1. Automated Peritoneal Dialysis Why and How? Advantages and Regimes
BALTIC PD SCHOOL
Automated Peritoneal Dialysis Why and How? Advantages and Regimes
Vladimirs Strazdins, MD
University Hospital for Children, Riga, Latvia
European Pediatric Dialysis Working Group
Riga Latvia

2. What’s The Difference? Quality of Life & Safety
BALTIC PD SCHOOL
What’s The Difference? Quality of Life & Safety
Drain 15’ Fill 15’ 4-5 times during daytime
Connection 15’ Once and nighttime
April 25, 2008
Baltic PD School

3. What’s The Difference? Efficacy
BALTIC PD SCHOOL
What’s The Difference? Efficacy
The major difference is in the daily volumes, defined as dialysis dose
Inadequate dialysis dose badly affects the outcome1, 2, 3
Traditional CAPD usually means the patient is underdialyzed, since the maximum fill volumes (3 L) are intolerable by most patients, and the number of exchanges is limited
5 is the theoretical maximum
Seldom achieved in real life
The demand for increased dialysis dose is growing worldwide4, 5
Optimal
dose
Lower morbidity and mortality
Good patient rehabilitation
High quality of life
Minimum acceptable dose
Avoidance of major uremic symptoms
Acceptable only as short-term therapy
CANUSA PD Study Group. Adequacy of dialysis and nutrition in continuous peritoneal dialysis: Association with clinical outcomes. J Am Soc Nephrol 1996; 7:
Blake P, Burkart JM, Churchill DN, et al. Recommended clinical practices for maximizing peritoneal dialysis clearances. Perit Dial Int 1996; 16:
Terry M, Villano R, Burkart J, et al. Prospective evaluation of a night exchange system in stable peritoneal dialysis patients. Dialysis & Transplantation 1997; 26:80-9
Perit Dial Int Jun ;27 (Supplement_2):S130-S (P,S,E,B). Advances In The Technology Of Automated, Tidal, And Continuous Flow Peritoneal Dialysis. Roberto Dell'aquila, et al.
Rapid Growth in the Use of Automated Peritoneal Dialysis (APD) in Adult Patients on Peritoneal Dialysis. Daisy Perry, et al.
April 25, 2008
Baltic PD School

4. Equilibrium point reached!
BALTIC PD SCHOOL
APD Demand Growing!
dialysis patients worldwide in 20041
11% on PD
30% on APD
APD grows by 1-2% each year
Automated peritoneal dialysis (APD) has seen the biggest growth in PD over the past years.2 This has helped address some of the issues that have forced patients to switch to HD. Automated PD is mainly used by those patients who fail to meet adequacy targets on CAPD, and a smaller percentage receive APD for lifestyle benefits.
Guo and Mujais, Kidney International, Vol 64, supp 88 (2003): Patient and technique survival on PD in the US; Evaluation in large incident
2007
Equilibrium point reached!
Automated Peritoneal Dialysis: Indications and management, D.Negoi & K.Nolph. Contrib Nephrol Karger, 2006, Vol 150
PD nursing in the United Kingdom — impact of the nurse and U.K. PD trends. Jo Marriott, RN. Peritoneal Dialysis International, Vol. 19, pp
April 25, 2008
Baltic PD School

5. BALTIC PD SCHOOL History. CAPD Peritoneal dialysis used to be:
CAPD 4 exchanges (bags) x 4 times/day
Each bag exchange +/- 30 min = 2 hrs/day = 14 hrs/week
(… not much different from CHD)
Frequently complicated by peritonitis
Less efficient but more ‘even’ than CHD
Limited by technique failure
Membrane failure of the peritoneum
Catheter failure
Leaks
Infection
In the late 1980-s and early 1990-s attempts were made to improve the efficacy of CAPD
NXD were introduced by Baxter
Cyclers were already available
Excellent functionality
Too big and clumsy
April 25, 2008
Baltic PD School

6. Only anuric PD patients with a low-transport membrane included
BALTIC PD SCHOOL
History. CAPD + NXD
It was generally believed that, to achieve adequacy targets, anuric patients with a low-transport membrane should be treated with CAPD or with CAPD with a night-exchange device. 1, 2
If adequacy targets were not reached, or if the patient could not tolerate the dwell volume necessary to achieve adequacy, it was suggested that the patient should be changed to HD. 3, 4
Cycler+ therapy clearances (Kt/V, CrCl) as relative ratios of the clearances achieved under continuous ambulatory peritoneal dialysis (CAPD) with a night-exchange device (NXD). 5
Only anuric PD patients with a low-transport membrane included
Night exchanges
Average increase in
(n)
Weekly Kt/V
Weekly CrCl
CAPD / NXD a 2
1,00
Cycler b 5
1,07
0,97 6
1,12 7
1,17
1,02 9
1,24
1,03
a. Exchanges: 3 per day + 2 overnight.
b. Exchanges: 2 per day + night cycler therapy at the indicated level.
Pagé D. The advantage of an extra nocturnal exchange using a two-bag inexpensive mini cycler. Perit Dial Int 1991; 11:S196.
Pagé D. CAPD with a night-exchange device is the only true CAPD. Adv Perit Dial 1998; 14:60–3.
Khanna R, Nolph KD. Principles of PD. In: Schrier RW, Henrick WL, Bennett WM, eds. Atlas of Diseases of the Kidney. Vol 5.
Amici G. Solute kinetics in automated peritoneal dialysis. Perit Dial Int 1999; 19:115–20.
Denis E. Pagé and Vincent Cheung. Role Still Exists for Cycler Therapy in Anuric Patients with a Low-Transport Membrane.
April 25, 2008
Baltic PD School

