Cross-Over Efficiency Comparison of Different Tidal Automated Peritoneal Dialysis Schedules

2016 ◽  
Vol 42 (4) ◽  
pp. 287-293 ◽  
Author(s):  
Alessandro Domenici ◽  
Anna Giuliani ◽  
Francesca Sivo ◽  
Clorinda Falcone ◽  
Giorgio Punzo ◽  
...  

This study compares 5 different tidal automated peritoneal dialysis (APD) prescriptions. Six low-average and 6 high-average transporters performed 3 separate sessions with 5 different schedules: (A) 50% tidal with initial fill volume (FV) 2 liters, (B) 50% tidal with 2.2 liters initial FV, (C) 2.2 liters initial FV with 70% tidal, (D) as in B, with one complete renewal of the initial FV at midsession, (E) 2.2 liters FV with breakpoint modality. Urea, creatinine and phosphate peritoneal clearances, sodium removal and ultrafiltration (UF) were compared using analysis of variance. Compared to treatment A, all the tested alternative schedules were associated with 10% significantly higher urea clearance; B, D and E, but not C, were associated with 10% higher creatinine clearance. Phosphate clearance was significantly higher with D, while sodium removal was larger with both C and D. UF was lower with A and E in high average transporters. Manipulation of the main prescriptive parameters of tidal APD has significant impact on its efficiency.

1999 ◽  
Vol 19 (2_suppl) ◽  
pp. 462-466 ◽  
Author(s):  
Michel Fischbach ◽  
Joëlle Terzic ◽  
Valerie Bergère ◽  
Christophe Gaugler ◽  
Emmanuel Provot

Objective To describe the optimal approach to peritoneal dialysis (PO) prescription in children. .Design: Review of the available literature. Results Unlike the situation in adults, the main method used for PO in children is automated peritoneal dialysis (APO). The prone position, while resting, permits the dialysis prescription to use a higher fill volume (IPV), as in continuous ambulatory peritoneal dialysis (CAPO), and is also probably more effective than PO in an upright position. However, because APO is limited to 10 hours, the dialytic effectiveness of nocturnal APO should avoid two potential risks: (1) use of too high an IPV per exchange, inducing lymphatic reabsorption, a factor in unsuitable water and sodium balance [Fischbach M. Peritoneal dialysis prescription for neonates. Perit Diallnt. 1996; 16(Suppl): S52–4]; and (2) use of too short a dwell time per exchange, limiting the purification of creatinine and phosphate despite an apparently adequate urea purification (Malhotra C, Murota GH, Tzamaloukas AH. Creatinine clearance and urea clearance in PO: What to do in case of discrepancy. Perit Diallnt. 1997; 17:532–5).


2012 ◽  
Vol 32 (2) ◽  
pp. 142-148 ◽  
Author(s):  
Steven Guest ◽  
Alp Akonur ◽  
Arshia Ghaffari ◽  
James Sloand ◽  
John K. Leypoldt

♦BackgroundIntermittent peritoneal dialysis (IPD) is an old strategy that has generally been eclipsed, in the home setting, by daily peritoneal therapies. However, for a select group of patients with exhausted vascular access or inability to receive PD at home, in-center IPD may remain an option or may serve as an incremental strategy before initiation of full-dose PD. We investigated the residual kidney clearance requirements necessary to allow thrice-weekly IPD regimens to meet current adequacy targets.♦MethodsThe 3-pore model of peritoneal transport was used to examine 2 thrice-weekly IPD dialysis modalities: 5 – 6 dwells with 10 – 12 L total volume (low-dose IPD), and 50% tidal with 20 – 24 L total volume (high-dose IPD). We assumed an 8-hour dialysis duration and 1.5% dextrose solution, with a 2-L fill volume, except in tidal mode. The PD Adequest application (version 2.0: Baxter Healthcare Corporation, Deerfield, IL, USA) and typical patient kinetic parameters derived from a large dataset [data on file from Treatment Adequacy Review for Gaining Enhanced Therapy (Baxter Healthcare Corporation)] were used to model urea clearances. The minimum glomerular filtration rate (GFR) required to achieve a total weekly urea Kt/V of 1.7 was calculated.♦ResultsIn the absence of any dialysis, the minimum residual GFR necessary to achieve a weekly urea Kt/V of 1.7 was 9.7 mL/min/1.73 m2. Depending on membrane transport type, the low-dose IPD modality met urea clearance targets for patients with a GFR between 6.0 mL/min/1.73 m2and 7.6 mL/min/1.73 m2. Similarly, the high-dose IPD modality met the urea clearance target for patients with a GFR between 4.7 mL/min/1.73 m2and 6.5 mL/min/1.73 m2.♦ConclusionsIn patients with residual GFR of at least 7.6 mL/min/1.73 m2, thrice-weekly low-dose IPD (10 L) achieved a Kt/V urea of 1.7 across all transport types. Increasing the IPD volume resulted in a decreased residual GFR requirement of 4.7 mL/min/1.73 m2(24 L, 50% tidal). In patients with residual kidney function and dietary compliance, IPD may be a viable strategy in certain clinical situations.


