adequacy in pediatric peritoneal dialysis - … · adequacy in pediatric peritoneal dialysis...

ADEQUACY IN PEDIATRIC PERITONEAL DIALYSIS

FRANCISCO CANO M.D.

DIVISION OF PEDIATRIC NEPHROLOGY

LUIS CALVO MACKENNA CHILDREN’S HOSPITAL

FACULTY OF MEDICINE, UNIVERSITY

OF CHILE

Supported by FONDECYT RESEARCH PROJECT 1110226

• Dialysis Dose and Mortality

• Dialysis Dose and Growth

• KtV recommendations

• Peritoneal Transport and Mortality

• Peritoneal Transport and Growth

• PET Recommendations

• Adequacy in terms of cardiovascular outcome

• Adequacy and Water transport

• PET and MiniPET

• Conclusions

Overview

Adequate dialysis:

OUTCOME

Adult patients: Mortality

Pediatrics: growth

• Adequacy

• Adaequat

• To make equivalent

• Barely satisfactory

• Sufficient to satisfy a

requirement or meet a need.

In search of the ideal dialysis prescription

ADEQUACY. THE CLASSICAL VIEW Kt/V and PET

DIALYSIS DOSE

KT/V

exchange volume

Urea nitrogen D/P

volume of distribution of urea (TBW)

Time (week)

PERITONEAL EQUILIBRIUM TEST

PET

CREATININE D/P

GLUCOSE D/D

ADEQUACY: Kt/V

DIALYSIS DOSE

KT/V

Exchange volume

Urea nitrogen D/P


Time (week)


PET

CREATININE D/P

GLUCOSE D/D

ADEQUACY

The recommended Kt/V

DIALYSIS DOSE

KT/V

THE BEST DIALYSIS DOSE

(outcome)

ADULTS:

MORTALITY

CANUSA (Churchill D, J Am Soc

Nephrol 1998)

ADEMEX (Paniagua R. J Am Soc

Nephrol, 2002)

HONG KONG TRIAL (Wai-Kei Lo, Kidney Int 2003)

Kt/V and Mortality

DIALYSIS DOSE

KT/V

Mortality

CANUSA: 1.5-2.3

ADEMEX: 1.45-1.74 vs 1.94-2.24

Hong Kong: 1.5-1.7;1.7-2;>2

DIALYSIS DOSE

KT/V

THE BEST DIALYSIS DOSE:

Mortality: A reanalysis of the CANUSA Study.

J Am Soc Nephrol 2001

For each 5 L/wk per 1.73 m2 increment in GFR, there was

a 12% decrease in the relative risk of death

Kt/V and Mortality

DIALYSIS DOSE

KT/V

THE BEST DIALYSIS DOSE:

mortality

Kt/V and Mortality

DIALYSIS DOSE

KT/V


(outcome)

PEDIATRICS: GROWTH

NAPRTCS 2011

Chadha V, Blowey D, Warady B

Perit Dial Int 2001;21:s179-84

IPPN 2014 KtV

Peritoneal KtV 2.6± 8.7

Residual KtV 0.8±1.4

Total KtV 3.4±8.7

KtV <1.8:

12.5%

ADEQUACY


NAPRTCS 2011

Annual Report

statistics

reality

Chadha V, Blowey D, Warady B

Perit Dial Int 2001;21:s179-84

Kt/V and Growth

Residual Kt/V

<0.05 0.86 2.8 0.95 1.70 Nitrogen Balance (gr/kg/day)

n.s. 0.42 1.38 0.39 1.31 PNA (gr/kg/day)

n.s. 0.44 1.36 0.36 1.34 PCR (gr/kg/day)

<0.05 1.44 3.5 0.65 2.7 DPI (gr/kg/day)

n.s. 1.55 3.51 1.61 3.55 Kt/V (total)

n.s. 0.88 1.91 0.61 1.66 Kt/V (peritoneal)

<0.05 1.06 1.27 1.67 1.88 Kt/V (residual)

p St dv mean St dv mean Variable

Growth positive , n:16 negative, n:12

Cano F., et al

Dialysis dose, nutrition and growth among pediatric patients on peritoneal dialysis

Rev Med Chile 2005 ;133(12):1455-64

KtV and Growth in PD Children

Kt/V and Growth

DIALYSIS DOSE

KT/V


Conclusions: In PD patients

1. total KtV>1.7 does not impact in mortality in

adults.

2. total KtV does not impact on Growth

3. Residual Renal Function is closely

related to mortality and growth.

ADEQUACY


ADEQUACY

Peritoneal Equilibrium Test

DIALYSIS DOSE

KT/V

Exchange volume

Urea nitrogen D/P


Time (week)


PET

CREATININE D/P

GLUCOSE D/D


Twardowski ZJ,. Perit Dial Bull 1987; 7:138–47.


Transport

Category

Solute

removal

Water

removal

Best choice

High fast poor APD

High av good good APD CAPD

Low av good good APD CAPD

Low slow good CAPD_HD

PET: the best transporter category


THE BEST PET CATEGORY

(outcome)

ADULTS:

MORTALITY

CANUSA

NECOSAD

EAPOS

CANUSA

Prospective,

2-y,

606 CAPD pts

NECOSAD

Prospective, 2-y,

118 CAPD pts

High transport status at baseline had no effect on

outcome

EAPOS

Prospective, 2-y,

177 anuric APD pts

Peritoneal membrane transport

status at baseline had no

effect on outcome

(Figure: UF> 750ml)

PET AND MORTALITY

Scott Brimble K., J Am Soc Nephrol 2006

0 21.9 45.7 77.3%

Schaefer et al.

