D08-P-02.PPT / Chart 1 / 33

Automated Peritoneal DialysisAutomated Peritoneal Dialysis

APDAPD

D08-P-02.PPT / Chart 2 / 33

APD Automated Peritoneal DialysisCAPD Continuous Ambulatory Peritoneal DialysisCCPD Continuous Cycling Peritoneal DialysisDAPD Daytime Ambulatory Peritoneal DialysisDOQI Dialysis Outcomes Quality InitiativeD/P dialysate to plasma ratio of solute concentrationsIPD Intermittent Peritoneal DialysisKt/V urea clearance normalized to urea distribution

volume (corresponding to total body water)NIPD Nightly Intermittent Peritoneal DialysisPD Peritoneal DialysisPET Peritoneal Equilibration TestTPD Tidal Peritoneal Dialysis

Glossary

D08-P-02.PPT / Chart 3 / 33

What What is is A P DA P D ????

APDAPD

D08-P-02.PPT / Chart 4 / 33

Description of Description of A P DA P D

Automated Adaptable

Affordable

D08-P-02.PPT / Chart 5 / 33

Automated Peritoneal Dialysis (APD)Automated Peritoneal Dialysis (APD)

no or less exchanges during the day

cycler machine does the work while you sleep

same advantages as CAPD

Advantages :

on a machine every night

storage space needed at home for supplies

same disadvantages as CAPD

Disadvantages :

++

D08-P-02.PPT / Chart 6 / 33

Dropout optionDropout option

CAPDCAPDtoto

APDAPD

D08-P-02.PPT / Chart 7 / 33

Medical Indications Medical Indications

chronic fluid overload

chronic uremia

frequent peritonitis

obesity

malnourished

hernias

D08-P-02.PPT / Chart 8 / 33

Psychosocial Indications Psychosocial Indications

non-compliance to CAPD

patient burn-out

partner burn-out

body image concerns

D08-P-02.PPT / Chart 9 / 33

A P D Clinical benefitsA P D Clinical benefits

low peritonits rates

low catheter infection rates

improved clearances

improved UF

D08-P-02.PPT / Chart 10 / 33

Medical Advantages of Medical Advantages of APD APD

increase clearance

increase ultrafiltration

decreased risk of peritonitis minimise complications from intraperitoneal pressure

reduced catheter complications

improved metabolic state

D08-P-02.PPT / Chart 11 / 33

APD :APD : 1st PD option1st PD option

When ?When ?

partner is requiredpatient worksCAPD contraindicatedtherapy accepted

D08-P-02.PPT / Chart 12 / 33

Customise TherapyCustomise Therapy

1.1. Volume required - per exchange

- per treatment

2.2. Dwell time clearance

ultrafiltration

3.3. Length of therapy sleep patterns

4.4. Day time dwell regular volume

low volume

dry day

D08-P-02.PPT / Chart 13 / 33

The peritoneum of all The peritoneum of all patients is not created equal !patients is not created equal !

D08-P-02.PPT / Chart 14 / 33

The advantages of PD Nightassisted nighttime treatment are:

No manual bag exchanges during the day*

Daytime freedom (ability to work etc.)Only few user steps neededLess Risk steps (= less risk of Peritonitis)Higher therapy dose possible

Peritoneal Dialysis with APD

D08-P-02.PPT / Chart 15 / 33

APD TherapyAPD Therapy

From CAPD to High Dose APD?

high doseNIPD

NIPD

CCPD+ CAPDNIPD

+ CAPD

Dialysis Clearance

RENAL ClearanceCreatinine Clearance(L/week/1,73m2)

20

60

40

Source: R. Brunkhorst et al ,Adequacy and Quality of Life with Automated Peritoneal Dialysis, PDI, Vol. 16 (1996), Supplement 1

D08-P-02.PPT / Chart 16 / 33

. System DescriptionUsed at patient´s home and in clinicsCCPD, TIDAL, NIPD, PD-PLUS ™Flexible parameter setting of desired:

Inflow volume, Dwell time, No. of cycles etc.Available Accessories:

Wallholder, Printer, Drainage Pump,Transport Case, Teledialysis

The PD-NIGHT ®

D08-P-02.PPT / Chart 17 / 33

No noisy pumps during nighttime (Gravity!)Big screen No time for preheating due to timer functionFull therapy range possiblePrinter for easy treatment protocolPD-Plus built in, no further suppliesA.N.D.Y. Snap technologyEasy maintenance

The PD-NIGHT ®

D08-P-02.PPT / Chart 18 / 33

CCPDIPDNIPDTPDFixed Program

PD - NIGHT

Treatments performed by PD - NIGHT

Continuous Cyclic PDIntermittent PDNocturnal Intermittent PDTidal PDprogrammed individually

PD-Plus Therapy APD plus daytime exchange

D08-P-02.PPT / Chart 19 / 33

Automated PD

0Time (hrs)

1000

2000

3000

day nightVol.(ml)

Tidal PD

D08-P-02.PPT / Chart 20 / 33

PD-Plus™ TherapyScientific Background

D08-P-02.PPT / Chart 21 / 33

…is an optimized peritoneal dialysis prescription in order to deliver an

enhanced dialysis dose most efficiently.

