ii. nkf-k/doqi clinical practice guidelines for peritoneal dialysis adequacy

72 Pages·2012·0.33 MB·English

II. NKF-K/DOQI CLINICALPRACTICE GUIDELINES FOR
PERITONEALDIALYSISADEQUACY:
UPDATE 2000
NOTE:Thecitationfortheseguidelinesshouldreadasfollows:NationalKidneyFoundation.K/DOQI
Clinical Practice Guidelines for Peritoneal DialysisAdequacy, 2000.Am J Kidney Dis 37:S65-S136,
2001(suppl1)
S65
Acronyms andAbbreviations
Abbreviation Term
ACE angiotensin-convertingenzyme
BSA bodysurfacearea
BUN bloodureanitrogenconcentration
CANUSA Canada/USAPeritonealDialysisStudy
CAPD continuousambulatoryperitonealdialysis
CCPD continuouscyclingperitonealdialysis
C creatinineclearance
Cr
C residualrenalcreatinineclearance
rCr
CKD chronickidneydisease
DI dialysisindex
DPI dietaryproteinintake
eC effectiveclearance
ESRD end-stagerenaldisease
GFR glomerularfiltrationrate
HD hemodialysis
K peritonealcreatinineclearance
pCr
K t/V theperitonealcomponentofKt/V
p urea urea
K t/V thesumofperitonealandrenalKt/V .ThesetermsareinterchangeableinthatKt/
pr urea urea
V istotalunlessotherwisenoted.
urea
Kt/V ureaclearance(cid:1)timenormalizedbytotalbodywater,thevolumeof
urea
distributionofurea
Kt/V therenalcomponentofKt/V
r urea urea
MTC masstransfercoefficient
n normalized
nBSA normalizedbodysurfacearea
NIPD nocturnalintermittentperitonealdialysis
nPCR normalizedproteincatabolicrate
nPNA normalizedproteinequivalentoftotalnitrogenappearance
nV normalizedvolume
PCR proteincatabolicrate
PD peritonealdialysis
PET peritonealequilibrationtest
PNA proteinequivalentofnitrogenappearance
QOL qualityoflife
RKF residualkidneyfunction
RRF residualrenalfunction
SGA subjectiveglobalassessment
SHR standardizedhospitalizationrates
SUN serumureanitrogenconcentration
t time
UKM ureakineticmodeling
UNA ureanitrogenappearance
URR ureareductionratio
USRDS UnitedStatesRenalDataSystem
V volumeofdistribution.Whenreferringtourea,thisistotalbodywater
S66
Introduction
T
HISWORKGROUPwaschargedwithpre- stated goal. That goal is some form of outcome
paring practice guidelines for the “ad- measure(s),andcouldbedeterminedbypatient,
equacyofperitonealdialysis,”atopicthatcould provider, payer, regulator or a combination of
bedefinedbroadlyornarrowly.TheWorkGroup these parties.At the lower extreme is the “mini-
elected to focus its guidelines on those areas of maleffectivedose.”Incertaincircumstancesthis
“adequacy”thatneededthemosturgentdevelop- may be interpreted as “adequate.” At the other
ment, knowing that subsequent guidelines will extreme is the “maximal effective dose,” the
bedevelopedorthatotherswerecurrentlyunder dose above which there are no additional ben-
development (eg, for management of peritoni- efits. For hemodialysis and peritoneal dialysis
tis). In addition, the Work Group focused on themaximaleffectivedoseisnotknown.Some-
topicsforwhichguidelineswouldlikelyhavethe where between these extremes is the “optimal
greatest impact on patient outcomes. However, dose,” the dose above which the additional de-
theWorkGroup’sfocusshouldnotbeconstrued rived benefit does not justify the additional cost
tomeanthatareasnotcoveredareunimportant. or burden. If one accepts this definition, the
Someexternalreviewerscriticizedtheseguide- Work Group intended to more precisely define
lines as too complex, while others wrote that “optimal dose” targets in a clinically relevant
they were not thorough enough. Some wanted and quantitative fashion. It was the intention of
guidelinesmerged,andothersthoughttheguide- theWork Group to bring “adequate dose” to the
lines were too dense. The Work Group consid- level of “optimal dose” by raising the outcome
eredalltheseissues. goals or expectations. The present guidelines
We advise the reader to first become familiar attempttomakerecommendationsbasedonavail-
with the Table of Contents, which provides a ablescientific/medicalevidence,resortingtoex-
listing of the Clinical Practice Guidelines for pert opinion only when necessary. It is clearly
Peritoneal Dialysis Adequacy; detailed ration- statedineachguidelinetitlewhenrecommenda-
ales are provided for each guideline. Redundan- tions were based on evidence, opinion, or both.
