aakp
Advisory:
  Peritoneal dialysis
emphasis shifted away
 from target Kt/V of
   2.0 to achieving
minimum Kt/V of 1.7.
M...
AAKP Advisory:
Emphasis shifted away from
target Kt/V of 2.0 to achieving
minimum Kt/V of 1.7. May offer
benefits by prese...
but their function continues to decline with
time. This residual kidney function declines
at a faster rate with hemodialys...
The decision on when to begin dialysis
in Stage 5 CKD is highly variable, and
depends upon many factors, including
the deg...
hemodialysis and PD. Residual kidney
function can also be expressed in terms
of Kt/V. Adequacy of kidney function
is calcu...
he/she is and how much protein he/she
eats. Urea is a waste product of protein.
How well it is removed indicates how well
...
causing him/her to always feel tired and
sick. Under-dialysis may cause many of
the following symptoms: weakness and
tired...
who are well dialyzed will experience a
sense of feeling well, and can enjoy a good
appetite. A well dialyzed patient shou...
patient’s blood across the peritoneal
membrane into the dialysate.
Everyone’s transport rate is not the same.
The PET esta...
she is unable to control his/her fluid weight,
his/her blood pressure is higher, or there
seems to be a decrease in drain ...
function; there is really no room for
missing exchanges, reducing fill volume
or shortening the time fluid is in the belly...
and weak, losing weight, having a poor
appetite and nausea, patients must receive
adequate and proper dialysis regularly,
...
laboratory testing serum albumin: certainly
above 3.3 g/dl, preferably 3.8-4.0 g/dl.


There are many reasons why serum al...
In addition, if a patient is increasing his/her
dialysis dose, he/she may eventually have
a bigger appetite and need more ...
#
    Checklist: Questions You Should Ask
    Your Doctor and PD Staff!

    1. Is my measured weekly Kt/V 1.7 or
       h...
#
       less than 100 mL/day. Steps to preserve
       kidney function include the use of
       medications such as an A...
#
    5. The peritoneal creatinine clearance is
       no longer recommended. Creatinine
       clearance is still measure...
#

    9. The dialysis prescription should be
       adjusted so drain volumes will be
       optimized and ultrafiltratio...
Membership Application
   Membership in AAKP offers you a
subscription to all of AAKP’s publications
      including, aakp...
This brochure is proudly
          sponsored by




             aakp
American Association of Kidney Patients

 3505 E. Fr...
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aakp Advisory:

  1. 1. aakp Advisory: Peritoneal dialysis emphasis shifted away from target Kt/V of 2.0 to achieving minimum Kt/V of 1.7. May offer benefits by preserving residual renal function aakp American Association of Kidney Patients
  2. 2. AAKP Advisory: Emphasis shifted away from target Kt/V of 2.0 to achieving minimum Kt/V of 1.7. May offer benefits by preserving residual renal function Home dialysis therapies are growing. New research findings related to peritoneal dialysis (PD), the most widely used home therapy, make this advisory extremely important. A previous advisory warned PD patients required a Kt/V of 2.0 per week. It has since been shown this is not associated with better outcomes than having minimal Kt/V of greater than 1.7. It has also been found the advantage PD offers in preserving residual kidney function may offer additional survival benefits. Furthermore, increased emphasis has been placed on achieving an ideal volume status. Volume status means managing your blood pressure as well as preserving residual kidney function. Residual kidney function P atients with progressive chronic kidney disease (CKD) often require dialysis when their glomerular filtration rate (GFR) is less than 15 mL/min. The initiation of dialysis does not necessarily cause the natural “native” kidneys to quit working,
  3. 3. but their function continues to decline with time. This residual kidney function declines at a faster rate with hemodialysis than with PD. Clinical trials have demonstrated residual kidney function protects the patient from cardiovascular events such as heart attacks. Keeping residual kidney functions for as long as possible may help reduce a patient’s risk for heart attack. How is residual kidney function measured? R esidual kidney function is ideally measured by a blood test and a 24-hour urine collection – averaging two key values, the 24-hour creatinine clearance (CrCL) and the 24-hour urea clearance. The average of these values (CrCL and urea) are used to calculate the GFR. Urine volume of 100ml per day or more (approximately three ounces) is considered significant and should be included with the measurement to determine the effectiveness of PD therapy. GFR can be estimated using mathematical equations. Equations are highly variable once kidneys fail. Therefore, in patients undergoing dialysis, actual measurements are more reliable.
