Peritoneal Dialysis

Peritoneal Dialysis Adequacy

&

Prescription Management
Peritoneal Dialysis

Background

• Target small solute clearances have been based

upon assumptions that peritoneal and renal
clearances are added together
• Renal small solute clearances are directly
correlated with patient survival
• There have been no randomized, controlled
interventional trials examining the role of
increases in peritoneal small solute clearances
on patient survival
Peritoneal Dialysis

Improving patient lifetime on therapy

Access Adequacy

QoL
Fluid control

Nutrition
Compliance

Infection control
Peritoneal Dialysis

Components of Prescription Management

Fixed Parameters Adjusted Parameters

• Disease Process • Fill Volume
• Lifestyle • Number of Exchanges
• Body Size • Dwell Time
• Residual Renal Function • Efficient Use of Total 24
(RRF) Hours
• Peritoneal Membrane • Glucose Concentration
Peritoneal Dialysis

Adequacy Targets have changed over the

last decade
Creat.clr KT/V
(l/week)

• In 1992: 40 1.5
• In 1995: 50 1.7
• In 1997: 60 2.0
• In 1999: 60 2.0 (high-avg/high transporters)
50 (low/low-avg transporters)

• In 2001* 50 1.7
• Ultrafiltration starts to get an increased focus
compared to earlier – 1L total water removal/day

*European PD guidelines, published 2001

Peritoneal Dialysis

What is Clearance?

• Clearance is the total amount of body fluid

completely cleared of a solute during a certain
time

• ml/min
• L/week

• Ex: Creatinine clearance = 50 l/week means:

50 L of body fluid is totally cleared for creatinine
during a week
Peritoneal Dialysis

Targets for solute clearance

CrCl
50 60

Kt/V
1.7 2.0
Suggested impact on outcome
Peritoneal Dialysis

The peritoneal equilibration test (PET)

• Semiquantitative assessment of peritoneal

membrane transport function
• Assess rates of solute equilibration between
peritoneal capillary blood and dialysate
• Uses the ratio of solute concentrations in dialysate
and plasma (D/P) at specific times to signify the
extent of equilibration
• Performed using a standardized method, using
standard solutions (2.27% glucose)

Twardowski ZJ, Nolph KD, Khanna R et al Perit Dial Bull 1987;7:138.

Peritoneal Dialysis

Clinical applications of the PET

• peritoneal membrane transport classification

• predict dialysis dose
• choose peritoneal dialysis regime
• monitor peritoneal membrane function
• diagnose acute membrane injury
• diagnose causes of inadequate ultrafiltration
• diagnose causes of inadequate solute clearance
• estimate D/P ratio of a solute at a particular time
Peritoneal Dialysis

The peritoneal equilibration test (PET)

• following a standard overnight exchange

• drain to dryness
• instill 2.27% 2000 ml glucose bag
• roll patient to ensure mixing
• sample PD fluid at time 0, 2, 4 hours
• blood test (assume blood concentrations
constant)
• drain out at 4 hours and measure drain volume
Peritoneal Dialysis

The peritoneal equilibration test (PET)

Drain volumes correlate positively with dialysate glucose and

negatively with D/P creatinine at 4 hours
Peritoneal Dialysis

Membrane transport type.

60

50

40

30

20

10

0
L LA HA H
Peritoneal Dialysis

Calculation of Peritoneal Urea Clearance

Drain No Dwell time Drain Vol. Drain urea

1 285 2500 11.9

2 285 2500 12.2

3 315 2625 10.0

4 597 2500 14.3

Plasma urea 14.4 mmol/l Total drain vol = 10125 ml

Volume of 31595 ml Average drain urea = 12.7

distribution
Peritoneal Dialysis

Calculation of peritoneal urea clearance

drain volume diaysate urea

weekly Kt / v  ( x )x 7
volume of distributi on plasma urea

10125 12.7
weekly Kt / v  x x7
31595 14.1

= 0.288 x 7
= 2.02
Peritoneal Dialysis

Calculation of Peritoneal Creat. Clearance

Drain No Dwell Drain Vol. Drain
time creatinine
1 285 2500 804

2 285 2500 800

3 315 2625 817

4 597 2500 1017

Plasma 1091 Total drain vol = 10125 ml

creatinine umol/l
Body 1.737 m2 Ave drain creat = 859.5 umol/l
surface
area
 Peritoneal Dialysis

