with metabolic alkalosis
Consider Mg depletion if hypokalemia is resistasnt to treatment
Don’t give K replacement therapy in dextrose solution

Question 23

What is the management of hypokalemia when serum K>2.5/<2.5?
Hypokalemia associated with metabolic acidosis?

Answer 23

If serum K >2.5mmol/L and ECG changes are absent:
Oral K replacement (syrup KCL 2-3g Q4H for 2-3 doses)
KCl 10-20mmol/hour in saline infusion (up to 40mmol/L) as continuous IV infusion

If serum K <2.5mmol/L and/or ECG changes present:
Consult ICU and cardiac monitor
KCl 20mmol/hour in saline infusion (concentration up to 80-100mmol/L; given via central vein for high conc KCl)
May combine with oral KCl 30-40mmol (3-4gm syrup KCl) Q4h

HypoK with metabolic acidosis
Give potassium citrate solution (1mmol/mL) 15-30mL 4x/day in juice after meals; start K replacement before HCO3- therapy in separate IV line if indicated

Question 24

What is the dosage form for treating hypokalemia?
What is the common pre-mixed K containing solution for maintenance IV infusion?

Answer 24

Dosage form:
Syrup KCl ( 1 gram = 13.5 mmoles K );
Slow K ( 8 mmoles K / 600 mg tablet );
Potassium citrate ( 1 mL = 1 mmole K );
Phosphate-sandoz ( 3 mmoles K, 16 mmoles phosphate / tablet ).

Common Pre-mixed K-containing solution for maintenance IV infusion
0.9% NS with 10 mmoles K / 500 mL (K conc: 20 mmol/L)
0.9% NS with 20 mmoles K / 500 mL (K conc: 40 mmol/L)
5% D5 with 10 mmoles K / 500 mL (K conc: 20 mmol/L)
5% D5 with 20 mmoles K / 500 mL (K conc: 40 mmol/L)
Lactated Ringer’s with 2 mmoles K /500 mL (K conc: 4 mmol/L)

Question 25

What are the causes of hypocalcemia?

Answer 25

Chronic renal failure, hypoparathyroidism, resistance to PTH
Consider sequestration of calcium (acute pancreatitis, rhabdomyolysis, tumor lysis syndorme), vit D deficiency, medications (bisphosphonate, cincalcet)
Rule out hypomagnesemia
Beware of pseud-hypocalcemia due to hypoalbuminemia (check corrected Ca or ionized Ca)

Question 26

What is Ix and Rx for hypocalcemia?

Answer 26

Ix: ionized Ca level, PO4, ALP, Mg, RFT, PTH, vit D, amylase, CK, ECG
Rx:
symptomatic hypocalcemia
correct hypomagnesemia
10% calcium culconate 20ml IV over 10-15 mins than 30ml 10% Ca gluconate in 500mL NS/D5 Q4-6H/pint
Monitor Ca level

Chronic cases (add vit D if no response after 2-4g Ca)
Ca supplement: caltrate (600mg elemental Ca/tablet), oscal (250mg elemental Ca/tablet), Ca gluconate (27mg elemental Ca/tablet)
Vit D: calcitriol: 0.25-2mg daily

Question 27

What electrolyte abnormalities associated with hypomagnesemia?
What conditions associated with hypoMg?

Answer 27

Associated with hypoK, hypOCa, arrhythmia, seziure
Due to increase renal loss or decrease GI absorption,
Common in chronic alcoholic
Check concomitant medication use (cyclosporine, diuretics, aminoglycoside, amphotericin B, PPI)
Check family history

Question 28

What is Ix for hypoMg?
What is rx in emergency, less urgent and chronic cases?

Answer 28

RFT, K, Ca, ECG
24h urine Mg excretion or fractional excretion (FE) of Mg = 100 x (UMgx PCr)/ (0.7 xPMg x UCr)

Emergency Rx: 4 mL 50% MgSO4 solution IV in 20mL NS/D5 infused over 15 mins then 10mL 50% MgSO4 in 500mL NS/D5 over 6 hours

Less urgent cases: 4ml MgSO4 (8mmol) solution in 500ml NS/D5 Q8H for 1 day

Chronic cases: normal average daily intake of Mg 15mmol (1/3 is absobred)
Mg supplement: Mylanta/Gelusil: 3.5mmol/tablet; Mg lactate 168 mg BD (better GI absorption)
Amiloride: 5-10mg daily PO (decreases urinary Mg loss)

Question 29

What is Rx for severe hypermagnesemia?

