Adequacy and prescription of pediatric peritoneal dialysis

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Adequacy and prescription of pediatric peritoneal dialysis

  1. 1. Adequacy and prescription of pediatric peritoneal dialysis Constantinos J. Stefanidis “ A.& P. Kyriakou” Children's Hospital, Athens, Greece [email_address]
  2. 2. Dialysis adequacy Dialysis adequacy is a concept introduced in the late 1980s linking outcomes of hemodialysis patients to adequacy targets . <ul><li>There is a strong correlation of the the adequacy parameters and: </li></ul><ul><ul><ul><ul><li>nutritional intake </li></ul></ul></ul></ul><ul><ul><li>bone disease </li></ul></ul><ul><ul><li>anemia </li></ul></ul>
  3. 3. Optimal and adequate dose of PD Adequate dose: the amount of PD below which there is an increase in morbidity and mortality Optimal dose: the amount of PD yielding clinical results which cannot further improve
  4. 4. CANUSA study 680 continuous peritoneal dialysis patients 5% decrease in patient survival with every 0.1 decrease in total weekly Kt/Vurea for Kt/Vurea between 1.5 - 2.3 Churchill DN et al. J Am Soc Nephrol 1996 These predictions assume that renal and peritoneal Kt/Vurea are equivalent.
  5. 5. Adequacy and clinical outcome Adequacy targets have been defined in adults because patient mortality and morbidity is much easier to define There are few data to correlate the clinical outcomes with delivered dialysis dose in children
  6. 6. Appropriate organization of PN Center Guidelines Evaluation of the clinical outcome Modify strategies Improvement of adequacy on PPD
  7. 7. Paediatric Nephrology Centers HD CRI PD Paediatricians (early referral) Paediatric surgeons (dialysis access) Tx Tx surgeons
  8. 8. Multi-disciplinary team <ul><li>Structure Doctors, nurses, dietitians, social workers, psychologists, play therapists, teachers. </li></ul><ul><li>Goal To deliver to children the care required for </li></ul><ul><li> their optimal quality of life. </li></ul><ul><li>Team meetings give the entire team opportunity for collaborative decision making. </li></ul><ul><li>Networking with other PN centers, multicenter </li></ul><ul><li>studies and global cooperation </li></ul>
  9. 9. Team working improves patient care and enhances the quality of the working life.
  10. 10. Appropriate organization of PN Center Guidelines Evaluation of the clinical outcome Modify strategies Improvement of adequacy on PPD
  11. 11. Parameters of the efficiency of PD Nr of exchanges per day (Nr) Peritoneal permeability Fill volume (Vf ) Gl H 2 O BUN Cr
  12. 12. Parameters of the efficiency of PD Nr of exchanges per day (Nr) Fill volume (Vf ) Gl H 2 O BUN Cr Peritoneal permeability
  13. 13. Parameters of the efficiency of PD (scaled for BSA) Ultrafilration volume (V UF ) Drained volume (V PD ) = (V f x Nr ) + Vu F 2L x 5 + 2L (D/P Creatinine) Nr of exchanges per day (Nr) Fill volume (V f ) Peritoneal permeability H 2 O BUN Cr Gl
  14. 14. Peritoneal equilibration test Time (hour) D/P Creatinine 0.88 0.37 0.77 0.64 0.51 High Low High avg. Low avg. 0.8 0.25 0.6 0.5 0.35 95 children 1.1 L/1.73 m 2 PD 2.5%. Warady BA J Am Soc Nephrol 1996
  15. 15. Creatinine adequacy parameters Muscle mass catabolism = ( 0.7 x 120 dl x 12 mg/dl) / 70 kg = 14.4 mg/kg/day = D/P creat. x V PD / S Creatinine clearance Wt: 70 kg 5 exchanges of 2 L UF 2 L PD Creatinine = D/P creat. x V PD x S cr /Wt Creatinine x 12 L x7x1.73 m 2 / 1.7m 2 0.7 Τ BW mg/dl 12 L/1.73m 2 /week 60 S. creatinine
  16. 16. Creatinine adequacy parameters Muscle mass catabolism S. creatinine = ( 0.6 x 120 dl x 14 mg/dl) / 70 kg = 14.4 mg/kg/day mg/dl x 12 L x7x1.73 m 2 / 1.7m 2 = D/P creat. x V PD / S Creatinine clearance 0.6 Τ BW 14 Wt: 70 kg 5 exchanges of 2 L UF 2 L PD Creatinine = D/P creat. x V PD x S cr /`Wt Creatinine L/1.73m 2 /week 50
  17. 17. Creatinine adequacy parameters Muscle mass catabolism S. creatinine mg/dl x 12 L x7x1.73 m 2 / 1.7m 2 L PD /1.73m 2 /week = D/P creat. x V PD / S Creatinine clearance 0.6 Τ BW 12 Wt: 70 kg 5 exchanges of 2 L UF 2 L 50 PD Creatinine + Urine Creatinine L Ur /1.73m 2 /week 10 `` Creatinine
