Chronic Kidney Failure

PediatricCovers.
QX
2/17/04
1:55 PM
Page 1
Care of the Pediatric Patient

on Peritoneal Dialysis
Clinical Process for Optimal Outcomes
PediatricCovers.QX
2/17/04
1:55 PM
Page 2
CONTRIBUTING AUTHORS
Bradley A. Warady, M.D.

Franz Schaefer, M.D.
Steven R. Alexander, M.D.
Catherine Firanek, B.S.N.
Salim Mujais, M.D.
Cover art by Morgan Ghosey, age 16
Pediatric Guide-SC3.qxd
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Page 3

Introduction
Ensuring adequate dialysis and optimal patient care is a multifaceted process in children
with end stage renal disease who receive peritoneal dialysis. Whereas clinicians typically
utilize clinical and laboratory indices when attempting to define and achieve adequate
dialysis, optimal care cannot be achieved by focusing on solute clearances alone. Attention
to nutrition therapy, correction of anemia and growth retardation, control of osteodystrophy, prevention/treatment of peritonitis and preparation for transplantation are also
mandatory, and excellence in each aspect of management is necessary if an optimal
patient outcome is to be achieved.
Care of the Pediatric Patient on Peritoneal Dialysis was developed based on a review
of the current medical literature and the authors clinical experience. It has been designed
to serve as a resource that can be easily integrated into clinical programs caring for
children, with the discussion of each major topic consisting of a treatment algorithm
and a brief but pertinent review of associated background material. An appendix with a
variety of clinical tools and list of references is also included. By its nature, this guide
cannot be considered to be exhaustive, and users are encouraged to pursue specific issues
that may not be covered herein. This guide is also not intended to be the practice of
medicine, nor does it replace sound medical clinical judgment.
Children who receive peritoneal dialysis and their families are deserving of the best care
we can possibly provide, in order to give them every opportunity to achieve their desired
goals. The authors hope that the information contained within this guide assists you to
that end.
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Table of Contents
Predialytic Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Modality Selection and Preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
PD Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Automated Peritoneal Dialysis (APD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Continuous Ambulatory Peritoneal Dialysis (CAPD)
Ultrafiltration Management
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Peritonitis Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Management of Growth Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Recombinant Growth Hormone Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Management of Malnutrition
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Mineral Metabolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Management of Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Preparation for Transplantation
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Appendix:
Guidelines for 24-Hr Dialysate Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Guidelines for 24-Hr Urine Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Clearance Calculations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Residual Renal Clearance Calculations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
PET in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Measurement of Intraperitoneal Pressure (IPP)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
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Predialytic Monitoring
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
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CLINICAL PROCESS FOR OPTIMAL OUTCOMES
TREATMENT GOAL
Full compensation for the complications of chronic kidney disease
Timely preparation for transplantation
Seamless transition to dialysis
DIALYSIS INITIATION: ABSOLUTE INDICATIONS

GFR <8 mL/min/1.73m2 (average of urea and creatinine clearances)
Overt uremia (uremic pericarditis, pleuritis)
Manifest edema
Congestive heart failure
Clinical or biochemical signs of malnutrition, wasting
Persistent hypertension despite antihypertensive treatment
Repeated hyperkalemic episodes
DIALYSIS INITIATION: RELATIVE INDICATIONS

GFR 914 mL/min/1.73m2
Fatigue
Deteriorating school performance
Hyperphosphatemia despite maximal medication
Excessive serum calcium-phosphate product
Poorly controlled hyperparathyroidism
EVALUATION SCHEME
Assessment of length/height and weight gain, head circumference (infants), blood
pressure, acid-base status, electrolytes, serum creatinine, BUN, hemoglobin/hematocrit,

serum albumin, intact PTH, serum ferritin, transferrin saturation (TSAT), 24-hour urine
collection or Schwartz determination for GFR measurement every 23 months
Ambulatory blood pressure monitoring (ABPM), echocardiography, hand X-ray every
612 months
Neurodevelopmental assessment in infants every 6 months
When GFR <30 mL/min/1.73m2, initiate discussion regarding dialysis modality choice
versus pre-emptive transplant
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g
PREDIALYTIC MONITORING
Child with advanced chronic renal failure (calculated GFR <30 mL/min/1.73 m2)
Monitor renal function, anthropometric and nutritional status,

blood pressure, acidosis, electrolytes, hemoglobin/hematocrit, TSAT,
serum ferritin, intact PTH at least every 23 months, ABPM,
echocardiogram every 612 months; initiate discussions regarding
dialysis modality choice vs. pre-emptive transplant
GFR <8
GFR 914
GFR 1529
Evidence of malnutrition, compromised

cardiac function, fluid retention,
hypertension, hyperphosphatemia,
hyperkalemia, uncontrolled
hyperparathyroidism despite adequate
medical treatment?
ood
matocrit,
ur urine
no
at least one yes
every
Select dialysis modality.
Initiate dialysis
choice
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Modality Selection and

Preparation
Modality Selection
and Preparation
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Modality Selection
Modality Selection and
Preparation
TREATMENT GOAL
Improvement of patients physical and mental well-being
Adequate performance of home dialysis by caregivers
Minimal interference with family/school/social life
INDICATIONS FOR PD IN PREFERENCE TO HD

Patient/caregiver choice if the modality is medically suitable
Very small/very young patients
Lack of vascular access
Contraindications to anticoagulation
Cardiovascular instability
Poorly controlled hypertension/hypertensive cardiomyopathy (relative)
PD TRAIN
Theory (>15
Functions
Practical/Tech
Aseptic te
exchanges
feeding (in
Peritonitis an
Recognitio
treatment
Noninfectiou
Hypotensi
Lack of proximity to a pediatric HD center (relative)

Desire for normal school attendance
More liberal fluid intake
ABSOLUTE CONTRAINDICATIONS TO PD
Omphalocoele
Gastroschisis
Bladder extrophy
Diaphragmatic hernia
Obliterated peritoneal cavity and peritoneal membrane failure
HOME V
Psychosocial
Family stru
Environment
Presence o
formula p
for treatm
Safety Asses
Locked me
Equipment A
Blood pres
RELATIVE CONTRAINDICATIONS TO PD
Imminent living-related transplantation
Impending/recent major abdominal surgery
Lack of an appropriate caregiver
Patient/caregiver choice if an alternate modality is available and medically suitable
12
Treatment As
Dressing c
blood pres
Cycler Manag
Average st
plan for an
able
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Modality Preparation
PD TRAINING CONTENT
Theory (>15 hours)
Functions of the kidney, pathophysiology of renal failure, osmosis, diffusion, fluid balance
Practical/Technical (>15 hours)
Aseptic technique, blood pressure monitoring, exit site care, performance of PD
exchanges, setup and function of cycler, problem-solving alarms, NG/gastrostomy tube
feeding (infants/small children)
Peritonitis and Exit site/Tunnel Infection
Recognition of signs and symptoms, initiating treatment, medicating bags for ongoing
treatment
Noninfectious Complications
Hypotension/hypertension, catheter flow problems, hernias
HOME VISIT CONTENT
Psychosocial Assessment
Family structure, financial status, school schedule
Environmental Assessment
Presence of heat, running water and electricity, function of smoke detector and telephone,
formula preparation facilities (infants/small children), purity of water supply, isolated area
for treatment
Safety Assessment
Locked medicine cabinet, storage of needles, location of local hospital
Equipment Assessment
Blood pressure monitor, scale, thermometer, cycler, tube feeding pump
Treatment Assessment
Dressing care, medications, dialysis supply location, hand washing station, home records,
blood pressure assessment
Cycler Management
Average start/end time for dialysis, proximity of caregiver bedroom to treatment area,
plan for answering alarms
13
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PD Prescription
PD Prescription
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Page 16
PD Prescription
DETERMINE BSA
Determine BSA by using the patients height and weight on the BSA chart located on
INITIATE
Initiate dia
pages 18-19. Prescription recommendations are based on patient size.
page 33 (C
SELECT MODALITY
MEASUR
Based on the patients lifestyle, physical condition and physicians recommendation,
patients may be started on either APD or CAPD. Each therapy offers distinct lifestyle and
clinical advantages.
PD Prescription
This section
prescription
are based on
Document
(See pages
ADJUST
Adjust the
dialysis do
Prescriptio
16
ated on
ation,
festyle and
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Page 17
This section of the guide was designed to assist you in integrating a simple peritoneal dialysis
prescription process into the management of individual patients. Recommended prescriptions
are based on patient Body Surface Area (BSA) and residual creatinine clearance (CrCl), if available.
INITIATE THERAPY
Initiate dialysis therapy by using the prescription options offered on page 23 (APD) and
page 33 (CAPD).
MEASURE CLEARANCES
Document an adequate dose of dialysis by measuring the actual clearances achieved.
(See pages 8285.)
ADJUST PRESCRIPTION
Adjust the prescription if the patient is not achieving desired clearance or an increase in
dialysis dose is required by clinical evaluation, using the guidelines in the Adjust
Prescription sections on pages 27 (APD) and 36 (CAPD).
17
Weight
(kg)
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
18
58
0.19
0.23
0.27
0.30
0.33
0.36
0.38
0.40
0.43
0.45
0.47
0.49
0.51
0.53
0.54
0.56
0.58
0.59
0.61
62
0.19
0.24
0.27
0.31
0.34
0.37
0.39
0.42
0.44
0.46
0.48
0.50
0.52
0.54
0.56
0.58
0.59
0.61
0.63
66
0.20
0.24
0.28
0.32
0.35
0.38
0.40
0.43
0.45
0.47
0.50
0.52
0.54
0.56
0.57
0.59
0.61
0.63
0.64
70
0.20
0.25
0.29
0.32
0.36
0.38
0.41
0.44
0.46
0.49
0.51
0.53
0.55
0.57
0.59
0.61
0.63
0.64
0.66
74
0.21
0.25
0.30
0.33
0.36
0.39
0.42
0.45
0.47
0.50
0.52
0.54
0.56
0.58
0.60
0.62
0.64
0.66
0.68
78
0.21
0.26
0.30
0.34
0.37
0.40
0.43
0.46
0.48
0.51
0.53
0.55
0.58
0.60
0.62
0.64
0.66
0.67
0.69
82
0.22
0.27
0.31
0.35
0.38
0.41
0.44
0.47
0.49
0.52
0.54
0.57
0.59
0.61
0.63
0.65
0.67
0.69
0.71
86
0.22
0.27
0.31
0.35
0.39
0.42
0.45
0.48
0.50
0.53
0.55
0.58
0.60
0.62
0.64
0.66
0.68
0.70
0.72
90
0.22
0.28
0.32
0.36
0.40
0.43
0.46
0.49
0.51
0.54
0.56
0.59
0.61
0.63
0.66
0.68
0.70
0.72
0.73
94
0.23
0.28
0.33
0.37
0.40
0.44
0.47
0.50
0.52
0.55
0.58
0.60
0.62
0.65
0.67
0.69
0.71
0.73
0.75
98
0.23
0.29
0.33
0.37
0.41
0.44
0.48
0.51
0.53
0.56
0.59
0.61
0.63
0.66
0.68
0.70
0.72
0.74
0.76
102
0.24
0.29
0.34
0.38
0.42
0.45
0.48
0.51
0.54
0.57
0.60
0.62
0.64
0.67
0.69
0.71
0.73
0.75
0.77
106
0.24
0.30
0.34
0.39
0.42
0.46
0.49
0.52
0.55
0.58
0.61
0.63
0.66
0.68
0.70
0.72
0.75
0.77
0.79
110
0.24
0.30
0.35
0.39
0.43
0.47
0.50
0.53
0.56
0.59
0.61
0.64
0.67
0.69
0.71
0.74
0.76
0.78
0.80
114
0.25
0.31
0.35
0.40
0.44
0.47
0.51
0.54
0.57
0.60
0.62
0.65
0.68
0.70
0.72
0.75
0.77
0.79
0.81
2/17/04
1:30 PM
Calculated by the formula:

Body Surface Area = 0.0235 x (Patients Height, cm)0.42246 x (Patients Weight, kg)0.51456 (Gehan E, George SL:
Estimation of human body surface area from height and weight. Cancer Chemother Rep Part 1 54:225-235, 1970).
54
0.18
0.22
0.26
0.29
0.32
0.34
0.37
0.39
0.41
0.44
0.46
0.47
0.49
0.51
0.53
0.54
0.56
0.58
0.59
50
0.18
0.22
0.25
0.28
0.31
0.33
0.36
0.38
0.40
0.42
0.44
0.46
0.48
0.49
0.51
0.53
0.54
0.56
0.57
Height (cm)
Page 18
Determine Body
Surface Area (BSA)
Tailoring the
BSA can be d
Weight
(kg)
20
22
24
26
28
30
32
34
36
38
40
42
44
46
48
50
52
54
56
58
60
114
0.81
0.85
0.89
0.93
0.97
1.00
1.03
1.07
1.10
1.13
1.16
1.19
1.22
1.25
1.27
1.30
1.33
1.35
1.38
1.40
1.43
118
0.82
0.87
0.90
0.94
0.98
1.01
1.05
1.08
1.11
1.15
1.18
1.21
1.24
1.26
1.29
1.32
1.35
1.37
1.40
1.42
1.45
122
0.84
0.88
0.92
0.96
0.99
1.03
1.06
1.10
1.13
1.16
1.19
1.22
1.25
1.28
1.31
1.34
1.37
1.39
1.42
1.44
1.47
126
0.85
0.89
0.93
0.97
1.01
1.04
1.08
1.11
1.15
1.18
1.21
1.24
1.27
1.30
1.33
1.36
1.38
1.41
1.44
1.46
1.49
130
0.86
0.90
0.94
0.98
1.02
1.06
1.09
1.13
1.16
1.19
1.23
1.26
1.29
1.32
1.35
1.38
1.40
1.43
1.46
1.48
1.51
134
0.87
0.91
0.95
0.99
1.03
1.07
1.11
1.14
1.18
1.21
1.24
1.27
1.30
1.33
1.36
1.39
1.42
1.45
1.48
1.50
1.53
138
0.88
0.92
0.97
1.01
1.05
1.08
1.12
1.16
1.19
1.22
1.26
1.29
1.32
1.35
1.38
1.41
1.44
1.47
1.49
1.52
1.55
142
0.89
0.94
0.98
1.02
1.06
1.10
1.13
1.17
1.21
1.24
1.27
1.30
1.34
1.37
1.40
1.43
1.46
1.49
1.51
1.54
1.57
146
0.90
0.95
0.99
1.03
1.07
1.11
1.15
1.18
1.22
1.25
1.29
1.32
1.35
1.38
1.41
1.44
1.47
1.50
1.53
1.56
1.59
150
0.91
0.96
1.00
1.04
1.08
1.12
1.16
1.20
1.23
1.27
1.30
1.34
1.37
1.40
1.43
1.46
1.49
1.52
1.55
1.58
1.60
154
0.92
0.97
1.01
1.06
1.10
1.14
1.17
1.21
1.25
1.28
1.32
1.35
1.38
1.42
1.45
1.48
1.51
1.54
1.57
1.59
1.62
158
0.93
0.98
1.02
1.07
1.11
1.15
1.19
1.22
1.26
1.30
1.33
1.37
1.40
1.43
1.46
1.49
1.52
1.55
1.58
1.61
1.64
162
0.94
0.99
1.03
1.08
1.12
1.16
1.20
1.24
1.27
1.31
1.35
1.38
1.41
1.45
1.48
1.51
1.54
1.57
1.60
1.63
1.66
166
0.95
1.00
1.05
1.09
1.13
1.17
1.21
1.25
1.29
1.32
1.36
1.39
1.43
1.46
1.49
1.52
1.56
1.59
1.62
1.65
1.67
170
0.96
1.01
1.06
1.10
1.14
1.18
1.22
1.26
1.30
1.34
1.37
1.41
1.44
1.48
1.51
1.54
1.57
1.60
1.63
1.66
1.69
2/17/04
1:30 PM
Calculated by the formula:

Body Surface Area = 0.0235 x (Patients Height, cm)0.42246 x (Patients Weight, kg)0.51456 (Gehan E, George SL:
Estimation of human body surface area from height and weight. Cancer Chemother Rep Part 1 54:225-235, 1970).
110
0.80
0.84
0.88
0.92
0.95
0.99
1.02
1.05
1.08
1.11
1.14
1.17
1.20
1.23
1.25
1.28
1.31
1.33
1.36
1.38
1.41
106
0.79
0.83
0.86
0.90
0.94
0.97
1.00
1.03
1.07
1.10
1.12
1.15
1.18
1.21
1.24
1.26
1.29
1.31
1.34
1.36
1.39
Height (cm)
Page 19
Tailoring the prescription to patient size is essential to achieve desired peritoneal clearances.
BSA can be determined from height and weight by referring to the tables below.
19
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Page 20
APD is perfor
exchanges p
exchange in
This therapy
ultrafiltratio
patients are
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Page 21
Automated Peritoneal
Dialysis (APD)
APD is performed at night with the help of a cycler. A typical APD prescription includes five
exchanges performed by the cycler while the patient is sleeping.The cycler instills a final (sixth)
exchange in the morning.This final exchange dwells in the peritoneal cavity during the day.
This therapy is especially well-suited for pediatric patients. Additional benefits include better
ultrafiltration due to shorter nighttime dwells, and decreased intra-abdominal pressure since
patients are supine.
Dialysis
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Page 22
APD Prescription Principles

The following APD prescription principles improve the efficiency of APD therapy:
STEP 1
ADEQUATE TIME ON CYCLER
Actual time on the cycler may vary by patient and should be adapted to the patients
clinical needs and lifestyle. A starting time of 10 hours is generally recommended.
STEP 2
ANURIC APD PATIENTS REQUIRE WET DAYS
All functionally anuric (CrCl<2mL/min/1.73 m2) patients must end with a fill for a daytime
dwell (wet day). A wet day makes effective use of the full 24 hours. When an
increase in dialysis dose is needed, it may be beneficial to add a midday exchange.
STEP 3
MAXIMIZE FILL VOLUME
2then start
usin
increas
Dialysis
Maximizing the fill volume improves the efficiency of dialysis. Increasing the amount of
solution included in each fill is more effective than increasing the number of cycles at night.
STEP 4
ADJUST CYCLE FREQUENCY TO TRANSPORT STATUS

E
Use of a higher number of exchanges will be more effective in patients with a higher
transport status by PET. In all patients, care should be taken to consider the number of
cycles in relation to the total time on cycler, as diminishing returns may occur because of
fill/drain requirements.
Init
(usually
Use
22
2/17/04
1:30 PM
Page 23
ples
herapy:
INITIATION OF APD
ients
d.
a daytime
an
ge.
ount of
es at night.
igher
mber of
ecause of
Implant catheter
Provide educational materials to caregivers, patients
no
Immediate PD required?
2- to 6-week healing period,

then start dialysis with 1224 exchanges
using 300 mL/m2 BSA volume*
increase fill volume to ~1100 mL/m2
BSA within 714 days
yes
Start supine dialysis with 1224 exchanges

using 300 mL/m2 BSA volume* for 7 days,
BSA within 1421 days
Establish maximally tolerable fill volume by either repeated IPP measurements

or clinical judgment, adjust to maximally tolerable fill volume
Initial prescription: 56 90120 min cycles with maximally tolerable fill volume
(usually ~1100 mL/m2 BSA) + 1 daytime cycle with >50% of nocturnal fill volume (CCPD)
or <50% of nocturnal fill volume (NIPD)
Perform PET, measure urinary and dialysate creatinine and urea clearances
at the end of training (preferably 4 weeks after start of PD)
Use PD dosing tables or software (PD Adequest or RenalSoft PD Rx Management)

to adjust PD prescription
* ~200 mL/m2 BSA during infancy
23
2/17/04
1:30 PM
Page 24
Management of
APD Prescriptions
TREATMENT GOAL
FACTORS
Physical and mental well-being, absence of uremic symptoms
Insufficien
Loss of res
Prescriptio
Reduced p
Loss of me
MANIFESTATIONS OF INADEQUATE DIALYSIS

Noncomp
Poorly fun
Manifest edema
Arterial hypertension requiring more than one antihypertensive agent
Absolute BUN value
Weekly Kt/Vurea and CrCl below K/DOQI recommendations
Hyperkalemic episodes
Hyperphosphatemia, excessive serum calcium-phosphate product
CRITERIA
CCPD (AP
Total K
Total C
averag
NIPD (APD
Total K
Total C
averag
Clearance
pressure, g
24
2/17/04
1:30 PM
Page 25
FACTORS CONTRIBUTING TO INADEQUATE DIALYSIS

Insufficient time on cycler
Loss of residual renal function
Prescription not adequate for membrane characteristics
Reduced peritoneal surface area due to extensive intra-abdominal adhesions
Loss of membrane solute transport/ultrafiltration capacity due to peritonitis
Noncompliance with PD prescription
Poorly functioning PD catheter
CRITERIA OF APD ADEQUACY

CCPD (APD with daytime dwell):
Total Kt/V urea >2.1/week

Total CrCl >63 L/1.73m2/week in high/high average transporters, >52.5 in low/low
average transporters
NIPD (APD with dry day):

Total CrCl >66 L/1.73m2/week in high/high average transporters, >55 in low/low
average transporters
Clearance associated with normal status for hydration, electrolyte balance, blood
pressure, growth, nutrition and psychomotor development
25
2/17/04
1:30 PM
Page 26
Management of
APD Prescriptions
OUTCOME EVALUATION
Monthly assessment of growth and weight gain, head circumference (infants); blood

serum albumin, record urine output and daily ultrafiltration
Serum ferritin, serum iron, total iron binding capacity (monthly until stable, then every
23 months)
Every 3 months assessment of intact PTH, alkaline phosphatase
Every 4 months assessment of 24-hour dialysate and urine collection for CrCl, Kt/Vurea;
possibly more frequent if prior assessment reveals failure to achieve adequacy targets;
school evaluation
Every 6 months neurodevelopmental assessment in infants <4 years of age
Consider annual:
- Ambulatory blood pressure monitoring (ABPM), especially if casual BP frequently
borderline or discrepant from home measurements, echocardiography
- Hand and wrist X-ray (especially if intact PTH frequently outside therapeutic range)
Ad
There are fou

weighed wit
lifestyle.
STEP 1
IN
Maximizin
impact on
prescriptio
STEP 2
Adding a
using a dr
add a dayt
HomeCho
MEASURE APD CLEARANCE