  4. 4. The decision on when to begin dialysis in Stage 5 CKD is highly variable, and depends upon many factors, including the degree of uremia, overall health status, coexisting cardiac condition and fluid management needs. Therefore, patients will start dialysis with varying degrees of residual kidney function. Once dialysis has begun, residual kidney function should be measured along with PD adequacy at one month, and every four months thereafter. When residual urine output is greater than 100mL per day, residual kidney function measurements should be included in the weekly adequacy goal. Residual kidney function, because of its importance in achieving a patient’s adequacy goal, should be assessed at least every two months. The weekly adequacy goal is defined by the term “Kt/V”. “Kt” stands for urea clearance and “V” stands for body. This number is calculated based on the results of multiple tests including blood analysis, urine analysis, PD solution analysis and body weight. What is “enough” dialysis? Changes in the AAKP Advisory T he Kt/V is a popular equation that helps doctors define dialysis adequacy. It can be useful in patients on hemodialysis, home
  5. 5. hemodialysis and PD. Residual kidney function can also be expressed in terms of Kt/V. Adequacy of kidney function is calculated by adding the weekly Kt/V determined by dialysis measurements and the Kt/V measured from blood and urine. This helps doctors assess the total minimum amount of dialysis and native kidney function necessary for an adequate treatment. The most recent guidelines from the International Society of Peritoneal Dialysis (ISPD), the National Kidney Foundation’s K/DOQI Workgroup, European Practice Guidelines (EPG) and Caring for Australians with Renal Impairment (CARI) have independently determined a Kt/V of 1.7 per week was equally effective as a Kt/V of 2.0. The rationale for this was a careful review of two clinical trials comparing patients on both doses of therapy. Nevertheless, it is essential patients receive this minimum amount of therapy. If a patient is not doing well with a Kt/V of 1.7, the PD prescription should be increased. Adequate PD is measured by how much of a patient’s body’s waste products carried in their blood are removed during one week. The amount of waste produced by the patient’s body depends on how active
  6. 6. he/she is and how much protein he/she eats. Urea is a waste product of protein. How well it is removed indicates how well other waste products are being removed. Therefore, urea removal is used as a marker of adequate dialysis. Urea removal in PD is measured by calculating the weekly Kt/V, which shows how effective dialysis treatments are. (In hemodialysis Kt/V is calculated per single treatment, rather than per week). The Kt (“K” stands for clearance and “t” stands for time) refers to the weekly clearance (removal) in liters of urea provided by the PD plus any remaining clearance of urea provided by the kidneys. This total urea clearance (Kt) in liters is divided by the volume (V) in liters of the total space taken up by water in the body. V, the total body water space, is calculated from a formula using height and weight. Currently, the desirable PD dose for patients is a total weekly Kt/V of 1.7 or more based upon several clinical studies and guideline group recommendations. Adequate dialysis treatments replace only a small part (less than 15 percent) of normal kidney function. If a patient does not get enough dialysis (i.e. being under- dialyzed or receiving inadequate dialysis), his/her body will retain waste products
  7. 7. causing him/her to always feel tired and sick. Under-dialysis may cause many of the following symptoms: weakness and tiredness, weight (muscle) loss, poor appetite, disturbed sleep, nausea and a bad taste in your mouth. The patient may also be at a higher risk for infections and prolonged bleeding. Under-dialysis also places patients at risk for eliminating toxic minerals such as acid and electrolytes. Many under-dialyzed patients may overlook or deny these symptoms and may not experience the more severe complications of uremia (infections, prolonged bleeding, vomiting, extreme loss of strength, inability to think clearly, etc.). In addition, continuing weight loss or failure to re-gain weight should cause serious worry. Failure to remove water weight during dialysis may mask true weight loss. The patient will know this is happening when his/her blood pressure seems to be higher than it used to be, he/she tire more easily when walking or climbing, he/she easily become short of breath, and he/she may get water in his/her lungs (pulmonary edema) as the water accumulates in the body. If a patient experiences any of these symptoms, bring it to the attention of the doctor and dialysis staff. They will decide if any of the symptoms are due to inadequate dialysis or another illness. On the other hand, patients
