腹膜透析充分性的国际指南解读.ppt

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1、,腹膜透析充分性的国际指南,Shijunbao,腹膜透析充分性的国际指南,ISPDGUIDELINE ON TARGETS FOR SOLUTE AND FLUID REMOVAL IN ADULT PATIENTS ON CHRONIC PERITONEAL DIALYSISKDOQICLINICAL PRACTICE GUIDELINES AND CLINICAL PRACTICE RECOMMENDATIONS 2006 UPDATESERA-EDTAEUROPEAN BEST PRACTICE GUIDELINES FOR PERITONEAL DIALYSIS,GUIDELINE O

2、N TARGETS FOR SOLUTE AND FLUID REMOVAL IN ADULT PATIENTS ON CHRONIC PERITONEAL DIALYSIS,ISPD GUIDELINES/RECOMMENDATIONS,RECOMMENDATIONS 1,Adequacy of dialysis should be interpreted clinicallyrather than by targeting only solute and fluid removal.,Clinical Assessment,Clinical and laboratory resultsPe

3、ritoneal and renal clearancesHydration statusAppetite and nutritional statusEnergy level,Hemoglobin concentrationResponsiveness to erythropoietin therapyElectrolytes and acidbase balanceCalcium phosphate homeostasisBlood pressure control,RECOMMENDATIONS 2,In order to emphasize that there is more to

4、adequate dialysis than a focus on small solute kinetics and ultrafiltration targets,the Committee decided to name this guidelineGuideline on Targets for Solute and Fluid Removal in Adult Patients on Chronic Peritoneal Dialysis instead of Guideline on Adequacy of Peritoneal Dialysis.,RECOMMENDATIONS

5、3,For small solute removal,the total(renal+peritoneal)Kt/V urea should not be less than 1.7 at any time(Evidence level A).That means,in anuric patients,peritoneal Kt/V urea has to be above 1.7.,RECOMMENDATIONS 3,In the presence of residual renal function,the contributions of renal and peritoneal cle

6、arances may be added for practical purposes,although,as mentioned previously,renal and peritoneal clearances may not be truly additive(Opinion).Solute removal above this level should not be equated with“adequate dialysis.”,RECOMMENDATIONS 3,Knowledge of the transport characteristics of the patients

7、peritoneal membrane by peritoneal equilibration test or other testsmay help to optimize the prescription to meet this target.,RECOMMENDATIONS 4,A separate target for creatinine clearance is not required in CAPD.In APD,due to a more variable relationship between urea and creatinine clearancean additi

8、onal target of 45 L/week/1.73 m2 for creatinine clearance is recommended(Evidence level C).,RECOMMENDATIONS 5,For patients who rely significantly on residual renal function to achieve the minimal target level of small solute clearance,residual renal function should be monitored regularly and at an a

9、ppropriate frequencyso that the PD prescription can be adjusted in a timely manner(Evidence level C).Every 1 2 months if practicable,otherwise no less frequently than every 4 6 months,RECOMMENDATIONS 5,If there is a decrease in urine volume or a change in blood chemistries suggesting a decline in re

10、sidual renal function,it should be measured sooner.,RECOMMENDATIONS 6,A continuous around-the-clock PD regime is preferred to an intermittent schedule whenever possible(Evidence level B),RECOMMENDATIONS 7,Attention should be paid to both urine volume and the amount of ultrafiltration,with the goal o

11、f maintaining euvolemia.,RECOMMENDATIONS 7,A small ultrafiltered volume despite the use of dialysis solutions with a high glucose concentration should be regarded as a warning sign for the presence of ultrafiltration failure.This should be investigated further with a peritoneal equilibration test ac

12、cording to the ISPD recommendations on evaluation and management of ultrafiltration problems(Evidence level B).,RECOMMENDATIONS 8,For patients with signs and symptoms suggestive of underdialysis,a trial of increasing dialysis should be provided even if Kt/V urea is well above the minimal target(Evid

13、ence level C).,RECOMMENDATIONS 9,The benefit of increasing the amount of peritoneal dialysate(either number of exchanges or volume of each exchange),or change to hemodialysis,when these targets cannot be met should be balanced againstThe potential side effectsEffects on the patients lifestyle Cost c

14、onsideration(Evidence level C).,Peritoneal Dialysis Adequacy,Clinical Practice Guidelines and Clinical Practice Recommendations2006 Updates,PERITONEAL DIALYSIS SOLUTE CLEARANCE TARGETS AND MEASUREMENTS,GUIDELINE 2.,GUIDELINE 2.,Data from RCTs suggested that the minimally acceptable small-solute clea

