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![Exchange time
• Dwell period
• Standard dwell period
– Usual dwell time is 30 min
– 2L per exchage 48 L per day
– [Urea] in drained dialysate will be 50-60% of plasma
• More stable patients
– If Not extremely hypercatabolic state
• longer dwell time 1.5-5 hrs
– At 5 hrs [UREA] dialysate = [UREA]plasma](https://image.slidesharecdn.com/apd-121019111647-phpapp02/85/PD-prescription-19-320.jpg)
![Monitor Clearance
• In general
– BUN should maintain below 80 mg/dl
– D:P ratio for urea
• [BUN]dialysate : [BUN]plasma ratio
• Multiplied by total daily dialysate volume urea daily
clearance
• Should be at least 10 ml/min
• 20-30 ml/min in hypercatabolic patient](https://image.slidesharecdn.com/apd-121019111647-phpapp02/85/PD-prescription-28-320.jpg)
![Complications
• Hyperglycemia
– IP insulin
• Hypernatremia
– UF generated in PD [Na] 70 mEq/L
– Increased loss of water
• Hypoalbuminemia
– Protein loss 10-20 gm /day
– Early oral or parenteral hyperalimentation should
be instituted](https://image.slidesharecdn.com/apd-121019111647-phpapp02/85/PD-prescription-31-320.jpg)
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PD prescription
This document discusses prescribing acute and chronic peritoneal dialysis. For acute PD, it recommends using a Tenckhoff catheter and automated cyclers. Exchanges should be hourly with 2L volumes. Clearance is monitored using BUN levels and D:P ratios. Complications include abdominal distention and peritonitis. For chronic PD, clearance targets are a Kt/V of 1.7 per week. Prescriptions are based on residual renal function, transporter status, and body size. CAPD and APD are both options depending on lifestyle. Clearance can be increased by optimizing exchange volumes, frequency, and solution tonicity.
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PD prescription
- 1. Peritoneal Dialysis Prescription & Adequatcy Piti Niyomsirivanich,MD.
- 2. • Peritoneal dialysisprescription – Acute • Introduction • Peritoneal Catheter • Use of automate cycler • Prescribing acute peritoneal dialysis • Complications
- 3. • Chronic • Choice of PD treatment modality – Modalities of PD therapy CAPD , APD ,hybrid – CAPD or PD ? • Choice of prescription – Clearance targets – Measurement of clearance – Determinants of clearance – prescription • Nutritional issues in PD
- 4. Acute peritoneal dialysis presciption
- 5. • Peritoneal dialysisprescription – Acute • Introduction • Peritoneal Catheter • Use of automate cycler • Prescribing acute peritoneal dialysis • Complications
- 6. Introduction • Acute PeritonealDialysis – Nonvascular alternative for dialysis – Acutely less efficient than conventional hemodialysis
- 7. Adventage / Disadventage Adventage Disadventage •Technically simpler than that of •Less efficient than hemodialysis hemodialysis (flash pulmonary edema , drug •Doesn’t require highly trained overdose , acidosis ,hyperkalemia , personnel or expensive, complex catabolic patient) equipment •Protein loss malnourished •Can be instituted quickly •Hyperglycemia •Avoids the potential problems related to vascular hemorrhage , air embolism •Serious morbidity (30%) and , thrombosis , infection mortality (5%) attributed Acute PD •Lower likelyhood of hypotensive and HD are similar episodes
- 8. Indications • Acute renalfailure • Benefit in volume overload with cardiovascular compromise • Hypothermia • Hemorrhagic pancreatitis • Most beneficial in Rx of hemodynamically unstable