1996 ◽  
Vol 16 (1_suppl) ◽  
pp. 167-171 ◽  
Author(s):  
Pierre Yves Durand ◽  
Philippe Freida ◽  
Belkacem Issad ◽  
Jacques Chanliau

This paper summarizes the basis of prescription for automated peritoneal dialysis (APD) established during a French national conference on APD. Clinical results and literature data show that peritoneal clearances are closely determined by peritoneal permeability and hourly dialysate flow rate, independently of dwell time or number of cycles. With APD, peritoneal creatinine clearance increases according to the hourly dialysate flow rate to a maximum (plateau), then decreases because of the multiplication of the drain-fill times. The hourly dialysate flow giving the maximum peritoneal creatinine clearance is defined as the “maximal effective dialysate flow” (MEDF). MEDF is higher for high peritoneal permeabilities: MEDF is 1.8 and 4.2 L/hr with nocturnal tidal peritoneal dialysis (TPD) for a 4-hr creatinine dialysate-to-plasma ratio (DIP) of 0.50 and 0.80, respectively. With nightly intermittent peritoneal dialysis (NIPD), MEDF is 1.6 and 2.3 Llhr for a DIP of 0.50 and 0.78, respectively. Under these conditions, tidal modalities can only be considered as a way to increase the MEDF. Using the MEDF concept for an identical APD session duration, the maximal weekly normalized peritoneal creatinine clearance can vary by 340% when 4hr DIP varies from 0.41 to 0.78. APD is not recommended when 4-hr creatinine DIP is lower than 0.50. However, the limits of this technique may be reached at higher peritoneal permeabilities in anurics because of the duration of sessions andlor the additional exchanges required by these patients.


1996 ◽  
Vol 16 (3) ◽  
pp. 307-315 ◽  
Author(s):  
Kinya Hiroshige ◽  
Kougi Yuu ◽  
Masasuke Soejima ◽  
Masayuki Takasugi ◽  
Akio Kuroiwa

Objective To determine the effect of peritoneal dialysis modalities such as nightly intermittent peritoneal dialysis (NIPD), continuous cyclic peritoneal dialysis (CCPD), and continuous ambulatory peritoneal dialysis (CAPD) on residual renal function. Design A six-month prospective, nonrandomized comparison study. Setting Outpatient CAPD unit of a university hospital. Participants Eighteen end-stage renal disease patients treated by peritoneal dialysis (8 by NIPD, 5 by CCPD, and 5 by CAPD). Interventions Samples from the total dialysate, blood, and 24hour urine collection were obtained monthly. Measurements Urea, creatinine, and beta2-microglobulin concentrations were measured. Renal and peritoneal clearances of each substance and KT/V urea were calculated. Residual renal function (RRF) was estimated by renal creatinine clearance (RCcr). Results No significant differences in age, sex, and primary renal disease among the three groups were noted. In all groups, anemic and hypertensive states were controlled identically, and mean weekly total (renal + peritoneal) KT/V urea (over 2.1/wk) and total creatinine clearance (over 60 L/wk/1.73 m2) were maintained during the whole experimental period. Starting mean RCcr was near 4.0 mL/min/1.73 m2 in all groups. Thereafter, a rapid and significant decline in RRF was demonstrated on NIPD and CCPD. The declining rates of RCcr values at 6 months after starting NIPD and CCPD were -0.29 and -0.34 mL/min/month, respectively, which were much greater than those of CAPD (+0.01 mL/min/month). Conclusion Because of a possibly characteristic progressive loss of RRF in automated peritoneal dialysis (APD), strict regular assessment of RRF should be performed from the start of APD.


