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Ultrafiltration Management in Peritoneal Dialysis

Ultrafiltration Management in Peritoneal Dialysis. Overview. Fluid Management in Peritoneal Dialysis Kinetics of Peritoneal Ultrafiltration Icodextrin: Chemistry & Pharmacokinetic Profile Icodextrin Efficacy Profile: Ultrafiltration Icodextrin Efficacy Profile: Other Clinical Benefits

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Ultrafiltration Management in Peritoneal Dialysis

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  1. Ultrafiltration Management in Peritoneal Dialysis

  2. Overview • Fluid Management in Peritoneal Dialysis • Kinetics of Peritoneal Ultrafiltration • Icodextrin: Chemistry & Pharmacokinetic Profile • Icodextrin Efficacy Profile: Ultrafiltration • Icodextrin Efficacy Profile: Other Clinical Benefits • Icodextrin: Prescribing Considerations

  3. Rationale = Maximise Fluid Balance • Primary function of renal replacement therapy • PD represents optimal approach to this therapeutic goal • Persistently high prevalence of hypertension and CV mortality among ESRD population underscores untapped potential of PD Mujais, et al. Perit. Dial Int. 2000;20(suppl 4):S5-S21.

  4. Effective Fluid Management Established Clinical Benefits • Controls blood pressure • Lowers cardiovascular risk - LVH - CHF - Stroke • Preserves GFR • Prevents uremia-like symptoms • Avoids acceleration of malnutrition, inflammation and atherosclerosis syndrome

  5. Fluid Balance A Clinical Challenge • Maintaining edema-free state • Dynamic nature of target weight • Reliance on clinical judgment and indicators of volume status • Individualized approach to fluid removal Mujais, et al. Perit. Dial Int. 2000;20(suppl 4):S5-S21.

  6. Optimizing Fluid Management • Symptomatic fluid retention noted in 25% of PD patients1: • Lower extremity edema 98.6% • Pleural effusions 76.1% • Pulmonary congestion 80.3% • Similar clinical observations in Japan,2 the Netherlands,3 and Sweden4 1Tzamaloukas, et al. J Am Soc Nephrol. 1995;6:198-206. 2Kawaguchi, et al. Kidney Int. 1997;52:S105-S107.3Ho-dac-Pannekeet, et al. Perit Dial Int. 1997;17:144-150. 4Heimbürger, et al. Perit Dial Int. 1999;19:S83-S90.

  7. Current PD StatusHigh Prevalence of Elevated BP Frankenfield, et al. Kidney Int. 1999;55:1998-2010. Cocchi, et al. Nephrol Dial Transplant. 1999;14:1536-1540.

  8. Volume Reduction & BP Control 47 hypertensive CAPD patients Na restriction 20 normotensive 3 normotensive with enalapril 27 hypertensive Na restriction &  UF 4 normotensive with enalapril 17 normotensive* 7 hypertensive 3 hypertensive *37 normotensives in total achieved with volume control alone Gunal, et al. Am J Kidney Dis. 2001;37:588-593.

  9. Fluid OverloadAn Underappreciated Cause of CV Mortality Causes of Death in Dialysis Patients1 • The majority of dialysis patients die of cardiac causes; 36% present with CHF1,2 • Hypervolemia and hypertension remain important underlying causes3 20% Cardiac Other known Infection Unknown Cerebrovascular Malignancy 7% 47% 4% 16% 6% 1USRDS 1997 Annual Report Data. 2Stack, et al. Am J Kidney Dis. 2001;38:992-1000. 3Lamiere, et al. Perit Dial Int. 2000;21:206-211.

  10. Fluid Overload vs UF FailureAn Important Distinction • Fluid overload is a common clinical syndrome with multiple causes • It is the inability to maintain target weight and oedema free state • UF failure is a pathophysiologic characterisation of one of the causes of the clinical syndrome • Distinction between syndrome and cause determines the intervention to be taken Mujais, et al. Perit. Dial Int. 2000;20(suppl 4):S5-S21.

