Transcript Slide 1

PD PEARLS
Ezra Hazzan MD
November 19, 2014
Case study
• 43 year old female, DM and now needs to start
dialysis. Works full time, highly motivated and good
support system.
• 65 year old male, Spanish speaking, unemployed,
recent immigrant with spouse at home.
• 50 year old male, obese, on HD with an IJ permacath
(failed fistula) and inquiring about PD.
• 20 year old male who drinks a lot of fluid >1.5liters,
and loves eating fruit( tons of potassium).
Peritoneal Dialysis Misconceptions
• The prevalence of infections is much higher in PD
than HD
• Patient survival is less on PD
• PD takes too much of the patient’s time
• Patients do not want PD
• PD requires high levels of understanding and
education
• PD requires a companion at home to help with
therapy
Reality of PD Infections
The prevalence of infections is
much higher in PD than in HD…
NOT TRUE
Patients survive less time on PD…
NOT TRUE
“ PD takes too much of the patient’s
time”
o On CAPD 4 exchanges x 30 minutes = 2 hours (14 hours a
week)
o On CCPD :
• Setting up machine, 15-20 min, connection/disconnection 5 min.
• Plus day time exchange 45 min = 1 hr 10/15 min.
• Total weekly set up time: 8-9 hr + sleep time.
o On HD:
• HD time 4 hours plus on/off time, about ½ hour.
• Waiting /travel time 1 hr @ treatment
• Total weekly time: 16 ½ hr (without resting after HD)
Courtesy of Karen Kelley, Baxter
PD takes too much of the
patient’s time, when compared
with HD…
NOT TRUE
Patient ratings of dialysis care with PD or HD
Rubin et al JAMA 291: 697-703,2004
• Cross- sectional survey at enrollment of patients who
recently started dialysis at 37 dialysis centers in 14
states participating in the CHOICE Study.
• A patient administered questionnaire included 20
items rating specific aspects of dialysis care, and 3
overall dialysis care ratings.
• Of 736 enrolled patients, 656 (89%) returned the
questionnaire after an average of 7 weeks on dialysis.
Satisfaction with renal replacement therapy and
education: the American Association of Kidney
Patients Survey
Fadem et al. CJASN 2011
• This was an open invitation on the AAKP website +
nearly 9000 patients received the invitation to
complete the survey.
• The survey consisted of 46 questions to measure
patient satisfaction with their RRT modality.
• Satisfaction was measured on a 1 (extremely
dissatisfied) to 7 (extremely satisfied) scale.
Requirements for PD
• Functioning PD catheter
• Dialyzer: functioning peritoneum
• Ability and interest in learning home
dialysis on part of patient or support
person
Patients need to understand that
there are two types of PD
• CAPD----continuous ambulatory peritoneal
dialysis, done 2-4 times per day.
• APD or CCPD----done at night using a machine
called a cycler.
From the patient perspective these are
not the same.
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CAPD: continuous ambulatory
peritoneal dialysis
Each exchange takes about 30 minutes.
Number of exchanges depends on residual kidney function
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APD: automated peritoneal
dialysis
At bedtime the patient places bags on
In the morning, the patient
cycler and attaches catheter to cycler tubing,
disconnects and discards used
pushes button to start the cycler. Takes about
tubing. (takes <5 min)
20 minutes.
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Deciding on modality
Cycler PD
In center HD
Nightly, while sleeping 3 times per week
Done by patient
Done by staff
Private
In center
PD catheter
TDC/Graft/fistula
No needles
Two needles 3 x wk
Risk of peritonitis
Risk of bacteremia
Why do patients choose PD-Issues of autonomy and control were important
for 95% of patients choosing PD.
Other reasons for choosing PD:
(1) flexibility
(2) convenience
(3) night-time dialysis
Adapted from Wuerth et al PDI 2002; 22:184-190
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Other notes on PD selection
• Non adherence is common on in center HD. If
PD is the patient choice, patient may be more
compliant with PD than HD.
• Most patients can learn PD with a good trainer
who tailors the therapy to the individual.
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Your patient has chosen PD.
What now?
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Schedule PD catheter placement
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The PD catheter can be placed as
same day surgery.
