C J Stefanidis . 2001
Adequacy and prescription of Adequacy and prescription of pediatric peritoneal dialysispediatric peritoneal dialysis
Constantinos J. StefanidisConstantinos J. Stefanidis
““A.& P. Kyriakou” Children's Hospital, Athens, GreeceA.& P. Kyriakou” Children's Hospital, Athens, Greece
[email protected]@hol.gr
C J Stefanidis 2001
Dialysis adequacyDialysis adequacy
Dialysis adequacy is a concept introduced in the Dialysis adequacy is a concept introduced in the
late 1980s linking late 1980s linking outcomesoutcomes of hemodialysis of hemodialysis
patients to patients to adequacy targetsadequacy targets..
There is a strong correlation of the the There is a strong correlation of the the adequacy parameters and:adequacy parameters and:
• nutritional intakenutritional intake
• bone diseasebone disease
• anemiaanemia
C J Stefanidis 2001
Optimal and adequate dose of PDOptimal and adequate dose of PD
Adequate dose:Adequate dose: the amount of the amount of PD below which there is an increase PD below which there is an increase in morbidity and mortalityin morbidity and mortality
Optimal dose:Optimal dose: the amount the amount of PD yielding clinical results of PD yielding clinical results which cannot further improvewhich cannot further improve
C J Stefanidis 2001
CANUSA studyCANUSA study
680 continuous peritoneal dialysis patients680 continuous peritoneal dialysis patients
5% decrease in patient survival 5% decrease in patient survival with every 0.1 decrease in total weekly Kt/Vurea with every 0.1 decrease in total weekly Kt/Vurea for Kt/Vurea between 1.5 - 2.3 for Kt/Vurea between 1.5 - 2.3
Churchill DN et al. J Am Soc Nephrol 1996Churchill DN et al. J Am Soc Nephrol 1996
These predictions assume that renal and These predictions assume that renal and peritoneal Kt/Vurea are equivalent. peritoneal Kt/Vurea are equivalent.
C J Stefanidis 2001
Adequacy and clinical outcomeAdequacy and clinical outcome
Adequacy targetsAdequacy targets have been defined in have been defined in adults because patient adults because patient mortality and mortality and morbiditymorbidity is much easier to define is much easier to define
There are few data to correlate the clinical There are few data to correlate the clinical outcomes with delivered dialysis dose in outcomes with delivered dialysis dose in
childrenchildren
C J Stefanidis 2001
Appropriate organization Appropriate organization of PN Centerof PN Center
GuidelinesGuidelines
Evaluation of Evaluation of the clinical outcomethe clinical outcomeModify strategiesModify strategies
Improvement of adequacy on PPD
C J Stefanidis 2001
Paediatric Nephrology CentersPaediatric Nephrology Centers
HDHD
CRICRI
PDPD
PaediatriciansPaediatricians(early referral)(early referral)
Paediatric surgeonsPaediatric surgeons (dialysis access)(dialysis access)
TxTx
Tx surgeonsTx surgeons
C J Stefanidis 2001
Multi-disciplinary team• Structure Structure Doctors, nurses, dietitians, social workers, Doctors, nurses, dietitians, social workers,
psychologists, play therapists, teachers. psychologists, play therapists, teachers.
• Goal Goal To deliver to children the care required forTo deliver to children the care required for their optimal quality of life.their optimal quality of life.
• Team meetings Team meetings give the entire team opportunity forgive the entire team opportunity for collaborative decision making. collaborative decision making.
• Networking Networking with other PN centers, multicenter with other PN centers, multicenter studies and global cooperationstudies and global cooperation
C J Stefanidis 2001
Team working improves patient care and Team working improves patient care and enhances the quality of the working life.enhances the quality of the working life.