  11. Causes of Fluid Overload in PD • Excessive salt & water intake • Loss of residual renal urine volume • Cardiac disease • Non compliance with PD prescription • Insufficient use of hypertonic exchanges • Dialysate leak • Catheter malfunction • Hyperglycaemia • UF failure

  12. Current UF ManagementHampered by Complexity Dietary counseling • Compliance issues • May complicate management Limiting renal excretion1 • Gradual decline to anuria • Failure to respond to diuretics Peritoneal Ultrafiltration (UF) • Challenge of the long dwell Medcalf, et al. Kidney Int. 2001;59:1128-1133.

  13. The Long Dwell in PD APD Long dwell Cycles 1 to 4 CAPD Manual exchange Manual exchange Manual exchange Long dwell Nighttime Daytime • APD and CAPD both have long dwells • In APD, even high-dose nighttime exchanges involve long dwells of 8-12 hours

  14. Value of the Long Dwell Toxin removal • Small solutes fluid flow-dependent • Middle and large MW toxins time-dependent • Continuously wet abdomen required for therapy success Lifestyle • Logistic burden and compliance • Realistic therapy imperative

  15. ISPD Ad Hoc CommitteeUF Management in PD “The most frequently ignored principles in PD that lead to UF difficulties are the need to avoid long dwells [with glucose] in high transporters and balancing glucose concentration and dwell time.” —Peritoneal Dialysis International, 2000 Mujais, et al. Perit Dial Int. 2000;20(suppl 4):S5-S21.

  16. 4.25% DextroseLong Dwell Limitations • Rapidglucose absorption andloss of UF potential and small solute clearance • Negative net UF • Fluid overload • Systemic metabolic effects and obesity • Local biocompatibility issues and impact on peritoneal membrane structure and function

  17. Assessing Volume Status Proactive Monitoring and Evaluation • Achieving and maintaining target weight (goal: normal BP, with euvolemia) • Review of dietary compliance/guidelines • Monitoring residual renal function • Evaluating solute clearance • Awareness of peritoneal function Mujais, et al. Perit. Dial Int. 2000;20(suppl 4):S5-S21.

  18. Redefining what is a “dry weight” Minimal definition • Oedema-free body weight Maximal definition • Weight below which further fluid removal results in signs and symptoms of hypovolemia Clinical definition • Between minimal and maximal definitions with resolution of volume-dependent derangements in homeostasis (explained – please make notes on this!) Mujais, et al. Perit. Dial Int. 2000;20(suppl 4):S5-S21.

  19. ISPD* GuidelinesOptimal Fluid Management in PD • Routine standardized monitoring and awareness of PET† status • Dietary counseling of appropriate salt and water intake • Protection of RRF‡ • Loop diuretics if RRF present • Patient education for enhanced compliance • Preservation of peritoneal membrane function • Hyperglycemia control *International Society for Peritoneal Dialysis;†Peritoneal equilibration test; ‡Residual renal function. Mujais, et al. Perit Dial Int. 2000;20(suppl 4):S5-S21.

  20. Definition of UF Failure • Drain volume <2400ml after 4 hour dwell with 2L 4.25% glucose • 4.25% is preferred to 2.5% PET because the greater osmotic challenge of a 4.25% dwell is more likely to be discriminating in the assessment of UF

  21. Type I High transport status Rapid loss of glucose osmotic gradient Commonest; increases with time Type II Low transport status Loss of peritoneal surface area Not common Type III High lymphatic flow rate By exclusion of other types only Prevalence unknown Type IV Aquaporin dysfunction Rare UFF Classification Overall, UFF occurs in <3% of patients in Year 1, In 9.5% by 3 years and in 30% by 6 years

  22. UF FailureA structured diagnostic approach to managing a patient UF FailureA Structured Diagnostic Approach RRF* REVERSIBLE CAUSES PERITONEUM Dietary indiscretion, compliance Appropriate Rx Mechanical causes Low transport Low-average or high-average transport Dwell time Leaks Deficient education Obstructions Dialysate tonicity High transport Complex regimen Entrapment Malposition *Residual renal function Burn-out Mujais, et al. Perit Dial Int. 2000;20(suppl 4):S5-S21.

  23. UF FailureEvaluating the Clinical Syndrome Clinical Syndrome Initial Evaluation for Reversible Causes Evaluation of Peritoneal Membrane Function UF Response Small Solute Transport Mujais, et al. Perit Dial Int. 2000;20(suppl 4):S5-S21.

