Transcript CAPD guide line VS 施孟甫 醫師 CAPD麗華 CR 蔡智生 醫師

CAPD guide line



VS 施孟甫 醫師
CAPD麗華
CR 蔡智生 醫師
透析的 開始時機
 每週
KT/V < 2
 GFR <10.5/min/1.73m2
DOQUI guideline 2
Before peritoneal dialysis
1. PD start 10 days to 2 weeks
after catheter placement.
2. If PD started in < 10 days
following catheter placement,
do low-volume, supine dialysis.
3. Obtain baseline 24-hour urine collection
for urea and creatinine clearance
Before peritoneal dialysis
4. Explain to patient/parents/caregivers that :
 The prescription will be individualized.
 Instilled volume almost increase over time.
 Their total solute clearance will be monitored
 IF RRF or peritoneal transport changes,
their prescription may need to change as well.
CAPD : (1.5L or 2L) x qid
First Prescription
CCPD : 10 L + last bag (1L-2L)
(Based on RRF, BSA)
NIPD : 10 L
1 month adjustment
CAPD(L, LA)
WKt/V<1.7
WnCCr<50
換液次數增加
3次4次 or
4次5次
BSA, RRF, PET, S/S
CAPD(H, HA)
WKt/V<2
WnCCr<60
NIDP
WKt/V<2.2
WnCCr<66
單袋灌注量增加
1.5L2L or
2L2.5L
CCPD
WKt/V<2.1
WnCCr<63
增加白天
換液次數
1L-2L
一次或二次
CCPD
HD
Initial prescription
(1) Full dose to meet minimal total solute
clearance goal
(2) Pt with a significant RRF, but Kt/V < 2.0
Incremental dosage of PD.
(3) Based on BSA and residual renal function
(4) During training, transporter type can be
predicted from drain volume during a timed
(4- hr) dwell with 2.5% glucose
Residual renal function
 Renal
GFR
=1/2 (renal CCr + renal UreaCr)

BSA
=0.007184xBW(Kg)0.425xBH(cm)0.725
透析型態的選擇

CAPD = 白天由人力換透析液3-4次
晚上滯留
CCPD= 白天last bag滯留9小時,或CAPD換液1-2次
晚上由機器換透析液4-6次
NIDP = 晚上由機器換透析液4-6次
白天dry
1. GFR >2 ml/min
A. If patient's lifestyle choice is CAPD:
BSA<1.7 m2
4 x 1.5 L exchanges/day
BSA 1.7 to 2 m2 4 x 2.0 L exchanges/day
BSA>2.0 m2  4 x 2.5 L exchanges/day
1. GFR >2 ml/min
B. If patient's lifestyle choice is CCPD:
 BSA<1.7 m2
6 x 1.5 L (9hours/night) +1 L/d(last bag)
 BSA 1.7 to 2.0 m2
4 x 2.0 L (9 hours/night)+1.5-2.0 L/day (last bag)
 BSA>2.0 m2
 4 x 2.0 L (9 hours/night)+2. L/day (last bag)
1. GFR >2 ml/min
C. If patient's lifestyle choice is NIPD:
 Used at the initiation of dialysis.
 Reserved for high or rapid transporters.
 Patients with significant RRF (and ability to
diuresis),
 Nightly exchanges only (dry day)
2. GFR ≦2 ml/min
A. If patient's lifestyle choice is CAPD:
BSA<1.7 m2
 4 x 2.0 L/day
BSA 1.7 to 2.0 m2  4 x 2.5 L/day
BSA >2.0 m2
 5 x 2.5 L/day
(Consider use of a simplified nocturnal
exchange device to achieve optimal dwell
times and to augment clearance.)
2. GFR ≦2 ml/min
B. If patient's lifestyle choice is CCPD:
 BSA<1.7 m2
6 x 1.5 L (9hours/night) +1 L/d(last bag)
 BSA 1.7 to 2.0 m2
4 x 2.0 L (9 hours/night)+1.5-2.0 L/day(last bag)
 BSA>2.0 m2
 4 x 2.0 L (9 hours/night)+2.0 L/day (last bag)
(可增加白天換液1-2次)
CAPD : (1.5L or 2L) x qid
First Prescription
CCPD : 10 L + last bag (1L-2L)
(Based on RRF, BSA)
NIPD : 10 L
1 month adjustment
CAPD(L, LA)
WKt/V<1.7
WnCCr<50
換液次數增加
3次4次 or
4次5次
BSA, RRF, PET, S/S
CAPD(H, HA)
WKt/V<2
WnCCr<60
NIDP
WKt/V<2.2
WnCCr<66
單袋灌注量增加
1.5L2L or
2L2.5L
CCPD
WKt/V<2.1
WnCCr<63
增加白天
換液次數
1L-2L
一次或二次
CCPD
HD
CAPD : (1.5L or 2L) x qid
First Prescription
CCPD : 10 L + last bag (1L-2L)
(Based on RRF, BSA)
NIPD : 10 L
1 month adjustment
CAPD(L, LA)
WKt/V<1.7
WnCCr<50
換液次數增加
3次4次 or
4次5次
BSA, RRF, PET, S/S
CAPD(H, HA)
WKt/V<2
WnCCr<60
NIDP
WKt/V<2.2
WnCCr<66
單袋灌注量增加
1.5L2L or
2L2.5L
CCPD
WKt/V<2.1
WnCCr<63
增加白天
換液次數
1L-2L
一次或二次
CCPD
HD
Adequate dialysis
1. Adequate solute removal ability
2. Adequate ultrafiltration
1st month adjustment
Depend on
 Peritoneal equilibration test (PET)
 Residual renal function (RRF)
 Body surface area (BSA)
 S/S
 weekly Kt/V and total nCCr
Adjustment of dialysis dose
Peritoneal Equilibration Test (PET)
前一晚以Dialysate灌入腹內,存留8-12hrs
 第二天早上，在PD Room以立姿引流全部
透析液20分(<25分)測引流量之容量。
 以臥姿每10分注入2.5% Dialysate 2000ml。
 每2分鐘 400ml速度，病人須在床上翻滾 以
利dialysate在腹腔內混合均勻。

