1. Peritoneal Dialysis Prescription
&
Adequatcy
Piti Niyomsirivanich,MD.

2. • Peritoneal dialysis prescription
– Acute
• Introduction
• Peritoneal Catheter
• Use of automate cycler
• Prescribing acute peritoneal dialysis
• Complications

3. • Chronic
• Choice of PD treatment modality
– Modalities of PD therapy CAPD , APD ,hybrid
– CAPD or PD ?
• Choice of prescription
– Clearance targets
– Measurement of clearance
– Determinants of clearance
– prescription
• Nutritional issues in PD

4. Acute peritoneal dialysis
presciption

5. • Peritoneal dialysis prescription
– Acute
• Introduction
• Peritoneal Catheter
• Use of automate cycler
• Prescribing acute peritoneal dialysis
• Complications

6. Introduction
• Acute Peritoneal Dialysis
– Nonvascular alternative for dialysis
– Acutely less efficient than conventional
hemodialysis

7. Adventage / Disadventage
Adventage Disadventage
•Technically simpler than that of •Less efficient than hemodialysis
hemodialysis (flash pulmonary edema , drug
•Doesn’t require highly trained overdose , acidosis ,hyperkalemia ,
personnel or expensive, complex catabolic patient)
equipment •Protein loss  malnourished
•Can be instituted quickly •Hyperglycemia
•Avoids the potential problems
related to vascular
hemorrhage , air embolism •Serious morbidity (30%) and
, thrombosis , infection mortality (5%) attributed Acute PD
•Lower likelyhood of hypotensive and HD are similar
episodes

8. Indications
• Acute renal failure
• Benefit in volume overload with
cardiovascular compromise
• Hypothermia
• Hemorrhagic pancreatitis
• Most beneficial in Rx of hemodynamically
unstable

9. Contraindications
• Recent surgery requiring abdominal drains
• Known fecal or fungal peritonitis
• Pleuroperitoneal fistula
• Relative contraindication
– Severe hypercatabolic states
– Abdominal wall cellulitis
– Adynamic ileus
– Presence of abdominal adhesions or fibrosis
– New aortic prosthesis

10. • Peritoneal dialysis prescription
– Acute
• Introduction
• Peritoneal Catheter
• Use of automate cycler
• Prescribing acute peritoneal dialysis
• Complications

11. Peritoneal catheter
• Pts. With
– multiorgan system failure
Can be anticipated
– Prolong period of renal failure
• initial insertion of a Tenckhoff catheter
(preferred > uncuffed temporary catheter) is
recommended

12. • Peritoneal dialysis prescription
– Acute
• Introduction
• Peritoneal Catheter
• Use of automate cycler
• Prescribing acute peritoneal dialysis
• Complications

13. Use of automated cyclers
• Traditionally been done using manual exchanged
• Automated cyclers are being used instead
– Saving nursing time (30-60 minutes exchange time)

14. • Peritoneal dialysis prescription
– Acute
• Introduction
• Peritoneal Catheter
• Use of automate cycler
• Prescribing acute peritoneal dialysis
• Complications

15. Prescribing acute peritoneal dialysis
• A: Session length
– In the setting of acute renal failure (catabolic ,
oliguric ), continuous removal of fluids and solutes
is required
– Need for hourly exchange on a continuous basis
for days or weeks
– Order for One day

16. Standard order for 1 day

17. Exchange volume
• Average-sized adult can usually tolerate 2L
exchanges
– Those with abdominal wall or inguinal hernias, the
exchange volume should be reduced
• Some may prefer start with smaller volumes(1-
1.5 L) for the first few exchanges
• The larger volume is , the greater the clearance
and UF rates

18. Exchange time
– Inflow 15 – dwell 30 - drain 15
– 1 hr.
• Inflow time
– Gravity
– 10 min.
– Prolonged
• Kinking
• Inflow resistance
• Inflow pain due to acidic , hypertonic solution