  24. UF FailureIdentifying Reversible Causes Clinical Syndrome Initial Evaluation for Reversible Causes Dietary Non-Compliance Appropriate Prescription Mechanical Problems Mujais, et al. Perit Dial Int. 2000;20(suppl 4):S5-S21.

  25. UF FailureAssessing UF Response Clinical Syndrome Initial Evaluation for Reversible Causes Evaluation of Peritoneal Membrane Function UF Response Drain Volume <2400 mL / 4 hr Drain Volume >2400 mL / 4 hr Mujais, et al. Perit Dial Int. 2000;20(suppl 4):S5-S21.

  26. UF FailurePeritoneal Membrane Function UF Response Drain Volume <2400 mL/4 hr Small Solute Profile Low Transport D/P Cr <0.5 High-Avg or Low-Avg 0.81> D/P Cr >0.5 High Transport D/P Cr >0.81 Mujais, et al. Perit Dial Int. 2000;20(suppl 4):S5-S21.

  27. UF FailureLow Drain, Low Transport Drain Volume <2400 mL/4 hr Small Solute Profile Low Transport D/P Cr <0.5 • Disruption of peritoneal space, adhesions, etc. • Peritoneography Mujais, et al. Perit Dial Int. 2000;20(suppl 4):S5-S21.

  28. UF FailureLow Drain, High-Avg or Low-Avg Transport Drain Volume <2400 mL/4 hr Small Solute Profile High-Avg or Low-Avg Transport 0.5< D/P Cr <0.81 • Mechanical problems • Tissue absorption • Aquaporin deficiency Mujais, et al. Perit Dial Int. 2000;20(suppl 4):S5-S21.

  29. UF FailureLow Drain, High Transport Drain Volume <2400 mL/4 hr Small Solute Profile High Transport D/P Cr >0.81 • Inherently high transport • Recent peritonitis • High transport of long-term PD Mujais, et al. Perit Dial Int. 2000;20(suppl 4):S5-S21.

  30. Therapeutic Approaches Universal Measures Mujais, et al. Perit Dial Int. 2000;20(suppl 4):S5-S21.

  31. Guidelines for improving UF CAPD • Avoidance of long dwells with low glucose concentrations • Use of nighttime exchange devices • Tailoring prescriptions to transport profiles determined by PET APD • Avoidance of long dwells with low glucose concentrations • Use of short day dwells even when no additional exchangesneeded for clearance

  32. Volume Control Algorithm

  33. Volume Control Algorithm

  34. Volume Control Algorithm

  35. Volume Control Algorithm

  36. Volume Control Algorithm

  37. Impact on outcomes in PD 100 % Surviving 90 High High Average Low Average Low 80 70 Time in Months 60 0 6 12 18 24 High transport & outcome High transporters: Efficient membranes for small solute clearancebut may have difficulty with ultrafiltration, especially during the long dwell Recent studies (Davis1 and Churchill2) have shown that high transporters had a worse prognosis probably due to a more difficult fluid balance management 1 Davis et al. KI 1999 Vol 54 p 2207 – 2217 2 Churchill et al JASN 1998 - Vol 9 1285 - 1292

  38. Therapeutic approaches Inherent high transporters • APD & icodextrin for the long dwell is the recommended therapeutic approach Recent peritonitis • “Several studies have indicated that UF during an episode of peritonitis can be satisfactorily achieved with the use of icodextrin” High transport during long term PD • For patients with a net UF less than 400 mL/4 hours and a high transport profile of small solute clearance, APD and icodextrin for the long dwell are the recommended therapeutic approaches Mujais, et al. Perit Dial Int. 2000;20(suppl 4):S5-S21.

  39. Summary: 12 Strategies to improve Volume Management in PD • Start PD earlier • Protect residual renal function • Use high-dose loop diuretics o maintain urine output • Educate patients regarding salt and water intake and regarding significance of oedema, weight gain, etc • Appropriate use of hypertonic solutions • Awareness of PET status

  40. Summary: 12 Strategies to improve Volume Management in PD 7. Consider APD in high and high average transporters 8. Night exchange device in CAPD if night –t im dwell is reabsorbed 9. Short day dwells on APD – long enough to give good clearance and short enough to give good UF 10. Icodextrin for long dwells in CAPD & APD 11. Frequent reassessment of the patient’s target weight 12. Anti-hypertensives only when volume removal has failed to reduce BP.

  41. Case Study

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