• Very important to chose operator to place the
PD catheter who will work with you.
– Can be surgeon, nephrologist, radiologist.
• Leave exit site covered with clean dressing
until training begins; do not allow patient to
get this wet.
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Urgent start PD
• PD catheter can be used the same day or the
next day.
• This is now called urgent start dialysis.
• Appropriate if dialysis needed sooner.
• PD should be supine with low volumes.
• Generally used when patient hospitalized.
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PD training
• We believe one-on-one training is best.
• Nurse doing the training must be trained in
not only PD but how to teach PD.
• Training best individualized to the patient.
• Training covers theory, basics of the
procedure, recognition of peritonitis.
• Test is given at the completion of training to
ensure knowledge.
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Dialysis fluid contains
Dextrose 1.5, 2.5, 4.25
Na and Cl
Lactate
Ca
Mg
sterile water
pH low
Efluent is the spent (dwelled) dialysate
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Obtain a clearance early in the
course of PD.
• Kt/V is used but described as per week.
• Obtained by collecting effluent for one day,
measuring urea nitrogen to calculate Kt and
divided by V. This is then multiplied by 7 to
get weekly value.
• Renal clearance is added into this, when
present.
Minimum: 1.7 per week.
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Peritonitis causes
pain,
hospitalization,
peritoneal membrane damage
and sometimes death.
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Peritonitis may contribute to death
• AUSNZ registry: examined 1316 PD pts who died
on PD or within 30 days of transfer to HD
• 19% of PD pt who died had peritonitis in the
preceding 30 days
• Even though only 6% coded as having died from
peritonitis.
Boudville et al JASN 2012: 23: 1-8
Infections are the second leading cause of
death in the dialysis patients
HD and PD both have associated infections but
different types:
– HD patients get bacteremia and
pneumonia
– PD patients get peritonitis
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Think about what causes
peritonitis
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Contamination
Enteric sources
Catheter related: exit site or slime related
Bacteremia (rare)
GU sources (rare)
Preventing peritonitis from
contamination: the nurse is allimportant in training the PD patient
Do not assume a nurse who knows PD,
knows how to teach PD. ISPD web site has a
section on Training the Trainer
Found at ispd.org
GI sources of peritonitis
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Transmural migration
Bowel ischemia
Diverticulitis
Colitis
Cholecystitis
Perforation of an organ
Appendicitis
GI procedures
Ischemic bowel
Cholecystitis
Procedures can lead to peritonitis
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•
•
•
•
Extensive dental work (streptococcus)
Colonoscopy/proctoscopy (enteric)
Lap cholecystectomy (enteric)
Percutaneous gastrostomy (enteric/fungal)
Endometrial biopsy/hysteroscopy
(streptococcus, funal, anaerobes)
Preventing peritonitis from ESI: Double
blinded multi-center RCT of exit site
gentamicin vs mupirocin
0.6
Exit site infections in episodes per year at risk
0.5
0.4
other
fungal
P aeruginsos
S aureus
0.3
0.2
0.1
0
mupirocin
gentamicin
Bernardini….Piraino JASN 2005: 16: 539-545
Peritonitis due to biofilm
Biofilm can lead to refractory,
relapsing or repeat peritonitis
Canadian study, POET data base:
181 patients 1996-2005 had 2 episodes peritonitis
with same organism
Nessim et al PDI 2012
-Coag neg staph caused 2/3
-1st episode coag neg staph peritonitis vs other
organisms had odds ratio of 2.1 of another episode
within one year
-½ occurred within 6 months of 1st episodes
Topics to be Discussed
• The impact of increased intra-abdominal pressure
Hernias
Abdominal and Genital Leaks
Hydrothorax
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Colored dialysis effluent
Psychosocial issues
Encapsulating Peritoneal Sclerosis
Metabolic changes secondary to PD
Increased Intra-abdominal
Pressure
• Hernias:
Incisional
Umbilical
Ventral
• Pericatheter Leaks:
Abdominal wall or
Genital
• Diaphragmatic Leaks
• Diagnosis:
Abdominal swelling or
bogginess or scrotal or
labial edema
physical exam , Radiological
studies CT scan, Technetium
scan
Management
• Hernias: Repair
• Leaks:
Use low pressure PD (eg APD with low volumes
with patient lying and a “dry day”).