Measuring the dose of dialysis received by the patient is critical
to ensure adequate therapy.
Assess the amount of clearance the patient is receiving using a 24-hour dialysate
collection. (See Appendix: Guidelines for 24-Hour Dialysate Collectionpage 82,

and Clearance Calculationspage 84.)
exchange(
exchanges
STEP 3
IN
Cycler tim
patients li
For patients with residual renal function, add residual clearance to dialysis clearance to
determine total clearance. (See Appendix: Guidelines for 24-Hour Urine Collection
page 83, and Residual Renal Clearance Calculationspage 85.)
Increasing
time, whic
Measurements can be done as early as 1 week after the patient is stabilized on a defined
prescription.
STEP 4
Once a patient achieves desired clearance, repeat measurements should be completed
every 4 months.
26
IN
An increas
patients w
may be re
2/17/04
1:30 PM
Page 27
Adjust APD Prescription
blood
matocrit,
en every
There are four basic options to adjust an APD prescription. The options must be
weighed with regard to improvements in clearance and the patients comfort and
lifestyle.
STEP 1
INCREASE FILL VOLUMES
Maximizing the fill volume is an effective means of improving clearance with a minimum
Kt/Vurea;
targets;
impact on patient lifestyle. Since patients tolerate larger fill volumes when supine, adjust
prescriptions first by increasing the volume of the nighttime exchanges.
STEP 2
quently
tic range)
ate
82,
rance to
tion
ADD A DAYTIME EXCHANGE
Adding a daytime exchange is an effective means of improving clearance. For patients
using a dry day prescription, add a wet day. For patients using a wet day prescription,
add a daytime exchange after school.
HomeChoice High Dose Therapy, combining conventional CCPD with additional daytime
exchange(s), minimizes impact on lifestyle by utilizing one cycler setup per day for all
exchanges. HomeChoice can be programmed to deliver the daytime exchange.
STEP 3
INCREASE TIME ON THE CYCLER
Cycler time can be extended to increase clearances, but this must be balanced with the
patients lifestyle needs.

Increasing cycler time while keeping the same number of exchanges increases the dwell
time, which results in increased clearance.
n a defined
mpleted
STEP 4
INCREASE NUMBER OF NIGHTTIME EXCHANGES
An increase in nighttime exchanges may increase clearance in high transporters. In
patients with a different transport profile, a simultaneous increase in the time on cycler
may be required.
27
2/17/04
1:30 PM
Page 28
Adjust APD Prescription

MAINTENANCE PD PRESCRIPTION IN NIPD
Measure dialytic and urinary CrCl and Kt/Vurea every 4 months
no
Low, low-average
transporters
High, high-average
transporters
Total weekly Kt/Vurea < 2.2

and/or CrCl <55 L/1.73m2 ?
Total weekly Kt/Vurea <2.2

yes
yes
no
Gradually augment fill volume to maximal tolerable volume (maximum

1400 mL/m2). Check total CrCl and Kt/Vurea 1 month after intervention
yes
Adequacy targets met?

no
Low, low-average
transporters
High-average
transporters
High
transporters
Increase total cycler time

by prolonging dwell time.
Keep cycle number
constant
Increase number of
cycles or increase total
cycler time by adding
cycles keeping dwell
time constant
Increase number of
cycles with constant total
cycler time
yes
no
Assess clinical status:
Adequate growth/nutrition status,
psychomotor development?
yes
no
Switch to CCPD (daytime dwell)
28
Continue close
monitoring
2/17/04
1:30 PM
Page 29
on
inue close
onitoring
MAINTENANCE PD PRESCRIPTION IN CCPD

no
Low, low-average
transporters
High, high-average
transporters

and/or CrCl <52.5 L/1.73m2 ?

yes
yes
no
Gradually augment fill volume to maximal tolerable volume (maximum

1400 mL/m2). Check total CrCl and Kt/Vurea 1 month after intervention
yes

no
Low, low-average
transporters
High-average
transporters
Increase total cycler time Increase total cycler time

by adding cycles
by prolonging dwell time.
keeping dwell
Keep cycle number
time constant
constant
High
transporters
Increase number of
cycles with constant total
cycler time
yes
no
yes
Continue close
monitoring
no
Consider adding afternoon cycle or change to hemodialysis
29
2/17/04
1:30 PM
Page 30
Co
Per
CAPD is perfo
exchanges, t
bedtime and
2/17/04
1:30 PM
Page 31
Continuous Ambulatory
Peritoneal Dialysis (CAPD)
CAPD is performed evenly over the entire course of a 24-hour period. It usually consists of four
exchanges, three of which are completed during the waking hours, and the last is performed before
bedtime and allowed to dwell overnight.
2/17/04
1:30 PM
Page 32
CAPD Prescription
Principles
The following CAPD prescription principles improve the efficiency of the therapy:
STEP 1
OPTIMIZE FILL VOLUMES
Fill volumes appropriate for patient body size are used in the recommended prescriptions.
These can be increased further if clearance targets are not met. When adjusting fill
volumes, care should be taken to account for patient tolerance.
STEP 2
DISTRIBUTE DAYTIME EXCHANGES EVENLY OVER THE COURSE OF

THE DAY
Dwell times during the waking hours should be of approximately the same duration
(46 hours).
STEP 3
USE APPROPRIATE TONICITY FOR ULTRAFILTRATION
2
then s
us
incre
Proper fluid balance improves the effectiveness of the therapy. Guidelines for ultrafiltration
management are listed on pages 4045.
32
2/17/04
1:30 PM
Page 33
herapy:
INITIATION OF CAPD
scriptions.
fill
Implant catheter
Provide educational materials to caregivers, patients
OURSE OF
no
Immediate PD required?
yes
ation
2- to 6-week healing period,
then start dialysis with 48 exchanges
using 300 mL/m2 BSA volume,*
BSA within 714 days
Start supine dialysis with 1224 exchanges

using 300 mL/m2 BSA volume* for 7 days,
BSA within 1421 days
trafiltration
Establish maximally tolerable fill volume by either repeated IPP measurements

or clinical judgment. Adjust to maximally tolerable fill volume
Initial prescription: 3 3- to 5-hour daytime + 1 9- to 12-hour nighttime cycles

with maximally tolerable fill volume (usually ~1100 mL/m2 BSA)
Perform PET, measure urinary and dialysate creatinine and urea clearances
at the end of training (preferaby 4 weeks after start of PD)
Use PD dosing tables or software (PD Adequest or RenalSoft PD Rx Management)

to adjust PD prescription
* ~200 mL/m2 BSA during infancy
33
2/17/04
1:30 PM
Page 34
Management of
CAPD Prescriptions
TREATMENT GOAL
OUTCOM
Physical and mental well-being, absence of uremic symptoms
Monthly a
pressure, a
serum alb
Serum fer
23 mont
Every 3 mo
Every 4 mo
possibly m
school eva
Every 6 mo
Consider a
Am
bor
Han

Manifest edema
Arterial hypertension requiring more than one antihypertensive agent
Absolute BUN value
Weekly Kt/V urea and CrCl below K/DOQI recommendations
Hyperkalemic episodes
Hyperphosphatemia, excessive serum calcium-phosphate product
FACTORS CONTRIBUTING TO INADEQUATE DIALYSIS

Loss of residual renal function
Prescription not adequate for membrane characteristics
Reduced peritoneal surface area due to extensive intra-abdominal adhesions
Loss of membrane solute transport/ultrafiltration capacity due to peritonitis
Noncompliance with PD prescription
Poorly functioning PD catheter
MEASUR
Measuring th
adequate the
Assess the
collection.
and Cleara
For patien
CRITERIA OF CAPD ADEQUACY

Total CrCl >60 L/1.73m2/week in high/high average transporters, >50 in low/low average
transporters
Clearance associated with normal status for hydration, electrolyte balance, blood
pressure, growth, nutrition and psychomotor development
determine
83, and Re
Measurem
prescriptio
Once a pa
every 4 mo
34
2/17/04
1:30 PM
Page 35
OUTCOME EVALUATION
Monthly assessment of growth and weight gain, head circumference (infants); blood

serum albumin, record urine output and daily ultrafiltration
Serum ferritin, serum iron, total iron binding capacity (monthly until stable, then every
23 months)
Every 3 months assessment of intact PTH, alkaline phosphatase
Every 4 months assessment of 24-hour dialysate and urine collection for CrCl, Kt/V urea ;
possibly more frequent if prior assessment reveals failure to achieve adequacy targets;
school evaluation
Every 6 months neurodevelopmental assessment in infants <4 years of age
Consider annual:
Ambulatory blood pressure monitoring (ABPM), especially if casual BP frequently
borderline or discrepant from home measurements, echocardiography
Hand and wrist X-ray (especially if intact PTH frequently outside therapeutic range)
MEASURE CAPD CLEARANCES

Measuring the dose of dialysis received by the patient is critical to ensure
adequate therapy.
Assess the amount of clearance the patient is receiving using a 24-hour dialysate
collection. (See Appendix: Guidelines for 24-Hour Dialysate Collectionpage 82,

and Clearance Calculationspage 85.)
For patients with residual renal function, add residual clearance to dialysis clearance to
determine total clearance. (See Appendix: Guidelines for 24-Hour Urine Collectionpage
83, and Residual Renal Clearance Calculationspage 85.)
ow average
od
Measurements can be done as early as 1 week after the patient is stabilized on a defined
prescription.
Once a patient achieves desired clearance, repeat measurements should be completed
every 4 months.
35
2/17/04
1:31 PM
Page 36
Adjust CAPD Prescription

There are two basic options for adjusting the CAPD prescription. These options must
be weighed with regard to improvements in clearance and the patients comfort and
lifestyle. Increasing fill volumes is preferred over adding additional exchanges.
INCREASE FILL VOLUMES

Maximizing fill volume is THE most effective means of improving clearance.
Start patients on the recommended prescription, and increase fill volumes if targets are
not met. You may elect to increase only two of the exchanges when first adjusting the
prescription. If targets are still not met, proceed by increasing the fill volume of all four
exchanges.
ADD AN ADDITIONAL EXCHANGE

A fifth exchange may be added manually during the daytime or at nighttime by the use
of an exchange device. The latter is feasible only with fill volumes greater than 1500 mL.
36
2/17/04
1:31 PM
Page 37
ion
tions must
omfort and
nges.
rgets are
sting the
f all four
by the use
1500 mL.
MAINTENANCE PD PRESCRIPTION IN CAPD

no
Low, low-average
transporters
High, high-average
transporters


yes
yes
no
Gradually augment intraperitoneal volume to maximal

tolerable volume (maximum 1400 mL/m2)
Check dialytic and urinary CrCl and Kt/Vurea

