unesp

Daniela Ponce

Therapeutic Modalities: CRRT, SLED, PD

PD

BOTUCATU SCHOOL OF MEDICINE, SAO PAULO STATE, BRAZIL

16 th CRRT, San Diego, California 2011

Case Study

A 55-year-old man was victim to a massive attack by Africanized bees (>500 beestings) in a rural area in Sao Paulo, Brazil.

Day 1: On admission to hospital, widespread erythematous and painful papuleswere found on his body and he was discharged from the hospital after oralmedication.

Day 6: He was admitted to a emergency medical assistance, complaining ofedema, urine volume reduction and weakness. No laboratory evaluation wasperformed and he was discharged from hospital.

Day 10: The patient was tranferred from another hospital 24 h after admissionfor high volume vomit, urine volume decrease and altered mental status. On PE hewas somnolent, emaciated 2, pale, BP= 160/100 mmHg, HR= 105 per minute andhis lungs with basilar rales (sat=90% in spontaneuos ventilation). The otheraspects of the PE were unremarkable.

• His blood laboratory examination showed haematocrit 16%;haemoglobin, 5.9 g/dl, serum creatinine 27 mg/dl; blood ureanitrogen, 221 mg/dl; serum potassium, 7.8 mEq/l, serum pH 7.15,bic 5, total CO2 18 mmol/L.

• He was transferred to the Intensive Care Unit (ICU) andsupportive measures were started (transfusion, oxygen therapyand bicarbonate)

• APACHE 2 = 15.6 ATN-ISS= 0.41

• output urine after 6 h = 40 ml

• We are asked to evaluate him at the same day because of labexams and low urine output

Start dialylis now

Volume overload

Metabolic acidosis

Hyperkalemia

Uremic state

Which dialysis method ?

CRRT SLED iHD PD

Continuous PD using a flexible catheter and a cycler was performed

24 hours 19 cycles 2 liters/cycle 1.5% glucose

Clinical and lab improvements were observed after 2 days oftreatment, but diuresis recovery was recorded only 20 days

PD was interrupted after 23 days

Seventy-one days after the attack he had full recovery of renalfunction

1- Is it used?

2- Why to indicate it ?

3- For whom?

4- How to prescribe it?

5- Which is the ideal dose ?

6- Is it better or worsen than other methods?

7- What is the real role of PD in AKI?

Peritoneal Dialysis in AKI

BEST Study * Latin America *0

20

40

60

80

100 %

Europe **

1. Is it used ?

CRRTHD

SLEDPD

* Uchino. JAMA, 2005** Ricci. NDT, 2006

SLANH***: 35% in Latin America

*** Lombardi. WCN 2007

0

20

40

60

80

1997 1998 1999 2000

HC - SP

Lima EQ. ASN, 2002

% %

HD PD CRRT

Botucatu School

Barretti P. Renal Failure, 1997Balbi AL. JBN, 2002. Balbi AL. No published

Methods of dialysis in Brazil

PD is still usedfor AKI despiteconcerns aboutits inadequacy

0

20

40

60

80

1997 2004 2006 2008 2009 2010

1- Is it used?

2- Why to indicate it ?

3- For whom?

4- How to prescribe it?

5- Which is the ideal dose ?

6- Is it better or worsen than other methods?

7- What is the real role of PD in AKI?

Peritoneal Dialysis in AKI

• simple technique

• no anticoagulation

• low risk of bleeding

• hemodynamically unstable patients

• low risk of electrolyte disorders

• less expansive than CRRT

Advantages of PD

2. Why ?

Advantages and disavantages

For a selected group of AKI

1- Is it used?

2- Why to indicate it ?

3- For whom?

4- How to prescribe it?

5- Which is the ideal dose ?

6- Is it better or worsen than other methods?

7- What is the real role of PD in AKI?

Peritoneal Dialysis in AKI

utilizar solamente em algunassituaciones hemodinâmicas

no utilizar en el catabolismo severo

Choice of dialysis method in AKI

Withoutindication

• recent abdominal or cardiothoracic surgery

• severe hyperkalemia

• severe respiratory failure

PD

• Indications and contra-indications for each method

• hemodinamic stability and hypercatalism

• nephrology experience

Unstable hemodinamic and

hypercatabolic patients?¿

No use in very unstable patients

No use in severe hypercatabolic patients

Our patient

Volume overloadMetabolic acidosis

HyperkalemiaUremic state

no respiratory failureno changes in ECGno recent surgeriesno unstable hemodinamicallysevere hypercatabolic

can be treated with PD

1- Is it used?

