PD PEARLS Ezra Hazzan MD November 19, 2014
Case study 43 year old female, DM and now needs to start dialysis. Works full Ime, highly moivated and good support system. 65 year old male, Spanish speaking, unemployed, recent immigrant with spouse at home. 50 year old male, obese, on HD with an IJ permacath (failed fistula) and inquiring about PD. 20 year old male who drinks a lot of fluid >1.5liters, and loves eaing fruit( tons of potassium).
Peritoneal Dialysis MisconcepIons The prevalence of infecions is much higher in PD than HD PaIent survival is less on PD PD takes too much of the paient s Ime PaIents do not want PD PD requires high levels of understanding and educaion PD requires a companion at home to help with therapy
Reality of PD InfecIons
The prevalence of infecions is much higher in PD than in HD NOT TRUE
PaIents survive less Ime on PD NOT TRUE
PD takes too much of the paient s Ime o On CAPD 4 exchanges x 30 minutes = 2 hours (14 hours a week) o On CCPD : Seang up machine, 15-20 min, connecion/disconnecion 5 min. Plus day Ime exchange 45 min = 1 hr 10/15 min. Total weekly set up Ime: 8-9 hr + sleep Ime. o On HD: HD Ime 4 hours plus on/off Ime, about ½ hour. WaiIng /travel Ime 1 hr @ treatment Total weekly Ime: 16 ½ hr (without resing aier HD) Courtesy of Karen Kelley, Baxter
PD takes too much of the paient s Ime, when compared with HD NOT TRUE
PaIent raings of dialysis care with PD or HD Rubin et al JAMA 291: 697-703,2004 Cross- secional survey at enrollment of paients who recently started dialysis at 37 dialysis centers in 14 states paricipaing in the CHOICE Study. A paient administered quesionnaire included 20 items raing specific aspects of dialysis care, and 3 overall dialysis care raings. Of 736 enrolled paients, 656 (89%) returned the quesionnaire aier an average of 7 weeks on dialysis.
SaIsfacIon with renal replacement therapy and educaion: the American AssociaIon of Kidney PaIents Survey Fadem et al. CJASN 2011 This was an open invitaion on the AAKP website + nearly 9000 paients received the invitaion to complete the survey. The survey consisted of 46 quesions to measure paient saisfacion with their RRT modality. SaIsfacIon was measured on a 1 (extremely dissaisfied) to 7 (extremely saisfied) scale.
Requirements for PD FuncIoning PD catheter Dialyzer: funcioning peritoneum Ability and interest in learning home dialysis on part of paient or support person
PaIents need to understand that there are two types of PD CAPD- - - - con%nuous ambulatory peritoneal dialysis, done 2-4 %mes per day. APD or CCPD- - - - done at night using a machine called a cycler. From the pa+ent perspec+ve these are not the same. 21
CAPD: coninuous ambulatory peritoneal dialysis Each exchange takes about 30 minutes. Number of exchanges depends on residual kidney funcion 22
APD: automated peritoneal dialysis At bedtime the patient places bags on In the morning, the paient cycler and attaches catheter to cycler tubing, disconnects and discards used pushes button to start the cycler. Takes about tubing. (takes <5 min) 20 minutes. 24
Deciding on modality Cycler PD In center HD Nightly, while sleeping 3 Imes per week Done by paient Done by staff Private In center PD catheter TDC/Grai/fistula No needles Two needles 3 x wk Risk of peritoniis Risk of bacteremia
Why do paients choose PD- - Issues of autonomy and control were important for 95% of paients choosing PD. Other reasons for choosing PD: (1) flexibility (2) convenience (3) night- Ime dialysis Adapted from Wuerth et al PDI 2002; 22:184-190 26
Other notes on PD selecion Non adherence is common on in center HD. If PD is the paient choice, paient may be more compliant with PD than HD. Most paients can learn PD with a good trainer who tailors the therapy to the individual. 27
Your paient has chosen PD. What now? 28
Schedule PD catheter placement 29