ciesareoftenintentionalbecauseitisanticipated Even when guidelines were based on opinion,
that a reader might review only selected topics. that opinion is supported by direct or extrapo-
However,theWorkGroupconsiderstheseguide- latedevidence.
lines as best viewed in their entirety, rather than Theseguidelinesareintendedforusebyhealth
intheircomponentparts. care professionals trained to understand varia-
There is a paucity of data on children in the tions in the practice of medicine and the neces-
areas covered by these guidelines. Pediatricians sity for such variation. These guidelines are not
were represented on the Work Group, and out- intended for punitive use by any oversight offi-
side pediatric consultations were obtained. Be- cial who does not understand the reasons or the
cause some recommendations for adults do not necessityforpracticevariationsincludingvaria-
apply to children, additional recommendations tionsinsocietiesdifferentfromthatoftheUnited
are included when appropriate for pediatric pa- States.
tients. For the purpose of these guidelines, a
childwasconsideredtobeapatientlessthan19
©2001bytheNationalKidneyFoundation,Inc.
yearsofage.
0272-6386/01/3701-0103$3.00/0
An “effective dose” is that which achieves its doi:10.1053/ajkd.2001.20778
AmericanJournalofKidneyDiseases,Vol37,No1,Suppl1(January),2001:ppS67 S67
I. Initiation of Dialysis
BACKGROUND result in unnecessary morbidity and potentially
highercostsaswell.Whileseeinganephrologist
Two clinical guidelines for when to initiate
does not guarantee that patients will be ad-
dialysis are provided because there appear to be
equately prepared and referred for dialysis, it
two independent predictors of clinical outcome.
dramatically increases the likelihood that this
Thefirstguidelineisbasedonthelevelofkidney
willoccur.13
function(asmeasuredbyKt/V perweek);the
r urea The initiation of dialysis guidelines as de-
second is based on nutritional indices and is
scribedinthissectionarebasedonadultdata.No
located in the K/DOQI Clinical Practice Guide-
suchdataexistyetinchildren.
linesinChronicRenalFailure(Guideline27).2
Although less than 1% of American dialysis
GUIDELINE 1
patients begin dialysis with a serum creatinine
concentration (cid:2)8.0 mg/dL or a CCr (cid:3)10 mL/ WhentoInitiateDialysis—Kt/VureaCriterion
min, approximately 60% suffer from nausea/ (Opinion)
vomitingatthetimeofdialysisinitiation.3Thus, Unless certain conditions are met, patients
the likelihood of malnutrition in this population shouldbeadvisedtoinitiatesomeformofdialy-
is high. Evidence from the Modification of Diet sis when the weekly renal Kt/V (Kt/V )
urea r urea
in Renal Disease (MDRD) study4 and a recent fallsbelow2.0.Theconditionsthatmayindicate
large Australian study5 clearly show that when dialysis is not yet necessary even though the
theglomerularfiltrationrate(GFR)decreasesto weeklyKt/V islessthan2.0are:
r urea
25 to 50 mL/min, patients adapt by reducing 1.Stableorincreasededema-freebodyweight.
their protein intake. Protein intake continues to Supportive objective parameters for adequate
decline as kidney disease progresses to kidney nutritionincludealeanbodymass(cid:3)63%,subjec-
failure, administratively termed end-stage renal tive global assessment score indicative of ad-
disease (ESRD). These observations have been equate nutrition (see Guideline 12: Nutritional
corroborated in a prospective study.6As kidney Status Assessment, and Appendix B: Detailed
function deteriorates, protein and energy intake Rationale for Guideline 2) and a serum albumin
decreases,leadingtochangesinbodyweight,fat concentrationinexcessofthelowerlimitforthe
mass,serumalbumin,andtransferrinconcentra- lab,andstableorrising;and
tions.Earlierinitiationofdialysismaypreventor 2. Nutritional indications for the initiation of
perhaps even reverse this deterioration in nutri- renalreplacementtherapyaredetailedinGuide-
tionalstatus.Increasedserumalbuminconcentra- line 27 of the NKF-K/DOQI Clinical Practice
tion has been shown to parallel the increase in Guidelines on Nutrition, part of which is repro-
Kt/V for HD patients.7 In addition, an edito- ducedasGuideline2ofthePDAdequacyGuide-
urea
rial review of cited data8 suggests that albumin lines.
level at initiation of dialysis is predictive of 3.Completeabsenceofclinicalsignsorsymp-
survival.9 tomsattributabletouremia.