Peritoneal Equilibration Test (PET)




Dialysate在全部注入後，為0分(0-dwell time)
立即引流200ml透析液，取10ml 送檢，其餘
再注入腹內而後病人可以自由活動。
120分時，病人須引流灌注量1/10 之dialysate
至透析液袋中搖晃均勻後，于透析液袋抽
出10ml透析液，再將剩餘透析液注入腹腔內。
120分抽血送驗其glucose, Cr 值。
240分時，以立姿將dialysate全部引流20分 測
其容積，並抽10ml dialysate送驗。
Peritoneal equilibration test
(PET)

Insertion 2 liters of 2.5% detrose dialysate
 0小時, 2小時, 4小時
 D/D0 glucose and D/P Cr之值 並畫圖
 Low transporter
Low everage transporter
High average transporter
High transporter
Adequate
solute removal ability
CAPD : (1.5L or 2L) x qid
First Prescription
CCPD : 10 L + last bag (1L-2L)
(Based on RRF, BSA)
NIPD : 10 L
1 month adjustment
CAPD(L, LA)
WKt/V<1.7
WnCCr<50
換液次數增加
3次4次 or
4次5次
BSA, RRF, PET, S/S
CAPD(H, HA)
WKt/V<2
WnCCr<60
NIPD
WKt/V<2.2
WnCCr<66
單袋灌注量增加
1.5L2L or
2L2.5L
CCPD
WKt/V<2.1
WnCCr<63
增加白天
換液次數
1L-2L
一次或二次
CCPD
HD
適量的腹膜透析
Weekly Kt/V
=7 x (peritoneal Kt/V + renal Kt/V)
Weekly nCCr
=7 x (Peritoneal CCr + renalGFR)/(BSA/1.73)
=7 x [Peritoneal CCr +
1/2( renal CCr+renal ureCr)]/(BSA/1.73)
Target of WKt/V, WnCcr
CAPD
L, LA H, HA
Weekly >1.7
>2.0
Kt/V
Weekly >50
>60
nCCr
L/week L/week
CCPD
NIPD
>2.1
>2.2
>63
L/week
>66
L/week
透析不足的S/S

溶質移除能力不足
-Cr↑, BUN ↑or ↓
-貧血 神經症狀 變嚴重
-食慾不振 噁心 嘔吐 消瘦 失眠
Adjust dialysate
and nCCr 不足 or S/S
 ↑dialysate 總量 or
 ↑換袋次數
 ↑單袋灌注量
 Kt/V

CAPD (L/LA) 2L qid 若Kt/V < 1.7 or nCCr<50
2L change 5 次 2.5L change 5 次
 CCPD (白天換二次 + 晚上10L)
 HD
CAPD (H/HA) 2L qid 若Kt/V < 2 or nCCr<60
2L change 5 次 2.5L change 5 次
 APD (晚上10L)
 CCPD (白天換二次 + 晚上10L) HD

APD :10 L (1.5%)若Kt/V < 2.2 or nCCr<66
CCPD (加白天一或二次換液)
CCPD :若Kt/V < 2.1 or nCCr<63
H/D
CAPD : (1.5L or 2L) x qid
First Prescription
CCPD : 10 L + last bag (1L-2L)
(Based on RRF, BSA)
NIPD : 10 L
1 month adjustment
CAPD(L, LA)
WKt/V<1.7
WnCCr<50
換液次數增加
3次4次 or
4次5次
BSA, RRF, PET, S/S
CAPD(H, HA)
WKt/V<2
WnCCr<60
NIPD
WKt/V<2.2
WnCCr<66
單袋灌注量增加
1.5L2L or
2L2.5L
CCPD
WKt/V<2.1
WnCCr<63
增加白天
換液次數
1L-2L
一次或二次
CCPD
HD
透析不足的S/S

