Fluid management in pd patient

pd

1. Fluid Management in PD Patients 1 Dina A Abdellatif Consultant Nephrologist Kasr El- Ainy Hospital ISN Fellow

2. Optimisin g Treatment 2

3. Disease Process Lifestyle Body Size Residual Renal Function Peritoneal Membrane Fill Volume Number of Exchanges Dwell Time Efficient Use of Total 24 Hours Glucose Concentration Fixed Parameters Adjusted Parameters Components of Prescription Management 3

4. “First … Do no harm” Balancing sufficient solute clearance with avoidance of too much dialysis fluid exposure Risks Membrane injury Worsening metabolic syndrome / obesity Cost Balancing Volume control Risks Loss of residual kidney function Membrane injury 4

5. How PD works?

6. Anatomy & Physiology 3 Pore Model 6

7. Ultra-small or transcellular pores (0.4-0.6 nm.) Exist in small numbers and constitute 1-2 % of all pores Transport water only (sieving) :aquaporin-1(water channel) Michael F. Flessner Am J Physiol Renal Physiol 288: F433–F442, 2005 Free water 7

8. Small pores (4.0-6.0 nm.) Exist in large numbers and constitute 95% of all pores transport small solutes and water: interendothelial cleft Michael F. Flessner Am J Physiol Renal Physiol 288: F433–F442, 2005 Small solute e.g. Na ,K , Cr 8

9. Large pores (20-24 nm) Exist in small numbers and constitute < 3% of all pores Transport macromolecules and anatomically large clefts between endothelial cells : convection Michael F. Flessner Am J Physiol Renal Physiol 288: F433–F442, 2005 albumin 9

10. How PD works? Ultrafiltration Key elements • Osmotic gradients: - Glucose concentration • Osmotic agent: - Cristalloïd (glucose, amino acids) - Colloïde (high molecular weight: ex. Icodextrine ) • Intra peritoneal Pressure (IPP): - Important to determine Intra peritoneal Volume • Transport type of the membrane: rapid or slow PET will determine the type of the membrane and determine the best dwell time to be prescribed • Dwell time is therefore also a key element 10

11. 1.5 % Solution 2.5 % Solution 4.25 % Solution Osmotic Pressure of Dextrose Solution

12. PLoS One. 2018 Aug 13;13(8): doi : 10.1371/ journal.pone.0202203 .

13. Initial Prescription 13

14. Initial prescription 14 Volume of Urea distribution (small, medium, large) Clinical & nutritional assessment Estimated RRF Initial membrane evaluation through assessment of drain volume Lifestyle, psychological and social preferences Initial prescription APD CAPD

15. CAPD Continuous Ambulatory Peritoneal Dialysis 15

16. CCPD – APD Continuous Cycling Peritoneal Dialysis 16

17. Adequacy 17

18. Adequate dialysis Narrow Sense Appropriate small molecular weight solute clearance Specifically measured as urea clearance In PD, we measure total Kt /V Renal Kt /V + Dialysate Kt /V 18

19. Adequate dialysis Broad sense Control of: – Acid-base status – BP and volume status – Cardiovascular Risk – Diet/nutrition – Mineral/Bone disorders – Small/middle molecules 19 Possibly most important: How the patient feels!

20. 20 RRF Euvolemia

21. Ultrafiltration during PD Depends on: 21

22. Treatment Sodium and fluid restriction  — We review the sodium restriction of <2 grams/day. We restrict fluids to approximately 2 L/day. Loop diuretics  — We treat all patients who have residual renal function with diuretics. We increase the dose in patients who develop hypervolemia.  Combination therapy with furosemide and a thiazide diuretic ( eg , metolazone) may also be effective.

23. Wim van Biesen et al. Nephrol . Dial. Transplant. 2010;25:2052-2062 Peritoneal membrane characteristics evaluation. 24

24. 25

25. Peritoneal Membrane types 26

26. Membrane Types 27

27. 28

28. Twardowski ZJ, Nolph KD, Khanna R et al Perit Dial Bull 1987;7:138. The Peritoneal Equilibration Test (PET) 29

29. The PET test 30

30. Interpretation of PET ?? 31 Drain volumes correlate positively with dialysate glucose and negatively with D/P creatinine at 4 hours

31. PET application Transporter Waste removal Water removal Best type of PD High Fast Poor Frequent exchanges, short dwells – APD Average OK OK CAPD or APD Slow Slow Good CAPD, 5 exchanges daily + 1 exchange at night 32

32. Common prescription errors - CAPD Mismatch dwell time and transport type Inappropriately short daytime dwell Inappropriate infused volumes Inappropriate glucose concentration for nighttime dwell 33

33. Common prescription errors - APD Inappropriate use of a dry day Inappropriately long drain times Failure to increase target dose to account for intermittent therapy Failure to consider a CAPD exchange during the day to increase clearance 34

34. Initiate Therapy Measure Clearances Adjust Therapy 35

35. Prescription Modification 36

36. Targeting goals Prescription CAPD Increase exchange volume Increase frequency of daily exchanges Increasing tonicity of dialysis solution APD Introduction of daily dwell Increase dwell volume on cycler Increase time on cycler Increase frequency of cycles Increasing dialysis solution tonicity 37

37. CAPD Prescription Modification 38

38. CAPD Prescription Modification 39

39. APD Prescription Modification 40

40. APD Prescription Modification 41 Effective means of improving clearance Minimum impact on patient lifestyle Adjust nighttime exchanges first Use 2.0L or greater whenever possible

41. APD Prescription Modification 42 Cycler time can be extended to 10 hours Increasing cycler time with a constant number of exchanges increases dwell time which increases clearance Increase Number of Nighttime Exchanges May increase clearance, but only if time on cycler is also increased

42. Prescription Modification 43 This is a very effective means of improving clearance Machine can be programmed to deliver the midday exchange APD

43. Adapted APD 44 APD

44. Adapted APD 45 Adapted APD First Ultrafiltration (low fill – short dwell) Then Purification (large fill – long dwell)  improved dialysis efficiency in terms of UF, Kt /V(urea), K( creat ), P, and Na. Those results were achieved without incurring any extra financial costs and with a reduction in the metabolic cost (assessed using glucose absorption).