…is an optimized peritoneal dialysis prescription in order to deliver an

enhanced dialysis dose most efficiently.

PD-Plus Therapy

Why do PD patients need enhanced prescriptions

Why do PD patients need enhanced prescriptions ?

D08-P-02.PPT / Chart 22 / 33

1 7 %

2 7 %

1 6 %

1 5 %

2 5 %1 8 %

2 5 %

1 4 %

1 5 %

2 8 %

Peritonitis

Psychosocial

InadequateDialysis

Catheter

Other medical

Psychosocial

InadequateDialysis

Catheter

Peritonitis

Other medical

Nolph: 15th Ann. Conf. on Peritoneal Dialysis (1995)

CAPDCAPD CCPDCCPD

Reasons for Drop Outs from PD to HD

D08-P-02.PPT / Chart 23 / 33

“… we describe as adequate a renal treatment that avoids uraemic symptoms in the presence of a sufficient dietary protein intake.” *

most commonly used quantifitative measures: the removal of small molecular weight substances (i.e. the clearance of small solutes)

➨ Kt/V urea➨ Creatinine clearance (L/week/1.73 m2)

AdequacyDefinition & Quantitative Measures

*Ronco, Nephol Dial Transplant 12, Suppl 1:68 (1997)

D08-P-02.PPT / Chart 24 / 33

Probability of survival at 2 years (%)

Patient survival (%)

Kt/V ≥ 1.9

Teehan et al.: Sem in Dialysis 5:189 (1992)

Months20 40 60 800

Kt/V <1.9

100

80

60

40

20

0

CANUSA / Churchill et al. JASN 7:198 (1996)

Kt/ V(per week)

C Crea (L/week/1.73 m2)

2.12.31.9

95

1.71.5

80 7055

40

Patient Survival on CAPDis affected by dialysis dose

100

80

60

40

20

0

D08-P-02.PPT / Chart 25 / 33

KT/V daily weekly CCr weekly

HCFA 0.21 1.5 > 40 L

Twardowski 40 - 50 L

NIH CDC 0.24 1.7

Teehan 0.27 1.9

Maiorca 0.28 2.0 58 L

Churchill 0.30 2.1 70 L

DOQI 0.28 2.0 60 L

Twardowski & Nolph, Semin Dial 1:75, 1988; NIH CDC, Ann Intern Med 121:62, 1994;Teehan, Semin Dial 5:189, 1992; Maiorca, NDT 10:2295, 1995; Churchill, JASN 7:198, 1996NKF Dialysis Outcomes Quality Initiative (DOQI) Clinical Practice Guidelines (AJKD 30, Suppl 2, S67-S136, 1997)

Clearance Targets

D08-P-02.PPT / Chart 26 / 33

Limitations in Peritoneal Dialysis

LargeBody Size

LimitedPeritonealTransport

DecliningResidual Renal

FunctionAdequate

Treatment byPeritonealDialysis

?

D08-P-02.PPT / Chart 27 / 33

More clearance is necessary in a large patientto achieve a given Kt/V

Urea to be removed

19 g/day 12

Urea to be removed

19 g/day 12

Urea distribution volume

46 L 35

Urea distribution volume

46 L 35

Body weight

80 kg 60

Body weight

80 kg 60

Assumptions: protein intake: 1 g/kg/d, zero nitrogen balance, non-urea-nitrogen loss 4 g/d,protein = 16% N, urea = 2.14*urea-N, V = 0.58 * body weight

Impact of Body Size

D08-P-02.PPT / Chart 28 / 33

DailyRegimenDailyRegimen

4 x 2 L

4 x 2.5 L

4 x 3 L

4 x 2 L

4 x 2.5 L

4 x 3 L

Target KT/V (per week)

>1.5 >1.7 >1.9 >2.1 Target KT/V (per week)

>1.5 >1.7 >1.9 >2.1

< 68 kg < 60 kg < 54 kg < 49 kg

68-87 kg 60-76 kg 54-76 kg 49-62 kg

87-107 kg 76-94 kg 76-84 kg 62-76 kg

< 68 kg < 60 kg < 54 kg < 49 kg

68-87 kg 60-76 kg 54-76 kg 49-62 kg

87-107 kg 76-94 kg 76-84 kg 62-76 kg

Assumptions:1 L, 1.5 L, and 2 L UF, respectively. V = 58%of body weight, D/P24h urea = 0.95

Blake PG, Perit Dial Int 16, Suppl.1:S143 (1996)

Weight Limitations in CAPD

D08-P-02.PPT / Chart 29 / 33

24 h dialysate collection

24 h urine collection

blood sample

laboratory analysis for urea and creatinine

calculation of Kt/V urea and creatinine clearance

Clearance Measurement in PD

K = *D/P volume

collection time t

ml

min( )

➨ renal

➨ peritoneal

➨ total

D08-P-02.PPT / Chart 30 / 33

Peritoneal Transport Function

Twardowski, Perit Dial Bull 7:138-147 (1987)

0 .0

0 .2

0 .4

0 .6

0 .8

1 .0

0 1 2 3 4D w e l l t im e (h )

