Transcript Adequacy and prescription of pediatric peritoneal dialysis Constantinos J. Stefanidis [email protected] “A.& P. Kyriakou” Children's Hospital, Athens, Greece C J Stefanidis .

Adequacy and prescription of
pediatric peritoneal dialysis
Constantinos J. Stefanidis
[email protected]
“A.& P. Kyriakou” Children's Hospital, Athens, Greece
C J Stefanidis . 2001
Dialysis adequacy
Dialysis adequacy is a concept introduced in the
late 1980s linking outcomes of hemodialysis
patients to adequacy
targets.
There is a strong correlation of the the
adequacy parameters and:
• nutritional intake
• bone disease
• anemia
C J Stefanidis 2001
Optimal and adequate dose of PD
Optimal dose: the amount
of PD yielding clinical results
which cannot further improve
Adequate dose: the amount of
PD below which there is an increase
in morbidity and mortality
C J Stefanidis 2001
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
These predictions assume that renal and
peritoneal Kt/Vurea are equivalent.
Churchill DN et al. J Am Soc Nephrol 1996
C J Stefanidis 2001
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
C J Stefanidis 2001
Improvement of adequacy on PPD
Appropriate organization
of PN Center
Modify strategies
Guidelines
Evaluation of
the clinical outcome
C J Stefanidis 2001
Paediatric Nephrology Centers
HD
Paediatricians
Tx surgeons
(early referral)
CRI
Tx
PD
Paediatric surgeons (dialysis access)
C J Stefanidis 2001
Multi-disciplinary team
• Structure Doctors, nurses, dietitians, social workers,
psychologists, play therapists, teachers.
• Goal
To deliver to children the care required for
their optimal quality of life.
• Team meetings give the entire team opportunity for
collaborative decision making.
• Networking with other PN centers, multicenter
studies and global cooperation
C J Stefanidis 2001
Team working improves patient care and
enhances the quality of the working life.
C J Stefanidis 2001
Improvement of adequacy on PPD
Appropriate organization
of PN Center
Modify strategies
Guidelines
Evaluation of
the clinical outcome
C J Stefanidis 2001
Parameters of the efficiency of PD
BUN
H2O
Cr
Fill volume (Vf )
Gl
Nr of exchanges
per day (Nr)
Peritoneal permeability
C J Stefanidis 2001
Parameters of the efficiency of PD
BUN
H2O
Cr
Fill volume (Vf )
Gl
Nr of exchanges
per day (Nr)
Peritoneal permeability
C J Stefanidis 2001
Parameters of the efficiency of PD
BUN
H2O
Cr
Fill volume (Vf )
(scaled for BSA)
Nr of exchanges
per day (Nr)
Gl
Peritoneal permeability
(D/P Creatinine)
Ultrafilration volume (VUF)
Drained volume (VPD ) = (Vf x Nr) + VuF
2L x 5 + 2L
C J Stefanidis 2001
Peritoneal equilibration test
95 children 1.1 L/1.73 m2 PD 2.5%.
D/P 1
Creatinine
0.88 High
0.77 High avg.
0.64
Low avg.