45. Alternate APD 46 APD

46. Targeting goals Prescription pitfalls in PD Loss of residual renal function Non compliance Prescription with “dry” time Inappropriate switch from CAPD to APD Inadequate attention to fluid removal 47

47. Extra Measures Resting the peritoneum –  We occasionally temporarily switch to maintenance hemodialysis via a temporary central venous catheter in order to rest the peritoneum

48. Clinical Practice Guidelines of the Canadian Society of Nephrology for treatments of Patients with CRF JASN 10: S287-S321, 1999 Monitoring frequency KT/V and Ccl : Within 6-8 weeks after commencing dialysis Every subsequent 6 month If patients clinical status changes unexpectedly, or if prescription is altered, take supplemental clearance measurements PET Within 6 weeks of initiating PD Repeat if unexpected changes in peritoneal UF occur 49

49. PD solutions 50

50. PD solutions 51

51.   Dextrose Amino acid Icodextrin Osmolality (mOsm/kg) 346, 396 and 485 365 282 Molecular Weight (Dalton) 182 100-200 20,000 Advantages Well studied Most commonly used for a long time Side effect profile well known to most of the nephrologists Can improve nutritional status in malnourished diabetic and/or patients with recurrent peritonitis Sustained ultrafiltration for many hours Decreased solute absorption Disadvantages Short lived ultrafiltration Metabolic complications like hyperinsulinemia, hyperglycemia , hyperlipidemia , and weight gain Expensive May increase nitrogen waste product in blood May cause/worsen acidosis Increases serum levels of maltose, maltotriose , and oligopolysacharides Indications first line peritoneal dialysis solution in all patients Malnourished diabetic patients or Malnourished patients with recurrent peritonitis Patients who lose UF to achieve sustained UF increased solute and fluid removal In diabetic patients PD Solutions 52

52. Biocompatible fluids Physioneal – Baxter 53 Balance – Fresenius

53. 54 Conclusions  The use of neutral-pH, low–glucose degradation products solutions results in: better preservation of residual renal function and greater urine volumes. The effect on residual renal function occurred early and persisted beyond 12 months.

54. Impact of icodextrin on clinical outcomes in peritoneal dialysis: a systematic review of randomized controlled trials 55 Conclusions  Icodextrin prescription improved peritoneal ultrafiltration, mitigated uncontrolled fluid overload and was not associated with increased risk of adverse events. Nephrol . Dial. Transplant.  (2013)28 (7): 1899-1907.

55. Treatment Icodextrin dialysate one exchange per day. We use icodextrin-containing dialysate during the overnight exchange in CAPD and for the long-day dwell in APD . The use of icodextrin dialysate enhances ultrafiltration, particularly during a long dwell in fast transporters. Since the compound is relatively inert and slowly absorbed, the osmotic gradient is maintained, thereby providing sustained ultrafiltration.

56. Making monitoring of adequacy easier Using a software program makes monitoring easier: Automated calculations of creat clearance, KT/V, nPNA Reporting function gives easy overview of one patient or whole patient population Easy to identify problem patients where actions might be needed Track and document improvements over time 57

57. 58 The use of bioimpedance spectroscopy to guide fluid management in patients receiving dialysis. Tabinor M1 , Davies SJ Eight trials (published 2010-2018) and two meta-analyses (2017) are reviewed. Both haemodialysis and peritoneal dialysis modalities are represented. Despite considerable heterogeneity in intervention, all are open-label randomized comparisons of a bioimpedance intervention with normal clinical practice in which clinicians were blinded to bioimpedance data. In a total of 1443 patients studied, no significant differences in mortality, cardiovascular or adverse events between groups were observed. Bioimpedance use was associated with a reduction in overhydration, especially when residual kidney function was not present and a greater reduction in blood pressure. A modest correlation in the change in fluid status and fall in systolic blood pressure was seen compared to baseline. A more rapid fall in urine volume was seen in the two studies with the greatest change in fluid status, with significantly higher risk of anuria in one. How bioimpedance was integrated with the complex process of decision making by clinicians was variable and not always explained. The usefulness of bioimpedance spectroscopy in guiding fluid management in dialysis patients is not yet clear. Bioimpedance can drive clinical decisions that lead to significant changes in fluid status but the best way to apply this in clinical practice requires further studies. Curr Opin Nephrol Hypertens . 2018 Nov;27 (6):406-412. doi : 10.1097/ MNH.0000000000000445 .

58. Guidelines 59

59. 60

60. 61 BMC Nephrology BMC series – open, inclusive and trusted2017 18 :333 https://doi.org/10.1186/s12882-017-0687-2

61. Take home message 62

62. Clin J Am Soc Nephrol . 2016 Jan 7; 11(1): 155–160. doi : 10.2215/ CJN.02920315