D/P

ratio

crea

tinine

High

High-averageHigh-average

Low-averageLow-average

Low

1.03

0.81

0.65

0.50

0.34

according to Peritoneal Equilibration Test (PET)

D08-P-02.PPT / Chart 31 / 33

D/PCreatinine1.0

0

0.5

0 2 4 6 8 h

High transport

Low transport

Optimizing Dwell Time

Kt = D/P * Drain VolumeKt = D/P * Drain Volume

Creatinine Clearance per Exchange

h

L

0

1

2

0 2 4 6 8

Total Dialyate Volume

2.6

2.3

1.7

2.0

L

0 2 4 6 8 h

Twardowski, Adv Perit Dial 1990:186-191 (1990)

D08-P-02.PPT / Chart 32 / 33

Dwell time adjusted

Improved solute removal

Dwell time (h)

Creatinine clearance per exchange (L)

0

1

2

0 2 4 6 8

High transporter

Low transporter

Optimizing Dwell Time

D08-P-02.PPT / Chart 33 / 33

0

10

20

30

40

50

1 2 3 4

ambulatory

Dialysate volume (L)

KoA urea (ml/min)

supineSupine

position

Increased KoAHigher volumes tolerated

Increased clearance

➨

➨

KoA or MTAC: Marker of diffusive peritoneal transport capacity

Optimizing Volumes

Schoenfeld et al. JASN 4:416 (1993)

D08-P-02.PPT / Chart 34 / 33

Dialysis dose can be enhanced byDialysis dose can be enhanced by

optimizing dwell timesoptimizing dwell timesoptimizing exchange volumesoptimizing exchange volumeseffective use of supine periodseffective use of supine periods

Optimizing PD Therapy

D08-P-02.PPT / Chart 35 / 33

CAPD

CCPD

PD-Plus

Volume

7 h7 h 22 h

PD-Plus

PD-Plus Therapy

cycler

D08-P-02.PPT / Chart 36 / 33

Expected Clearance with 12 L CCPD

D/P creatinine

Dwell time (h)

0 .0

0 .2

0 .4

0 .6

0 .8

1 .0

0 1 2 3 4

Creatinine clearance = 0.8*2.4 L + 0.4*13 L = (1.92 + 5.2) L

= 7.12 L/day = 49.8 L/week

Kt = D/P * Drain VolumeKt = D/P * Drain Volume

Dwell time (h) 14 2 10

V inflow (L) 2 2 10

V outflow (L) 2.4 2.6 13

D/P creatinine 0.8 0.4 0.4

daynight

percycle

5cycles

in a low-average transporter

D08-P-02.PPT / Chart 37 / 33

Expected Clearance with 11.5 L PD-Plus

Creatinine clearance = 0.8*2.4 L + 0.7*2.4 L + 0.5*9.3 L

= (1.92 +1.68 + 4.65) L= 8.25 L/day = 57.8 L/week

Dwell time (h) 9 6 3 9

V inflow (L) 2 2 2.5 7.5

V outflow (L) 2.4 2.4 3.1 9.3

D/P creatinine 0.8 0.7 0.5 0.5

nightper

cycle3

cycles

daylastbag PD+

D/P creatinine

Dwell time (h)

0 .0

0 .2

0 .4

0 .6

0 .8

1 .0

0 1 2 3 4

in a low-average transporter

Kt = D/P * Drain VolumeKt = D/P * Drain Volume

D08-P-02.PPT / Chart 38 / 33

SA = 1.78m2

D/P4h urea = 0.85low-av. transport

1.471.68

1.82

1.401.68

1.96

2.31

0.0

0.5

1.0

1.5

2.0

2.5

KpT/V

CAPD 10L (2.5)CAPD 8LCAPD 10L (2) CCPD 10LCCPD 12LPD+ 10LPD+ 10LPD+ 12LPD+ 12L

Comparative KpT/V for various PD regimens

Diaz-Buxo, Am J Kidney Dis 27:92-98, 1996

D08-P-02.PPT / Chart 39 / 33

Enhanced Dialysis Dose by PD-Plus

110 patients for ≥ 3 months on CAPD/CCPD and PD-Plus, respectively Youngblood et al. PDI 17 Suppl 1:16, 1997

0

20

40

60

80

100

120

140

% of clearance on CAPD/CCPD

1.47 ± 0.35

39.01± 27.64

1.89± 0.42

52.22± 11.0

KpT/V ureaper week

KpT/V ureaper week

Cp creatinineL/week/1.73 m2

Cp creatinineL/week/1.73 m2

+ 29 % + 29 % + 34 % + 34 %

CAPDCCPD

PD-Plus

D08-P-02.PPT / Chart 40 / 33

Recommendations

High

High-av.High-av.

Low-av.Low-av.

Low

CAPD CCPD NIPD PD-Plus

— — + +++ ++ ±± ++++ ±± —— ++± — — ±

Note:Prior to deciding which prescription might be suitable, the residual renal function, body size and transport characteristics must be considered care-fully. In low transporters, peritoneal dialysis might be inadequate in large patients and/or in patients without residual renal function.