therapy modality: automated peritoneal dialysis ( apd )

31
Therapy Modality: Automated Peritoneal Dialysis (APD) Renal Division Baxter Healthcare

Upload: patsy

Post on 18-Mar-2016

67 views

Category:

Documents


3 download

DESCRIPTION

Therapy Modality: Automated Peritoneal Dialysis ( APD ). Renal Division Baxter Healthcare. APD – prescription basics. Automated (cycler) therapy Flexible prescription volumes Recommended – ( European APD Advanced Club ) 9 hour total therapy time (CCPD, NIPD) 12-14L. total therapy volume - PowerPoint PPT Presentation

TRANSCRIPT

Page 1: Therapy Modality: Automated Peritoneal Dialysis ( APD )

Therapy Modality:Automated Peritoneal

Dialysis (APD)

Renal DivisionBaxter Healthcare

Page 2: Therapy Modality: Automated Peritoneal Dialysis ( APD )

2APD

APD – prescription basics

• Automated (cycler) therapy• Flexible prescription volumes

Recommended – (European APD Advanced Club)• 9 hour total therapy time (CCPD, NIPD)• 12-14L. total therapy volume• ‘Wet’ days, i.e. long day dwell of 12-15 hr (Extraneal) • 4-8 nightly cycles, with (optional) 1-2 additional day

exchanges /cycles• Daily therapy, 7 days week• 30 minute – 120 minute dwell times each cycle

(depending on PET result)

Page 3: Therapy Modality: Automated Peritoneal Dialysis ( APD )

3APD

Types of PD

CAPD APD CCPD NIPD OCPD IPD

Continuous Ambulatory PD Ambulatory PD Continuous Cycling PD Nightly Intermittent PD Optimised Continuous PD Intermittent PD

Page 4: Therapy Modality: Automated Peritoneal Dialysis ( APD )

4APD

APD benefitsAPD benefits

1. Optimum dialysis for high transporters, large body surface area, and minimal residual renal function

2. Offers potential for better clearances than in CAPD3. Volumetric control of fill, drain and therapy volume

delivery4. Supine positions at night permit larger fill volumes, a

major determinant of treatment adequacy5. Short dwells may increase ultrafiltration & clearance

Page 5: Therapy Modality: Automated Peritoneal Dialysis ( APD )

5APD

APD benefitsAPD benefits

7. Reduced risk of intra-peritoneal pressure complications:hernias, leak, back pain, reduced appetite

8. Reported lower incidence of peritonitis than CAPD9. Treatment of choice for children – avoids school

interruptions and encourages peer integration (“normality”)

10. Daytime freedom and comfort

Page 6: Therapy Modality: Automated Peritoneal Dialysis ( APD )

6APD

APD benefitsAPD benefits

11. Employment and school uninterrupted

12. Improved patient compliance

13. Increased patient comfort

14. Possible to monitor patient compliance at home

Page 7: Therapy Modality: Automated Peritoneal Dialysis ( APD )

7APD

‘A prescription that is compatible with the patient’s preferences and lifestyle is

likely to reduce the risk of patient « burnout » and noncompliance’

Clinical Practice Guidelines of the Canadian Society of Nephrology for treatments of Patients with CRF JASN 10: S287-S321, 1999

Page 8: Therapy Modality: Automated Peritoneal Dialysis ( APD )

8APD

APD regimens

CCPD “wet day” orlong day dwell

shortday dwell

shortday dwell

Night dwells

Night dwells

OCPD(Optimized Continuous Peritoneal Dialysis)

(long) day dwell

(long) day dwell

day dwell day dwell

(short)day dwell

(short)day dwell

Night dwells

Page 9: Therapy Modality: Automated Peritoneal Dialysis ( APD )

9APD

APD APD Nightly Intermittent PD (NIPD)Nightly Intermittent PD (NIPD)

• APD performed nightly only, with complete fill and drain of the peritoneal cavity

• Most patients cannot be maintained on NIPD alone without diurnal additions

Limitations:1. Not efficient in anuric patients2. Inadequate in large BSA patients (>2m2)3. Inadequate in low – low average Transporters4. High cost may be prohibitive