C J Stefanidis 2001
Appropriate organization Appropriate organization of PN Centerof PN Center
Guidelines
Evaluation of Evaluation of the clinical outcomethe clinical outcomeModify strategiesModify strategies
Improvement of adequacy on PPD
C J Stefanidis 2001
Parameters of the efficiency of PDParameters of the efficiency of PD
Nr of exchangesNr of exchangesper day (Nr)per day (Nr) Peritoneal permeabilityPeritoneal permeability
Fill volume (Vf )Fill volume (Vf )
GlGl
HH22OO BUNBUNCrCr
C J Stefanidis 2001
Parameters of the efficiency of PDParameters of the efficiency of PD
Nr of exchangesNr of exchangesper day (Nr)per day (Nr) Peritoneal permeabilityPeritoneal permeability
Fill volume (Vf )Fill volume (Vf )
GlGl
HH22OO BUNBUNCrCr
C J Stefanidis 2001
Parameters of the efficiency of PDParameters of the efficiency of PD
(scaled for BSA)
Nr of exchangesNr of exchangesper day (Nr)per day (Nr)
Fill volumeFill volume (V (Vff ) )
Peritoneal permeabilityPeritoneal permeability
HH22OO BUNBUNCrCr
GlGl
Ultrafilration volume (VUltrafilration volume (VUFUF))
Drained volumeDrained volume (V (VPDPD ) = (V ) = (Vf x Nrf x Nr) ) + Vu+ VuFF
2L x 5 + 2L2L x 5 + 2L
(D/P(D/P Creatinine)Creatinine)
C J Stefanidis 2001
Peritoneal equilibration testPeritoneal equilibration test
0
0,2
0,4
0,6
0,8
1
0 1 2 3 4
`
Time (hour)Time (hour)
D/PD/P CreatinineCreatinine0.880.88
0.370.37
0.770.770.640.64
0.510.51
HighHigh
LowLow
High avg.High avg.
Low avg.Low avg.
0.80.8
0.250.25
0.60.6
0.50.5
0.350.35
95 children 1.1 L/1.73 m2 PD 2.5%.
Warady BA J Am Soc Nephrol 1996
C J Stefanidis 2001
Creatinine adequacy parametersCreatinine adequacy parameters
Muscle mass catabolismMuscle mass catabolism
= (= (0.7 x 0.7 x 120 120 dl x dl x 12 mg/dl) / 70 kg12 mg/dl) / 70 kg
= = 14.4 14.4 mg/kg/daymg/kg/day
= D/P= D/Pcreat.creat. x V x VPD PD / S/ SCreatinine clearanceCreatinine clearance
x 12 L x7x1.73x 12 L x7x1.73mm22 / / 1.7m1.7m2 2 0.70.7ΤΤB
WB
W
mg/dlmg/dl12 12
Wt: 70 Wt: 70 kgkg5 exchanges of 2 5 exchanges of 2 LLUF 2 UF 2 LL
L/1.73mL/1.73m22/week/week6060
PD CreatininePD Creatinine = D/P= D/Pcreat.creat. x V x VPD PD x S cr /Wtx S cr /Wt
S. creatinineS. creatinineCreatinineCreatinine
C J Stefanidis 2001
Creatinine adequacy parametersCreatinine adequacy parameters
Muscle mass catabolismMuscle mass catabolism
S. creatinineS. creatinine
= (= (0.6 x 0.6 x 120 120 dl x dl x 14 mg/dl) / 70 kg14 mg/dl) / 70 kg
= = 14.4 14.4 mg/kg/daymg/kg/day
mg/dlmg/dl
x 12 L x7x1.73x 12 L x7x1.73mm22 / / 1.7m1.7m2 2
= D/P= D/Pcreat.creat. x V x VPD PD / S/ SCreatinine clearanceCreatinine clearance
0.60.6ΤΤB
WB
W14 14
Wt: 70 Wt: 70 kgkg5 exchanges of 2 5 exchanges of 2 LLUF 2 UF 2 LL
L/1.73mL/1.73m22/week/week5050
PD CreatininePD Creatinine = D/P = D/Pcreat.creat. x V x VPD PD x S cr /`Wtx S cr /`Wt
CreatinineCreatinine
C J Stefanidis 2001
Creatinine adequacy parametersCreatinine adequacy parameters
Muscle mass catabolismMuscle mass catabolism
S. creatinineS. creatinine mg/dlmg/dl
x 12 L x7x1.73x 12 L x7x1.73mm22 / / 1.7m1.7m2 2
L PD /1.73mL PD /1.73m22/week/week
= D/P= D/Pcreat.creat. x V x VPD PD / S/ SCreatinine clearanceCreatinine clearance
0.60.6ΤΤB
WB
W12 12
Wt: 70 Wt: 70 kgkg5 exchanges of 2 5 exchanges of 2 LLUF 2 UF 2 LL
5050
PD Creatinine + Urine CreatininePD Creatinine + Urine Creatinine
L Ur /1.73mL Ur /1.73m22/week/week1010``
CreatinineCreatinine
C J Stefanidis 2001
Urine volume (ml) before, 1 and 2 Urine volume (ml) before, 1 and 2 years after dialysisyears after dialysis
0
500
1000
1500
2000
2500
HD
J Feber et al. Ped Nephrol 1994.
