Chronic Kidney Failure

Care of the Pediatric Patienton Peritoneal Dialysis

Clinical Process for Optimal Outcomes

PediatricCovers.QX 2/17/04 1:55 PM Page 1

Cover art by Morgan Ghosey, age 16

C O N T R I B U T I N G A U T H O R S

Bradley A. Warady, M.D.

Franz Schaefer, M.D.

Steven R. Alexander, M.D.

Catherine Firanek, B.S.N.

Salim Mujais, M.D.

PediatricCovers.QX 2/17/04 1:55 PM Page 2

Ensuring adequate dialysis and optimal patient care is a multifaceted process in children

with end stage renal disease who receive peritoneal dialysis. Whereas clinicians typically

utilize clinical and laboratory indices when attempting to define and achieve adequate

dialysis, optimal care cannot be achieved by focusing on solute clearances alone. Attention

to nutrition therapy, correction of anemia and growth retardation, control of osteodys-

trophy, prevention/treatment of peritonitis and preparation for transplantation are also

mandatory, and excellence in each aspect of management is necessary if an optimal

patient outcome is to be achieved.

Care of the Pediatric Patient on Peritoneal Dialysis was developed based on a review

of the current medical literature and the authors clinical experience. It has been designed

to serve as a resource that can be easily integrated into clinical programs caring for

children, with the discussion of each major topic consisting of a treatment algorithm

and a brief but pertinent review of associated background material. An appendix with a

variety of clinical tools and list of references is also included. By its nature, this guide

cannot be considered to be exhaustive, and users are encouraged to pursue specific issues

that may not be covered herein. This guide is also not intended to be the practice of

medicine, nor does it replace sound medical clinical judgment.

Children who receive peritoneal dialysis and their families are deserving of the best care

we can possibly provide, in order to give them every opportunity to achieve their desired

goals. The authors hope that the information contained within this guide assists you to

that end.



Introduction

Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 3



Predialytic Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Modality Selection and Preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

PD Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Automated Peritoneal Dialysis (APD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Continuous Ambulatory Peritoneal Dialysis (CAPD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Ultrafiltration Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Peritonitis Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Management of Growth Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Recombinant Growth Hormone Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Management of Malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Mineral Metabolism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Management of Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Preparation for Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Appendix:

Guidelines for 24-Hr Dialysate Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

Guidelines for 24-Hr Urine Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Clearance Calculations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Residual Renal Clearance Calculations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

PET in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

Measurement of Intraperitoneal Pressure (IPP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Table of Contents


Predialytic Monitoring

Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

Pred

ialy

tic M

onito

ring


TREATMENT GOAL

Full compensation for the complications of chronic kidney disease Timely preparation for transplantation Seamless transition to dialysis

DIALYSIS INITIATION: ABSOLUTE INDICATIONS

GFR

9 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

oodmatocrit,ur urine

every

choice

g

CLINICAL PROCESS FOR OPTIMAL OUTCOMES

PREDIALYTIC MONITORING

Select dialysis modality.Initiate dialysis

Child with advanced chronic renal failure (calculated GFR

Modality Selectionand Preparation


Mod

ality

Sel

ectio

n an

dPr

epar

atio

n


PD TRAIN

Theory (>15 Functions

Practical/Tech Aseptic te

exchangesfeeding (in

Peritonitis an Recognitio

treatment

Noninfectiou Hypotensi

HOME V

Psychosocial Family stru

Environment Presence o

formula pfor treatm

Safety Asses Locked me

Equipment A Blood pres

Treatment As Dressing c

blood pres

Cycler Manag Average st

plan for an

TREATMENT GOAL

Improvement of patients physical and mental well-being Adequate performance of home dialysis by caregivers Minimal interference with family/school/social life

INDICATIONS FOR PD IN PREFERENCE TO HD

Patient/caregiver choice if the modality is medically suitable Very small/very young patients Lack of vascular access Contraindications to anticoagulation Cardiovascular instability Poorly controlled hypertension/hypertensive cardiomyopathy (relative) Lack of proximity to a pediatric HD center (relative) Desire for normal school attendance More liberal fluid intake

ABSOLUTE CONTRAINDICATIONS TO PD

Omphalocoele Gastroschisis Bladder extrophy Diaphragmatic hernia Obliterated peritoneal cavity and peritoneal membrane failure

RELATIVE CONTRAINDICATIONS TO PD

Imminent living-related transplantation Impending/recent major abdominal surgery Lack of an appropriate caregiver Patient/caregiver choice if an alternate modality is available and medically suitable

Copyright 2004, Baxter Healthcare Corporation. All rights reserved.12

Modality Selection MCLINICAL PROCESS FOR OPTIMAL OUTCOMES

Mod

ality

Sel

ectio

n an

dPr

epar

atio

nPediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 12

PD TRAINING CONTENT

Theory (>15 hours) Functions of the kidney, pathophysiology of renal failure, osmosis, diffusion, fluid balance

Practical/Technical (>15 hours) Aseptic technique, blood pressure monitoring, exit site care, performance of PD

exchanges, setup and function of cycler, problem-solving alarms, NG/gastrostomy tubefeeding (infants/small children)

Peritonitis and Exit site/Tunnel Infection Recognition of signs and symptoms, initiating treatment, medicating bags for ongoing

treatment

Noninfectious Complications Hypotension/hypertension, catheter flow problems, hernias

HOME VISIT CONTENT

Psychosocial Assessment Family structure, financial status, school schedule

Environmental Assessment Presence of heat, running water and electricity, function of smoke detector and telephone,

formula preparation facilities (infants/small children), purity of water supply, isolated areafor treatment

Safety Assessment Locked medicine cabinet, storage of needles, location of local hospital

Equipment Assessment Blood pressure monitor, scale, thermometer, cycler, tube feeding pump

Treatment Assessment Dressing care, medications, dialysis supply location, hand washing station, home records,

blood pressure assessment

Cycler Management Average start/end time for dialysis, proximity of caregiver bedroom to treatment area,

plan for answering alarms


able

Modality PreparationCLINICAL PROCESS FOR OPTIMAL OUTCOMES


PD Prescription


PDPr

escr

iptio

n


INITIATE

Initiate diapage 33 (C

MEASUR

Document(See pages

ADJUST

Adjust thedialysis doPrescriptio

This section prescriptionare based on

DETERMINE BSA

Determine BSA by using the patients height and weight on the BSA chart located onpages 18-19. Prescription recommendations are based on patient size.

SELECT MODALITY

Based on the patients lifestyle, physical condition and physicians recommendation,patients may be started on either APD or CAPD. Each therapy offers distinct lifestyle andclinical advantages.


PD PrescriptionCLINICAL PROCESS FOR OPTIMAL OUTCOMES

PDPr

escr

iptio


INITIATE THERAPY

Initiate dialysis therapy by using the prescription options offered on page 23 (APD) andpage 33 (CAPD).

MEASURE CLEARANCES

Document an adequate dose of dialysis by measuring the actual clearances achieved.(See pages 8285.)

ADJUST PRESCRIPTION

Adjust the prescription if the patient is not achieving desired clearance or an increase indialysis dose is required by clinical evaluation, using the guidelines in the AdjustPrescription sections on pages 27 (APD) and 36 (CAPD).


