Therapy Modality: Automated Peritoneal Dialysis (APD) Renal Division Baxter Healthcare

APD – prescription basics Automated (cycler) therapy Flexible prescription volumes Recommended – (European APD Advanced Club) 9 hour total therapy time (CCPD, NIPD) 12-14L. total therapy volume ‘Wet’ days, i.e. long day dwell of 12-15 hr (Extraneal) 4-8 nightly cycles, with (optional) 1-2 additional day exchanges /cycles Daily therapy, 7 days week 30 minute – 120 minute dwell times each cycle (depending on PET result)

Types of PD

APD benefits Optimum dialysis for high transporters, large body surface area, and minimal residual renal function Offers potential for better clearances than in CAPD Volumetric control of fill, drain and therapy volume delivery Supine positions at night permit larger fill volumes, a major determinant of treatment adequacy Short dwells may increase ultrafiltration & clearance

APD benefits Reduced risk of intra-peritoneal pressure complications:hernias, leak, back pain, reduced appetite 8. Reported lower incidence of peritonitis than CAPD 9. Treatment of choice for children – avoids school interruptions and encourages peer integration (“normality”) 10. Daytime freedom and comfort

APD benefits Employment and school uninterrupted Improved patient compliance 13. Increased patient comfort 14. Possible to monitor patient compliance at home

Clinical Practice Guidelines of the Canadian Society of Nephrology for treatments of Patients with CRF JASN 10: S287-S321, 1999 ‘A prescription that is compatible with the patient’s preferences and lifestyle is likely to reduce the risk of patient « burnout » and noncompliance’

APD regimens

APD Nightly Intermittent PD (NIPD) APD performed nightly only, with complete fill and drain of the peritoneal cavity Most patients cannot be maintained on NIPD alone without diurnal additions Limitations: Not efficient in anuric patients Inadequate in large BSA patients (>2m2) Inadequate in low – low average Transporters High cost may be prohibitive

APD modalities TIDAL PD Dialysis fill volume is only partly drained, leaving a ‘reserve’ volume in contact with peritoneum Tidal fill volume brings fresh fluid to mix with the reserve volume each cycle Tidal therapy increases dialysate flow and reduces drain and fill times (therapy rationale) Combined with larger fill volumes, it will raise clearances in ‘High’ to ‘High Average’ transporters Only option for anephric patient clearance Less ‘drain-pain’ an added advantage

APD modalities CCPD – Continuous Cyclic PD Nocturnal therapy, with day time long dwell (only realistic if Icodextrin containing solution used for day dwell) 5-8 exchanges in relatively short dwell periods, maximising U/F and clearances Therapy most used in practice

APD modalities IPD - Intermittent PD PD prescribed mainly 2-3 times per week for 12-20 hours each session Large volumes (20-40 litres) are cycled each session, short dwells, fill volumes 1.5-3.0 litres IPD fails to deliver sufficient quantity dialysis if BSA, RRF Mostly used in elderly; acute patients; new catheter conditioning – N.B. no longer a preferred modality for majority of patients Only adequate for high transport patients Reduced protein losses, glucose absorption and fluid retention

APD - therapy programming Inputs required: Total therapy volume Total therapy time Fill volume Last fill: volume, and same or different dextrose Machine calculates: Number of cycles Estimated Dwell time per cycle

Programming the HomeChoice System Example therapy: Total therapy volume = 12000 ml Total therapy time = Nine hours Fill volume = 2000 ml Last bag = 2000 ml, same dextrose Machine calculates: Number of cycles = 5 cycles Estimated Dwell time per cycle = 1:19 1. HomeChoice assumes 'typical' flow rates to calculate Drain and Fill times. 2. Dwell times are updated throughout the therapy depending on actual time required for Fill and Drain. 3. HomeChoice ALWAYS DELIVERS THE MAXIMUM AMOUNT OF DWELL TIME WITHIN THE PROGRAMMED THERAPY TIME!