Answer 29

• Take off Mg supplement if any
• Saline diuresis: NS 300–500 mL/hr infusion
• 10% Calcium gluconate 10–20 mL in 100 mL NS over 15 minutes
• Furosemide 20 – 40 mg Q2-4H (aim at urine output ~ 200 mL/hr )
• Urgent haemodialysis if necessary

Question 30

What is Ix and Rx for hyperP?

Answer 30

Ix: RFT CaPO4 CO2 ALP
Rx:
1. Low phosphate diet.
2. Start phosphate-binder with meal e.g. caltrate, sevalamer, alusorb
3. Arrange dialysis if necessary.

Question 31

What are causes for hypoP?

Answer 31

Malabsorption, vit D deficiency
Transcellular shift (refeeding syndrome, respiratory alkalosis), hungry bone syndrome
Increase urinary loss: primary hyperparathyroidism, increase phosphatonins (FGF23), renal tubular defects (Fanconi syndrome)

Question 32

What is Ix and Rx for hypoP?
When PO4 <0.5 (mild), <0.3 with symptoms, chornic therapy

Answer 32

Check RFT serum Ca/PO4 ALP, vit D, PTH Fractional excretion (FE) of phosphate:
FE = 100(UpPCr) / (UCrPp)
(In the presence of hypoPO4, FE >5% indicates urinary loss)

Rx: Usually required no treatment if serum PO4 >0.5 mmol/L Rapid IV PO4 replacement may cause symptomatic acute hypocalcaemia
Suggested rate of replacement ~0.08–0.16 mmol/kg per 6 hours

Mild hypophosphataemia (PO4 <0.5 mmol/L)
- Oral PO4 replacement (e.g. Sandoz-phosphate tab 1 four times a day PO) (16 mmoles PO4; 20 mmoles Na; 3 mmoles K / per tablet)
-
If serum PO4 <0.3 mmol/L with symptoms:
- IV 6 mL potassium di-phosphate solution in 500 mL D5 Q12H infusion (Potassium di-phosphate solution: 14.5 mmoles PO4 + 25 mmoles K per 10 mL solution)
- Rapid IV replacement may cause acute symptomatic hypocalcaemia and CaPO4 precipitation; switch to oral replacement when PO4 >0.5 mmol/L

Chronic therapy:
- Treat Vitamin D deficiency if present
- Sandoz-phosphate 1 tablet four times a day PO
- Dipyridamole 75mg three to four times a day (for renal phosphate
wasting)

Question 33

What is cause of hypervolemic hypernatremia?
What is treatment?

Answer 33

(Primary Hyperaldosteronism, Cushing’s syndrome, acute salt overload)
- Treat the underlying disorder
- Start D5 infusion to correct water deficit;
- Add furosemide 40–80 mg IV or PO Q12–24H

Question 34

What is the cause of isovolemic or hypovolemic hypernatremia?
How is it managed?

Answer 34

(Diabetes insipidus, osmotic diuresis, large insensible water loss [sweat], renal / GI loss)
- For haemodynamic unstable patient
- Correct the volume status by isotonic fluid
- Early administration of water via PO or RT if possible
- Replace fluid with D5 or 1⁄2 : 1⁄2 solution Q6–8H; more rapid correction is warranted for acute hypernatraemia.
- Rate of correction: <8–10 mmol/L in 24h. Rapid correction may lead to cerebral oedema
- Body water deficit (L) = {0.6BW(kg)(measured [Na]–140)}/140
- Close monitoring of [Na] and glucose during treatment; correction of hyperglycaemia if necessary

Question 35

What is the management of acute and chronic central DI?
Chronic nephrogenic DI?

Answer 35

For acute central DI: give DDAVP 4-8 microgram Q 3-4 H prn;
For chronic central DI: DDAVP 10-40 microgram daily intranasally (in one to two divided doses)
For chronic nephrogenic DI:
- Decrease salt and solute intake
- Thiazide diuretic, e.g. hydrochlorothiazide 25 mg daily, indapamide
2.5 mg daily, amiloride 5 mg daily

Question 36

What is the Ix and hints for finding out underlying cause of hyperNa?

