Does APD vs CAPD plays a role in Better Outcome?

Dr Lily Mushahar

Department of Nephrology

Hospital Tuanku Ja’afar

PD Masterclass 2018

Le Meridien Putrajaya

6-7 October 2018

Outline

• APD vs CAPD: Any difference in patient outcome?• Solute clearance• Residual renal function• Quality of life• PD related infection• Technique survival• Patient survival

History of Peritoneal

Dialysis

Ebers Papyrus (1550 BC)

Successful History of Treating Acute Kidney injury

1946 – Seligman, Fine & Frank developed

closed PD system using 2 catheters

History of CAPD

1976 – first application of CAPD using glass containers by Moncrief & Popovich

1977 - exchanging with plastic bag was introduced by D. Oreopolous

1980’s – introduced in Malaysia - non-disconnecting

system

1990’s – Y disconnect system was introduced

6

The First CyclersThe First Cyclers

1962- Developed by Boen

The first automated peritoneal delivery system

S.T. Boen, C.M. Mion, F.T. Curtis and G. Shilipetar developed an automated

device to do peritoneal dialysis at home. It utilized a 40-liter bottle that was

filled and sterilized at the University of Washington. The bottles were delivered

to the patient's home and returned to the hospital after use.

A cam cycler timer was used to meter the peritoneal fluid into and out of the

peritoneal cavity. A heater plate heated the solution to body temperature and

the effluent from the peritoneum was measured.

Fred Boen, MD, used the "repeated puncture" method for access. This

required that a physician go to the patient's home and surgically place a 14F

trocar in the patient's abdomen. The patient's helper would be trained to

remove the trocar after the peritoneal dialysis treatment.

Boen ST, Mion CM, Curtis FK, Shilipetar G. Periodic peritoneal dialysis using

the repeated puncture technique and an automatic cycling machine. Trans Am

Soc Artif Intern Organs. 196; 10: 408-14.

In 1966 lasker introduced a simple gravity fed cycler. This device used sterile

dialysate in 2 l glass bottles, plastic tubing for delivery and a plastic bag for

collection of dialysate.This was the forerunner of all modern cyclers. This

system could deliver variable amout of warm dialysate.

6

History of APD

Introduced by Boen in 1964

Modalities of PD

ManualVs

Automation

CAPDAPD

Choosing PD modalityFinancial Resources

Cost of CAPD (per year)

Cost of APD(per year)

Malaysia RM29,000(USD 6,8000)

RM 51,000(USD 11,880)

United Kingdom £16,000 (USD 21,000)

£18,000(USD 23,000)

CAPD vs APD Usage in Malaysia

1464

1662

1838

19962064

2178

2455

2773

3208

3746

88144 121

246296

371 404477 497

569

1552

1806

2083

2212

2360

2549

2859

3250

3705

4315

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Nu

mb

er

of

pat

ien

ts

CAPD APD Total

CAPD vs APD Usage in other Countries

Developing Country Developed Country

Choosing PD ModalityFactors to Consider

• Long term Outcomes Technique failure

Mortality

Volume & BP control

• Residual renal function

• Risk of peritonitis

• Peritoneal transporter status

• Patient preference

• Patient preference• Financial resources• ? Transport status

Traditional APD Indications

• Enhance small solute clearances

• Enhance ultrafiltration (esp high transport)

• Social reasons• Employment

• School

• Care of elderly/debilitated patients

• Mechanical problems• Hernias, leaks, back pain, body image

• Reduce peritonitis rates

Choosing PD modality: Peritoneal membrane transporter

•High transporter

independent predictor of mortality ultrafiltration problems hypoalbuminemia

CAPD vs APDMortality & Technique failure

• Most studies are observational

• Significant reduction in mortality & technique failure for the past 20 years due to: improvement in connectology in both CAPD & APD

lower peritonitis rate

• 2 potential causal physiologic mechanism that affect mortality:

RRF and serum albumin level

21

The outcomes of continuous ambulatory and The outcomes of continuous ambulatory and

automated peritoneal dialysis are similarautomated peritoneal dialysis are similarMehrotra et al, Kidney Mehrotra et al, Kidney IntInt 2009; 76,972009; 76,97--107107