0
500
1000
1500
2000
2500
PD
C J Stefanidis 2001
Protein catabolismProtein catabolism
mg/dlmg/dl7070
UNAUNA
= 1 x (10+2) x 7 L / 42 == 1 x (10+2) x 7 L / 42 =
ΤΤBW BW = 0.6 x Wt = 42 L= 0.6 x Wt = 42 L
22
= D/P= D/Pureaurea x V x VPD PD x BUN / Wtx BUN / Wt
PNAPNA = = 6.25 x UNA (g/kg) + 0.5 6.25 x UNA (g/kg) + 0.5 1.21.2==
Wt: 70 Wt: 70 kgkg5 exchanges of 2 5 exchanges of 2 LLUF 2 UF 2 LL
Urea adequacy parametersUrea adequacy parameters
ΤΤB
WB
W
BUNBUNBUNBUN Kt/VureaKt/Vurea= = D/PD/Pureaurea x V x VPD / ΤPD / ΤBWBW
C J Stefanidis 2001
Protein catabolismProtein catabolism
BUNBUN mg/dlmg/dl
ΤΤB
WB
W7070
UNAUNA
Kt/VureaKt/Vurea= = D/PD/Pureaurea x V x VPDPD / / 0.6 x Wt0.6 x Wt
= 1 x (10+2) x 7 L / 42 == 1 x (10+2) x 7 L / 42 = 22
= = D/PD/Pureaurea x V x VPDPD x BUN /x BUN / Wt Wt
PNAPNA = = 6.25 x UNA (g/kg) + 0.5 6.25 x UNA (g/kg) + 0.5 1.21.2==
Wt: 70 Wt: 70 kgkg5 exchanges of 2 5 exchanges of 2 LLUF 2 UF 2 LL
Urea adequacy parametersUrea adequacy parameters
C J Stefanidis 2001
Protein catabolismProtein catabolism
BUNBUN mg/dlmg/dl
ΤΤB
WB
W7070Kt/VureaKt/Vurea
22
PNAPNA
PNA - 0.5
Wt: 70 Wt: 70 kgkg5 exchanges of 2 5 exchanges of 2 LLUF 2 UF 2 LL
Urea adequacy parametersUrea adequacy parameters
BUN= 187 x
=
1.21.2==
C J Stefanidis 2001
BUNBUN mg/dlmg/dl7070
1.7 1.7 g/kg/dayg/kg/day 2 2 g/kg/dayg/kg/day
443.23.2
1.2 1.2 g/kg/dayg/kg/dayPNAPNA
22
= 187 (PNA - 0.5) / BUN Kt/VureaKt/Vurea
Weight: Weight: 70 70 kg kg S=1.7mS=1.7m22 ΤΒW =42 L ΤΒW =42 L
Weight: Weight: 3535 kg kg S=1.2mS=1.2m22 ΤΒW= 21 L ΤΒW= 21 L
Weight: Weight: 1414 kg kg S=0.6mS=0.6m22 ΤΒW: 8.5 L ΤΒW: 8.5 L
C J Stefanidis 2001
1.2 1.2 g/kg/dayg/kg/day
BUNBUN mg/dlmg/dl9090
PNAPNA 1.7 1.7 g/kg/dayg/kg/day 2 2 g/kg/dayg/kg/day
= 187 (PNA - 0.5) / BUN
1.51.5 3.13.12.42.4
Kt/VureaKt/Vurea
Weight: Weight: 70 70 kg kg S=1.7mS=1.7m22 ΤΒW =42 L ΤΒW =42 L
Weight: Weight: 3535 kg kg S=1.2mS=1.2m22 ΤΒW= 21 L ΤΒW= 21 L
Weight: Weight: 1414 kg kg S=0.6mS=0.6m22 ΤΒW: 8.5 L ΤΒW: 8.5 L
Increase of 23%Increase of 23%
Decrease of 23%Decrease of 23%
C J Stefanidis 2001
Serum creatinineSerum creatinine
12 12 mg/dlmg/dl 77 mg/dl mg/dl 5 5 mg/dlmg/dl
CreatinineCreatinine of urine and PDof urine and PD 1515 mg mg /kg/day/kg/day
Creatinine clearance Creatinine clearance ((L/weekL/week/1.73/1.73mm22))
6161 7676 8585
Weight: Weight: 70 70 kg kg S=1.7mS=1.7m22 ΤΒW =42 L ΤΒW =42 L
