Prescription

peritoneal dialysis

Pantipa Tonsawan, MD

Case

Female , 50 yrs, ESRD PD

BW 50 kg , Ht 155 cm (BSA 1.50m2,
GFR 2ml/min = CCr 20L/wk Kt/V =
0.5 /wk) PET low
average transport

NKF-DOQI (weely CCr
60L/1.73m2)

ESRD ??????

Mode PD Vs HD
PD :CAPD or APD
APD : CCPD, NIPD TPD
Prescribe?? :Dwell time , fill volume
, cycle, tidal volume
Follow up : lab, adequacy

Indication / Contraindications
of PD

80% of patients have no contraindication to any of the dialysis

methods and may choose according to
their life style between HD or PD

Absolute contra-indications of PD:

1.peritoneal fibrosis and adhesions
following intra-abdominal operations
2.inflammatory gut diseases

Relative Contra-indications of PD
pleuro-peritoneal

leakage (Hydrothorax)
hernia
significant loin pain
big polycystic kidneys

diverticulosis

colostomy
obesity
blindness

severe deformity arthritis

psychosis
significant decrease of lung
functions

PD :Advantage

Preserve residual renal function

Control acid- base
HD stable
No vascular access
Control HT
No anticoagulant

Why to start with PD ?

Clinical outcomes comparable to

HD, no difference
Saves vascular access
Preferred for children (APD)
Modality choice is a lifestyle
issue
Control HT

Adjusted all-cause DR for nondiabetic

patients treated with HD and PD.
USRDS annual reports covering the cohort

USRDS annual reports covering the cohort

J Am Soc Nephrol 10:354-365, 1999

Adjusted all-cause DR for younger (age

<50) diabetic patients treated with HD
and PD.

J Am Soc Nephrol 10:354-365, 1999

Adjusted all-cause DR for younger (age

>50) diabetic patients treated with HD
and PD.

J Am Soc Nephrol 10:354-365, 1999

Mortality studies comparing peritoneal

dialysis and hemodialysis: what do they
tell us?

Total of six large-scale registry studies & three prospective

cohort studies conducted in the United States (US), Canada,
Denmark, and the Netherlands were reviewed.
PD was generally found to be associated with equal or better
survival among non-diabetic patients and younger diabetic
patients
older diabetic patients, results varied by country
Canadian & Danish :no difference in survival between PD & HD
US, HD associated with better survival for diabetics aged 45
and older

Kidney Int Suppl. 2006 Nov;

(103):S3-11.

Conclude
overall patient survival is similar for PD
& HD but that important differences do exist
within select subgroups of patients,
particularly those subgroups defined by age
and the presence or absence of diabetes.

Why to start with PD ?

Dose residual renal function decline in HD more
than PD

Advancce in peritoneal dialysis ;vol 20 ;2004

Why to start with PD ?

1. better maintenance of residual renal function

Why to start with PD ?

Dose residual renal function decline in HD more than PD

Decline residual renal function :20-80 %

NECOSAD study group KI :

2002

SELECTION OF DIALYSIS MODALITY

PD/HD
Indication & Contraindication
Prefer
Family member, care giver
Underlying disease
Socioeconomic status

Term PD cycle

Fill volume
Exchange
volume,
dwell volume

Start

Last
fill

Tidal volume

Inflo
w

Dwell
time

Outflo
w

Dwell time

Principle of

Fill volume :risk factor

Low fill volume

UF failure
Increase
morbidity &
mortality

high fill volume

Pain, abdominal
discomfort
Dyspnea
Hernia formation
Hydrothorax
Loss UF by enhance
lymphatic drainage

Tidal volume

Increase amount ;diffusion

Increase : toxin removal

Inflow + outflow: limit

Depend of catheter resistant or

obstruction
Gravity
Drain volume

Mode

Peritoneal
dialysis

Continuous
CAPD

CCPD

Standard vol.
Standard dose
High volume
Standard dose

Standard vol.
High dose
High vol.
High dose

Intermittent

NIPD
Add

DAPD
High NIPD
NTPD

Mode
CAPD :continuous ambulatory peritoneal
dialysis

CCPD :Continuous cyclic peritoneal

dialysis

DAPD :daytime ambulatory peritoneal

dialysis

NIPD :night-time intermittent peritoneal

dialysis

Factors that need to be taken into account in choosing CAPD or APD

CAPD

APD

Easy technique

More difficult

Daytime exchange can be difficult if

working or carier doing exchanges

None (with icodextrin) or only 1 daytime

exchange

Poor UF if high transporter requiring use of

higher concentration glucose exchanges

Easier to achieve good UF independent of

transporter status

Some difficulty to increase adequacy by

increasing number or volume of exchanges

Easier to increase adequacy by increasing

number of exchanges overnight/daytime

Increasing exchange volume leads to

increased intra-abdominal pressure when
patient ambulant. Increased risk of hernia

