PrescriptionPrescription peritoneal dialysis peritoneal dialysis

Pantipa Tonsawan, MD

Case Case

Female , 50 yrs, ESRD Female , 50 yrs, ESRD ตั�ดสิ�นใจเลื�อก ตั�ดสิ�นใจเลื�อก PD PD

BW 50 kg , Ht 155 cm BW 50 kg , Ht 155 cm ((BSA 1.50m2, BSA 1.50m2, GFR 2ml/min =GFR 2ml/min = CCr 20L/wkCCr 20L/wk แลืะ แลืะ Kt/V = Kt/V = 0.5 /wk0.5 /wk ) ) เคยประเมิ�น เคยประเมิ�น PET PET อย��ในกลื��มิ อย��ในกลื��มิ low low average transport average transport ถ้�าตั�องการสิ��งการร�กษาถ้�าตั�องการสิ��งการร�กษาเป�นไปตัามิ เป�นไปตัามิ NKF-DOQI NKF-DOQI ((weely CCr ≥ weely CCr ≥ 60L/1.73m260L/1.73m2 ) ) จะตั�องสิ��งการร�กษาอย�างไรจะตั�องสิ��งการร�กษาอย�างไร

ESRD ??????ESRD ??????

Mode PD Vs HDMode PD Vs HD PD :CAPD or APDPD :CAPD or APD APD : CCPD, NIPD TPDAPD : CCPD, NIPD TPD Prescribe?? :Dwell time , fill volume Prescribe?? :Dwell time , fill volume

, cycle, tidal volume , cycle, tidal volume Follow up : lab, adequacyFollow up : lab, adequacy

Indication / Contraindications Indication / Contraindications of PDof PD

80% of patients have no contra-80% of patients have no contra-indication to any of the dialysis indication to any of the dialysis methods and may choose according to methods and may choose according to their life style between HD their life style between HD oror PD PD

Absolute contra-indicationsAbsolute contra-indications of PD: of PD: 1.peritoneal fibrosis and adhesions 1.peritoneal fibrosis and adhesions

following intrafollowing intra--abdominal operations abdominal operations 2.inflammatory gut diseases 2.inflammatory gut diseases

pleuro-peritoneal pleuro-peritoneal leakageleakage (Hydrothorax) (Hydrothorax)

herniahernia significant loin painsignificant loin pain big polycystic kidneys big polycystic kidneys

Relative Relative CContraontra--indications of PDindications of PD

• severe deformity arthritis • psychosis• significant decrease of lung

functions

* diverticulosis

• colostomy • obesity

• blindness

PD :Advantage PD :Advantage

Preserve residual renal functionPreserve residual renal function Control acid- baseControl acid- base HD stableHD stable No vascular accessNo vascular access Control HTControl HT No anticoagulantNo anticoagulant

Why toWhy to start with PD ?

Clinical outcomes comparable to HD, no difference

Saves vascular access Preferred for children (APD) Modality choice is a lifestyle

issue Control HT

USRDS annual reports covering the cohortUSRDS annual reports covering the cohort

Adjusted allAdjusted all--cause DR for nondiabetic cause DR for nondiabetic patients treated with HD and PDpatients treated with HD and PD..

J Am Soc Nephrol 10:354-365, 1999

USRDS annual reports covering the cohort

Adjusted allAdjusted all--cause DR for younger cause DR for younger ((age age <50<50 ) ) diabetic patients treated with HD diabetic patients treated with HD

and PDand PD..

J Am Soc Nephrol 10:354-365, 1999

J Am Soc Nephrol 10:354-365, 1999

Adjusted allAdjusted all--cause DR for younger cause DR for younger ((age age >50>50 ) ) diabetic patients treated with HD diabetic patients treated with HD

and PDand PD..

Mortality studies comparing peritoneal Mortality studies comparing peritoneal dialysis and hemodialysisdialysis and hemodialysis : : what do they what do they

tell us?tell us? Total of six largeTotal of six large--scale registry studies & three prospective scale registry studies & three prospective

cohort studies conducted in the United States cohort studies conducted in the United States ((USUS)), Canada, , Canada, Denmark, and the Netherlands were reviewedDenmark, and the Netherlands were reviewed . .