0.51
0.37 Low
0.8
0.6
0.5
0,8
0,6
0.35
0,4
`
0.25
0,2
0
0
1
2
Time (hour)
3
4
Warady BA J Am Soc Nephrol 1996
C J Stefanidis 2001
Creatinine adequacy parameters
Wt: 70 kg
5 exchanges of 2 L
UF 2 L
Muscle mass catabolism
S. creatinine
12
mg/dl
ΤBW
Creatinine
Creatinine clearance
= D/Pcreat. x VPD / S
0.7
60
PD Creatinine
x 12 L x7x1.73m2 / 1.7m2
L/1.73m2/week
= D/Pcreat. x VPD x S cr /Wt
= (0.7 x 120 dl x 12 mg/dl) / 70 kg
= 14.4 mg/kg/day
C J Stefanidis 2001
Creatinine adequacy parameters
Wt: 70 kg
5 exchanges of 2 L
UF 2 L
Muscle mass catabolism
14
mg/dl
ΤBW
S. creatinine
Creatinine
Creatinine clearance
= D/Pcreat. x VPD / S
0.6
50
x 12 L x7x1.73m2 / 1.7m2
L/1.73m2/week
PD Creatinine = D/Pcreat. x VPD x
S cr /`Wt
= (0.6 x 120 dl x 14 mg/dl) / 70 kg
= 14.4 mg/kg/day
C J Stefanidis 2001
Creatinine adequacy parameters
Wt: 70 kg
5 exchanges of 2 L
UF 2 L
Muscle mass catabolism
12
mg/dl
ΤBW
S. creatinine
Creatinine
Creatinine clearance
= D/Pcreat. x VPD / S
0.6
50
10
x 12 L x7x1.73m2 / 1.7m2
L PD /1.73m2/week
L Ur /1.73m2/week
PD Creatinine + Urine Creatinine
C J Stefanidis 2001
Urine volume (ml) before, 1 and 2
years after dialysis
2500
2000
1500
1000
500
0
2500
2000
1500
1000
500
0
HD
PD
J Feber et al. Ped Nephrol 1994.
C J Stefanidis 2001
Urea adequacy parameters
Wt: 70 kg
5 exchanges of 2 L
UF 2 L
Protein catabolism
70
mg/dl
BUN
ΤBW
BUN
Kt/Vurea
= D/Purea x VPD / ΤBW
= 1 x (10+2) x 7 L / 42 =
2
ΤBW = 0.6 x Wt = 42 L
UNA = D/Purea x VPD x BUN / Wt
PNA = 6.25 x UNA (g/kg) + 0.5 = 1.2
C J Stefanidis 2001
Urea adequacy parameters
Wt: 70 kg
5 exchanges of 2 L
UF 2 L
Protein catabolism
BUN
mg/dl
ΤBW
70
Kt/Vurea
= D/Purea x VPD / 0.6 x Wt
= 1 x (10+2) x 7 L / 42 =
2
UNA = D/Purea x VPD x BUN / Wt
PNA = 6.25 x UNA (g/kg) + 0.5 = 1.2
C J Stefanidis 2001
Urea adequacy parameters
Wt: 70 kg
5 exchanges of 2 L
UF 2 L
Protein catabolism
70
mg/dl
ΤBW
BUN
Kt/Vurea
= 187 x
PNA - 0.5
BUN
= 2
PNA = 1.2
C J Stefanidis 2001
Weight:
70 kg
S=1.7m2 ΤΒW =42 L
Weight: 35 kg
S=1.2m2 ΤΒW= 21 L
BUN 70
Weight:
S=0.6m2 ΤΒW: 8.5 L
mg/dl
1.7 g/kg/day
PNA 1.2 g/kg/day
Kt/Vurea
= 187 (PNA - 0.5) / BUN
2
3.2
14 kg
2 g/kg/day
4
C J Stefanidis 2001
Weight:
70 kg
S=1.7m2 ΤΒW =42 L
Weight: 35 kg
S=1.2m2 ΤΒW= 21 L
BUN 90
mg/dl
Weight:
S=0.6m2 ΤΒW: 8.5 L
Increase of 23%
1.7 g/kg/day
PNA 1.2 g/kg/day
Kt/Vurea
= 187 (PNA - 0.5) / BUN
1.5
2.4
14 kg
2 g/kg/day
3.1
Decrease of 23%
C J Stefanidis 2001
Weight:
70 kg
S=1.7m2 ΤΒW =42 L
Weight: 35 kg
S=1.2m2 ΤΒW= 21 L
Weight:
14 kg
S=0.6m2 ΤΒW: 8.5 L
Serum creatinine
12 mg/dl
7 mg/dl
5 mg/dl
Creatinine of urine and PD 15 mg /kg/day
Creatinine clearance (L/week/1.73m2)