Calculation of Peritoneal Creat Clearance

dialysate creatinine
weekly creatinine clearance (l )  total drain volume x x7
plasma creatinine

= 10.7 x 0.788 x 7
= 59 l/wk

Normalise to BSA = CCl x 1.73/ patients BSA

Normalised weekly CCl = 59 l/wk/1.73 m2

Peritoneal Dialysis

A standard patient?

2.0 10 l
1.0

drain volu me D
target urea clearance  x x7
distn volu me P

35l

= 0.286 x 7
= 2.0
Peritoneal Dialysis

Optimizing peritoneal dialysis dose

Schedule dwell
Increase dialysis times to
dose by maximise
increasing drain clearance
volumes

drain volu me D
target urea clearance  x x7
distn volu me P

Problems
arise for
large body
weights
Peritoneal Dialysis

Treatment guidelines – a summary

• Patients with BSA> 1.7m2 or body weight >65 kg

• Routinely prescribed 2.5L fill volume
• Patients with BSA> 2 m2 or body weight >80 kg
• Routinely prescribed 3 L fill volume
• Patients requiring 5 day exchanges should use a
night time exchange device to deliver the 5th
exchange
• Patients on APD should do one or more day time
exchanges (unless small BSA or high RRF)

Clinical Practice Guidelines of the Canadian Society of Nephrology for treatments of Patients with CRF
JASN 10: S287-S321, 1999
Peritoneal Dialysis

Main principles behind

the APD guidelines
• Patients with higher D/P require an increased number of exchanges during
the night
• Patients with higher BSA require higher fill volume per exchange
• Anuric patients are advised to have an extra day exchange (OCPD)
• Extraneal is encouraged to be used in all patients during a long day well
as it can improve the UF and clearance of patients

L LA HA H
(D /P < 0 .5 ) (D /P 0 .5 -0 .6 5 ) (D /P 0 .6 5 -0 .8 1 ) (D /P > 0 .8 1 )

S m a ll (< 1 .7 1 B S A )

Increase number of exchanges

M e d iu m (1 .7 1 - 2 .0 B S A )
Increase
fill
L a r g e (> 2 .0 B S A ) volume
Peritoneal Dialysis

Overview of guidelines
RRF >2 ml/min
Low D/P Low Avg. D/P High Avg. D/P High D/P

3x2.5L + 3x2.5L+ 4x2L+ 4-5x2L+

Small 2x2L or 1x2.5 L 2L 2L 2L
BSA

3x3L+ 3x2.5-3L+ 4x2.5L+ 4x2.5L or 5x2L+

Medium 2x2L or 1x2.5L 2.5L 2L 2L
BSA

3x3L+ 3x3L + 4x3L+ 4-5x2.5L+

Large 2x2.5L 3L 2.5L 2.5L
BSA
All prescriptions include 9 hours overnight treatment. If targets are over achieved,
reducing therapy time at night can be an option. Monitor with care
Varied glucose concentrations and Extraneal® are advised to use in order to meet the
required UF of min.1 L
Peritoneal Dialysis