19. Exchange time
• Dwell period
• Standard dwell period
– Usual dwell time is 30 min
– 2L per exchage 48 L per day
– [Urea] in drained dialysate will be 50-60% of plasma
• More stable patients
– If Not extremely hypercatabolic state
•  longer dwell time 1.5-5 hrs
– At 5 hrs [UREA] dialysate = [UREA]plasma

20. Exchange time
• Outflow time
– Gravity
– 20-30 min
– Depend on
• Total volume
• Resistance to outflow
• Height
• 1st exchange
• Outflow obstruction
• Outflow pain

21. CEPD (Continouous equilibration
peritoneal dialysis)
• Alternative approach
• Modified version of CAPD
• Standard manual exchange every 3 to 6 hours
• Adventage
– Simplicity
– Lower cost
– Less labor-intense
• Disadventage
– Clearance are less
– Not be adequate in more catabolic patient

22. Choosing the dialysis solution
• 1.5% dextrose
– Sufficient to remove 50-150 of fluid per hour (2L
,60min exchange time)
– UF rate 1.2-3.6 L/day
• 4.25% dextrose
– UF 300-400 ml/hr
– Acquired for treatment of CHF

23. Effect of peritonitis
• During peritonitis
– Enhanced absorption of glucose
– Rapidly reducing the osmotic gradient
– Maintaining the efficiency of UF
• reduced exchange time
• More hypertonic exchange

24. Dialysis Solution additives
• KCl
– Hypokalemia  KCl 3-5 mEq/L can be added
– Correction of acidosis K shift  hypokalemia
• Heparin
– Catheter obstruction due to fibrin
– 1000 U/2 L
• Insulin
– Glucose absorbed from the dialysis solution

25. Insulin

26. • Antibiotics
– Intraperitoneal administration

27. Monitoring fluid balance

28. Monitor Clearance
• In general
– BUN should maintain below 80 mg/dl
– D:P ratio for urea
• [BUN]dialysate : [BUN]plasma ratio
• Multiplied by total daily dialysate volume urea daily
clearance
• Should be at least 10 ml/min
• 20-30 ml/min in hypercatabolic patient

29. • Peritoneal dialysis prescription
– Acute
• Introduction
• Peritoneal Catheter
• Use of automate cycler
• Prescribing acute peritoneal dialysis
• Complications

30. Complications
• Abdominal distention
– Incomplete drainage
• Peritonitis
– 12% of cases
– Occur within first 48 hrs
– Gram +ve organisms (>50%)
– Prolong used of Multiple antibiotics  fungus
• Hypotention
– Removal large amout of fluid

31. Complications
• Hyperglycemia
– IP insulin
• Hypernatremia
– UF generated in PD [Na] 70 mEq/L
– Increased loss of water
• Hypoalbuminemia
– Protein loss 10-20 gm /day
– Early oral or parenteral hyperalimentation should
be instituted

32. Adequacy of Peritoneal Dialysis and
Chronic Peritoneal Dialysis
Prescription

33. • Chronic
• Choice of PD treatment modality
– Modalities of PD therapy CAPD , APD ,hybrid
– CAPD or PD ?
• Choice of prescription
– Clearance targets
– Measurement of clearance
– Determinants of clearance
– prescription
• Nutritional issues in PD

34. • Choice of modality
– CAPD
– APD
– Variant of APD : CCPD , NIPD
– hybrid
• Selection based on
– Clearance
– UF
– Nutritional requirement

35. Diagrammatic
Representation of various
continuous ambulatory
peritoneal dialysis and
automate peritoneal
dialysis

37. Modality of peritoneal dialysis therapy
• CAPD
– Low cost
– Freedom from dialysis machinery
– Continuous therapy and a steady physiologic state
– Nomalization of blood pressure is possible in most
patients.
– Multiple procedural sessions
– Can be done away from home
– Episodes of peritonitis