7. BALTIC PD SCHOOL Modern Times. CCPD = APD
Decreasing the dwell time and increasing the number of exchanges delivers a significant improvement in Kt/V in these patients who, up to now, were thought not to be candidates for APD prescription.
APD has not significant advantages over CAPD in terms of important clinical outcomes. 1
Though CAPD still accounts for ~50% of all PD patients, automated overnight ‘nocturnal’ peritoneal dialysis (APD) is an increasingly attractive option.
Initially used only for patients with particular PD membrane “transport” characteristics, APD is now more a lifestyle choice and is ideal if patients seek …
Freedom for work / family / social activities
Lower peritonitis rates
Better mental health 2, 3
Less hospitalization 4
The Cochrane Database of Systematic Reviews 2008 Issue 1
Mental health of APD patients was found to be better than that of CAPD patients. Comparison of quality of life of patients on automated and continuous ambulatory PD. De Wit,Merkus MP,Krediet RT, de Charro FT, PDI 2001 May-Jun;21(3):306-12
APD patients were less anxious and depressed than CAPD patients. APD Symposium: APD and the elderly. P.Kadambi, N.Gorban-Brennan, A.S.Kliger, F.O.Finkelstein. Semin Dial, Vol 15, Issue 6, 430, November 2002
Factor
Days
CrCl (l/wk)
>80
14,4
60-80
17,9
<60
27,8
Kt/V
>2,1
18,1
1,7-2,1
18,7
<1,7
25,8
4. CANUSA Peritoneal Dialysis Study Group, 1996
April 25, 2008
Baltic PD School

8. BALTIC PD SCHOOL Why APD? Summary Reasons: Patient preference 1
Cyclers today are simpler and lighter
Personalized dialysis prescriptions
More elderly patients (Assisted APD) 2, 3
Remote monitoring with teledialysis
Increased clearances 4
A prescription that is compatible with the patient’s preferences and lifestyle is likely to reduce the risk of patient « burnout» and noncompliance. Clinical Practice Guidelines of the Canadian Society of Nephrology for treatments of Patients with CRF. JASN 10: S287-S321, 1999
Use of automated cyclers to treat elderly ESRD patients is effective, well accepted and does not increase the risk of complications or technique failure. J.Povlsen et al, PDI Vol 25, Suppl 3, 2005  
Assisted APD may be a feasible and safe option for RRT for frail elderly and physically dependent patients with ESRD. Assisted Automated Peritoneal dialysis (AAPD) for the functionally dependent and elderly patient. J.Povlsen et al, PDI Vol 25, Suppl 3, 2005  
Careful management of APD prescription can result in adequate solute and fluid removal in the vast majority of patients even in anuric and large patients. APD: Indications and management: D.Negoi & K.Nolph, Contrib Nephrol, Karger, Basel 2006 Vol 150
April 25, 2008
Baltic PD School

9. BALTIC PD SCHOOL Why APD? Survival April 25, 2008 Baltic PD School
Month 24 18 12 6
Proportion Surviving
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
Patient 78%
Technique 62%
Combined 49%
EAPOS: 2-year patient and technique survival are identical to those reported from the NECOSAD study (HD and PD). Brown, et al. J Am Soc Nephrol. 2003;14: 95 80 70 55 40
CrCl (L/wk/1,73 m2)
Est. 2-year survival
86 %
82 %
78 %
72 %
65 %
CANUSA Peritoneal Dialysis Study Group, 1996
Variable Relative mortality risk P
Kt/V  0,1/week  6% 0.03
ClCr  5 L/week  7%
April 25, 2008
Baltic PD School

10. Current Recommendations. Targets 1
BALTIC PD SCHOOL
Current Recommendations. Targets 1
> 90 Latvia (Pediatric) > 3,0
> France (Pediatric) > 4,0
Desirable
CrCl
70 L/week
60 L/week
50 L/week
Kt/V
2,09
1,90
1,70
Acceptable
Borderline
Use Caution
1. AdHoc committee on PD Adequacy, PDI 1996
April 25, 2008
Baltic PD School