Page 10: Therapy Modality: Automated Peritoneal Dialysis ( APD )

10APD

APD modalitiesAPD modalities

• Dialysis fill volume is only partly drained, leaving a ‘reserve’ volume in contact with peritoneum

• Tidal fill volume brings fresh fluid to mix with the reserve volume each cycle

• Tidal therapy increases dialysate flow and reduces drain and fill times (therapy rationale)

• Combined with larger fill volumes, it will raise clearances in ‘High’ to ‘High Average’ transporters

• Only option for anephric patient clearance• Less ‘drain-pain’ an added advantage

TIDAL PD

Page 11: Therapy Modality: Automated Peritoneal Dialysis ( APD )

11APD

APD modalitiesAPD modalities

• Nocturnal therapy, with day time long dwell (only realistic if Icodextrin containing solution used for day dwell)

• 5-8 exchanges in relatively short dwell periods, maximising U/F and clearances

• Therapy most used in practice

CCPD – Continuous Cyclic PD

Page 12: Therapy Modality: Automated Peritoneal Dialysis ( APD )

12APD

APD modalitiesAPD modalities

• PD prescribed mainly 2-3 times per week for 12-20 hours each session

• Large volumes (20-40 litres) are cycled each session, short dwells, fill volumes 1.5-3.0 litres

• IPD fails to deliver sufficient quantity dialysis if BSA, RRF

• Mostly used in elderly; acute patients; new catheter conditioning – N.B. no longer a preferred modality for majority of patients

• Only adequate for high transport patients

• Reduced protein losses, glucose absorption and fluid retention

IPD - Intermittent PD

Page 13: Therapy Modality: Automated Peritoneal Dialysis ( APD )

13APD

APD - therapy programming

Inputs required:

Total therapy volume Total therapy time Fill volume Last fill: volume, and same or different dextrose

Machine calculates: Number of cycles Estimated Dwell time per cycle

Page 14: Therapy Modality: Automated Peritoneal Dialysis ( APD )

14APD

Programming the HomeChoice SystemExample therapy:

Total therapy volume = 12000 ml Total therapy time = Nine hours Fill volume = 2000 ml Last bag = 2000 ml, same dextrose

Machine calculates: Number of cycles = 5 cycles Estimated Dwell time per cycle = 1:19

1. HomeChoice assumes 'typical' flow rates to calculate Drain and Fill times. 2. Dwell times are updated throughout the therapy depending on actual time required for Fill and Drain.3. HomeChoice ALWAYS DELIVERS THE MAXIMUM AMOUNT OF DWELL TIME WITHIN THE

PROGRAMMED THERAPY TIME!

Page 15: Therapy Modality: Automated Peritoneal Dialysis ( APD )

15APD

How does it work ?

SETUP of system (example):– A. One 5000ml bag on the heater plate – B. Other bags connected to the HomeChoice set:

Baxter

Press go to start

5 litre

5 2.5

Page 16: Therapy Modality: Automated Peritoneal Dialysis ( APD )

16APD

APD made easier

PD LINKäsoftware

PRO Card

PATIENT’S HOME HOSPITAL

The PRO Card is used to download therapy information from the HomeChoice PRO and is read, at the hospital, using the PD Link software

Page 17: Therapy Modality: Automated Peritoneal Dialysis ( APD )

17APD

How does it work?

1 Write a Prescription

2 Program HomeChoice PRO with Pro Card

4 Retrieve therapy results

5 Analyze therapy results

or

3 HomeChoice PRO records therapy results

Page 18: Therapy Modality: Automated Peritoneal Dialysis ( APD )

18APD

The balance results in Improved Outcomes

Dialysate Clearances Quality of Life

Balancing Clinical and Lifestyle Needs:

Managing Patients on Home Therapies

Page 19: Therapy Modality: Automated Peritoneal Dialysis ( APD )

19APD

1

2

3

Procedural Modifications- to improve UF

I ncreasecycle num ber

Modifyton icity

I ncreasecycler tim e

Considerfi ll vo lum e

Cycler

O ptim izeshort dw ell U F

4

Page 20: Therapy Modality: Automated Peritoneal Dialysis ( APD )