Weight: Weight: 3535 kg kg S=1.2mS=1.2m22 ΤΒW= 21 L ΤΒW= 21 L
Weight: Weight: 1414 kg kg S=0.6mS=0.6m22 ΤΒW: 8.5 L ΤΒW: 8.5 L
C J Stefanidis 2001
Serum creatinineSerum creatinine
12 12 mg/dlmg/dl 77 mg/dl mg/dl 6 6 mg/dlmg/dl
CreatinineCreatinine of urine and PDof urine and PD 1515 mg mg /kg/day/kg/day
Creatinine clearance Creatinine clearance ((L/weekL/week/1.73/1.73mm22))
6161 7676 7171
Weight: Weight: 70 70 kg kg S=1.7mS=1.7m22 ΤΒW =42 L ΤΒW =42 L
Weight: Weight: 3535 kg kg S=1.2mS=1.2m22 ΤΒW= 21 L ΤΒW= 21 L
Weight: Weight: 1414 kg kg S=0.6mS=0.6m22 ΤΒW: 8.5 L ΤΒW: 8.5 L
5 5 mg/dlmg/dl
8585
Increase of 16.6 %Increase of 16.6 %
C J Stefanidis 2001
Creatinine and urea adequacy parametersCreatinine and urea adequacy parameters
PNA
Protein intakeMuscle mass catabolismMuscle mass catabolism
Creatinine of urine and PDCreatinine of urine and PD
Creatinine clearanceCreatinine clearance
= 60 L/1.73m= 60 L/1.73m22/week/week= 2= 2
D/PD/Pcreatcreat x V x VPDPD
SS==
D/PD/Pureaurea x V x VPDPD
ΤΤBWBW==
KKtt/Vurea/Vurea
C J Stefanidis 2001
Ratio of Creat. Clearance / Ratio of Creat. Clearance / Kt/VureaKt/Vurea
Creat clearance Creat clearance
Kt/VureaKt/Vurea==
D/PcrD/Pcr x x BWBW
D/PD/Purur X X SS
C J Stefanidis 2001
D/P of urea and creatinineD/P of urea and creatinine
1.0
0.5
1 2 4 hours
0.90.9D/P
D/P
UreaUrea
0.750.75
0.650.65CreatinineCreatinine0.50.5
C J Stefanidis 2001
Continuous ambulatory peritoneal dialysisContinuous ambulatory peritoneal dialysisCAPD
Cr. clearanceCr. clearance
22Kt/VKt/Vureaurea
6060D/P cr D/P cr 0.70.7D/P Ur D/P Ur 11
VVPD PD 12 L12 LNocturnal intermittent peritoneal dialysisNocturnal intermittent peritoneal dialysisNIPD
Cr. clearanceCr. clearance
22Kt/VKt/Vureaurea
5050D/P cr D/P cr 0.500.50D/P Ur D/P Ur 0.850.85VVPD PD 14 L14 LNightNightDayDay
Ratio of Creat. Clearance / Ratio of Creat. Clearance / Kt/VureaKt/Vurea
C J Stefanidis 2001
Continuous ambulatory peritoneal dialysisContinuous ambulatory peritoneal dialysisCAPD
Cr. clearanceCr. clearance
22Kt/VKt/Vureaurea
6060D/P cr D/P cr 0.70.7D/P Ur D/P Ur 11
VVPD PD 12 L12 LNocturnal intermittent peritoneal dialysisNocturnal intermittent peritoneal dialysisNIPD
Cr. clearanceCr. clearance
22Kt/VKt/Vureaurea
5050D/P cr D/P cr 0.500.50D/P Ur D/P Ur 0.850.85VVPD PD 14 L14 LNightNightDayDay
Ratio of Creat. Clearance / Ratio of Creat. Clearance / Kt/VureaKt/Vurea
Cr. clearanceCr. clearance
0.10.1Kt/VKt/Vureaurea