2009 ◽  
Vol 29 (2_suppl) ◽  
pp. 102-107 ◽  
Author(s):  
Vassilios Liakopoulos ◽  
Nicholas Dombros

The use of the various forms of automated peritoneal dialysis (APD) has increased considerably in the past few years. This increase has in part been driven by technology, through improved cycler design. Other contributing factors include better adjustment of APD to patient lifestyle, the flexibility that APD offers to patients, and the increased ability of APD to achieve adequacy and ultrafiltration targets. For high transporters and for patients unable to perform peritoneal dialysis (PD) on their own (for example, pediatric and elderly patients), APD is considered the most suitable PD modality. Furthermore, APD has been associated with improved compliance, lower intraperitoneal pressure, and lower incidences of peritonitis. On the other hand, concerns have been raised regarding increased complexity and cost, a more rapid decline in residual renal function, inadequate sodium removal, and disturbed sleep. Automated PD is an alternative to continuous ambulatory PD when a higher dialysis dose is needed, and it could be a reliable alternative for unplanned or urgent dialysis start. Other than beneficial results in high transporters, the medical advantages of APD remain controversial. Individual patient choice therefore remains the main indication for the application of APD, which should be made available to all patients starting PD.


2001 ◽  
Vol 21 (3_suppl) ◽  
pp. 133-137 ◽  
Author(s):  
Edwina A. Brown ◽  
Simon J. Davies ◽  
Olof Heimbürger ◽  
Frederique Meeus ◽  
George Mellotte ◽  
...  

♦ Objective Conventional continuous ambulatory peritoneal dialysis (CAPD) in patients without residual renal function and with high solute transport is associated with worse clinical outcomes. Automated peritoneal dialysis (APD) has the potential to improve both solute clearance and ultrafiltration in these circumstances, but its efficacy as a treatment modality is unknown. The European Automated Peritoneal Dialysis Outcomes Study (EAPOS) is a 2-year, prospective, European multi-center study designed to determine APD feasibility and clinical outcomes in anuric patients. The present article describes the baseline data for patients recruited into the study. ♦ Design All PD patients treated in the participating centers were screened for inclusion criteria [urinary output < 100 mL/24 h, or residual renal function (RRF) < 1 mL/min, or both]. After enrollment, changes were made to the dialysis prescription to achieve a weekly creatinine clearance above 60 L per 1.73 m2 and an ultrafiltration rate above 750 mL in 24 hours. ♦ Setting The study is being conducted in 26 dialysis centers in 13 European countries. ♦ Baseline Data Collection The information collected includes patient demographics, dialysis prescription, achieved weekly creatinine clearance, and 24-hour ultra-filtration (UF). ♦ Results The study enrolled 177 anuric patients. Median dialysis duration before enrollment was 22.5 months (range: 0 – 285 months). Mean solute transport measured as the dialysate-to-plasma ratio of creatinine (D/PCr) was 0.74 ± 0.12. Patients received APD for a median of 9.0 hours overnight (range: 7 – 12 hours) using a median of 11.0 L of fluid (range: 6 – 28.75 L). Median daytime volume was 4.0 L (range: 0.0 – 9.0 L). Tidal dialysis was used in 26 patients, and icodextrin in 86 patients. At baseline, before treatment optimization, the weekly mean total creatinine clearance was 65.2 ± 14.4 L/1.73 m2, with 105 patients (60%) achieving the target of more than 60 L/1.73 m2. At baseline, 81% of patients with high transport, 69% with high-average transport, and 40% with low-average transport met the target. At baseline, 70% of patients with a body surface area (BSA) below 1.7 m2, 60% with a BSA of 1.7 – 2.0 m2, and 56% with a BSA above 2.0 m2 achieved 60 L/1.73 m2 weekly. Median UF was 1090 mL/24 h, and 75% of patients achieved the UF target of more than 750 mL/24 h. ♦ Conclusion This baseline analysis of anuric patients recruited into the EAPOS study demonstrates that a high proportion of anuric patients on APD can achieve dialysis and ultrafiltration targets using a variety of regimes. This 2-year follow-up study aims to optimize APD prescription to reach predefined clearance and ultrafiltration targets, and to observe the resulting clinical outcomes.


