Adequacy and prescription of pediatric peritoneal dialysis

1
Adequacy and prescription of pediatric peritoneal
dialysis

• Constantinos J. Stefanidis
• A. P. Kyriakou Children's Hospital, Athens,
  Greece

stefanid_at_hol.gr
2
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

3
Optimal and adequate dose of PD
4
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 Churchill DN et al. J Am
Soc Nephrol 1996
These predictions assume that renal and
peritoneal Kt/Vurea are equivalent.
5
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
6
Improvement of adequacy on PPD
Appropriate organization of PN Center
Guidelines
Evaluation of the clinical outcome
Modify strategies
7
Paediatric Nephrology Centers
8
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

9
Team working improves patient care and enhances
the quality of the working life.
10
Improvement of adequacy on PPD
Guidelines
Appropriate organization of PN Center
Evaluation of the clinical outcome
Modify strategies
11
Parameters of the efficiency of PD
Nr of exchanges per day (Nr)
12
Parameters of the efficiency of PD
BUN
Fill volume (Vf )
H2O
Cr
Gl
Nr of exchanges per day (Nr)
13
Parameters of the efficiency of PD
(scaled for BSA)
(D/P Creatinine)
Ultrafilration volume (VUF)
Drained volume (VPD ) (Vf x Nr) VuF
2L x 5 2L
14
Peritoneal equilibration test
95 children 1.1 L/1.73 m2 PD 2.5.
Creatinine
D/P
0.88
High
0.8
0.77
High avg.
0.6
0.64
Low avg.
0.5
0.51
Low
0.35
0.37
0.25
Time (hour)
Warady BA J Am Soc Nephrol 1996
15
Creatinine adequacy parameters
Wt 70 kg 5 exchanges of 2 L UF 2 L
Muscle mass catabolism
Creatinine
Creatinine clearance
D/Pcreat. x VPD / S
PD Creatinine
D/Pcreat. x VPD x S cr /Wt
(0.7 x 120 dl x 12 mg/dl) / 70 kg 14.4
mg/kg/day
16
Creatinine adequacy parameters
Wt 70 kg 5 exchanges of 2 L UF 2 L
Muscle mass catabolism
S. creatinine
Creatinine
Creatinine clearance
mg/dl
D/Pcreat. x VPD / S
14
?BW
0.6
x 12 L x7x1.73m2 / 1.7m2
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
17
Creatinine adequacy parameters
Wt 70 kg 5 exchanges of 2 L UF 2 L
Muscle mass catabolism
S. creatinine
Creatinine
Creatinine clearance
mg/dl
D/Pcreat. x VPD / S
12
?BW
0.6
x 12 L x7x1.73m2 / 1.7m2
50
L PD /1.73m2/week
10
L Ur /1.73m2/week

PD Creatinine Urine Creatinine
18
Urine volume (ml) before, 1 and 2 years after
dialysis
J Feber et al. Ped Nephrol 1994.
19
Urea adequacy parameters
Wt 70 kg 5 exchanges of 2 L UF 2 L
Protein catabolism
Kt/Vurea
D/Purea x VPD / ?BW
2
1 x (102) x 7 L / 42 ?BW 0.6 x Wt 42 L
UNA
D/Purea x VPD x BUN / Wt
PNA 6.25 x UNA (g/kg) 0.5
20
Urea adequacy parameters
Wt 70 kg 5 exchanges of 2 L UF 2 L
Protein catabolism
BUN
Kt/Vurea D/Purea x VPD / 0.6 x Wt 1 x (102)
x 7 L / 42
70
mg/dl
?BW
2
UNA
D/Purea x VPD x BUN / Wt
PNA 6.25 x UNA (g/kg) 0.5

1.2
21
Urea adequacy parameters
Wt 70 kg 5 exchanges of 2 L UF 2 L
Protein catabolism
BUN
Kt/Vurea
70
mg/dl
?BW
PNA - 0.5
187 x
BUN

2
PNA

1.2
22
1.7 g/kg/day
2 g/kg/day
4
3.2
2
23
Weight 70 kg S1.7m2 ??W 42 L
Weight 35 kg S1.2m2 ??W 21 L
Weight 14 kg S0.6m2 ??W 8.5 L
BUN
mg/dl
90
Increase of 23
PNA
1.7 g/kg/day
2 g/kg/day
1.2 g/kg/day
Kt/Vurea
187 (PNA - 0.5) / BUN
1.5
3.1
2.4
Decrease of 23
24
Weight 70 kg S1.7m2 ??W 42 L
Weight 35 kg S1.2m2 ??W 21 L
Weight 14 kg S0.6m2 ??W 8.5 L
7 mg/dl
5 mg/dl
15 mg /kg/day
Creatinine of urine and PD
76
85
25
Weight 70 kg S1.7m2 ??W 42 L
Weight 35 kg S1.2m2 ??W 21 L
Weight 14 kg S0.6m2 ??W 8.5 L
5 mg/dl
Serum creatinine
12 mg/dl
7 mg/dl
6 mg/dl
Increase of 16.6
15 mg /kg/day
Creatinine of urine and PD
Creatinine clearance (L/week/1.73m2)
61
76
71
85
26
Creatinine and urea adequacy parameters
Protein intake
Muscle mass catabolism
Kt/Vurea
Creatinine clearance
D/Pcreat x VPD

S
60 L/1.73m2/week
2
PNA
Creatinine of urine and PD
27
Ratio of Creat. Clearance / Kt/Vurea

28
D/P of urea and creatinine
Urea
1.0
D/P
0.9
0.75
0.5
1 2 4 hours
29
Ratio of Creat. Clearance / Kt/Vurea
CAPD
Continuous ambulatory peritoneal dialysis
Day
Night
30
Ratio of Creat. Clearance / Kt/Vurea
CAPD
Continuous ambulatory peritoneal dialysis
Day
Night
31
Automated peritoneal dialysis
Nocturnal intermittent peritoneal dialysis
NIPD
Continuous cycling peritoneal dialysis
CCPD
Continuous optimal peritonal dialysis
COPD
Day
Night
32
(No Transcript)
33
Ratio of Creat. Clearance / Kt/Vurea

Residual renal function
hyperpermeable state
34
Conclusions
The residual renal function is an important
component of the adequacy parameters.
Early initiation of PD might preserve RRF
Nephrotoxic medicines deteriorate RRF
35
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 ?Wt / S
The final outcome might relate with the ratio
MDt/P
MD time/Patient