Overview of guidelines RRF <2 ml/min

Low D/P Low Avg. D/P High Avg. D/P High D/P

CAPD, Quantum 3x2.5*+ 4x2L+ 4-5x2L+

Small 2x2L 2x2L 2x2L
BSA APD *
3x2.5L (9-10 hrs)+
2x2.5L

CAPD, Quantum or 3x3L+ 4x2.5L+ 4 x 2.5L or 5 x2L

HD
Medium 2x2.5L 2x2.5L + 2x2L
APD *
BSA 3x3L (9-10 hrs)
+2x3L

Large CAPD, Quantum or

CAPD, Quantum or HD 4 x 3L+ 4-5x2.5L+
BSA
HD APD*
3x3L (9-10 hrs)
2x2.5L 2x2.5L
+ 2x3L

All prescriptions include 9 hours overnight treatment if not otherwise noted

Varied glucose concentrations and Extraneal® are advised to use in order to meet the required UF of
min.1 L
APD* For these patient groups, APD therapy will probably not reach both KT/V and Creat clr. targets.
Monitor with care. Two day time exchanges can be beneficial for motivated patients in order to meet
targets.
Peritoneal Dialysis

Impact of larger CAPD volumes on total

CCl versus a 5th exchange (calculated).
No of 4 5 4
exchanges
Total CCr 56.7 58.9 66.1
(l/1.73m2)
Drain 2000 2000 2500
volume

Assume 70 kg male, anuria, 4 hr D/P = 0.65,

BSA 1.73m2, 2l UF.
Peritoneal Dialysis
Relationship Between Dwell Time
and Transport

Transport Solute Cl UF Prescription

Rapid ++++ + Short dwell
High A +++ ++ CAPD/CCPD
Low A ++ +++ CAPD/CCPD
Low + ++++ Long Dwells

> Always maximize fill volumes

Peritoneal Dialysis

Common prescription errors - CAPD

• mismatch dwell time and transport type

• inappropriately short daytime dwell

• inappropriate infused volumes

• inappropriate glucose concentration for

nighttime dwell
Peritoneal Dialysis

Common prescription errors - APD

• inappropriate use of a dry day

• inappropriately long drain times

• failure to increase target dose to account for

intermittent therapy

• failure to consider a CAPD exchange during

the day to increase clearance
Peritoneal Dialysis

ADEMEX

• ADEMEX (ADEquacy of PD in MEXico) is a

randomized, active controlled, prospective trial
• Hypothesis tested: increases in peritoneal
clearance of small solutes improves the PD
patients’ survival
• The primary outcome was mortality.
Peritoneal Dialysis

ADEMEX
Summary of Design

Patient Numbers
• 965 Mexican patients current or new to dialysis from 24
participating centers were randomized
• 484 Control
• 481 Treated
• Initial recruitment started on June 1, 1998
• First patient randomized July 9, 1998
• Follow-up through May 6, 2001
• A minimum follow-up of two years following enrollment
Peritoneal Dialysis

Study Design

Screening
pCrCl < 60 L/week/1.73 m2

Randomization
centralized

Control Group Intervention Group

Continue on standard therapy 2 prescription adjustments
4 x 2L per day Aim pCrCl > 60 L/week/1.73 m2
N= 484 N= 481
Peritoneal Dialysis
ADEMEX: Treatment Characteristics

Peritoneal CrCl L/wk/1.73 m2

95% Confidence Limits on
Means
Mean Trends in Peritoneal CrCl

p<.001

Months After Randomization

Peritoneal Dialysis

ADEMEX: Treatment Characteristics

Peritoneal Kt/V
95% Confidence Limits on Means
Mean Trends in pKt/V

p<.001

Months After Randomization

Peritoneal Dialysis

ADEMEX: Primary Outcome

% Patient Survival

p=0.9842

RR(Treated:Control)=1.00
95% CI: (0.80, 1.24)

