Small solute clearance targets in peritoneal dialysis (original) (raw)
Related papers
Maintaining Peritoneal Dialysis Adequacy: The Process of Incremental Prescription
2018
Urea kinetics (weekly Kt/V) greater than 1.7 generally define adequate peritoneal dialysis (PD). Adequacy of PD depends on residual renal function and PD clearance. Preserving residual renal function and peritoneal membrane characteristics helps to maintain PD adequacy.The dose of PD can be augmented by increasing the total dialysate volume. Greater volume can be achieved by increasing either the fill volume per exchange or the number of exchanges. Increased time on dialysis can be achieved by keeping PD fluid in the peritoneal cavity at all times. Increasing the convective force enhances solute removal with ultrafiltration.Incremental PD is used during urgent starts and in patients who are newly starting or who have been on PD. Urgent starts require use of frequent low-volume exchanges to avoid leaks at surgical sites. The dialysate volume can be gradually increased provided that no leakage occurs, up to approximately 2 L per exchange on day 14 for an average-size adult. New-start ...
Recommended clinical practices for maximizing peritoneal dialysis clearances
Peritoneal dialysis international : journal of the International Society for Peritoneal Dialysis
Data from the Canada-U.S.A. (CANUSA) Study have recently confirmed a long-suspected linkage between total clearance and patient survival in peritoneal dialysis (PD). Recognizing that what we have historically accepted as adequate PD simply is not, the Ad Hoc Committee on Peritoneal Dialysis Adequacy met in January, 1996. This committee of invited experts was convened by Baxter Healthcare Corporation to prepare a consensus statement that provides clinical recommendations for achieving clearance guidelines for peritoneal dialysis. Through an analysis of 806 PD patients, the group concluded that adequate clearance delivered with PD can be achieved in almost all patients if the prescription is individualized according to the patient's body surface area, amount of residual renal function, and peritoneal membrane transport characteristics. Use of 2.5 L to 3.0 L fill volumes, the addition of an extra exchange, and giving automated peritoneal dialysis patients a "wet" day are ...
Peritoneal Dialysis International: Journal of the International Society for Peritoneal Dialysis
The International Society for Peritoneal Dialysis last published a guideline on prescribing peritoneal dialysis (PD) in 2006. This focused on clearance of toxins and used a measure of waste product removal by dialysis using urea as an example. This guideline suggested that a specific quantity of small solute removal was needed to achieve dialysis 'adequacy'. It is now generally accepted, however, that the well-being of the person on dialysis is related to many different factors and not just removal of specific toxins. This guideline has been written with the focus on the person doing PD. It is proposed that dialysis delivery should be 'goal-directed'. This involves discussions between the person doing PD and the care team (shared decision-making) to establish care goals for dialysis delivery. The aims of these care goals are (1) to allow the person doing PD to achieve his/her own life goals and (2) to promote the provision of high-quality dialysis care by the dialysis team. Key recommendations 1. PD should be prescribed using shared decision-making between the person doing PD and the care team. The aim is to establish realistic care goals that (1) maintain quality of life for the person doing PD as much as possible by enabling them to meet their life goals, (2) minimize symptoms and treatment burden while (3) ensuring high-quality care is provided.
The Prescription of Peritoneal Dialysis
Seminars in Dialysis, 2008
In addition to the maintenance of normal extracellular electrolyte composition, the prescription of continuous peritoneal dialysis (CPD) should address four other specific issues: (i) prevention of uremia by achievement of adequate clearance of azotemic substances, (ii) prevention of progressive expansion of the extracellular volume by adequate peritoneal ultrafiltration, (iii) prevention of loss of residual renal function, and (iv) prevention of deterioration of the peritoneal membrane structure and function. Urea clearance, in the form of Kt/VUrea, is the index of removal of azotemic substances proposed by current guidelines. The target total (renal plus peritoneal) Kt/VUrea is ≥1.7 weekly. To provide the desired peritoneal Kt/VUrea (Kpt/VUrea), the prescription of peritoneal dialysis must provide a daily drain volume (Dv) defined by the clearance equations as Dv = V × (Kpt/VUrea)/(D/PUrea), where V is body water obtained from published anthropometric formulas, Kpt/VUrea = (1.7 − renal Kt/VUrea)/7 and D/PUrea is the dialysate-to-plasma urea concentration ratio at the dwell time prescribed. Computer programs obtain the relevant D/PUrea values from formal studies of peritoneal transport. In the absence of these studies (for example, at initiation of CPD), D/PUrea values can be obtained from published studies with similar dwell times. Body size, indicated by V, is the major determinant of the Kpt/VUrea limit provided by a given CPD schedule. Other obstacles to achievement of adequate urea clearance are created by poor patient compliance, inaccuracies of the anthropometric formulas estimating V, and mechanical complications of CPD that lead to retention of dialysate in the body. The main requirements for the prescription of adequate ultrafiltration are knowledge of the individual peritoneal transport characteristics, monitoring of urinary volume, and restriction of dietary sodium intake. Excessive dietary sodium intake is the major cause of extracellular volume expansion in CPD. Ideally, sodium intake should be kept at the level of total (peritoneal plus renal) sodium removal. Preventing the loss of residual renal function involves avoidance of nephrotoxic influences in the form of medications, radiocontrast agents, urinary obstruction and infection, and possibly other influences, such an elevated calcium–phosphorus product and anemia. Use of the lowest dialysate dextrose concentration that will allow adequate ultrafiltration is currently the most widespread practical measure of prevention of peritoneal membrane deterioration. Formulation of biocompatible dialysate is a major ongoing research effort and may greatly enhance the success of CPD in the future.