1 month after intervention
yes
no

yes
Continue close
monitoring
no
Low, low-average
transporters
High, high-average
transporters
Consider APD
in low-average transporter.
Consider hemodialysis
Consider APD
37
2/17/04
1:31 PM
Page 38
2/17/04
1:31 PM
Page 39
Ultrafiltration
Management
Ultrafiltration
Management
2/17/04
1:31 PM
Page 40
Ultrafiltration
Management
Adjusting a patients prescription to achieve and maintain fluid balance is an essential
component of PD prescription management. Peritoneal dialysis, due to its continuous
nature, offers some distinct advantages such as avoiding fluctuating volume status and
offering better homeostatic stability than an intermittent therapy.
In PD, ultrafiltration is driven by the osmotic gradient between the plasma and dialysate
compartments. The two key factors to consider when adjusting the patients prescription
for fluid removal are the nature of the osmotic agent used, concentration and dwell time.
These are interrelated and need to be considered jointly. Dextrose performs adequately in
short dwells, but for the long nighttime dwell in CAPD and the daytime dwell in APD, a
significant proportion of patients manifest fluid retention with dextrose-based solutions.
Ultrafiltration is time dependent. The net ultrafiltration rate with dextrose-based solutions
is greatest at the beginning of an exchange and peaks at about 2-3 hours. Because the
glucose osmotic gradient dissipates with time, and lymphatic absorption continues, net
ultrafiltration then begins to decrease. An alternate osmotic agent may be more appropriate
for the long dwell.
FACTO
Dietary
Inappro
Decreas
Mechan
Transpo
reabsor
COMPO
Determ
Dietary
Protecti
Optiona
Ultrafilt
DETER
TREATMENT GOAL
Adjust a patients prescription to achieve and maintain fluid balance
Patient edema free
Achieve normotension with minimal use of or need for antihypertensive medications.

Peripheral edema
Systolic hypertension
Diastolic hypertension
Pulmonary congestion
Ultrafiltration
Management
Pleural effusions
40
Periton
that the
remova
Dwell t
in UF be
Tonicity
increase
The use
negative
tial
ous
s and
lysate
ription
ell time.
ately in
APD, a
utions.
olutions
e the
s, net
propriate
cations.
2/17/04
1:31 PM
Page 41
Ultrafiltration
Management
FACTORS CONTRIBUTING TO INADEQUATE FLUID BALANCE
Dietary noncompliance with salt and water
Inappropriate/noncompliance to PD prescription
Decreased residual renal function
Mechanical PD catheter issues
Transport characteristics: Reduced membrane function/high permeability/lymphatic
reabsorption
COMPONENTS OF FLUID BALANCE MANAGEMENT

Determination of appropriate target weight,
Dietary counseling concerning appropriate salt and water intake,
Protection of residual renal function by avoiding nephrotoxic agents,
Optional use of loop diuretics if residual function is present,
Ultrafiltration management utilizing the appropriate PD prescription.
DETERMINANTS OF ULTRAFILTRATION IN PD
Peritoneal transport status: the dependence of UF on the osmotic gradient implies
that the transport properties of the peritoneal membrane can significantly affect fluid
removal when dextrose solutions are used
Dwell time: an increase in dwell time with dextrose-based solutions leads to a decrease
in UF because of dissipation of the osmotic gradient.
Tonicity: with dextrose-based solutions, an increase in tonicity is associated with an
increase in ultrafiltration.
The use of an alternate osmotic agent may allow for a long dwell without the risk of
negative ultrafiltration.
41
2/17/04
1:31 PM
Page 42
Ultrafiltration
Management
STRATEGIES TO MAXIMIZE LONG DWELL UF CAPD/APD
Ultrafil
If the patient manifests negative UF during the long dwell
Utilize alternate osmotic agent

Shorten dwell time
Replace single long dwell exchange with two exchanges
Increase dextrose concentration
If the patient has adequate UF during the long dwell:
Minimize use of 4.25% dextrose preparations to protect the peritoneal membrane

and avoid the metabolic complications of very hypertonic dextrose.
STRATEGIES TO MAXIMIZE SHORT DWELL UF

APD
Increase the number of cycles
Increase overall cycler treatment time
Consider increasing the fill volume
CAPD
Decrease dwell time/increase number of exchanges
Consider increasing fill volume
Figures:
Dependence of UF on peritoneal transport status and dialysis solution tonicity for dextrose based solutions.
42
Ultrafiltr
2/17/04
1:31 PM
Page 43
Ultrafiltration
Management
Ultrafiltration response to 1.5% dextrose based on peritoneal transport type
embrane
utions.
43
2/17/04
1:31 PM
Page 44
Ultrafiltration
Management
44
ort type
2/17/04
1:31 PM
Page 45
Ultrafiltration
Management
Ultrafiltration response to dextrose
45
2/17/04
1:31 PM
Page 46
Pe
2/17/04
1:31 PM
Page 47
Peritonitis Management
2/17/04
1:31 PM
Page 48
INITIAL EMPIRIC MANAGEMENT OF PERITONITIS
STEP 1
STEP 4 ...
KEY ASSESSMENTS
Cloudy effluent
Abdominal pain and/or fever
An empiric diagnosis of peritonitis should be made if:
Peritoneal effluent is cloudy and
Effluent with WBC >100/mm3 of which at least 50% are polymorphonuclear neutrophils (PMN)
STEP 2
PATIENT/PARENTS EDUCATION
Immediately report cloudy effluent, abdominal pain and/or fever to PD unit

Obtain specimen of effluent for laboratory testing prior to administration of antibiotics
Initiate palliative steps
In presence of pain,begin 23 rapid exchanges
Add intraperitoneal antibiotics for duration of required therapy
Add heparin 500 U/L to each bag until clear
Report persistent cloudiness to PD unit
Schedule retraining for technique issues
STEP 4
OUTCOMES EVALUATION
Date of culture,organism,drug therapy

Date infection resolved
Recurrent organisms,date of drug therapy
Method of interim renal replacement therapy
Date of catheter removal
Date of new catheter reinsertion
Document contributing factors
Break-in technique,patient factors,exit site infections,tunnel infections
STEP 4 CONTINUES ON THE TOP OF PAGE 49...
48
Date of re
Re-evalua
Enter data
KEY ACTIVITIES
Initiate the following (Performed by the patient or by the PD nurse in the dialysis unit):
Disconnect drained bag and send sample to laboratory for cell count with differential,Gram stain and
culture prior to administration of antibiotics
In presence of cloudy effluent,add heparin 500 U/L to new bag until effluent clears (usually 4872 hours)
In asymptomatic patients with only cloudy effluent,initiation of therapy may be delayed 23 hours until
laboratory results are available
In presence of cloudy effluent with pain and/or fever:
Begin 23 rapid exchanges to relieve discomfort
Initiate empiric antibiotic therapy within 1 hour while waiting for test results
Consider antifungal prophylaxis to accompany antibiotic therapy
After peritonitis resolved,schedule re-evaluation of total (dialysis plus residual renal function) creatinine
clearance and Kt/V urea
STEP 3
Optimal long-t
Prevention of
most importan
following the
prompt interv
an
In pat
infection
omm
history
Cefaz
Cepha
Ceftaz
Vanco
Teico
* Continue
tables fo
For p
(244
cleari
needs
ent
NITIS
72 hours)
3 hours until
) creatinine
1:31 PM
Page 49
Optimal long-term management of the peritoneal dialysis patient hinges on prevention of peritonitis.
Prevention of peritonitis includes proper catheter placement, use of advanced disconnect systems and
most importantly, the patients adherence to aseptic technique during the exchange procedure and
following the protocol for exit site care. Early identification of the signs and symptoms of peritonitis and
prompt intervention should be emphasized in the patient training program and follow-up care.
STEP 4 ... CONTINUED
Date of re-education/training
Re-evaluation of total (dialysis plus residual renal function) creatinine clearance and Kt/V urea
Enter data into catheter management database (e.g.,RenalSoft Access Management,POET 2.1 software)
MN)
stain and
2/17/04
THERAPEUTICSEMPIRIC THERAPY
0 hour
Initiate Empiric Therapy* with Cefazolin or Cephalothin

and Ceftazidime or Glycopeptide (Vancomycin or Teicoplanin)
and Ceftazidime
In patients with cloudy effluent, without fever and/or severe abdominal pain, and no risk factors for severe
infection, the combined intraperitoneal administration of a first-generation cephalosporin and ceftazidime is recommended. In patients with fever and/or severe abdominal pain, a history of MRSA infection, a recent
history or current evidence of an exit site/tunnel or nasal/exit site colonization with S. aureus, and in patients
younger than 2 years, a glycopeptide combined with ceftazidime should be administered.
Continuous Dosing
Intermittent Dosing
Cefazolin or
Cephalothin
250 mg/L load, then 125

mg/L in each exchange
15 mg/kg in single exchange q day
Ceftazidime
250 mg/L load, then

125 mg/L in
each exchange
15 mg/kg in single exchange q day
Vancomycin
500 mg/L load, then

30 mg/L in each
exchange
30 mg/kg in single exchange q 57 days
Teicoplanin
200 mg/L load, then

20 mg/L in each exchange
15 mg/kg in single exchange q 57 days
* Continued assessment and modification of therapy are based on culture and sensitivity results; refer to subsequent
tables for specific organisms cultured and antibiotic dosing recommendations.
For patients on automated peritoneal dialysis (APD) with short dwell times for routine therapy, the initial
(2448 hours) treatment of peritonitis should include a prolongation of dwell time to 36 hours, until there is
clearing of the peritoneal effluent. This does not apply to asymptomatic patients or those with ultrafiltration
needs requiring more frequent exchanges.
OF PAGE 49...
49
2/17/04
1:31 PM
Page 50
GRAM POSITIVE AND GRAM NEGATIVE PERITONITIS
STEP 1
STEP 4 ... C
KEY ASSESSMENTS
Cloudy effluent
Abdominal pain and/or fever
An empiric diagnosis of peritonitis should be made if:
Peritoneal effluent is cloudy and
Effluent with WBC >100/mm3,of which at least 50% are polymorphonuclear neutrophils (PMN)
STEP 2
KEY ACTIVITIES
Initiate the following (Performed by the patient or by the PD nurse in the dialysis unit):
Disconnect drained bag and send sample to laboratory for cell count with differential,
Gram stain and culture
In presence of cloudy effluent add heparin 500 U/L to new bag until effluent clears (usually 48 to 72 hours)
In asymptomatic patients with only cloudy effluent,initiation of therapy may be delayed 2 to 3 hours until
laboratory results are available
In presence of cloudy effluent with pain and/or fever:
Begin 23 rapid exchanges to relieve discomfort
Initiate empiric antibiotic therapy within one 1 while waiting for test results
Consider antifungal prophylaxis to accompany antibiotic therapy
After peritonitis is resolved,schedule re-evaluation of total (dialysis plus residual renal function) creatinine
clearance and Kt/V urea
STEP 3
PATIENT/PARENTS EDUCATION
Immediately report cloudy effluent,abdominal pain and/or fever to PD unit