2014 ◽  
Vol 12 (2) ◽  
pp. 77-83
Author(s):  
Evangelia Dounousi ◽  
Anila Duni ◽  
Konstantinos Leivaditis ◽  
Vassilios Liakopoulos

Abstract The use of the various forms of Automated Peritoneal Dialysis (APD) has considerably increased in the past few years. This increase is driven by improved cycler design, apparent lifestyle advantages, and the increased ability to achieve adequacy and ultrafiltration targets. It is therefore reasonable to raise the question whether APD is superior to Continuous Ambulatory Peritoneal Dialysis (CAPD). APD is considered the most suitable Peritoneal Dialysis (PD) modality for high transporters as well as for assisted PD. It has also been associated with improved compliance, lower intraperitoneal pressure and possibly lower incidence of peritonitis. On the other hand, there are concerns regarding increased cost, a more rapid decline in residual renal function, inadequate sodium removal and disturbed sleep. Besides its beneficial results in high transporters, other medical advantages of APD still remain unclear. Individual patient’s choice remains the most important indication for applying APD, which should be made available to all patients starting PD.


2007 ◽  
Vol 27 (5) ◽  
pp. 537-543 ◽  
Author(s):  
Neil C. Boudville ◽  
Peter Cordy ◽  
Kristie Millman ◽  
Laura Fairbairn ◽  
Ajay Sharma ◽  
...  

Objectives To examine the control of blood pressure and volume, and the role of sodium removal in a single, large, contemporary, automated peritoneal dialysis (APD) population where icodextrin is used liberally and there is a policy to avoid long duration glucose-based daytime dwells. Design Observational cross-sectional study. Setting A university hospital. Patients 56 APD patients, with a mean duration on peritoneal dialysis of 1.9 years; 50% were prescribed icodextrin. Main Outcome Measures Blood pressure, extracellular water volume (ECW)-to-intracellular water volume (ICW) ratio, and total (peritoneal and urinary) sodium removal. Results Sodium Removal: Mean total sodium removal, while low at 102.9 ± 64.6 mmol/day, showed a wide range, with 41% having a sodium removal of >120 mmol/day. Total sodium removal correlated with total body water, ECW, and ICW ( p < 0.001, p < 0.001, p < 0.025, respectively), as well as with height and weight ( p < 0.06, p < 0.01 respectively). On multivariate analysis, only ultra-filtration volume and urine volume were significantly associated with total sodium removal ( r2 = 0.67, p < 0.0001 for both). There was also a correlation between sodium removal and urea nitrogen appearance ( r2 = 0.31, p < 0.001), with urea nitrogen appearance in turn being closely correlated with ICW ( p < 0.001). Volume Status: The ECW/ICW ratio was 0.88 ± 0.17, which was not significantly different to that found in hemodialysis patients without clinical evidence of fluid overload, either predialysis (0.96 ± 0.16) or postdialysis (0.92 ± 0.16); p = 0.07 and 0.36 respectively. Blood Pressure: Mean ± standard deviation systolic blood pressure (BP) was 111.9 ± 18.2 mmHg and diastolic BP was 63.3 ± 11.9 mmHg, with only 4 (7%) patients having a systolic BP > 140 mmHg and 1 (2%) having a diastolic BP > 80 mmHg. Median number of antihypertensives was 1 per day. Blood pressure control and ECW/ICW ratio were similar in those with sodium removal >120 mmol/day compared to those with sodium removal ≤120 mmol/day ( p = 0.39 for SBP, p = 0.70 for diastolic B P, p = 0.24 for ECW/ICW). Conclusions We have shown that good blood pressure and volume control is achievable in a large contemporary APD population with liberal use of icodextrin and avoidance of long daytime glucose-based dwells. Neither low nor high sodium removal was associated with more frequent hypertension or volume expansion.