Temporary HD to allow healing.
Hydrothorax
• The presence of peritoneal dialysis fluid in the
pleural cavity.
• PD fluid moves through congenital or acquired
defects in the diaphragm.
• Diagnosis:
a.
b.
c.
Pleural tap with fluid analysis
Technitium scan, CT scan
Stop and restart PD with monitoring of extent of pleural effusion.
•
Treatment: temporary respite from PD pleurodesis,
pleuroscopic repair (diaphragmatic defects
identified and patched or sutured)
Metabolic Problems of the CKD
Patient
General for CKD patients
• Thyroid dysfunction
• Metabolic syndrome
• Abnormalities of sex
hormones
• Lipid abnormalities
• Glucose intolerance
• Mineral metabolism
• Insulin resistance
PD Specific
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•
•
•
•
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Dextrose exposure
Weight gain
Metabolic syndrome
Specific lipid related issues
Insulin resistance
Others: Leptin,
Adinoponectin, Ghrelin
• Protein losses
Lipid Changes After the Start of PD
Pennell
Clin Nephrol 62:35, 2004
• A significant increase in total cholesterol, LDL,
cholesterol, triglyceride, and VLDL levels occur
after start of PD.
• No change in HDL levels
• These changes can be ameliorated with
appropriate management protocols.
Metabolic Syndrome and the
PD Patient
Jhang et al : Blood Purification , 26:423, 2008
• Increased risk in PD patients (c.
50% of prevalent PD patients,
20% HD patients, 30% CKD
patients.
• The driving forces for the
development of Metabolic
Syndrome in Pd patients are
clearly related to glucose
absorption.
• 195 non-diabetic patients
maintained on PD
• 22% of patients met criteria for
MS* at initiation of PD
• After mean of 34 months (range
20 – 60 months), 69% met criteria
for MS
• Development of MS was
correlated with dextrose
exposure and duration of PD.
* Defined with National Cholesterol Education
Adult Treatment Panel III criteria.
Conclusion
• There are a variety of non-infectious problems
that are specific to peritoneal dialysis.
• With increasing experience, the impact of
these problems may be manageable
• The largest problem relates to chronic
dextrose exposure, which in turn results in
changes in transport characteristics, damage
to the peritoneal membrane and various
metabolic issues.
Recommendations
• Limiting dextrose exposure must be a
cornerstone of PD management
• Liberal use of icodextrin and high dose
furosemide therapy (in those patients with
residual function) to minimize dextrose
exposure is critically important.
• Targeting Kt/V algorithms to achieve levels of
1.7 – 2.0 should be the standard; there is no
benefit of targeting higher doses.
What is important when
prescribing PD?
• Clearance targets.
• Adequate ultrafiltration to control volume.
• Avoiding excess glucose exposure.
• Cost of prescription.
What is important when
prescribing PD?
But this is the era of patient centered
care and we need patient centered PD
so…
Patient symptoms
Patient lifestyle
INTRODUCTION
• Achieving high solute clearance in PD is a
whole lot easier since the Ademex Study and
the consequent reduction in K/DOQI targets.
• A target Kt/V of 1.7 per week for all patients –
CAPD and APD, high and low transporters.
Clearance on PD determinants
1. Residual renal function.
2. Body size.
3. Peritoneal transport status.
4. PD prescription
Present Kt/V Targets
• Easy to reach if patients have residual renal
function.
• Typically, 60-70% do and it is often substantial
due to earlier start on dialysis.
• Each ml/min urea clearance equals about 0.25
Kt/V per week so 4 mls/min = 1.0 Kt/V
Increasing Clearance in CAPD
• Three options:
• Increase dwell volume
• Increase number of exchanges
• Increase dialysate tonicity
Increasing Dwell Volume
• Most cost effective way to increase clearance.
• Diffusion gradient lasts longer
• Equilibration for 2.5L is only slightly less than
with standard 2L volumes.
• Raised intraperitoneal pressure is limiting
factor – mechanical side effects.
Strategies to Achieve Targets CAPD
• In CAPD, many smaller patients will achieve
pKt/V 1.7 on 4 x 2L daily.
