Prescription of pediatric peritoneal dialysis Constantinos J. Stefanidis stefanid@hol.gr “A.& P. Kyriakou” Children's Hospital, Athens, Greece C J Stefanidis . 2001

EPPWG adequacy guidelines The European Paediatric Peritoneal Working Group was established in 1999 by paediatric nephrologists experts in peritoneal dialysis. The guidelines on adequacy were initiated by two members of the group. Then they were discussed at meetings of the group and by e-mail to develop consensus of opinion based upon clinical experience and reported studies. C J Stefanidis 2001

EPPWG adequacy guidelines M Fischbach, Centre Hospitalier Regional, Strasbourg, France C Stefanidis, A & K Kyriakou Children's Hospital, Athens, Greece A R Watson,Children & Young People's Kidney Unit Nottingham UK C Schroder, Wilhelmina Kinderziekenhuis, Utrecht, The Netherlands A Zurowska, Medical University of Gdansk, Gdansk, Poland V Strazdins, University Hospital, Riga, Latvia K Ronnholm, University of Helsinki, Helsinki, Finland E Simkova, University Hospital Motol, Prague, Czech Republic A Edefonti, Clinica Pediatrica C&D de Marchi, Un. of Milan, Italy C J Stefanidis 2001

EPPWG adequacy guidelines Guidelines by an Ad Hoc European Committee on Adequacy and the Pediatric Peritoneal Dialysis Prescription Michel Fischbach, Constantinos J Stefanidis, Alan R Watson for the European Pediatric Peritoneal Dialysis Working Group† Nephrol Dial Transplant (in press) C J Stefanidis 2001

Νational Κidney Foundation Dialysis Outcomes Quality Initiative D O Q I Dialysis Outcomes Quality Initiative In 1995 206 / >11 000 articles were selected by 70 professionals for the final publication. In 1997 114 evidence-based clinical practice guidelines were developed. Am J Kidney Dis 1997 In 2001 DOQI becomes K/DOQI and is updated. Am J Kidney Dis 2001 C J Stefanidis 2001

Adequate Dose of Peritoneal Dialysis V. Adequate Dose of Peritoneal Dialysis Guideline 15 and 16 Recomended weekly Doses CAPD Kt/Vurea > 2.0 and cr. clearance >60 L/1.73 m2 CCPD Kt/Vurea > 2.1 and cr. clearance >63 L/1.73 m2 NIPD Kt/Vurea > 2.2 and cr. clearance > 66 L/1.73 m2 C J Stefanidis 2001

Recommended protein intake in children with CRI < 3 years of age 2.5 g/kg/day 3 - 12 years of age 2.0 g/kg/day >12 years of age 1.5 g/kg/day C J Stefanidis 2001

BUN PNA Kt/Vurea 70 = 187 (PNA - 0.5) / BUN 2 3.2 4 1.2 g/kg/day Weight: 70 kg S=1.7m2 ΤΒW =42 L Weight: 35 kg S=1.2m2 ΤΒW= 21 L Weight: 14 kg S=0.6m2 ΤΒW: 8.5 L BUN mg/dl 70 1.2 g/kg/day PNA 1.7 g/kg/day 2 g/kg/day = 187 (PNA - 0.5) / BUN Kt/Vurea 2 3.2 4 C J Stefanidis 2001

Scaling of the dialysate fill volume Area of the peritoneal membrane / Wt Infants: 533 m2/kg Adults: 284 m2/kg Area of the per. membrane correlates with BSA Scaling of the dialysate fill volume by BSA C J Stefanidis 2001

Initial prescription of CAPD 3-5 exchanges per day according to RRF Fill volume per exchange: 600-800ml/m² day 800-1000ml/m² overnight Glucose solution with lowest concentration (1.36%) Disconnectable system with double bag are preferred C J Stefanidis 2001

High peritoneal fill volume a risk factor ? High peritoneal fill volume might cause: pain hernia formation dyspnoea hydrothorax gastro-oesophageal reflux with anorexia loss of UFR by enhanced lymphatic drainage reduce dialysis efficiency C J Stefanidis 2001

Low peritoneal fill volume a risk factor ? Low peritoneal fill volume might cause: inadequate dialysis ultrafiltration failure hyperpermeable state growth failure C J Stefanidis 2001

