PET and Adequacy Atma Gunawan
PET (peritoneal equilibrum test) Information on the rate of peritoneal transport of small solute and ultrafiltration capacity
Peritoneal Dialysis
Applications of the PET
• • • • • •
peritoneal membrane transport classification predict dialysis dose choose peritoneal dialysis regime monitor peritoneal membrane function diagnose causes of inadequate ultrafiltration diagnose causes of inadequate solute clearance
When PET performed ? • PET should be performed approximately 4 weeks after initiating peritoneal dialysis, but no earlier • PETs should be repeated at 2 years and then annualy.
The CARI Guidelines – Caring for Australians with Renal Impairment
Aquaporine channel
PRINCIPLES OF PERITONEAL DIALYSIS ( the three pores model of peritoneal transport)
Ultrapores (4-6 An). Water sieving,Aquaporin water Channel. (Natrium, Urea N, Kreatinin tidak lolos) Small pores (40-60An),celah di endotel meloloskan small solute,air Large pores (100-200 An), celah di endotel,meloloskan macromolecules
Persiapan PET • Malam : dwell dengan dialisat 2.5% • Dwell time : 8-12 jam • Drain out di di klinik CAPD
1. Posisi
duduk : drain out dialisat 2.5% setelah dwell 810 jam (malam)
2. Posisi baring drain in dialisat 2.5% 2 liter, sekitar 10 menit. Setiap 400 ml masuk, pasien posisi pasien miring kanan-miring kiri
3. Drain out dialisat 200 cc ke dalam kantong dibalik-balik. 4. Bersihkan medication port dengan bethadine selama 5 menit, aspirasi 10cc cairan dialisat dengan spuit, taruh kedalam red top tube. Masukkan sisanya 190 cc ke rongga peritoneum
= Dialisat 0 jam
5. Setelah dwell 2 jam, ulangi prosedur no 4. konektor transfer set boleh dilepas
= Darah 2 jam
= Dialisat 2 jam
6. Ambil darah 5cc.
7. Jam ke-4: drain out semua dialisat, lakukan seperti protokol no 4. Lanjutkan dengan cairan dialisat sehari-harinya.
= Dialisat 4 jam
0 jam (PET 1)
2 jam (PET 2
•Kreatinin •Glukosa
4 jam (PET 3)
PERHITUNGAN PET D/P = KONSENTRASI DIALISAT KONSENTRASI PLASMA 4,2 = .68 6.1 D/P = 1,0 berarti bahwa dialisat mempunyai konsentrasi solut yang sama dengan plasma, atau men capai 100 % keseimbangan. 0.68 berarti dialisat dalam 68 % keseimbangan
CORRECTION FACTOR • TINGGINYA KONSENTRASI GLUKOSA PADA CAIRAN DIALISAT DAPAT MEMPENGARUHI HASIL PENILAIAN LABORATORIUM DARI KREATININ (menghasilkan kreatinin tinggi palsu) • PERLU FAKTOR KOREKSI
KREATININ TERKOREKSI
• KREATININ TERKOREKSI mg/dl = KREATININ mg/dl (GLUKOSA X CORRECTION FACTOR) CORRECTION FACTOR FROM FRESH 2.5% DIANEAL = .000210526 Contoh :
SERUM kreatinin =12 GLUKOSA = 95 CORRECTED SERUM CREATININE = 12 - (95 X .000210526)= 12-.0199975= 11.9
Peritoneal Equilibration Test
Copyright of Baxter Healthcare
Peritoneal Dialysis
Relationship Between Dwell Time and Transport Transport Rapid High A Low A Low
Solute Cl ++++ +++ ++ +
UF Prescription + Short dwell ++ CAPD/CCPD +++ CAPD/CCPD ++++ Long Dwells
Peritoneal membrane characteristics according to PET result Membrane type 4-hr D/P creatinine
Australian Non-diabetics (ANZDATA 2003)
Australian Diabetics (ANZDATA 2003)
High
0.81 – 1.03
9%
10%
High Average
0.65 – 1.80
56%
51%
Low Average
0.50 – 1.64
32%
37%
Low
0.34 – 1.49
3%
2%
The CARI Guidelines – Caring for Australians with Renal Impairment
PROFIL PASIEN CAPD DI RSSA MALANG 2015 Karakteristik (n = 68 pasien) Usia (tahun)
Hasil (mean ± SD atau %) 47.79 ± 11.25
Jenis Kelamin (n %) - Laki-Laki
40 (58.8%)
- Perempuan
28 (41.2%)
BMI (kg/m2)
23.84 ± 4.7
BSA (m2)
1.6 ± 0.19
Lama CAPD (bulan)
24.47 ± 29.2
Total Urine (mL)
289.41 ± 371.76
Total Drain (mL)
8730 ± 1226.45
D/P H4Cr
0.68 ± 0.12
DM (n %) - DM
23(33.8%)
- Non DM
45(66.2%)
Peritonitis (n %) - Peritonitis
11(16.2%)
- Non Peritonitis
57 (83.8%)
Tipe Membran Peritoneal Pasien CAPD di RSSA Malang
Adequacy of PD
What is Clearance? • Clearance is the total amount of body fluid completely cleared of a solute during a certain time • ml/min • L/week
