PD Adequacy

Question 1

How to determine PD adequacy?

Answer 1

1. 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

2. UF
3. nutritional status
4. Clinical parameters
   - CKD-MBD
   - Hb

*5. QoL

Question 2

Landmark trial in PD (adequacy)

Answer 2

1. CANUSA
   (1999) 0.1 lower kt/v associated with increased mortality
   (2001) lower mortality with RRF
2. ADEMEX
   (2002) similar survival Kt/v 1.7 vs 2.0
3. Hong Kong Trial
   (2003) ureamia and poor UF with Kt/v < 1.7

Question 3

How to tackle fluid overload?

Answer 3

1. Volume and salt restriction
2. Optimize diuretics
3. Use icodextrin
4. Adjust duration of dextrose dwell to maximize UF according to membrane charectaristic
5. Consider more hypertonic saline
6. Set a proper dry weight
   Objectively: BCM

Question 4

What to do if suboptimal solute clearance?

Answer 4

1. Increase volume by 20-30%
   - volume >2L have little added benefit
2. Increase exchanges if volume maxed
3. Limit APD exchange not > than 5
4. in APD: add day exchanges / long day dwell
5. If APD exchanges maximized, consider day dwell with icodextrin / APD plus / wet-day

Question 5

What is Kt / v (urea)?
Target?
Factors influence?

Answer 5

Kt : weekly urea clearance

V: estimated volume of urea distribution

Target 1.7

Factors affecting:
- variation of total body water

Question 6

how to improve the PD uptake?

Answer 6

answer in diagram

Wiley Online Library: The case for increased peritoneal dialysis utilization in low- and lower-middle-income countries (Jan 2022)

Question 7

How much protein loss through dialysis?

Question 8

Kt/v measurement

Answer 8

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