Obtain specimen of effluent for laboratory testing prior to administration of antibiotics
Initiate palliative steps
In presence of pain,begin 23 rapid exchanges
Add intraperitoneal antibiotics for duration of required therapy
Add heparin 500 U/L to each bag until clear
Report persistent cloudiness to PD unit
Schedule retraining for technique issues
STEP 4
an
E
S
Disconti
glycope
start a
**A seco
aminog
based o
p
Vancom
may be u
OUTCOMES EVALUATION
Date of culture,organism,drug therapy

Date infection resolved
Recurrent organisms,date of drug therapy
Method of interim renal replacement therapy
Date of catheter removal
Date of new catheter reinsertion
Document contributing factors
Break-in technique,patient factors,exit site infections,tunnel infections
STEP 4 CONTINUES ON THE TOP OF PAGE 51...
50
Date of re-e
Re-evaluatio
Enter data in
*Refer to
** NOTIC
on Periton
tivation of
antibiotics
to exercise
Handbook
2/17/04
1:31 PM
Page 51
ent
ONITIS
STEP 4 ... CONTINUED
Date of re-education/training
Re-evaluation of total (dialysis plus residual renal function) creatinine clearance and Kt/V urea
Enter data into catheter management database (e.g.,RenalSoft Access Management,POET 2.1 software)
PMN)
to 72 hours)
o 3 hours until
on) creatinine
OF PAGE 51...
THERAPEUTICS GRAM POSITIVE PERITONITIS

0 hour

and Ceftazidime
2448 hours
Gram Positive Organism on Culture

(Choice of therapy guided by sensitivity patterns)
Enterococcus
Streptococcus
Staphylococcus aureus
Other Gram Positive

Organisms
Discontinue cephalosporin or
glycopeptide and ceftazidime;
start ampicillin 125 mg/L
Methicillin sensitive:
Continue cephalosporin
Discontinue
ceftazidime and glycopeptide;
consider addition of rifampin
20 mg/kg/day PO in divided doses
(maximum 600 mg/day)
Methicillin sensitive:
Discontinue ceftazidime
and glycopeptide;
continue cephalosporin
**A second antibiotic such as an

aminoglycoside may be added
based on sensitivity results and
patient response
Vancomycin or clindamycin
may be used in case of ampicillin
resistance
Methicillin resistant:
Discontinue ceftazidime
Continue or substitute
glycopeptide or clindamycin
96 hours
If no improvement, reculture and evaluate

Consider ultrasound evaluating for occult tunnel infection
For peritonitis with exit site or tunnel infection, consider catheter removal
Duration of Therapy
14 Days
21 Days
14 Days
*Refer to Initial Empiric Management of Peritonitis and antibiotic dosing recommendations (page 49)
** NOTICE: The therapeutic recommendations provided above are those recommended by the ISPD Advisory Committee
on Peritonitis Management in Pediatric Patients. Baxter Healthcare is aware of literature which documents the potential inactivation of aminoglycosides by ampicillin in parenteral solution. The manufacturers precaution labeling states that these
antibiotics should not be mixed together in the same solution container (see references). Baxter Healthcare urges physicians
to exercise good medical judgment in selecting antibiotic combinations in the treatment of peritonitis. Ref. Trissel, LA,
Handbook on Injectable Drugs, 12th ed. Macmillan Publishers LTD, ASHP, 2002; Physicians Desk Reference, 58th ed.
51
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GRAM NEGATIVE PERITONITIS
THERAPEUTICS GRAM NEGATIVE PERITONITIS

0 hour

and Ceftazidime
2448 hours
Gram Negative Organism on Culture

(Choice of therapy guided by sensitivity patterns)
Single Gram Negative
Organism
(Non-Stenotrophomonas)
Adjust antibiotics to
sensitivity patterns.
May continue ceftazidime
Pseudomonas/
Stenotrophomonas
Multiple Organisms
and/or Anaerobes
Discontinue cephalosporin
or glycopeptide; continue
ceftazidime; add agent with
activity against this
pseudomonas/
stenotrophomonas**
Consider surgical
intervention and add
metronidazole
15 mg/kg/day in divided
doses every 8 hours
(maximum dose 1.5 gm/day),
PO, IV or rectally
96 hours
Clinical improvement: continue above therapy

No clinical improvement: repeat cell count, culture and Gram stain
If culture remains positive, remove catheter
If no clinical improvement and exit site infection present, remove catheter
Duration of Therapy***
14 Days
21 Days
21 Days
* Refer to Initial Empiric Management of Peritonitis and Antibiotic Dosing Recommendations (page 49).
** Additional agents may include piperacillin, ciprofloxacin, aminoglycoside or aztreonam as susceptibility
indicates.
*** Duration may need to be adjusted on clinical grounds but never shorter than recommended.
52
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Page 53
Management of
Growth Failure
ent
n)
ms
es
l
dd
ded
rs
m/day),
y
Management of
Growth Failure
er
.
ity
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Page 54
Management of
Growth Failure
Management of
Growth Failure
TREATMENT GOAL
Optimal: final adult height = midparental height
(i.e., mean of parents heights +6.5 cm for boys, 6.5 cm for girls)
Minimal: final adult height above third percentile (i.e., > 1.88 SDS)
Goal while still growing: target height standard deviation score (SDS) (= midparental
height SDS)
Heigh
Check
PATTERNS OF GROWTH FAILURE

Loss of relative height (downward crossing of percentiles)
Percentile-parallel growth below third percentile
Subnormal pubertal growth spurt
acid-bas
FACTORS CONTRIBUTING TO UREMIC GROWTH FAILURE

Malnutrition (most important factor in infants)
Evide
Electrolyte imbalance (sodium, potassium deficiency; metabolic acidosis)

Impaired growth hormone/IGF-1 action (most important factor beyond infancy)
In adolescents: delayed onset of puberty
Infection/inflammation (occult or overt)
Ina
Medications (glucocorticoids)
Complete loss of residual renal function
Inadequate dialysis
Excessive dialytic protein losses
Excessiv
or low-
Low-turnover bone disease/severe secondary hyperparathyroidism

Severe psychosocial stress/depression/anorexia
Si
infec
OUTCOME EVALUATION
Monthly measurement of supine length/standing height
Annual bone age assessment
54
S
(g
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MANAGEMENT OF GROWTH FAILURE DURING DIALYSIS

Height <3rd percentile for age
and deviating
Height <3rd percentile but

growing along percentiles
Height still normal but

losing percentiles
Check anthropometric status
Check nutritional intake
Check labs
arental
y)
Evidence of
acid-base/electrolyte imbalance?
yes
Correct by supplementation
to total CO2 22mEq/L
yes
Go to malnutrition algorithm
yes
Go to NIPD/CCPD/CAPD
maintenance prescription
algorithms
yes
Go to uremic
hyperparathyroidism
algorithm
yes
Find and treat

underlying cause
no
Evidence of malnutrition?
no
Inadequate dialysis?
Monitor growth
for 3 months
after correction
of problem
no
Excessive renal osteodystrophy
or low-turnover bone disease?
Growth rate
improved?
no
Signs of subclinical
infection/inflammation?
no
yes
no
Start rGH treatment

(go to rGH algorithm)
Continue
current
management
55
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Page 56
Recombinant Growth
Hormone Therapy
TREATMENT GOAL
BASELIN
Optimal: final adult height = midparental height
Monthly: m
(i.e., mean of parents heights +6.5 cm for boys, 6.5 cm for girls)
Minimal: final adult height above third percentile (i.e., >1.88 SDS)
Goal while still growing: target height SDS (= midparental height SDS)
Every 3 mo
Every 12 m
SAFETY
RESPONSE CRITERIA
Baseline: h
Increase in annual height velocity by >2 cm/year above baseline height velocity in first 2
Initial 12
treatment years
Change in standardized height by >0.1 SDS /treatment year in subsequent years (as long
as height SDS < 1.88)
At least ev
Before and
funduscop
rGH DOSE
0.05 mg/kg/day by once daily subcutaneous injection
Ad
Consider dose doubling in primary or secondary nonresponders
STRATEGIES FOR OPTIMIZED USE OF rGH

Correct/treat causes of growth failure before start of rGH:
Electrolyte imbalance (sodium, potassium deficiency; metabolic acidosis)

Hypothyroidism (frequent in patients with cystinosis!)
Latent or overt inflammation (consider focal, systemic causes)
Glucocorticoid medication
Inadequate dialysis
Inadequate treatment of renal osteodystrophy
Start early in the course of chronic renal failure
Start before growth retardation is severe
Never use less than standard dose
Regularly adjust dose to body weight
Assure compliance with daily s.c. injections
Continue therapy until transplantation or attainment of target height SDS
Be alert to possibility of catch-down growth after discontinuation
Discontinue rGH if persistently ineffective (height velocity <2 cm/year above
pretreatment level), particularly in patients with syndromal growth failure
56
Cont
Perform r
Transplantat
Discontinue rG
Re-evaluate
growth after
months
Catch
yes
Resume rGH
treatment
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Page 57
h
BASELINE/OUTCOME EVALUATION
Monthly: measurement of supine length/standing height
Every 3 months: puberty staging in peripubertal patients
Every 12 months: hand and wrist X-ray
SAFETY EVALUATION
Baseline: hip X-rays
y in first 2
Initial 12 months: intensified monitoring of blood pressure and fluid status

At least every 3 months: intact PTH, alkaline phosphatase
ars (as long
Before and at least every 12 months after start of treatment: glycosylated hemoglobin,
funduscopy (exclude benign intracranial hypertension)
MANAGEMENT OF rGH THERAPY

Administer rGH once daily; start with 0.025 mg/kg/day, increase within 4 weeks to 0.05 mg/kg/day
Monitor growth monthly for 6 months
no
Annualized height velocity increased by >2 cm/year?
Continue treatment.
Perform regular safety checks
Transplantation
Target height
SDS exceeded
Discontinue rGH.
Re-evaluate
growth after 12
months
Discontinue rGH.
Evaluate height
velocity every
34 months
yes
Continue treatment.
Perform regular
safety checks
Secondary nonresponsiveness
(drop of 6-month height velocity
to pretreatment level)
Signs of subclinical
inflammation ?
yes
Find and treat

underlying disorder
yes
Improve
nutritional status
yes
Increase
dialysis dose
no
Catch-down growth?
New evidence of malnutrition?

no
yes
Resume rGH
treatment
no
Continue
monitoring
Rapid loss of residual GFR/signs

of inadequate dialysis?
yes
no
Consider doubling rGH dose
no
Annualized height velocity

increased by >2 cm/year 3
months after intervention?
57
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Page 59
Management of
Malnutrition
Management of
Malnutrition
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Page 60
Management of
Malnutrition
TREATMENT GOAL
RESPONS
Energy intake 100% RDA
Percentile-
Protein intake 120% RDA
height per
Energy int
dietary ass
Water soluble vitamin intake 100% RDA

BMI, skinfolds within normal range for height age
Linear growth at target height SDS
STRATEG
Management of
Malnutrition
MANIFESTATIONS
Suppleme
Poor weight gain
Institute co
Poor growth
Consider c
Poor brain growth during infancy
Maintain r
Poor school performance

Impaired exercise activity
Impaired wound healing
Impaired sense of well-being/quality of life
CONTRIBUTING FACTORS
Anorexia
Emesis
Food refusal
Food preference
Peritonitis
Inadequate dialysis
Constipation
Gastroesophageal reflux
Pica
Economic factors
Impaired physical eating skills
60
OUTCOM
Monthly: m
and skinfo
Every 3 mo
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RESPONSE CRITERIA
Percentile-parallel growth and weight gain (catch-up pattern if below target
height percentile)
Energy intake = 100%, protein intake 120% of individual requirement (RDA) by
dietary assessment
STRATEGIES FOR ENTERAL TUBE SUPPORT
Supplement may be provided by bolus or continuous infusion
Institute continuous feedings at rate of approximately 12 mL/kg/hr
Consider concomitant use of antiemetic/motility agents if emesis present
Maintain regular oral stimulation during infancy to enhance oral-motor development
OUTCOMES EVALUATION
Monthly: measurement of supine length/standing height, weight, head circumference
and skinfolds (if available); calculation of BMI; biochemical assessment

Every 3 months: head circumference until age 36 months
61
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Management of
Malnutrition
MANAGEMENT OF MALNUTRITION WITH
GROWTH FAILURE IN INFANTS
Evidence of malnutrition based on dietary history,
anthropometric status and biochemistry
Review dietary (formula) prescription.

