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1 CAPD Guideline VS 施孟甫醫師 CAPD 麗華 CR 蔡智生醫師

2 透析的開始時機每週 KT/V < 2 GFR <10.5/min/1.73m 2 DOQUI guideline 2

3 Before peritoneal dialysis 1. PD start 10 days to 2 weeks after catheter placement. 2. If PD started in < 10 days following catheter placement, do low-volume, volume, supine dialysis. 3. Obtain baseline 24-hour urine collection for urea and creatinine clearance

4 Before peritoneal dialysis 4. Explain to patient/parents/caregivers that : The prescription will be individualized. Instilled volume almost increase over time. Their total solute clearance will be monitored IF RRF or peritoneal transport changes, their prescription may need to change as well.

5 First Prescription (Based on RRF, BSA) CAPD : (1.5L or 2L) x qid CCPD : 10 L + last bag (1L-2L) NIPD : 10 L 1 month adjustment BSA, RRF, PET, S/S CAPD(L, LA) CAPD(H, HA) WKt/V<1.7 WKt/V<2 WnCCr<50 WnCCr<60 NIDP WKt/V<2.2 WnCCr<66 CCPD WKt/V<2.1 WnCCr<63 換液次數增加 3 次 4 次 or 4 次 5 次單袋灌注量增加 1.5L 2L or 2L 2.5L CCPD 增加白天換液次數 1L-2L 一次或二次 HD

6 Initial prescription (1) Full dose to meet minimal total solute clearance goal (2) Pt with a significant RRF, but Kt/V < 2.0 Incremental dosage of PD. (3) Based on BSA and residual renal function (4) During training, transporter type can be predicted from drain volume during a timed (4- hr) dwell with 2.5% glucose

7 Residual renal function Renal GFR =1/2 (renal CCr + renal UreaCr) BSA = xBW(Kg) xbh(cm) 0.725

8 透析型態的選擇 CAPD = 白天由人力換透析液 3-4 次晚上滯留 CCPD= 白天 last bag 滯留 9 小時, 或 CAPD 換液 1-2 次晚上由機器換透析液 4-6 次 NIDP = 晚上由機器換透析液 4-6 次白天 dry

9 1. GFR >2 ml/min A. If patient's lifestyle choice is CAPD: BSA<1.7 m x 1.5 L exchanges/day BSA 1.7 to 2 m x 2.0 L exchanges/day BSA>2.0 m 2 4 x 2.5 L exchanges/day

10 1. GFR >2 ml/min B. If patient's lifestyle choice is CCPD: BSA<1.7 m x 1.5 L (9hours/night) +1 L/d(last bag) BSA 1.7 to 2.0 m x 2.0 L (9 hours/night) L/day (last bag) BSA>2.0 m 2 4 x 2.0 L (9 hours/night)+2. L/day (last bag)

11 1. GFR >2 ml/min C. If patient's lifestyle choice is NIPD: Used at the initiation of dialysis. Reserved for high or rapid transporters. Patients with significant RRF (and ability to diuresis), Nightly exchanges only (dry day)

12 2. GFR 2 2 ml/min A. If patient's lifestyle choice is CAPD: BSA<1.7 m 2 4 x 2.0 L/day BSA 1.7 to 2.0 m 2 4 x 2.5 L/day BSA >2.0 m 2 5 x 2.5 L/day (Consider use of a simplified nocturnal exchange device to achieve optimal dwell times and to augment clearance.)

13 2. GFR 2 2 ml/min B. If patient's lifestyle choice is CCPD: BSA<1.7 m x 1.5 L (9hours/night) +1 L/d(last bag) BSA 1.7 to 2.0 m x 2.0 L (9 hours/night) L/day(last bag) BSA>2.0 m 2 4 x 2.0 L (9 hours/night)+2.0 L/day (last bag) ( 可增加白天換液 1-2 次 )

14 First Prescription (Based on RRF, BSA) CAPD : (1.5L or 2L) x qid CCPD : 10 L + last bag (1L-2L) NIPD : 10 L 1 month adjustment BSA, RRF, PET, S/S CAPD(L, LA) CAPD(H, HA) WKt/V<1.7 WKt/V<2 WnCCr<50 WnCCr<60 NIDP WKt/V<2.2 WnCCr<66 CCPD WKt/V<2.1 WnCCr<63 換液次數增加 3 次 4 次 or 4 次 5 次單袋灌注量增加 1.5L 2L or 2L 2.5L CCPD 增加白天換液次數 1L-2L 一次或二次 HD

15 First Prescription (Based on RRF, BSA) CAPD : (1.5L or 2L) x qid CCPD : 10 L + last bag (1L-2L) NIPD : 10 L 1 month adjustment BSA, RRF, PET, S/S CAPD(L, LA) CAPD(H, HA) WKt/V<1.7 WKt/V<2 WnCCr<50 WnCCr<60 NIDP WKt/V<2.2 WnCCr<66 CCPD WKt/V<2.1 WnCCr<63 換液次數增加 3 次 4 次 or 4 次 5 次單袋灌注量增加 1.5L 2L or 2L 2.5L CCPD 增加白天換液次數 1L-2L 一次或二次 HD

