adequacy in pediatric peritoneal dialysis - … · adequacy in pediatric peritoneal dialysis...
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ADEQUACY IN PEDIATRIC PERITONEAL DIALYSIS
FRANCISCO CANO M.D.
DIVISION OF PEDIATRIC NEPHROLOGY
LUIS CALVO MACKENNA CHILDREN’S HOSPITAL
FACULTY OF MEDICINE, UNIVERSITY
OF CHILE
Supported by FONDECYT RESEARCH PROJECT 1110226
• Dialysis Dose and Mortality
• Dialysis Dose and Growth
• KtV recommendations
• Peritoneal Transport and Mortality
• Peritoneal Transport and Growth
• PET Recommendations
• Adequacy in terms of cardiovascular outcome
• Adequacy and Water transport
• PET and MiniPET
• Conclusions
Overview
Adequate dialysis:
OUTCOME
Adult patients: Mortality
Pediatrics: growth
• Adequacy
• Adaequat
• To make equivalent
• Barely satisfactory
• Sufficient to satisfy a
requirement or meet a need.
In search of the ideal dialysis prescription
ADEQUACY. THE CLASSICAL VIEW Kt/V and PET
DIALYSIS DOSE
KT/V
exchange volume
Urea nitrogen D/P
volume of distribution of urea (TBW)
Time (week)
PERITONEAL EQUILIBRIUM TEST
PET
CREATININE D/P
GLUCOSE D/D
ADEQUACY: Kt/V
DIALYSIS DOSE
KT/V
Exchange volume
Urea nitrogen D/P
volume of distribution of urea (TBW)
Time (week)
PERITONEAL EQUILIBRIUM TEST
PET
CREATININE D/P
GLUCOSE D/D
ADEQUACY
The recommended Kt/V
DIALYSIS DOSE
KT/V
THE BEST DIALYSIS DOSE
(outcome)
ADULTS:
MORTALITY
CANUSA (Churchill D, J Am Soc
Nephrol 1998)
ADEMEX (Paniagua R. J Am Soc
Nephrol, 2002)
HONG KONG TRIAL (Wai-Kei Lo, Kidney Int 2003)
Kt/V and Mortality
DIALYSIS DOSE
KT/V
Mortality
CANUSA: 1.5-2.3
ADEMEX: 1.45-1.74 vs 1.94-2.24
Hong Kong: 1.5-1.7;1.7-2;>2
DIALYSIS DOSE
KT/V
THE BEST DIALYSIS DOSE:
Mortality: A reanalysis of the CANUSA Study.
J Am Soc Nephrol 2001
For each 5 L/wk per 1.73 m2 increment in GFR, there was
a 12% decrease in the relative risk of death
Kt/V and Mortality
DIALYSIS DOSE
KT/V
THE BEST DIALYSIS DOSE:
mortality
Kt/V and Mortality
DIALYSIS DOSE
KT/V
THE BEST DIALYSIS DOSE
(outcome)
PEDIATRICS: GROWTH
NAPRTCS 2011
Chadha V, Blowey D, Warady B
Perit Dial Int 2001;21:s179-84
IPPN 2014 KtV
Peritoneal KtV 2.6± 8.7
Residual KtV 0.8±1.4
Total KtV 3.4±8.7
KtV <1.8:
12.5%
ADEQUACY
The recommended Kt/V
NAPRTCS 2011
Annual Report
statistics
reality
Chadha V, Blowey D, Warady B
Perit Dial Int 2001;21:s179-84
Kt/V and Growth
Residual Kt/V
<0.05 0.86 2.8 0.95 1.70 Nitrogen Balance (gr/kg/day)
n.s. 0.42 1.38 0.39 1.31 PNA (gr/kg/day)
n.s. 0.44 1.36 0.36 1.34 PCR (gr/kg/day)
<0.05 1.44 3.5 0.65 2.7 DPI (gr/kg/day)
n.s. 1.55 3.51 1.61 3.55 Kt/V (total)
n.s. 0.88 1.91 0.61 1.66 Kt/V (peritoneal)
<0.05 1.06 1.27 1.67 1.88 Kt/V (residual)
p St dv mean St dv mean Variable
Growth positive , n:16 negative, n:12
Cano F., et al
Dialysis dose, nutrition and growth among pediatric patients on peritoneal dialysis
Rev Med Chile 2005 ;133(12):1455-64
KtV and Growth in PD Children
Kt/V and Growth
DIALYSIS DOSE
KT/V
THE BEST DIALYSIS DOSE
Conclusions: In PD patients
1. total KtV>1.7 does not impact in mortality in
adults.
2. total KtV does not impact on Growth
3. Residual Renal Function is closely
related to mortality and growth.
ADEQUACY
The recommended Kt/V
ADEQUACY
Peritoneal Equilibrium Test
DIALYSIS DOSE
KT/V
Exchange volume
Urea nitrogen D/P
volume of distribution of urea (TBW)
Time (week)
PERITONEAL EQUILIBRIUM TEST
PET
CREATININE D/P
GLUCOSE D/D
Peritoneal Equilibrium Test
Twardowski ZJ,. Perit Dial Bull 1987; 7:138–47.
Peritoneal Equilibrium Test
Peritoneal Equilibrium Test
Transport
Category
Solute
removal
Water
removal
Best choice
High fast poor APD
High av good good APD CAPD
Low av good good APD CAPD
Low slow good CAPD_HD
PET: the best transporter category
PERITONEAL EQUILIBRIUM TEST
THE BEST PET CATEGORY
(outcome)
ADULTS:
MORTALITY
CANUSA
NECOSAD
EAPOS
CANUSA
Prospective,
2-y,
606 CAPD pts
NECOSAD
Prospective, 2-y,
118 CAPD pts
High transport status at baseline had no effect on
outcome
EAPOS
Prospective, 2-y,
177 anuric APD pts
Peritoneal membrane transport
status at baseline had no
effect on outcome
(Figure: UF> 750ml)
PET AND MORTALITY
Scott Brimble K., J Am Soc Nephrol 2006
0 21.9 45.7 77.3%
Schaefer et al.