This section of the guide was designed to assist you in integrating a simple peritoneal dialysisprescription process into the management of individual patients. Recommended prescriptionsare based on patient Body Surface Area (BSA) and residual creatinine clearance (CrCl), if available.

ated on

ation,festyle and



Tailoring theBSA can be d


Determine Body Surface Area (BSA)


2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

50 0.18

0.22

0.25

0.28

0.31

0.33

0.36

0.38

0.40

0.42

0.44

0.46

0.48

0.49

0.51

0.53

0.54

0.56

0.57

54 0.18

0.22

0.26

0.29

0.32

0.34

0.37

0.39

0.41

0.44

0.46

0.47

0.49

0.51

0.53

0.54

0.56

0.58

0.59

58 0.19

0.23

0.27

0.30

0.33

0.36

0.38

0.40

0.43

0.45

0.47

0.49

0.51

0.53

0.54

0.56

0.58

0.59

0.61

62 0.19

0.24

0.27

0.31

0.34

0.37

0.39

0.42

0.44

0.46

0.48

0.50

0.52

0.54

0.56

0.58

0.59

0.61

0.63

66 0.20

0.24

0.28

0.32

0.35

0.38

0.40

0.43

0.45

0.47

0.50

0.52

0.54

0.56

0.57

0.59

0.61

0.63

0.64

70 0.20

0.25

0.29

0.32

0.36

0.38

0.41

0.44

0.46

0.49

0.51

0.53

0.55

0.57

0.59

0.61

0.63

0.64

0.66

74 0.21

0.25

0.30

0.33

0.36

0.39

0.42

0.45

0.47

0.50

0.52

0.54

0.56

0.58

0.60

0.62

0.64

0.66

0.68

78 0.21

0.26

0.30

0.34

0.37

0.40

0.43

0.46

0.48

0.51

0.53

0.55

0.58

0.60

0.62

0.64

0.66

0.67

0.69

82 0.22

0.27

0.31

0.35

0.38

0.41

0.44

0.47

0.49

0.52

0.54

0.57

0.59

0.61

0.63

0.65

0.67

0.69

0.71

86 0.22

0.27

0.31

0.35

0.39

0.42

0.45

0.48

0.50

0.53

0.55

0.58

0.60

0.62

0.64

0.66

0.68

0.70

0.72

90 0.22

0.28

0.32

0.36

0.40

0.43

0.46

0.49

0.51

0.54

0.56

0.59

0.61

0.63

0.66

0.68

0.70

0.72

0.73

94 0.23

0.28

0.33

0.37

0.40

0.44

0.47

0.50

0.52

0.55

0.58

0.60

0.62

0.65

0.67

0.69

0.71

0.73

0.75

98 0.23

0.29

0.33

0.37

0.41

0.44

0.48

0.51

0.53

0.56

0.59

0.61

0.63

0.66

0.68

0.70

0.72

0.74

0.76

102

0.24

0.29

0.34

0.38

0.42

0.45

0.48

0.51

0.54

0.57

0.60

0.62

0.64

0.67

0.69

0.71

0.73

0.75

0.77

106

0.24

0.30

0.34

0.39

0.42

0.46

0.49

0.52

0.55

0.58

0.61

0.63

0.66

0.68

0.70

0.72

0.75

0.77

0.79

110

0.24

0.30

0.35

0.39

0.43

0.47

0.50

0.53

0.56

0.59

0.61

0.64

0.67

0.69

0.71

0.74

0.76

0.78

0.80

114

0.25

0.31

0.35

0.40

0.44

0.47

0.51

0.54

0.57

0.60

0.62

0.65

0.68

0.70

0.72

0.75

0.77

0.79

0.81

Hei

gh

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Cal

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Tailoring the prescription to patient size is essential to achieve desired peritoneal clearances.BSA can be determined from height and weight by referring to the tables below.


20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60

106

0.79

0.83

0.86

0.90

0.94

0.97

1.00

1.03

1.07

1.10

1.12

1.15

1.18

1.21

1.24

1.26

1.29

1.31

1.34

1.36

1.39

110

0.80

0.84

0.88

0.92

0.95

0.99

1.02

1.05

1.08

1.11

1.14

1.17

1.20

1.23

1.25

1.28

1.31

1.33

1.36

1.38

1.41

114

0.81

0.85

0.89

0.93

0.97

1.00

1.03

1.07

1.10

1.13

1.16

1.19

1.22

1.25

1.27

1.30

1.33

1.35

1.38

1.40

1.43

118

0.82

0.87

0.90

0.94

0.98

1.01

1.05

1.08

1.11

1.15

1.18

1.21

1.24

1.26

1.29

1.32

1.35

1.37

1.40

1.42

1.45

122

0.84

0.88

0.92

0.96

0.99

1.03

1.06

1.10

1.13

1.16

1.19

1.22

1.25

1.28

1.31

1.34

1.37

1.39

1.42

1.44

1.47

126

0.85

0.89

0.93

0.97

1.01

1.04

1.08

1.11

1.15

1.18

1.21

1.24

1.27

1.30

1.33

1.36

1.38

1.41

1.44

1.46

1.49

130

0.86

0.90

0.94

0.98

1.02

1.06

1.09

1.13

1.16

1.19

1.23

1.26

1.29

1.32

1.35

1.38

1.40

1.43

1.46

1.48

1.51

134

0.87

0.91

0.95

0.99

1.03

1.07

1.11

1.14

1.18

1.21

1.24

1.27

1.30

1.33

1.36

1.39

1.42

1.45

1.48

1.50

1.53

138

0.88

0.92

0.97

1.01

1.05

1.08

1.12

1.16

1.19

1.22

1.26

1.29

1.32

1.35

1.38

1.41

1.44

1.47

1.49

1.52

1.55

142

0.89

0.94

0.98

1.02

1.06

1.10

1.13

1.17

1.21

1.24

1.27

1.30

1.34

1.37

1.40

1.43

1.46

1.49

1.51

1.54

1.57

146

0.90

0.95

0.99

1.03

1.07

1.11

1.15

1.18

1.22

1.25

1.29

1.32

1.35

1.38

1.41

1.44

1.47

1.50

1.53

1.56

1.59

150

0.91

0.96

1.00

1.04

1.08

1.12

1.16

1.20

1.23

1.27

1.30

1.34

1.37

1.40

1.43

1.46

1.49

1.52

1.55

1.58

1.60

154

0.92

0.97

1.01

1.06

1.10

1.14

1.17

1.21

1.25

1.28

1.32

1.35

1.38

1.42

1.45

1.48

1.51

1.54

1.57

1.59

1.62

158

0.93

0.98

1.02

1.07

1.11

1.15

1.19

1.22

1.26

1.30

1.33

1.37

1.40

1.43

1.46

1.49

1.52

1.55

1.58

1.61

1.64

162

0.94

0.99

1.03

1.08

1.12

1.16

1.20

1.24

1.27

1.31

1.35

1.38

1.41

1.45

1.48

1.51

1.54

1.57

1.60

1.63

1.66

166

0.95

1.00

1.05

1.09

1.13

1.17

1.21

1.25

1.29

1.32

1.36

1.39

1.43

1.46

1.49

1.52

1.56

1.59

1.62

1.65

1.67

170

0.96

1.01

1.06

1.10

1.14

1.18

1.22

1.26

1.30

1.34

1.37

1.41

1.44

1.48

1.51

1.54

1.57

1.60

1.63

1.66

1.69

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A Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

APD is perforexchanges pexchange in

This therapyultrafiltratiopatients are


Automated PeritonealDialysis (APD)


APD is performed at night with the help of a cycler. A typical APD prescription includes fiveexchanges performed by the cycler while the patient is sleeping. The cycler instills a final (sixth)exchange in the morning. This final exchange dwells in the peritoneal cavity during the day.

This therapy is especially well-suited for pediatric patients. Additional benefits include betterultrafiltration due to shorter nighttime dwells, and decreased intra-abdominal pressure sincepatients are supine.

Auto

mat

ed P

erito

neal

Dial

ysis


The following APD prescription principles improve the efficiency of APD therapy:

STEP 1 ADEQUATE TIME ON CYCLER

Actual time on the cycler may vary by patient and should be adapted to the patients clinical needs and lifestyle. A starting time of 10 hours is generally recommended.