- 9. Contraindications • Recent surgeryrequiring abdominal drains • Known fecal or fungal peritonitis • Pleuroperitoneal fistula • Relative contraindication – Severe hypercatabolic states – Abdominal wall cellulitis – Adynamic ileus – Presence of abdominal adhesions or fibrosis – New aortic prosthesis
- 10. • Peritoneal dialysisprescription – Acute • Introduction • Peritoneal Catheter • Use of automate cycler • Prescribing acute peritoneal dialysis • Complications
- 11. Peritoneal catheter • Pts.With – multiorgan system failure Can be anticipated – Prolong period of renal failure • initial insertion of a Tenckhoff catheter (preferred > uncuffed temporary catheter) is recommended
- 12. • Peritoneal dialysisprescription – Acute • Introduction • Peritoneal Catheter • Use of automate cycler • Prescribing acute peritoneal dialysis • Complications
- 13. Use of automatedcyclers • Traditionally been done using manual exchanged • Automated cyclers are being used instead – Saving nursing time (30-60 minutes exchange time)
- 14. • Peritoneal dialysisprescription – Acute • Introduction • Peritoneal Catheter • Use of automate cycler • Prescribing acute peritoneal dialysis • Complications
- 15. Prescribing acute peritonealdialysis • A: Session length – In the setting of acute renal failure (catabolic , oliguric ), continuous removal of fluids and solutes is required – Need for hourly exchange on a continuous basis for days or weeks – Order for One day
- 16. Standard order for1 day
- 17. Exchange volume • Average-sizedadult can usually tolerate 2L exchanges – Those with abdominal wall or inguinal hernias, the exchange volume should be reduced • Some may prefer start with smaller volumes(1- 1.5 L) for the first few exchanges • The larger volume is , the greater the clearance and UF rates
- 18. Exchange time – Inflow 15 – dwell 30 - drain 15 – 1 hr. • Inflow time – Gravity – 10 min. – Prolonged • Kinking • Inflow resistance • Inflow pain due to acidic , hypertonic solution
- 19. Exchange time • Dwellperiod • Standard dwell period – Usual dwell time is 30 min – 2L per exchage 48 L per day – [Urea] in drained dialysate will be 50-60% of plasma • More stable patients – If Not extremely hypercatabolic state • longer dwell time 1.5-5 hrs – At 5 hrs [UREA] dialysate = [UREA]plasma
- 20. Exchange time • Outflowtime – Gravity – 20-30 min – Depend on • Total volume • Resistance to outflow • Height • 1st exchange • Outflow obstruction • Outflow pain
- 21. CEPD (Continouous equilibration peritoneal dialysis) • Alternative approach • Modified version of CAPD • Standard manual exchange every 3 to 6 hours • Adventage – Simplicity – Lower cost – Less labor-intense • Disadventage – Clearance are less – Not be adequate in more catabolic patient
- 22. Choosing the dialysissolution • 1.5% dextrose – Sufficient to remove 50-150 of fluid per hour (2L ,60min exchange time) – UF rate 1.2-3.6 L/day • 4.25% dextrose – UF 300-400 ml/hr – Acquired for treatment of CHF
- 23. Effect of peritonitis •During peritonitis – Enhanced absorption of glucose – Rapidly reducing the osmotic gradient – Maintaining the efficiency of UF • reduced exchange time • More hypertonic exchange
- 24. Dialysis Solution additives •KCl – Hypokalemia KCl 3-5 mEq/L can be added – Correction of acidosis K shift hypokalemia • Heparin – Catheter obstruction due to fibrin – 1000 U/2 L • Insulin – Glucose absorbed from the dialysis solution
- 25.
- 26. • Antibiotics – Intraperitoneal administration
- 27.