Adverse clinical and economic consequences AweeklyKt/V of2.0approximatesakid-
r urea
of failure to properly manage patients with pro- ney urea clearance of 7 mL/min and a kidney
gressivechronickidneydiseaseastheyapproach creatinine clearance that varies between 9 to 14
ESRDandbecomedialysisdependentwerefirst mL/min/1.73 m2. Urea clearance should be nor-
described in Britain.10 These observations have malized to total body water (V) and creatinine
now been corroborated in other regions of Brit- clearance should be expressed per 1.73 m2 of
ain, the United States, and France.11-14 Specifi- bodysurfacearea.TheGFR,whichisestimated
cally, costs, hospitalization, and morbidities de- bythearithmeticmeanoftheureaandcreatinine
crease if attention is paid to nutrition, acid-base clearances, will be approximately 10.5 mL/min/
status, hypocalcemia, hyperphosphatemia, ane- 1.73m2whentheKt/V isabout2.0.
r urea
mia, hypertension, volume status, and dialysis Rationale Adetailedrationaleisdescribedin
access(vascularorperitoneal).Hence,itislikely AppendixA.Thefollowingisasummary.
that delays in referral for initiation of dialysis It is paradoxical that nephrologists have fo-
S68 AmericanJournalofKidneyDiseases,Vol37,No1,Suppl1(January),2001:ppS68-S71
INITIATIONOFDIALYSIS S69
cusedonoptimizingureaclearanceoncepatients tion (RKF) will be necessary to assure that total
are started on dialysis, but have accepted much delivered solute removal does not drop below
lowerlevelsofkidneyureaclearanceduringthe targets (see Guidelines 3: Frequency of Deliv-
pre-dialysis phase of patient management. For ered PD Dose and Total Solute Clearance Mea-
example,aweeklytotal(residualrenalplusperi- surement Within Six Months of Initiation, and
toneal dialysis) Kt/V (K t/V ) of 2.0 or Guideline 5: Frequency of Measurement of Kt/
urea pr urea
higher is associated with improved outcomes in V , Total C , PNA, and Total CreatinineAp-
urea Cr
patients on PD (see Guideline 15: Weekly Dose pearance).Alternatively, the initiation of a “full
of CAPD), yet dialysis is usually not initiated dose” of PD may be offered (equivalent of four
untilweeklyKt/V fallstotherangeof0.71to 2-Lexchangesperday,whichmayyieldaweekly
r urea
1.3. There is no definitive direct proof for the K t/V of 1.5 to 2.0, depending on transport
p urea
beliefthatagivenlevelofureaclearancebythe characteristics, ultrafiltration, and body size).
kidneyisassociatedwithbettercontrolofuremia With initiation of “full dose” PD, frequency of
than PD with this same urea clearance. In fact, measurementofRRFcanbelessintense.
recent studies suggest that the relationship be- The Work Group strongly supports the opin-
tweenproteinintakeandweeklyKt/V isnearly ion that the PD outcome data for a weekly
urea
identicalinpatientswithchronicrenalfailurenot Kt/V of(cid:1)2.0aresocompellingthatusingthe
urea
yetondialysisandinpatientsonPD.Thus,until same figure for initiation of dialysis justifies the
provenotherwise,residualkidneyandperitoneal small risks of performing peritoneal dialysis.
clearancesofsmallsolutesshouldbeconsidered Thoserisksincludeinfectionsandthepossibility
equivalent. thatincreasingthelengthoftimeonPDcontrib-
Once Kt/V falls below 2.0 per week, pa- utestoeventualpatient“burn-out.”Ifapatientis
r urea
tients should be considered at increased risk for suspected to be at high risk for these complica-
malnutritionanduremiccomplications.Withfur- tions, PD may not be the best choice for renal
therdecreasesinKt/V intheabsenceofrenal replacementtherapy.TheWorkGroupacknowl-
r urea
replacementtherapy,theriskincreases.Dialysis, edges that the risks of early initiation of PD are
orsomeformofrenalreplacementtherapy,should not clearly known, but that the risks of late
be strongly considered when Kt/V falls be- initiation are known and are unacceptable. Fur-
r urea
low 2.0 (or C falls in the range of 9 to 14 thermore, not knowing which initiation strategy
Cr
mL/min/1.73m2)anddefinitelyimplementedif: (incremental versus full therapy initiation) is
1. Despite vigorous attempts to optimize pro- better, the Work Group recommends that either
tein and energy intake, any of the following approachbeusedtoreachorexceedtargets.