STEP 2 ANURIC APD PATIENTS REQUIRE WET DAYS

All functionally anuric (CrCl


herapy:

ients d.

a daytimean

ge.

ount ofes at night.

igher mber ofecause of

ples


INITIATION OF APD

Implant catheter

Initial prescription: 56 90120 min cycles with maximally tolerable fill volume (usually ~1100 mL/m2 BSA) + 1 daytime cycle with >50% of nocturnal fill volume (CCPD)

or


Management of APD Prescriptions


FACTORS

Insufficien Loss of res Prescriptio Reduced p Loss of me Noncomp Poorly fun

CRITERIA

CCPD (APTotal KTotal Caverag

NIPD (APDTotal KTotal Caverag

Clearancepressure, g

TREATMENT GOAL

Physical and mental well-being, absence of uremic symptoms Minimal interference with family/school/social life

MANIFESTATIONS OF INADEQUATE DIALYSIS

Overt uremia (uremic pericarditis, pleuritis) Manifest edema Clinical or biochemical signs of malnutrition, wasting Congestive heart failure Arterial hypertension requiring more than one antihypertensive agent Absolute BUN value Weekly Kt/Vurea and CrCl below K/DOQI recommendations Hyperkalemic episodes Hyperphosphatemia, excessive serum calcium-phosphate product




FACTORS CONTRIBUTING TO INADEQUATE DIALYSIS

Insufficient time on cycler Loss of residual renal function Prescription not adequate for membrane characteristics Reduced peritoneal surface area due to extensive intra-abdominal adhesions Loss of membrane solute transport/ultrafiltration capacity due to peritonitis Noncompliance with PD prescription Poorly functioning PD catheter

CRITERIA OF APD ADEQUACY

CCPD (APD with daytime dwell):Total Kt/Vurea >2.1/weekTotal CrCl >63 L/1.73m2/week in high/high average transporters, >52.5 in low/lowaverage transporters

NIPD (APD with dry day): Total Kt/Vurea >2.2/weekTotal CrCl >66 L/1.73m2/week in high/high average transporters, >55 in low/lowaverage transporters

Clearance associated with normal status for hydration, electrolyte balance, blood pressure, growth, nutrition and psychomotor development


OUTCOME EVALUATION

Monthly assessment of growth and weight gain, head circumference (infants); bloodpressure, acid-base status, electrolytes, serum creatinine, BUN, hemoglobin/hematocrit,serum albumin, record urine output and daily ultrafiltration

Serum ferritin, serum iron, total iron binding capacity (monthly until stable, then every 23 months)

Every 3 months assessment of intact PTH, alkaline phosphatase Every 4 months assessment of 24-hour dialysate and urine collection for CrCl, Kt/Vurea;

possibly more frequent if prior assessment reveals failure to achieve adequacy targets;school evaluation

Every 6 months neurodevelopmental assessment in infants


bloodmatocrit,

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ate 82,

rance totion

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mpleted

Adjust APD Prescription


There are four basic options to adjust an APD prescription. The options must beweighed with regard to improvements in clearance and the patients comfort andlifestyle.

STEP 1 INCREASE FILL VOLUMES

Maximizing the fill volume is an effective means of improving clearance with a minimumimpact on patient lifestyle. Since patients tolerate larger fill volumes when supine, adjustprescriptions first by increasing the volume of the nighttime exchanges.

STEP 2 ADD A DAYTIME EXCHANGE

Adding a daytime exchange is an effective means of improving clearance. For patientsusing a dry day prescription, add a wet day. For patients using a wet day prescription,add a daytime exchange after school.

HomeChoice High Dose Therapy, combining conventional CCPD with additional daytimeexchange(s), minimizes impact on lifestyle by utilizing one cycler setup per day for allexchanges. HomeChoice can be programmed to deliver the daytime exchange.

STEP 3 INCREASE TIME ON THE CYCLER

Cycler time can be extended to increase clearances, but this must be balanced with thepatients lifestyle needs.

Increasing cycler time while keeping the same number of exchanges increases the dwelltime, which results in increased clearance.

STEP 4 INCREASE NUMBER OF NIGHTTIME EXCHANGES

An increase in nighttime exchanges may increase clearance in high transporters. Inpatients with a different transport profile, a simultaneous increase in the time on cyclermay be required.



Adjust APD Prescription


MAINTENANCE PD PRESCRIPTION IN NIPD

Measure dialytic and urinary CrCl and Kt/Vurea every 4 months

Switch to CCPD (daytime dwell)

Low, low-average transporters

Adequacy targets met?


Total weekly Kt/Vurea < 2.2 and/or CrCl


on


inue close onitoring

MAINTENANCE PD PRESCRIPTION IN CCPD


Consider adding afternoon cycle or change to hemodialysis




Total weekly Kt/Vurea

CoPer


CAPD is perfoexchanges, tbedtime and


Continuous AmbulatoryPeritoneal Dialysis (CAPD)


CAPD is performed evenly over the entire course of a 24-hour period. It usually consists of fourexchanges, three of which are completed during the waking hours, and the last is performed beforebedtime and allowed to dwell overnight.

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The following CAPD prescription principles improve the efficiency of the therapy:

STEP 1 OPTIMIZE FILL VOLUMES

Fill volumes appropriate for patient body size are used in the recommended prescriptions.These can be increased further if clearance targets are not met. When adjusting fill volumes, care should be taken to account for patient tolerance.

STEP 2 DISTRIBUTE DAYTIME EXCHANGES EVENLY OVER THE COURSE OFTHE DAY

Dwell times during the waking hours should be of approximately the same duration (46 hours).

STEP 3 USE APPROPRIATE TONICITY FOR ULTRAFILTRATION

Proper fluid balance improves the effectiveness of the therapy. Guidelines for ultrafiltrationmanagement are listed on pages 4045.


CAPD PrescriptionPrinciples


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herapy:

scriptions.fill

OURSE OF

ation

trafiltration


INITIATION OF CAPD

Implant catheter

Initial prescription: 3 3- to 5-hour daytime + 1 9- to 12-hour nighttime cycles with maximally tolerable fill volume (usually ~1100 mL/m2 BSA)

Provide educational materials to caregivers, patients

Establish maximally tolerable fill volume by either repeated IPP measurements or clinical judgment. Adjust to maximally tolerable fill volume

Perform PET, measure urinary and dialysate creatinine and urea clearancesat the end of training (preferaby 4 weeks after start of PD)

Use PD dosing tables or software (PD Adequest or RenalSoft PD Rx Management) to adjust PD prescription

* ~200 mL/m2 BSA during infancy

Immediate PD required?no yes

2- to 6-week healing period,then start dialysis with 48 exchanges

using 300 mL/m2 BSA volume,*increase fill volume to ~1100 mL/m2

BSA within 714 days

Start supine dialysis with 1224 exchangesusing 300 mL/m2 BSA volume* for 7 days,

increase fill volume to ~1100 mL/m2

BSA within 1421 days


OUTCOM

Monthly apressure, aserum alb

Serum fer23 mont

Every 3 mo Every 4 mo

possibly mschool eva

Every 6 mo Consider a

Ambor

Han

MEASUR

Measuring thadequate the

Assess thecollection.and Cleara

For patiendetermine83, and Re

Measuremprescriptio

Once a paevery 4 mo

TREATMENT GOAL

Physical and mental well-being, absence of uremic symptoms Minimal interference with family/school/social life


Overt uremia (uremic pericarditis, pleuritis) Manifest edema Clinical or biochemical signs of malnutrition, wasting Congestive heart failure Arterial hypertension requiring more than one antihypertensive agent Absolute BUN value Weekly Kt/Vurea and CrCl below K/DOQI recommendations Hyperkalemic episodes Hyperphosphatemia, excessive serum calcium-phosphate product

FACTORS CONTRIBUTING TO INADEQUATE DIALYSIS

Loss of residual renal function Prescription not adequate for membrane characteristics Reduced peritoneal surface area due to extensive intra-abdominal adhesions Loss of membrane solute transport/ultrafiltration capacity due to peritonitis Noncompliance with PD prescription Poorly functioning PD catheter

CRITERIA OF CAPD ADEQUACY

Total Kt/Vurea >2.0/week Total CrCl >60 L/1.73m2/week in high/high average transporters, >50 in low/low average

transporters Clearance associated with normal status for hydration, electrolyte balance, blood

pressure, growth, nutrition and psychomotor development


Management of CAPD Prescriptions



OUTCOME EVALUATION

Monthly assessment of growth and weight gain, head circumference (infants); bloodpressure, acid-base status, electrolytes, serum creatinine, BUN, hemoglobin/hematocrit,serum albumin, record urine output and daily ultrafiltration

Serum ferritin, serum iron, total iron binding capacity (monthly until stable, then every 23 months)

Every 3 months assessment of intact PTH, alkaline phosphatase Every 4 months assessment of 24-hour dialysate and urine collection for CrCl, Kt/Vurea;

possibly more frequent if prior assessment reveals failure to achieve adequacy targets;school evaluation

Every 6 months neurodevelopmental assessment in infants

There are two basic options for adjusting the CAPD prescription. These options mustbe weighed with regard to improvements in clearance and the patients comfort andlifestyle. Increasing fill volumes is preferred over adding additional exchanges.

