Ultrafiltration Management in Peritoneal Dialysis
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Transcript of Ultrafiltration Management in Peritoneal Dialysis
Peritoneal Dialysis
Ultrafiltration Management
in Peritoneal Dialysis
Peritoneal Dialysis
Overview
• Fluid Management in Peritoneal Dialysis
• Kinetics of Peritoneal Ultrafiltration
• Icodextrin: Chemistry & Pharmacokinetic Profile
• Icodextrin Efficacy Profile: Ultrafiltration
• Icodextrin Efficacy Profile: Other Clinical Benefits
• Icodextrin: Prescribing Considerations
Peritoneal Dialysis
Rationale = Maximise Fluid Balance
Primary function of renal replacement therapy
PD represents optimal approach to this therapeutic goal
Persistently high prevalence of hypertension and CV mortality among ESRD population underscores untapped potential of PD
Mujais, et al. Mujais, et al. Perit. Dial IntPerit. Dial Int. 2000;20(suppl 4):S5-S21.. 2000;20(suppl 4):S5-S21.
Peritoneal Dialysis
Effective Fluid ManagementEstablished Clinical BenefitsEstablished Clinical Benefits
Controls blood pressureLowers cardiovascular risk
- LVH- CHF- Stroke
Preserves GFRPrevents uremia-like symptomsAvoids acceleration of malnutrition, inflammation and
atherosclerosis syndrome
Peritoneal Dialysis
Fluid Balance
A Clinical ChallengeMaintaining edema-free state
Dynamic nature of target weight
Reliance on clinical judgment and indicators of volume status
Individualized approach to fluid removal
Mujais, et al. Mujais, et al. Perit. Dial IntPerit. Dial Int. 2000;20(suppl 4):S5-S21.. 2000;20(suppl 4):S5-S21.
Peritoneal Dialysis
Optimizing Fluid Management
• Symptomatic fluid retention noted in 25% of PD patients1:• Lower extremity edema 98.6%• Pleural effusions 76.1%• Pulmonary congestion 80.3%
• Similar clinical observations in Japan,2 the Netherlands,3 and Sweden4
11Tzamaloukas, et al. Tzamaloukas, et al. J Am Soc Nephrol.J Am Soc Nephrol. 1995;6:198-206. 1995;6:198-206. 2 2Kawaguchi, et al. Kawaguchi, et al. Kidney Int.Kidney Int. 1997;52:S105-S107. 1997;52:S105-S107. 33 Ho-dac-Pannekeet, et al. Ho-dac-Pannekeet, et al. Perit Dial Int.Perit Dial Int. 1997;17:144-150. 1997;17:144-150. 44Heimbürger, et al. Heimbürger, et al. Perit Dial Int.Perit Dial Int. 1999;19:S83-S90. 1999;19:S83-S90.
Peritoneal Dialysis
Current PD Status
High Prevalence of Elevated BP
05
10152025303540
Normal High-normal Stage 1 Stage 2 Stage 3
JNC6 BP Category
Num
ber o
f Pat
ient
s (%
) I talyUSA
Frankenfield, et al. Frankenfield, et al. Kidney Int.Kidney Int. 1999;55:1998-2010. 1999;55:1998-2010. Cocchi, et al. Cocchi, et al. Nephrol Dial Transplant.Nephrol Dial Transplant. 1999;14:1536-1540. 1999;14:1536-1540.
Peritoneal Dialysis
Volume Reduction & BP Control
Gunal, et al. Gunal, et al. Am J Kidney DisAm J Kidney Dis. 2001;37:588-593.. 2001;37:588-593.
47 hypertensive CAPD patients
20 normotensive20 normotensive
Na restriction & Na restriction & UF UF
3 normotensive 3 normotensive with enalaprilwith enalapril
17 normotensive*17 normotensive* 4 normotensive 4 normotensive with enalaprilwith enalapril
7 hypertensive
3 hypertensive
*37 normotensives in total achieved with volume control alone *37 normotensives in total achieved with volume control alone
Na restrictionNa restriction
27 hypertensive
Peritoneal Dialysis
Fluid Overload
An Underappreciated Cause of CV Mortality
• The majority of dialysis patients die of cardiac causes; 36% present with CHF1,2
• Hypervolemia and hypertension remain important underlying causes3
Causes of Death in Dialysis Causes of Death in Dialysis PatientsPatients11
CardiacCardiacOther knownOther knownInfectionInfectionUnknownUnknownCerebrovascularCerebrovascularMalignancyMalignancy
47%
20%
7%
4%
16%
6%
11USRDS 1997 Annual Report Data. USRDS 1997 Annual Report Data. 22Stack, et al. Stack, et al. Am J Kidney DisAm J Kidney Dis. . 2001;38:992-1000. 2001;38:992-1000. 33Lamiere, et al. Lamiere, et al. Perit Dial IntPerit Dial Int. 2000;21:206-211. . 2000;21:206-211.