nutritionalindicatorsshowevidenceofdeteriora- Compared to CAPD, it is more complex to
tion:(a)morethana6%involuntaryreductionin calculate the incremental dose of hemodialysis
edema-free usual body weight (%UBW) or to (HD) that would be needed such that the total
lessthan90%ofstandardbodyweight(NHANES continuous delivered weekly Kt/V would be
urea
II)inlessthan6months;(b)areductioninserum greater than 2.0. However, it can be estimated
albuminbygreaterthanorequalto0.3g/dLand using the fundamental assumption underlying
tolessthan4.0g/dL(seeNutritionGuideline3), CAPD, that at the same protein catabolic rate,
in the absence of acute infection or inflamma- continuousrenalreplacementtherapymustkeep
tion, confirmed by repeat laboratory testing; or the steady state BUN equal to the average pre-
(c) a deterioration in SGA by one category (ie, hemodialysisBUN.(SeeAppendixGforfurther
normal, mild moderate, severe; see Nutrition discussion of this assumption.) If weekly Kt/
r
Guideline9andNutritionAppendixVI). V is 1.6 , for example, a one time per week
urea
If PD is initiated, the K t/V could be in- HD treatment must deliver an equilibrated
p urea
creased incrementally so the combined weekly (double-pool) Kt/V of 2.0 to achieve a total
urea
value of Kt/V (cid:4) K t/V (K t/V or total continuous weekly Kt/V equivalent to 2.0.
r urea p urea pr urea urea
Kt/V ) does not fall below the target level of This is quite difficult to achieve, so two HD
urea
2.0. With the incremental initiation approach treatments per week may be more realistic for
frequent measurement of residual kidney func- thislevelofRRF.IfweeklyKt/V is0.5,two
r urea
S70 GUIDELINESFORPERITONEALDIALYSISADEQUACY
HDtreatmentsmusteachdeliveranequilibrated ing maintenance dialysis, if protein-energy mal-
(double-pool) Kt/V of 2.0 to achieve a total nutrition(PEM)developsorpersistsdespitevig-
urea
continuous weekly Kt/V equivalent to 2.0. orous attempts to optimize protein and energy
urea
This is also quite difficult to achieve, so three intakeandthereisnoapparentcauseformalnu-
HD treatments per week may be more realistic tritionotherthanlownutrientintake,initiationof
for this level of RKF. More technical details maintenance dialysis or a renal transplant is
aboutintermittentHDaredescribedinAppendix recommended.(Opinion)
A, including the role of biocompatible mem- Note: This is Guideline 27 of the K/DOQI
branestohelppreserveRKF. Nutrition Guidelines, reproduced here without
It is a general consensus that patients with thespecificreferencecitationsincluded.Seethe
diabetesshouldinitiatedialysisatlevelsofRKF Nutrition Guidelines2 for these details. This
higher than in patients with causes of ESRD Guideline was written by members of both the
other than diabetes. That practice is not altered PDAdequacyandNutritionWorkGroups.
bythisguideline. Rationale It is well documented that mortal-
TheWorkGroupalsorecognizesthatformany
ity and morbidity are increased in individuals
clinicians,initiatingdialysisbasedonKt/V is
urea with ESRD who begin dialysis therapy with
a new concept.Therefore, we have attempted to
overt evidence of PEM.Accumulating evidence
equate this to the traditional measure of urea
also indicates that initiation of dialysis more in
clearance,C ,andGFR(estimatedbythearith-
Cr line with current NKF-K/DOQI practice guide-
meticmeanofureaandcreatinineclearance). lines (ie, GFR (cid:5)10.5 mL/min) results in im-
The Work Group recognizes that the patient
proved patient outcomes compared with when
will play a major role in accepting the initiation dialysis is delayed until the GFR is (cid:2)5 mL/min
ofdialysisbasedonacertain“laboratoryvalue.”
andsymptomaticuremiaandassociatedmedical
It is the responsibility of the care providers to
complications are present. Furthermore, there is
makecleartothepatienttherationaleforinitiat-
evidencethatinitiatingmaintenancedialysisun-
ing dialysis when the above conditions become
der these circumstances, and when there has
applicable. In particular, the nephrologist must
been nutritional deterioration, results in an im-
explain to the patient the risk of malnutrition
provement in nutritional indices. There is no
withdelayedinitiationofdialysisandthestrong
evidencethatearlierinitiationofdialysisleadsto
inferential evidence that survival might be im-
improvednutritionalstatusamongpatientswith-
proved with an earlier start of dialysis. Thus,
out overt uremia. Moreover, it has not been
appropriate patient education regarding an in-
establishedthatimprovednutritionalstatusatthe
formeddecisionaboutdialysisisnecessary.Medi-
initiation of dialysis directly leads to improved
cal conditions that may explain why dialysis is
survivalorfewerdialysis-relatedcomplications.
not being initiated when weekly Kt/V is less
r urea
Despite the lack of evidence from controlled
than 2.0 need to be documented. These condi-
clinical trials, interventions that maintain or im-
tionsaredescribedabove.
prove nutritional status before the requirement
Someindividualshaveexpressedconcernthat
forrenalreplacementtherapyarelikelytoresult
this guideline will run afoul of the Health Care
inimprovedlong-termsurvival.