15、rance for PD is less than the prior recommended level of a weekly Kt/Vurea of 2.0.Furthermore,increasing evidence indicates the importance of RKF as opposed to peritoneal small-solute clearance with respect to predicting patient survival.Therefore,prior targets have been revised as indicated next.,G

16、UIDELINE 2.,2.1 For patients with RKF(considered to be significant when urine volume is 100 mL/d):2.1.1 The minimal“delivered”dose of total small-solute clearance should be a total(peritoneal and kidney)Kt/Vurea of at least 1.7 per week.(B),GUIDELINE 2.,2.1 For patients with RKF(considered to be sig

17、nificant when urine volume is 100 mL/d):2.1.2 Total solute clearance(residual kidney and peritoneal,in terms of Kt/Vurea)should be measured within the first month after initiating dialysis therapy and at least once every 4 months thereafter.(B),GUIDELINE 2.,2.1 For patients with RKF(considered to be

18、 significant when urine volume is 100 mL/d):2.1.3 If the patient has greater than 100 mL/d of residual kidney volume and residual kidney clearance is being considered as part of the patients total weekly solute clearance goal.,GUIDELINE 2.,2.1 For patients with RKF(considered to be significant when

19、urine volume is 100 mL/d):2.1.3 A 24-hour urine collection for urine volume and solute clearance determinations should be obtained at a minimum of every 2 months.(B),GUIDELINE 2.,2.2 For patients without RKF(considered insignificant when urine volume is 100 mL/d):2.2.1 The minimal“delivered”dose of

20、total small-solute clearance should be a peritoneal Kt/Vurea of at least 1.7 per week measured within the first month after starting dialysis therapy and at least once every 4 months thereafter.(B),MAINTENANCE OF EUVOLEMIA,GUIDELINE 4.,GUIDELINE 4.,Volume overload is associated with CHF,LVH,and hype

21、rtension;therefore,it is important to monitor ultrafiltration volume,dry weight,sodium intake,and other clinical assessments of volume status.,GUIDELINE 4.,4.1 Each facility should implement a program that monitors and reviews peritoneal dialysate drain volume,RKF,and patient blood pressure on a mon

22、thly basis.(B),GUIDELINE 4.,4.2 Some of the therapies one should consider to optimize extracellular water and blood volume include,but are not limited to,restricting dietary sodium and water intake,use of diuretics in patients with RKF,and optimization of peritoneal ultrafiltration volume and sodium

23、 removal.(B),PERITONEAL DIALYSIS PRESCRIPTION TARGETS AND MEASUREMENTS,GUIDELINE 2.,GUIDELINE 2.,In a PD prescription,there are certain general considerations.,GUIDELINE 2.,2.1 Regardless of delivered dose,if a patient is not thriving and has no other identifiable cause other than possible kidney fa

24、ilure,consideration should be given to increasing dialysis dose.,GUIDELINE 2.,GUIDELINE 2.,2.2 In a patient with minimal RKF,a continuous(rather than intermittent)24 h/d of PD dwell PD prescription should be used to maximize middle-molecule clearance.,GUIDELINE 2.,2.3 If either peritoneal Kt/Vurea i

25、s at least 1.7 or 24-hour urine output is less than 100 mL,monitoring of RKF is not required for monitoring the dose of PD.,GUIDELINE 2.,2.4 All measurements of peritoneal solute clearance should be obtained when the patient is clinically stable and at least 1 month after resolution of an episode of

26、 peritonitis.,GUIDELINE 2.,2.5 More frequent measurements of either peritoneal urea clearance or RKF should be obtained when clinically indicated.,GUIDELINE 2.,2.6 When calculating Kt/Vurea,one should estimate V from either the Watson or Hume equation in adults.2.6 In the absence of evidence,use of

27、the patients ideal or standard(rather than actual)weight should be considered in the calculation of V.,GUIDELINE 2.,2.7 The determination of peritoneal CCr is of little added value for predicting risk for death;therefore,for simplicity,adequacy targets are based on urea kinetics only.2.7 Peritoneal

28、creatinine excretion rate may be used to monitor estimates of muscle mass over time.,GUIDELINE 2.,2.8 During the monthly evaluation of the PD patient,nutritional status should be estimated.2.8 Serum albumin levels should be monitored,and when obtaining 24-hour total solute clearances,estimations of

