C J Stefanidis . 2001

Prescription of pediatric peritoneal Prescription of pediatric peritoneal dialysisdialysis

Constantinos J. StefanidisConstantinos J. Stefanidis

stefanid@hol.grstefanid@hol.gr

““A.& P. Kyriakou” Children's Hospital, Athens, GreeceA.& P. Kyriakou” Children's Hospital, Athens, Greece

C J Stefanidis 2001

EPPWG adequacy guidelinesEPPWG adequacy guidelines

The European Paediatric Peritoneal Working The European Paediatric Peritoneal Working Group was established in 1999 by paediatric Group was established in 1999 by paediatric nephrologists experts in peritoneal dialysis. nephrologists experts in peritoneal dialysis.

The guidelines on adequacy were initiated by The guidelines on adequacy were initiated by two members of the group. Then they were two members of the group. Then they were discussed at meetings of the group and by e-discussed at meetings of the group and by e-mail to develop consensus of opinion based mail to develop consensus of opinion based upon clinical experience and reported studies. upon clinical experience and reported studies.

C J Stefanidis 2001

EPPWG adequacy guidelinesEPPWG adequacy guidelines

M FischbachM Fischbach, Centre Hospitalier Regional, Strasbourg, France, Centre Hospitalier Regional, Strasbourg, France

C StefanidisC Stefanidis, A & K Kyriakou Children's Hospital, Athens, Greece, A & K Kyriakou Children's Hospital, Athens, Greece

A R WatsonA R Watson,Children & Young People's Kidney Unit Nottingham UK,Children & Young People's Kidney Unit Nottingham UK

C SchroderC Schroder, Wilhelmina Kinderziekenhuis, Utrecht, The Netherlands, Wilhelmina Kinderziekenhuis, Utrecht, The Netherlands

A ZurowskaA Zurowska, Medical University of Gdansk, Gdansk, Poland, Medical University of Gdansk, Gdansk, Poland

V StrazdinsV Strazdins, University Hospital, Riga, Latvia, University Hospital, Riga, Latvia

K RonnholmK Ronnholm, University of Helsinki, Helsinki, Finland, University of Helsinki, Helsinki, Finland

E SimkovaE Simkova, University Hospital Motol, Prague, Czech Republic, University Hospital Motol, Prague, Czech Republic

A EdefontiA Edefonti, Clinica Pediatrica C&D de Marchi, Un. of Milan, Italy, Clinica Pediatrica C&D de Marchi, Un. of Milan, Italy

C J Stefanidis 2001

EPPWG adequacy guidelinesEPPWG adequacy guidelines

Guidelines by an Ad Hoc European Committee Guidelines by an Ad Hoc European Committee on Adequacy and the Pediatric on Adequacy and the Pediatric Peritoneal Dialysis Prescription Peritoneal Dialysis Prescription

Michel Fischbach, Constantinos J Stefanidis, Alan R WatsonMichel Fischbach, Constantinos J Stefanidis, Alan R Watsonfor the European Pediatric Peritoneal Dialysis Working Group†for the European Pediatric Peritoneal Dialysis Working Group†

Nephrol Dial Transplant (in press)Nephrol Dial Transplant (in press)

C J Stefanidis 2001

In In 1997 1997 114 evidence-based clinical practice 114 evidence-based clinical practice guidelines were developedguidelines were developed.. Am J Kidney Dis 1997Am J Kidney Dis 1997

Νational Κidney Νational Κidney FoundationFoundation

D O Q ID O Q IDialysis Outcomes Quality InitiativeDialysis Outcomes Quality Initiative

In In 1995 1995 206 / >11 000 articles were selected206 / >11 000 articles were selectedby 70 professionals for the final publication.by 70 professionals for the final publication.

In 2001 2001 DOQI becomes K/DOQI and is updated. Am J Kidney Dis 2001Am J Kidney Dis 2001

C J Stefanidis 2001

V. Adequate Dose of Peritoneal DialysisV. Adequate Dose of Peritoneal Dialysis

Guideline 15 and 16Guideline 15 and 16 Recomended weekly DosesRecomended weekly Doses

CAPD Kt/Vurea > CAPD Kt/Vurea > 2.02.0 and cr. clearance > and cr. clearance >6060 L/1.73 m L/1.73 m22

CCPD Kt/Vurea > CCPD Kt/Vurea > 2.12.1 and cr. clearance > and cr. clearance >6363 L/1.73 mL/1.73 m22