Financing Administration (HCFA) regulations
There is ample evidence that the survival of
regarding the initiation of dialysis (eg, form
2728, ESRD Medicare Medical Evidence Re- patients with ESRD is closely associated with
port). The leadership of the NKF-K/DOQI is their nutritional status (Guidelines 3 through 6,
working with HCFAto ensure that this will not 8,18,and23).Thesefindingshavebeendemon-
bethecase. strated not only in large, diverse populations of
prevalent maintenance dialysis (MD) patients,
GUIDELINE 2 but also in patients commencing MD therapy.
Hypertension, pre-existing cardiac disease, and
IndicationsforRenalReplacementTherapy
lowserumalbuminconcentrationswereindepen-
In patients with chronic kidney failure (eg, dentlyassociatedwithdiminishedlong-termsur-
GFR(cid:2)15to20mL/min)whoarenotundergo- vival in 683 ESRD patients who started dialysis
INITIATIONOFDIALYSIS S71
during 1970 through 1989. In 1,982 hemodialy- poor outcome, it is recommended that MD be
sis (HD) patients, a low serum albumin concen- initiated or kidney transplantation performed in
trationattheinitiationofdialysiswasassociated patientswithadvancedCKD(ie,GFR(cid:2)20mL/
with a significant increase in the relative risk of min) if there is evidence of deteriorating nutri-
death.Adirect relation between serum albumin tional status or frank PEM, no other apparent
and survival and an independent association be- cause for the malnutrition, and efforts to correct
tweenmodifiedSGAandsurvivalwasobserved the nutritional deterioration or PEM are unsuc-
in680incidentCPDpatients.Incontrast,inone cessful, despite the absence of other traditional
studynosignificantassociationswerefoundbe- indicationsfordialysis(eg,pericarditisorhyper-
tween serum albumin, creatinine, and urea con- kalemia).Althoughthefollowingcriteriaarenot
centrationsandsurvivalinincidentHDpatients. considered rigid or definitive, initiation of renal
Thesamplesizeinthelatterstudywasrelatively replacement therapy should be considered if,
small (n (cid:6) 139), and 94% of the study sample despite vigorous attempts to optimize protein
wereblack(83%)orHispanic(11%).Nostudies and energy intake, any of the following nutri-
have specifically examined the relations among tionalindicatorsshowevidenceofdeterioration:
other nutritional indicators (eg, %SBW, PNA, (1) more than a 6% involuntary reduction in
andDEXA)andsurvivalinincidentHDorperi- edema-free usual body weight (%UBW) or to
tonealdialysispatients. lessthan90%ofstandardbodyweight(NHANES
Low-protein (eg, 0.60 g protein/kg/d), high II)inlessthan6months;(2)areductioninserum
energy(35kcal/kg/d)dietsmayretardtherateof albuminbygreaterthanorequalto0.3g/dLand
progression of chronic kidney disease (CKD) tolessthan4.0g/dL(Guideline3),intheabsence
and should maintain patients with chronic renal ofacuteinfectionorinflammation,confirmedby
diseaseingoodnutritionalstatus(Guidelines24 repeatlaboratorytesting;or(3)adeteriorationin
and 25). However, it is recognized that such SGAby one category (ie, normal, mild, moder-
low-protein diets may not maintain adequate ate,orsevere;Guideline9andAppendixVI).
nutritionalstatusinallpatients,particularlyifan
adequateenergyintakeisnotmaintained(Guide- RECOMMENDATIONS FOR RESEARCH
line 25). Furthermore, there is evidence that the 1. Studies to assess the optimal timing and
spontaneous intake of protein and energy, and indications for commencing renal replacement
other indicators of nutritional status, tend to therapyareneeded.
diminish in patients with progressive CKD who 2.Serialevaluationsofnutritionalstatusinthe
are consuming unregulated diets.Therefore, pa- course of these studies will help to determine
tients with CKD need to undergo nutritional whether initiation of dialysis indeed improves
assessmentatfrequentintervalssothatanydete- nutritionalstatus.
rioration in nutritional status can be detected 3. Studies should be conducted to determine
early (Guidelines 23 and 26 andAppendix IV). whether any GFR level can be used to indicate
The plan of care and nutritional interventions whenmaintenancedialysisshouldbeinitiated.
outlinedinGuideline18forthenutritionalman- 4. Whether earlier initiation of renal replace-
agement of the dialysis patient is also appropri- ment therapy can prevent the development or
ateforpatientswithprogressiveCRI. worsening of PEM and its attendant complica-
Because of the association between PEM and tionsneedstobeevaluatedinacontrolledstudy.
