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  • CLINICAL PRACTICE GUIDELINES

    Peritoneal Dialysis

    UK Renal Association

    5th Edition, 2009-2012

    Final Draft Version (09.05.10)

    Dr Graham Woodrow & Prof Simon Davies

    Posted at www.renal.org/guidelines

    Please check for updates

    Please send feedback for the next edition to Dr Graham Woodrow at Graham.Woodrow@leedsth.nhs.uk & Prof Simon Davies at simondavies1@compuserve.com

  • Contents Introduction

    Summary of clinical practice guidelines for Peritoneal Dialysis

    1. Equipment and Resources (Guidelines 1.1-1.5) 2. Preparation for Peritoneal Dialysis (Guidelines 2.1-2.4) 3. Solute Clearance (Guidelines 3.1-3.2) 4. Ultrafiltration and Fluid Management (Guidelines 4.1-4.5) 5. Infectious Complications (Guidelines 5.1-5.2) 6. Metabolic Factors (Guidelines 6.1-6.4) 7. Encapsulating peritoneal sclerosis (Guidelines 7.1-7.2)

    Summary of audit measures for Peritoneal Dialysis

    (Audit measures 1-23)

    Rationale for clinical practice guidelines for Peritoneal Dialysis

    1. Equipment and Resources (Guidelines 1.1-1.5) 2. Preparation for Peritoneal Dialysis (Guidelines 2.1-2.4) 3. Solute Clearance (Guidelines 3.1-3.2) 4. Ultrafiltration and Fluid Management (Guidelines 4.1-4.5) 5. Infectious Complications (Guidelines 5.1-5.2) 6. Metabolic Factors (Guidelines 6.1-6.4) 7. Encapsulating peritoneal sclerosis (Guidelines 7.1-7.2)

    Acknowledgements

    Appendix

  • Introduction

    Peritoneal dialysis (PD) is long established as a major option for renal replacement

    therapy in patients with end-stage renal disease. It is an important part of an

    integrated service for renal replacement therapy that is frequently selected by patients

    as their preferred initial mode of therapy and is a therapeutic option for patients

    wishing or needing to swap from HD and after renal transplant failure.

    This guideline is an update of the PD module published on-line on the Renal

    Association website, www.renal.org in 2007. The English language literature was

    searched to identify relevant articles on PD published between 2006 and 2010

    including:

    Medline search using peritoneal dialysis combined with relevant terms

    Cochrane Database of Systematic Reviews

    Review of other national / international PD clinical guidelines

    Identification of further articles quoted in identified papers

    The recommendations in this version of the Renal Association Clinical Practice

    Guidelines for Peritoneal Dialysis guideline have been assessed according to the

    modified GRADE system. The system was produced by a group of guideline

    developers and experts in evidence-based medicine. It explicitly describes both the

    strength of the recommendations and the quality of the underlying evidence, with the

    aim of maximising applicability to standard clinical practice (1-6). The system grades

    level of expert recommendation as strong (Grade 1) or weak (Grade 2) according

    to balance of benefits, risk, burden and cost. The quality or level of evidence is

    assessed as high (Grade A), moderate (Grade B), low (Grade C) or very low

    (D) depending on factors such as study design, directness of evidence and consistency

    of results. The modified GRADE system has been adopted by the Renal Association

    Clinical Practice Guidelines Committee and is widely used by a large number of

    clinical guideline organisations including NICE, SIGN, KDIGO, ERBP, KDOQI,

    BMJ and WHO (4,7,8). The recommendations in this guideline have been harmonised

    with other PD guidelines whenever possible and the recommendations to follow

    international PD guidelines have not been graded.

  • Grade of Recommendation

    Clarity of risk/benefit Quality of supporting evidence Implications

    1A Strong recommendation. High quality evidence.

    Benefits clearly outweigh risk and burdens, or vice versa

    Consistent evidence from well performed randomized, controlled trials or overwhelming evidence of some other form. Further research is unlikely to change our confidence in the estimate of benefit and risk.

    Strong recommendations, can apply to most patients in most circumstances without reservation. Clinicians should follow a strong recommendation unless there is a clear rationale for an alternative approach.

    1B Strong recommendation. Moderate quality evidence.

