Transcript In dialisi peritoneale qual è il miglior indice di adeguatezza dialitica

Bari, 20 marzo 2010
In dialisi peritoneale qual è il miglior
indice di adeguatezza dialitica tra Kt/V e
Clearance della creatinina/ sett?
Dr. Renzo Scanziani
Divisione di Nefrologia e Dialisi
Azienda Ospedaliera di Desio e Vimercate
• During the 1980s to 1990s large effort were
made to quantify the dialysis prescription
in both peritoneal dialysis and
hemodialysis treatment based on kinetic
modeling.
• Several different adequacy indices have
been suggested, but at present mainly Kt/v
urea (urea clearance normalized to total
body water) and weekly creatinine
clearance normalized to body surface area
are used as estimates of PD adequacy
Heimburger O Contr Nephrol 2009; 163: 140
Adeguatezza Dialitica
in DP negli anni
• Studio CANUSA e importanza del Kt/V e della
CrCl
• ADEMEX e “ridimensionamento” dei target
• Importanza della funzione renale residua in
dialisi peritoneale e altri fattori di adeguatezza
Studi osservazionali
CANUSA Study
n = 680 pz incidenti
Expected 2-year patient survival according to
sustained weekly Kt/V and CCr(L/1.73 m2)
Kt/V
Survival%
CCr
2.3
2.1
1.9
1.7
1.5
81
78
74
71
66
95
80
70
55
40
Survival%
86
81
78
72
65
“MORE DIALYSIS IS BETTER”
Churchill DN et al; JASN 1996, 7 (2):198-207
RECOMMENDED TOTAL SMALL SOLUTE
CLEARANCE GOALS FROM VARIOUS
NATIONAL SOCIETIES
Society
NFK-DOQI
Year
60
50
63
66
NA
NA
NA
NA
2.0
2.0
60
50
NA
NA
1.7
NA
1L
1998
Low and LA
High and HA
EUROPEAN
2.0
2.0
2.1
2.0
UF
2000
CAPD(Low and LA)
CAPD(High andHA)
CCPD
NIPD
CANADIAN
Kt/V urea
Goal
Creatinina
Clearance
Goal
2002
Effect of Increased Peritoneal Clearances on
Mortality Rates in Peritoneal Dialysis.
ADEMEX
% Patient Survival
•gruppo di controllo (n=484)-> Kt/Vtot medio 1.8; CrCl 54.1 l/w
•gruppo di intervento (n=481)->Kt/Vtot medio 2.27; CrCl 62.9 l/w
100%
Studio randomizzato, controllato (965 pazienti in 2 gruppi)
90%
80%
p = 0.9842
Control
Treated
70%
60%
RR (Treated:Control) = 1.00
50%
95% CI: (0.80, 1.24)
40%
0
4
8
12 16 20 24 28
Months after randomization
32
36
Paniagua R et al; JASN 2002; 13: 1307-1320
Effect of Increased Peritoneal Clearances on
Mortality Rates in Peritoneal Dialysis.
ADEMEX
Paniagua R et al; JASN 2002; 13: 1307-1320
Relative Contribution of Residual Renal Function
and Peritoneal Clearance to Adequacy of Dialysis:
A Reanalysis of the CANUSA Study
VARIABILE
Età
CDV
SGA
CrCl peritoneale 5 l/W
FRR (5 L/W)
Volume urinario (per 250 ml)
RR di morte
1.02
2.42
0.74
1.00
0.88
0.64
La FRR è molto più importante
della Clearance peritoneale (in
parte per la miglior clearance
di tossine a medio od alto PM)
For a 250 ml increment in urine volume,
there was a 36% decrease in RR of death
Bargman JM, JASN, 2001
ADEQUACY OF PERITONEAL DIALYSIS
Guidelines
A. Adequacy targets for dialysis should be include both urea removal and
fluid removal (C)
B. These targets should be based on those achieved by peritoneal dialysis
only. Urine production and renal urea clearance can be subtracted from
the targets (C)
C. The minimum peritoneal target for Kt/Vurea in anuric patients is weekly
value of 1.7 (A); the minimum peritoneal target for net UF in anuric
patients is 1.0 l/day (B). The presence of residual renal function can
compensate when these peritoneal targets are not achieved
D. When targets are not achieved patients should be monitored carefully
for signs of overhydration, uraemic complaints and malnutrition (C)
E. In APD patients with a slow transport status an additional target of 45
l/week/1.73 m2 for peritoneal creatinine clearance should be aimed at in
addition to achieving the Kt/Vurea target of 1.7 (C)
European Best Practice Guidelines; 2005
Weekly Ccr and Kt/V Urea
44 CAPD Pts
Nolph K.D. et al. Perit Dial Int 1992, Vol 12, pp 298-303
Weekly st Kt/Vu and stKt/Vcr levels calculated
and shown as functions of sex and BSA
for CAPD prescriptions
Gotch F.A, Perit Dial int 2000, Vol 20, Suppl 2
Weekly Clearances of Urea and Creatinine
on CAPD and NIPD
Nolph KD. PDI 1992; 12: 298-303
Weekly peritoneal creatinine clearance
8.30 h NTPD
80
70
60
50
40
30
20
10
0
0,78
0,73
0,69
0,65
0,49
0,41
5
10
15
20
25
30
35
40
Total dialysate volume liters
Durand et al, PDI 16:S167-170, 1996
CREATININE IS THE BEST MOLECULE TO TARGET
ADEQUACYOF PERITONEAL DIALYSIS?
Blake PG. PDI 2000;20 Suppl 2:S65-9
Conclusions
• There is general agreement that target Kt/V urea in PD should
be 1.7 or higher
• Neither creatinine clearance nor urea clearance is the perfect
index for predicting outcome in PD patients.
• Creatinine clearance gives greater weight to residual renal
function, and residual renal function is probably a stronger
predictor of patient outcome than peritoneal clearance per se.
•
• Creatinine clearance has a particular weakness in low
transporters; values have to be interpreted with discretion in
this group
• PD adequacy should be involve many other aspects of the
treatment