How does it work ? 5 litre 5 2.5 SETUP of system (example): A. One 5000ml bag on the heater plate B. Other bags connected to the HomeChoice set: 5 litre 5 2.5 Press go to start Baxter

APD made easier PRO Card PATIENT’S HOME HOSPITAL PD LINKä software PRO Card The PRO Card is used to download therapy information from the HomeChoice PRO and is read, at the hospital, using the PD Link software

How does it work? 1 Write a Prescription 2 Program HomeChoice PRO with Pro Card 3 HomeChoice PRO records therapy results 4 Retrieve therapy results or 5 Analyze therapy results

Managing Patients on Home Therapies Balancing Clinical and Lifestyle Needs: Dialysate Clearances Quality of Life The balance results in Improved Outcomes

Procedural Modifications - to improve UF 1 2 3 4

Procedural Modifications - fill (dwell) volume Increasing fill volumes maximises the peritoneal capacity and improves solute clearances. You will notice that the time between exchanges however does NOT change.

Procedural Modification - no. of exchanges

Procedural Modifications - partial day fill

APD - Increasing Clearance Programme an increase in fill volume Effective means of improving clearance Minimum impact on patient lifestyle Adjust nighttime exchanges first Use 2.0L or greater whenever possible Add a daytime exchange Increase Time on Cycler Increase Number of Nighttime Exchanges

APD - Increasing Clearance Increase fill volumes Add a daytime exchange This is a very effective means of improving clearance HomeChoice can be programmed to deliver an exchange at midday Increase Time on Cycler Increase Number of Nighttime Exchanges

APD - Increasing Clearance Increase fill volumes Add a daytime exchange Increase Programmed Time on Cycler Cycler time can be extended to 10 hours Increasing cycler time with a constant number of exchanges increases dwell time which increases clearance Increase Number of Night-time Exchanges - May increase clearance, but only if dwell time on cycler is also increased

The Importance of “Wet Days” > 85% of APD patients - all except High Transporters – will require a daytime dwell to achieve adequate dialysis > High transporters need daytime dwells with Icodextrin to achieve ultrafiltration targets > 85% Wet Day Dry Day 0% 5% 10% 15% 20% 25% 30% 35% Low Average High CCPD+CAPD CCPD NIPD

Fluid Balance - General Guidelines for APD Evaluation and Management of Ultrafiltration problems in PD, ISPD Recommendations, PDI Vol 20, suppl 4, 2000 Avoidance of long dwells with low glucose Use of mid-day drain even when no additional exchange is needed for clearance “The most frequently ignored principles in PD that lead to UF difficulties are the need to avoid long glucose dwells in high transporters and balancing glucose concentration and dwell time”

Designing the Optimal APD Therapy Fact: APD utilizes shorter dwell times, relative to CAPD. Therefore, more solution volume is needed to provide adequate clearance Fiction: More total solution volume will always provide better clearance for APD patients The Key to success with APD is a balance of: Solution Volume and Dwell Time Excessive solution volume = too many cycles = wasted time filling and draining = reduced clearances

CAPD or APD? CAPD Easy technique Daytime exchanges can be difficult if working or for carer Poor UF if high transporter resulting in use of high dextrose fluids APD More difficult technique No or only 1 daytime exchange Easier to achieve high UF independent of transporter status

CAPD or APD? CAPD Difficult to  adeq by  exchange number or volume  exchange volume  intraperitoneal pressure when patient ambulant  risk of herniae and leaks APD Easy to  adequacy by  exchange number overnight Intraperitoneal pressure lower when patient supine  risk of herniae and leaks

CAPD or APD? CAPD Adequacy  in low transporters by 5th exchange - ‘Quantum’ or 1/wk HD Ease of travel Peritonitis 1/20-24 mths APD Difficult to achieve adequacy in low transporters Can travel with machine or revert to CAPD Peritonitis 1/30-40 mths