1. Quality Improvement on Pediatric Peritoneal Dialysis (PPD) Appropriate organization of PN Center Quality reassurance in PPD (guidelines) Evaluation of the clinical outcome Modify strategies Constantinos J. Stefanidis

2. Advantages of PD in children The quality of life of children and their family is better during PD than HD. The residual renal function is better preserved during PD than HD. There are logistical advantages of PD. It requires: a lower staff : patient ratio than HD a lower dose of rHUEPO

3. PD is the dialysis of choice : For children with weight < 15 kg For children expected to have a prolonged period of dialysis For children living too far from a pediatric hemodialysis unit

4. Percentage of ESRD children on PD (NAPRTCS and EDTA)

5. Appropriate organization of PN Center Quality reassurance in PPD (guidelines) Evaluation of the clinical outcome Modify strategies Quality Improvement on PPD

6. Paediatric Nephrology Centers CRI Tx HD PD Paediatricians (early referral) Paediatric surgeons (dialyis access) Tx surgeons

7. Paediatric Nephrology Centers per million of child population Loirat et al. Nephr Dial Transplant 1993

8. Paediatric Nephrology Centers 130 centers in 22 European countries Loirat et al. Nephr Dial Transplant 1993

9. End Stage Renal Disease in Children 5 - 10 children/year per million of child population (pmcp) Pediatric ESRD is accounting for only 1.8% of all ESRD United States Renal Data System (USRDS) 1 PN center pmcp (per 4-6 m total population) (cp = 25-40% of total population) (cp = 25-40% of total population) 5 - 10 new children with ESRD / year 220 - 440 children/yr start dialysis in countries of SEPNWG If 50 - 60% of them receive a transplant / year The number of ESRD children will increase by 100-200/yr

10. Child population per paediatric nephrologist 131 146 381 132 212 225 233 140 220 191 155 623 353 547 317 243 Child population (x1000) per paediatric nephrologist 467 9542 500120 32050 Child population (millions) 95 42 Paediatric nephrologists 500 120 Members of ESPN 320 50

11. Multi-disciplinary team Structure Doctors, nurses, dietitians, social workers, psychologists, play therapists, teachers. Structure Doctors, nurses, dietitians, social workers, psychologists, play therapists, teachers. Goal To deliver to children the care required for their long-term well being and for their optimal quality of life. Goal To deliver to children the care required for their long-term well being and for their optimal quality of life. Team meetings give the entire team opportunity for interaction and collaborative decision making. Team meetings give the entire team opportunity for interaction and collaborative decision making.

12. Team working improves patient care and enhances the quality of the working life.

13. Continuous education of all health professionals. Continuous education of all health professionals. Each member of the team should have inovative approach and the goal to achieve the excellence. Each member of the team should have inovative approach and the goal to achieve the excellence. A set of standards of clinical practice and detailed protocols should be available. A set of standards of clinical practice and detailed protocols should be available. A detailed registry of patients should be updated. A detailed registry of patients should be updated. Networking with other PN centers, multicenter studies and global cooperation should be a priority Networking with other PN centers, multicenter studies and global cooperation should be a priority Quality improvement on the organization of PN centers

14. Quality Improvement on PPD Appropriate organization of PN Center Quality reassurance in PPD (guidelines) Evaluation of the clinical outcome Modify strategies

15. Steps for quality reassurance in PPD All children on PD should be managed in a pediatric nehrology center. All children on PD should be managed in a pediatric nehrology center. Peritoneal catheters should implanted surgically under general anesthesia. Peritoneal catheters should implanted surgically under general anesthesia. A lateral technique through the rectus muscle and two purse-string sutures around the peritoneum might reduce the risk for leakage. The training for the parents at the initiating PD treatment should be detailed and last > 2 weeks. The training for the parents at the initiating PD treatment should be detailed and last > 2 weeks. A '’closed twin-bag PD system with Y-line'' or automated PD should be preferred. A '’closed twin-bag PD system with Y-line'' or automated PD should be preferred.