29、dietary protein intake(DPI;such as nPNA)should be measured.,RECOMMENDED LABORATORY MEASUREMENTS FOR PERITONEAL MEMBRANE FUNCTION AND ULTRAFILTRATION VOLUME,GUIDELINE 3.,GUIDELINE 3.,Total solute clearance and peritoneal effluent volume ultimately are influenced by peritoneal membrane transport chara

30、cteristics.Multiple tests are documented to be efficacious for determining peritoneal membrane transport.None of these tests has been shown to be clinically superior to the others.,GUIDELINE 3.,GUIDELINE 3.,3.1 Each center should choose one of these tests to use when characterizing peritoneal transp

31、ort in their patients.3.2 Baseline peritoneal membrane transport characteristics should be established after initiating a daily PD therapy.,GUIDELINE 3.,3.3 Data suggest that it would be best to wait 4 to 8 weeks after starting dialysis to obtain this baseline measurement.3.4 Peritoneal membrane tra

32、nsport testing should be repeated when clinically indicated.,GUIDELINE 3.,GUIDELINE 3.,3.5 All measurements of peritoneal transport characteristics should be obtained when the patient is clinically stable and at least 1 month after resolution of an episode of peritonitis.,WRITING THE PERITONEAL DIAL

33、YSIS PRESCRIPTION,GUIDELINE 4.,GUIDELINE 4.,The PD modality has an impact on adherence and QOL,which are important considerations in writing a PD prescription.,GUIDELINE 4.,Ultrafiltration,which is important in optimizing volume control and thus patient survival,is dependent on the prescription and

34、peritoneal membrane characteristics.Clearance of middle molecules,while not proved to influence patient survival,should be an important consideration in the prescription.,GUIDELINE 4.,4.1 The patients schedule and QOL should be taken into account when prescribing PD.,GUIDELINE 4.,4.2 To optimize mid

35、dle-molecule clearance in patients who have minimal RKF,the PD prescription should preferentially include dwells for the majority of the 24-hour day.4.2 This is recommended even if small-molecule clearance is above target without the longer dwell.,GUIDELINE 4.,4.3 As tolerated by the patient,to opti

36、mize small-solute clearance and minimize cost,one should first increase instilled volume per exchange before increasing the number of exchanges per day.4.3 The exchange volume of the supine exchange(s)should be increased first because this position has the lowest intra-abdominal pressure.,GUIDELINE

37、4.,4.4 The patients record of PD effluent volume should be reviewed monthly,with particular attention to the drain volume from the overnight dwell(s)of CAPD and the daytime dwell(s)of APD.,GUIDELINE 4.,4.5 A number of techniques can be used to optimize volume and blood pressure control.,GUIDELINE 4.

38、,4.5.1 To achieve the desired volume status,the lowest possible dialysate dextrose concentration should be used.4.5.2 When appropriate,implement dietary sodium and fluid restriction.,GUIDELINE 4.,4.5.3 In patients with RKF,to achieve dry weight,diuretics may be preferred to increasing dialysate dext

39、rose concentration.4.5.4 Drain volume should be optimized during the overnight dwell(s)of CAPD and the daytime dwell(s)of APD to maximize solute clearance and ultrafiltration volume.,GUIDELINE 4.,4.5.5 In patients who are hypertensive or who show evidence of volume overload,ultrafiltration generally

40、 should not be negative(ie,no absorption)for any daytime or nighttime exchanges.,EUROPEAN BEST PRACTICE GUIDELINES FOR PERITONEAL DIALYSIS,Adequacy of peritoneal dialysis,GUIDELINE A,Adequacy targets for dialysis should include both urea removal and uid removal.(Evidence level C),GUIDELINE B,These t

41、argets should be based on those achieved by peritoneal dialysis only.Urine production and renal urea clearance can be subtracted from the targets.(Evidence level C),GUIDELINE C,The minimum peritoneal target for Kt/Vurea in anuric patients is a weekly value of 1.7;(Evidence level A)The minimum perito

42、neal target for net ultraltration in anuric patients is 1.0 l/day.(Evidence level B)The presence of residual renal function can compensate when these peritoneal targets are not achieved.(Evidence level C),GUIDELINE D,When the targets are not achieved,patients should be monitored carefully for signs

43、of overhydration,uraemic complaints and malnutrition.Appropriate therapy changes might be considered.(Evidence level C),GUIDELINE E,Some APD patients who use frequent short exchanges and have a slow transport status can full the above targets,but may have a low peritoneal creatinine clearance.In these patients,an additional target of 45 l/week/1.73m2 for peritoneal creatinine clearance should be aimed at in addition to achieving the Kt/Vurea target of 1.7.(Evidence level C),