2- Why to indicate it ?

3- For whom?

4- How to prescribe it?

5- Which is the ideal dose ?

6- Is it better or worsen than other methods?

7- What is the real role of PD in AKI?

Peritoneal Dialysis in AKI

For decreasing complications

and improving efficciency

• flexible catheter (1 o 2 “cuffs”)

• automated method - cycler

• continuous DP

Fast exchanges h/h,sessions of 16-20 hs,2-3xx/weekly

exchanges with dweltime longer (2-6 hs)

Fast exchanges (30 min)during 8-10 hs, withresidual volum (0.5-1 l) (>solut3 clearance)

HVPD

Fast exchanges(h/h), sessions of24 h, 7xx a week

Dialysis protocols for CPD

Metabolic control and fluid balance

Gabriel DP. PDI, 2007

Creatinine clearance/session (ml/min) 15.8 ± 4.16Urea nitrogen clearance/session (ml/min) 17.3 ± 5.01

Prescribed Kt/V

per session 0.65

weekly 4.5

Delivered Kt/V

per session 0.55 ± 0.12a a

weekly 3.85 ± 0.62a a

Solute Reduction Index (%) 41 ± 9.9

a= p>0.05 from prescribed Kt/V

Variable Median ± SD

Dialysis dose parameters

17%

7%

86%

23%

13%

7%

57%

Complications Outcome

no complications peritonitis

mechanical

death

recovery

no recoverymethod change

CPD is an effective methodfor treating AKI patients

Our patient

• Continuous PD: 24 h

• High Volume PD: 38 l

• Cycler

• Flexible catheter

• There are not complications: mechanic, metabolic, infectious

Cr levels mg /dl

BUN levels mg /dl

Urine output ml/day

tempo em dias

tempo - dias

-50

50

150

250

0

2000

4000

6000

0 20 40 60 80

0

10

20

30

Follow up

Prescribed Kt/V = 0.65

K=? volume of dialysis solution prescribed in 24 hours (mL) _ 0.60 (considering the D/P relationship for dwel time between 30 and 60 min)

t = 1 treatment duration (24 h = 1 day)

V = 35l patient urea distribuition volume (Watson formule)

Weigh = 76 kg (estimated 8 kg of edema) 68 kg V = 35 l K=38 l

The number of dialysis solution exchanges in 24 hours was obtained by dividingthe K value by 2 L (infusion volume)

Total duration of 1 session: 24 hoursInflow time = 10 minOutflow time= 20 minDwell time= 45 mimGlicose concentration = 1.5 %total exchanges/session= 19Total dialysate volume= 38 lFlow rate= 26.4 ml/min

Prescription

Our patient

Calcutating Peritoneal Dialysis Dose:

Delivered Kt/V

Kt/V = [mean dialysate urea nitrogen (mg/dL) / mean serum urea nitrogen

pre andpost dialysis (mg/dL)] _ [drained 24-hour volume (mL) /patient urea

distribution volume (mL)].

Dialysis dose

delivered Kt/V UF (ml) BF (ml) session weekly session day

0,54 4,2 1170 +8800,57 4,5 1350 +6550,61 1480 +3200,63 1765 -3400,61 2205 -10900,64 2800 -18800,62 3050 -20170,64 2785 -21800,63 2240 -21900,62 2030 -18900,65 1975 -30500,64 1030 -27500,62 910 -1470

1- Is it used?

2- Why to use it ?

3- For whom?

4- How to prescribe it?

5- Which is the ideal dose ?

6- Is it better or worsen than other methods?

7- What is the real role of PD in AKI?

Peritoneal Dialysis in AKI

Ideal dialysis dose in AKI is controversial

There are not studies that evaluated the effects ofdifferent PD doses on outcome of AKI patients

• prospective and randomized study in India

• evaluated two modes of automatic PD (CPD and tidal)

• 87 patients with AKI and no severe catabolism

Total volume of dialysate per session was similar in two groups: 26 l

Results and conclusions

Pre-dialysis BUN (mg/dL) 77.9 ± 22.1 78.8 ± 8.3 0.67

Post-dialysis BUN (mg/dl) 64.7 ± 12.4 50.8 ± 11.3 0.04

KT/V (session) 0.26 ± 0.07 0.34 ± 0.14 0.001

(week) 1.8 ± 0.32 2.43 ± 0.87 0.001

SRI (%) 20.6 ± 6 28.4 ± 4 0.02

UF (L/session) 2.01 ± 0.28 2.88 ± 0.7 0.03

Total protein loss (g/session) 6.6 ± 1.2 10.5 ± 1.5 0.001

Albumin loss (g/session) 3.48 ± 2.1 6.32 ± 1.03 0.02

CPD TPD p

“Both CPD and TPD are reasonable options for mil-moderate hyper catabolic ARF. TPDprovides better clearances at the same volume. Higher protein loss in TPD was the only

limitation to its use in ARF.”