61
76
85
C J Stefanidis 2001
Weight:
70 kg
S=1.7m2 ΤΒW =42 L
Weight: 35 kg
Weight:
S=1.2m2 ΤΒW= 21 L
S=0.6m2 ΤΒW: 8.5 L
5 mg/dl
6 mg/dl
Serum creatinine
12 mg/dl
7 mg/dl
Creatinine of urine and PD
14 kg
Increase of 16.6 %
15 mg /kg/day
Creatinine clearance (L/week/1.73m2)
61
76
85
71
C J Stefanidis 2001
Creatinine and urea adequacy parameters
Muscle mass catabolism
Protein intake
Kt/Vurea
Creatinine clearance
D/Purea x VPD
=
ΤBW
D/Pcreat x VPD
=
S
= 60 L/1.73m2/week
Creatinine of urine and PD
=2
PNA
C J Stefanidis 2001
Ratio of Creat. Clearance / Kt/Vurea
Creat clearance
D/Pcr x BW
=
Kt/Vurea
D/Pur
XS
C J Stefanidis 2001
D/P of urea and creatinine
D/P
Urea
1.0
0.5
0.9
0.75
0.65
0.5
1 2
Creatinine
4
hours
C J Stefanidis 2001
Ratio of Creat. Clearance / Kt/Vurea
CAPD
Continuous ambulatory peritoneal dialysis
D/P cr 0.7
D/P Ur 1
NIPD
Kt/Vurea
2
VPD 12 L
Nocturnal intermittent peritoneal dialysis
D/P cr
D/P Ur
Day
Cr. clearance 60
Night
0.50
0.85
VPD 14 L
Cr. clearance 50
Kt/Vurea
2
C J Stefanidis 2001
Ratio of Creat. Clearance / Kt/Vurea
CAPD
Continuous ambulatory peritoneal dialysis
D/P cr 0.7
D/P Ur 1
NIPD
Kt/Vurea
2
68
2.1
VPD 12 L
Nocturnal intermittent peritoneal dialysis
D/P cr
D/P Ur
Day
Cr. clearance 60
Night
0.50
0.85
Cr. clearance 50
Kt/Vurea
VPD 14 L
RRF
2
Cr. clearance
Kt/Vurea
58
2.1
8
0.1
C J Stefanidis 2001
Automated peritoneal dialysis
Nocturnal intermittent peritoneal dialysis
NIPD
Continuous cycling peritoneal dialysis
CCPD
Continuous optimal peritonal dialysis
COPD
Night
Day
C J Stefanidis 2001
Weight:
70 kg
Weight: 35 kg
S=1.7m2 ΤΒW =42 L
Creat clearance
S=1.2m2 ΤΒW= 21 L
D/P cr x VPD x 1.73m2 /S
D/Purea x VPD / BW x0.6
14 kg
S=0.6m2 ΤΒW: 8.5 L
D/Pcr x
= 1.04 x
=
Kt/Vurea
Expected
Ratio
Weight:
BW
D/Pur X S
30
21
17
Creatinine
clearance
Kt/Vurea
60
75
80
2
3
4
Ratio
30
25
20
C J Stefanidis 2001
Ratio of Creat. Clearance / Kt/Vurea
Creat clearance
D/Pcr x BW
=
Kt/Vurea
Ratio
D/Pur
XS
Ratio
Residual renal function
Residual renal function
PD volume and
number of exchanges
PD volume and
number of exchanges
hyperpermeable state
C J Stefanidis 2001
Conclusions
The residual renal function is an important
component of the adequacy parameters.
Early initiation of PD might preserve RRF
Nephrotoxic medicines deteriorate RRF
C J Stefanidis 2001
Conclusions
Both Kt/Vurea and creatinine clearance should be
used for the assessment of dialysis adequacy
The age differences of the ratio
cr. clearance /Kt/Vurea
have to do with the ratio:
ΒWt / S
The final outcome might relate
with the ratio: MDt/P *
* MD time/Patient
C J Stefanidis 2001