J Am Soc Nephrol 1999;10:1786-92


Growth in children

Cano F, Sanchez L., Rebori A. et

al., Ped Nephrol 2010

PET: The classical test and the Short PET

(…and the Center effect)

International Pediatric PD Network

Ethnic variation in peritoneal transport

characteristics: Findings from the IPPN Registry

F. Cano1, A. Sander2, E. Serdaroglu3, H. Xu4, R.L. Munarriz5, K. Vondrak6, I.S. Ha7,

B.A. Warady8, F. Schaefer9

1Hospital Luis Calvo Mackenna, Santiago, Chile; 2Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany; 3Dr. Behcet Uz Children Research and Education Hospital, Izmir, Turkey; 4Fudan University Children's Hospital, Shanghai, China; 5Cayetano Heredia Hospital, Lima, Peru; 6University Hospital Motol, Prague, Czech Republic; 7National University Children's Hospital, Seoul, Korea; 8Children's Mercy Hospital, Kansas City, MO USA 9Heidelberg University Center for Pediatrics and Adolescent Medicine,

Heidelberg, Germany

PET CATEGORIES WHAT DO WE BELIEVE?

IPPN DATA 2013

(n: 745)

24,9

75,1

LOW AV (31%)

CAPD

APD

15,6

84,4

LOW (12%)

CAPD

APD

PET CATEGORIES WHAT DO WE BELIEVE?

IPPN DATA 2013

30,7

69,3

HIGH (22%)

CAPD

APD36,9

63,1

HIGH AV (34%)

CAPD

APD

PERITONEAL EQUILIBRIUM

TEST

THE BEST PET

CATEGORY

Conclusions: In PD patients

1. High Transport Category is associated to higher mortality

in CAPD and (less) in APD patients

2. The relationship between Transport Categories and Growth in children needs

reevaluation

3. Categories need to be defined by Center and

Ethnicity

4.Pediatric Nephrologists do not follow PET categories to

adjust PD (?)


Cardiovascular Disease is a leading cause of death in CKD.

(or…Adequacy and Volume Overload)

Mc Donald S et al., New England Journal of Medicine 2004: Long-Term Survival of Children with End-Stage Renal Disease

Shroff R et al.: Pediatric Nephrology 2007: Long-term outcome of chronic dialysis in children

Mitsnefes MM: Adv. Chronic Kidney Dis 2005: Cardiovascular disease in children with chronic kidney disease.

Mitsnefes MM: Pediatric Nephrology 2008: Cardiovascular complications of pediatric chronic kidney disease.

Monteucci M: J Am Soc Nephrol 2006: Left ventricular geometry in children with mild to moderate chronic renal insufficiency.

Cardiac disease

Cerebrovascular \

Infections/neoplasm

Other

Foley RN, et al. Am J Kidney Dis.

1998;32(suppl 3):S112-S119.

Effect of fluid and sodium removal on mortality in peritoneal

dialysis patients

Ates y cols., Kidney Int 2001

Peritoneal Water Transport

Concept of Sodium Seaving

Twardowski Z., Advances in Peritoneal Dialysis,1987

Adequacy and Volume Overload

The three-pore model

Rippe B, Kidney Int 1991; 40: 315–5

Ni J. et al. Kidney Int 2006,69:1518-25

Peritoneal Free Water Transport

Peritoneal Free Water Transport:

The MiniPET

• Dip NaD (meq/L)

Na out − Na in

• Dip D/PNa

D/PNa 60 − D/PNa 0

• Na removal

total Na60 – total Na1

[Volume Out (L) * Na Out(meq/L)] − [Volume In(L) * Na In (meq/L)]

• UFSP (mL)

[NaR(meq) • 1000]/ Nap

• FWT

Total UF (mL) − UFSP (mL)

Mini-peritoneal equilibration test: A simple and fast method

to assess free water and small solute transport across

the peritoneal membrane

La Milia V., Kidney Int 2005

The mini-PET in pediatric peritoneal dialysis: A useful tool

to predict volume overload?

Cano et al., Ped Nephrol 2013

r=0,58, p=0,02




Adequacy and Volume Overload

The three-pore model

Rippe B, Kidney Int 1991; 40: 315–5

PET

MINI

PET

CONCLUSIONS

The ideal PD prescription is one that allows a

normal cardiovascular status.

Fischbach M, Warady B.

Pediatr Nephrol 2009

1. RRF should be preserved, but not at the price of volume overload

2. High transporters should be carefully monitored. They are at

serious CV risk.

3. Water and Sodium Removal should be balanced through

dialysis dwell-time and glucose concentration.

4.Preserve peritoneal membrane as long as you could: Biocompatible Fluids

Patients should be evaluated through MiniPET+classical PET

Peritoneal Dialysis Adequacy

Conclusions

Muchas gracias

adequacy in pediatric peritoneal dialysis - … · adequacy in pediatric peritoneal dialysis...

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