NIPD NIPD Kt/Vurea > Kt/Vurea > 2.22.2 and cr. clearance > and cr. clearance > 6666 L/1.73 mL/1.73 m22

Adequate Dose of Peritoneal DialysisAdequate Dose of Peritoneal Dialysis

C J Stefanidis 2001

< 3 years of age 2.5 g/kg/day< 3 years of age 2.5 g/kg/day

Recommended protein intake in children with CRIRecommended protein intake in children with CRI

>12 years of age 1.5 g/kg/day>12 years of age 1.5 g/kg/day

3 - 12 years of age 2.0 g/kg/day3 - 12 years of age 2.0 g/kg/day

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

Scaling of the dialysate fill volume Scaling of the dialysate fill volume

Area of the peritoneal membrane / WtArea of the peritoneal membrane / Wt

Infants: 533 mInfants: 533 m22/kg/kg

Adults: 284 mAdults: 284 m22/kg/kg

Scaling of the dialysate fill volume by BSAScaling of the dialysate fill volume by BSA

Area of the per. membrane correlates with BSAArea of the per. membrane correlates with BSA

C J Stefanidis 2001

Initial prescription of CAPDInitial prescription of CAPD

Initial prescription

3-53-5 exchanges per day according to RRF exchanges per day according to RRF

Fill volume per exchange: Fill volume per exchange: 600-800ml/m²600-800ml/m² day day

800-1000ml/m²800-1000ml/m² overnight overnight

Disconnectable system with double bag are preferredDisconnectable system with double bag are preferred

Glucose solution with lowest concentration (1.36%)Glucose solution with lowest concentration (1.36%)

C J Stefanidis 2001

High peritoneal fill volume a risk factor ?High peritoneal fill volume a risk factor ?

• pain pain

High peritoneal fill volume might cause:High peritoneal fill volume might cause:

• reduce dialysis efficiencyreduce dialysis efficiency

• hernia formationhernia formation

• gastro-oesophageal reflux with anorexia gastro-oesophageal reflux with anorexia

• dyspnoea dyspnoea • hydrothorax hydrothorax

• loss of UFR by enhanced lymphatic drainageloss of UFR by enhanced lymphatic drainage

C J Stefanidis 2001

Low peritoneal fill volume a risk factor ?Low peritoneal fill volume a risk factor ?

Low peritoneal fill volume might cause:Low peritoneal fill volume might cause:

• hyperpermeable state hyperpermeable state

• inadequate dialysis inadequate dialysis

ultrafiltration failureultrafiltration failure

growth failuregrowth failure

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 statehyperpermeable state

RatioRatio

Residual renal function Residual renal function

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

Fill volume per exchange increase : Fill volume per exchange increase : Gradual increase assessing intraperitoneal pressure Gradual increase assessing intraperitoneal pressure up to: up to:

1200ml/m²1200ml/m² for the day exchanges for the day exchanges

1400ml/m²1400ml/m² for the night exchange for the night exchange

If there is inadequate filtrationIf there is inadequate filtration

Adapted prescription of CAPDAdapted prescription of CAPD

• Icodextrine dialysis solutionsIcodextrine dialysis solutions

• Increase number of exchangesIncrease number of exchanges

• Increase glucose concentrationIncrease glucose concentration

C J Stefanidis 2001

Solutions containing lowerSolutions containing lower amounts of calcium mayamounts of calcium may be required when hypercalcaemia is notedbe required when hypercalcaemia is noted

Nutritional requirements are met by:Nutritional requirements are met by:• oral supplements oral supplements • gastrostomy/nasogastric feedinggastrostomy/nasogastric feeding• amino acid dialysis solutionsamino acid dialysis solutions

Sodium supplements (orally given) Sodium supplements (orally given) are often needed in young infants.are often needed in young infants.

Adapted prescription of CAPDAdapted prescription of CAPD

C J Stefanidis 2001

Initial prescription of Initial prescription of of of NIPDNIPD

Duration of a session: Duration of a session: 9 to 12 hours9 to 12 hoursFill volume per exchange: Fill volume per exchange: 800-1000ml/m²800-1000ml/m² according to age and toleranceaccording to age and tolerance.

