Adequacy of peritoneal dialysis and chronic peritoneal dialysis

Adequacy of peritoneal dialysis and chronic peritoneal dialysis
Yousaf khan
Renal Dialysis lecturer
IPMS -KMU

1. Adequacy of Peritoneal dialysis and Chronic Peritoneal dialysis Prescription Yousaf khan Lecturer Renal Dialysis IPMS-KMU

2. Prescription of PD Involves a number of elements Initially choice of PD modality b/w CAPD and APT and their variants. Specific prescription based on clearance, ultrafiltration and nutritional requirement. 1: choice of a PD treatment modality A: Modalities of peritoneal dialysis therapy CAPD APD Hybrid forms of peritoneal dialysis 1. CAPD with automated nocturnal exchange 2. APD with additional exchange during the day d. Intermittent peritoneal dialysis (IPD)

3. Diagrammatic representation of various CAPD and APD

4. Comparison of typical CAPD and APD prescription CAPD CCPD NIPD PD solution used (L per week ) 56 -72 70 -120 84 -120 Dialysis time (h/week ) 168 168 70 Time on machine (h/week) 63 -70 63 - 70 Number of procedure/ week 28 14 14 Kt /V urea/week 1.5 -2.4 1.5 -2.6 1.2- 2.0 CrCl (L/week) 40 -70 40 -70 25 - 50

5. Choice of Prescription A: Clearance Targets. Target Kt /V for all modalties of PD is 1.7 per week B: Measurement of clearance: Kt /V Kt = Total Kt = Peritoneal Kt + Renal Kt A: Peritoneal Kt = 24 hour collection of peritoneal dialysate effulent Measure urea concentration in dialysate Estimate total urea content = urea conc. × volume of effulent Peritoneal Kt = urea content in dialysate / serum urea level

6. Measurement of clearance: B: Renal Kt : 24 hour collection of urine Measure urea concentration in urine Estimate total urea content = urea conc. × urine volume Renal Kt = urea content in Urine / serum urea level V (by watson formula ) V = 2.447 – 0.09516 A + 0.170 H + 0.3362 W (in Male) V = - 2.097 + 0.1069 H + 0.2466 W (in female ) Where A = age (Year), H= height ( cm) and W = weight (kg)

7. Measurement of clearance: CrCl ( Creatinine clearance ) CrCl = Total CrCl corrected for 1.73 m 2 body surface area Total CrCl = Peritoneal CrCl + Renal CrCl Peritoneal CrCl = 24 hour dialysate creatinine content / Serum creatinine Renal CrCl = 0.5 [ 24 hour urine creatnine content / serum creatnine + 24 hr urine urea nitrogen content / serum urea nitrogen ] Body surface area ( DuBois formula) BSA (m 2 ) = 0.00718 × W 0.425 × H 0.725 C: Determinants of clearance:

8. Factors determining clearance in peritoneal dialysis patients 1: Nonprescription factors Residual renal function Body size Peritoneal transport characteristics 2: Prescription factors CAPD Frequency of exchange Dwell volume Tonicity of dialysis solution (b ) APD Number of day dwells Volume of day dwells Tonicity of day dwells Time on cycler Cycle frequency Cycler dwell volume Tonicity of cycler solution

9. Nutritional issues in peritoneal dialysis Nutritional measurement in PD patient have been repeatedly shown to predict patient survival and other outcome. It is recommended that a number of these be routinely monitored to identify high risk patient with a view to appropriate intervention. Normalized protein equivalent of nitrogen appearance ( nPNA ) Serum albumin Subjective global assessment Lean body mass as estimated from creatinine excretion

10. A: Nutritional Indices Caloric intake Normalized protein equivalent of nitrogen appearance ( nPNA ) Serum albumin Subjective global assessment Creatnine excretion B: Treatment of malnutrition: Dietitian support Nutritional supplements Promotility agents Anabolic steroids Amino acid