II. Measures of Peritoneal Dialysis Dose
GUIDELINE 3 will improve patient outcomes (see Guideline
FrequencyofDeliveredPDDoseandTotal 15: Weekly Dose of CAPD). To assure delivery
SoluteClearanceMeasurementWithinSix of adequate solute clearance, measurements for
MonthsofInitiation(Opinion) solute clearance are required. In dialysis, as in
other human endeavors, continuous education
The total solute clearance (delivered PD dose
and repetition of a process diminish the fre-
plus residual kidney function) should be mea-
quency of errors, or at least increase the likeli-
sured at least twice and possibly three times
hoodofrecognitionofsucherrorsandcompensa-
within the first 6 months after initiation of PD.
tion for them. Furthermore, physiological
For patients initiating dialysis for the first time
variations occur which must be taken into ac-
and/or patients with substantial residual kidney
count.17 These lines of reasoning apply to mea-
function, the first measurement should be per-
surementofthedoseofPD.Thus,measurement
formed approximately 2 to 4 weeks after initia-
ofdeliveredPDdoseshouldberepeatedperiodi-
tionofPD.Forpatientstransferringfromanother
cally. The recommendation to measure C and
renal replacement therapy to PD and/or for pa- Cr
Kt/V three times within the first 6 months
tients who do not have substantial residual kid- urea
relates to items discussed in Guideline 7: PD
ney function, the first measurement of delivered
Dose Troubleshooting, specifically, establishing
dose of PD should be made by 2 weeks after
initiation of PD.To establish a baseline, at least a baseline creatinine excretion and following
one and possibly two additional measurements residual kidney function.The rationale for three
will need to be performed in the subsequent 5 measurementsinthefirst6monthsistoestablish
months. The frequency of measurement of re- amoreaccuratebaselineexcretionofcreatinine.
sidual kidney function depends on the PD pre- Two measurements within the first 6 months
scription of incremental versus full dose (see are probably sufficient if the results are similar.
TableII-1). Basedonourcollectivepersonalexperience,the
Rationale Adequatetotalsoluteclearance(de- Work Group believes that patient compliance
livereddoseofPDplusresidualkidneyfunction) with a prescribed PD regimen is highest soon
after initiation of PD, eg, within the first 6
TableII-1. PeritonealDialysisDoseandTotalSolute
ClearanceMeasurementSchedule:Initial6Months months; hence, this period is used to establish a
baseline.
PDFluid PET Urine*
Deliveredperitonealdialysisdosedependson
Month Kt/V C Kt/V C many factors, including the transport properties
p urea Crp r urea Crr
of the peritoneal membrane, assessed by the
1† X X X X X peritoneal equilibration test (PET).18,19 There is
2‡ Y Y
evidencethatthePETperformedwithinthefirst
3‡ Y Y
4‡ X X X X week after initiation of PD may yield higher
5‡ Y Y transport results than a PET performed a few
6‡ X X X X weeks later.20This difference is statistically sig-
nificant, but may not be clinically relevant. It
NOTE. X, measurement; Y, additional measurement if
maybemoreconvenienttoperformthefirstPET
“incremental”PDutilized.
*For patients who void infrequently ((cid:2)3 times in 24 attheendoftraining,ratherthanattheendofthe
hours),collecturineovera48-hourperiod. first month, and the Work Group thinks this is
†If possible, at the end of month 1, but at the end of acceptable.However,theresultsafteramonthof
trainingifthatismoreconvenient.
PDmaymoreaccuratelyreflectperitonealtrans-
‡Themeasurementintervalinmonths2to6isflexible.