The PD catheter can be placed as same day surgery. Very important to chose operator to place the PD catheter who will work with you. Can be surgeon, nephrologist, radiologist. Leave exit site covered with clean dressing unil training begins; do not allow paient to get this wet. 30
Urgent start PD PD catheter can be used the same day or the next day. This is now called urgent start dialysis. Appropriate if dialysis needed sooner. PD should be supine with low volumes. Generally used when paient hospitalized. 31
PD training We believe one- on- one training is best. Nurse doing the training must be trained in not only PD but how to teach PD. Training best individualized to the paient. Training covers theory, basics of the procedure, recogniion of peritoniis. Test is given at the compleion of training to ensure knowledge. 32
Dialysis fluid contains Dextrose 1.5, 2.5, 4.25 Na and Cl Lactate Ca Mg sterile water ph low Efluent is the spent (dwelled) dialysate 33
Obtain a clearance early in the course of PD. Kt/V is used but described as per week. Obtained by collecing effluent for one day, measuring urea nitrogen to calculate Kt and divided by V. This is then muliplied by 7 to get weekly value. Renal clearance is added into this, when present. Minimum: 1.7 per week. 34
PeritoniIs causes pain, hospitaliza%on, peritoneal membrane damage and some%mes death. 35
PeritoniIs may contribute to death AUSNZ registry: examined 1316 PD pts who died on PD or within 30 days of transfer to HD 19% of PD pt who died had peritonifs in the preceding 30 days Even though only 6% coded as having died from peritoniis. Boudville et al JASN 2012: 23: 1-8
InfecFons are the second leading cause of death in the dialysis pafents HD and PD both have associated infecions but different types: HD pa%ents get bacteremia and pneumonia PD pa%ents get peritoni%s 37
Think about what causes peritoniis ContaminaIon Enteric sources Catheter related: exit site or slime related Bacteremia (rare) GU sources (rare)
PrevenIng peritoniis from contaminaion: the nurse is all- important in training the PD paient Do not assume a nurse who knows PD, knows how to teach PD. ISPD web site has a secion on Training the Trainer Found at ispd.org
GI sources of peritoniis Transmural migraion Bowel ischemia DiverIculiIs ColiIs CholecysIIs PerforaIon of an organ AppendiciIs GI procedures Ischemic bowel CholecysFFs
Procedures can lead to peritoniis Extensive dental work (streptococcus) Colonoscopy/proctoscopy (enteric) Lap cholecystectomy (enteric) Percutaneous gastrostomy (enteric/fungal) Endometrial biopsy/hysteroscopy (streptococcus, funal, anaerobes)
PrevenIng peritoniis from ESI: Double blinded muli- center RCT of exit site gentamicin vs mupirocin 0.6 Exit site infections in episodes per year at risk 0.5 0.4 other fungal P aeruginsos S aureus 0.3 0.2 0.1 0 mupirocin gentamicin Bernardini.Piraino JASN 2005: 16: 539-545
PeritoniIs due to biofilm Biofilm can lead to refractory, relapsing or repeat peritonifs Nessim et al PDI 2012 Canadian study, POET data base: 181 paients 1996-2005 had 2 episodes peritoniis with same organism - Coag neg staph caused 2/3-1 st episode coag neg staph peritoniis vs other organisms had odds raio of 2.1 of another episode within one year - ½ occurred within 6 months of 1 st episodes
Topics to be Discussed The impact of increased intra- abdominal pressure Hernias Abdominal and Genital Leaks Hydrothorax Colored dialysis effluent Psychosocial issues EncapsulaIng Peritoneal Sclerosis Metabolic changes secondary to PD
Increased Intra- abdominal Pressure Hernias: Incisional Umbilical Ventral DiaphragmaIc Leaks Pericatheter Leaks: Abdominal wall or Genital Abdominal swelling or bogginess or scrotal or labial edema Diagnosis: physical exam, Radiological studies CT scan, TechneIum scan
Management Hernias: Repair Leaks: Use low pressure PD (eg APD with low volumes with paient lying and a dry day ). Temporary HD to allow healing.