38. Modality of peritoneal dialysis therapy
• APD
– CCPD
• Continuous therapy
• Need for cycler
• Complications associated c a prolonged day dwell
– Excessive resorption of dialysate
» Icodextrin are useful in day dwell
– NIPD
• No dialysis fluid during day time
• Suitable for patient with good residual renal function

39. • Hybrid forms of PD
– CAPD with automated nocturnal exchange
• A night exchange device
– APD with additional exchange during the day
• IPD
– Almost extinct
– Cycler in hospital 2-3 times weekly duration 12-24 hr

40. • Chronic
• Choice of PD treatment modality
– Modalities of PD therapy CAPD , APD ,hybrid
– CAPD or PD ?
• Choice of prescription
– Clearance targets
– Measurement of clearance
– Determinants of clearance
– prescription
• Nutritional issues in PD

41. CAPD or APD
• Based on
– Lifestyle ,emplyment , place of residence comfort
with the cycle technology and family and social
support
• Previously APD better than APD
– Na Sieving
• Risk of net fluid resorption with long day dwells
• Led to concerns about Na removal with APD
– Systolic hypertension with APD > CAPD (no
randomized trial but generalizable)

42. • Risk of peritonitis
– Decade ago
• APD showed less peritonitis
• But APD techinique improved now
• Relative cost

43. • Chronic
• Choice of PD treatment modality
– Modalities of PD therapy CAPD , APD ,hybrid
– CAPD or PD ?
• Choice of prescription
– Clearance targets
– Measurement of clearance
– Determinants of clearance
– prescription
• Nutritional issues in PD

44. Choice of a prescription
• Clearance targets
– ADEMEX study
• 1000 CAPD patients
– 4X2 L CAPD versus a high peritoneal clearance regimen
– 2 years
– Mean Kt/V 1.62 and 2.12 / wk
A concensus target Kt/V for PD  1.7 /wks

46. • Chronic
• Choice of PD treatment modality
– Modalities of PD therapy CAPD , APD ,hybrid
– CAPD or PD ?
• Choice of prescription
– Clearance targets
– Measurement of clearance
– Determinants of clearance
– prescription
• Nutritional issues in PD

47. Frequency of measurement
• Within 1 month of initiation
• And then q 4 months
• Discordance between Kt/V and CrCl
– APD
• Cr has higher molecular weight than urea

48. • Chronic
• Choice of PD treatment modality
– Modalities of PD therapy CAPD , APD ,hybrid
– CAPD or PD ?
• Choice of prescription
– Clearance targets
– Measurement of clearance
– Determinants of clearance
– prescription
• Nutritional issues in PD

49. Determinants of clearance
• Residual renal function
– Account for as much as 50% of total clearance
– Preserved in patient on CAPD
•  ACEI ,ARB
• Avoid nephrotoxic agents i.e. aminoglycoside
• Peritoneal transport status
– PET
• Low transporter  high volume ,long duration dwell
– Low average
– High average
• High transporter  short duration dwell

50. • Body size
– Large body size  harder to achieve clearance
• Prescription
– Change
– Focus on lifestyle factors

51. • Chronic
• Choice of PD treatment modality
– Modalities of PD therapy CAPD , APD ,hybrid
– CAPD or PD ?
• Choice of prescription
– Clearance targets
– Measurement of clearance
– Determinants of clearance
– prescription
• Nutritional issues in PD

52. CAPD
• Initial
– 4x2 L or 4x2.5 in larger patients
– Increase peritoneal Kt/V in CAPD
• Increasing exchange volumes
– Increase backpain
– Abdominal distention
– Shortness of breath
• Increasing the frequency of daily exchange
– Most CAPD pts. Do 4 exchange daily
– 45 lead to burn out (alt. night exchange)
• Increase the tonicity of dialysis solution
– Increase UF and clearance

53. APD
• 10-12 L daily (15 L in larger)
• Good residual renal function  NIPD
• High transporter  short day time/second
dwell
• Typical cycler time is 8-10 hrs
– dwell volumes 2 L