INCREASE FILL VOLUMES

Maximizing fill volume is THE most effective means of improving clearance.

Start patients on the recommended prescription, and increase fill volumes if targets arenot met. You may elect to increase only two of the exchanges when first adjusting theprescription. If targets are still not met, proceed by increasing the fill volume of all fourexchanges.

ADD AN ADDITIONAL EXCHANGE

A fifth exchange may be added manually during the daytime or at nighttime by the useof an exchange device. The latter is feasible only with fill volumes greater than 1500 mL.


Adjust CAPD Prescription




tions mustomfort andnges.

rgets aresting thef all four

by the use1500 mL.

ion


MAINTENANCE PD PRESCRIPTION IN CAPD




Total weekly Kt/Vurea

UltrafiltrationManagement


Ultra

filtra

tion

Man

agem

ent


Adjusting a patients prescription to achieve and maintain fluid balance is an essential component of PD prescription management. Peritoneal dialysis, due to its continuousnature, offers some distinct advantages such as avoiding fluctuating volume status andoffering better homeostatic stability than an intermittent therapy.

In PD, ultrafiltration is driven by the osmotic gradient between the plasma and dialysatecompartments. The two key factors to consider when adjusting the patients prescriptionfor fluid removal are the nature of the osmotic agent used, concentration and dwell time.These are interrelated and need to be considered jointly. Dextrose performs adequately inshort dwells, but for the long nighttime dwell in CAPD and the daytime dwell in APD, asignificant proportion of patients manifest fluid retention with dextrose-based solutions.

Ultrafiltration is time dependent. The net ultrafiltration rate with dextrose-based solutionsis greatest at the beginning of an exchange and peaks at about 2-3 hours. Because theglucose osmotic gradient dissipates with time, and lymphatic absorption continues, netultrafiltration then begins to decrease. An alternate osmotic agent may be more appropriatefor the long dwell.


Ultrafiltration Management


FACTO

Dietary Inappro Decreas Mechan Transpo

reabsor

COMPO

Determ Dietary Protecti Optiona Ultrafilt

DETER

Peritonthat theremova

Dwell tin UF be

Tonicityincrease

The usenegative

TREATMENT GOAL

Adjust a patients prescription to achieve and maintain fluid balance Patient edema free Achieve normotension with minimal use of or need for antihypertensive medications.


Peripheral edema Systolic hypertension Diastolic hypertension Pulmonary congestion Pleural effusions

Ultra

filtra

tion

Man

agem

ent



tial ouss and

lysateriptionell time.ately in

APD, autions.

olutionse thes, netpropriate



FACTORS CONTRIBUTING TO INADEQUATE FLUID BALANCE

Dietary noncompliance with salt and water Inappropriate/noncompliance to PD prescription Decreased residual renal function Mechanical PD catheter issues Transport characteristics: Reduced membrane function/high permeability/lymphatic

reabsorption

COMPONENTS OF FLUID BALANCE MANAGEMENT

Determination of appropriate target weight, Dietary counseling concerning appropriate salt and water intake, Protection of residual renal function by avoiding nephrotoxic agents, Optional use of loop diuretics if residual function is present, Ultrafiltration management utilizing the appropriate PD prescription.

DETERMINANTS OF ULTRAFILTRATION IN PD

Peritoneal transport status: the dependence of UF on the osmotic gradient impliesthat the transport properties of the peritoneal membrane can significantly affect fluidremoval when dextrose solutions are used

Dwell time: an increase in dwell time with dextrose-based solutions leads to a decreasein UF because of dissipation of the osmotic gradient.

Tonicity: with dextrose-based solutions, an increase in tonicity is associated with anincrease in ultrafiltration.

The use of an alternate osmotic agent may allow for a long dwell without the risk ofnegative ultrafiltration.

cations.


UltrafilSTRATEGIES TO MAXIMIZE LONG DWELL UF CAPD/APD

If the patient manifests negative UF during the long dwell Utilize alternate osmotic agent Shorten dwell time Replace single long dwell exchange with two exchanges Increase dextrose concentration

If the patient has adequate UF during the long dwell:

Minimize use of 4.25% dextrose preparations to protect the peritoneal membraneand avoid the metabolic complications of very hypertonic dextrose.

STRATEGIES TO MAXIMIZE SHORT DWELL UF

APD Increase the number of cycles Increase dextrose concentration Increase overall cycler treatment time Consider increasing the fill volume

CAPD Increase dextrose concentration Decrease dwell time/increase number of exchanges Consider increasing fill volume

Figures:

Dependence of UF on peritoneal transport status and dialysis solution tonicity for dextrose based solutions.




Ultrafiltr


Ultrafiltration response to 1.5% dextrose based on peritoneal transport type


embrane

utions.





ort type




Ultrafiltration response to dextrose



Pe


Peritonitis Management

Perit

oniti

s M

anag

emen

t



STEP 1 KEY ASSESSMENTS

Cloudy effluent Abdominal pain and/or fever

An empiric diagnosis of peritonitis should be made if: Peritoneal effluent is cloudy and Effluent with WBC >100/mm3 of which at least 50% are polymorphonuclear neutrophils (PMN)

STEP 2 KEY ACTIVITIES

Initiate the following (Performed by the patient or by the PD nurse in the dialysis unit): Disconnect drained bag and send sample to laboratory for cell count with differential, Gram stain and

culture prior to administration of antibiotics In presence of cloudy effluent,add heparin 500 U/L to new bag until effluent clears (usually 4872 hours) In asymptomatic patients with only cloudy effluent, initiation of therapy may be delayed 23 hours until

laboratory results are available In presence of cloudy effluent with pain and/or fever:

Begin 23 rapid exchanges to relieve discomfort Initiate empiric antibiotic therapy within 1 hour while waiting for test results

Consider antifungal prophylaxis to accompany antibiotic therapy After peritonitis resolved, schedule re-evaluation of total (dialysis plus residual renal function) creatinine

clearance and Kt/V urea

STEP 3 PATIENT/PARENTS EDUCATION

Immediately report cloudy effluent, abdominal pain and/or fever to PD unit Obtain specimen of effluent for laboratory testing prior to administration of antibiotics Initiate palliative steps

In presence of pain, begin 23 rapid exchanges Add intraperitoneal antibiotics for duration of required therapy Add heparin 500 U/L to each bag until clear Report persistent cloudiness to PD unit Schedule retraining for technique issues

STEP 4 OUTCOMES EVALUATION

Date of culture, organism, drug therapy Date infection resolved Recurrent organisms, date of drug therapy Method of interim renal replacement therapy Date of catheter removal Date of new catheter reinsertion Document contributing factors

Break-in technique, patient factors, exit site infections, tunnel infections

STEP 4 CONTINUES ON THE TOP OF PAGE 49...

Optimal long-tPrevention of most importanfollowing the prompt interv

* Continuetables fo For p

(244clearineeds

In patinfection,

ommhistory

CefazCepha

Ceftaz

Vanco

Teico

an

STEP 4 ...

Date of re Re-evalua Enter data

Peritonitis ManagementINITIAL EMPIRIC MANAGEMENT OF PERITONITIS

Perit

oniti

s M

anag

emen

t CLINICAL PROCESS FOR OPTIMAL OUTCOMES



MN)

stain and

72 hours)3 hours until

) creatinine

OF PAGE 49...

Optimal long-term management of the peritoneal dialysis patient hinges on prevention of peritonitis.Prevention of peritonitis includes proper catheter placement, use of advanced disconnect systems andmost importantly, the patients adherence to aseptic technique during the exchange procedure and following the protocol for exit site care. Early identification of the signs and symptoms of peritonitis andprompt intervention should be emphasized in the patient training program and follow-up care.

