CAPD guide line VS 施孟甫 醫師 CAPD麗華 CR 蔡智生 醫師

透析的 開始時機 每週 KT/V < 2 GFR <10.5/min/1.73m2 DOQUI guideline 2

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, supine dialysis. 3. Obtain baseline 24-hour urine collection for urea and creatinine clearance

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.

1 month adjustment BSA, RRF, PET, S/S 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 增加白天 換液次數 1L-2L 一次或二次 CCPD HD

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

Residual renal function Renal GFR =1/2 (renal CCr + renal UreaCr) BSA =0.007184xBW(Kg)0.425xBH(cm)0.725

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

GFR >2 ml/min A. If patient's lifestyle choice is CAPD: BSA<1.7 m2 4 x 1.5 L exchanges/day BSA 1.7 to 2 m2 4 x 2.0 L exchanges/day BSA>2.0 m2  4 x 2.5 L exchanges/day

GFR >2 ml/min B. If patient's lifestyle choice is CCPD: BSA<1.7 m2 6 x 1.5 L (9hours/night) +1 L/d(last bag) BSA 1.7 to 2.0 m2 4 x 2.0 L (9 hours/night)+1.5-2.0 L/day (last bag) BSA>2.0 m2  4 x 2.0 L (9 hours/night)+2. L/day (last bag)

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)

2. GFR ≦2 ml/min A. If patient's lifestyle choice is CAPD: BSA<1.7 m2  4 x 2.0 L/day BSA 1.7 to 2.0 m2  4 x 2.5 L/day BSA >2.0 m2  5 x 2.5 L/day (Consider use of a simplified nocturnal exchange device to achieve optimal dwell times and to augment clearance.)

2. GFR ≦2 ml/min B. If patient's lifestyle choice is CCPD: BSA<1.7 m2 6 x 1.5 L (9hours/night) +1 L/d(last bag) BSA 1.7 to 2.0 m2 4 x 2.0 L (9 hours/night)+1.5-2.0 L/day(last bag) BSA>2.0 m2  4 x 2.0 L (9 hours/night)+2.0 L/day (last bag) (可增加白天換液1-2次)

1 month adjustment BSA, RRF, PET, S/S 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 增加白天 換液次數 1L-2L 一次或二次 CCPD HD

1 month adjustment BSA, RRF, PET, S/S 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 增加白天 換液次數 1L-2L 一次或二次 CCPD HD

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

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

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。

Peritoneal Equilibration Test (PET) Dialysate在全部注入後，為0分(0-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。

Peritoneal equilibration test (PET) Insertion 2 liters of 2.5% detrose dialysate  0小時, 2小時, 4小時  D/D0 glucose and D/P Cr之值 並畫圖  Low transporter Low everage transporter High average transporter High transporter

solute removal ability Adequate solute removal ability

1 month adjustment BSA, RRF, PET, S/S 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 增加白天 換液次數 1L-2L 一次或二次 CCPD HD

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)

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

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

Adjust dialysate Kt/V and nCCr 不足 or S/S  ↑dialysate 總量 or  ↑換袋次數  ↑單袋灌注量

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  APD (晚上10L)  CCPD (白天換二次 + 晚上10L) HD

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

1 month adjustment BSA, RRF, PET, S/S 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 增加白天 換液次數 1L-2L 一次或二次 CCPD HD

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

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, HBsAg, Anti-HCV

Adequate ultrafiltration

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.

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

Management of Ultrafiltration inadequate ↑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

-高血壓 水腫 -使用高濃度透析液的次數增加 First prescription  ↑dialysate 總量 or  ↑換袋次數 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

體液過量 導管問題 透析液漏出 遵醫性不良 灌注2公升之透析液 24H urine 流出量不變 檢查流出量 流出量↓ 下降 真正失去UF RFF減少 PET 上升 下降 不變 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 Type II UFF 1.硬化性腹膜炎 2.粘連

Type I UFF 70%-80% Peritonitis  ↑transport effect (D/PCr ↑, D/D0 glucose↓) Reversible after 1 month

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

Type III UFF High lymphatic absorption rate Uncommon

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

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 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 校正導管位置 用腹腔鏡 Type III UFF 淋巴吸收增加 無有效治療方法

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

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 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．

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

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 not allow maximization of UF, resulting in less total clearance.