2000 ◽  
Vol 20 (5) ◽  
pp. 548-556 ◽  
Author(s):  
Rafael A. Perez ◽  
Peter G. Blake ◽  
Susan McMurray ◽  
Lou Mupas ◽  
Dimitrios G. Oreopoulos

Objective The recent increase in the use of automated peritoneal dialysis (APD) has led to concerns about the adequacy of clearances delivered by this modality. Few clinical studies looking at the effects of varying the individual components of the APD prescription on delivered clearance have been done, and most published data are derived from computer modeling. Most controversial is the optimal frequency of exchanges per APD session. Many centers prescribe 4 to 6 cycles per night but it is unclear if this is optimal. The purpose of this study was to address at what point the beneficial effect of more frequent cycles is outweighed by the concomitant increase in the proportion of the total cycling time spent draining and filling. Methods A comparison was made between the urea and creatinine clearances (CCrs) achieved by 4 different APD prescriptions, used for 7 days each, in 18 patients. The prescriptions were for 9 hours each and were all based on 2-L dwell volumes, but differed in the frequency of exchanges. They were 5 x 2 L, 7 x 2 L, and 9 x 2 L, as well as a 50% tidal peritoneal dialysis (TPD) prescription using 14 L. Ultrafiltration, dwell time, glucose absorption, sodium and potassium removal, protein excretion, and relative cost were also compared. Clearances due to day dwells and residual renal function were not included in the calculation. Results Mean urea clearances were 7.5, 8.6, 9.1, and 8.3 L/night for the four prescriptions respectively. Urea clearance with 9 x 2 L was significantly greater than with the other three prescriptions ( p < 0 0.05). Urea clearance with 7 x 2 L and TPD were superior to 5 x 2 L ( p < 0.05). Mean CCr was 5.1, 6.1, 6.4, and 5.6 L/night, respectively. Compared to 5 x 2-L, the 7 x 2-L, 9 x 2-L, and TPD prescriptions achieved greater CCr ( p < 0.05). Taking both urea and CCr into account, 9 x 2 L was the optimal prescription in 12 of the 18 patients. Ultrafiltration and sodium and potassium removals were all significantly greater with the higher frequency prescriptions. Conclusion The 5 x 2-L prescription significantly underutilizes the potential of APD to deliver high clearances, and 7 x 2 L is a consistently superior prescription if 2-L dwells are being used. Although more costly, 9 x 2 L should be considered if higher clearances are required.


2019 ◽  
Vol 32 (6) ◽  
pp. 1011-1019 ◽  
Author(s):  
Sarju Raj Singh Maharjan ◽  
Andrew Davenport

Abstract Background Optimal fluid balance for peritoneal dialysis (PD) patients requires both water and sodium removal. Previous studies have variously reported that continuous ambulatory peritoneal dialysis (CAPD) removes more or equivalent amounts of sodium than automated PD (APD) cyclers. We therefore wished to determine peritoneal dialysate losses with different PD treatments. Methods Peritoneal and urinary sodium losses were measured in 24-h collections of urine and PD effluent in patients attending for their first assessment of peritoneal membrane function. We adjusted fluid and sodium losses for CAPD patients for the flush before fill technique. Results We reviewed the results from 659 patients, mean age 57 ± 16 years, 56.3% male, 38.9% diabetic, 24.0% treated by CAPD, 22.5% by APD and 53.5% APD with a day-time exchange, with icodextrin prescribed to 72.8% and 22.7 g/L glucose to 31.7%. Ultrafiltration was greatest for CAPD 650 (300–1100) vs 337 (103–598) APD p < 0.001, vs 474 (171–830) mL/day for APD with a day exchange. CAPD removed most sodium 79 (33–132) vs 23 (− 2 to 51) APD p < 0.001, and 51 (9–91) for APD with a day exchange, and after adjustment for the CAPD flush before fill 57 (20–113), p < 0.001 vs APD. APD patients with a day exchanged used more hypertonic glucose dialysates [0 (0–5) vs CAPD 0 (0–1) L], p < 0.001. Conclusion CAPD provides greater ultrafiltration and sodium removal than APD cyclers, even after adjusting for the flush-before fill, despite greater hypertonic usage by APD cyclers. Ultrafiltration volume and sodium removal were similar between CAPD and APD with a day fill.


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