    Benefits clearly outweigh risk and burdens, or vice versa

    Evidence from randomized, controlled trials with important limitations (inconsistent results, methods flaws, indirect or imprecise), or very strong evidence of some other research design. Further research may impact on our confidence in the estimate of benefit and risk.

    Strong recommendation and applies to most patients. Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.

    1C Strong recommendation. Low quality evidence.

    Benefits appear to outweigh risk and burdens, or vice versa

    Evidence from observational studies, unsystematic clinical experience, or from randomized, controlled trials with serious flaws. Any estimate of effect is uncertain.

    Strong recommendation, and applies to most patients. Some of the evidence base supporting the recommendation is, however, of low quality.

    1D Strong recommendation Very low quality evidence

    Benefits appear to outweigh risk and burdens, or vice versa

    Evidence limited to case studies Strong recommendation based mainly on case studies and expert judgement

    2A Weak recommendation. High quality evidence.

    Benefits closely balanced with risks and burdens

    Consistent evidence from well performed randomized, controlled trials or overwhelming evidence of some other form. Further research is unlikely to change our confidence in the estimate of benefit and risk.

    Weak recommendation, best action may differ depending on circumstances or patients or societal values

    2B Weak recommendation. Moderate quality evidence.

    Benefits closely balanced with risks and burdens, some uncertainly in the estimates of benefits, risks and burdens

    Evidence from randomized, controlled trials with important limitations (inconsistent results, methods flaws, indirect or imprecise), or strong evidence of some other research design. Further research may change the estimate of benefit and risk.

    Weak recommendation, alternative approaches likely to be better for some patients under some circumstances

    2C Weak recommendation. Low quality evidence.

    Uncertainty in the estimates of benefits, risks, and burdens; benefits may be closely balanced with risks and burdens

    Evidence from observational studies, unsystematic clinical experience, or from randomized, controlled trials with serious flaws. Any estimate of effect is uncertain.

    Very weak recommendation; other alternatives may be equally reasonable

    2D Weak recommendation Very low quality evidence

    Uncertainty in the estimates of benefits, risks, and burdens; benefits may be closely balanced with risks and burdens

    Evidence limited to case studies Weak recommendation based mainly on case studies and expert judgement

  • References

    1. Atkins D, Best D, Briss PA et al. Grading quality of evidence and strength of recommendations. BMJ 2004; 328:1490

    2. Guyatt G, Gutterman D, Baumann MH et al. Grading strength of recommendations and quality of evidence in clinical guidelines. Chest 2006; 129: 174-181

    3. Guyatt GH, Oxman AD, Vist GE et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008; 336:924-926

    4. Guyatt GH, Oxman AD, Kunz R et al. GRADE: going from evidence to recommendations. BMJ 2008; 336: 1049-1051

    5. Guyatt GH, Oxman AD, Kunz R et al. GRADE: Incorporating considerations of resources use into grading recommendations. BMJ 2008; 336:1170-1173

    6. Jaeschke R, Guyatt GH, Dellinger P et al. Use of GRADE grid to reach decisions on clinical practice guidelines when consensus is elusive. BMJ 2008; 337:327-330

    7. Uhlig K, MacLeod A, Craig J et al. Grading evidence and recommendations for clinical practice guidelines in nephrology. A position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int 2006; 70:2058-2065

    8. Kidney Disease: Improving Global Outcomes. KDIGO clinical practice guidelines for the prevention, diagnosis, evaluation and treatment of Hepatitis C in chronic kidney disease. Kidney Int 2008; 73 (S109): S1-S99

    Summary of Clinical Practice Guidelines for Peritoneal Dialysis 1. Peritoneal Dialysis (PD) (Guidelines PD 1.1 1.5) Guideline 1.1 PD : Equipment and Resources We recommend that Peritoneal Dialysis should be delivered in the context of a comprehensive and integrated service for renal replacement therapies, including haemodialysis (including temporary backup facilities), transplantation and conservative care. Both continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD), in all its forms should be available. Dedicated PD nursing staff (1 W.T.E. per 20 patients) should be part of the multidisciplinary team (1C). We recommend that each unit has a designated lead clinician for PD (1C). Assisted PD should be available to patients wishing to have home dialysis treatment but unable to perform self-care PD. (1C)

    Guideline 1.2 PD : Equipment and Resources We recommend that all equipment used in the delivery and monitoring of therapies should comply with the relevant standards for medical electrical equipment [BS-EN 6

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