PD PD was generally found to be associated was generally found to be associated with equal or betterwith equal or better survival among survival among nonnon--diabetic patients and younger diabeticdiabetic patients and younger diabetic patientspatients

older diabeticolder diabetic patients, patients, results variedresults varied by country by country Canadian & Danish :Canadian & Danish :no difference in survivalno difference in survival between PD & between PD &

HDHD US, HD associated with better survival for diabetics aged 45 US, HD associated with better survival for diabetics aged 45

and olderand older

Kidney Int SupplKidney Int Suppl 2006 1. Nov;( 2006 1. Nov;(-03 311):S .-03 311):S .

Conclude Conclude

overall patient survival is similar for PD overall patient survival is similar for PD & HD & HD but that important differences do exist but that important differences do exist within select subgroups of patients, within select subgroups of patients, particularly those subgroups defined by age particularly those subgroups defined by age and the presence or absence of diabetesand the presence or absence of diabetes..

Dose residual renal function decline in HD more Dose residual renal function decline in HD more than PDthan PD

Advancce in peritoneal dialysis ;vol 20 ;2004

Why to start with PD ?Why to start with PD ?

Why to start with PD ?Why to start with PD ?

1. better maintenance of residual renal function1. better maintenance of residual renal function

NECOSAD study group KI :2002

Why to start with PD ?Why to start with PD ?Dose residual renal function decline in HD more than PDDose residual renal function decline in HD more than PD

Decline residual renal function :20-80 %

SELECTION OF DIALYSIS MODALITYSELECTION OF DIALYSIS MODALITY  

PD/HDPD/HD Indication & ContraindicationIndication & Contraindication PreferPrefer Family member, care giverFamily member, care giver Underlying disease Underlying disease Socioeconomic statusSocioeconomic status

Term PD cycle Term PD cycle

Inflow

Outflow

Dwell time

Fill volume Exchange

volume, dwell volume

Tidal volumeStart

Last fill

Dwell time

Principle of dialysis

Fill volumeFill volume :risk factor:risk factor

UF failureUF failure Increase Increase

morbidity & morbidity & mortalitymortality

Pain, abdominal Pain, abdominal discomfortdiscomfort

DyspneaDyspnea Hernia formationHernia formation HydrothoraxHydrothorax Loss UF by enhance Loss UF by enhance

lymphatic drainagelymphatic drainage

Low fill volume high fill volume

Tidal volumeTidal volume

Increase amount ;diffusionIncrease amount ;diffusion Increase : toxin removalIncrease : toxin removal

Inflow + outflow: limit Inflow + outflow: limit

Depend of catheter resistant or Depend of catheter resistant or obstructionobstruction

GravityGravity Drain volumeDrain volume

ModeMode Peritoneal dialysis

Continuous Intermittent

CAPD CCPD NIPD DAPD

Standard vol.Standard dose

High volumeStandard dose

Standard vol.High dose

High vol.High dose

High NIPD

NTPD

Add

ModeMode

CCPD :Continuous cyclic peritoneal dialysis

CAPD :continuous ambulatory peritoneal dialysis

DAPD :daytime ambulatory peritoneal dialysis

NIPD :night-time intermittent peritoneal dialysis

Factors that need to be taken into account in choosing CAPD or APD

CAPD APD Easy technique More difficult

Daytime exchange can be difficult if working or carier doing exchanges

None (with icodextrin) or only 1 daytime exchange

Poor UF if high transporter requiring use of higher concentration glucose exchanges

Easier to achieve good UF independent of transporter status

Some difficulty to increase adequacy by increasing number or volume of exchanges

Easier to increase adequacy by increasing number of exchanges overnight/daytime

Increasing exchange volume leads to increased intra-abdominal pressure when patient ambulant. Increased risk of hernia

Intra-abdominal pressure lower when supine. Decreased risk of hernia; better management of patient with hernias, leaks

Ease of travel Can travel with machine or revert to CAPD

Peritonitis rate 1 episode/20–30 months Peritonitis rate 1 episode/30–40 months

PD – First prescriptionPD – First prescription

Consider;Consider;– Size – BSASize – BSA– Residual renal functionResidual renal function– PET – but only if you can PET – but only if you can tell the tell the

futurefuture– Mode :CAPD or APDMode :CAPD or APD

 Solute transport determined by PET.BSA, body surface area; N, night; D, day.

Brown, et al. J Am Soc Nephrol. 2003;14:2948-2957.