16 Adequate dialysis 1. Adequate solute removal ability 2. Adequate ultrafiltration

17 1st month adjustment Depend on Peritoneal equilibration test (PET) Residual renal function (RRF) Body surface area (BSA) S/S weekly Kt/V and total nccr Adjustment of dialysis dose

18 Peritoneal Equilibration Test (PET) 前一晚以 Dialysate 灌入腹內, 存留 8-12hrs 第二天早上, 在 PD Room 以立姿引流全部透析液 20 分 (<25 分 ) 測引流量之容量以臥姿每 10 分注入 2.5% Dialysate 2000ml 每 2 分鐘 400ml 速度, 病人須在床上翻滾以利 dialysate 在腹腔內混合均勻

19 Peritoneal Equilibration Test (PET) Dialysate 在全部注入後, 為 0 分 (0-dwell dwell time) 立即引流 200ml 透析液, 取 10ml 送檢, 其餘再注入腹內而後病人可以自由活動 120 分時, 病人須引流灌注量 1/10 之 dialysate 至透析液袋中搖晃均勻後, 于透析液袋抽出 10ml 透析液, 再將剩餘透析液注入腹腔內 120 分抽血送驗其 glucose, Cr 值 240 分時, 以立姿將 dialysate 全部引流 20 分測其容積, 並抽 10ml dialysate 送驗

20 Peritoneal equilibration test (PET) Insertion 2 liters of 2.5% detrose dialysate 0 小時, 2 小時, 4 小時 D/D 0 glucose and D/P Cr 之值並畫圖 Low transporter Low everage transporter High average transporter High transporter

24 Adequate solute removal ability

25 First Prescription (Based on RRF, BSA) CAPD : (1.5L or 2L) x qid CCPD : 10 L + last bag (1L-2L) NIPD : 10 L 1 month adjustment BSA, RRF, PET, S/S CAPD(L, LA) CAPD(H, HA) WKt/V<1.7 WKt/V<2 WnCCr<50 WnCCr<60 NIPD WKt/V<2.2 WnCCr<66 CCPD WKt/V<2.1 WnCCr<63 換液次數增加 3 次 4 次 or 4 次 5 次單袋灌注量增加 1.5L 2L or 2L 2.5L CCPD 增加白天換液次數 1L-2L 一次或二次 HD

26 適量的腹膜透析 Weekly Kt/V =7 x (peritoneal Kt/V + renal Kt/V) Weekly nccr =7 x (Peritoneal CCr + renalgfr)/(bsa/1.73) =7 x [Peritoneal CCr + 1/2( renal CCr+renal urecr)]/(bsa/1.73)

27 Target of WKt/V, WnCcr Weekly Kt/V Weekly nccr CAPD CCPD NIPD L, LA H, HA >1.7 >2.0 >2.1 >2.2 >50 L/week >60 L/week >63 L/week >66 L/week

28 透析不足的 S/S 溶質移除能力不足 -Cr,, BUN or - 貧血神經症狀變嚴重 - 食慾不振噁心嘔吐消瘦失眠

29 Adjust dialysate Kt/V and nccr 不足 or S/S dialysate dialysate 總量 or 換袋次數單袋灌注量

30 CAPD (L/LA) 2L qid 若 Kt/V < 1.7 or nccr<50 2L change 5 次 2.5L change 5 次 CCPD ( 白天換二次 + 晚上 10L) HD CAPD (H/HA) 2L qid 若 Kt/V < 2 or nccr<60 2L change 5 次 2.5L change 5 次 APD ( 晚上 10L) CCPD ( 白天換二次 + 晚上 10L) HD

31 APD :10 L (1.5%) 若 Kt/V < 2.2 or nccr<66 CCPD CCPD ( 加白天一或二次換液 ) CCPD : 若 Kt/V < 2.1 or nccr<63 H/DH/D

32 First Prescription (Based on RRF, BSA) CAPD : (1.5L or 2L) x qid CCPD : 10 L + last bag (1L-2L) NIPD : 10 L 1 month adjustment BSA, RRF, PET, S/S CAPD(L, LA) CAPD(H, HA) WKt/V<1.7 WKt/V<2 WnCCr<50 WnCCr<60 NIPD WKt/V<2.2 WnCCr<66 CCPD WKt/V<2.1 WnCCr<63 換液次數增加 3 次 4 次 or 4 次 5 次單袋灌注量增加 1.5L 2L or 2L 2.5L CCPD 增加白天換液次數 1L-2L 一次或二次 HD

33 透析不足的 S/S 容質移除能力不足 -Cr,, BUN or - 貧血神經症狀變嚴重 - 食慾不振噁心嘔吐消瘦失眠

34 定期評估透析量每月ㄧ次 :Hb,, Ht, WBC, DC, Sugar, alb, A/G, Alk-P, Chole,, TG, BUN, Cr, Uric Acid, Cr, K, NA, Ca, P, 每三月ㄧ次 : MCV, Ret, Iron, TIBC, Ferritin, GOT, GPT, 每六月ㄧ次 : ipth, Vit B12, Folic acid, nccr,, Kt/V 每年ㄧ次 : PET,, X-ray, X HBsAg,, Anti-HCV

35 Adequate ultrafiltration

36 簡單 UFF 之定義病人即使每天使用 2-3 袋的高濃度 (4.25%) 之透析液, 而仍會發生水腫. 即使限水亦無法達到乾體重.