16. Targets for adequacy of peritoneal dialysis Adequate dose of PD is the amount of PD below which there is an increase in morbidity and mortality Optimal dose of PD is the amount of PD yielding clinical results which cannot further improve CJ Stefanidis 2001 Adequate dose Optimal dose

17. NKF-DOQI began in March 1995 Work Groups of 70 professionals reviewed > 11,000 articles. Only 206 articles were included at the final publication. In 1997 114 evidence-based clinical practice guidelines were developed. Am J Kidney Dis 1997 Sep;30 (3 Suppl 2) : S67-136 Continuous quality improvement: DOQI becomes K/DOQI and is updated. National Kidney Foundation's Dialysis Outcomes Quality Initiative. Am J Kidney Dis 2001 Jan;37(1):179-194 Am J Kidney Dis 2001 Jan;37(1):179-194 Νational Κidney Foundation D O Q I Dialysis Outcomes Quality Initiative

18. BUN (= Purea / 2) = 6.25 x UNA (g/kg) + 0.5 PNA = 6.25 x UNA (g/kg) + 0.5 Protein intake ΤBW Muscle mass catabolism S. creatinine Creatinine of urine and PD Creatinine clearance 0.66 x 12 L x 7 x 1.73m 2 1.6m 2 = 60 L/1.73m 2 /week = 0.85 x 12 L x 7 days 0.85 x 12 L x 7 days 60kg x 0.6 (L/kg) = 2 = D/P creat x V PD S = D/P urea x V PD ΤBW = Kt/Vurea Creatinine and urea adequacy parameters

19. 4 5.7 5.7 7.1 Weight: 70 kg S=1.7m 2 ΤΒW =42 L Weight : 35 kg S=1.2m 2 ΤΒW= 21 L Weight : 14 kg S=0.6m 2 ΤΒW: 8.5 L Creat. clear. D/P creat x V PD X 1.73 /S D/P urea x V PD / ΤBW Kt/Vurea = = D/P creat. D/P urea ΤBW x S (x 100) ΤBW S (x 100) 60 2 x 100 70 3.1 x 100 80 4 x 100 3.3 4.4 4.4 5.0

20. Recommended protein intake for children on PD Initial prescription 0.6-0.8 L/m²/day, 0.8-1 L/m² overnight Adapted prescription 1-1.2 L/m²/day, up to1.4 L/m² overnight Recommended volume of PD fluid (V PD ) K/DOQI Guidelines for PD Adequacy Am J Kidn Dis S94-S99 2001 Guidelines of EPPWG on Adequacy and the dialysis prescription

21. Quality Improvement on PPD Appropriate organization of PN Center Quality reassurance in PPD (guidelines) Evaluation of the clinical outcome Modify strategies

22. Measurement of PD Patient SurvivalMeasurement of PD Patient Survival Measurement of PDTechnical SurvivalMeasurement of PDTechnical Survival Measurement of HospitalizationMeasurement of Hospitalization Measurement of Hemoglobin /HematocritMeasurement of Hemoglobin /Hematocrit Measurement of Albumin ConcentrationMeasurement of Albumin Concentration Measurement of Normalized PNAMeasurement of Normalized PNA Measurement of Patient-Based Assessment of quality of lifeMeasurement of Patient-Based Assessment of quality of life Measurement of Growth, Developmental Progress and School AttendenceMeasurement of Growth, Developmental Progress and School Attendence Am J Kidn Dis S94-S99 2001 Clinical outcome goals of K/DOQI for PD patients

23. PD Patient Survival is dependent upon uncontrollable and controllable (inadequste dialysis) variables PD Technical Survival is dependent upon: Complications (peritonitis)Complications (peritonitis) inadequste dialysis malnutrition peritonitis inadequste dialysis malnutrition peritonitis ` 75% 2-year technique survival rate Inability to perform PDInability to perform PD (lack of access, medical contraindications) (lack of access, medical contraindications) Patient request/lifestyle issues (burnout)Patient request/lifestyle issues (burnout)

24. Measurement of HospitalizationsMeasurement of Hospitalizations 1.8 times/year (CANUSA) Measurement of HemoglobinMeasurement of Hemoglobin Should be 11-13 g/dl in 75% of patients. Measurement of Albumin ConcentrationMeasurement of Albumin Concentration Measurement of Normalized PNAMeasurement of Normalized PNA Am J Kidn Dis S94-S99 2001 Clinical outcome goals of K/DOQI for PD patients

25. w h a t S E P N W G s h o u l d d o ? Quality Improvement on PPD Register the PN centers of the area of SEPNWG. Enhance the appropriate organization of the PN. centers and disseminate the use of clinical guidelines. The clinical outcome of patients should be continuously evaluated. The problems of children on PD should be discussed and appropriate solutions should be advised.