54. Increase clearance of APD
• Introduction of a day dwell
– NIPD
• Adding day dwell  increase Kt/V and CrCl by 25%-50%
• Disadventage
– In high transporter  increase net fluid resorption
– Icodextrin or shortening day dwell
• Increase dwell volumes on cycler
– Because patients are supine during cyclingtolerate
larger dwell volume
– 4X2.5 L per session is better than 5X2 L per session

55. Increase clearance of APD
• Time on cycler
– The longer time ,the better clearance
• Increasing frequency of cycles
– More frequent cycle  increase clearance on APD
– But More frequent cycle Dialysis time lost
• Increasing dialysis solution tonicity
– concern about glocose-related complications arise

56. Incremental versus maximal prescription
• Incremental approach
– Suitable when dialysis is being initiated early
– 2-3 CAPD exchanges daily or a low-volume
– Less costly and less onerous
– Decrease total glucose exposure and risk of peritonitis
– Require regular monitoring of resiual function
• To ensure that the clearance achieved doesn’t below target
levels

57. Empirical versus Modeled approach
• Modeled approach
• collecting patient anthropometric data , PET , residual
renal function
• Computer program uses the data to predict
• Actual clearance still have to be measure
• because discrepancy between actual and modeled

58. Empirical versus Modeled approach
• Empirical approach
– Physician uses knowledge of the patient’s size , residual renal function
, and peritoneal transport status
– And choose a resonable prescription
– Advantage
• Less trial and error
• Earlier identification of an appropriate prescription

59. Prescription pitfalls in peritoneal dialysis
• Loss of residual renal function
– Not monitored closely enough
• Noncompliance
– No single test that identifies this problem
– Serial measurement of 24-hr dialysate plus urinary Cr excretion
• High serum creatinine despite good clearances
– Kt/V > 1.7/wk but serum Cr > 12-15
– Non compliance
– Kt/V high and CrCl low
– Residual renal function fades away
– Hight lean body mass

60. • Inappropriate switch form CAPD to APD
– Particular in low transporter
• Inadequate attention to fluid removal
– Particular in high , high-average transporter and
long dwells that result in net fluid resorption

61. • Chronic
• Choice of PD treatment modality
– Modalities of PD therapy CAPD , APD ,hybrid
– CAPD or PD ?
• Choice of prescription
– Clearance targets
– Measurement of clearance
– Determinants of clearance
– prescription
• Nutritional issues in PD

62. Nutritional Issues in PD
• nPNA
– Normalized protein equivalent of nitrogen appearance
– Include
• Serum albumin
• Subjective global assessment
• Lean body mass
– Measure 24 hr of dialysate and urine (intake
output)
– Bergstrom
– Recommend 1.2 gm/kg/day

63. • Caloric intake
– = dietary intake + glucose absorbed
– 35 kcal/kg/day
– 10-30% come from glucose (depend on tonicity)

64. Bergstrom formulas
• 1) PNA (g per day)=20.1 + 7.5 UNA (g per day)
or
• 2) PNA (g per day)= 15.1 + 6.95 UNA + dialysate
protein losses (g per day)
• UNA = urinary nitrogen losses (g/day) + dialysiate
urea nitrogen losses
• 1) if dialysate protein losses are unknown
• 2) if dialysate protein losses are known

65. Serum albumin
• Strongest predictors of patient survival on PD
• Influences
– dialysate albumin losses
– Inflammation
– More than dietary protein intake

66. Subject global assessment
• Simple clinical tool
• Predict patient outcome
• KDOQI , Canadian Society

67. Creatinine excretion
• 24 hr urine and dialysate collections

68. Treatment of malnutrition
• Dietitian support
– Dietition to ensure adequate protein intake
• Nutritional Supplement
• Promotility agent
– Gastric emptying is impaired
• Anabolic steroid
– 1 RCT ,Nandrolone 100 mg IM weekly for 6 months 
improve lean body mass
• Amino acid
– amino acid based dwell