  18. 18. Urine volume (ml) before, 1 and 2 years after dialysis J Feber et al. Ped Nephrol 1994.
  19. 19. Protein catabolism UNA = 1 x (10+2) x 7 L / 42 = Τ BW = 0.6 x Wt = 42 L 2 = D/P urea x V PD x BUN / Wt PNA = 6.25 x UNA (g/kg) + 0.5 Wt: 70 kg 5 exchanges of 2 L UF 2 L Urea adequacy parameters Kt/Vurea = D/P urea x V PD / Τ BW mg/dl 70 1.2 = Τ BW BUN BUN
  20. 20. Protein catabolism BUN mg/dl Τ BW 70 UNA Kt/Vurea = D/P urea x V PD / 0.6 x Wt = 1 x (10+2) x 7 L / 42 = 2 = D/P urea x V PD x BUN / Wt PNA = 6.25 x UNA (g/kg) + 0.5 1.2 = Wt: 70 kg 5 exchanges of 2 L UF 2 L Urea adequacy parameters
  21. 21. Protein catabolism BUN mg/dl Τ BW 70 Kt/Vurea 2 PNA PNA - 0.5 Wt: 70 kg 5 exchanges of 2 L UF 2 L Urea adequacy parameters BUN = 187 x = 1.2 =
  22. 22. 1.7 g/kg/day 2 g/kg/day 4 3.2 2 BUN mg/dl 70 1.2 g/kg/day PNA = 187 (PNA - 0.5) / BUN Kt/Vurea Weight: 70 kg S=1.7m 2 ΤΒW =42 L Weight: 35 kg S=1.2m 2 ΤΒW= 21 L Weight: 14 kg S=0.6m 2 ΤΒW: 8.5 L
  23. 23. 1.2 g/kg/day BUN mg/dl 90 PNA 1.7 g/kg/day 2 g/kg/day = 187 (PNA - 0.5) / BUN 1.5 3.1 2.4 Kt/Vurea Weight: 70 kg S=1.7m 2 ΤΒW =42 L Weight: 35 kg S=1.2m 2 ΤΒW= 21 L Weight: 14 kg S=0.6m 2 ΤΒW: 8.5 L Increase of 23% Decrease of 23%
  24. 24. 7 mg/dl 5 mg/dl Creatinine of urine and PD 15 mg /kg/day 76 85 Weight: 70 kg S=1.7m 2 ΤΒW =42 L Weight: 35 kg S=1.2m 2 ΤΒW= 21 L Weight: 14 kg S=0.6m 2 ΤΒW: 8.5 L Serum creatinine 12 mg/dl Creatinine clearance ( L/week /1.73 m 2 ) 61
  25. 25. Serum creatinine 12 mg/dl 7 mg/dl 6 mg/dl Creatinine of urine and PD 15 mg /kg/day Creatinine clearance ( L/week /1.73 m 2 ) 61 76 71 Weight: 70 kg S=1.7m 2 ΤΒW =42 L Weight: 35 kg S=1.2m 2 ΤΒW= 21 L Weight: 14 kg S=0.6m 2 ΤΒW: 8.5 L 5 mg/dl 85 Increase of 16.6 %
  26. 26. Creatinine and urea adequacy parameters PNA Protein intake Muscle mass catabolism Creatinine of urine and PD Creatinine clearance = 60 L/1.73m 2 /week = 2 D/P creat x V PD S = K t /Vurea D/P urea x V PD Τ BW =
  27. 27. Ratio of Creat. Clearance / Kt/Vurea = Creat clearance Kt/Vurea D/Pcr x BW D/P ur X S
  28. 28. D/P of urea and creatinine 1.0 0.5 1 2 4 hours 0.9 D/P Urea 0.75 0.65 Creatinine 0.5
  29. 29. Ratio of Creat. Clearance / Kt/Vurea Continuous ambulatory peritoneal dialysis CAPD Night Day Cr. clearance 2 Kt/V urea 60 D/P cr 0.7 D/P Ur 1 V PD 12 L Nocturnal intermittent peritoneal dialysis NIPD Cr. clearance 2 Kt/V urea 50 D/P cr 0.50 D/P Ur 0.85 V PD 14 L
  30. 30. Ratio of Creat. Clearance / Kt/Vurea Continuous ambulatory peritoneal dialysis CAPD Night Day Cr. clearance 2 Kt/V urea 60 D/P cr 0.7 D/P Ur 1 V PD 12 L Nocturnal intermittent peritoneal dialysis NIPD Cr. clearance 2 Kt/V urea 50 D/P cr 0.50 D/P Ur 0.85 V PD 14 L Cr. clearance 0.1 Kt/V urea 8 RRF 2.1 68 2.1 58
  31. 31. Automated peritoneal dialysis Night Nocturnal intermittent peritoneal dialysis Day NIPD CCPD Continuous cycling peritoneal dialysis Continuous optimal peritonal dialysis COPD
  32. 32. Kt/V urea Weight: 70 kg S=1.7m 2 ΤΒW =42 L 60 Creatinine clearance Ratio 2 30 Expected Ratio 30 Weight: 35 kg S=1.2m 2 ΤΒW= 21 L 75 3 25 21 Weight: 14 kg S=0.6m 2 ΤΒW: 8.5 L 80 4 20 17 Creat clearance D/P urea x V PD / BW x0.6 D/P cr x V PD x 1.73 m 2 /S Kt/V urea = = D/Pcr x BW D/P ur X S 1.04 x
  33. 33. Ratio of Creat. Clearance / Kt/Vurea = hyperpermeable state Residual renal function Creat clearance Kt/Vurea D/Pcr x BW D/P ur X S Ratio Ratio PD volume and number of exchanges PD volume and number of exchanges Residual renal function
  34. 34. The residual renal function is an important component of the adequacy parameters. Conclusions Nephrotoxic medicines deteriorate RRF Early initiation of PD might preserve RRF
  35. 35. Conclusions The age differences of the ratio cr. clearance / Kt/Vurea have to do with the ratio: Β Wt / S The final outcome might relate with the ratio: MD t /P * * MD time /Patient Both Kt/Vurea and creatinine clearance should be used for the assessment of dialysis adequacy

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