Peritoneal Dialysis
Fluid Overload vs UF Failure
An Important Distinction
• Fluid overload is a common clinical syndrome with multiple causes
• It is the inability to maintain target weight and oedema free state
• UF failure is a pathophysiologic characterisation of one of the causes of the clinical syndrome
• Distinction between syndrome and cause determines the intervention to be taken
Mujais, et al. Mujais, et al. Perit. Dial IntPerit. Dial Int. 2000;20(suppl 4):S5-S21.. 2000;20(suppl 4):S5-S21.
Peritoneal Dialysis
Causes of Fluid Overload in PD
• Excessive salt & water intake• Loss of residual renal urine volume• Cardiac disease• Non compliance with PD prescription• Insufficient use of hypertonic exchanges• Dialysate leak• Catheter malfunction• Hyperglycaemia• UF failure
Peritoneal Dialysis
Current UF ManagementHampered by Complexity
Dietary counseling Compliance issues May complicate management
Limiting renal excretion1
Gradual decline to anuria Failure to respond to diuretics
Peritoneal Ultrafiltration (UF) Challenge of the long dwell
Medcalf, et al. Medcalf, et al. Kidney Int. Kidney Int. 2001;59:1128-1133.2001;59:1128-1133.
Peritoneal Dialysis
The Long Dwell in PD
Nighttime DaytimeAPD and CAPD both have long dwellsAPD and CAPD both have long dwellsIn APD, even high-dose nighttime exchanges involve long In APD, even high-dose nighttime exchanges involve long
dwells of 8-12 hoursdwells of 8-12 hours
Long dwell
Long dwell Manual exchange
Manual exchange
Manual exchange
Cycles 1 to 4
APDAPD
CAPDCAPD
Peritoneal Dialysis
Value of the Long Dwell
Toxin removal Small solutes fluid flow-dependent Middle and large MW toxins time-dependent Continuously wet abdomen required for therapy
success
Lifestyle Logistic burden and compliance Realistic therapy imperative
Peritoneal Dialysis
ISPD Ad Hoc Committee
UF Management in PD
“The most frequently ignored principles in PD that lead to UF difficulties are the need to avoid long dwells [with glucose] in high transporters and balancing glucose concentration and dwell time.”
—Peritoneal Dialysis International, 2000
Mujais, et al. Mujais, et al. Perit Dial IntPerit Dial Int. 2000;20(suppl 4):S5-S21.. 2000;20(suppl 4):S5-S21.
Peritoneal Dialysis
4.25% Dextrose
Long Dwell Limitations• Rapid glucose absorption and loss of UF potential
and small solute clearance
• Negative net UF
• Fluid overload
• Systemic metabolic effects and obesity
• Local biocompatibility issues and impact on peritoneal membrane structure and function
Peritoneal Dialysis
Achieving and maintaining target weight
(goal: normal BP, with euvolemia)
Review of dietary compliance/guidelines
Monitoring residual renal function
Evaluating solute clearance
Awareness of peritoneal function
Assessing Volume Status
Proactive Monitoring and Evaluation
Mujais, et al. Mujais, et al. Perit. Dial IntPerit. Dial Int. 2000;20(suppl 4):S5-S21.. 2000;20(suppl 4):S5-S21.
Peritoneal Dialysis
Redefining what is a “dry weight”
Minimal definition Oedema-free body weight
Maximal definition Weight below which further fluid removal results in signs and
symptoms of hypovolemia
Clinical definition Between minimal and maximal definitions with resolution of
volume-dependent derangements in homeostasis (explained – please make notes on this!)
Mujais, et al. Mujais, et al. Perit. Dial IntPerit. Dial Int. 2000;20(suppl 4):S5-S21.. 2000;20(suppl 4):S5-S21.