Number of exchanges: Number of exchanges: 5-10 /session5-10 /session according to age, UFR and RRFaccording to age, UFR and RRF

GlucoseGlucose solution with lowest concentration ( solution with lowest concentration (1.361.36%)%)

C J Stefanidis 2001

Adapted prescription of Adapted prescription of NIPDNIPD

Gradual increase assessing intraperitonal pressure Gradual increase assessing intraperitonal pressure up to: 1400ml/m² for the night exchangeup to: 1400ml/m² for the night exchange

Total max. amount of PD fluid per session: 8 L /m²Total max. amount of PD fluid per session: 8 L /m²

Nocturnal intermittent peritoneal dialysis

Icodextrin solution:Icodextrin solution: limits dialysate reabsorption limits dialysate reabsorption over day and therefore increase dialysis efficiencyover day and therefore increase dialysis efficiency

NightNight DayDay

Aminoacid solutionAminoacid solution if nutrition assistance is wished if nutrition assistance is wished.

C J Stefanidis 2001

Adapted prescription of Adapted prescription of CCPDCCPD

If NIPD not fully effective, CCPD should be consideredIf NIPD not fully effective, CCPD should be considered

CCPD

Continuous cycling peritoneal dialysisContinuous cycling peritoneal dialysis

Nocturnal intermittent peritoneal dialysisNocturnal intermittent peritoneal dialysis

NIPD

NightNight DayDay

C J Stefanidis 2001

Adapted prescription Adapted prescription COPDCOPD

If CCPD not fully effective, COPD should be consideredIf CCPD not fully effective, COPD should be considered

CCPD

Continuous cycling peritoneal dialysisContinuous cycling peritoneal dialysis

NightNight DayDay

Continuous optimal peritonal dialysis Continuous optimal peritonal dialysis

COPD

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

Peritoneal equilibration test (PET)Peritoneal equilibration test (PET)

ProteinProteinlossloss

GlucoseGlucoseabsorptionabsorption

s. Albumins. Albumin

Creatinine clearanceCreatinine clearance

D/P

cre

atin

ine

D/P

cre

atin

ine

1.0

0.5

0.850.85

0.500.50

2 4 hours

High transporters

Low transporters

0.65

TGTG

UFUF

C J Stefanidis 2001

Peritoneal equilibration testPeritoneal equilibration test

0.370.37

0.640.64

0.510.51

0.880.88

0.770.77HighHigh

LowLow

High avg.High avg.

Low avg.Low avg.

D/PD/P Creatinine 4 hrsCreatinine 4 hrs

Concentration of PD glucoseConcentration of PD glucose

Icodextrin Icodextrin

Number of exchangesNumber of exchanges

C J Stefanidis 2001

Peritoneal equilibration testPeritoneal equilibration test

0.370.37

0.640.64

0.510.51

0.880.88

0.770.77HighHigh

LowLow

High avg.High avg.

Low avg.Low avg.

D/PD/P Creatinine 4 hrsCreatinine 4 hrs

Concentration of PD glucoseConcentration of PD glucose

Volume of PD fluidVolume of PD fluid

Icodextrin Icodextrin Number of exchangesNumber of exchanges

Nr of exchangesNr of exchanges

APDAPD

C J Stefanidis 2001

Appropriate organization Appropriate organization of PN Centerof PN Center

GuidelinesGuidelines

Evaluation of the clinical outcomeModify strategiesModify strategies

Improvement of adequacy on PPD

C J Stefanidis 2001

Clinical outcome goals of K/DOQI

PD Patient Survival PD Patient Survival is dependent upon uncontrollable is dependent upon uncontrollable and controllable (inadequste dialysis) variablesand controllable (inadequste dialysis) variables

PD Technical SurvivalPD Technical Survival

Measurement of HospitalizationsMeasurement of Hospitalizations1.8 times/year (CANUSA)1.8 times/year (CANUSA)

C J Stefanidis 2001

Measurement of Albumin ConcentrationMeasurement of Albumin Concentration

Measurement of Normalized PNAMeasurement of Normalized PNA

Measurement of HemoglobinMeasurement of Hemoglobin Should be 11-13 g/dl in 75% of patients.Should be 11-13 g/dl in 75% of patients.

Am J Kidn Dis S94-S99 2001Am J Kidn Dis S94-S99 2001

Clinical outcome goals of K/DOQI

Measurement of Patient-Based Assessment of Measurement of Patient-Based Assessment of quality of lifequality of life

Measurement of Growth, Developmental Progress Measurement of Growth, Developmental Progress and School Attendenceand School Attendence

C J Stefanidis 2001

ConclusionConclusion

Individual prescription for Individual prescription for each patient on CAPDeach patient on CAPD

is recommended in terms of is recommended in terms of tolerance and effectivenesstolerance and effectiveness