88RRFRRF
2.12.16868
2.12.15858
C J Stefanidis 2001
Automated peritoneal dialysisAutomated peritoneal dialysis
NightNight
Nocturnal intermittent peritoneal dialysisNocturnal intermittent peritoneal dialysis
DayDay
NIPD
CCPDContinuous cycling peritoneal dialysisContinuous cycling peritoneal dialysis
Continuous optimal peritonal dialysis Continuous optimal peritonal dialysis
COPD
C J Stefanidis 2001
Kt/VKt/Vureaurea
Weight: Weight: 70 70 kg kg S=1.7mS=1.7m22 ΤΒW =42 L ΤΒW =42 L
6060CreatinineCreatinine clearanceclearance
RatioRatio
22
3030
Expected Expected RatioRatio 3030
Weight: Weight: 3535 kg kg S=1.2mS=1.2m22 ΤΒW= 21 L ΤΒW= 21 L
7575
33
2525
2121
Weight: Weight: 1414 kg kg S=0.6mS=0.6m22 ΤΒW: 8.5 L ΤΒW: 8.5 L
8080
44
2020
1717
Creat clearanceCreat clearance
D/PD/Pureaurea x V x VPDPD / BW x0.6 / BW x0.6
D/P cr x VD/P cr x VPD x PD x 1.731.73mm22 /S /S
Kt/VKt/Vureaurea== ==
D/Pcr x D/Pcr x BWBW
D/PD/Pur ur X X SS1.04 x1.04 x
C J Stefanidis 2001
Ratio of Creat. Clearance / Ratio of Creat. Clearance / Kt/VureaKt/Vurea
Creat clearance Creat clearance
Kt/VureaKt/Vurea==
D/PcrD/Pcr x x BWBW
D/PD/Purur X X SS
hyperpermeable state hyperpermeable state
Residual renal function Residual renal function
RatioRatio RatioRatio
PD volume andPD volume andnumber of exchangesnumber of exchanges
PD volume andPD volume andnumber of exchangesnumber of exchanges
Residual renal function Residual renal function
C J Stefanidis 2001
The residual renal function is an important The residual renal function is an important component of the adequacy parameters.component of the adequacy parameters.
ConclusionsConclusions
Nephrotoxic medicines deteriorate RRFNephrotoxic medicines deteriorate RRF
Early initiation of PD might preserve RRFEarly initiation of PD might preserve RRF
C J Stefanidis 2001
The age differencesThe age differences ofof the ratio the ratio cr. clearance /cr. clearance /Kt/VureaKt/Vurea
have to do with the ratio: have to do with the ratio: ΒΒWt / SWt / S
The final outcome might relate The final outcome might relate
with the ratio: with the ratio: MDMDtt/P */P ** MD * MD timetime/Patient/Patient
BothBoth Kt/Vurea Kt/Vurea and and creatinine clearance creatinine clearance should should
be used for the assessment of dialysis adequacybe used for the assessment of dialysis adequacy
ConclusionsConclusions
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