Peritoneal Dialysis
ISPD* GuidelinesOptimal Fluid Management in PD
Routine standardized monitoring and awareness of PET† status
Dietary counseling of appropriate salt and water intakeProtection of RRF‡
Loop diuretics if RRF presentPatient education for enhanced compliancePreservation of peritoneal membrane functionHyperglycemia control
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*International Society for Peritoneal Dialysis;*International Society for Peritoneal Dialysis;††Peritoneal equilibration test; Peritoneal equilibration test; ‡‡Residual renal function.Residual renal function.
Peritoneal Dialysis
Definition of UF Failure
• Drain volume <2400ml after 4 hour dwell with 2L 4.25% glucose
• 4.25% is preferred to 2.5% PET because the greater osmotic challenge of a 4.25% dwell is more likely to be discriminating in the assessment of UF
Peritoneal Dialysis
UFF Classification
Type I High transport status Rapid loss of glucose
osmotic gradient Commonest; increases
with timeType II Low transport status Loss of peritoneal surface
area Not common
Type III High lymphatic flow rate By exclusion of other
types only Prevalence unknown
Type IV Aquaporin dysfunction Rare
Overall, UFF occurs in <3% of patients in Year 1,In 9.5% by 3 years and in 30% by 6 years
Peritoneal Dialysis
UF FailureA Structured Diagnostic Approach
Mujais, et al. Mujais, et al. Perit Dial IntPerit Dial Int. 2000;20(suppl 4):S5-S21.. 2000;20(suppl 4):S5-S21.
REVERSIBLE CAUSESRRF* PERITONEUM
Appropriate Rx
Dwell time
Dialysate tonicity
Dietaryindiscretion,compliance
Mechanicalcauses
Deficienteducation
Complexregimen
Burn-out
Leaks
Obstructions
Entrapment
Malposition
Low-average or high-average
transport
High transport
*Residual renal function*Residual renal function
Low transport
UF FailureA structured diagnostic approach to managing a patient
Peritoneal Dialysis
UF FailureEvaluating the Clinical Syndrome
Clinical Syndrome
Initial Evaluation for Reversible Causes
Evaluation of Peritoneal Membrane Function
UF Response
Small Solute Transport
Mujais, et al. Mujais, et al. Perit Dial IntPerit Dial Int. 2000;20(suppl 4):S5-S21.. 2000;20(suppl 4):S5-S21.
Peritoneal Dialysis
UF FailureIdentifying Reversible Causes
Clinical Syndrome
Initial Evaluation for Reversible Causes
Dietary Non-Compliance
Appropriate Prescription
Mechanical Problems
Mujais, et al. Mujais, et al. Perit Dial IntPerit Dial Int. 2000;20(suppl 4):S5-S21.. 2000;20(suppl 4):S5-S21.
Peritoneal Dialysis
UF FailureAssessing UF Response
Clinical Syndrome
Initial Evaluation for Reversible Causes
Evaluation of Peritoneal Membrane Function
UF Response
Drain Volume<2400 mL / 4 hr
Drain Volume>2400 mL / 4 hr
Mujais, et al. Mujais, et al. Perit Dial IntPerit Dial Int. 2000;20(suppl 4):S5-S21.. 2000;20(suppl 4):S5-S21.
Peritoneal Dialysis
UF FailurePeritoneal Membrane Function
Drain Volume<2400 mL/4 hr
Small Solute Profile
Low TransportD/P Cr <0.5
High TransportD/P Cr >0.81
High-Avg or Low-Avg0.81> D/P Cr >0.5
UF Response
Mujais, et al. Mujais, et al. Perit Dial IntPerit Dial Int. 2000;20(suppl 4):S5-S21.. 2000;20(suppl 4):S5-S21.
Peritoneal Dialysis
UF FailureLow Drain, Low Transport
Low TransportD/P Cr <0.5
Disruption of peritoneal space, adhesions, etc. Peritoneography
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Drain Volume<2400 mL/4 hr
Small Solute Profile
Peritoneal Dialysis
UF FailureLow Drain, High-Avg or Low-Avg Transport
High-Avg or Low-Avg Transport0.5< D/P Cr <0.81
Mechanical problems Tissue absorption Aquaporin deficiency
Mujais, et al. Mujais, et al. Perit Dial IntPerit Dial Int. 2000;20(suppl 4):S5-S21.. 2000;20(suppl 4):S5-S21.