Monitor nutritional status for 12 months
Nutritional status improved?
GR
Apply
K/DOQI Pediatric
Nutritional
Guidelines
yes
no
Start PEG/NG tube feeding.*

yes
no
Frequent vomiting?
no
yes
Growth rate improved?
no
yes
Start rGH
treatment
(see growth
hormone
algorithm)
Continue
current
management
Modify feeding patterns (continuous nocturnal

pump; frequent small-volume feeding)
no
yes
Psychosocial assessment and

intervention if necessary.
Consider jejunal PEG,
fundoplication.
Consider rGH treatment
*Malnourished infants/small children should receive NG feeds for 34 months prior to PEG placement to decrease risk of leak, infection.
62
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Page 63
MANAGEMENT OF MALNUTRITION WITH

GROWTH FAILURE IN SCHOOLCHILDREN AND ADOLESCENTS
Evidence of malnutrition based on dietary history,
anthropometric status and biochemistry
Intensify dietary counseling. Increase energy intake

if insufficient, consider psychosocial assessment
Apply
K/DOQI Pediatric
Nutritional
Guidelines
yes
no
Consider PEG/NG tube feeding.

Consider psychosocial intervention
Growth rate improved?
no
yes
Start rGH
treatment
(see growth
hormone
algorithm)
Continue
current
management
no
yes
Consider rGH treatment
63
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Mineral Metabolism
Mineral Metabolism
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Management of Calciumphosphate Metabolism

TREATMENT GOAL
Normal bone turnover
Prevention of vascular and soft tissue calcifications
Control of hyperparathyroidism
Normal growth
Prevention of skeletal deformities (rickets)
Hyperphosphatemia
MANIFESTATIONS
Hyperparathyroidism
Soft tissue and vascular calcifications
MANIFES
Uremic os
gro
bon
ske
abn
den
red
Myocardia
Myopathy
Vascular a
Hypercalce
CONTRIB
Hyperpho
Mineral Metabolism
Impaired renal phosphate excretion

Dietary phosphorus intake (meat, milk products)
Inadequate dialysis:
low fill volume,

lack of daytime dwell(s) in APD
Insufficient dietary phosphate binder therapy or
Nonadherence to phosphate binder prescription
TREATM
Dietary ph
Phosphate
Hypercalcemia
MANIFESTATIONS
Low-turnover bone disease
Soft tissue and vascular calcifications
Severe hyperparathyroidism
Vitamin D toxicity
Low turnover bone disease
Use of calcium containing phosphate binders
Use of high calcium PD fluid (1.75 mM/3.5 mEq/L Ca2+)
66
ina
- ina
Decreased
Hypocalce
hyp
dec
ske
calc
sev
Oral calcit
com
hyp
RESPONS
Serum pho
Serum inta
OUTCOM
Serum calc
Serum inta
Serum alk
mm
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Page 67
Hyperparathyroidism
MANIFESTATIONS
Uremic osteodystrophy
growth failure
bone pain
skeletal deformities
abnormal gait
dental abnormalities
red eye syndrome
Myocardial fibrosis
Myopathy, neuropathy
Vascular and soft tissue calcifications
Hypercalcemia
Hyperphosphatemia due to:
inadequate dietary phosphorus restriction

- inadequate oral phosphate binder therapy
Decreased levels of calcitriol due to impaired renal calcitriol synthesis
Hypocalcemia due to:
hyperphosphatemia,
decreased GI calcium absorption
skeletal resistance to PTH
TREATMENT STRATEGIES
Dietary phosphorus restriction
Phosphate binder therapy
calcium carbonate/acetate if serum calcium low or normal

sevelamer if hypercalcemia present or Ca intake with binders >200% RDA
Oral calcitriol therapy
combined with low-calcium PD fluid and/or sevelamer in the presence of
hypercalcemia
RESPONSE CRITERIA
Serum phosphorus, calcium and calcium-phosphorus ion product in normal range for age
Serum intact PTH 150300 pg/mL (normal 1065 pg/mL)
OUTCOMES EVALUATION
Serum calcium, phosphorus every 4 weeks
Serum intact PTH at least every 23 months
Serum alkaline phosphatase activity every 6 months
67
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Page 68
MANAGEMENT OF UREMIC HYPERPARATHYROIDISM

IN CHILDREN ON PD
PTH <150 pg/mL

Ca >2.5 mmol/L (10mg/dl)
Pi normal or elevated
Discontinue calcitriol.
Use low-calcium PD fluid.
Reduce or hold calcium carbonate/acetate
and add calcium/aluminum-free phosphate binder
PTH <150 pg/mL

Ca <2.5 mmol/L
Pi normal or elevated
Reduce calcitriol dose by 50%
PTH 150300 pg/mL

Ca <2.5 mmol/L
Pi in normal range
Continue/reinstitute calcitriol.
Continue phosphate binders
PTH >300 pg/mL

Ca <2.5 mmol/L
Pi in normal range
Start/increase calcitriol
PTH >300 pg/mL

Ca <2.5 mmol/L
Pi elevated
Intensify dietary counseling.

Increase dialytic phosphate clearance
(dialysate quantity/daytime dwell).
Start/increase calcium carbonate/acetate
PTH >500 pg/mL

Ca >2.5 mmol/L
Pi elevated
Hold calcitriol and consider calcitriol analogue.

Use low-calcium PD fluid.
Reduce or hold calcium carbonate/acetate,
and add calcium/aluminum-free phosphate binder.
If persistent: consider subtotal
parathyroidectomy
Ma
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Management of Anemia
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TREATMENT GOAL
Hemoglobin 1112 g/dL
Hematocrit 3336%
MANIFESTATIONS
Anorexia
Fatigue
Decreased exercise capacity
Increased risk for patient mortality
Left ventricular hypertrophy
Poor cardiac function
Impaired school performance
Iron deficiency (absolute, functional)

Blood loss
Vitamin B12, B6 and folate deficiency
Carnitine deficiency
Secondary hyperparathyroidism
Infection/inflammation
Surgery
Trauma
Hemolysis
Medications (e.g., ACE inhibitors)
Hemoglobinopathies (alpha & beta thalassemia, sickle cell anemia)
Malnutrition
Inadequate dialysis
Aluminum toxicity
OUTCOME EVALUATION
Hemoglobin/hematocrit at least monthly
Serum ferritin/TSAT monthly until stable, then every 3 months
IRON PREPARATIONS
Oral iron (35 mg/kg/day elemental iron)
Ferrous gluconate (tablets) 12% elemental iron

Ferrous sulfate (syrup, elixir, drops, tablets, capsules) powder 20% elemental iron,
dried 30% elemental iron
Ferrous fumarate (drops, suspension, tablets) 33% elemental iron
Polysaccharide iron complex (capsules, elixir, tablets)
Intravenous
Iron dextran Ferric gluconate Iron sucrose
70
If using d
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Page 71
mia
mental iron,
INITIATION OF ERYTHROPOIETIN (EPO) THERAPY
Hgb <11 gm/dL and/or presence of

anemia-related symptoms
Iron replete or receiving iron therapy?
no
yes
See iron administration

algorithm
Initiate subcutaneous EPO therapy at

50 u/kg/dose twice weekly (>5 yrs)
or
100 u/kg/dose twice weekly (<5 yrs)
yes
Hgb increase 0.50.75 g/dL weekly

up to target Hgb of 1112 g/dL?
no
Factors present
that decrease EPO effect?
Continue
current
therapy
yes
no
Identify and
correct factors
Increase EPO
dosage 25%.
Repeat Hgb in
12 weeks
Monitor Hgb every 12 weeks following initiation and monthly during maintenance therapy.
If using darbepoetin alfa, provide weekly equivalent epoetin dose; if epoetin dosing 23 times weekly, convert to darbepoetin alfa dosing once weekly;
if epoetin dosing once weekly, convert to darbepoetin alfa dosing every other week [100 IU epoetin = 0.5 g darbepoetin alfa].
71
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MAINTENANCE ERYTHROPOIETIN (EPO) THERAPY
Receiving Maintenance EPO
Hgb 1112 g/dL
Hgb <11 g/dL
Factors present that

decrease EPO effect?
yes
Iron replete?
Continue current therapy
Hgb >12 g/dL

and increasing
Patient undergoing surgery

or with significant infection
Decrease dosage by 25%.

