1. Prescription of pediatric peritoneal dialysis
Constantinos J. Stefanidis
“A.& P. Kyriakou” Children's Hospital, Athens, Greece
C J Stefanidis

2. 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 to develop consensus of opinion based upon clinical experience and reported studies.
C J Stefanidis 2001

3. 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

4. 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

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

6. 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

7. Recommended protein intake in children with CRI
< 3 years of age g/kg/day
years of age g/kg/day
>12 years of age g/kg/day
C J Stefanidis 2001

8. 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

9. 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

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

11. 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

12. 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

13. 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

14. 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

15. 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

16. Initial prescription of of NIPD
Duration of a session: 9 to 12 hours
Fill volume per exchange: ml/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

17. 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

18. 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

19. 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

20. 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

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

22. 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

23. 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

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

25. 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

26. Clinical outcome goals of K/DOQI
Measurement of Albumin Concentration
Measurement of Normalized PNA
Measurement of Hemoglobin
Should be 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-S
C J Stefanidis 2001

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