   

Prescribing APD – EAPOS Prescribing APD – EAPOS guidelinesguidelinesSolute Solute

TransportTransport LowLow Low Low AverageAverage

High High AverageAverage HighHigh

BSA BSA < 1.71 m< 1.71 m22

CAPDCAPD N: 3 x 2.5 L N: 3 x 2.5 L (9-10 hr) (9-10 hr)

D: 2 x 2LD: 2 x 2L

N: 4 x 2 L N: 4 x 2 L (8 hr) (8 hr)

D: 2 x 2LD: 2 x 2L

N: 4 x 2.5 L N: 4 x 2.5 L (8 hr) (8 hr)

D: 2 x 2LD: 2 x 2L

BSA BSA

1.71 – 2.0 m1.71 – 2.0 m22

CAPD or HDCAPD or HD

APD APD N: 3 x 2 L N: 3 x 2 L

(9-10 hr) (9-10 hr)D: 2 x 2 LD: 2 x 2 L

N: 3 x 2.5 L N: 3 x 2.5 L (9-10 (9-10 hr)hr)

D: 2 x 2.5LD: 2 x 2.5L

N: 4 x 2.5 L N: 4 x 2.5 L (8 hr) (8 hr)

D: 2 x 2.5L D: 2 x 2.5L

N: 4 x 2.5 L N: 4 x 2.5 L or 5 x 2 or 5 x 2 L (8 hr)L (8 hr)

D: 2 x 2.5 LD: 2 x 2.5 L

BSA BSA 2.0 m2.0 m22

CAPD or HDCAPD or HD CAPD or HDCAPD or HD

APD APD N: 3 x 3 L N: 3 x 3 L

(9-10 hr) (9-10 hr)D: 2 x 3 L D: 2 x 3 L

N: 4 x 3 L N: 4 x 3 L (8 hr) (8 hr)

D: 2 x 2.5L D: 2 x 2.5L

N: 4-5 x 2.5 N: 4-5 x 2.5 L (8 L (8 hr)hr)

D: 2 x 2.5 L D: 2 x 2.5 L

Choice of PD scheme depends of BSA and Choice of PD scheme depends of BSA and type of transporttype of transport

CAPD Vs APDCAPD Vs APD

Copyright restrictions may apply.

Rabindranath, K. S. et al. Nephrol. Dial. Transplant. 2007 22:2991-2998; doi:10.1093/ndt/gfm515

Impact of PD modality on various clinically important outcomes

Copyright restrictions may apply.Rabindranath, K. S. et al. Nephrol. Dial. Transplant. 2007 22:2991-2998; doi:10.1093/ndt/gfm515

Complications expressed as episodes per patient-year

Automated vs continuous ambulatory peritoneal dialysis :a systematic review of randomized controlled trials

The Cochrane Collaboration, currently published in The Cochrane Database of Systematic Reviews 2009 Issue 3,

The influence of automated peritoneal The influence of automated peritoneal dialysis on the decrease in residual renal dialysis on the decrease in residual renal functionfunction

Nephrology Dialysis Transplantation, 1999,Vol 14, Issue 5 1224-1228,

APD 18 pts compare CAPD 18 pts : F/U 6 mo & 1 yr

SummarySummary

APD CAPD : peritonitisAPD CAPD : peritonitis Caution APD decline RRF > CAPDCaution APD decline RRF > CAPD Other non significantOther non significant SelectionSelection method method :1. patient :1. patient

contraindication , preference base on contraindication , preference base on life style, comfort with cycler & family life style, comfort with cycler & family + social support+ social support

2.medical requirement: 2.medical requirement: adequacyadequacy

PrescriptionPrescription

Acute peritoneal dialysisAcute peritoneal dialysis Chronic peritoneal dialysisChronic peritoneal dialysis

Acute peritoneal dialysisAcute peritoneal dialysis orderorder

Session lengthSession length: 24 hr at time: 24 hr at time Exchange volumeExchange volume :depend size of :depend size of

peritoneal cavity, tolerate 2-L peritoneal cavity, tolerate 2-L exchangeexchange

Smaller dose :pulmonary diseaseSmaller dose :pulmonary disease Prefer start :1-1.5 L :1Prefer start :1-1.5 L :1stst exchange exchange

((leakageleakage)) In large pt or hypercatabolic : 2.5- In large pt or hypercatabolic : 2.5-