  8. 8. who are well dialyzed will experience a sense of feeling well, and can enjoy a good appetite. A well dialyzed patient should be able to look ahead to doing many of the things which were planned before renal disease began. Evaluating membrane transport T he Peritoneal Equilibration Test and similar tests measure how well the peritoneal membrane functions, and should be done 4 to 8 weeks after starting PD, and repeated if dialysis or fluid removal problems occur. This test is useful in guiding the physician in writing and changing the patient’s PD prescription. The PET test should always be performed when the patient is clinically stable. It should never be performed within one month of an episode of peritonitis. Other tests that measure peritoneal function are the SPA (standard peritoneal permeability analysis) and PDC (peritoneal dialysis capacity). The preference of one test over another varies from dialysis center to center. Membrane function influences the amount of time (dwell time) dialysate stays in the belly. The amount of clearance during an exchange depends on the transport rate or speed the peritoneal membrane allows urea, creatinine and other molecules to move from the
  9. 9. patient’s blood across the peritoneal membrane into the dialysate. Everyone’s transport rate is not the same. The PET establishes each individual’s peritoneal membrane transport rate. The PET will show if a patient’s peritoneal membrane is a high (fast), average or low (slow) transporter. It is assumed high transporters require shorter dwell times; and low transporters require longer dwell times (up to 6 hours per exchange). Generally, peritoneal membrane function remains the same over time but may change due to peritonitis or technique failure. It is believed high transport is the consequence of systemic inflammation or chronic damage to the lining of the blood vessels. The result of being a high transporter is inadequate fluid removal, but this can often be improved with nocturnal intermittent PD, which offers shorter, more frequent exchanges. When a PET shows a change has occurred, the dialysis prescription may need to be changed. Low transporters generally need longer dwell times while high transporters require shorter dwell times and an increased number of exchanges. If a patient notices easy fatigue or shortness of breath, that he/
  10. 10. she is unable to control his/her fluid weight, his/her blood pressure is higher, or there seems to be a decrease in drain volume, it is very important to bring this to the attention of the medical team, particularly if he/she has recently had peritonitis. Any change in PD stability requires a new PET test be performed. It should not be done for at least one month after an illness, hospitalization or peritonitis episode. Your Peritoneal Dialysis Prescription T he PD prescription (target weekly Kt/V) determines the number of exchanges, fill volume, the concentration of dialysate and for automated PD, the machine settings. The patient may be required to bring to the unit all the dialysate bags (or take a small sample from each bag) used over a 24-hour period. Routine evaluation by the medical team is recommended on a monthly basis. The actual amount of dialysis the patient receives depends on how completely he/she carries out his/her prescribed exchanges and dwell times for CAPD or APD. Inadequate dialysis and uremic symptoms may occur if the patient misses exchanges, reduces fill volume or shortens dwell time. Remember, PD replaces less than 15 percent of normal kidney