Peritoneal dialysis adequacy: A model to assess feasibility with various modalities
Kidney International, 1999
Background. The current standard of adequacy for peritoor more [3]. Recognized weaknesses of these guidelines neal dialysis (PD) is to provide a weekly normalized urea include: (a) the lack of evidence to establish equivalency clearance (Kt/V) of 2.0 or more and a creatinine clearance between the renal and peritoneal contributions of small (C Cr) of 60 liter/1.73 m 2 or more. As native renal function is lost, it is important to determine the effectiveness of the available solute removal to clinical outcome; and (b) the uncertain therapeutic modalities in achieving these goals. value of urea versus creatinine as markers of uremia Methods. A model to assess our ability to provide a weekly [4, 5]. Most clinical outcome studies have included pa-Kt/V urea of 2.0 or more and a C Cr of 60 liter/1.73 m 2 or more tients at various stages of uremia therapy with different to anuric patients undergoing continuous ambulatory PD degrees of residual renal function (RRF). The most (CAPD) and automated PD (PD Plus) was developed. The body surface area (BSA) distribution was obtained from 38,768 quoted prospective study, CANUSA, was not designed patients undergoing dialysis during January 1997. The distributo evaluate the relative effect of RRF and the peritoneal tion of peritoneal transport rates (PTRs) was obtained from clearance on patient outcome [2, 6, 7]. Furthermore, 2531 peritoneal equilibration tests performed during 1996. The patients with significant RRF are more likely to achieve weekly K p t/V urea was calculated for the various PTR groups higher clearances of creatinine than anuric patients beand the range of BSA with four PD prescriptions: CAPD 8 liters, CAPD 10 liters, PD Plus 12 liters, and PD Plus 15 liters, cause of tubular secretion of creatinine in advanced renal using a previously validated kinetic program (PackPD). failure. Few prospective studies have been performed in Results. The predicted percentage of patients capable of anuric patients undergoing PD. However, Selgas et al achieving the adequacy goals for Kt/V and C Cr , respectively, studied patients who had a minimum of three years on
Assessment of Peritoneal Dialysis Adequacy – Does it Impact on Patient Outcomes?
2017
The provision of adequate dialysis is important for the survival of Peritoneal Dialysis (PD) patients. Small solute clearance indices of urea and creatinine are widely used as markers of PD adequacy although several other factors are also known to affect optimal outcome in PD patients. Recently there is continued debate on the interpretation and precise prognostic value of small solute clearance in PD patients despite issuance of clinical practice guidelines and recommendations based on the solute clearance indices. We reviewed available literature on solute clearance indices in the assessment of PD adequacy and its association with patient outcome. Electronic data base such as the EMBASE, MEDLINE, OVID and Google internet search engines were used for the search as well as relevant textbooks. Several prospective cohort studies have been published on the effects of small solute clearance and other factors on mortality, morbidity and quality of life of PD patients. There are also some...
Changes in the demographics and prescription of peritoneal dialysis during the last decade
American Journal of Kidney Diseases, 1998
• Changes in the demographics and prescription of peritoneal dialysis (PD) during the past decade are reviewed using data from the United States and Canada. The number of patients in North America undergoing PD has increased markedly over the past decade, but the percentage of total chronic dialysis patients using the modality has remained relatively stable or decreased slightly during recent years. The average age of the patients undergoing PD has increased, and the percentage with diabetes has also increased. Comorbidity has otherwise remained relatively stable and tends to be significantly less than that in patients undergoing chronic hemodialysis (HD). The proportion of PD patients undergoing automated PD (APD) has increased markedly over the past decade and now includes more than one third of the PD patients in North America. The issue of adequacy of clearance achieved on PD has received a lot of attention over the past decade, and this is now being translated into changes in prescription. Patients undergoing continuous ambulatory PD (CAPD) are being prescribed larger dwell volumes, and more than one quarter use 2.5-L dwells or greater. A small number in the United States are being prescribed more than four exchanges a day, but this practice is more common in Canada. With regard to APD, the proportion of patients doing day dwells is now more than two thirds, and the average cycler dwell volumes have also increased. There are no baseline clearance data from a decade ago for comparative purposes, but it appears that clearances have increased in recent years. In general, more than 70% of the patients are achieving recommended clearance targets at the initiation of PD but, among prevalent US patients, the percentage achieving targets is in the range of 40% to 45%, reflecting a loss of residual renal function. In Canada, 60% to 70% of prevalent patients are achieving these targets. PD is a rapidly changing therapy at present. There have been dramatic and impressive improvements in prescription practices, but they need to change further if a higher proportion of patients is to achieve recommended clearance targets.
Peritoneal dialysis international: journal of the International Society for Peritoneal Dialysis
The International Society for Peritoneal Dialysis last published a guideline on prescribing peritoneal dialysis (PD) in 2006. This focused on clearance of toxins and used a measure of waste product removal by dialysis using urea as an example. This guideline suggested that a specific quantity of small solute removal was needed to achieve dialysis 'adequacy'. It is now generally accepted, however, that the well-being of the person on dialysis is related to many different factors and not just removal of specific toxins. This guideline has been written with the focus on the person doing PD. It is proposed that dialysis delivery should be 'goal-directed'. This involves discussions between the person doing PD and the care team (shared decision-making) to establish care goals for dialysis delivery. The aims of these care goals are (1) to allow the person doing PD to achieve his/her own life goals and (2) to promote the provision of high-quality dialysis care by the dialysis team. Key recommendations 1. PD should be prescribed using shared decision-making between the person doing PD and the care team. The aim is to establish realistic care goals that (1) maintain quality of life for the person doing PD as much as possible by enabling them to meet their life goals, (2) minimize symptoms and treatment burden while (3) ensuring high-quality care is provided.