How to determine PD adequacy?
- Small solute clearance
- Total kt/v urea (weakly) = peritoneal + renal >1.7
- total creat clearance CL Cr (weekly) = peritoneal + renal = 45L normalised to 1.73m2 body surface area
- UF
- nutritional status
- Clinical parameters
- CKD-MBD
- Hb
*5. QoL
Landmark trial in PD (adequacy)
- CANUSA
(1999) 0.1 lower kt/v associated with increased mortality
(2001) lower mortality with RRF - ADEMEX
(2002) similar survival Kt/v 1.7 vs 2.0 - Hong Kong Trial
(2003) ureamia and poor UF with Kt/v < 1.7
How to tackle fluid overload?
- Volume and salt restriction
- Optimize diuretics
- Use icodextrin
- Adjust duration of dextrose dwell to maximize UF according to membrane charectaristic
- Consider more hypertonic saline
- Set a proper dry weight
Objectively: BCM
What to do if suboptimal solute clearance?
- Increase volume by 20-30%
- volume >2L have little added benefit - Increase exchanges if volume maxed
- Limit APD exchange not > than 5
- in APD: add day exchanges / long day dwell
- If APD exchanges maximized, consider day dwell with icodextrin / APD plus / wet-day
What is Kt / v (urea)?
Target?
Factors influence?
Kt : weekly urea clearance
V: estimated volume of urea distribution
Target 1.7
Factors affecting:
- variation of total body water
how to improve the PD uptake?
answer in diagram
Wiley Online Library: The case for increased peritoneal dialysis utilization in low- and lower-middle-income countries (Jan 2022)
How much protein loss through dialysis?
Kt/v measurement
a. 24hrs dialysate
- Day1: 1 discard/ 2-4 - keep
- Day 2: 1 keep
- weight the volume
- aspirate 1% from each bag and mix
- aspirate 10ml from the mixture - send for Creat / urea
b. 24hrs urine
- same day as dialysate collection
- 1st sample of the day - discard, the rest keep
- until 1st sample next day
- collect all - send to lab
send to lab
1. 10mls of dialysate - creat + urea
2. urine collection - creat + urea
3. blood - creat + urea + alb + glucose