  11. 11. function; there is really no room for missing exchanges, reducing fill volume or shortening the time fluid is in the belly. To be sure the patient’s general condition is stable and not having exchange or other health problems, the medical team will evaluate the patient’s condition on a regular basis. Before a visit, always think carefully about what needs to be discussed and be truthful when asked if there are any symptoms of uremia, or any other health problems. If the patient misses exchanges, reduces fill volume or shortens the cycler time, tell the caregivers. They need that information to improve a patient’s care, and may be able to provide the patient with more acceptable alternatives and treatment schedules. In addition to dialysis adequacy, it is essential patients and the healthcare team work closely together to preserve residual kidney function and to avoid cardiovascular complications such as uncontrolled hypertension and congestive heart failure. Furthermore, controlling vascular calcification and atherosclerosis are crucial to good care, and are discussed in other advisories. To decrease your risk of a premature death, and decrease the chances of feeling tired
  12. 12. and weak, losing weight, having a poor appetite and nausea, patients must receive adequate and proper dialysis regularly, but also work to maintain residual kidney function, and make sure volume status is under control. Maintain Proper Nutrition PD patients who maintain proper nutrition (eating enough calories and protein daily) tend to feel better and live longer. For each kilogram (2.2 pounds) of body weight, daily intake of 35-45 calories including 1.2 grams of protein are recommended for proper nutrition of PD patients. While it is sometimes difficult to eat enough calories and protein, research has shown malnourished patients are more likely to die earlier, spend more time in the hospital, and even have more problems with their PD access than well nourished patients. Proper nutrition is as important as adequate dialysis is to the quality and length of a patient’s life. One measure of nutritional status is the value of serum albumin concentration, which is normally included in monthly blood tests. PD patients who are well dialyzed and eating satisfactorily should have a serum albumin concentration in the normal range for the
  13. 13. laboratory testing serum albumin: certainly above 3.3 g/dl, preferably 3.8-4.0 g/dl. There are many reasons why serum albumin varies and may be below normal: 1. Protein intake in the diet is inadequate 2. Some protein is normally lost in drained dialysate 3. Some patients lose large amounts of protein in the urine or have gastrointestinal diseases that interfere with proper absorption of protein 4. Complicating illness such as infection, an episode of heart failure or a surgical procedure, uncontrolled diabetes, as well as the flare-up of an autoimmune disorder interferes with albumin synthesis 5. Metabolic acidosis can interfere with appetite, cause muscle wasting and decreased albumin synthesis 6. Protein and albumin losses in drained dialysate increase with peritonitis 7. Under-dialyzed patients may have malnutrition - albumin levels that are below normal due to loss of appetite, poor protein and calorie intake.
  14. 14. In addition, if a patient is increasing his/her dialysis dose, he/she may eventually have a bigger appetite and need more protein. Patients who are maintaining proper nutrition and being well dialyzed should not be losing weight or suffering from a poor appetite. If a patient is well dialyzed and are still losing weight then another cause should be sought. A patient with low albumin levels needs to discuss this and other symptoms with his/ her doctor or dietitian to determine the cause and what must be done to increase the serum albumin and maintain proper nutrition. Is Your Peritoneal Access OK? S uccessful PD depends on having a peritoneal catheter (access) which works well. A well functioning catheter allows infusion of two liters of dialysate in 10 minutes and adequate drainage in 15-20 minutes. Poorly functioning catheters may contribute to inadequate dialysis as well as many visits to the unit, most of which can be avoided if problems are corrected early. Talk with the doctor and PD staff about the access and ask them to make sure it is working properly. If the catheter exit site feels tender, shows redness or shows yellowish drainage or pus, it may be an exit site infection, and the patient needs to talk with the doctor or PD nurse when he/she first notices it.