Ratio of Creat. Clearance / Kt/Vurea D/Pcr x BW D/Pur X S = Ratio Residual renal function Ratio PD volume and number of exchanges PD volume and number of exchanges Residual renal function hyperpermeable state C J Stefanidis 2001

Adapted prescription of CAPD Fill volume per exchange increase : Gradual increase assessing intraperitoneal pressure up to: 1200ml/m² for the day exchanges 1400ml/m² for the night exchange If there is inadequate filtration Increase glucose concentration Increase number of exchanges Icodextrine dialysis solutions C J Stefanidis 2001

Adapted prescription of CAPD Sodium supplements (orally given) Solutions containing lower amounts of calcium may be required when hypercalcaemia is noted Nutritional requirements are met by: oral supplements gastrostomy/nasogastric feeding amino acid dialysis solutions Sodium supplements (orally given) are often needed in young infants. C J Stefanidis 2001

Initial prescription of of NIPD Duration of a session: 9 to 12 hours Fill volume per exchange: 800-1000ml/m² according to age and tolerance. Number of exchanges: 5-10 /session according to age, UFR and RRF Glucose solution with lowest concentration (1.36%) C J Stefanidis 2001

Adapted prescription of NIPD Nocturnal intermittent peritoneal dialysis Gradual increase assessing intraperitonal pressure up to: 1400ml/m² for the night exchange Total max. amount of PD fluid per session: 8 L /m² Night Day Icodextrin solution: limits dialysate reabsorption over day and therefore increase dialysis efficiency Aminoacid solution if nutrition assistance is wished. C J Stefanidis 2001

Adapted prescription of CCPD If NIPD not fully effective, CCPD should be considered Nocturnal intermittent peritoneal dialysis NIPD Continuous cycling peritoneal dialysis CCPD Night Day C J Stefanidis 2001

Adapted prescription COPD If CCPD not fully effective, COPD should be considered Continuous cycling peritoneal dialysis CCPD Continuous optimal peritonal dialysis COPD Night Day C J Stefanidis 2001

Peritoneal equilibration test 95 children 1.1 L/1.73 m2 PD 2.5%. D/P Creatinine 0.88 High 0.8 0.77 High avg. 0.6 0.64 Low avg. 0.5 0.51 Low 0.35 0.37 0.25 Time (hour) Warady BA J Am Soc Nephrol 1996 C J Stefanidis 2001

Peritoneal equilibration test (PET) 1.0 0.5 0.85 0.50 2 4 hours High transporters Low transporters 0.65 Creatinine clearance D/P creatinine Protein loss s. Albumin Glucose absorption TG UF C J Stefanidis 2001

Peritoneal equilibration test D/P Creatinine 4 hrs 0.88 0.77 High Concentration of PD glucose Number of exchanges High avg. 0.64 Icodextrin Low avg. 0.51 Low 0.37 C J Stefanidis 2001

Peritoneal equilibration test D/P Creatinine 4 hrs 0.88 0.77 High Concentration of PD glucose Number of exchanges High avg. Icodextrin 0.64 Low avg. 0.51 Volume of PD fluid Low Nr of exchanges 0.37 APD C J Stefanidis 2001

Improvement of adequacy on PPD Appropriate organization of PN Center Guidelines Evaluation of the clinical outcome Modify strategies C J Stefanidis 2001

Clinical outcome goals of K/DOQI Measurement of Hospitalizations PD Patient Survival is dependent upon uncontrollable and controllable (inadequste dialysis) variables PD Technical Survival Measurement of Hospitalizations 1.8 times/year (CANUSA) C J Stefanidis 2001

Clinical outcome goals of K/DOQI Measurement of Albumin Concentration Measurement of Normalized PNA Measurement of Hemoglobin Should be 11-13 g/dl in 75% of patients. Measurement of Patient-Based Assessment of quality of life Measurement of Growth, Developmental Progress and School Attendence Am J Kidn Dis S94-S99 2001 C J Stefanidis 2001

Conclusion Individual prescription for each patient on CAPD is recommended in terms of tolerance and effectiveness C J Stefanidis 2001