Intra-abdominal pressure lower when

supine. Decreased risk of hernia; better
management of patient with hernias, leaks

Ease of travel

Can travel with machine or revert to CAPD

Peritonitis rate 1 episode/2030 months

Peritonitis rate 1 episode/3040 months

PD First prescription

Consider;
Size BSA
Residual renal function
PET but only if you can tell the
future
Mode :CAPD or APD

Prescribing APD EAPOS

guidelines
Brown, et al. J Am Soc Nephrol. 2003;14:2948-2957.
Solute
Transport

Low

Low
Average

High
Average

High

BSA
< 1.71 m2

CAPD

N: 3 x 2.5 L
(9-10 hr)
D: 2 x 2L

N: 4 x 2 L
(8 hr)
D: 2 x 2L

N: 4 x 2.5 L
(8 hr)
D: 2 x 2L

BSA
1.71 2.0 m2

CAPD or HD

N: 3 x 2.5 L
(9-10
hr)
D: 2 x 2.5L

N: 4 x 2.5 L
(8 hr)
D: 2 x 2.5L

N: 4 x 2.5 L
or
5x2
L (8 hr)
D: 2 x 2.5 L

BSA
2.0 m2

CAPD or HD

CAPD or HD

N: 4 x 3 L
(8 hr)
D: 2 x 2.5L

N: 4-5 x 2.5
L
(8
hr)
D: 2 x 2.5 L

APD
N: 3 x 2 L
(9-10 hr)
D: 2 x 2 L

APD
N: 3 x 3 L
(9-10 hr)
D: 2 x 3 L

Solute transport determined by PET.

BSA, body surface area; N, night; D, day.

Choice of PD scheme depends of BSA and

type of transport

CAPD Vs APD

Impact of PD modality on various clinically important outcomes

Rabindranath, K. S. et al. Nephrol. Dial. Transplant. 2007 22:2991-2998;

doi:10.1093/ndt/gfm515

Copyright restrictions may apply.

Automated vs continuous ambulatory peritoneal dialysis:

a systematic review of randomized controlled trials
Complications expressed as episodes per patient-year

Rabindranath, K. S. et al. Nephrol. Dial. Transplant. 2007 22:2991-2998;

Copyright
restrictions may apply.
doi:10.1093/ndt/gfm515

The Cochrane Collaboration, currently published in

The Cochrane Database of Systematic Reviews 2009 Issue

The influence of automated peritoneal

dialysis on the decrease in residual renal
function

APD 18 pts compare CAPD 18 pts : F/U 6 mo & 1 yr

Nephrology Dialysis Transplantation, 1999,Vol 14, Issue 5 1224-1228,

Summary

APD CAPD : peritonitis

Caution APD decline RRF > CAPD
Other non significant
Selection method :1. patient
contraindication , preference base on
life style, comfort with cycler & family +
social support
2.medical requirement: adequacy

Prescription

Acute peritoneal dialysis

Chronic peritoneal dialysis

Acute peritoneal dialysis

order

Session length: 24 hr at time

Exchange volume :depend size of
peritoneal cavity, tolerate 2-L
exchange
Smaller dose :pulmonary disease
Prefer start :1-1.5 L :1st exchange
(leakage)
In large pt or hypercatabolic : 2.5- 3 L

Acute peritoneal dialysis

order

Exchange time :inflow , dwell &

drain
Dialysis solution : depend on
indication
standard 1.5 %, high : 4.25 %

Table : Estimated ultrafiltration volume

during acute peritoneal dialysis
Dextros
e

Solution
osmolarity

Glucose

Ultrafiltration
volume

g/dl

g/dl

mg/dl

mmol/L mOsm/L

ml per
exchange

1.5
2.5
4.25

1.36

1360

76

346

50-150

1.2-3.6

2.27

2270

126

396

100-300

2.4-7.2

3.86

3860

215

485

300-400

7.2-9.6

L per day

2 L exchange volume, 60 min exchange time

Handbook of dialysis 4th ed 2007

Acute peritoneal dialysis

order
1.