There were no significant differences

in adjusted mortality rates in patients

treated with CAPD or APD for virtually

all the time periods examined

There were no significant

differences in either time dependent

or overall relative risk for technique

failure between CAPD and APD

patients

21

No significant differences in adjusted mortality rate between CAPD vs APD patients Mehrotra et al, Kidney Int 2009

CAPD vs APDMortality & Technique failure

• 66,300 patients USRDS

• 1994-2004

---- APD__ CAPD

No significant differences in technique survival between CAPD vs APD patients

---- APD__ CAPD

CAPD vs APDMortality & Technique failure

CAPD vs APDSodium removal

• Management of sodium & water balance is crucial especially in anuric patients

• Sodium balance correlates strongly with fluid removal

APD patient tend to have poorer solute removal due to: sodium sieving overnight dwell

CAPD vs APDUltrafiltration

0

200

400

600

800

1000

1200

1400

1600

1800

UF

(m

l/d

ay)

P=NS

N=25

Bro et al Perit Dial Int 19:526-33,1999

CAPD APD

200

400

600

800

1000

0

1200

1400

1600

Ultrafiltration(mls)

• Recumbent position in APD:

increase peritoneal solute transport

associated with reduce ultrafiltration

capacity

hinder proper drainage of dialysate

increase likelihood of incomplete

emptying at the end of every

exchanges

CAPD vs APDUltrafiltration

CAPD vs APDNutrient Loss

•APD tends have more peritoneal protein loss compared to CAPD

CAPD vs APDResidual Renal Function (RRF)

• Each 250 mls of increase urine output associated with reduction in mortality risk by 36%

CANUSA study

• Each increase in RRF of CrCl 10 L/week/1.73 m2 was associated with an 11% decrease in mortality

ADEMEX study

CAPD vs APDResidual Renal Function (RRF)

0

1

2

3

4

5

6

7

0 6 12

Follow-up (months)

Resi

du

al

Cl C

r (m

l/m

in)

CAPD APD

Hufnagel et al Nephrol Dial Transplant 14:1224-8, 1999

* ** p<0.05

n=36

CAPD vs APDResidual Renal Function (RRF)

• Faster decline of RRF in APD compared to CAPD patients 4 longitudinal observational studies

confounded by patient selection bias & underlying renal disease, older

patients with more comorbid treated more with CAPD

• No difference in the rate of decline in RRF between CAPD and APD

No difference in the rate of decline in RRF between CAPD and APDMehrotra R, Perit Dial Int 2009

• CAPD and APD differ significantly in the frequency and method of making the connections and disconnections between the PD catheter & dialysate bags

• Improvements in PD connectology (Y-set, Luer lock technology, flush before fill) is the dominant reason for reduction in risk for peritonitis

CAPD vs APDPeritonitis

CAPD vs APDPeritonitis

• Data seems to suggest APD patients to have lower rates of peritonitis than CAPD

• However, most published studies do not include description of connecting system used by the CAPD & APD patients

** Need to be critical in interpreting the results from studies in different period

No association between PD modality & time to first peritonitis

episode

CAPD vs APDReduce pressure related symptoms

• Hernias• Leaks

CAPD vs APDQuality of Life (QOL)

Scale Scores Parameter

APD

(n=12)

CAPD

(n=13)

P Value

Social Time 3.21.2 1.20.5 0.0005

Physical discomfort 1.91.0 2.21.3 NS

Emotional discomfort 1.81.0 2.21.4 NS

Anorexia 2.81.3 2.90.6 NS

Sleep Problems 2.30.9 1.81.3 NS

Choosing PD modalityLifestyle & Patient Preference

CAPD vs APDPatient Preference

Advantage of CAPD• Cheaper

• Easier to be trained

• Undisturbed from alarms

Advantage of APD• More time available for work,

family and social activities

Conclusion

• The choice of the initial PD modality should be based on patient preference and available resources

• No difference between both modality in terms of: overall mortality and technique failure residual renal function peritonitis for APD compared with CAPD in incident dialysis patients.

• Thus, countries in which prescription of APD is limited because of limited resources do not provide an inferior therapy for their patients WHEN THEY prescribe

Thank You