Atleastoneadditionalmeasurementafterthefirstmonth’s portpropertiesforthesubsequentperiod.
measurement is necessary. If the results of the second In patients initiating ESRD therapy for the
measurement are similar to those of the first measure- firsttimewhohavesomeRKF,delayingthePET
ment,anadequatebaselineisestablished,obviatingthe
andthefirstmeasurementofdelivereddosefora
third measurement. If the result of the second measure-
month is safe and appropriate. However, for
mentisdiscrepant,athirdmeasurementisnecessaryto
establishamorereliablebaseline. patients initiating PD because of transfer from
S72 AmericanJournalofKidneyDiseases,Vol37,No1,Suppl1(January),2001:ppS72-S77
MEASURESOFPERITONEALDIALYSISDOSE S73
HDand/orforpatientswhodonothavesubstan- ally, when properly performed, these measures
tialRKF,thefirstmeasurementofdelivereddose are reproducible enough to be useful in routine
of PD should be performed earlier. In the ab- clinicalpractice.
sence of substantial RKF, waiting 1 month to The urea-based measure, Kt/V , measures
urea
measuredelivereddosemayresultininadequate removal of the direct product of protein catabo-
dialysis for 1 month. Thus, the Work Group lism. The creatinine clearance (C ) measures
Cr
recommendsthatthesepatientsundergomeasure- removal of a product of muscle metabolism,
mentofdelivereddoseofPDat2weekspostini- which provides insight into lean (ie, fat-free,
tiation, assuming maintenance exchange vol- edema-free)bodymassandpossiblyintocompli-
umeshavebeenachieved.Patientcaretechnicians ance (see Guideline 7: PD Dose Troubleshoot-
maybeabletoperformthesemeasurements. ing).InGuideline1:WhentoInitiateDialysis—
If“incremental”PDisinitiatedinsteadof“full Kt/V Criterion, and Guideline 15: Weekly Dose
dose” (see Guideline 1: When to Initiate Dialy- ofCAPD,thereisadiscussionofthecomparison
sis—Kt/V Criterion, and Appendix A, De- ofthesetwodifferentmeasures.SeeGuideline6:
urea
tailed Rationale for Guideline 1), RKF must be Assessing Residual Kidney Function, for a defi-
followed carefully and frequently such that PD nitionoftotalweeklyC .
Cr
dosecanbeincreasedasRKFdeteriorates.While These two recommended measures have both
urineproductionrateispresumedtobeaclueto been used to measure delivered dialysis dose.
deteriorating RKF, that is not always the case.21 Since each measure provides slightly different
Thus, for patients initiating PD with “incremen- information, the Work Group recommends that
tal”PD,theWorkGrouprecommendsmeasuring bothmeasuresbeused.Bothcreatinineandurea
RKFevery2months.Forpatientson“fulldose” concentrationcanbeobtainedonthesamesample
PD, the Work Group recommends measuring of urine, blood, and dialysate. No additional
RKF with total solute removal measurements samples need to be collected to perform both,
every 4 months. If urine production rate is de- ratherthanone,ofthesemeasures.Mostlabora-
creasing, measure RKF every 2 months or as toriesperformbothmeasuressimultaneously(eg,
often as needed and considered helpful, but at 6/60,Chem6,etc)onautomatedequipmentand
leastevery4months.OnceweeklyKt/Vfallsto thecostisthesameforoneorbothmeasures.
r
less than 0.1, RKF can be considered negligible
and its routine measurement can be stopped. GUIDELINE 5
Guideline 11: Dialysate and Urine Collections,
FrequencyofMeasurementofKt/V ,Total
addressesthissubjectagain. urea
C ,PNA,andTotalCreatinineAppearance
Cr
(Opinion)
GUIDELINE 4
After 6 months, total Kt/V , total C , and
MeasuresofPDDoseandTotalSolute urea Cr
PNA (with all its components) should be mea-
Clearance(Opinion)
suredevery4months,unlesstheprescriptionhas
Bothtotalweeklycreatinineclearancenormal- been changed or there has been a significant
ized to 1.73 m2 body surface area (BSA) and changeinclinicalstatus(seeTableII-2).