* Continued assessment and modification of therapy are based on culture and sensitivity results; refer to subsequenttables for specific organisms cultured and antibiotic dosing recommendations. For patients on automated peritoneal dialysis (APD) with short dwell times for routine therapy, the initial

(2448 hours) treatment of peritonitis should include a prolongation of dwell time to 36 hours, until there is clearing of the peritoneal effluent. This does not apply to asymptomatic patients or those with ultrafiltrationneeds requiring more frequent exchanges.

In patients with cloudy effluent, without fever and/or severe abdominal pain, and no risk factors for severeinfection, the combined intraperitoneal administration of a first-generation cephalosporin and ceftazidime is rec-

ommended. In patients with fever and/or severe abdominal pain, a history of MRSA infection, a recent history or current evidence of an exit site/tunnel or nasal/exit site colonization with S. aureus, and in patients

younger than 2 years, a glycopeptide combined with ceftazidime should be administered.

0 hour

Cefazolin orCephalothin

Ceftazidime

Vancomycin

Teicoplanin

250 mg/L load, then 125mg/L in each exchange

250 mg/L load, then125 mg/L in

each exchange

500 mg/L load, then30 mg/L in each

exchange

200 mg/L load, then20 mg/L in each exchange

15 mg/kg in single exchange q day

15 mg/kg in single exchange q day

30 mg/kg in single exchange q 57 days

15 mg/kg in single exchange q 57 days

Intermittent DosingContinuous Dosing

Initiate Empiric Therapy* with Cefazolin or Cephalothinand Ceftazidime or Glycopeptide (Vancomycin or Teicoplanin)

and Ceftazidime

THERAPEUTICSEMPIRIC THERAPY

STEP 4 ... CONTINUED

Date of re-education/training Re-evaluation of total (dialysis plus residual renal function) creatinine clearance and Kt/V urea Enter data into catheter management database (e.g., RenalSoft Access Management, POET 2.1 software)

entNITIS




Peritonitis Management

STEP 1 KEY ASSESSMENTS

Cloudy effluent Abdominal pain and/or fever

An empiric diagnosis of peritonitis should be made if: Peritoneal effluent is cloudy and Effluent with WBC >100/mm3, of which at least 50% are polymorphonuclear neutrophils (PMN)

STEP 2 KEY ACTIVITIES

Initiate the following (Performed by the patient or by the PD nurse in the dialysis unit): Disconnect drained bag and send sample to laboratory for cell count with differential,

Gram stain and culture In presence of cloudy effluent add heparin 500 U/L to new bag until effluent clears (usually 48 to 72 hours) In asymptomatic patients with only cloudy effluent, initiation of therapy may be delayed 2 to 3 hours until

laboratory results are available In presence of cloudy effluent with pain and/or fever:

Begin 23 rapid exchanges to relieve discomfort Initiate empiric antibiotic therapy within one 1 while waiting for test results

Consider antifungal prophylaxis to accompany antibiotic therapy After peritonitis is resolved, schedule re-evaluation of total (dialysis plus residual renal function) creatinine

clearance and Kt/V urea

STEP 3 PATIENT/PARENTS EDUCATION

Immediately report cloudy effluent, abdominal pain and/or fever to PD unit Obtain specimen of effluent for laboratory testing prior to administration of antibiotics Initiate palliative steps

In presence of pain, begin 23 rapid exchanges Add intraperitoneal antibiotics for duration of required therapy Add heparin 500 U/L to each bag until clear Report persistent cloudiness to PD unit Schedule retraining for technique issues

STEP 4 OUTCOMES EVALUATION

Date of culture, organism, drug therapy Date infection resolved Recurrent organisms, date of drug therapy Method of interim renal replacement therapy Date of catheter removal Date of new catheter reinsertion Document contributing factors

Break-in technique, patient factors, exit site infections, tunnel infections

STEP 4 CONTINUES ON THE TOP OF PAGE 51...

an

*Refer to

STEP 4 ... C

Date of re-e Re-evaluatio Enter data in

ES

Discontiglycope

start a

**A secoaminogbased o

pVancom

may be u

** NOTICon Peritontivation ofantibioticsto exerciseHandbook

GRAM POSITIVE AND GRAM NEGATIVE PERITONITIS




ent

PMN)

to 72 hours)o 3 hours until

on) creatinine

OF PAGE 51...

0 hour


and Ceftazidime2448 hours

Gram Positive Organism on Culture(Choice of therapy guided by sensitivity patterns)

Duration of Therapy

96 hours

If no improvement, reculture and evaluate Consider ultrasound evaluating for occult tunnel infection For peritonitis with exit site or tunnel infection, consider catheter removal

14 Days 21 Days 14 Days

*Refer to Initial Empiric Management of Peritonitis and antibiotic dosing recommendations (page 49)

THERAPEUTICS GRAM POSITIVE PERITONITIS

STEP 4 ... CONTINUED

Date of re-education/training Re-evaluation of total (dialysis plus residual renal function) creatinine clearance and Kt/V urea Enter data into catheter management database (e.g., RenalSoft Access Management, POET 2.1 software)

EnterococcusStreptococcus

Discontinue cephalosporin orglycopeptide and ceftazidime;

start ampicillin 125 mg/L

**A second antibiotic such as anaminoglycoside may be addedbased on sensitivity results and

patient responseVancomycin or clindamycin

may be used in case of ampicillinresistance

Staphylococcus aureus

Methicillin sensitive:Continue cephalosporin

Discontinueceftazidime and glycopeptide;

consider addition of rifampin20 mg/kg/day PO in divided doses

(maximum 600 mg/day)

Methicillin resistant:Discontinue ceftazidime

Continue or substitute glycopeptide or clindamycin

Other Gram PositiveOrganisms

Methicillin sensitive:Discontinue ceftazidime

and glycopeptide; continue cephalosporin

** NOTICE: The therapeutic recommendations provided above are those recommended by the ISPD Advisory Committeeon Peritonitis Management in Pediatric Patients. Baxter Healthcare is aware of literature which documents the potential inac-tivation of aminoglycosides by ampicillin in parenteral solution. The manufacturers precaution labeling states that theseantibiotics should not be mixed together in the same solution container (see references). Baxter Healthcare urges physiciansto exercise good medical judgment in selecting antibiotic combinations in the treatment of peritonitis. Ref. Trissel, LA,Handbook on Injectable Drugs, 12th ed. Macmillan Publishers LTD, ASHP, 2002; Physicians Desk Reference, 58th ed.

ONITIS




2448 hours

Gram Negative Organism on Culture(Choice of therapy guided by sensitivity patterns)

96 hours

Clinical improvement: continue above therapy No clinical improvement: repeat cell count, culture and Gram stain If culture remains positive, remove catheter If no clinical improvement and exit site infection present, remove catheter

* Refer to Initial Empiric Management of Peritonitis and Antibiotic Dosing Recommendations (page 49).** Additional agents may include piperacillin, ciprofloxacin, aminoglycoside or aztreonam as susceptibility

indicates.*** Duration may need to be adjusted on clinical grounds but never shorter than recommended.

Duration of Therapy***

14 Days 21 Days 21 Days


and Ceftazidime

THERAPEUTICS GRAM NEGATIVE PERITONITIS

0 hour

Single Gram NegativeOrganism

(Non-Stenotrophomonas)

Adjust antibiotics to sensitivity patterns.