容質移除能力不足
-Cr↑, BUN ↑or ↓
-貧血 神經症狀 變嚴重
-食慾不振 噁心 嘔吐 消瘦 失眠
定期評估透析量

每月ㄧ次 :Hb, Ht, WBC, DC, Sugar, alb, A/G,
Alk-P, Chole, TG, BUN, Cr, Uric Acid,
Cr, K, NA, Ca, P,


每三月ㄧ次 : MCV, Ret, Iron, TIBC, Ferritin,
GOT, GPT,
每六月ㄧ次 : iPTH, Vit B12, Folic acid, nCCr, Kt/V

每年ㄧ次 : PET, X-ray, HBsAg, Anti-HCV
Adequate ultrafiltration
簡單UFF 之定義

病人即使每天使用2-3袋的高濃度 (4.25%)之
透析液, 而仍會發生水腫. 即使限水亦無法達
到乾體重.
超過率能力不足

S/S
-高血壓 水腫
-使用高濃度透析液的次數增加
Management of
Ultrafiltration inadequate

↑dialysate 總量 or
 ↑換袋次數
 ↑單袋灌注量
 ↑Dextrous 濃度( 1.25%2.5%4.25%)
 Extraneal (Icodextrin)
 限制水份攝取
 urine <500cc/day Transamin1#Bid
First
prescription
CAPD : (2L or 1.5L ) x qid
CCPD : 10 L +last bag (1L-2L)
NIPD : 10 L
-高血壓 水腫
-使用高濃度透析液的次數增加
 ↑dialysate 總量 or
 ↑換袋次數
 ↑單袋灌注量
 ↑Dextrous 濃度( 1.25%2.5%4.25%)
 Extraneal (Icodextrin)
 限制水份攝取
 urine <500cc/day Transamin1#Bid
體液過量
遵醫性不良
灌注2公升之透析液
不變
24H
urine
導管問題
透析液漏出
流出量不變
檢查流出量
下降
流出量↓
真正失去UF
PET
RFF減少
下降
Type II UFF
1.硬化性腹膜炎
2.粘連
不變
1.淋巴吸收上升
2.透析液滲漏
3.導管問題
4.經細胞穿透力下降
上升
Type I UFF
新生的腹膜炎
Type I UFF
 70%-80%
 ↑transport effect
(D/PCr ↑, D/D0 glucose↓)
 Reversible after 1 month
 Peritonitis
Type II UFF

較少

Sclerosing peritonitis and
peritoneal adhesion
腹膜表面積減少, 穿透性下降
 同時會出現UFF 及inadequate solute
transport

Type III UFF
High lymphatic absorption rate
 Uncommon

Type IV UFF






Aquaporin deficiency
Rare
↓Water channels or ↓ ultra-small pore
deficient crystalloid-induced UF
Dx :<400ml UF with 4.25%PET
lack of Na sieving early in the dwell
Tx : colloid osmotic agents (icodextrin)
Type I UFF
滲透性增加
Type II UFF
硬化性腹膜炎
黏連
便秘
避免夜間
留存太久
若有尿
可加 lasix
若有尿
可加 lasix
軟便劑
疝氣
滲漏
高纖食物
手術修復
導管位置不良
校正導管
位置
Type III UFF
淋巴吸收增加
無有效治
療方法
改成NPD
暫時HD or
改用icodetran
試tidal PD
轉HD
用腹腔鏡
暫停PD
Icodextrin 7.5%





Glucose polymer
MW=16800
Osmolality 285mOsm/kg
UF occurred by colloid osmosis via small pores
No UF via ultra pores, through which glucose
mainly acts, so no sodium sieving
腹膜透析轉血液透析的適應症
適應症 :無法達適當腹膜透析量
無法達到適當水分控制、
無法控制的高血脂症、
無法接受的高腹膜炎發生率或
其他腹膜透析併發症、技術問題、
無法矯正的營養不良．
Pitfalls in Prescription of PD


Noncompliance
Patients on Standard CAPD are:
(a) inappropriate dwell times
(b) failure to ↓ dialysis dose
to compensate for loss of RRF;
(c) inappropriate instilled volume
(d) multiple rapid exchanges and 1 very long dwell
(e) inappropriate selection of dialysate glucose
Pitfalls in Prescription of PD

Patients on cycler therapy.
=The drain time may be inappropriately long
(> 20 min).
=Inappropriately short dwell times
=Failure to augment total dialysis dose
with a daytime dwell ("wet" day vs "dry" day)
could also result in underdialysis.
=Inappropriate selection of dialysate glucose
may not allow maximization of UF,
resulting in less total clearance.