Volume-Based Peritoneal Dialysis Prescription Guide to Achieve Adequacy Targets

Abstract

♦ Background: The use of automated and continuous ambulatory peritoneal dialysis (APD and CAPD) prescriptions (Rxs) to achieve adequate uremic toxin and fluid removal targets is important for attaining optimal patient outcomes. One approach for predicting such Rxs is the use of kinetic modeling. ♦ Methods: Demographic data and peritoneal membrane characteristics derived from a peritoneal equilibration test (PET) were available from 1,005 patients in North American centers who participated in a national adequacy initiative in 1999. Twelve patient subgroups were identified according to peritoneal membrane transport type and tertiles of total body water, assumed equal to urea distribution volume (V urea ). Each patient was then modeled using PD Adequest 2.0 to be treated by 12 CAPD and 34 APD Rxs using both glucose and icodextrin solutions to achieve adequacy targets of weekly urea Kt/V of 1.7 and 1 L of daily ultrafiltration (UF). Residual kidney function (RKF) was assumed to be 0, 2, 4, and 6 mL/min. Feasible peritoneal dialysis (PD) Rxs were identified where: 1) the 95% confidence limit achieved the goal of meeting the targets for urea Kt/V, daily UF, and both in 85%, 75%, and 70% of patients, respectively; 2) average PD solution dextrose concentration was < 2.5%; and 3) the number of daytime exchanges was minimized. ♦ Results: Feasible PD Rxs were similar when RKF was ≥ 2 mL/min, allowing condensed recommendations based on RKF ≥ 2 mL/min or < 2 mL/min. Individuals with lower or slower membrane transport required relatively greater 24-h solution volumes to achieve adequacy targets when RKF fell below 2 mL/min. With increasing V urea , there was disproportionately greater dependence on RKF to achieve targets. While multiple Rxs achieving urea Kt/V and daily UF goals were identified for all membrane transport types, use of icodextrin in the long dwell reduced the need for a midday exchange in APD, glucose exposure, required fill and 24-h dwell volumes, irrespective of RKF and V urea . While these benefits were most notable in high and high-average transporters, similar results were also seen in low and low-average transporters.

APD or CAPD: one glove does not fit all

“…A real patient data-based simulation model comparing icodextrin with 2.27% glucose solutions clearly showed that the use of icodextrin for the long well (day dwell in APD and night dwell in CAPD) resulted in both increased ultrafiltration efficiency and sodium removal across the whole spectrum of peritoneal membrane transport types. The authors also showed equal sodium removal in both modalities [ 62 ]. Similarly, a more recent publication reported that sodium removal was not associated with PD modality but increased with the use of icodextrin and with solutions of higher glucose concentration [ 63 ].…”

Changing Landscape for Peritoneal Dialysis: Optimizing Utilization

“…In PD patients, volume and blood pressure should be closely monitored and effectively addressed to avoid both an increase in left ventricular mass index and an increase in cardiothoracic ratio . Volume‐based PD prescriptions incorporating icodextrin rather than glucose in the long dwell reduced the complexity of PD regimens, total glucose exposure, and 24‐hour total treatment solution volumes .…”

Ultrafiltration in Patients on Automated Peritoneal Dialysis with Homechoice Claria connected to Sharesource: A Pilot Study

“…Previous trials reported that the UF percentage ranged from − 3.50-16.50% with 1.5% dextrose [33][34][35][36] , 10.50-18.76% with 2.5% dextrose 31,34,35,[37][38][39] , 30.60-51.40% with 4.25% dextrose [33][34][35] , and 11.7-12.62% with mixed dextrose concentrations 40,41 , with the same FV (2 liters) and different DTs (ranging from 1.5 hours to 6 hours). The UF/FV/DT values ranged from 0.97 to 6.07 ‱/min with 1.5% dextrose 35,36 and 2.93 to 11.85 ‱/min with 2.5% dextrose 31,35,[37][38][39] . Our results were all in accordance with previous trials.…”