Hydrothorax The presence of peritoneal dialysis fluid in the pleural cavity. PD fluid moves through congenital or acquired defects in the diaphragm. Diagnosis: a. Pleural tap with fluid analysis b. TechniIum scan, CT scan c. Stop and restart PD with monitoring of extent of pleural effusion. Treatment: temporary respite from PD pleurodesis, pleuroscopic repair (diaphragmaic defects idenified and patched or sutured)
Metabolic Problems of the CKD PaIent General for CKD paients Thyroid dysfuncion Metabolic syndrome AbnormaliIes of sex hormones Lipid abnormaliies Glucose intolerance Mineral metabolism Insulin resistance PD Specific Dextrose exposure Weight gain Metabolic syndrome Specific lipid related issues Insulin resistance Others: LepIn, AdinoponecIn, Ghrelin Protein losses
Lipid Changes Aier the Start of PD Pennell Clin Nephrol 62:35, 2004 A significant increase in total cholesterol, LDL, cholesterol, triglyceride, and VLDL levels occur aier start of PD. No change in HDL levels These changes can be ameliorated with appropriate management protocols.
Metabolic Syndrome and the PD PaIent Jhang et al : Blood PurificaIon, 26:423, 2008 Increased risk in PD paients (c. 50% of prevalent PD paients, 20% HD paients, 30% CKD paients. The driving forces for the development of Metabolic Syndrome in Pd paients are clearly related to glucose absorpion. 195 non- diabeic paients maintained on PD 22% of paients met criteria for MS* at iniiaion of PD Aier mean of 34 months (range 20 60 months), 69% met criteria for MS Development of MS was correlated with dextrose exposure and duraion of PD. * Defined with NaIonal Cholesterol EducaIon Adult Treatment Panel III criteria.
Conclusion There are a variety of non- infecious problems that are specific to peritoneal dialysis. With increasing experience, the impact of these problems may be manageable The largest problem relates to chronic dextrose exposure, which in turn results in changes in transport characterisics, damage to the peritoneal membrane and various metabolic issues.
RecommendaIons LimiIng dextrose exposure must be a cornerstone of PD management Liberal use of icodextrin and high dose furosemide therapy (in those paients with residual funcion) to minimize dextrose exposure is criically important. TargeIng Kt/V algorithms to achieve levels of 1.7 2.0 should be the standard; there is no benefit of targeing higher doses.
What is important when prescribing PD? Clearance targets. Adequate ultrafiltraion to control volume. Avoiding excess glucose exposure. Cost of prescripion.
What is important when prescribing PD? But this is the era of paient centered care and we need paient centered PD so PaIent symptoms PaIent lifestyle
INTRODUCTION Achieving high solute clearance in PD is a whole lot easier since the Ademex Study and the consequent reducion in K/DOQI targets. A target Kt/V of 1.7 per week for all paients CAPD and APD, high and low transporters.
Clearance on PD determinants 1. Residual renal funcion. 2. Body size. 3. Peritoneal transport status. 4. PD prescripion
Present Kt/V Targets Easy to reach if paients have residual renal funcion. Typically, 60-70% do and it is oien substanial due to earlier start on dialysis. Each ml/min urea clearance equals about 0.25 Kt/V per week so 4 mls/min = 1.0 Kt/V
Increasing Clearance in CAPD Three opions: Increase dwell volume Increase number of exchanges Increase dialysate tonicity
Increasing Dwell Volume Most cost effecive way to increase clearance. Diffusion gradient lasts longer EquilibraIon for 2.5L is only slightly less than with standard 2L volumes. Raised intraperitoneal pressure is limiing factor mechanical side effects.
