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CAPD and APD PRESCRIPTION WRITING

PERITONEAL DIALYSIS SOLUTIONS . Dextrose g/dl0.5% - 1.5% - 2.5% - 4.25

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CAPD and APD PRESCRIPTION WRITING

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    1. CAPD and APD PRESCRIPTION WRITING By D.G. OREOPOULOS PROFESSOR OF MEDICINE UNIVERSITY OF TORONTO

    2. PERITONEAL DIALYSIS SOLUTIONS

    3. CAPD PRESCRIPTION SHOULD ADDRESS NEEDS FOR SOLUTE CLEARANCES ULTRAFILTRATION OTHER (insulin, antibiotics etc.)

    4. PRESCRIPTION FOR SOLUTE CLEARANCES Minimum Requirements (Total) Kt/V = 1.8/week (Total) WCC: 50-60 L/week

    5. EXAMPLE: 60 Kg anuric man – average peritoneal permeability D/P Creat: 0.65 WCC: 2L x 0.65 = 1.3L Creat/exch x 4 x7 = 36.4 L/Week Kt/V 100% equilibration of urea in 6H Kt = 2L x 4 = 8L/day = 54 L/week V= 60% TBW 60 kg = 36 54 = 1.5 36

    6. IN PATIENTS WITH RRF 1 ml/min GFR* = 0.28 Kt/V or 10L WCC INCREMENTAL DIALYSIS IN A PATIENT WITH RESIDUAL RF CAPD 3 x 2L Dianeal 2 x 2L Dianeal + 1 x 2L Icodextrin (if UF is required CHF etc) 3 x 1.5L Dianeal – if hernia is present NIPD 10L / 8-9 hours D/P Creat ? D/P urea ? (0.30 – 0.60) WCC disproportionaly lower than urea clearance _______ GFR = C creat + C urea 2

    7. CAPD PRESCRIPTION IN ANURIC PATIENTS Difficult to achieve minimum target (Kt/V = 1.7 – WCC 50L/week) in Large Persons CAPD: 5 x 2L exchanges 5 x 2.5L exchanges 4 x 2.0L exchange + 1x2L Icodextrin at night 4 x 3L exchanges (?) (Six daily exchanges are impracticable) (Concern with hernias with large volumes) Include patient’s clinical condition in your decision

    8. PRESCRIPTION IN APD PATIENTS (Consider RRF) NIGHT DAY Duration 8-10 h 14-15 h Volumes 10L 2L 15L 2L+2L (Enhanced) 20L 2L+2L (Enhanced)

    9. PRESCRIPTION TO ADDRESS UF NEEDS The higher the permeability (D/P Creat) the lower the UF Hypertonic Exchanges will give more UF Avoid using Hypertonic Exchanges (for long-term patients) Combine with Salt and Water restrictions and use diuretics in pharmacological dose “No concerns” if diuresis is present

    10. If D/P > 0.80 or if patient absorbs fluid at the end of a 6h exchange of 1.5% or 2.5% Consider: Daytime dialysis only (shorter exchanges) 4x2L or 3x2L only during daytime Dry during night NIPD only. Dry during day.

    11. If D/P Creat >0.8 or if patient absorbs fluid at the end of a 6h exchange of 1.5% or 2.5% Consider: Icodextrin For Night Exchange in CAPD Icodextrin for Day Exchange in CCPD

    12. IN ANURIC PATIENTS Minimum UF Required > 750 ml/day CCPD with night dialysis of 10-15 L / 9-10 hrs and Icodextrin during day-time If patient does not UF at all and patient wants (or has) to stay on PD consider PD + HD one/week for UF

    13. USE ICODEXTRIN In Long-Term Patients who Absorb fluid after 6L In New Patients who Absorb fluid To prevent peritoneal damage (?) and decrease Glucose Load In patients with CHF (1x2L exchange/night) (2 x 2L Icodextrin exchange/day) In patients with peritonitis (instead of 4.25%) Careful with BS measurements

