1. “Adequacy in PD prescription What, How, When?
Wim Van Biesen

2. Overview What is “adequacy”? How to measure adequacy?
How much is enough?:impact of adequacy
How to improve adequacy?

3. Aims of dialysis Remove uremic toxins
Remove salt and water ( blood-pressure, fluid control)
Avoid toxic side effects (glucose, hyperlipidemia; obesitas)
At the lowest cost and inconvenience for patient and society (decrease incompliance, increase quality of life, decrease cost)

4. THREE PHYSICO-CHEMICAL TYPES OF TOXINS
The small water soluble compounds (prototype urea): < 500D
The protein-bound compounds (prototype p-cresol)
The larger “middle molecules” (prototype ß2-microglobulin): > 500D
Some of these exceed 12,000 D (prototype leptin)

5. Quantified measurement of adequacy
Biochemical parameters
Urea:* influenced by protein intake, hydration
*low urea correlated with high mortality(Degoulet et al, Nephron, , 1982)
Creatinine: * influenced by nutritional status, muscle mass
* inverse correlation Screa-mortality (Lowrie et al, AJKD, 15, ,1990)
Conclusion: “Static” biochemical markers are no good markers of adequacy

6. Quantified measurement of adequacy
Urea kinetic modelling:
1) Kt/V: sum of the peritonal clearance of urea and the residual renal urea clearance, multiplied by 24 hours and divided by the volume of distribution.

7. Quantified measurement of adequacy
Urea kinetic modelling:
1) Kt/V: sum of the peritonal clearance of urea and the residual renal urea clearance, multiplied by 24 hours and divided by the volume of distribution.
Total urinary volume * urinary urea concentration
plasma urea concentration * V
Kt/V renal=
Total DRAINED dialysate volume * dialysate urea concentration
plasma urea concentration * V
Kt/Vper =

8. BCM – Body Composition Monitor…
quantifies individual overhydration
determines urea distribution volume V for dialysis dose assessment
provides a basis for nutritional assessment
measures non-invasively, fast and easy

9. Removal of Uraemic Toxins CAPD vs high volume APD
Eloot et al, PDI, 2014

10. Quantified measurement of adequacy
Urea kinetic modelling:
1) Kt/V: sum of the peritonal clearance of urea and the residual renal urea clearance, multiplied by 24 hours and divided by the volume of distribution.
Total urinary volume * urinary urea concentration
plasma urea concentration * V
Kt/V renal=
Total DRAINED dialysate volume * dialysate urea concentration
plasma urea concentration * V
Kt/Vper =

11. PET test.

13. Quantified measurement of adequacy
Ratio’s of D/P for creatinine and urea

15. Phosphate clearance in CAPDvs CCPD
Liters dialysate
Phosphate clearance ml/min
Sedlacek et al, AJKD 2000, 36,

16. P-cresol and Beta 2 microglobulin clearance in CAPDvs CCPD
Evenepoel et al, KI, 2006

17. A PD dwell
Dwell time
IP volume
Drain
fill
Time

19. More (shorter) exchanges:
steeper transperitoneal transport rate
more « no exchange time » due to in and outflow
Inefficient use of fluid volume
Take care for « larger » molecules: Kt/V urea and creatinine clearance tell different stories
Less (longer) dwells
at the end, slower transperitoneal transport rate
risk of lower drained volume

20. Efficient use of solution in APD.
BSA m²
RRF = 0 mL
CrCl/L/Wk/1.73m²
Blake et al, PDI, 16, 1996.

21. Efficient use of solution in APD.
BSA m²
RRF = 0 mL
CrCl/L/Wk/1.73m²
Blake et al, PDI, 16, 1996.

22. Demetriou et al, KI 2006

23. APD and adequacy
Demetriou et al, KI 2006

24. Impact of normal vs high volume APD
Demetriou et al, KI 2006

25. More is not always better!

26. Survival

28. Peritoneal Kt/V péritoneale and survival
Rumpsfeld et al, PDI, 2009

29. Peritoneal Kt/V péritoneale and survival
If you push too far, you get into trouble…
Rumpsfeld et al, PDI, 2009

30. ADEMEX: Causes of dropout%

31. AGE’s and GDP Pyrraline (pmol/mgprotein) in fluid
Zeier et al, Kidney Int, 63,

32. Effect of dwell number on compliance
p=NS
Blake et al, AJKD, 35, 3, , 2000

33. Impact of volume on intraperitoneal pressure
Peritonitis free survival
Dejardin et al, NDT, 2007

34. Impact of intra abdominal pressure
Figure 2.
Impact of intra abdominal pressure
Gastrointestinal microcirculation and cardiopulmonary function during experimentally increased intra-abdominal pressure *.
Olofsson, Pia; Berg, Soren; MD, PhD; Ahn, Henrik; MD, PhD; Brudin, Lars; MD, PhD; Vikstrom, Tore; MD, PhD; Johansson, Kenth; MD, PhD
Critical Care Medicine. 37(1): , January 2009.
DOI: /CCM.0b013e318192ff51
Figure 2. Microcirculatory organ blood flow (mean +/- sem). Micorcirculatory flow (% of baseline) measured by laser Doppler flowmeter at each pressure level (mm Hg). The blood flow is reduced progressively with increased intra-abdominal pressure. This reduction is less pronounced in small bowel mucosa. x = statistically significant difference (p o = statistically significant difference (p < 0.05) compared with the previous value. 2

36. Adequate dialysis Remove uremic toxins
Remove salt and water ( blood-pressure, fluid control)

39. I am preserving my residual renal function

40. Icodextrin and residual renal function
GFR ml/min
P=0.001
Konings et al, KI, 2003

41. Icodextrin and residual renal function
Change in daily diuresis
Davies et al, JASN 2003

42. Aims of dialysis Remove uremic toxins
Remove salt and water ( blood-pressure, fluid control)
Avoid toxic side effects (glucose, hyperlipidemia; obesitas)

43. Body Composition PD vs HD: the EuroBCM trial
Van Biesen et al, NDT, 2013

44. Body Composition PD vs HD: the EuroBCM trial
Van Biesen et al, NDT, 2013

45. Relation inflammation, nutrition, fluid overload
Albumin [g/L]
<35.0
>40.0 N
Mean ± SD
BMI [kg/m2]
314
25.0±4.6
333
26.3±4.9
302
26.5±4.8
LTI [kg/m2]
311
13.1±3.1
329
13.5±3.2
300
14.2±3.5
FTI [kg/m2]
310
7.8±3.8
8.9±4.2
7.7±4.0
FO [L]
2.9±2.6
1.6±2.1
1.0±1.7
CRP [mg/L]
267
13.7±24.1
276
10.0±21.0
257
5.8±10.4
Verger, ISPD, 2014

46. Relation inflammation, nutrition, fluid overload
Verger, ISPD, 2014