adequacy and prescription of pediatric peritoneal dialysis

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  • 1. Adequacy and prescription of pediatric peritoneal dialysis Constantinos J. Stefanidis A.& P. Kyriakou Children's Hospital, Athens, Greece [email_address]

2. Dialysis adequacy Dialysis adequacy is a concept introduced in the late 1980s linkingoutcomes of hemodialysis patients toadequacy targets .

  • There is a strong correlation of the the adequacy parameters and:
        • nutritional intake
    • bone disease
    • anemia

3. Optimal and adequate dose of PD Adequate dose:the amount of PD below which there is an increase in morbidity and mortality Optimal dose: the amount of PD yielding clinical results which cannot further improve 4. CANUSA study 680 continuous peritoneal dialysis patients 5% decrease in patient survivalwith every 0.1 decrease in total weekly Kt/Vureafor Kt/Vurea between 1.5 - 2.3Churchill 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 targetshave been defined in adults because patientmortality and morbidityis much easier to define There are few data to correlate the clinical outcomes with delivered dialysis dose inchildren 6. Appropriate organizationof PN Center Guidelines Evaluation ofthe clinical outcome Modify strategies Improvement of adequacy on PPD 7. Paediatric Nephrology Centers HD CRI PD Paediatricians (early referral) Paediatric surgeons (dialysis access) Tx Tx surgeons 8. Multi-disciplinary team

  • StructureDoctors, nurses, dietitians, social workers,psychologists, play therapists, teachers.
  • GoalTo deliver to children the care required for
  • their optimal quality of life.
  • Team meetingsgive the entire team opportunity for collaborative decision making.
  • Networkingwith other PN centers, multicenter
  • studies and global cooperation