Prospective study with different doses of CPD (flexible catheter , cycler, 24 h 7 x a week)

Patients with AKI of ATN were randomly assigned to receive:

Lower intensity PD: prescribed Kt/V = 0.5 (n=60)

Higher intensity PD: prescribed Kt/V=0.8 per session (n=60)

In press

To evaluatevaluate thethe effectseffects ofof differentdifferent PD doses PD doses onon outcomeoutcome ofof AKI AKI patientspatients

This study was early interrupted because group assigned to higher intensitydialysis received lower dialysis dose than that prescribed.

Ponce D, Abrão JMG, Berbel MN, André Luis Balbi

Ä

Table 1. Peritoneal Dialysis session characteristics

Ä

Characteristics Lower intensity Higher intensity

Kt/V=0.5 Kt/V=0.8

Ä

Dialysate fluid/cycle (l) 2.0 2..0

Inflow time (min) 10 10

Outflow time (min) 20 20

Dwell time (min) 45°©60 30-45

Duration /cycle (min) 75-90 60-75

Total exchanges/session 16-19 20-24

Total dialysate volum/session 32-38 40-48

Total duration of session (h) 24 24

Flow rate mL/minute 22-26.5 27.8-33.3

Glucose (%) 1.5-4.25 1.5-4.25Ä

Ä

Ä

Ä

Ponce D, Abrão JMG, Berbel MN, Balbi AL

Patients Characterísticss

Characteristics Higher Lower p (n=31) (n=30)

Male (%) 71 65 0.58

Age (years) 64.2 ± 18.8 62.8 ± 16.2 0.32

Oliguria (%) 56 58 0.78

ATN-ISS 0.67 0.66 0.48

APACHE II 26.4 ± 6.9 24.8 ± 8.6 0.18

Sessions (number) 6.1 5.7 0.48

Pre BUN (mg/ 100 ml) 118.8± 32.6 114.2±34.8 0.78

Pre creat (mg/100 ml) 5.6 ± 1.9 5.8 ± 1.4 0.79

Cause of AKI (%)

Sepsis 48 50 0.77

Heart failure 25 22 0.58

Post-surgery 11 14 0.65

Etiology of ATN (%)

Ischemic 82 78 0.38

Mixed 16 20 0.61

Indication of dialysis (%)

Azotemia 64 66 0.78

Volume overload 20 18 0.84

Ponce D, Abrão JMG, Berbel MN, Balbi AL

Higher Lower p n=31 n=30

KT/V per session:

prescribed 0.8 0.5

delivered 0.59±0.1a 0.43±0.1 0.03weekly:

prescribed 5.6 3.5delivered 4.13±0.6a 3.43±0.2 0.03

UF per session (L) 2.41 ± 0,7 2.11 ± 0.6 0.42

a Significantly different from prescribed Kt/V (p=0.04)

Table 03. Weekly and per Session Kt/V and UKF inPatients undergoing higher and lower intensity PD dose

0

20

40

60

80

100

120

140

BUN

(mg/

dl)

a. BUN (mg/dl)

0

1

2

3

4

5

6

7

Cr (m

g/dl

)

0

5

10

15

20

25

0

1

2

3

4

5

6

b. Creatinine (mg/dl)

c. Bicarbonate (mEq/L)d. Potassium (mEq/L)

Figure 3. Comparison of metabolic control in higher and lower-intensity peritoneal dialysis dose. Median serum levels of (a) BUN, (b)creatinine, (c) bicarbonate, (d) potassium, at the beginning of treatment and after each session.