Drain Volume<2400 mL/4 hr
Small Solute Profile
Peritoneal Dialysis
UF FailureLow Drain, High Transport
Drain Volume<2400 mL/4 hr
Small Solute Profile
High TransportD/P Cr >0.81
Inherently high transport Recent peritonitis High transport of long-term PD
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Peritoneal Dialysis
Therapeutic Approaches
Universal MeasuresLow Drain, High Transport
– CAPDAPD– Icodextrin for long dwells
Low Drain, High-Avg or Low-Avg Transport
– Icodextrin for long dwells– Dextrose for short dwells
Low Drain, Low Transport
– High-dose loop diuretics with RRF
– Adjunctive HD or transfer to HD
Mujais, et al. Mujais, et al. Perit Dial IntPerit Dial Int. 2000;20(suppl 4):S5-S21.. 2000;20(suppl 4):S5-S21.
Peritoneal Dialysis
Guidelines for improving UF
CAPD Avoidance of long dwells with low glucose concentrations Use of nighttime exchange devices Tailoring prescriptions to transport profiles determined by PET
APD Avoidance of long dwells with low glucose concentrations Use of short day dwells even when no additional exchanges
needed for clearance
Peritoneal Dialysis
Volume Control Algorithm
SaltF lu id
DietaryEvaluation
VolumeTrend
Meds/effects
ResidualRenal Function
Long dw ellTotal UF
PET
PeritonealPrescrip tion
Interventions
Peritoneal Dialysis
Volume Control Algorithm
QOL issuesInventory control
Delivered dose
EvaluateCom pliance
localized vs.generalized
Trend
CharacterizeEdem a
Outflow obsLeaks/hernia
CatheterFunction
Interventions
Peritoneal Dialysis
Volume Control Algorithm
ReviewPET
Modifydw ell tim e
Modifytonicity
Alternateosm otic agent
N egativenet UF
O ptionalm in im ize 4 .25%
Positivenet UF
EvaluateLong dw ell U F
24 hr UF
Perit. P rescription
Peritoneal DialysisVolume Control Algorithm
I ncreasecycle num ber
Modifyton icity
I ncreasecycler tim e
Considerfi ll volum e
Cycler
Modifyton icity
Consideradditional exchange
Considerfi ll volum e
CAPD
O ptim izeshort dw ell U F
Peritoneal Dialysis
Volume Control Algorithm
Nephrotoxins?
<200 m l/day
ConsiderD iuretics
>200 m l/day
UrineOutput
Peritoneal Dialysis
High transport & outcomeHigh transporters: Efficient membranes for small solute clearancebut may have difficulty with ultrafiltration, especially during the long dwell Recent studies
(Davis1 and Churchill2) have shown that high transporters had a worse prognosis probably due to a more difficult fluid balance management
60
70
80
90
100
0 6 12 18 24
% S
urvi
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Time in Months
HighHigh AverageLow AverageLow
Impact on outcomes in PD
1 Davis et al. KI 1999 Vol 54 p 2207 – 2217 2 Churchill et al JASN 1998 - Vol 9 1285 - 1292
Peritoneal Dialysis
Therapeutic approaches
Inherent high transporters• APD & icodextrin for the long dwell is the
recommended therapeutic approach
Recent peritonitis• “Several studies have indicated that UF during an episode
of peritonitis can be satisfactorily achieved with the use of icodextrin”
High transport during long term PD• For patients with a net UF less than 400 mL/4 hours and a
high transport profile of small solute clearance, APD and icodextrin for the long dwell are the recommended therapeutic approaches
Mujais, et al. Mujais, et al. Perit Dial IntPerit Dial Int. 2000;20(suppl 4):S5-S21.. 2000;20(suppl 4):S5-S21.
Peritoneal Dialysis
Summary: 12 Strategies to improve Volume Management in PD
1. Start PD earlier2. Protect residual renal function3. Use high-dose loop diuretics o maintain urine
output4. Educate patients regarding salt and water
intake and regarding significance of oedema, weight gain, etc
5. Appropriate use of hypertonic solutions6. Awareness of PET status
Peritoneal Dialysis
7. Consider APD in high and high average transporters8. Night exchange device in CAPD if night –t im dwell
is reabsorbed9. Short day dwells on APD – long enough to give
good clearance and short enough to give good UF10. Icodextrin for long dwells in CAPD & APD11. Frequent reassessment of the patient’s target
weight12. Anti-hypertensives only when volume removal has
failed to reduce BP.
Summary: 12 Strategies to improve Volume Management in PD
Peritoneal Dialysis
Case Study