Adequat dialyse Kvalitetssikring K t / V

Hvad er kvalitet…..Effektivitet ?

X Effektivitet =

X Effektivitet =

X Kt/V = Effektivitet = Watson 2.447 - (0.09156 x age) + (0.1074 x height) + (0.3362 x weight)

Kt/V = Din renale

Kt/V = Din renale = 3,6 pr dag . 25 pr uge X 100 ml/min 1440 min

Peritoneal Dialyse Kt/V

+ Kt/V 24 timers opsamling Måling Total dialyse dræn Total Residual urin Total dialyse dræn Måling 10

Målinger Total Urin volumen (liter) u-Carbamid (mmol/l) u-Kreatinin (mmol/l) Total drænmængde(liter) d-Carbamid (mmol/l) d-kreatinin (mmol/l) s-carbamid (mmol/l) s-kreatinin (mmol/l)

Alt kan beregnes med en simpel calculator

K t / V pr uge Kt/V = dialyse Kt/V + renal Kt/V Body Water (watson) Renal carbamid Kt/V: volumen (liter) u-Carb (mmol/l) d-Carb (mmol/l) s-Carb (mmol/l) u-Carbamid s-Carbamid X urin volumen x 7 Body Water (watson) Dialyse carbamid Kt/V: d-Carbamid s-Carbamid x dialysat volumen x 7 Body Water (watson) Kt/V = dialyse Kt/V + renal Kt/V

(Renal clear. + Dialys clear.) x 1,73 m2 Kreatinin Clearance Renal kreatininclearance (GFR): u-kreatinin x volumen + u-carb x volumen volym (liter) u-Urea (mmol/l) u-Kreatinin (mmol/l) d-Urea (mmol/l) d-kreatinin (mmol/l) s-Urea (mmol/l) s-kreatinin (mmol/l) S-kreatinin S-urea 2 Dialyse kreatininclearance: d-kreatinin s-kreatinin x dialysat volumen Om man endast räknar u-kreatinin/s-kreatinin så får man ett falskt högt renalt kreatininclearace då kreatinin inte bara filtreras i glumeruli utan dessutom sekreeras i tubuli Total normaliseret kreatinin clearance: (Renal clear. + Dialys clear.) x 1,73 m2 Patientens BSA 14

Protein Catabolic Rate (nPCR) Calculations Randerson nPCR nPCR = 5.02 * {[Urea Generation Rate (mmol/min) * 60.06] + 3.12} / Weight in kg Bergstrom nPCR nPCR = {19 + (0.213 * Urea Appearance Rate)} / Weight in kg Urea Appearance Rate = {[24 hour Urine(mLs) * Urine Urea (mmol/L)] + [24 hour Drain Volume * Dialysate Urea(mmol/L)]} / 1000

Ideal Body Weight Kun effekt på beregninger af nPCR. Total Body Water og BSA bruger stadig aktuelle vægt.

Målsætning ? Kvalitet og Kt/V

1996: CANUSA : mortality decreased by 6% for each 0 1996: CANUSA : mortality decreased by 6% for each 0.1 u/week increase in weekly Kt/Vurea, and decreased by 7% for each 5L/week/1.73m2 increase in creatinine clearance. 2001: CANUSA reanalysis: (1) PD outcome was predicted by renal Kt/Vurea but not peritoneal Kt/Vurea, (2) changes in survival over time were due to changes in residual renal function, (3) each 5L/week renal GFR was associated with a 12% survival benefit. 2002: ADEMEX: 965 CAPD patients in Mexico   The study achieved a good separation between the two groups (pCcr of 46 vs. 57 L/week/1.73m2). There was no difference in survival at the end of 2 years. Interestingly, the overall mortality rates in this study were similar to the 2 year survival rates seen in the HEMO trial, which evaluated the effect of dialysis dose on outcomes in hemodialysis. 2003: Hong Kong Trial : 320 incident PD patients were randomized to three target pKt/Vurea goals (1.5 - 1.7, 1.7 - 2.0, and > 2.0). This study achieved good separation between the groups, and residual renal function was the same in all groups. There was no difference in survival between the groups; however, the lowest Kt/V group (pKt/Vurea 1.5 - 1.7) exhibited more dropout due to inadequate dialysis, and also require higher doses of ESA to achieve hemoglobin targets.

ISPD GUIDELINES/RECOMMENDATIONS Egen nyrefunktion er godt Residual renal function (measured by renal clearance or urine volume), but not peritoneal clearance, is predictive of survival in prospective observational studies and can account for most of the association between total clearance and survival Mere dialyse ingen effekt Prospective randomized interventional studies do not provide evidence to support a beneficial effect of increasing dialysis to total Kt/V urea above 2.0, or creatinine clearance above 60 L/week/1.73 m2, in patients on continuous ambulatory peritoneal di- alysis (CAPD) with a total Kt/V urea above 1.70 For lidt dialyse ikke godt Interventional studies have demonstrated that total Kt/V below 1.70 is associated with poorer primary or secondary outcome.

Adequacy of dialysis should be interpreted clinically ISPD GUIDELINES/RECOMMENDATIONS Adequacy of dialysis should be interpreted clinically rather than by targeting only solute and fluid removal.

Trivsel Energi Job Ca-P-PTH BT Ødemer Anæmi …….. …….

Målsætning Kvalitet og Kt/V K t / V >= 1.7

d -carbamid = 25 (100 % mætning) bags = 8 - 12 liter/dag Maximum Kt/V 80 kg Water = 40 L se-carbamid = 25 d -carbamid = 25 (100 % mætning) bags = 8 - 12 liter/dag ( D- Carbamid X D-Volumen Ud/ S-Carbamid ) / Body Water poser ialt 8 L : (25 x 8 / 25 ) / 40 = 0,2 day ---> 1,4 weekly poser ialt 12 L : (25 x 12 / 25 ) / 40 = 0,3 day ---> 2,1 weekly

https://www.advancedrenaleducation.com/pd-calculator

Regimen predictions 50 80

Optimization results

Monitor individual patient's clearances over time

The Group Distribution