May continue ceftazidime

Pseudomonas/Stenotrophomonas

Discontinue cephalosporinor glycopeptide; continue

ceftazidime; add agent withactivity against this

pseudomonas/stenotrophomonas**

Multiple Organismsand/or Anaerobes

Consider surgical intervention and add

metronidazole15 mg/kg/day in divided

doses every 8 hours (maximum dose 1.5 gm/day),

PO, IV or rectally

Peritonitis ManagementGRAM NEGATIVE PERITONITIS



Management of Growth Failure


er

.ity

n)

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l dd

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m/day),y

ent

Man

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fGr

owth

Fai

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TREATMENT GOAL

Optimal: final adult height = midparental height (i.e., mean of parents heights +6.5 cm for boys, 6.5 cm for girls)

Minimal: final adult height above third percentile (i.e., > 1.88 SDS) Goal while still growing: target height standard deviation score (SDS) (= midparental

height SDS)

PATTERNS OF GROWTH FAILURE

Loss of relative height (downward crossing of percentiles) Percentile-parallel growth below third percentile Subnormal pubertal growth spurt

FACTORS CONTRIBUTING TO UREMIC GROWTH FAILURE

Malnutrition (most important factor in infants) Electrolyte imbalance (sodium, potassium deficiency; metabolic acidosis) Impaired growth hormone/IGF-1 action (most important factor beyond infancy) In adolescents: delayed onset of puberty Infection/inflammation (occult or overt) Medications (glucocorticoids) Complete loss of residual renal function Inadequate dialysis Excessive dialytic protein losses Low-turnover bone disease/severe secondary hyperparathyroidism Severe psychosocial stress/depression/anorexia

OUTCOME EVALUATION

Monthly measurement of supine length/standing height Annual bone age assessment


Management of Growth Failure


Check

S(g

acid-bas

Evide

Ina

Excessivor low-

Siinfec

Heigh

Man

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arental

y)


MANAGEMENT OF GROWTH FAILURE DURING DIALYSIS

yes

yes

yes

yes

yesyes

no

Check anthropometric status

Start rGH treatment(go to rGH algorithm)

Evidence ofacid-base/electrolyte imbalance?

no

Evidence of malnutrition?

no

Inadequate dialysis?

no

no

Excessive renal osteodystrophyor low-turnover bone disease?

no

Signs of subclinicalinfection/inflammation?

Correct by supplementationto total CO2 22mEq/L

Go to malnutrition algorithm

Go to NIPD/CCPD/CAPD maintenance prescription

algorithms

Monitor growthfor 3 months

after correctionof problem

Continuecurrent

management

Growth rateimproved?

Go to uremic hyperparathyroidism

algorithm

Find and treat underlying cause

Check labsCheck nutritional intake

Height

BASELIN

Monthly: m Every 3 mo Every 12 m

SAFETY

Baseline: h Initial 12 At least ev Before and

funduscop

TREATMENT GOAL

Optimal: final adult height = midparental height(i.e., mean of parents heights +6.5 cm for boys, 6.5 cm for girls)

Minimal: final adult height above third percentile (i.e., >1.88 SDS) Goal while still growing: target height SDS (= midparental height SDS)

RESPONSE CRITERIA

Increase in annual height velocity by >2 cm/year above baseline height velocity in first 2treatment years

Change in standardized height by >0.1 SDS /treatment year in subsequent years (as longas height SDS < 1.88)

rGH DOSE

0.05 mg/kg/day by once daily subcutaneous injection Consider dose doubling in primary or secondary nonresponders

STRATEGIES FOR OPTIMIZED USE OF rGH

Correct/treat causes of growth failure before start of rGH: Electrolyte imbalance (sodium, potassium deficiency; metabolic acidosis) Hypothyroidism (frequent in patients with cystinosis!) Latent or overt inflammation (consider focal, systemic causes) Glucocorticoid medication Inadequate dialysis Inadequate treatment of renal osteodystrophy

Start early in the course of chronic renal failure Start before growth retardation is severe Never use less than standard dose Regularly adjust dose to body weight Assure compliance with daily s.c. injections Continue therapy until transplantation or attainment of target height SDS Be alert to possibility of catch-down growth after discontinuation Discontinue rGH if persistently ineffective (height velocity

BASELINE/OUTCOME EVALUATION

Monthly: measurement of supine length/standing height Every 3 months: puberty staging in peripubertal patients Every 12 months: hand and wrist X-ray

SAFETY EVALUATION

Baseline: hip X-rays Initial 12 months: intensified monitoring of blood pressure and fluid status At least every 3 months: intact PTH, alkaline phosphatase Before and at least every 12 months after start of treatment: glycosylated hemoglobin,

funduscopy (exclude benign intracranial hypertension)


y in first 2

ars (as long

)

hCLINICAL PROCESS FOR OPTIMAL OUTCOMES

MANAGEMENT OF rGH THERAPY

yes

yes

yes

yes

yes yes

Continue treatment. Perform regular safety checks

Consider doubling rGH dose

no

no

no

Discontinue rGH.Re-evaluate

growth after 12months

Transplantation

Discontinue rGH.Evaluate heightvelocity every 34 months

Resume rGHtreatment

Continue monitoring

Find and treat underlying disorder

Continue treatment. Perform regularsafety checks

Improve nutritional status

Increasedialysis dose

Target heightSDS exceeded

Secondary nonresponsiveness(drop of 6-month height velocity

to pretreatment level)

Signs of subclinical inflammation ?

no

New evidence of malnutrition?

no

no

Rapid loss of residual GFR/signsof inadequate dialysis?

Annualized height velocityincreased by >2 cm/year 3months after intervention?

Catch-down growth?

Administer rGH once daily; start with 0.025 mg/kg/day, increase within 4 weeks to 0.05 mg/kg/day

Monitor growth monthly for 6 months

Annualized height velocity increased by >2 cm/year?


Management ofMalnutrition

Man

agem

ent o

f M

alnu

tritio

n





RESPONS

Percentile-height per

Energy intdietary ass

STRATEG

Suppleme Institute co Consider c Maintain r

OUTCOM

Monthly: mand skinfo

Every 3 mo

TREATMENT GOAL

Energy intake 100% RDA Protein intake 120% RDA Water soluble vitamin intake 100% RDA BMI, skinfolds within normal range for height age Linear growth at target height SDS

MANIFESTATIONS

Poor weight gain Poor growth Poor brain growth during infancy Poor school performance Impaired exercise activity Impaired wound healing Impaired sense of well-being/quality of life

CONTRIBUTING FACTORS

Anorexia Emesis Food refusal Food preference Peritonitis Inadequate dialysis Constipation Gastroesophageal reflux Pica Economic factors Impaired physical eating skills

Man

agem

ent o

f M

alnu

tritio




RESPONSE CRITERIA

Percentile-parallel growth and weight gain (catch-up pattern if below target height percentile)

Energy intake = 100%, protein intake 120% of individual requirement (RDA) by dietary assessment

STRATEGIES FOR ENTERAL TUBE SUPPORT

Supplement may be provided by bolus or continuous infusion Institute continuous feedings at rate of approximately 12 mL/kg/hr Consider concomitant use of antiemetic/motility agents if emesis present Maintain regular oral stimulation during infancy to enhance oral-motor development

OUTCOMES EVALUATION

Monthly: measurement of supine length/standing height, weight, head circumferenceand skinfolds (if available); calculation of BMI; biochemical assessment

Every 3 months: head circumference until age 36 months





MANAGEMENT OF MALNUTRITION WITH GROWTH FAILURE IN INFANTS

no

no no

no Nutritional status improved?

Nutritional status improved? Growth rate improved?

Nutritional status improved?

yes

yes

yes

yes

yes

Frequent vomiting?Start rGH treatment

(see growthhormone

algorithm)

Continuecurrent

management

Evidence of malnutrition based on dietary history,anthropometric status and biochemistry

Review dietary (formula) prescription.Monitor nutritional status for 12 months

Start PEG/NG tube feeding.* Monitor nutritional status for 12 months

Modify feeding patterns (continuous nocturnalpump; frequent small-volume feeding)

*Malnourished infants/small children should receive NG feeds for 34 months prior to PEG placement to decrease risk of leak, infection.

Psychosocial assessment andintervention if necessary.

Consider jejunal PEG, fundoplication.

Consider rGH treatment

GR

Apply K/DOQI Pediatric

NutritionalGuidelines

no




.

MANAGEMENT OF MALNUTRITION WITH GROWTH FAILURE IN SCHOOLCHILDREN AND ADOLESCENTS

no no

Nutritional status improved? Growth rate improved?

yes

yes

yes

Consider rGH treatment

Evidence of malnutrition based on dietary history,anthropometric status and biochemistry

Intensify dietary counseling. Increase energy intake if insufficient, consider psychosocial assessment

Monitor nutritional status for 23 months

Monitor nutritional status for 23 months

Consider PEG/NG tube feeding. Consider psychosocial intervention

no

Nutritional status improved?