3 L3 L

Acute peritoneal dialysisAcute peritoneal dialysis orderorder

Exchange timeExchange time :inflow , dwell & :inflow , dwell & draindrain

Dialysis solution Dialysis solution : depend on : depend on indicationindication

standard 1.5standard 1.5 %, high : 4.25 %%, high : 4.25 %

DextrosDextrosee

GlucoseGlucose SolutionSolutionosmolarityosmolarity

UltrafiltrationUltrafiltrationvolumevolume

g/dlg/dl g/dl mg/dl mmol/L g/dl mg/dl mmol/L

mOsm/LmOsm/L ml per L per dayml per L per dayexchange exchange

1.51.5 1.36 1360 761.36 1360 76 346346 50-150 1.2-3.650-150 1.2-3.6

2.52.5 2.27 2270 1262.27 2270 126 396396 100-300 2.4-7.2100-300 2.4-7.2

4.254.25 3.86 3860 2153.86 3860 215 485485 300-400 7.2-9.6300-400 7.2-9.6

Table : Estimated ultrafiltration volume during acute peritoneal dialysis

2 L exchange volume, 60 min exchange time

Handbook of dialysis 4th ed 2007

Acute peritoneal dialysis Acute peritoneal dialysis orderorder

1.

Acute peritoneal dialysis Acute peritoneal dialysis orderorder

2.

3.Complicatio

ns

Prescription of CAPDPrescription of CAPD

Dose : cycle/dayDose : cycle/day Volume : exchange volumeVolume : exchange volume Standard dose :3-4 time/dayStandard dose :3-4 time/day Standard volume :6-8 L/dayStandard volume :6-8 L/day Typical order :4* 2L dailyTypical order :4* 2L daily Dialysis solution: 1.5, 2.5 .4.25 %Dialysis solution: 1.5, 2.5 .4.25 %

Ca : low Ca , normal CaCa : low Ca , normal Ca

Augmentation UF :CAPDAugmentation UF :CAPD

Increase exchange volumeIncrease exchange volume Increase frequencyIncrease frequency Increase tonicityIncrease tonicity

Prescription Prescription ModificationModification

Prescription Prescription ModificationModification

Automated PD Automated PD

Mode : PET testMode : PET test Dialysis solution : glucose / CaDialysis solution : glucose / Ca Duration : dwell time, cycle, Duration : dwell time, cycle, Tidal volume :Tidal volume : Last fill volume Last fill volume :??:??

Initial APD prescriptionInitial APD prescription

Mode : NIPD Mode : NIPD Solution : 1.5%Solution : 1.5% Duration ;8-12 hrDuration ;8-12 hr Fill volume : 1.5-2.0 mlFill volume : 1.5-2.0 ml Dwell Day volume:2-L : Dwell Day volume:2-L :

caution :fluid reabsorption caution :fluid reabsorption ((if high if high transporttransport ) ) other choice : other choice : icodextrin :icodextrin : - water soluble glucose polymer- water soluble glucose polymer

First prescription First prescription KDOQIKDOQI

If GFR > 2 ml/minIf GFR > 2 ml/min If GFR < 2 ml/minIf GFR < 2 ml/min

How to improved How to improved clearance in clearance in APD ????APD ????

Prescription ModificationPrescription Modification

Prescription Prescription ModificationModification

Prescription Prescription ModificationModification

Using computer support to Using computer support to helphelp

Increase peritoneal Increase peritoneal

clearance ?clearance ?

Day dwell volumeDay dwell volume :increase Kt/V :increase Kt/V & CrCl 25-50 % & CrCl 25-50 %

Increase dwell volume on cycler Increase dwell volume on cycler Time on cyclerTime on cycler Increase frequency of cyclesIncrease frequency of cycles Increase tonicity of dialysis Increase tonicity of dialysis

solutionsolution

Prescription AIM Prescription AIM

Adequacy : Kt/VAdequacy : Kt/V EuvolemiaEuvolemia : PCWP ?: PCWP ?

== no edema : no edema : UFUF

normal BP &normal BP & minimize anti HT drugminimize anti HT drug

> 750 ml/d

<750 ml/d

Fluid Removal and Outcome

Initiate Therapy

Measure clearanceand UF

Adjust Therapy

Managing PD adequacy & Managing PD adequacy &

prescriptionprescription

Don’t forget!