total weekly Kt/V should be used to measure Rationale Despite the establishment in 1993
urea
deliveredPDdoses. of ESRD Network/Health Care FinanceAdminis-
Rationale Avalid and reproducible measure tration guidelines that measurements of delivered
of PD dose is essential to assess the quantity of PD dose and total solute clearance be performed
dialysis delivered to an individual patient. The twice yearly, a Network Core Indicator review of
quantityofdialysisisanimportantcomponentof 1,208 patient charts in 1995 revealed that data
the quality of dialysis. Of the few available sufficienttocalculatesuchmeasureswereavailable
measures of PD dose, total weekly Kt/V and foronlyonethirdofthepatients.Thepreliminary
urea
total creatinine clearance normalized to 1.73 m2 1996 results reveal that 69% of the patient charts
BSAarethebest,becausetheyaremoststrongly have such data (Diane Frankenfield, a member of
associated with mortality and morbidity (see theHCFA/HSQBESRDCoreIndicatorsPDSub-
Guideline15:WeeklyDoseofCAPD).Addition- committee, written communication, December 4,
S74 GUIDELINESFORPERITONEALDIALYSISADEQUACY
TableII-2. PeritonealDialysisDoseandTotalSolute can be increased as RKF deteriorates. While
ClearanceMeasurementScheduleAfter6Months urineproductionrateispresumedtobeaclueto
deteriorating RKF, that is not always the case.21
PDFluid Urine*
Thus, for patients initiating PD with “incremen-
Month Kpt/Vurea CCrp Krt/Vurea CCrr tal”PD,theWorkGrouprecommendsmeasuring
RKF every 2 months (see Table II-2). For pa-
7
tientson“fulldose”PD,theWorkGrouprecom-
8 X† X†
9 mendsmeasuringRKFwithtotalsoluteremoval
10 X X X X measurements every 4 months. If urine produc-
11 tion rate is decreasing, measure RKF every 2
12 X† X†
months, or as often as needed and considered
13
helpful,butatleastevery4months.Onceweekly
14 X X X X
Kt/V falls to less than 0.1, RKF can be consid-
r
NOTE.X,measurement. ered negligible and its routine measurement can
*IfincrementalPDisstillbeingutilizedatthispoint,the be stopped. Guideline 11: Dialysate and Urine
frequencyofRKFtestingappliesasdescribedinTable1of
Collections,addressesthissubjectagain.
Guideline 3: Frequency of Delivered PD Dose and Total
Theimpactofachangeinprescriptionshould
SoluteClearanceMeasurementWithinSixMonthsofInitia-
tion. For patients who void infrequently ((cid:2)3 times in 24 be assessed within 2 to 4 weeks in order to
hours), collect urine over a 48-hour period. Urine testing determine if the recommended change has actu-
canceasewhentheresidualkidneyfunctioncomponentis allybeenexecutedandifithasaccomplishedits
aweeklyKt/V (cid:2)0.1.
r urea goal.Thepromptnessoftheassessmentisimpor-
†For young children who have greater difficulty with
tant because clinical events could occur in the
accurateurinecollectionthanadults,thismaybedeferred
until full urine and dialysate collections occur every 4 interval which could postpone the measurement
months(seeGuideline11:DialysateandUrineCollection). or confound the results (see Guideline 10: Tim-
ingofMeasurement).
1996; also available on the Internet at http://
Someclinicaleventsmayimpairthequalityof
www.hcfa.gov/medicare/hsqb/hsqb1.htm).
delivered PD. A change in clinical condition
MeasurementsofdeliveredPDdoseandtotal
which warrants measurement of delivered PD
soluteclearanceareeasytoperform,butrequire
dose is defined as any serious problem which
attentiontodetailandprecisionintechniquefor
affectsnutritionalstatus,theabilityofthepatient
patients and dialysis staff. A variety of clinical
toperformPDmechanicallyortechnically(such
andpsychosocialeventscaninterruptandinvali-
as stroke or arthritis, loss of surface area from
date these measurements. It is imperative that
surgery,decreasedexchangevolumesduetoher-
these measurements become a routine for the
nias, etc), or permanently affects the transport
patients and facility staff. Setting a goal of per-
propertiesoftheperitoneum(eg,protractedperi-
forming measurements every 4 months builds
tonitis).22 Many conditions that lead to hospital-
flexibility and leeway into a complex care plan,
ization fall into one of these categories. Any
whileassuringthatalengthyintervalofpossibly
suggestion of exacerbation of uremia should
inadequate PD does not occur. The 4-month
prompt a measurement of delivered dose of PD.
intervalbetweencompletemeasurementsoftotal
The Work Group recognizes that technical
Kt/Vurea, total CCr, and PNA is recommended problems in urine collections in some children
because it strikes a balance: every 4 months is may justifiably decrease the frequency of urine
often enough to be clinically helpful, but not so collectionsinselectedcases.
oftenastobeintrusiveintoapatient’slifestyleor
tocreateaburdenforthedialysisfacility.Aware- GUIDELINE 6
ness of loss of RKF must be paramount. If
AssessingResidualKidneyFunction(Evidence)
“incremental” PD is initiated instead of “full
dose” (see Guideline 1: When to Initiate Dialy- Residual kidney function (RKF), which can
sis—Kt/V Criterion, and Appendix A: Detailed provide a significant component of total solute
Rationale for Guideline 1), RKF must be fol- and water removal, should be assessed by mea-
lowedcarefullyandfrequentlysuchthatPDdose suringtherenalcomponentofKt/V (Kt/V )
urea r urea