Answer 36

• Ix: serum/urine osmlality, serum glucose, Na, K and Ca
• Check drug history e.g. lithium
• Urine osmolarity <300 mOsm/L in hyperNa is suggestive of DI
• Estimate daily solute excretion (urine osmolality x urine volume) for osmotic diuresis
• Response to DDVP to differentiate between central vs nephrogenic DI

Question 37

How to assess adaptive response to primary acid base disorder?

Answer 37

Question 38

In acid base disorder after assessing adaptive response, what are the next steps?

Answer 38

• Calculate serum anion gap to look for unmeasured anion
• Calcualte the osmolar gap for increase AG metabolic acidosis to look for unmeasured osmoles (e.g. methanol, toxic alcohol ethylene glycol). Osmolar gap = measured osmolarity-(2x (Na+K) + urea+ glucose) Normal <10
• Patients with acidosis. Compare AG with serum HCO3 (abnormal if discrepancy >5). AG>serum HCO3-: mixed metabolic acidosis. AG <serum HCO3-0: mixed normal anion gap/ increased AG metabolica acidosis
• Measure urine electrolytes, pH

Question 39

What information can the urine eletrolytes/pH give in acid base disorder?
For patients with metabolic alkalosis
Suspected renal tubular acidosis

Answer 39

Patients with metabolic alkalosis
* Urine Cl<15mmol/L: chloride responsive alkalosis e.g. vomiting, chronic diuretic use
* Urine Cl>15mmol/L: chloride resistant metabolic alkalosis e.g. mineralcorticoid excess, alkali administration, severe hypoK during diuretic therapy

Suspected RTA. Appropriate renal response in acidosis: -ve
Urine osmolar gap: urine osmolarity - 2(Na+K) - urea-glucose/2 (normal >30)
* Abnormal value indicates low ammonium excretion (inappropriate renal response to acidosis e.g. RTA)
* False positive conditions: presence of unusual anions in urine e.g. ketone, toluence metabolites (such as hippuric acid), drug anion, excessive bicarbonaturia, urine pH>6.5
* Check urine pH (>5.3 for distal RTA (hyperK), <5.3 for proximal RTA (inability to excrete H+ despite metabolic acidosis), hypoK)

Question 40

What is the therapeutic options in patient with metabolic acidosis?

Answer 40

Question 41

What is the therapeutic options in patient with metabolic alkalosis?

Answer 41

Question 42

What is the periop management in uremic patients?

Answer 42

Question 43

What is the treatment of acute kidney injury?

Answer 43

Question 44

What is the treatment of chronic kidney disease/ End stage kidney disease?

Answer 44

1. Consult nephrologist for assessment of feasibility of long-term renal replacement therapy.
2. Avoid blood taking / BP measurement from AV fistula arm.
3. Monitor AV fistula daily for HD patients.
4. Monitor exit site condition and dressing daily for CAPD patients.

Question 45

What are the SS of emergencies in renal transplant patients?

Answer 45

Fever: underlying infection, acute graft rejection
Oliguria/anuria

Question 46

Fever is a emergency in renal transplant patients
What is the 2 main causes for fever?
How to workup the patients?

Answer 46

Question 47

Oliguria/anuria is a emergency in renal transplant patients
What is the ddx?
How to workup the patients?

Answer 47

Question 48

What is the drug dosage adjustment in renal failure?

Answer 48

Question 49

What are common drugs not requiring dosage adjustment in renal failure?

Answer 49

Question 50

What are the drugs that interact with calcineurin inhibitor (tacrolimus, cyclosporine)?

Answer 50

Question 51

Define CAPD related peritonitis
What is the general management?

Answer 51

Question 52

What is the CAPD peritonitis intermttet dosing method?

Answer 52

Question 53

What are the gram+ve organisms causing CAPD peritonitis?
What types and antibiotics duration and special remarks?