Strategies to Achieve Targets CAPD In CAPD, many smaller paients will achieve pkt/v 1.7 on 4 x 2L daily. Larger paients will require 4 x 2.5L Few will need 4 x 3L or 5 x 2L or switch to APD
Thank you.
APD PrescripIon Cycler Related: Number of cycles Day Dwell Related: No cf Day dwells Dwell volume Dwell volume Cycler Ime Dwell duraion Tonicity Tonicity
Day Dwells Single most effecive way to raise clearance in a day. Dry APD paient is to add a day dwell raises Kt/V 30 40% If already has a day dwell, the most effecive intervenion is a second day dwell raises Kt/V c 20%. Should be at least 4 hours duraion to get full benefit in Kt/V
Day Dwells POINTS TO REMEMBER The larger the dwell volume the greater the clearance i.e. 2.5v 2v 1.5L Day dwells can be done more simply and less expensively using cycler tubing and large volume bags. Adding a second day dwell creates more work for the paient or caregiver.
Day Dwells POINTS TO REMEMBER Longer glucose based day dwells may lead to net fluid resorpion and so may actually decrease clearance as well as UF. There are a number of strategies to deal with this.
Day Dwell OpIons for Be{er UF Go day dry an opion if there is lots of residual funcion. Do 2 day dwells drain and refill maximizes clearance. Shorten day dwell by draining and remaining dry part of the day. Use Icodextrin for day dwell increasingly popular.
Increasing Cycler Clearance Longer Ime raises clearance but > 9 hrs is not acceptable to most paients. What about dwell volume? Is 4 x 2.5 L cycles be{er than 5 x 2L? What about cycle frequency? Is 7 x 2L be{er than 5 x 2L? Is 9 x 2L be{er than 7 x 2L?
OpImal Cycle Frequency There is confusion about whether or not increasing the number of cycles raises clearance significantly. Concern is that more Ime is spent draining and filling (down Ime) and less actually dialyzing. However, frequent cycling keeps blood to dialysate gradient high and so promotes more diffuse clearance.
OpImal Cycle Frequency Study Perez et al (PDI 2000) 18 paients at 2 centers 4 different prescripions for 7 days each Measurement of clearances, UF, Na, K+, and protein losses and glucose absorpion on days 5-7 on each prescripion. Clearance due to residual renal funcion and day dwells was ignored.
OpImal Cycle Frequency Study 4 prescripions 1. 5 x 2L over 9 hours 2. 7 x 2L over 9 hours 3. 9 x 2L over 9 hours 4. 15L TPD (50%) using 1L + 14 x 1L over 9 hours
OpImal Cycle Frequency Study Perez et al (PDI 2000) 9 x 2L was the best in 12 of the 18 (in 9 by > 10%) 7 x 2L was the best in 3, TPD in 2 Advantage of 9 x 2L was greatest for Kt/V Advantage was seen in both low and high transporters for both Kt/V and Cr Cl UF was be{er in 7 x 2L and 9 x 2L versus 5 x 2L.
OpImal Cycle Frequency Study Conclusion More cycles raise clearance significantly in most paients. 4 5 cycles per 9 hours under- uses clearance potenial of APD. But cost was 27% greater for 15L vs. 10L and 54% for 18L vs. 10L so adding day dwells is more cost effecive but also more work for paient.
Incremental Dialysis Idea that full dialysis dose need not be prescribed iniially in paients with substanial residual renal funcion. In HD twice weekly treatments. In PD 3 dwells daily in CAPD or day dry in APD
Incremental Dialysis London Approach All elecive starts do day dry APD. Quarterly measurements of pkt/v and rkt/v as well as clinical assessment. ConInue without day dwell as long as paient well and Kt/V > 1.7 Some cycle < 7 nights a week.
Incremental PD DefiniIon Total weekly Kt/V reaching target of > 1.7 with peritoneal Kt/V < 1.7. PLUS A day dry or < 7 nights/ week schedule for APD paients. OR < 8L/ day schedule for CAPD paients.