20APD

Procedural Modifications - fill (dwell) volume

Page 21: Therapy Modality: Automated Peritoneal Dialysis ( APD )

21APD

Procedural Modification- no. of exchanges

Page 22: Therapy Modality: Automated Peritoneal Dialysis ( APD )

22APD

Procedural Modifications- partial day fill

Page 23: Therapy Modality: Automated Peritoneal Dialysis ( APD )

23APD

APD - Increasing Clearance

• Programme an increase in fill volume– Effective means of improving clearance– Minimum impact on patient lifestyle– Adjust nighttime exchanges first– Use 2.0L or greater whenever possible

• Add a daytime exchange • Increase Time on Cycler• Increase Number of Nighttime Exchanges

Page 24: Therapy Modality: Automated Peritoneal Dialysis ( APD )

24APD

APD - Increasing Clearance

• Increase fill volumes• Add a daytime exchange

– This is a very effective means of improving clearance

– HomeChoice can be programmed to deliver an exchange at midday

• Increase Time on Cycler• Increase Number of Nighttime Exchanges

Page 25: Therapy Modality: Automated Peritoneal Dialysis ( APD )

25APD

APD - Increasing Clearance

• Increase fill volumes• Add a daytime exchange• Increase Programmed Time on Cycler

– Cycler time can be extended to 10 hours– Increasing cycler time with a constant number of

exchanges increases dwell time which increases clearance

• Increase Number of Night-time Exchanges - May increase clearance, but only if dwell time on cycler is also increased

Page 26: Therapy Modality: Automated Peritoneal Dialysis ( APD )

26APD

The Importance of “Wet Days”

• > 85% of APD patients - all except High Transporters – will require a daytime dwell to achieve adequate dialysis• > High transporters need daytime dwells with Icodextrin to achieve ultrafiltration targets

> 85%

Wet Day Dry Day

0%5%

10%15%20%25%30%35%

Low LowAverage

HighAverage

High

CCPD+CAPD CCPD NIPD

Page 27: Therapy Modality: Automated Peritoneal Dialysis ( APD )

27APD

Fluid Balance - General Guidelines for APD

• Avoidance of long dwells with low glucose• Use of mid-day drain even when no additional exchange is

needed for clearance

• “The most frequently ignored principles in PD that lead to UF difficulties are the need to avoid long glucose dwells in high transporters and balancing glucose concentration and dwell time”

Evaluation and Management of Ultrafiltration problems in PD, ISPD Recommendations, PDI Vol 20, suppl 4, 2000

Page 28: Therapy Modality: Automated Peritoneal Dialysis ( APD )

28APD

Designing the Optimal APD Therapy

Fact: APD utilizes shorter dwell times, relative to CAPD. Therefore, more solution volume is needed to provide adequate clearance

Fiction: More total solution volume will always provide better clearance for APD patients

The Key to success with APD is a balance of:Solution Volume and Dwell Time

Excessive solution volume = too many cycles = wasted time filling and draining = reduced clearances

Page 29: Therapy Modality: Automated Peritoneal Dialysis ( APD )

29APD

CAPD or APD?

CAPD Easy technique Daytime exchanges can

be difficult if working or for carer

Poor UF if high transporter resulting in use of high dextrose fluids

APD More difficult technique No or only 1 daytime

exchange Easier to achieve high

UF independent of transporter status

Page 30: Therapy Modality: Automated Peritoneal Dialysis ( APD )

30APD

CAPD or APD?

CAPD Difficult to adeq by

exchange number or volume

exchange volume intraperitoneal pressure when patient ambulant

risk of herniae and leaks

APD Easy to adequacy by

exchange number overnight

Intraperitoneal pressure lower when patient supine

risk of herniae and leaks

Page 31: Therapy Modality: Automated Peritoneal Dialysis ( APD )

31APD

CAPD or APD?

CAPD Adequacy in low

transporters by 5th exchange - ‘Quantum’ or 1/wk HD

Ease of travel Peritonitis 1/20-24 mths

APD Difficult to achieve

adequacy in low transporters

Can travel with machine or revert to CAPD

Peritonitis 1/30-40 mths