• Larger patients will require 4 x 2.5L
• Few will need 4 x 3L or 5 x 2L or switch to APD
Thank you.
APD Prescription
Cycler Related:
• Number of cycles
Day Dwell Related:
• No cf Day dwells
• Dwell volume
• Dwell volume
• Cycler time
• Dwell duration
• Tonicity
• Tonicity
Day Dwells
• Single most effective way to raise clearance in
a day. Dry APD patient is to add a day dwell –
raises Kt/V 30 – 40%
• If already has a day dwell, the most effective
intervention is a second day dwell raises Kt/V
c 20%.
• Should be at least 4 hours duration to get full
benefit in Kt/V
Day Dwells
POINTS TO REMEMBER
• The larger the dwell volume the greater the
clearance i.e. 2.5v 2v 1.5L
• Day dwells can be done more simply and less
expensively using cycler tubing and large
volume bags.
• Adding a second day dwell creates more work
for the patient or caregiver.
Day Dwells
POINTS TO REMEMBER
• Longer glucose based day dwells may lead to
net fluid resorption and so may actually
decrease clearance as well as UF.
• There are a number of strategies to deal with
this.
Day Dwell Options for Better UF
• Go “day dry” – an option if there is lots of
residual function.
• Do 2 day dwells – drain and refill – maximizes
clearance.
• Shorten day dwell by draining and remaining
dry part of the day.
• Use Icodextrin for day dwell – increasingly
popular.
Increasing Cycler Clearance
• Longer time raises clearance but > 9 hrs is not
acceptable to most patients.
• What about dwell volume?
Is 4 x 2.5 L cycles better than 5 x 2L?
• What about cycle frequency?
Is 7 x 2L better than 5 x 2L?
Is 9 x 2L better than 7 x 2L?
Optimal Cycle Frequency
• There is confusion about whether or not increasing
the number of cycles raises clearance significantly.
• Concern is that more time is spent draining and
filling (down time) and less actually dialyzing.
• However, frequent cycling keeps blood to dialysate
gradient high and so promotes more diffuse
clearance.
Optimal Cycle Frequency Study
Perez et al (PDI 2000)
• 18 patients at 2 centers
• 4 different prescriptions for 7 days each
• Measurement of clearances, UF, Na, K+, and
protein losses and glucose absorption on days
5 -7 on each prescription.
• Clearance due to residual renal function and
day dwells was ignored.
Optimal Cycle Frequency Study
4 prescriptions
1.
5 x 2L over 9 hours
2.
7 x 2L over 9 hours
3.
9 x 2L over 9 hours
4.
15L TPD (50%) using
1L + 14 x 1L over 9 hours
Optimal Cycle Frequency Study
Perez et al (PDI 2000)
• 9 x 2L was the best in 12 of the 18 (in 9 by >
10%)
• 7 x 2L was the best in 3, TPD in 2
• Advantage of 9 x 2L was greatest for Kt/V
• Advantage was seen in both low and high
transporters for both Kt/V and Cr Cl
• UF was better in 7 x 2L and 9 x 2L versus 5 x
2L.
Optimal Cycle Frequency Study
Conclusion
• More cycles raise clearance significantly in
most patients.
• 4 – 5 cycles per 9 hours under-uses clearance
potential of APD.
• But cost was 27% greater for 15L vs. 10L and
54% for 18L vs. 10L so adding day dwells is
more cost effective but also more work for
patient.
Incremental Dialysis
• Idea that full dialysis dose need not be
prescribed initially in patients with substantial
residual renal function.
• In HD – twice weekly treatments.
• In PD – 3 dwells daily in CAPD or “day dry” in
APD
Incremental Dialysis
“London Approach”
• All elective starts do “day dry” APD.
• Quarterly measurements of pKt/V and rKt/V
as well as clinical assessment.
• Continue without day dwell as long as patient
well and Kt/V > 1.7
• Some cycle < 7 nights a week.
Incremental PD
Definition
• Total weekly Kt/V reaching target of > 1.7 with
peritoneal Kt/V < 1.7.
PLUS
• A “day – dry” or < 7 nights/ week schedule for
APD patients.
OR
• < 8L/ day schedule for CAPD patients.