Apply K/DOQI Pediatric

NutritionalGuidelines

Start rGH treatment

(see growthhormone

algorithm)

Continuecurrent

management



M


Mineral Metabolism


Min

eral

Met

abol

ism


MANIFES

Uremic os gro bon ske abn den red

Myocardia Myopathy Vascular a Hypercalce

CONTRIB

Hyperpho ina- ina

Decreased Hypocalce

hyp dec ske

TREATM

Dietary ph Phosphate

calc sev

Oral calcit com

hyp

RESPONS

Serum pho Serum inta

OUTCOM

Serum calc Serum inta Serum alk

TREATMENT GOAL

Normal bone turnover Prevention of vascular and soft tissue calcifications Control of hyperparathyroidism Normal growth Prevention of skeletal deformities (rickets)

Hyperphosphatemia

MANIFESTATIONS

Hyperparathyroidism Soft tissue and vascular calcifications


Impaired renal phosphate excretion Dietary phosphorus intake (meat, milk products) Inadequate dialysis:

low fill volume, lack of daytime dwell(s) in APD

Insufficient dietary phosphate binder therapy or Nonadherence to phosphate binder prescription

Hypercalcemia

MANIFESTATIONS

Low-turnover bone disease Soft tissue and vascular calcifications


Severe hyperparathyroidism Vitamin D toxicity Low turnover bone disease Use of calcium containing phosphate binders Use of high calcium PD fluid (1.75 mM/3.5 mEq/L Ca2+)


Management of Calcium-phosphate Metabolism


H

Min

eral

Met

abol

ism


MANIFESTATIONS

Uremic osteodystrophy growth failure bone pain skeletal deformities abnormal gait dental abnormalities red eye syndrome

Myocardial fibrosis Myopathy, neuropathy Vascular and soft tissue calcifications Hypercalcemia


Hyperphosphatemia due to: inadequate dietary phosphorus restriction - inadequate oral phosphate binder therapy

Decreased levels of calcitriol due to impaired renal calcitriol synthesis Hypocalcemia due to:

hyperphosphatemia, decreased GI calcium absorption skeletal resistance to PTH

TREATMENT STRATEGIES

Dietary phosphorus restriction Phosphate binder therapy

calcium carbonate/acetate if serum calcium low or normal sevelamer if hypercalcemia present or Ca intake with binders >200% RDA

Oral calcitriol therapy combined with low-calcium PD fluid and/or sevelamer in the presence of

hypercalcemia

RESPONSE CRITERIA

Serum phosphorus, calcium and calcium-phosphorus ion product in normal range for age Serum intact PTH 150300 pg/mL (normal 1065 pg/mL)

OUTCOMES EVALUATION

Serum calcium, phosphorus every 4 weeks Serum intact PTH at least every 23 months Serum alkaline phosphatase activity every 6 months


m-m Hyperparathyroidism




Ma


MANAGEMENT OF UREMIC HYPERPARATHYROIDISM IN CHILDREN ON PD

PTH 2.5 mmol/L (10mg/dl)

Pi normal or elevated

PTH

Management of Anemia


Man

agem

ent o

f Ane

mia


TREATMENT GOAL

Hemoglobin 1112 g/dL Hematocrit 3336%

MANIFESTATIONS

Anorexia Fatigue Decreased exercise capacity Increased risk for patient mortality Left ventricular hypertrophy Poor cardiac function Impaired school performance


Iron deficiency (absolute, functional) Blood loss Vitamin B12, B6 and folate deficiency Carnitine deficiency Secondary hyperparathyroidism Infection/inflammation Surgery Trauma Hemolysis Medications (e.g., ACE inhibitors) Hemoglobinopathies (alpha & beta thalassemia, sickle cell anemia) Malnutrition Inadequate dialysis Aluminum toxicity

OUTCOME EVALUATION

Hemoglobin/hematocrit at least monthly Serum ferritin/TSAT monthly until stable, then every 3 months

IRON PREPARATIONS

Oral iron (35 mg/kg/day elemental iron) Ferrous gluconate (tablets) 12% elemental iron Ferrous sulfate (syrup, elixir, drops, tablets, capsules) powder 20% elemental iron,

dried 30% elemental iron Ferrous fumarate (drops, suspension, tablets) 33% elemental iron Polysaccharide iron complex (capsules, elixir, tablets)

Intravenous Iron dextran Ferric gluconate Iron sucrose




If using d

Man

agem

ent o

f Ane

mia



mental iron,

mia


INITIATION OF ERYTHROPOIETIN (EPO) THERAPY

no

no

noIron replete or receiving iron therapy?

Hgb increase 0.50.75 g/dL weeklyup to target Hgb of 1112 g/dL?

Factors presentthat decrease EPO effect?

yes

yes

yes

See iron administration algorithm

Identify and correct factors

Increase EPOdosage 25%.Repeat Hgb in

12 weeks

Continuecurrent therapy

Hgb 5 yrs)

or100 u/kg/dose twice weekly (




MAINTENANCE ERYTHROPOIETIN (EPO) THERAPY

no

no

yes

yes

Iron replete?

See iron managementalgorithm

Identify and correct other factors

Increase EPOdosage by

25%. RepeatHgb in

12 weeks

Receiving Maintenance EPO

Hgb 12 g/dL and increasing

Increase dosage by 2550%.

Repeat Hgb in 12 weeks

Decrease dosage by 25%.Repeat Hgb in 12 weeks

Continue current therapyFactors present thatdecrease EPO effect?

Monitor Hgb every 12 weeks following initiation and monthly during maintenance therapy.If using darbepoetin alfa, provide weekly equivalent epoetin dose; if epoetin dosing 23 times weekly, convert to darbepoetin alfa dosing once weekly;

if epoetin dosing once weekly, convert to darbepoetin alfa dosing every other week [100 IU epoetin = 0.5 g darbepoetin alfa].

yes

Factors presthat decreaEPO effec

TSAT >20ser

>100 ng/m

Hgb


mia


g surgeryinfection

ge by .

2 weeks

weekly;

IRON ADMINISTRATION

no

no

yes

yes

Factors presentthat decreaseEPO effect?

Consider course of IV iron

Identify and correct

Continue current therapy

Baseline TSAT* and serum ferritin

Initiate oral iron therapy 35 mg/kg/day elemental iron

TSAT and serum ferritin

TSAT >20% to 100 ng/mL to 50%and/or

serum ferritin >800 ng/mL

TSAT

Preparation forTransplantation


Prep

arat

ion

for

Tran

spla

ntat

ion


COMPON

Physical Exam Height, we

evaluationMedical Histo

Detailed pLaboratory S

BUN, creaALT, GGTP

Serology Stu Serology f

Immunizatio DPT, Hep A

months ofHistocompat

Blood typeRadiologic

In infants patency of

Consultation Urology ev

obstructive

TREATMENT GOALS

Thorough evaluation to determine patient suitability/readiness for transplantation Detect and treat reversible medical conditions that may influence transplant outcome Complete all live attenuated viral vaccinations (if possible) 612 weeks prior to transplant

TIMING OF EVALUATION

When progression toward end stage renal disease becomes evident When patient/family is medically/psychologically prepared for evaluation and subsequent

transplant

INDICATION FOR TRANSPLANTATION

Symptoms of uremia not responsive to standard medical therapies Failure to thrive due to limitations in total caloric intake Delayed psychomotor development Hypervolemia Hyperkalemia Metabolic bone disease due to renal osteodystrophy not responsive to standard medical

therapies

CONTRAINDICATION FOR TRANSPLANTATION

Active or untreated malignancy HIV infection Chronic active infection with Hepatitis B Severe multiorgan failure that precludes a combined transplant with a kidney Severe, irreversible neurologic impairment/persistent vegetative state




Prep

arat

ion

for

Tran

spla

ntat

ion


COMPONENTS OF EVALUATION

Physical Exam Height, weight, dental evaluation, pelvic examination (if applicable), ophthalmologic

evaluationMedical History

Detailed patient and family medical history, record of all blood transfusionsLaboratory Studies

BUN, creatinine, electrolytes, calcium, magnesium, glucose, phosphorus, albumin, AST,ALT, GGTP, PT, PTT, CBC with differential/platelets, monthly PRA

Serology Studies Serology for CMV, EBV, VZV, HZV, HIV and Hepatitis A,B,C

Immunizations DPT, Hep A and B, HIB, IPV, pneumococcal, influenza; VZV and MMR (not within 2

months of transplant)Histocompatibility

Blood type, HLA, PRA, cross-matchRadiologic

In infants and small children with history of central venous access, CT/MRI evaluation forpatency of abdominal and pelvic vasculature

Consultation Urology evaluation for assessment of children with history of bladder dysfunction,

obstructive uropathy


ionutcometransplant

ubsequent

d medical






yes

yes

yes

yes

yes

yes

Recipient Evaluation

Medical/nutritional history andphysical examination completed?