    14. PRESCRIPTION TO ADDRESS PHOSPHOROUS – CALCIUM NEEDS

    15. DIALYSATE Ca++ “Standard” Ca “Low” Ca Solutions Solutions Ca (mM/L) 1.62 1.25 Mg (mM/L) 0.75 0.25 Lactate (mM/L) 35 40

    16. Consider using “Low” Ca solutions in patients with ? P and normal or high Ca in combination with large doses of CaCO3 (or in combination with Mg C03). Low Ca solutions enhance PTH secretion (?Why) and decrease serum Mg (Risk of ? PTH and vascular calcifications) “Low” Ca Solutions

    17. INTRAPERITONEAL ADDITIVES

    18. BLOOD SUGAR CONTROL WITH IP INSULIN In CAPD Patients: Principles: Double the amount of daily Insulin Sc/d ľ during day time – Ľ during night (risk of night hypoglycemia) Dose does not increase proportionally with glucose concentration It takes 2-4 days to find final dose Do BS before each exchange and adjust dose EM BS reflects night dose Use sliding scale In APD patients: Continue SC dose

    19. Sample of CAPD Orders with Intraperitoneal Insulin (previously on 20 units insulin s.c. daily) Add Humulin R per 2 litre bag as follows: Bag strength Day Bags Night Bags 0.5% 8 units 6 units 1.5% 10 units 7 units 2.5% 12 units 8 units 4.25% 14 units 10 units

    20. Sliding Scale: BS Result Change of insulin per Bag (regardless of bag volume) <2 Drain immediately, instill 2.5% without insulin Call MD 2 – 3.9 subtract 4 u insulin per bag 4 – 7.9 subtract 2 u insulin per bag 8 – 13.9 No change 14 – 17.9 add 2 u insulin per bag 18 – 21.9 add 4 u insulin per bag 22 – 44 add 6 u insulin per bag. Call MD

    21. To switch from IP insulin on CAPD to SC: Calculate the 24 hr insulin on CAPD. Reduce by 50%. If pt able, advocate multidose insulin dosing first, otherwise divide into 2/3 AM and 1.3 PM, then further divide each dose into 2/3 long acting and 1/3 short acting. Pts who were on dietary control and/or oral agent pre-CAPD may return to pre-CAPD status.

    22. Insulin Therapy in CCPD

    23. PERITONEAL DIALYSIS PRESCRIPTION For all PD prescriptions, order volume & frequency of exchanges, additives and Target Weight. An “exchange” includes the fill, dwell and drain time of a specified volume. Specify target weight as “full” or “drained” weight. “Target weight (full)” includes the instilled volume of fluid.

    24. CAPD (Continuous Ambulatory Peritoneal Dialysis) AM |___|___|___|_____________PM 4-5 exchanges/day with long dwell overnight Dwell times average 4-6 hours during day and 8-10 hours overnight For patients with diabetes, options of intraperitoneal (IP) insulin or s.c. insulin may be used (see section insulin therapy in CAPD pg 49).

    25. Sample Prescription of CAPD: CAPD: 2 L volume QID. Target weight 68.0 kg (full) CCPD (Continuous Cyclic Peritoneal Dialysis AM |____(|)*_____|_|_|_|_|_|_ PM Exchanges delivered overnight utilizing a machine with last exchange left indwelling during the day for 12-14 hours.

    26. CCPD cont’d Reconnect to machine at night to drain and resume overnight exchanges *CCPD Enhanced – day time exchanges done to interrupt long day dwell (i.e. fluid exchanged manually at 1400) Overnight exchange volume and day volume may differ. If patient has back pain/herniae, may tolerate larger exchange volume at night with smaller volume during day. Patients with diabetes are managed with s.c. insulin, may require larger doses at night

    27. Sample Prescription CCPD Total Volume: 12 L (5 exchanges of 2 L volume overnight plus last fill of 2 L) Therapy Time: 9 Hours Exchange Volume: 2L Target Weight: 70 kg (full)

    28. NIPD (Nocturnal Intermittent Peritoneal Dialysis) AM _____________|_|_|_|_|_|_ PM Similar to CCPD, but no last fill. While it is preferable to have a day dwell, the dry day may be used for patients who do not toleratel day exchanges (i.e. severe back pain/herniae)

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