- 28. Monitor Clearance • Ingeneral – BUN should maintain below 80 mg/dl – D:P ratio for urea • [BUN]dialysate : [BUN]plasma ratio • Multiplied by total daily dialysate volume urea daily clearance • Should be at least 10 ml/min • 20-30 ml/min in hypercatabolic patient
- 29. • Peritoneal dialysisprescription – Acute • Introduction • Peritoneal Catheter • Use of automate cycler • Prescribing acute peritoneal dialysis • Complications
- 30. Complications • Abdominal distention – Incomplete drainage • Peritonitis – 12% of cases – Occur within first 48 hrs – Gram +ve organisms (>50%) – Prolong used of Multiple antibiotics fungus • Hypotention – Removal large amout of fluid
- 31. Complications • Hyperglycemia – IP insulin • Hypernatremia – UF generated in PD [Na] 70 mEq/L – Increased loss of water • Hypoalbuminemia – Protein loss 10-20 gm /day – Early oral or parenteral hyperalimentation should be instituted
- 32. Adequacy of PeritonealDialysis and Chronic Peritoneal Dialysis Prescription
- 33. • Chronic • Choice of PD treatment modality – Modalities of PD therapy CAPD , APD ,hybrid – CAPD or PD ? • Choice of prescription – Clearance targets – Measurement of clearance – Determinants of clearance – prescription • Nutritional issues in PD
- 34. • Choice ofmodality – CAPD – APD – Variant of APD : CCPD , NIPD – hybrid • Selection based on – Clearance – UF – Nutritional requirement
- 35. Diagrammatic Representation of various continuous ambulatory peritoneal dialysis and automate peritoneal dialysis
- 37. Modality of peritonealdialysis therapy • CAPD – Low cost – Freedom from dialysis machinery – Continuous therapy and a steady physiologic state – Nomalization of blood pressure is possible in most patients. – Multiple procedural sessions – Can be done away from home – Episodes of peritonitis
- 38. Modality of peritonealdialysis therapy • APD – CCPD • Continuous therapy • Need for cycler • Complications associated c a prolonged day dwell – Excessive resorption of dialysate » Icodextrin are useful in day dwell – NIPD • No dialysis fluid during day time • Suitable for patient with good residual renal function
- 39. • Hybrid formsof PD – CAPD with automated nocturnal exchange • A night exchange device – APD with additional exchange during the day • IPD – Almost extinct – Cycler in hospital 2-3 times weekly duration 12-24 hr
- 40. • Chronic • Choice of PD treatment modality – Modalities of PD therapy CAPD , APD ,hybrid – CAPD or PD ? • Choice of prescription – Clearance targets – Measurement of clearance – Determinants of clearance – prescription • Nutritional issues in PD
- 41. CAPD or APD •Based on – Lifestyle ,emplyment , place of residence comfort with the cycle technology and family and social support • Previously APD better than APD – Na Sieving • Risk of net fluid resorption with long day dwells • Led to concerns about Na removal with APD – Systolic hypertension with APD > CAPD (no randomized trial but generalizable)
- 42. • Risk ofperitonitis – Decade ago • APD showed less peritonitis • But APD techinique improved now • Relative cost
- 43. • Chronic • Choice of PD treatment modality – Modalities of PD therapy CAPD , APD ,hybrid – CAPD or PD ? • Choice of prescription – Clearance targets – Measurement of clearance – Determinants of clearance – prescription • Nutritional issues in PD
- 44. Choice of aprescription • Clearance targets – ADEMEX study • 1000 CAPD patients – 4X2 L CAPD versus a high peritoneal clearance regimen – 2 years – Mean Kt/V 1.62 and 2.12 / wk A concensus target Kt/V for PD 1.7 /wks
- 46. • Chronic • Choice of PD treatment modality – Modalities of PD therapy CAPD , APD ,hybrid – CAPD or PD ? • Choice of prescription – Clearance targets – Measurement of clearance – Determinants of clearance – prescription • Nutritional issues in PD
- 47. Frequency of measurement •Within 1 month of initiation • And then q 4 months • Discordance between Kt/V and CrCl – APD • Cr has higher molecular weight than urea
- 48. • Chronic • Choice of PD treatment modality – Modalities of PD therapy CAPD , APD ,hybrid – CAPD or PD ? • Choice of prescription – Clearance targets – Measurement of clearance – Determinants of clearance – prescription • Nutritional issues in PD
- 49. Determinants of clearance •Residual renal function – Account for as much as 50% of total clearance – Preserved in patient on CAPD • ACEI ,ARB • Avoid nephrotoxic agents i.e. aminoglycoside • Peritoneal transport status – PET • Low transporter high volume ,long duration dwell – Low average – High average • High transporter short duration dwell
- 50. • Body size – Large body size harder to achieve clearance • Prescription – Change – Focus on lifestyle factors