PD – getting startedPD – getting started

Measure Clearances at 2-4 weeks, then Measure Clearances at 2-4 weeks, then 2-3 times in first 6 months2-3 times in first 6 months

Thereafter every 3-4 monthsThereafter every 3-4 months Measure PET at 1 monthMeasure PET at 1 month If urine volume low – use 48hr collectionIf urine volume low – use 48hr collection Leave clearances for a month after Leave clearances for a month after

peritonitisperitonitis P creatinine – CAPD anytime, APD mid P creatinine – CAPD anytime, APD mid

daytimedaytime

Case Case

Female , 50 yrs, ESRD Female , 50 yrs, ESRD ตั�ดสิ�นใจเลื�อก ตั�ดสิ�นใจเลื�อก PD PD

BW 50 kg , Ht 155 cm BW 50 kg , Ht 155 cm ((BSA 1.50m2, BSA 1.50m2, GFR 2ml/min =GFR 2ml/min = CCr 20L/wkCCr 20L/wk แลืะ แลืะ Kt/V Kt/V = 0.5 /wk= 0.5 /wk ) ) เคยประเมิ�น เคยประเมิ�น PET PET อย��ในกลื��มิ อย��ในกลื��มิ low low average transport average transport ถ้�าตั�องการสิ��งการร�กษาถ้�าตั�องการสิ��งการร�กษาเป�นไปตัามิ เป�นไปตัามิ NKF-DOQI NKF-DOQI ((weely CCr ≥ weely CCr ≥ 60L/1.73m260L/1.73m2 ) ) จะตั�องสิ��งการร�กษาอย�างไรจะตั�องสิ��งการร�กษาอย�างไร

Calculated Calculated Principle :Principle :

Total target CCr = Total target CCr = +

60 L/1.73 m2

20 L/1.73 m2

40 L/1.73m2

BSA pt 1.5 ;

Need =35 L/ week

*** Dialysis volume = dialysate CCr/ 7* D/Pcr ****

D/Pcr = ratio concentration of Cr ใน dialysate/plasma(24 hr)

Or estimated PET : D/Pcr at 6 hr

Weekly

??????

Calculated Calculated Need =35 L/ week

Dialysis volume = dialysate CCr/ 7* D/Pcr

Estimated PET : D/Pcr at 6 hr :low average transport = 0.59

= 35 /7*0.59

8.47 L/day(7.2)

ลดปริ�มาณ 10 -20 % : clearance ;ultrafiltration & convection

Mode

CCPD :Continuous cyclic peritoneal dialysis

CAPD :continuous ambulatory peritoneal dialysis

1.5 L * 5 cycle

2 * 4

2.5 * 3

Day time 1.5 L , Night : 2 L * 3 cycles

Vs Patient ; preference

SummarySummary Prescribing PD is important and Prescribing PD is important and

important factors includeimportant factors include– SizeSize– Transport statusTransport status– Residual renal functionResidual renal function– Other factorsOther factors

Check clinical statusCheck clinical status – supported by – supported by measurements eg UF and adequacymeasurements eg UF and adequacy

Blood pressure control in Blood pressure control in dialysis patient :HD Vs PDdialysis patient :HD Vs PD

Case Case Male , 50 yrs, ESRD with morbid obesity, BW Male , 50 yrs, ESRD with morbid obesity, BW

86 kg , Ht 155 cm 86 kg , Ht 155 cm ถ้�าตั�องการสิ��งการร�กษาเป�นไปตัามิ ถ้�าตั�องการสิ��งการร�กษาเป�นไปตัามิ NKF-DOQI NKF-DOQI ((weekly CCr ≥ weekly CCr ≥ 60L/1.73m260L/1.73m2 ) ) :prescribe?:prescribe?

Female 70 yrs, DM , HT ,ESRD & ICM BW Female 70 yrs, DM , HT ,ESRD & ICM BW 45 :prescribe?45 :prescribe?

Female , 40 years , ESRD , Hx TB peritonitis Female , 40 years , ESRD , Hx TB peritonitis * 2* 2 time on anti Tb drug complete time on anti Tb drug complete course :prescribe ?course :prescribe ?

Male 50 yrs ,ESRD, HT & alcoholic cirrhosis Male 50 yrs ,ESRD, HT & alcoholic cirrhosis child B ascites positive : child B ascites positive :

Different HD & PDDifferent HD & PD

Prefer PDPrefer PD Prefer HDPrefer HD