Answer 53

Corynebacterium species: at least 21 days
Enterococcus: at least 21 days (consider adding IP aminoglycoside for synergistic effect)
MSSA: at least 21 days. Substitute vancomycin with cefazolin to avoid emergence of VRE. Consider adding rifampciin PO (450mg daily for <50kg; 600mg daily for >50kg) for 3-5 days as an adjunct for the prevention of relapse or repeat peritonitis
MRSE/MRSA: if vancomycin is used (either IP or IV, 1 gram every 5-7 days), check vancomycin trough aiming 15-20ug/ml at least 3 weeks
Other gram+ve: at least 14 days

Question 54

What are the gram-ve organisms causing CAPD peritonitis?
What types and antibiotics duration and special remarks?

Answer 54

SPICE (serratia, pseudomonas, indole positive organisms e.g. proteus and providentia, citrobater and enterobacter): give 2 different antibiotics acting in different ways that organism is sensitive to (IP amikacin + IP ceftazidime) for 21 days
Pseudomonas or stenotrophomonas: give 2 different antibiotics acting in different ways that organism is sensitive to (e.g. PO septrin + PO levofloxacin for stenotrophomonas); duration (21-28 days)
Other gram-ve: antibiotics given for at least 21-28 days

Question 55

What are the polymicrobial organisms causing CAPD peritonitis? Culture negative peritonitis? Fungal peritonitis?
What types and antibiotics duration and special remarks?

Answer 55

Polymicrobial peritonitis
Mixed gram +ve/gram -ve or mixed gram -ve organisms: antibiotic of choice (carbapenem/tazocin) or antibiotics according to sensitivity. Duration: 21-28 days
Mixed gram positive: antibiotics according to sensitivity testing. Duration: 14-21 days (depending on type of organisms, see above)

Culture negative peritonitis: if response to initial antibiotics, keep the same regime for 14 days. If refractory peritonitis, consider further workup to rule out mycobacterium peritonitis, fungal peritonitis or other non infectious causes

Fungal peritonitis: empirical treatment for fungal peritonitis: amphotericin B30mg/200ml D5 IV infusion over 6 hours daily.
Duration: at least 14 days after catheter removed

Question 56

What is done for workup of CAPD peritonitis?

Answer 56

• If there is evidence of septicemia, admit patient and give parenteral antibiotics
• Change antibiotics later according to c/st result and adequate duration of antibiotics
• Repeat PDF for absolute WCC and gram smear, culture on day 3-5 after started or changed antibitics with reassessment of S/S
• If clinically responds to medical therapy, repeat PDF for absolute WCC and gram smear, culture after completion of all antibiotics
• Arrange transfer set change when post treatment culture come back to be negative with WCC <100/mm
• For refractory peritonitis: arrange removal of Tenckhoof catheter. Continue appropriate antibiotics for 2 weeks after catheter removal. Consider re-insertion of catheter at least 2-3 weeks after removal of catheter

Question 57

What is the protocal for treatment of CAPD exit site infection?

Answer 57

Exit site infection: purulent discharge from exit site
Treatment: equivocal exit site infection (chlorhexidine dressing TDS, consider local treatment in appropriate case e.g. 0.1% gentamycin cream, 2% mupirocin cream to exit site wound TDS)

Exit site infection
* Oral penicillinase resistant penicillin (cloxacillin 500-1000mg 4x a day) or a 1st gen cepahlosporin (cephalexin 500mg BD to TDS) for 14 days if gram +ve organism suspected
* Oral fluoroquinolones e.g. levofloxacin 250mg daily po for 14 days if gram -ve organism suspected. Treatment for at least 3 weeks is probably necessary for exit site infection caused by pseudomonas aeruginosa. 2 different kinds of antibiotic may be necessary for P. aeruginosa ESI.
* Change antibiotics according to culture and sensitivity result
* For slowly resolving or severe S. aureus exit site infection –> add rifampicin 450mg daily
* If ESI + peritonitis: arrange early removal of Tenckhoff catheter.

• Refractory ESI: double cuffed Tenkhoff catheter, consider shaving of external cuff if the external cuff is eroded and extruded
• Recurrent ESI: counsel on personal hygiene. Screen for carrier of drug resistant organisms (nasal swab for MRSA) and consider decolonization of appropriate)

Question 58

What is the frequency of intermittent peritoneal dialysis (PD volume, dialysis and drain time) and the content?
What are relative contraindications to peritoneal dialysis?

Answer 58

Question 59

What is the prep for Tenckhoff catheter insertion?

Answer 59