Acute peritoneal dialysis

order
2.

3.

Complicatio
ns

Prescription of CAPD

Dose : cycle/day
Volume : exchange volume
Standard dose :3-4 time/day
Standard volume :6-8 L/day
Typical order :4* 2L daily
Dialysis solution: 1.5, 2.5 .4.25 %
Ca : low Ca , normal Ca

Augmentation UF :CAPD

Increase exchange volume

Increase frequency
Increase tonicity

Prescription
Modification

Prescription
Modification

Automated PD

Mode : PET test

Dialysis solution : glucose / Ca
Duration : dwell time, cycle,
Tidal volume :
Last fill volume :??

Initial APD prescription

Mode : NIPD
Solution : 1.5%
Duration ;8-12 hr
Fill volume : 1.5-2.0 ml
Dwell Day volume:2-L : caution
:fluid reabsorption (if high
transport) other choice : icodextrin :
water-soluble glucose polymer

First prescription KDOQI

If GFR > 2 ml/min

If GFR < 2 ml/min

How to improved
clearance in APD
????

Prescription Modification

Prescription
Modification

Prescription
Modification

Using computer support to

help

Increase peritoneal
clearance ?

Day dwell volume :increase Kt/V

& CrCl 25-50 %
Increase dwell volume on cycler
Time on cycler
Increase frequency of cycles
Increase tonicity of dialysis
solution

Prescription AIM

Adequacy : Kt/V
Euvolemia : PCWP ?
= no edema : UF
normal BP &
minimize anti HT drug

> 750 ml/d

<750 ml/d

Fluid Removal and Outcome

Managing PD adequacy &

prescription

Initiate Therapy
Dont forget!

Measure clearance
and UF

Adjust Therapy

PD getting started

Measure Clearances at 2-4 weeks, then

2-3 times in first 6 months
Thereafter every 3-4 months
Measure PET at 1 month
If urine volume low use 48hr collection
Leave clearances for a month after
peritonitis
P creatinine CAPD anytime, APD mid
daytime

Case

Female , 50 yrs, ESRD PD

BW 50 kg , Ht 155 cm (BSA 1.50m2,
GFR 2ml/min = CCr 20L/wk Kt/V
= 0.5 /wk) PET
low average transport
NKF-DOQI (weely CCr
60L/1.73m2)

Calculated

??????

Principle :
Total target CCr =

Weekly

60 L/1.73
m2

BSA pt
1.5 ;

40
L/1.73m2

20 L/1.73
m2

Need =35 L/
week

*** Dialysis volume = dialysate CCr/ 7* D/Pcr ****

D/Pcr = ratio concentration of Cr dialysate/
plasma(24 hr)

Calculated

Need =35 L/
week

Estimated PET : D/Pcr at 6 hr :low average transport

= 0.59
Dialysis volume = dialysate CCr/ 7* D/Pcr
= 35 /7*0.59
Mode
8.47 L/
day(7.2)
10 -20 % :
clearance
;ultrafiltration &
convection

CAPD :continuous ambulatory peritoneal

dialysis
1.5 L * 5
cycle
2

Vs

2.5 *

Patient ; preference

CCPD :Continuous cyclic peritoneal

dialysis

Day time 1.5 L , Night : 2 L * 3 cycles

Summary

Prescribing PD is important and

important factors include

Size
Transport status
Residual renal function
Other factors

Check clinical status supported by

measurements eg UF and adequacy

Blood pressure control in

dialysis patient :HD Vs PD

Case

Male , 50 yrs, ESRD with morbid obesity, BW

86 kg , Ht 155 cm
NKF-DOQI (weekly CCr 60L/1.73m2)
:prescribe?
Female 70 yrs, DM , HT ,ESRD & ICM BW 45
:prescribe?
Female , 40 years , ESRD , Hx TB peritonitis *
2 time on anti Tb drug complete course
:prescribe ?
Male 50 yrs ,ESRD, HT & alcoholic cirrhosis
child B ascites positive :

Different HD & PD

Prefer PD

Prefer HD