J Am Soc Nephrol 1999;10:1786-92
PET: the best transporter category
Growth in children
Cano F, Sanchez L., Rebori A. et
al., Ped Nephrol 2010
PET: The classical test and the Short PET
(…and the Center effect)
International Pediatric PD Network
Ethnic variation in peritoneal transport
characteristics: Findings from the IPPN Registry
F. Cano1, A. Sander2, E. Serdaroglu3, H. Xu4, R.L. Munarriz5, K. Vondrak6, I.S. Ha7,
B.A. Warady8, F. Schaefer9
1Hospital Luis Calvo Mackenna, Santiago, Chile; 2Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany; 3Dr. Behcet Uz Children Research and Education Hospital, Izmir, Turkey; 4Fudan University Children's Hospital, Shanghai, China; 5Cayetano Heredia Hospital, Lima, Peru; 6University Hospital Motol, Prague, Czech Republic; 7National University Children's Hospital, Seoul, Korea; 8Children's Mercy Hospital, Kansas City, MO USA 9Heidelberg University Center for Pediatrics and Adolescent Medicine,
Heidelberg, Germany
PET CATEGORIES WHAT DO WE BELIEVE?
IPPN DATA 2013
(n: 745)
24,9
75,1
LOW AV (31%)
CAPD
APD
15,6
84,4
LOW (12%)
CAPD
APD
PET CATEGORIES WHAT DO WE BELIEVE?
IPPN DATA 2013
30,7
69,3
HIGH (22%)
CAPD
APD36,9
63,1
HIGH AV (34%)
CAPD
APD
PERITONEAL EQUILIBRIUM
TEST
THE BEST PET
CATEGORY
Conclusions: In PD patients
1. High Transport Category is associated to higher mortality
in CAPD and (less) in APD patients
2. The relationship between Transport Categories and Growth in children needs
reevaluation
3. Categories need to be defined by Center and
Ethnicity
4.Pediatric Nephrologists do not follow PET categories to
adjust PD (?)
PET: the best transporter category
Cardiovascular Disease is a leading cause of death in CKD.
(or…Adequacy and Volume Overload)
Mc Donald S et al., New England Journal of Medicine 2004: Long-Term Survival of Children with End-Stage Renal Disease
Shroff R et al.: Pediatric Nephrology 2007: Long-term outcome of chronic dialysis in children
Mitsnefes MM: Adv. Chronic Kidney Dis 2005: Cardiovascular disease in children with chronic kidney disease.
Mitsnefes MM: Pediatric Nephrology 2008: Cardiovascular complications of pediatric chronic kidney disease.
Monteucci M: J Am Soc Nephrol 2006: Left ventricular geometry in children with mild to moderate chronic renal insufficiency.
Cardiac disease
Cerebrovascular \
Infections/neoplasm
Other
Foley RN, et al. Am J Kidney Dis.
1998;32(suppl 3):S112-S119.
Effect of fluid and sodium removal on mortality in peritoneal
dialysis patients
Ates y cols., Kidney Int 2001
Peritoneal Water Transport
Concept of Sodium Seaving
Twardowski Z., Advances in Peritoneal Dialysis,1987
Adequacy and Volume Overload
The three-pore model
Rippe B, Kidney Int 1991; 40: 315–5
Ni J. et al. Kidney Int 2006,69:1518-25
Peritoneal Free Water Transport
Peritoneal Free Water Transport:
The MiniPET
• Dip NaD (meq/L)
Na out − Na in
• Dip D/PNa
D/PNa 60 − D/PNa 0
• Na removal
total Na60 – total Na1
[Volume Out (L) * Na Out(meq/L)] − [Volume In(L) * Na In (meq/L)]
• UFSP (mL)
[NaR(meq) • 1000]/ Nap
• FWT
Total UF (mL) − UFSP (mL)
Mini-peritoneal equilibration test: A simple and fast method
to assess free water and small solute transport across
the peritoneal membrane
La Milia V., Kidney Int 2005
The mini-PET in pediatric peritoneal dialysis: A useful tool
to predict volume overload?
Cano et al., Ped Nephrol 2013
Cano et al., Ped Nephrol 2013
The mini-PET in pediatric peritoneal dialysis: A useful tool
to predict volume overload?
Cano et al., Ped Nephrol 2013
The mini-PET in pediatric peritoneal dialysis: A useful tool
to predict volume overload?
r=0,58, p=0,02
Cano et al., Ped Nephrol 2013
The mini-PET in pediatric peritoneal dialysis: A useful tool
to predict volume overload?
Adequacy and Volume Overload
The three-pore model
Rippe B, Kidney Int 1991; 40: 315–5
PET
MINI
PET
CONCLUSIONS
The ideal PD prescription is one that allows a
normal cardiovascular status.
Fischbach M, Warady B.
Pediatr Nephrol 2009
1. RRF should be preserved, but not at the price of volume overload
2. High transporters should be carefully monitored. They are at
serious CV risk.
3. Water and Sodium Removal should be balanced through
dialysis dwell-time and glucose concentration.
4.Preserve peritoneal membrane as long as you could: Biocompatible Fluids
Patients should be evaluated through MiniPET+classical PET
Peritoneal Dialysis Adequacy
Conclusions
Muchas gracias