Psychosocial assessment ofpatient and family complete?

Laboratory and serologic evaluation completed

and satisfactory?

Genitourinary evaluation completed and satisfactory?

Immunizations up-to-date?

Histocompatibility testing completed?

Complete assessment.Dietary consult if indicated

Refer to Psychologist/Social Worker

Obtain outstanding laboratory data

Refer to pediatric urologist. Review GU history and

radiologic/urodynamic results

Provide immunizations. Delay transplant following live

virus vaccines

Complete testing

no

no

no

no

no

no

Recipient Preparation Complete

Preparation for Transplant




yes

yes no

Proceed with LD transplant evaluation or

list for cadaveric donation

Continue decisionprocess

no

Donor selection

Decision made?

Donor options discussed with patient/family?

Conference with patient/family and transplant personnel


Appendix


Appe

ndix


CAPD Have the patient drain and discard dialysate. Collect all dialysate for the next 24 hours. Dialysate does not require refrigeration OR a

preservative. Draw a blood sample in close proximity to the 24-hr collection period. Send blood

sample to lab for creatinine and urea nitrogen (BUN) measurement. Two methods are common for dialysate collection:

Batch method Pool the entire volume of dialysate and mix thoroughly. Measure the 24-hr. dialysate volume. Draw a final sample of mixed dialysate. Send dialysate sample to lab for creatinine and urea nitrogen (DUN)

measurement. or

Aliquot Method Empty each dialysate bag into a measuring container. Record the individual bag volume. Move the decimal point 3 places to the left. Draw this amount in mL from that

sample of effluent and place in a red top test tube. (i.e., if effluent volume is2350 mL, 2.35 mL are placed in the test tube).

Repeat the process for all bags. Mix all dialysate samples in single container. Send dialysate sample to lab for creatinine and urea nitrogen (DUN).

APD Begin the cycler treatment by draining the patient and saving the drained volume. Collect all dialysate during the cycler treatment using a 15-liter drain bag. If a daytime

exchange is performed, it must be included in the total collection. Instruct the patient to mix the solution thoroughly and obtain a sample. Record the total volume drained. Draw a blood sample in close proximity to the 24-hr collection period. Send to lab for

creatinine and urea nitrogen (BUN) measurement. Send dialysate sample to lab for creatinine and urea nitrogen (DUN) measurement.

Note: When performing 24-hr. collections, standard precautions should be taken when handlingblood or drained dialysate.


Guidelines for 24-HrDialysate Collection


Twenty-fourcollection (ththe growth oits protocol.

To perform t First, have Collect all

bacterial b End the te

complete Draw a blo

to lab for c Measure 2 Send urine

Note: For patrecommendedby 2 to create

G

Appe

ndix


ion OR a

ood

)

L from thatolume is

).

me.daytime

o lab for

ment.

when handling

r

Twenty-four-hour urine collection requires either a preservative be added to thecollection (thymol is the recommended preservative) or refrigeration to inhibit the growth of bacteria that can break down urea. Check with your laboratory forits protocol.

To perform the 24-hr collection: First, have the patient empty his/her bladder and discard urine. Collect all urine for the next 24 hours. Refrigerate urine OR add thymol to prevent

bacterial breakdown of urea End the test by having the patient empty his/her bladder. Save the urine to

complete the 24-hr collection Draw a blood sample in close proximity to the 24-hr collection period. Send blood sample

to lab for creatinine and urea nitrogen (BUN) measurement Measure 24-hr urine volume Send urine sample to lab for creatinine and urea nitrogen (UUN) measurement

Note: For patients who void infrequently (less than 3 times per 24 hours), a 48-hr collection isrecommended. If the sample is a 48-hr collection, the total volume collected should be dividedby 2 to create a 24-hr volume result.


Guidelines for 24-Hr Urine Collection




Clearance Calculations


Cl

Residual renaclearance. Ca

Renal Clearan

Urea Clearan

Creatinine Cle

It is important to measure achieved clearances to document the actual dialysis dosereceived. The following are simplified formulas to calculate patient clearance.

Creatinine Clearance (CrCl) calculation is normalized to BSA. (Refer to the Body Surface Area chart on pages 1819.)

Dialysis CrCl L/week = 24-Hr D/P Cr x 24-Hr Drained Volume x 7 x 1.73m2 BSA

Patients BSA

*D/P = Dialysate concentration/Plasma concentration

Kt/Vurea is the urea clearance normalized for the urea distribution space. Kt is the ureaclearance during the sampling period, and V is the distribution volume of urea. A simplemethod for determining the volume of urea distribution is to estimate the patientstotal body water. It is important to note that different equations exist for estimatingtotal body water, and using a different equation may give different values.

V can be estimated by the following pediatric total body water prediction equation(Morgenstern et al.*):

TBW ( V ) = 0.098 x ( Ht x Wt )0.63

Dialysis Kt/V = 24-Hr D/P Urea x 24-Hr Drained Volume x 7

V

For those patients with renal function, clearance from their residual function is added tothe calculated dialysate clearance for a total combined clearance.

Renal Kt/V = mL/min Urea clearance x 1440 min/day x 7

1000 mL x V

*Morgenstern BZ, Mahoney DW, Wuhl E, Schaefer F and Warady BA. Total Body Water (TBW) in Children on PeritonealDialysis. J Am Soc Nephrol (abst) 2002; 13: 2A



ns Residual Renal Clearance Calculations


Residual renal clearance is calculated as the average of creatinine clearance and ureaclearance. Calculate residual renal clearance using the following formulas.

Renal Clearance:

Urea Clearance mL/min = Volume of 24-Hr Urine in mL x Urine Urea Nitrogen Concentration

1440 min/day x Blood Urea Nitrogen Concentration

Creatinine Clearance mL/min = Volume of 24-Hr Urine in mL x Urine Creatinine Concentration

1440 min/day x Serum Creatinine Concentration

ysis dosece.

m2 BSA

is the urearea. A simplepatientsstimating

quation

s added to

on Peritoneal


Dwell period: 4 hours Fill volume: 1100 mL/m2 BSA* 2.32.4% anhydrous glucose dialysis solution (Europe) 2.5% dextrose dialysis solution (North America, Japan)

Test exchange after prolonged (8 hours) dwell, if possible as follows: Drain the overnight dwell Record the length of the dwell and the volume drained. Also note the dextrose

and volume infused Infuse the calculated fill volume, note infusion time Keep patient in supine position Drain


dextrose

minutesnt

dialysate

curves

evaluation.

g Method of Performing a PET in Children


PEDIATRIC CREATININE PET CURVE

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0

D/P

Crea

tinin

e

0 2 4

Time in Hours

High High Average Low Average Low

Source: Warady, et al., Peritoneal Membrane Transport Function in Children Receiving Long-Term DialysisJournal of the American Society of Nephrology, Vol.7, Number 11, 1996 p.2385-2391

PEDIATRIC GLUCOSE PET CURVE

1

0.9

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0

D/D0

Glu

cose

0 2 4

Time in Hours

High High Average Low Average Low

Source: Warady, et al., Peritoneal Membrane Transport Function in Children Receiving Long-Term DialysisJournal of the American Society of Nephrology, Vol.7, Number 11, 1996 p.2385-2391



1. Schroder CH

peritoneal d

2. Fischbach M

a useful too

3. Sanchez CP

disease. Sem4. Schroder CH

patients. Gu

5. Davis ID, Bu

transplantat

of Transplan

6. Haffner D, S

with chronic

343(13):923

7. Wuhl E, Wit

Reusz GS, R

children nor

8. Warady BA,

Verrina E; In

Patients. Co

Chronic Kidney Failure

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