  15. 15. # Checklist: Questions You Should Ask Your Doctor and PD Staff! 1. Is my measured weekly Kt/V 1.7 or higher for CAPD? 2. Does my measured weekly creatinine # clearance in liters indicate I am receiving adequate dialysis? What is my prescribed weekly creatinine clearance? 3. If my weekly Kt/V and/or weekly creatinine clearances are low, what can I do to increase them? 4. Is my peritoneal membrane function changing? Discuss with your medical team these tips on getting enough PD, maintaining the correct fluid volume and preserving residual kidney function. 1. Although the Kt/V recommendations have been lowered to 1.7 per week, patients who are not doing well at this dose should have their prescription increased. 2. Residual kidney function should be measured every two months if the patient has greater than 100 mL/day urine volume and every four months if
  16. 16. # less than 100 mL/day. Steps to preserve kidney function include the use of medications such as an ACE inhibitor (Angiotensin Converting Enzyme Inhibitor) or an ARB (Angiotensin # Receptor Blocker). In addition, the blood pressure should be closely monitored and controlled. A salt restricted diet will help control blood pressure. 3. The toxic molecules removed by the kidneys come is all sizes. Some are known as “middle molecules,” and while they are difficult to measure, they can cause symptoms. Continuous dialysis or a day dwell will help eliminate them once residual kidney function has deteriorated. 4. The PET test should not be performed until a patient has been stable and on dialysis for at least 4 to 8 weeks. It should not be performed for at least one month after an episode of peritonitis. Any change in the clinical condition that may appear is the result of under dialysis or inadequate fluid removal dictates the PET test be repeated. Carefully observe drain volumes and drain times following severe peritonitis episodes, illnesses or hospitalizations.
  17. 17. # 5. The peritoneal creatinine clearance is no longer recommended. Creatinine clearance is still measured by some doctors as an indicator of phosphorous—even if it is no longer # required, it may still be tested by some. 6. The serum albumin, dietary protein intake, metabolic acidosis status, salt and processed food history are also important. These should be discussed regularly with the doctor and dietitian. The serum albumin level should be 3.8 to 4.0 mg/dL (or normal for the laboratory testing it). A low serum albumin indicates malnutrition that can be due to poor dietary intake. It may also indicate under-dialysis or a chronic medical condition. 7. Salt restriction is essential but underemphasized. It is highly challenging, but very desirable and effective in promoting good volume and blood pressure control. Sodium is used in food processing, so patients should discuss how to read food labels carefully with the dietitian – and with the grocer. 8. To help control fluids and blood pressure, the lowest effective dose of dextrose concentration should be used.
  18. 18. # 9. The dialysis prescription should be adjusted so drain volumes will be optimized and ultrafiltration will not be negative. # 10. Diuretics may be helpful to control blood pressure and fluids in patients with residual kidney function. 11. Routine clinic visits monthly and evaluation by doctor and PD staff: to check for symptoms of inadequate dialysis, determine if the patient’s peritoneal exchanges are going smoothly, confirm blood chemistries are stable, and evaluate general health and nutrition. aakp American Association of Kidney Patients 3505 E. Frontage Rd., Suite 315 Tampa, Florida 33607 800-749-2257 info@aakp.org www.aakp.org
  19. 19. Membership Application Membership in AAKP offers you a subscription to all of AAKP’s publications including, aakpRENALIFE and aakpDelicious!, a membership packet filled with numerous brochures and a voice in national legislative issues. Please return completed form and payment to: American Association of Kidney Patients 3505 E. Frontage Rd., Suite 315 Tampa, Florida 33607 # Name: _________________________ Street Address: __________________ City: _________________State: ____ Zip: ___________________________ Telephone (include area code): _____________________________ Transplant Hemodialysis CAPD # CCPD Family Member Indicate which AAKP membership category below: Patient/Family ($25) Professional($45) Life ($1,000) I’m already a member of AAKP, but I’d like to make a donation of $ _____ Check enclosed (payable to AAKP) Please charge my credit card: Visa Mastercard AmEx Account number _________________ Exp. Date _______________________ Signature________________________ PDA
  20. 20. This brochure is proudly sponsored by aakp American Association of Kidney Patients 3505 E. Frontage Rd., Suite 315 Tampa, FL 33607 800-749-2257 info@aakp.org www.aakp.org

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