- 51. • Chronic • Choice of PD treatment modality – Modalities of PD therapy CAPD , APD ,hybrid – CAPD or PD ? • Choice of prescription – Clearance targets – Measurement of clearance – Determinants of clearance – prescription • Nutritional issues in PD
- 52. CAPD • Initial – 4x2 L or 4x2.5 in larger patients – Increase peritoneal Kt/V in CAPD • Increasing exchange volumes – Increase backpain – Abdominal distention – Shortness of breath • Increasing the frequency of daily exchange – Most CAPD pts. Do 4 exchange daily – 45 lead to burn out (alt. night exchange) • Increase the tonicity of dialysis solution – Increase UF and clearance
- 53. APD • 10-12 Ldaily (15 L in larger) • Good residual renal function NIPD • High transporter short day time/second dwell • Typical cycler time is 8-10 hrs – dwell volumes 2 L
- 54. Increase clearance ofAPD • Introduction of a day dwell – NIPD • Adding day dwell increase Kt/V and CrCl by 25%-50% • Disadventage – In high transporter increase net fluid resorption – Icodextrin or shortening day dwell • Increase dwell volumes on cycler – Because patients are supine during cyclingtolerate larger dwell volume – 4X2.5 L per session is better than 5X2 L per session
- 55. Increase clearance ofAPD • Time on cycler – The longer time ,the better clearance • Increasing frequency of cycles – More frequent cycle increase clearance on APD – But More frequent cycle Dialysis time lost • Increasing dialysis solution tonicity – concern about glocose-related complications arise
- 56. Incremental versus maximalprescription • Incremental approach – Suitable when dialysis is being initiated early – 2-3 CAPD exchanges daily or a low-volume – Less costly and less onerous – Decrease total glucose exposure and risk of peritonitis – Require regular monitoring of resiual function • To ensure that the clearance achieved doesn’t below target levels
- 57. Empirical versus Modeledapproach • Modeled approach • collecting patient anthropometric data , PET , residual renal function • Computer program uses the data to predict • Actual clearance still have to be measure • because discrepancy between actual and modeled
- 58. Empirical versus Modeledapproach • Empirical approach – Physician uses knowledge of the patient’s size , residual renal function , and peritoneal transport status – And choose a resonable prescription – Advantage • Less trial and error • Earlier identification of an appropriate prescription
- 59. Prescription pitfalls inperitoneal dialysis • Loss of residual renal function – Not monitored closely enough • Noncompliance – No single test that identifies this problem – Serial measurement of 24-hr dialysate plus urinary Cr excretion • High serum creatinine despite good clearances – Kt/V > 1.7/wk but serum Cr > 12-15 – Non compliance – Kt/V high and CrCl low – Residual renal function fades away – Hight lean body mass
- 60. • Inappropriate switchform CAPD to APD – Particular in low transporter • Inadequate attention to fluid removal – Particular in high , high-average transporter and long dwells that result in net fluid resorption
- 61. • Chronic • Choice of PD treatment modality – Modalities of PD therapy CAPD , APD ,hybrid – CAPD or PD ? • Choice of prescription – Clearance targets – Measurement of clearance – Determinants of clearance – prescription • Nutritional issues in PD
- 62. Nutritional Issues inPD • nPNA – Normalized protein equivalent of nitrogen appearance – Include • Serum albumin • Subjective global assessment • Lean body mass – Measure 24 hr of dialysate and urine (intake output) – Bergstrom – Recommend 1.2 gm/kg/day
- 63. • Caloric intake – = dietary intake + glucose absorbed – 35 kcal/kg/day – 10-30% come from glucose (depend on tonicity)
- 64. Bergstrom formulas • 1)PNA (g per day)=20.1 + 7.5 UNA (g per day) or • 2) PNA (g per day)= 15.1 + 6.95 UNA + dialysate protein losses (g per day) • UNA = urinary nitrogen losses (g/day) + dialysiate urea nitrogen losses • 1) if dialysate protein losses are unknown • 2) if dialysate protein losses are known
- 65. Serum albumin • Strongestpredictors of patient survival on PD • Influences – dialysate albumin losses – Inflammation – More than dietary protein intake
- 66. Subject global assessment •Simple clinical tool • Predict patient outcome • KDOQI , Canadian Society
- 67. Creatinine excretion • 24hr urine and dialysate collections
- 68. Treatment of malnutrition •Dietitian support – Dietition to ensure adequate protein intake • Nutritional Supplement • Promotility agent – Gastric emptying is impaired • Anabolic steroid – 1 RCT ,Nandrolone 100 mg IM weekly for 6 months improve lean body mass • Amino acid – amino acid based dwell