PET and Adequacy. Atma Gunawan

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PET and Adequacy

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PET (peritoneal equilibrum

test)

Information on the rate of

peritoneal transport of small solute

and ultrafiltration capacity

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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

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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.

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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

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Persiapan PET

• Malam : dwell dengan dialisat 2.5%

• Dwell time : 8-12 jam

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1. Posisi duduk : drain out dialisat 2.5% setelah dwell 8-10 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

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5. Setelah dwell 2 jam, ulangi prosedur no 4. konektor transfer set boleh dilepas

6. Ambil darah 5cc.

= Darah 2 jam

7. Jam ke-4: drain out semua dialisat, lakukan seperti protokol no 4. Lanjutkan dengan cairan dialisat sehari-harinya.

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0 jam (PET 1) 2 jam (PET 2 _{4 jam (PET 3)}

•Kreatinin •Glukosa

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PERHITUNGAN PET

D/P = KONSENTRASI DIALISAT

KONSENTRASI PLASMA

4,2 = .68

6.1 D/P = 1,0 berarti bahwa dialisat mempunyai

kon-sentrasi solut yang sama dengan plasma, atau men

capai 100 % keseimbangan.

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CORRECTION FACTOR

• TINGGINYA KONSENTRASI GLUKOSA PADA CAIRAN

DIALISAT DAPAT MEMPENGARUHI HASIL PENILAIAN

LABORATORIUM DARI KREATININ (menghasilkan

kreatinin tinggi palsu)

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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

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Copyright of Baxter Healthcare

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Transport Solute Cl UF Prescription

Rapid ++++ + Short dwell

High A +++ ++ CAPD/CCPD

Low A ++ +++ CAPD/CCPD

Low + ++++ Long Dwells

Relationship Between Dwell Time

and Transport

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The CARI Guidelines – Caring for Australians with Renal Impairment 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%

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Karakteristik (n = 68 pasien) Hasil (mean ± SD atau %) Usia (tahun) 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%)

PROFIL PASIEN CAPD DI RSSA MALANG 2015

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Tipe Membran Peritoneal

Pasien CAPD di RSSA Malang

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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

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Patient survival according to Kt/V group

(Hongkong Trial)

Peritoneal Dialysis International, Vol. 21, pp. 441–447

p value of the difference was 0.0582 at 12 months, and 0.295 at 24 months

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Targets for solute clearance (

2005 European Best Practices Guidelines and the 2006 International Society for Peritoneal Dialysis (ISPD) Guidelines/Recommendations)

Suggested impact on outcome

50

60

1.7

2.0 CrCl

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Calculation of Peritoneal Creat. Clearance

Drain No Dwell time

Drain Vol. Drain

creatinine 1 285 2500 804 2 285 2500 800 3 315 2625 817 4 597 2500 1017 Plasma creatinine 1091 umol/l

Total drain vol = 10125 ml Body

surface area

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Calculation of Peritoneal Creat Clearance

7 ) ( x creatinine plasma creatinine dialysate x volume drain total l clearance creatinine weekly  = 10.7 x 0.788 x 7 = 59 l/wk

Normalise to BSA = CCl x 1.73/ patients BSA

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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

distribution

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7 ) ( / x a plasma ure rea diaysate u x on distributi of volume volume drain v Kt weekly  7 14.1 12.7 31595 10125 / v x x Kt weekly  = 0.288 x 7 = 2.02

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V(men)=55% BW V(women)=50% BW

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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

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Peritoneal Dialysis High High Average Low Average Type Membran 1.800 1.650 1.500 1.350 1.200 1.050 0.900 0.750 0.600 0.450 0.300 0.150 0.000 K T/ V

Gambar Perbedaan Kt/V pada Masing-Masing Type Membran

Mean=1,125

Mean=0,818 Mean=0,876

Kt/V HA <> Kt/V H (t=2,380 P=0,026)

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Kontribusi renal terhadap total kliren kreatinin

(pasien CAPD RSSA Malang 2006, n=37)

Cl.Cr 96.41%

Renal Cr 3.59%

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Optimizing peritoneal dialysis dose

7 me

distr volu

me

drain volu

clearance

urea

target

x

P

D

x



Problems arise for large body weights Increase dialysis dose by increasing drain volumes Schedule dwell times to maximise clearance

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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 ) L A ( D / P 0 .5 - 0 .6 5 ) H A ( D / P 0 .6 5 - 0 .8 1 ) H ( D / P > 0 .8 1 ) S m a l l ( < 1 .7 1 B S A ) M e d i u m ( 1 .7 1 - 2 .0 B S A ) L a r g e ( > 2 .0 B S A )

Increase number of exchanges

Increase fill volume

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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

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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

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