• Ex: Creatinine clearance = 50 l/week means: 50 L of body fluid is totally cleared for creatinine during a week • Other indicator urea clearance : KT/V
Patient survival according to Kt/V group (Hongkong Trial)
p value of the difference was 0.0582 at 12 months, and 0.295 at 24 months Peritoneal Dialysis International, Vol. 21, pp. 441–447
Targets for solute clearance (2005 European Best Practices Guidelines and the 2006 International Society for Peritoneal Dialysis (ISPD) Guidelines/Recommendations)
CrCl
50
60
1.7
2.0
Kt/V
Suggested impact on outcome
Calculation of Peritoneal Creat. Clearance Drain No Dwell time 1 285
Drain Vol. 2500
Drain creatinine 804
2
285
2500
800
3
315
2625
817
4
597
2500
1017
Plasma 1091 creatinine umol/l Body 1.737 m2 surface area
Total drain vol = 10125 ml Ave drain creat = 859.5 umol/l
Calculation of Peritoneal Creat Clearance dialysate creatinine weekly creatinine clearance(l ) total drain volume x x7 plasma creatinine
= 10.7 x 0.788 x 7 = 59 l/wk Normalise to BSA
= CCl x 1.73/ patients BSA
Normalised weekly CCl = 59 l/wk/1.73 m2
Calculation of Peritoneal Urea Clearance Drain No
Dwell time Drain Vol.
Drain urea
1
285
2500
11.9
2
285
2500
12.2
3
315
2625
10.0
4
597
2500
14.3
Plasma urea 14.4 mmol/l Total drain vol = 10125 ml Volume of 31595 ml distribution
Average drain urea = 12.7
Calculation of peritoneal urea clearance weekly Kt / v (
drain volume diaysate urea x )x 7 volume of distribution plasma urea
10125 12.7 weekly Kt / v x x7 31595 14.1 = 0.288 x 7 = 2.02
Volume distribution urea
V(men)=55% BW V(women)=50% BW
Adekuasi pasien CAPD RSSA Malang (n=68), th 2015
Klirens urea (wKT/V) : 1,84 ± 0,56 liter/minggu
Klirens kreatinin (wCCr) : 61,51 ± 23,69 liter/minggu/m2
Standar NKF/K- DOQI : wKT/V ≥ 1.7 liter/minggu wCCr ≥ 60 liter/minggu/m2
Peritoneal Dialysis
Gambar Perbedaan Kt/V pada Masing-Masing Type Membran 1.800 1.650
Kt/V HA <> Kt/V H (t=2,380 P=0,026)
1.500 1.350 Mean=1,125
1.200
KT/V
1.050 0.900 0.750
Mean=0,876
Mean=0,818
0.600 0.450 0.300 0.150 0.000
Low Average
High Average
Type Membran
High
Peritoneal Dialysis Kontribusi renal terhadap total kliren kreatinin (pasien CAPD RSSA Malang 2006, n=37)
Renal Cr 3.59%
Cl.Cr 96.41%
Optimizing peritoneal dialysis dose
Increase dialysis dose by increasing drain volumes
Schedule dwell times to maximise clearance
drain volu me D target urea clearance x x7 distr volu me P Problems arise for large body weights
Main principles behind the PD guidelines •
• • •
Patients with higher D/P require an increased number of exchanges during the night Patients with higher BSA require higher fill volume per exchange Anuric patients are advised to have an extra day exchange (OCPD) Extraneal is encouraged to be used in all patients during a long day well as it can improve the UF and clearance of patients L (D /P < 0 .5 )
LA (D /P 0 .5 -0 .6 5 )
HA (D /P 0 .6 5 -0 .8 1 )
H (D /P > 0 .8 1 )
S m a ll (< 1 .7 1 B S A )
Increase number of exchanges M e d iu m (1 .7 1 - 2 .0 B S A )
L a r g e (> 2 .0 B S A )
Increase fill volume
Treatment guidelines – a summary • Patients with BSA> 1.7m2 or body weight >65 kg • Routinely prescribed 2.5L fill volume
• Patients with BSA> 2 m2 or body weight >80 kg • Routinely prescribed 3 L fill volume
• Patients requiring 5 day exchanges should use a night time exchange device to deliver the 5th exchange • Patients on APD should do one or more day time exchanges (unless small BSA or high RRF)
Clinical Practice Guidelines of the Canadian Society of Nephrology for treatments of Patients with CRF JASN 10: S287-S321, 1999
2006 K/DOQI guidelines For patients with RKF (if urine volume is >100 mL/day): • The minimal delivered dose of small solute clearance should be a total (PD and RKF) Kt/Vurea of at least 1.7/week. For patients without RKF (if urine volume is <100 mL/day): • The minimal delivered dose of small solute clearance should be a peritoneal Kt/Vurea of at least 1.7/week. The dose should be measured within the first month of starting dialysis and at least every four months
Wassalam
