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In dialisi peritoneale qual è il miglior indice di adeguatezza dialitica tra Kt/V e Clearance della creatinina/ sett?. Dr. Renzo Scanziani Divisione di Nefrologia e Dialisi Azienda Ospedaliera di Desio e Vimercate. Bari, 20 marzo 2010. - PowerPoint PPT Presentation
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In dialisi peritoneale qual è il miglior indice di adeguatezza dialitica tra Kt/V e
Clearance della creatinina/ sett?
Dr. Renzo ScanzianiDivisione di Nefrologia e Dialisi Azienda Ospedaliera di Desio e Vimercate
Bari, 20 marzo 2010
• During the 1980s to 1990s large effort were made to quantify the dialysis prescription in both peritoneal dialysis and hemodialysis treatment based on kinetic modeling.
• Several different adequacy indices have been suggested, but at present mainly Kt/v urea (urea clearance normalized to total body water) and weekly creatinine clearance normalized to body surface area are used as estimates of PD adequacy
Heimburger O Contr Nephrol 2009; 163: 140
Adeguatezza Dialitica in DP negli anni
• Studio CANUSA e importanza del Kt/V e della CrCl
• ADEMEX e “ridimensionamento” dei target
• Importanza della funzione renale residua in dialisi peritoneale e altri fattori di adeguatezza
Churchill DN et al; JASN 1996, 7 (2):198-207
n = 680 pz incidenti
Kt/V Survival% CCr Survival%2.32.11.91.71.5
8178747166
9580705540
8681787265
Expected 2-year patient survival according to sustained weekly Kt/V and CCr(L/1.73 m2)
Studi osservazionaliCANUSA Study
“MORE DIALYSIS IS BETTER”
RECOMMENDED TOTAL SMALL SOLUTE CLEARANCE GOALS FROM VARIOUS
NATIONAL SOCIETIES
Society YearKt/V urea
Goal
Creatinina Clearance
Goal
NFK-DOQICAPD(Low and LA)CAPD(High andHA)CCPDNIPD
CANADIAN Low and LA High and HA
EUROPEAN
2000
1998
2002
2.02.02.12.0
2.02.0
1.7
60506366
6050
NA
UF
NANANANA
NANA
1 L
100%
90%
80%
70%
60%
50%
40%0 4 8 12 16 20 24 28 32 36
% P
atie
nt S
urvi
val
Months after randomization
RR (Treated:Control) = 1.00
95% CI: (0.80, 1.24)
p = 0.9842ControlTreated
Paniagua R et al; JASN 2002; 13: 1307-1320
Effect of Increased Peritoneal Clearances on Mortality Rates in Peritoneal Dialysis.
ADEMEX•gruppo di controllo (n=484)-> Kt/Vtot medio 1.8; CrCl 54.1 l/w
•gruppo di intervento (n=481)->Kt/Vtot medio 2.27; CrCl 62.9 l/w
Studio randomizzato, controllato (965 pazienti in 2 gruppi)
Effect of Increased Peritoneal Clearances on Mortality Rates in Peritoneal Dialysis.
ADEMEX
Paniagua R et al; JASN 2002; 13: 1307-1320
Relative Contribution of Residual Renal Function and Peritoneal Clearance to Adequacy of Dialysis:
A Reanalysis of the CANUSA Study
Bargman JM, JASN, 2001
VARIABILE RR di morte
EtàCDVSGACrCl peritoneale 5 l/WFRR (5 L/W)Volume urinario (per 250 ml)
1.022.420.741.000.880.64
For a 250 ml increment in urine volume,there was a 36% decrease in RR of death
La FRR è molto più importante della Clearance peritoneale (in parte per la miglior clearance di tossine a medio od alto PM)
ADEQUACY OF PERITONEAL DIALYSISGuidelines
A. Adequacy targets for dialysis should be include both urea removal and fluid removal (C)
B. These targets should be based on those achieved by peritoneal dialysis only. Urine production and renal urea clearance can be subtracted from the targets (C)
C. The minimum peritoneal target for Kt/Vurea in anuric patients is weekly value of 1.7 (A); the minimum peritoneal target for net UF in anuric patients is 1.0 l/day (B). The presence of residual renal function can compensate when these peritoneal targets are not achieved
D. When targets are not achieved patients should be monitored carefully for signs of overhydration, uraemic complaints and malnutrition (C)
E. In APD patients with a slow transport status an additional target of 45 l/week/1.73 m2 for peritoneal creatinine clearance should be aimed at in addition to achieving the Kt/Vurea target of 1.7 (C)
European Best Practice Guidelines; 2005
Nolph K.D. et al. Perit Dial Int 1992, Vol 12, pp 298-303
Weekly Ccr and Kt/V Urea
44 CAPD Pts
Weekly st Kt/Vu and stKt/Vcr levels calculated and shown as functions of sex and BSA
for CAPD prescriptions
Gotch F.A, Perit Dial int 2000, Vol 20, Suppl 2
Weekly Clearances of Urea and Creatinine on CAPD and NIPD
Nolph KD. PDI 1992; 12: 298-303
Weekly peritoneal creatinine clearance
Total dialysate volume liters
Wee
kly
CrC
l (Li
ters
) 8070605040302010
05 10 15 20 25 30 35 40
0,780,730,690,65
0,490,41
8.30 h NTPD
Durand et al, PDI 16:S167-170, 1996
CREATININE IS THE BEST MOLECULE TO TARGET
ADEQUACYOF PERITONEAL DIALYSIS?
Blake PG. PDI 2000;20 Suppl 2:S65-9
Conclusions• There is general agreement that target Kt/V urea in PD should be 1.7 or
higher
• Neither creatinine clearance nor urea clearance is the perfect index for predicting outcome in PD patients.
• Creatinine clearance gives greater weight to residual renal function, and residual renal function is probably a stronger predictor of patient outcome than peritoneal clearance per se.
• • Creatinine clearance has a particular weakness in low transporters; values
have to be interpreted with discretion in this group
• PD adequacy should be involve many other aspects of the treatment