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

stefanid@hol.grstefanid@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