Repeat Hgb in 12 weeks
Increase dosage by
2550%.
Repeat Hgb in 12 weeks
TSAT >20
ser
>100 ng/m
no
Hgb <1
large
Increase EPO
dosage by
25%. Repeat
Hgb in
12 weeks
yes
Factors pres
that decrea
EPO effec
no
See iron management

algorithm
yes
Identify and correct

other factors
Monitor Hgb every 12 weeks following initiation and monthly during maintenance therapy.
If using darbepoetin alfa, provide weekly equivalent epoetin dose; if epoetin dosing 23 times weekly, convert to darbepoetin alfa dosing once weekly;
if epoetin dosing once weekly, convert to darbepoetin alfa dosing every other week [100 IU epoetin = 0.5 g darbepoetin alfa].
72
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Page 73
mia
IRON ADMINISTRATION
Baseline TSAT* and serum ferritin
Initiate oral iron therapy 35 mg/kg/day elemental iron
g surgery
infection
1 month
TSAT and serum ferritin
ge by
.
2 weeks
TSAT >20% to <50% and

serum ferritin
>100 ng/mL to <800 ng/mL
TSAT <20%
and
serum ferritin >100 ng/mL
TSAT <20%
and
serum ferritin <100 ng/mL
TSAT >50%
and/or
serum ferritin >800 ng/mL
Hgb <11 g/dL and/or

large EPO dose? **
Inflammatory block?
Compliant with oral iron?
Hold iron therapy
yes
no
yes
no
Functional
Treat source of
Factors present
Continue
inflammation iron deficiency
that decrease
current therapy
likely.
and re-evaluate
EPO effect?
Consider
course of IV
iron
yes
no
Evaluate for
blood loss.
Consider
course of IV
iron
Consider
change of oral
iron preparation or course
of IV iron
1 month
Repeat TSAT and serum ferritin
Within therapeutic range?
no
yes
Consider course
of IV iron
yes
no
Resume iron at
33%50%
lower dose
Continue to
hold iron
therapy and
monitor TSAT
and serum
ferritin
monthly
Identify and correct
weekly;
*TSAT = serum FE/TIBC
**Large EPO dose is 23 x typical age-related dose
73
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Page 75
Preparation for
Transplantation
Preparation for
Transplantation
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Page 76
Preparation for
Transplantation
TREATMENT GOALS
Thorough evaluation to determine patient suitability/readiness for transplantation
Detect and treat reversible medical conditions that may influence transplant outcome
Complete all live attenuated viral vaccinations (if possible) 612 weeks prior to transplant
TIMING OF EVALUATION
When progression toward end stage renal disease becomes evident
When patient/family is medically/psychologically prepared for evaluation and subsequent
transplant
INDICATION FOR TRANSPLANTATION

Symptoms of uremia not responsive to standard medical therapies
Failure to thrive due to limitations in total caloric intake
Delayed psychomotor development
Hypervolemia
Hyperkalemia
Metabolic bone disease due to renal osteodystrophy not responsive to standard medical
therapies
CONTRAINDICATION FOR TRANSPLANTATION

Active or untreated malignancy
HIV infection
Chronic active infection with Hepatitis B
Severe multiorgan failure that precludes a combined transplant with a kidney
Preparation for
Transplantation
Severe, irreversible neurologic impairment/persistent vegetative state
76
COMPON
Physical Exam
Height, we
evaluation
Medical Histo
Detailed p
Laboratory S
BUN, crea
ALT, GGTP
Serology Stu
Serology f
Immunizatio
DPT, Hep A
months of
Histocompat
Blood type
Radiologic
In infants
patency of
Consultation
Urology ev
obstructive
ion
utcome
transplant
ubsequent
d medical
2/17/04
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Page 77
COMPONENTS OF EVALUATION
Physical Exam
Height, weight, dental evaluation, pelvic examination (if applicable), ophthalmologic
evaluation
Medical History
Detailed patient and family medical history, record of all blood transfusions
Laboratory Studies
BUN, creatinine, electrolytes, calcium, magnesium, glucose, phosphorus, albumin, AST,
ALT, GGTP, PT, PTT, CBC with differential/platelets, monthly PRA
Serology Studies
Serology for CMV, EBV, VZV, HZV, HIV and Hepatitis A,B,C
Immunizations
DPT, Hep A and B, HIB, IPV, pneumococcal, influenza; VZV and MMR (not within 2
months of transplant)
Histocompatibility
Blood type, HLA, PRA, cross-match
Radiologic
In infants and small children with history of central venous access, CT/MRI evaluation for
patency of abdominal and pelvic vasculature
Consultation
Urology evaluation for assessment of children with history of bladder dysfunction,
obstructive uropathy
77
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Page 78
Preparation for
Transplantation
Preparation for Transplant
Recipient Evaluation
Medical/nutritional history and

physical examination completed?
no
Complete assessment.
Dietary consult if indicated
no
Refer to
Psychologist/Social Worker
no
Obtain outstanding
laboratory data
no
Refer to pediatric urologist.

Review GU history and
radiologic/urodynamic results
no
Provide immunizations.
Delay transplant following live
virus vaccines
no
Complete testing
yes
Psychosocial assessment of
patient and family complete?
yes
Laboratory and serologic

evaluation completed
and satisfactory?
yes
Genitourinary evaluation
completed and satisfactory?
yes
Immunizations up-to-date?
yes
Histocompatibility
testing completed?
yes
78
Recipient Preparation Complete
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Page 79
Donor selection
Donor options discussed

with patient/family?
no
Conference with patient/family

and transplant personnel
yes
Decision made?
yes
no
Proceed with
LD transplant
evaluation or
list for
cadaveric
donation
Continue
decision
process
79
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Page 80
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Page 81
Appendix
Appendix
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Page 82
Guidelines for 24-Hr

Dialysate Collection
Appendix
CAPD
Have the patient drain and discard dialysate.
Collect all dialysate for the next 24 hours. Dialysate does not require refrigeration OR a
preservative.
Draw a blood sample in close proximity to the 24-hr collection period. Send blood
sample to lab for creatinine and urea nitrogen (BUN) measurement.
Two methods are common for dialysate collection:
Batch method
Pool the entire volume of dialysate and mix thoroughly.
Measure the 24-hr. dialysate volume.
Draw a final sample of mixed dialysate.
Send dialysate sample to lab for creatinine and urea nitrogen (DUN)
measurement.
or
Aliquot Method
Empty each dialysate bag into a measuring container.
Record the individual bag volume.
Move the decimal point 3 places to the left. Draw this amount in mL from that
sample of effluent and place in a red top test tube. (i.e., if effluent volume is
2350 mL, 2.35 mL are placed in the test tube).
Repeat the process for all bags.
Mix all dialysate samples in single container.
Send dialysate sample to lab for creatinine and urea nitrogen (DUN).
APD
Begin the cycler treatment by draining the patient and saving the drained volume.
Collect all dialysate during the cycler treatment using a 15-liter drain bag. If a daytime
exchange is performed, it must be included in the total collection.
Instruct the patient to mix the solution thoroughly and obtain a sample.
Record the total volume drained.
Draw a blood sample in close proximity to the 24-hr collection period. Send to lab for
creatinine and urea nitrogen (BUN) measurement.
Send dialysate sample to lab for creatinine and urea nitrogen (DUN) measurement.
Note: When performing 24-hr. collections, standard precautions should be taken when handling
blood or drained dialysate.
82
Twenty-four
collection (th
the growth o
its protocol.
To perform t
First, have
Collect all
bacterial b
End the te
complete
Draw a blo
to lab for c
Measure 2
Send urine
Note: For pat

recommended
by 2 to create
ion OR a
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Page 83
Guidelines for 24-Hr

Urine Collection
Twenty-four-hour urine collection requires either a preservative be added to the
collection (thymol is the recommended preservative) or refrigeration to inhibit
the growth of bacteria that can break down urea. Check with your laboratory for
its protocol.
ood
L from that
olume is
To perform the 24-hr collection:

First, have the patient empty his/her bladder and discard urine.
Collect all urine for the next 24 hours. Refrigerate urine OR add thymol to prevent
bacterial breakdown of urea
End the test by having the patient empty his/her bladder. Save the urine to
complete the 24-hr collection
Draw a blood sample in close proximity to the 24-hr collection period. Send blood sample
to lab for creatinine and urea nitrogen (BUN) measurement
Measure 24-hr urine volume
Send urine sample to lab for creatinine and urea nitrogen (UUN) measurement
Note: For patients who void infrequently (less than 3 times per 24 hours), a 48-hr collection is
recommended. If the sample is a 48-hr collection, the total volume collected should be divided
by 2 to create a 24-hr volume result.
).
me.
daytime
o lab for
ment.
when handling
83
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Page 84
Clearance Calculations
It is important to measure achieved clearances to document the actual dialysis dose
received. The following are simplified formulas to calculate patient clearance.
Creatinine Clearance (CrCl) calculation is normalized to BSA.
(Refer to the Body Surface Area chart on pages 1819.)
Dialysis CrCl L/week = 24-Hr D/P Cr x 24-Hr Drained Volume x 7 x 1.73m2 BSA
Patients BSA
*D/P = Dialysate concentration/Plasma concentration
Kt/Vurea is the urea clearance normalized for the urea distribution space. Kt is the urea
clearance during the sampling period, and V is the distribution volume of urea. A simple
method for determining the volume of urea distribution is to estimate the patients
total body water. It is important to note that different equations exist for estimating
total body water, and using a different equation may give different values.
V can be estimated by the following pediatric total body water prediction equation
(Morgenstern et al.*):
TBW ( V ) = 0.098 x ( Ht x Wt )0.63
Dialysis Kt/V = 24-Hr D/P Urea x 24-Hr Drained Volume x 7
V
For those patients with renal function, clearance from their residual function is added to
the calculated dialysate clearance for a total combined clearance.
Renal Kt/V = mL/min Urea clearance x 1440 min/day x 7
1000 mL x V
*Morgenstern BZ, Mahoney DW, Wuhl E, Schaefer F and Warady BA. Total Body Water (TBW) in Children on Peritoneal
Dialysis. J Am Soc Nephrol (abst) 2002; 13: 2A
84
Cl
Residual rena
clearance. Ca
Renal Clearan
Urea Clearan
Creatinine Cle
ns
ysis dose
ce.
m2 BSA
2/17/04
1:31 PM
Page 85
Residual Renal
Clearance Calculations
Residual renal clearance is calculated as the average of creatinine clearance and urea
clearance. Calculate residual renal clearance using the following formulas.
Renal Clearance:
Urea Clearance mL/min = Volume of 24-Hr Urine in mL x Urine Urea Nitrogen Concentration
1440 min/day x Blood Urea Nitrogen Concentration

Creatinine Clearance mL/min = Volume of 24-Hr Urine in mL x Urine Creatinine Concentration
1440 min/day x Serum Creatinine Concentration
is the urea
rea. A simple
patients
stimating
quation
s added to
on Peritoneal
85
2/17/04
1:31 PM
Page 86
Method of Performing
a PET in Children
Me
Dwell period: 4 hours

Fill volume: 1100 mL/m2 BSA*
2.32.4% anhydrous glucose dialysis solution (Europe)
0.8
2.5% dextrose dialysis solution (North America, Japan)

Test exchange after prolonged (8 hours) dwell, if possible as follows:
Drain the overnight dwell