Control metabolico

Table 4. Outcomes according to treatment group

Higher Lower p value (n=31) (n=30)

Mortality (%) 55 53 0.83Recovery of kidney function (%)* 86 86 0.97Duration of treatment (days) 6.1± 2.7 5.7 ± 2.1 0.42

* Recovery and resolution of kidney function of survivors only

Fig 2. Comparison patient survival after 30 days treatment

Ponce D, Abrão JMG, Berbel MN, Balbi AL

Conclusion

This study showed that increasing the intensity of continuous HVPD does not: :

reduce mortality or dependence on dialysis improve metabolic control among critically ill patients.

Peritoneal clearance is limited by: dialysate flow, membrane permeability, and area (KoA)

leading to a maximum delivered Kt/V of 0.6 per session

It suggests that prescribed Kt/V of 0.5 per session is enough to get a satisfactorymetabolic control and patient outcome

Ponce D, Abrão JMG, Berbel MN, Balbi AL

1- Is it used?

2- Why to use it ?

3- For whom?

4- How to prescribe it?

5- Which is the ideal dose ?

6- Is it better or worsen than other methods?

7- What is the real role of PD in AKI?

Peritoneal Dialysis in AKI

• prospective and randomized study

• 2 groups: 70 patients (PD = 36 and HF= 34)

• protocol was discontinued: mortality rate > PD (RR=3.2)

N Engl J Med 2002;347:895-902

Observations regarding results

PD

• rigid catheters

• manual exchanges

• dwell time < 15 min (70 l/day)

• no dialysis dose quantification

Daugirdas. NEJM, 2002Rao. PDI, 2003

Is not PD indicated in AKI ?

Kid Int (2008) 73,S87-S93

PD DHD p

KT/V per session:

prescribed 0.65 1.2delivered 0.53 0.79 <0.01

weekly:prescribed 4.5 7.2delivered 3.51 4.8 <0.01

UFper session (L) 2.1 ± 0,7 2.4 ± 0,7 0.39

Complications (%)infectious 18 8.5 0.21mechanical 5 18 0.13

30,0025,0020,0015,0010,005,000,00

Time ( days)

1,0

0,8

0,6

0,4

0,2

0,0

Su

rviv

al

(%)

DHD

HVPD

p = 0.48

Sobrevida en 30 días

High Volume PD x Extended Daily Hemodialysis in patients with AKI

AL Balbi, GA Brito, JMG Abrão, M Pinto, D Ponce

University Hospital, Botucatu School of Medicine, São Paulo, Brazil, 2008

• Prospective randomized trial

• 180 hemodynamically unstable AKI patients treated with HVPD or EDH

• Objectives are evaluate death within 60 days

recovery of kidney function metabolic control

From now: 64 patients in SLED and 48 patients in HVPD

Further Studies

HVPD (48)SLED (64)Characteristics

Male (%) 70.1 70.8

age (years) 66.8 ± 10 58.9 ± 18

ATN-ISS (media) 0.63 0.72

Ischemic AKI (%) 89 83

BUN (mg/dl) 91 ± 30 96 ± 25

creatinine (mg/dl) 4.8 ± 1.5 5.7 ± 3.2

Table 1: Characteristics of patients

High Volume PD x Extended Daily Hemodialysis in patients with AKI

AL Balbi, GA Brito, JMG Abrão, M Pinto, D Ponce

mortality Recovery renalfunction (survival)

0

25

50

75

100%

76,1%

69,6%

81%87%

SLED HVPD

p>0.05

Mortality rate and recovery of renal function

HVPD and EDH can be effective and similar methods

for treating AKI patients

Conclusion

1- Is it used?

2- Why to use it ?

3- For whom?

4- How to prescribe it?

5- Which is the ideal dose ?

6- Is it better or worsen than other methods?

7- What is the real role of PD in AKI?

Peritoneal Dialysis in AKI

it is an important therapeutic alternative for a selected group of patients, manly in developing countries

to overcome limitations, it must be carried in continuous and

automatic method with high volume of dialysate

prescription should be individual to achieve adequate solute and

fluid control

Kt/V =0.5 per session seems to be enough

There is room for a more frequent use of PD in AKI

In press

Ponce D, Balbi AL

Peritoneal Dialysis in Acute Kidney Injury: a Viable Alternative

André Luis Balbi

Germana Alves de Brito

Juliana Gera Abrão

Marina Nogueira Berbel

Milene Perón Rodrigues

Laudilene R Marinho

Cibele T. P. Almeida

Andréa V. Hecker

Elza Maria Januário

Ana Cristina Paulino Leite

dponce@fmb.unesp.br

BOTUCATU SCHOOL OF MEDICINE, SAO PAULO STATE, BRAZIL