Months on Study
Peritoneal Dialysis

ADEMEX: Conclusions

• There was no difference in patient survival with

variations in peritoneal small solute clearance
within ranges achievable in current clinical
practice.
• Survival remained similar between the two groups
even after adjusting for factors known to be
associated with mortality in patients on PD (age,
diabetes, albumin, nPNA, anuria)
Peritoneal Dialysis
Recommended Total Solute
Clearance Targets
CAPD Kt/V CCr/1.73m2
NKF-DOQI 1997 2.0 60 L
NKF-DOQI 2000
L&LA 2.0 50 L
HA&H 2.0 60 L
Canadian guidelines
L & LA 2.0 50 L
HA & H 2.0 60 L
Renal Assoc - UK 1.7 50 L
EDTA-ERA 1.7 (Peritoneal)
Peritoneal Dialysis

Prescription Modification
Peritoneal Dialysis

Prescription Modification
Peritoneal Dialysis

Prescription Modification
Peritoneal Dialysis

Prescription Modification
Peritoneal Dialysis

Prescription Modification
Peritoneal Dialysis

APD - Increasing Clearance

• Increase fill volumes

• Add a daytime exchange

• Increase Time on Cycler

• Increase Number of Nighttime Exchanges

Peritoneal Dialysis

APD - Increasing Clearance

• Increase fill volumes

• Effective means of improving clearance
• Minimum impact on patient lifestyle
• Adjust nighttime exchanges first
• Use 2.0L or greater whenever possible
• Add a daytime exchange
• Increase Time on Cycler
• Increase Number of Nighttime Exchanges
Peritoneal Dialysis

APD - Increasing Clearance

• Increase fill volumes

• Add a daytime exchange
• This is a very effective means of improving clearance
• HomeChoice can be programmed to deliver the midday
exchange
• Increase Time on Cycler
• Increase Number of Nighttime Exchanges
Peritoneal Dialysis

APD - Increasing Clearance

• Increase fill volumes

• Add a daytime exchange
• Increase Time on Cycler
• Cycler time can be extended to 10 hours
• Increasing cycler time with a constant number of
exchanges increases dwell time which increases
clearance
• Increase Number of Nighttime Exchanges
Peritoneal Dialysis

APD - Increasing Clearance

• Increase fill volumes

• Add a daytime exchange
• Increase Time on Cycler
• Increase Number of Nighttime Exchanges
• May increase clearance, but only if time on cycler is
also increased
Peritoneal Dialysis

Solute Control Algorithm

Initiate Therapy

Measure Clearances

Adjust Therapy
Peritoneal Dialysis

Monitoring frequency

• KT/V and Creat.clr:

• Within 6-8 weeks after commencing dialysis
• Every subsequent 6 month
• If patients clinical status changes unexpectedly, or if
prescription is altered, take supplemental clearance
measurements
• PET
• Within 6 weeks of initiating PD
• Repeat if unexpected changes in peritoneal UF occur

Clinical Practice Guidelines of the Canadian Society of Nephrology for treatments of Patients with CRF
JASN 10: S287-S321, 1999
Peritoneal Dialysis

Making monitoring of adequacy

easier
Using a software program makes monitoring
easier:

• Automated calculations of creat clearance, KT/V,

nPNA
• Reporting function gives easy overview of one patient
or whole patient population
• Easy to identify problem patients where actions might
be needed
• Track and document improvements over time
Peritoneal Dialysis

Auditing clinical outcomes in PD

• Monitor patient and technique survival in all large programs
• Monitor % of patients in all PD programs who fail to
achieve targets
• Record % of patients in all PD programs with inadequate
nPNA values and severe hypoalbuminemia

• A good program will have 80-85% of patients achieving

adequacy targets
• Review the proportions of patients exceeding targets
every 3-6 months

Clinical Practice Guidelines of the Canadian Society of Nephrology for treatments of Patients with CRF
JASN 10: S287-S321, 1999
Peritoneal Dialysis

Conclusion.

• There is uncertainty about the target clearance in

PD

• Patient management in peritoneal dialysis

involves much more than small solute clearance –
of particular importance are for example residual
renal function and ultrafiltration volume, as well as
the other complex of factors central to holistic
management of renal failure patients.