Record the length of the dwell and the volume drained. Also note the dextrose
and volume infused
Infuse the calculated fill volume, note infusion time
Keep patient in supine position
Drain <10% of dialysate solution into the drain bag at 0, 120 and 240 minutes
Invert bag for mixing and obtain sample. Reinfuse any remaining effluent
Obtain blood sample after 120 minutes
Measure creatinine and glucose in each sample
Calculate dialysate to plasma (D/P) creatinine and dialysate glucose to baseline dialysate
glucose (D/DO) concentration ratios
Determine transporter state by comparing creatinine and glucose equilibration curves
with pediatric reference percentiles (see next page)
D/P Creatinine
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Source: War
Journal of th
D/D0 Glucose
*In early infancy, volume may not be tolerable; if occurs, conduct PET with regular daily exchange volume for evaluation.
Source: Wa
Journal of t
86
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Page 87
Method of Performing
a PET in Children
PEDIATRIC CREATININE PET CURVE
0.8
dextrose
D/P Creatinine
0.7
0.6
0.5
0.4
0.3
0.2
0.1
Time in Hours
minutes
nt
0
0
High
High Average
Low Average
Low
Source: Warady, et al., Peritoneal Membrane Transport Function in Children Receiving Long-Term Dialysis
Journal of the American Society of Nephrology, Vol.7, Number 11, 1996 p.2385-2391
dialysate
curves
PEDIATRIC GLUCOSE PET CURVE
evaluation.
1
0.9
D/D0 Glucose
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
Time in Hours
0
0
High
High Average
Low Average
Low
Source: Warady, et al., Peritoneal Membrane Transport Function in Children Receiving Long-Term Dialysis
Journal of the American Society of Nephrology, Vol.7, Number 11, 1996 p.2385-2391
87
2/17/04
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Page 88
Measurement of Intraperitoneal
Pressure (IPP)
1. Schroder CH
peritoneal d
Supplies
Metric measurement of the height of the dialysis fluid column in the PD tube, directly
connected to the peritoneal cavity (like a central venous pressure)
A rule (scale graduated in centimeters) on a bracket
CAPD connecting system, either a disconnect system (e.g., Y-system) or
nondisconnect system
Procedure
Patient is at rest, lying in a supine position
Connection with the peritoneal system is made (as usual), and the patients peritoneal
cavity is filled
The PD line is fixed vertically on the bracket, and there is no counterpressure in the distal
part of the measurement tubing
The level of the column of dialysis fluid in the PD line is read with a scale graduated in
centimeters after the height of the column stabilizes, first after deep inspiration (IPP insp)
and second after expiration (IPP exp); determination of mean IPP:
2. Fischbach M
a useful too
3. Sanchez CP
disease. Sem
4. Schroder CH
patients. Gu
5. Davis ID, Bu
transplantat
of Transplan
6. Haffner D, S
with chronic
343(13):923
7. Wuhl E, Wit
Reusz GS, R
children nor
8. Warady BA,
Verrina E; In
Patients. Co
IPP insp + IPP exp
2000; 20(6)
9. Holloway M
rates. Perit D
The zero level of the column is set at the center of the abdominal cavity, on the
midaxillary line
The peritoneal cavity is emptied after taking the IPP reading, and the volume of the
drained dialysis fluid is measured, correlated to the measured mean IPP
IPP is measured at atmospheric pressure without any counterpressure in the distal part
of the measurement tubing. The technique used depends upon the geometry of the PD
system. In disconnect systems, there is no counterpressure in the line or in the empty
drainage bag after the line has been connected. In nondisconnect systems, there is
almost always a moderate counterpressure, so an air inlet is needed, accomplished
before the readings are made by introducing a trocar at the injection site of the bag.
Normal level for children greater than 2 years of age
10. Warady BA,
dialysis. Am
11. Abu-Alfa A,
Kidney Int S
12. Mujais, S, V
13. NKF-K/DOQ
14. NKF-K/DOQ
pp132-180.
15. Schaefer F, K
practice of p
16. Schaefer F, K
properties a
1999; 10: 17
IPV mL/m
IPP cm of water
88
990 160
8.2 3.8
1400 50
14.1 3.6
17. Fischbach M
European co
18. Watson AR,
for Elective C
2/17/04
oneal
1:31 PM
Page 89
References
1. Schroder CH; European Paediatric Peritoneal Dialysis Working Group. The choice of dialysis solutions in pediatric chronic
peritoneal diaysis: guidelines by an ad hoc European committee. Perit Dial Int 2001; 21(6):568-574.
2. Fischbach M, Terzic J, Laugel V, Escande B, Dangelser C, Helmstetter A. Measurement of hydrostatic intraperitoneal pressure:
e, directly
a useful tool for the improvement of dialysis dose prescription. Pediatr Nephrol 2003; 18(10):976-980.
3. Sanchez CP. Prevention and treatment of renal osteodystrophy in children with chronic renal insufficiency and end-stage renal
disease. Semin Nephrol 2001; 21(5):441-450.
4. Schroder CH; European Pediatric Peritoneal Dialysis Working Group. The management of anemia in pediatric peritoneal dialysis
patients. Guidelines by an ad hoc European committee. Pediatr Nephrol 2003; 18(8):805-809.
5. Davis ID, Bunchman TE, Grimm PC, Benfield MR, Briscoe DM, Harmon WE, Alexander SR, Avner ED. Pediatric renal
transplantation: indications and special considerations. A position paper from the Pediatric Committee of the American Society
of Transplant Physicians. Pediatr Transplant 1998; 2(2):117-129.
peritoneal
e in the distal
aduated in
tion (IPP insp)
6. Haffner D, Schaefer F, Nissel R, Wuhl E, Tonshoff B, Mehls O. Effect of growth hormone treatment on the adult height of children
with chronic renal failure. German Study Group for Growth Hormone Treatment in Chronic Renal Failure. N Engl J Med 2000;
343(13):923-930.
7. Wuhl E, Witte K, Soergel M, Mehls O, Schaefer F, Kirschstein M, Busel C, Danne T, Gellermann J, Holl R, Krull F, Reichert H,
Reusz GS, Rascher W; German Working Group on Pediatric Hypertension. Distribution of 24-h ambulatory blood pressure in
children normalized reference values and role of body dimensions. J Hypertens 2002; 20(10):1995-2007.
8. Warady BA, Schaefer F, Holloway M, Alexander S, Kandert M, Piraino B, Salusky I, Tranaeus A, Divino J, Honda M, Mujais S,
Verrina E; International Society for Peritoneal Dialysis *ISPD) Advisory Committee on Peritonitis Management in Pediatric
Patients. Consensus guidelines for the treatment of peritonitis in pediatric patients receiving peritoneal dialysis. Perit Dial Int
2000; 20(6):610-624. (Comment) Perit Dial Int 2000; 20(6):607 and (Erratum) Perit Dial Int Dial 2001; 21(1):6.
9. Holloway M, Mujais S, Kandert M, Warady BA. Pediatric peritoneal dialysis training: characteristics and impact on peritonitis
rates. Perit Dial Int 2001; 21(4):401-404.
e of the
distal part
try of the PD
he empty
there is
plished
the bag.
10. Warady BA, Alexander SR, Watkins S, Kohaut E, Harmon WE. Optimal care of the pediatric end-stage renal disease patient on
dialysis. Am J Kidney Dis 1999; 33(3):567-583.
11. Abu-Alfa A, Burkart J, Piraino B, Pulliam J, Mujais S. Approach to fluid management in peritoneal dialysis: A practical algorithm.
Kidney Int Suppl 2002;62;s8

12. Mujais, S, Vonesh E. Profiling of peritoneal ultrafiltration. Kidney Int 2002;62;S17-S22.
13. NKF-K/DOQI Clinical Practice Guidelines for Anemia of Chronic Kidney Disease. New York, National Kidney Foundation, 2001.
14. NKF-K/DOQI Clinical Practice Guidelines for Nutrition in Chronic Renal Failure. New York, National Kidney Foundation, 2001;
pp132-180.
References
the
15. Schaefer F, Klaus G, Mller-Wiefel DE, Mehls O, and Mid European Pediatric Peritoneal Dialysis Study Group (MEPPS). Current
practice of peritoneal dialysis in children: Results of a longitudinal survey. Periton Dial Int 1999; 19 (Suppl.2): S445-S449.
16. Schaefer F, Klaus G, Mehls O and Mid European Pediatric Peritoneal Dialysis Study Group (MEPPS). Peritoneal transport
properties and dialysis dose affect growth and nutritional status in children on chronic peritoneal dialysis. J Am Soc Nephrol
1999; 10: 1786-1792.
17. Fischbach M, Stefanidis CJ, Watson AR; European Paediatric Peritoneal Dialysis Working Group. Guidelines by an ad hoc
European committee on adequacy of the paediatric peritoneal dialysis prescription. Nephrol Dial Transplant 2002;17:380-5.
18. Watson AR, Gartland C; European Paediatric Peritoneal Dialysis Working Group. Guidelines by an Ad Hoc European Committee
for Elective Chronic Peritoneal Dialysis in Pediatric Patients. Perit Dial Int. 2001;21:240-4.
89
PediatricCovers.QX
2/17/04
1:55 PM
Page 3
This information does not reflect the opinions of BAXTER HEALTHCARE

CORPORATION, but is that of the authors of the Care of the Pediatric
Patient on Peritoneal Dialysis. Readers must evaluate this information
and make changes in their own patient management practices only if it
seems prudent. Baxter assumes no liability for any practice changes that
centers make as a result of reading this material.
PD Adequest, RenalSoft, and HomeChoice are trademarks of

Baxter Healthcare Corporation
PediatricCovers.QX
2/17/04
1:55 PM
Page 4

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PediatricCovers.

Care of the Pediatric Patient

Bradley A. Warady, M.D.

Cover art by Morgan Ghosey, age 16

Care of the Pediatric Patient

Care of the Pediatric Patient

Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

CLINICAL PROCESS FOR OPTIMAL OUTCOMES

DIALYSIS INITIATION: ABSOLUTE INDICATIONS

DIALYSIS INITIATION: RELATIVE INDICATIONS

pressure, acid-base status, electrolytes, serum creatinine, BUN, hemoglobin/hematocrit,

Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

CLINICAL PROCESS FOR OPTIMAL OUTCOMES

Monitor renal function, anthropometric and nutritional status,

Evidence of malnutrition, compromised

at least one yes

Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

Modality Selection and

Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

CLINICAL PROCESS FOR OPTIMAL OUTCOMES

INDICATIONS FOR PD IN PREFERENCE TO HD

Lack of proximity to a pediatric HD center (relative)

Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

CLINICAL PROCESS FOR OPTIMAL OUTCOMES

Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

CLINICAL PROCESS FOR OPTIMAL OUTCOMES

pages 18-19. Prescription recommendations are based on patient size.

Based on the patients lifestyle, physical condition and physicians recommendation,

Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

CLINICAL PROCESS FOR OPTIMAL OUTCOMES

(See pages 8285.)

Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

Calculated by the formula:

CLINICAL PROCESS FOR OPTIMAL OUTCOMES

Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

Calculated by the formula:

CLINICAL PROCESS FOR OPTIMAL OUTCOMES

Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

CLINICAL PROCESS FOR OPTIMAL OUTCOMES

APD Prescription Principles

ADEQUATE TIME ON CYCLER

ANURIC APD PATIENTS REQUIRE WET DAYS

MAXIMIZE FILL VOLUME

ADJUST CYCLE FREQUENCY TO TRANSPORT STATUS

Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

CLINICAL PROCESS FOR OPTIMAL OUTCOMES

Provide educational materials to caregivers, patients

2- to 6-week healing period,

Start supine dialysis with 1224 exchanges

Establish maximally tolerable fill volume by either repeated IPP measurements

Use PD dosing tables or software (PD Adequest or RenalSoft PD Rx Management)

* ~200 mL/m2 BSA during infancy

Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

CLINICAL PROCESS FOR OPTIMAL OUTCOMES

Physical and mental well-being, absence of uremic symptoms

Minimal interference with family/school/social life

MANIFESTATIONS OF INADEQUATE DIALYSIS

Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

CLINICAL PROCESS FOR OPTIMAL OUTCOMES