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Dr. Renzo Scanziani Divisione di Nefrologia e Dialisi Azienda Ospedaliera di Desio e Vimercate

In dialisi peritoneale qual è il miglior indice di adeguatezza dialitica tra Kt/V e Clearance della creatinina/ sett?. Dr. Renzo Scanziani Divisione di Nefrologia e Dialisi Azienda Ospedaliera di Desio e Vimercate. Bari, 20 marzo 2010.

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Dr. Renzo Scanziani Divisione di Nefrologia e Dialisi Azienda Ospedaliera di Desio e Vimercate

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  1. In dialisi peritoneale qual è il miglior indice di adeguatezza dialitica tra Kt/V e Clearance della creatinina/ sett? Dr. Renzo Scanziani Divisione di Nefrologia e Dialisi Azienda Ospedaliera di Desio e Vimercate Bari, 20 marzo 2010

  2. During the 1980s to 1990s large effort were made to quantify the dialysis prescription in both peritoneal dialysis and hemodialysis treatment based on kinetic modeling. • Several different adequacy indices have been suggested, but at present mainly Kt/v urea (urea clearance normalized to total body water) and weekly creatinine clearance normalized to body surface areaare used as estimates of PD adequacy Heimburger O Contr Nephrol 2009; 163: 140

  3. Adeguatezza Dialitica in DP negli anni • Studio CANUSA e importanza del Kt/V e della CrCl • ADEMEX e “ridimensionamento” dei target • Importanza della funzione renale residua in dialisi peritoneale e altri fattori di adeguatezza

  4. Studi osservazionali CANUSA Study n = 680 pz incidenti Expected 2-year patient survival according to sustained weekly Kt/V and CCr(L/1.73 m2) Kt/V Survival% CCr Survival% 2.3 2.1 1.9 1.7 1.5 81 78 74 71 66 86 81 78 72 65 95 80 70 55 40 “MORE DIALYSIS IS BETTER” Churchill DN et al; JASN 1996, 7 (2):198-207

  5. RECOMMENDED TOTAL SMALL SOLUTE CLEARANCE GOALS FROM VARIOUS NATIONAL SOCIETIES UF NA NA NA NA NA NA 1 L

  6. Effect of Increased Peritoneal Clearances on Mortality Rates in Peritoneal Dialysis. ADEMEX • gruppo di controllo (n=484)->Kt/Vtot medio 1.8; CrCl 54.1 l/w • gruppo di intervento (n=481)->Kt/Vtot medio 2.27; CrCl 62.9 l/w 100% 90% 80% 70% 60% 50% 40% Studio randomizzato, controllato (965 pazienti in 2 gruppi) p = 0.9842 Control Treated % Patient Survival RR (Treated:Control) = 1.00 95% CI: (0.80, 1.24) 0 4 8 12 16 20 24 28 32 36 Months after randomization Paniagua R et al; JASN 2002; 13: 1307-1320

  7. Effect of Increased Peritoneal Clearances on Mortality Rates in Peritoneal Dialysis. ADEMEX Paniagua R et al; JASN 2002; 13: 1307-1320

  8. Relative Contribution of Residual Renal Function and Peritoneal Clearance to Adequacy of Dialysis: A Reanalysis of the CANUSA Study VARIABILE RR di morte Età CDV SGA CrCl peritoneale 5 l/W FRR (5 L/W) Volume urinario (per 250 ml) 1.02 2.42 0.74 1.00 0.88 0.64 La FRR è molto più importante della Clearance peritoneale (in parte per la miglior clearance di tossine a medio od alto PM) For a 250 ml increment in urine volume, there was a 36% decrease in RR of death Bargman JM, JASN, 2001

  9. ADEQUACY OF PERITONEAL DIALYSISGuidelines • Adequacy targets for dialysis should be include both urea removal and fluid removal (C) • These targets should be based on those achieved by peritoneal dialysis only. Urine production and renal urea clearance can be subtracted from the targets (C) • The minimum peritoneal target for Kt/Vurea in anuric patients is weekly value of 1.7 (A); the minimum peritoneal target for net UF in anuric patients is 1.0 l/day (B). The presence of residual renal function can compensate when these peritoneal targets are not achieved • When targets are not achieved patients should be monitored carefully for signs of overhydration, uraemic complaints and malnutrition (C) • In APD patients with a slow transport status an additional target of 45 l/week/1.73 m2 for peritoneal creatinine clearance should be aimed at in addition to achieving the Kt/Vurea target of 1.7 (C) European Best Practice Guidelines; 2005

  10. Weekly Ccr and Kt/V Urea 44 CAPD Pts Nolph K.D. et al. Perit Dial Int 1992, Vol 12, pp 298-303

  11. Weekly st Kt/Vu and stKt/Vcr levels calculated and shown as functions of sex and BSA for CAPD prescriptions Gotch F.A, Perit Dial int 2000, Vol 20, Suppl 2

  12. Weekly Clearances of Urea and Creatinine on CAPD and NIPD Nolph KD. PDI 1992; 12: 298-303

  13. Weekly peritoneal creatinine clearance 8.30 h NTPD 80 70 60 50 40 30 20 10 0 0,78 0,73 0,69 0,65 Weekly CrCl (Liters) 0,49 0,41 5 10 15 20 25 30 35 40 Total dialysate volume liters Durand et al, PDI 16:S167-170, 1996

  14. CREATININE IS THE BEST MOLECULE TO TARGET ADEQUACYOF PERITONEAL DIALYSIS? Blake PG. PDI 2000;20 Suppl 2:S65-9

  15. Conclusions • There is general agreement that target Kt/V urea in PD should be 1.7 or higher • Neither creatinine clearance nor urea clearance is the perfect index for predicting outcome in PD patients. • Creatinine clearance gives greater weight to residual renal function, and residual renal function is probably a stronger predictor of patient outcome than peritoneal clearance per se. • Creatinine clearance has a particular weakness in low transporters; values have to be interpreted with discretion in this group • PD adequacy should be involve many other aspects of the treatment

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