9. Team working improves patient care and enhances the quality of the working life. 10. Appropriate organizationof PN Center Guidelines Evaluation ofthe clinical outcome Modify strategies Improvement of adequacy on PPD 11. Parameters of the efficiency of PD Nr of exchanges per day (Nr) Peritoneal permeability Fill volume (Vf ) Gl H 2 O BUN Cr 12. Parameters of the efficiency of PD Nr of exchanges per day (Nr) Fill volume (Vf ) Gl H 2 O BUN Cr Peritoneal permeability 13. Parameters of the efficiency of PD (scaled for BSA) Ultrafilration volume (V UF ) Drained volume (V PD) = (V f x Nr )+ Vu F 2Lx5 +2L (D/P Creatinine) Nr of exchanges per day (Nr) Fill volume(V f) Peritoneal permeability H 2 O BUN Cr Gl 14. Peritoneal equilibration test Time (hour) D/P Creatinine 0.88 0.37 0.77 0.64 0.51 High Low Highavg. Lowavg. 0.8 0.25 0.6 0.5 0.35 95 children 1.1 L/1.73 m 2 PD 2.5%.Warady BAJ Am Soc Nephrol 1996 15. Creatinine adequacy parameters Muscle mass catabolism = ( 0.7 x120dl x12 mg/dl) / 70 kg =14.4mg/kg/day = D/P creat.x V PD/ S Creatinine clearance Wt:70kg 5 exchanges of 2L UF 2L PD Creatinine = D/P creat.x V PDxS cr /Wt Creatinine x 12 L x7x1.73 m 2/1.7m 20.7 BW mg/dl 12L/1.73m 2 /week 60 S. creatinine 16. Creatinine adequacy parameters Muscle mass catabolism S. creatinine = ( 0.6 x120dl x14 mg/dl) / 70 kg =14.4mg/kg/day mg/dl x 12 L x7x1.73 m 2/1.7m 2= D/P creat.x V PD/ S Creatinine clearance 0.6 BW 14Wt:70kg 5 exchanges of 2L UF 2L PD Creatinine= D/P creat.x V PDxS cr /`Wt Creatinine L/1.73m 2 /week 50 17. Creatinine adequacy parameters Muscle mass catabolism S. creatinine mg/dl x 12 L x7x1.73 m 2/1.7m 2L PD /1.73m 2 /week = D/P creat.x V PD/ S Creatinine clearance 0.6 BW 12Wt:70kg 5 exchanges of 2L UF 2L 50 PD Creatinine + Urine Creatinine LUr /1.73m 2 /week 10 `` Creatinine 18. Urine volume (ml) before, 1 and 2 years after dialysis J Feber et al.Ped Nephrol 1994. 19. Protein catabolism UNA = 1 x (10+2) x 7 L / 42= BW= 0.6 x Wt = 42 L 2 = D/P ureax V PDxBUN / Wt PNA =6.25 x UNA (g/kg) + 0.5Wt:70kg 5 exchanges of 2L UF 2L Urea adequacy parameters Kt/Vurea =D/P ureax V PD / BW mg/dl 70 1.2 = BW BUN BUN 20. Protein catabolism BUN mg/dl BW 70 UNA Kt/Vurea =D/P ureax V PD/0.6 x Wt = 1 x (10+2) x 7 L / 42= 2 =D/P ureax V PD xBUN /Wt PNA =6.25 x UNA (g/kg) + 0.51.2 = Wt:70kg 5 exchanges of 2L UF 2L Urea adequacy parameters 21. Protein catabolism BUN mg/dl BW 70 Kt/Vurea 2 PNA PNA - 0.5 Wt:70kg 5 exchanges of 2L UF 2L Urea adequacy parameters BUN = 187 x = 1.2 = 22. 1.7g/kg/day 2g/kg/day 4 3.2 2 BUN mg/dl 70 1.2g/kg/day PNA = 187 (PNA - 0.5)/BUN Kt/Vurea Weight:70 kgS=1.7m 2W =42 L Weight:35 kgS=1.2m 2W= 21 L Weight:14 kgS=0.6m 2W: 8.5 L 23. 1.2g/kg/day BUN mg/dl 90 PNA 1.7g/kg/day 2g/kg/day = 187 (PNA - 0.5)/BUN 1.5 3.1 2.4 Kt/Vurea Weight:70 kgS=1.7m 2W =42 L Weight:35 kgS=1.2m 2W= 21 L Weight:14 kgS=0.6m 2W: 8.5 L Increase of 23% Decrease of 23% 24. 7mg/dl 5mg/dl Creatinine of urine and PD 15mg /kg/day 76 85 Weight:70 kgS=1.7m 2W =42 L Weight:35 kgS=1.2m 2W= 21 L Weight:14 kgS=0.6m 2W: 8.5 L Serum creatinine 12mg/dl Creatinine clearance( L/week /1.73 m 2 ) 61 25. Serum creatinine 12mg/dl 7mg/dl 6mg/dl Creatinine of urine and PD 15mg /kg/day Creatinine clearance( L/week /1.73 m 2 ) 61 76 71 Weight:70 kgS=1.7m 2W =42 L Weight:35 kgS=1.2m 2W= 21 L Weight:14 kgS=0.6m 2W: 8.5 L 5mg/dl 85 Increase of 16.6 % 26. Creatinine and urea adequacy parameters PNA Protein intake Muscle mass catabolism Creatinine of urine and PD Creatinine clearance = 60L/1.73m 2 /week = 2 D/P creatx V PD S = K t /Vurea D/P ureax V PD BW = 27. Ratio of Creat. Clearance /Kt/Vurea = Creat clearanceKt/Vurea D/PcrxBW D/P ur XS 28. D/P of urea and creatinine 1.0 0.5 124hours 0.9 D/P Urea 0.75 0.65 Creatinine 0.5 29. Ratio of Creat. Clearance /Kt/Vurea Continuous ambulatory peritoneal dialysis CAPD Night Day Cr. clearance 2 Kt/V urea 60 D/P cr0.7 D/P Ur1 V PD12 L Nocturnal intermittent peritoneal dialysis NIPD Cr. clearance 2 Kt/V urea 50 D/P cr0.50 D/P Ur0.85 V PD14 L 30. Ratio of Creat. Clearance /Kt/Vurea Continuous ambulatory peritoneal dialysis CAPD Night Day Cr. clearance 2 Kt/V urea 60 D/P cr0.7 D/P Ur1 V PD12 L Nocturnal intermittent peritoneal dialysis NIPD Cr. clearance 2 Kt/V urea 50 D/P cr0.50 D/P Ur0.85 V PD14 L Cr. clearance 0.1 Kt/V urea 8 RRF 2.1 68 2.1 58 31. Automated peritoneal dialysis Night Nocturnal intermittent peritoneal dialysis Day NIPD CCPD Continuous cycling peritoneal dialysis Continuous optimal peritonal dialysisCOPD 32. Kt/V urea Weight:70 kgS=1.7m 2W =42 L 60 Creatinine clearance Ratio 2 30 ExpectedRatio 30 Weight:35 kgS=1.2m 2W= 21 L 75 3 25 21 Weight:14 kgS=0.6m 2W: 8.5 L 80 4 20 17 Creat clearance D/P ureax V PD/ BW x0.6D/P cr x V PD x1.73 m 2/S Kt/V urea = = D/Pcr xBW D/P urXS 1.04 x 33. Ratio of Creat. Clearance /Kt/Vurea = hyperpermeable stateResidual renal functionCreat clearanceKt/Vurea D/PcrxBW D/P ur XS Ratio Ratio PD volume and number of exchanges PD volume and number of exchanges Residual renal function 34. The residual renal function is an important component of the adequacy parameters. Conclusions Nephrotoxic medicines deteriorate RRF Early initiation of PD might preserve RRF 35. Conclusions The age differences ofthe ratiocr. clearance / Kt/Vurea have to do with the ratio: Wt / S The final outcome might relatewith the ratio:MD t /P * * MDtime /Patient BothKt/Vureaandcreatinine clearanceshould be used for the assessment of dialysis adequacy

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