11. Dialysis dose. Problems
BALTIC PD SCHOOL
Dialysis dose. Problems
Can the patient tolerate
larger fill volumes?
YES
“The more the better” NO
Medical barriers
Hernia
Pain
Leakage
Loss of appetite
Breathing difficulties
Increased glucose absorption
Mental barriers
Healthcare staff
“I can’t do this to my patients”
Patient
“I can never do it”
Clearance ökar avsevärt med ökad fyllnadsvolym. Det är dock inte ovanligt att man tvekar för att höja volymen. Hindren kan vara medicinska så väl som mentala... där de mentala ofta överväger.
En ökning av fyllnads volymen är vanligtvis det effektivaste sättet att öka dialysdosen. 2,5 liter går ofta bra - om det föreligger några hinder som inte går att överbrygga, så kan APD vara en lösning, alternativt kan man i CAPD välja att till att börja med endast öka fyllnads volymen under natten.
April 25, 2008
Baltic PD School

12. Classic CCPD (APD) + Long Dwell
BALTIC PD SCHOOL
APD Regimes (Finally)
Classic CAPD
CAPD + Long Dwell
Classic CCPD (APD) + Long Dwell
Tidal APD + Long Dwell
Patient-related differences between “classic” and Tidal
Less outflow pain
Fewer cycler alarms
Better quality of life
April 25, 2008
Baltic PD School

13. Some pediatric details
BALTIC PD SCHOOL
Some pediatric details
Catheters
Surgically implanted Tenckhoff-type “pig-tails”
One cuff preferred
Extrusion
Two sizes only needed
37 (39) cm and 57 cm fit all ages
Dialysis dose and fill volumes
The “standard” initial dose (daily volume) stays as proposed by Twardovsky decades ago, at 1,75 L/kg/week
Everybody is happy
No one bothered to revise
Should be BSA-based
Fill volumes nowadays are BSA-based
Further corrections
Done monthly
Adequest-based
April 25, 2008
Baltic PD School

14. More pediatric details A, B, C
BALTIC PD SCHOOL
More pediatric details A, B, C
Dose
1,75 liters/kg/week
Later adjustments, where necessary
Volumes
Currently recommended fill volumes
Initial ml/m2
Gradual increase to ml/m2
Maximum ml/m2
1.600 ml/m2 causes pain
1.800 ml/m2 physically impossible
Extrapolation to “standard” adults
70 kg x 1,75 liters = 122,5 liters/week = 17,5 liters/day
Impossible even with five (!) 3-liter exchanges
Are all CAPD adults underdialyzed?
A. Guidelines By An Ad Hoc European Committee On Adequacy Of The Paediatric Peritoneal Dialysis Prescription.
Michel Fischbach, Constantinos J. Stefanidis And Alan R. Watson for the EPDWG. Nephrol Dial Transplant (2002) 17:
B. Renal Replacement Therapy For Acute Renal Failure In Children: European Guidelines.
Vladimirs Strazdins, Alan R. Watson, Ben Harvey for the EPDWG. Pediatr Nephrol (2004) 19:199–207
C. Guidelines By An Ad Hoc European Committee For Elective Chronic Peritoneal Dialysis In Pediatric Patients.
Alan R. Watson and Claire Gartland, on behalf of the EPDWG. Perit Dial Int 2001; 21:
April 25, 2008
Baltic PD School

15. BALTIC PD SCHOOL Remarks Efficacy speculations
High-dose Tidal is similar to CAPD in single-cycle kinetics
Due to cycle overlapping, efficacy seem to increase
CFPD concept is Tidal-based
Shorter cycles provide better small molecule clearances
Some bigger molecules are less cleared
APD vs CAPD risks
Almost none, except few hyponatremia reports in infants
Easily cured by bigger fill volumes, making the cycles longer
Future technologies
Continuous Flow (CFPD or CFAPD)
Classic
Requires huge amounts of dialysate = too costly
Online
Requires sophisticated machinery
Recycling
April 25, 2008
Baltic PD School

16. BALTIC PD SCHOOL Conclusions
The crucial PD issue is the dialysis dose (daily volume) delivered
Adequacy targets are constantly rising throughout the world
CAPD is incapable to ensure the adequacy due to medical and mental barriers
This makes the APD the growing and currently already leading PD modality both in USA and EU
Prediction: complete CAPD elimination in 5-10 years
Two main APD regimes are used:
CCPD
More discomfort and more frequent cycler alarms
Tidal
Less discomfort and most alarms are avoided
Daytime long dwell nowadays is a standard feature in APD
Modern APD ensure acceptable efficacy and survival even in elderly and anuric patients
The only limiting factor in CAPD vs. APD “competition” is higher APD cost, related to cycler price1
PD nursing in the United Kingdom — impact of the nurse and U.K. PD trends. Jo Marriott, RN. Peritoneal Dialysis International, Vol. 19, pp
April 25, 2008
Baltic PD School