37 超過率能力不足 S/S - 高血壓水腫 - 使用高濃度透析液的次數增加

38 Management of Ultrafiltration inadequate dialysate 總量 or 換袋次數單袋灌注量 Dextrous 濃度 ( 1.25% 2.5% 2.5% 4.25%) Extraneal (Icodextrin) 限制水份攝取 urine <500cc/day Transamin1#Bid

39 First prescription CAPD : (2L or 1.5L ) x qid CCPD : 10 L +last bag (1L-2L) NIPD : 10 L - 高血壓水腫 - 使用高濃度透析液的次數增加 dialysate 總量 or 換袋次數單袋灌注量 Dextrous 濃度 ( 1.25% 2.5% 4.25%) Extraneal (Icodextrin) 限制水份攝取 urine <500cc/day Transamin1#Bid

40 遵醫性不良不變 24H urine 下降流出量不變體液過量灌注 2 公升之透析液檢查流出量導管問題透析液漏出流出量真正失去 UF RFF 減少 PET 下降不變上升 Type II UFF 1. 硬化性腹膜炎 2. 粘連 1. 淋巴吸收上升 2. 透析液滲漏 3. 導管問題 4. 經細胞穿透力下降 Type I UFF 新生的腹膜炎

41 Type I UFF 70%-80% Peritonitis transport transport effect (D/P Cr, D/D 0 glucose Reversible after 1 month 0 glucose )

42 Type II UFF 較少 Sclerosing peritonitis and peritoneal adhesion 腹膜表面積減少, 穿透性下降同時會出現 UFF 及 inadequate solute transport

43 Type III UFF High lymphatic absorption rate Uncommon

44 Type IV UFF Aquaporin deficiency Rare Water channels or ultra-small pore deficient crystalloid-induced induced UF Dx :<400ml UF with 4.25%PET lack of Na sieving early in the dwell Tx : colloid osmotic agents (icodextrin( icodextrin)

45 Type I UFF 滲透性增加避免夜間留存太久若有尿可加 lasix 改成 NPD 暫時 HD or 改用 icodetran Type II UFF 硬化性腹膜炎黏連若有尿可加 lasix 試 tidal PD 轉 HD 便秘軟便劑高纖食物疝氣滲漏手術修復暫停 PD 導管位置不良 Type III UFF 淋巴吸收增加校正導管位置無有效治療方法用腹腔鏡

46 Icodextrin 7.5% Glucose polymer MW=16800 Osmolality 285mOsm/kg UF occurred by colloid osmosis via small pores No UF via ultra pores,, through which glucose mainly acts, so no sodium sieving

47 腹膜透析轉血液透析的適應症適應症 : 無法達適當腹膜透析量無法達到適當水分控制無法控制的高血脂症無法接受的高腹膜炎發生率或其他腹膜透析併發症技術問題無法矯正的營養不良.

48 Pitfalls in Prescription of PD Noncompliance Patients on Standard CAPD are: (a) inappropriate dwell times (b) failure to dialysis dose to compensate for loss of RRF; (c) inappropriate instilled volume (d) multiple rapid exchanges and 1 very long dwell (e) inappropriate selection of dialysate glucose

49 Pitfalls in Prescription of PD Patients on cycler therapy. =The drain time may be inappropriately long (> 20 min). =Inappropriately short dwell times =Failure to augment total dialysis dose with a daytime dwell ("wet" day vs "dry" day) could also result in underdialysis. =Inappropriate selection of dialysate glucose may may not allow maximization of UF, resulting in less total clearance.

29.? ?? ? ? ? ? ? ? KT/ V? KT/ V? ? ,? ? ? ? ? ? 30 4

29.? ?? ? ? ? ? ? ? KT/ V? KT/ V? ? ,? ? ? ? ? ? 30 4 1.? 1 2.? 1 3.? 3 4.? 4 5.? 4 6.? 5 7.? 5 8.? 6 9.? 7 10.? 8 11.? 8 12.? 9 13.? 9 14.? 9 15.? 10 16.? 11 17.? 12 18.? 13 19.? 13 20.? 14 21.? 15 22.? 16 23.? 16 24.? 16 25.?? 18 26.? 18 27.? 19 28.? 20