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Quality Improvement on Pediatric Peritoneal Dialysis (PPD)

Quality Improvement on Pediatric Peritoneal Dialysis (PPD). Constantinos J. Stefanidis. Appropriate organization of PN Center. Quality reassurance in PPD (guidelines). Evaluation of the clinical outcome. Modify strategies. Advantages of PD in children.

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Quality Improvement on Pediatric Peritoneal Dialysis (PPD)

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  1. Quality Improvement on Pediatric Peritoneal Dialysis (PPD) Constantinos J. Stefanidis Appropriate organization of PN Center Quality reassurance in PPD (guidelines) Evaluation of the clinical outcome Modify strategies

  2. Advantages of PD in children • The quality of life of children and their family is better during PD than HD. • The residual renal function is better preserved during PD than HD. • There are logistical advantages of PD. It requires:a lower staff : patient ratio than HD a lower dose of rHUEPO

  3. PD is the dialysis of choice : • For children with weight < 15 kg • For children expected to have a prolonged period of dialysis • For children living too far from a pediatric hemodialysis unit

  4. Percentage of ESRD children on PD (NAPRTCS and EDTA)

  5. Quality Improvement on PPD Appropriate organization of PN Center Quality reassurance in PPD (guidelines) Evaluation of the clinical outcome Modify strategies

  6. Paediatric Nephrology Centers HD Paediatricians (early referral) Tx surgeons CRI Tx PD Paediatric surgeons(dialyis access)

  7. Paediatric Nephrology Centersper million of child population Loirat et al. Nephr Dial Transplant 1993

  8. Paediatric Nephrology Centers 130 centers in 22 European countries Loirat et al. Nephr Dial Transplant 1993

  9. End Stage Renal Disease in Children 5 - 10 children/year per million of child population (pmcp) Pediatric ESRD is accounting for only 1.8% of all ESRD United States Renal Data System (USRDS) 1PN center pmcp (per 4-6 m total population) (cp = 25-40% of total population) 5 - 10new children with ESRD / year 220 - 440children/yr start dialysis in countries of SEPNWG If 50 - 60% of them receive a transplant / year The number of ESRD children will increase by 100-200/yr

  10. Child population (x1000) per paediatric nephrologist Child population per paediatric nephrologist 146 131 381 212 132 220 225 353 191 243 317 233 140 467 Child population (millions) 9542 Paediatric nephrologists 500120 Members of ESPN 32050 623 547 155

  11. Multi-disciplinary team • Structure Doctors, nurses, dietitians, social workers, psychologists, play therapists, teachers. • Goal To deliver to children the care required for their long-term well being and for their optimal quality of life. • Team meetings give the entire team opportunity for interaction and collaborative decision making.

  12. Team working improves patient care and enhances the quality of the working life.

  13. Quality improvement on the organization of PN centers • Continuous education of all health professionals. • Each member of the team should have inovative approach and the goal to achieve the excellence. • A set of standards of clinical practice and detailed protocols should be available. • A detailed registry of patients should be updated. • Networking with other PN centers, multicenter studies and global cooperation should be a priority

  14. Quality Improvement on PPD Quality reassurance in PPD (guidelines) Appropriate organization of PN Center Evaluation of the clinical outcome Modify strategies

  15. Steps for quality reassurance in PPD • All children on PD should be managed in a pediatric nehrology center. • Peritoneal catheters should implanted surgically under general anesthesia. • A lateral technique through the rectus muscle and two purse-string sutures around the peritoneum might reduce the risk for leakage. • The training for the parents at the initiating PD treatment should be detailed and last > 2 weeks. • A '’closed twin-bag PD system with Y-line'' or automated PD should be preferred.

  16. Targets for adequacy of peritoneal dialysis Adequate dose of PD is the amount of PD below which there is an increase in morbidity and mortality Optimal dose of PD is the amount of PD yielding clinical results which cannot further improve Optimal dose Adequate dose CJ Stefanidis 2001

  17. Νational Κidney Foundation D O Q I Dialysis Outcomes Quality Initiative NKF-DOQI began in March 1995 Work Groups of 70 professionals reviewed > 11,000 articles. Only 206 articles were included at the final publication. In 1997 114 evidence-based clinical practice guidelines were developed. Am J Kidney Dis 1997 Sep;30 (3 Suppl 2) : S67-136 Continuous quality improvement: DOQI becomes K/DOQI and is updated. National Kidney Foundation's Dialysis Outcomes Quality Initiative. Am J Kidney Dis 2001 Jan;37(1):179-194

  18. D/Purea x VPD = ΤBW 0.66 x 12 L x 7 x 1.73m2 = 1.6m2 = 60 L/1.73m2/week Creatinine and urea adequacy parameters Muscle mass catabolism Protein intake S. creatinine BUN (= Purea / 2) Kt/Vurea Creatinine clearance ΤBW D/Pcreat x VPD = S 0.85 x 12 L x 7 days = 60kg x 0.6 (L/kg) = 2 PNA= 6.25 x UNA (g/kg) + 0.5 Creatinine of urine and PD

  19. S (x 100) ΤBW Weight: 70 kg S=1.7m2ΤΒW =42 L Weight : 35 kg S=1.2m2ΤΒW= 21 L Weight : 14 kg S=0.6m2 ΤΒW: 8.5 L Kt/Vurea D/Purea x VPD / ΤBW D/Purea S = x = D/P creat x VPD X 1.73 /S D/P creat. ΤBW Creat. clear. 3.1 x 100 2 x 100 3.3 4.4 4 x 100 5.0 (x 100) 70 60 80 4 5.7 7.1

  20. Recommended protein intake for children on PD K/DOQI Guidelines for PD Adequacy Am J Kidn Dis S94-S99 2001 Recommended volume of PD fluid (VPD ) Initial prescription0.6-0.8 L/m²/day, 0.8-1 L/m² overnight Adapted prescription 1-1.2 L/m²/day, up to1.4 L/m² overnight Guidelines of EPPWG on Adequacy and the dialysis prescription

  21. Quality Improvement on PPD Appropriate organization of PN Center Quality reassurance in PPD (guidelines) Evaluation of the clinical outcome Modify strategies

  22. Clinical outcome goals of K/DOQI for PD patients • Measurement of PD Patient Survival • Measurement of PDTechnical Survival • Measurement of Hospitalization • Measurement of Hemoglobin /Hematocrit • Measurement of Albumin Concentration • Measurement of Normalized PNA • Measurement of Patient-Based Assessment of quality of life • Measurement of Growth, Developmental Progress and School Attendence Am J Kidn Dis S94-S99 2001

  23. Clinical outcome goals of K/DOQI for PD patients • PD Patient Survival is dependent uponuncontrollable and controllable (inadequste dialysis) variables • PD Technical Survival is dependent upon: • Complications (peritonitis) • inadequste dialysis malnutrition peritonitis • ` 75% 2-year technique survival rate • Inability to perform PD • (lack of access, medical contraindications) • Patient request/lifestyle issues (burnout)

  24. Clinical outcome goals of K/DOQI for PD patients • Measurement of Hospitalizations • 1.8 times/year (CANUSA) • Measurement of Hemoglobin • Should be 11-13 g/dl in 75% of patients. • Measurement of Albumin Concentration • Measurement of Normalized PNA Am J Kidn Dis S94-S99 2001

  25. Quality Improvement on PPD what SEPNWG should do ? • Register the PN centers of the area of SEPNWG. • Enhance the appropriate organization of the PN. centers and disseminate the use of clinical guidelines. • The clinical outcome of patients should be continuously evaluated. • The problems of children on PD should be discussed and appropriate solutions should be advised.

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