腹膜透析充分性的国际指南,Shijunbao,腹膜透析充分性的国际指南,ISPD GUIDELINE ON TARGETS FOR SOLUTE AND FLUID REMOVAL IN ADULT PATIENTS ON CHRONIC PERITONEAL DIALYSIS KDOQI CLINICAL PRACTICE GUIDELINES AND CLINICAL PRACTICE RECOMMENDATIONS 2006 UPDATES ERA-EDTA EUROPEAN BEST PRACTICE GUIDELINES FOR PERITONEAL DIALYSIS,GUIDELINE ON TARGETS FOR SOLUTE AND FLUID REMOVAL IN ADULT PATIENTS ON CHRONIC PERITONEAL DIALYSIS,ISPD GUIDELINES/RECOMMENDATIONS,RECOMMENDATIONS 1,Adequacy of dialysis should be interpreted clinically rather than by targeting only solute and fluid removal.,Clinical Assessment,Clinical and laboratory results Peritoneal and renal clearances Hydration status Appetite and nutritional status Energy level,Hemoglobin concentration Responsiveness to erythropoietin therapy Electrolytes and acidbase balance Calcium phosphate homeostasis Blood pressure control,RECOMMENDATIONS 2,In order to emphasize that there is more to adequate dialysis than a focus on small solute kinetics and ultrafiltration targets, the Committee decided to name this guideline Guideline on Targets for Solute and Fluid Removal in Adult Patients on Chronic Peritoneal Dialysis instead of Guideline on Adequacy of Peritoneal Dialysis.,RECOMMENDATIONS 3,For small solute removal, the total (renal + peritoneal) Kt/V urea should not be less than 1.7 at any time (Evidence level A). That means, in anuric patients, peritoneal Kt/V urea has to be above 1.7.,RECOMMENDATIONS 3,In the presence of residual renal function, the contributions of renal and peritoneal clearances may be added for practical purposes, although, as mentioned previously, renal and peritoneal clearances may not be truly additive (Opinion). Solute removal above this level should not be equated with “adequate dialysis.”,RECOMMENDATIONS 3,Knowledge of the transport characteristics of the patients peritoneal membrane by peritoneal equilibration test or other tests may help to optimize the prescription to meet this target.,RECOMMENDATIONS 4,A separate target for creatinine clearance is not required in CAPD. In APD, due to a more variable relationship between urea and creatinine clearance an additional target of 45 L/week/1.73 m2 for creatinine clearance is recommended (Evidence level C).,RECOMMENDATIONS 5,For patients who rely significantly on residual renal function to achieve the minimal target level of small solute clearance, residual renal function should be monitored regularly and at an appropriate frequency so that the PD prescription can be adjusted in a timely manner (Evidence level C). Every 1 2 months if practicable, otherwise no less frequently than every 4 6 months,RECOMMENDATIONS 5,If there is a decrease in urine volume or a change in blood chemistries suggesting a decline in residual renal function, it should be measured sooner.,RECOMMENDATIONS 6,A continuous around-the-clock PD regime is preferred to an intermittent schedule whenever possible (Evidence level B),RECOMMENDATIONS 7,Attention should be paid to both urine volume and the amount of ultrafiltration, with the goal of maintaining euvolemia.,RECOMMENDATIONS 7,A small ultrafiltered volume despite the use of dialysis solutions with a high glucose concentration should be regarded as a warning sign for the presence of ultrafiltration failure. This should be investigated further with a peritoneal equilibration test according to the ISPD recommendations on evaluation and management of ultrafiltration problems (Evidence level B).,RECOMMENDATIONS 8,For patients with signs and symptoms suggestive of underdialysis, a trial of increasing dialysis should be provided even if Kt/V urea is well above the minimal target (Evidence level C).,RECOMMENDATIONS 9,The benefit of increasing the amount of peritoneal dialysate (either number of exchanges or volume of each exchange), or change to hemodialysis, when these targets cannot be met should be balanced against The potential side effects Effects on the patients lifestyleCost consideration(Evidence level C).,Peritoneal Dialysis Adequacy,Clinical Practice Guidelines and Clinical Practice Recommendations 2006 Updates,PERITONEAL DIALYSIS SOLUTE CLEARANCE TARGETS AND MEASUREMENTS,GUIDELINE 2.,GUIDELINE 2.,Data from RCTs suggested that the minimally acceptable small-solute clearance for PD is less than the prior recommended level of a weekly Kt/Vurea of 2.0. Furthermore, increasing evidence indicates the importance of RKF as opposed to peritoneal small-solute clearance with respect to predicting patient survival. Therefore, prior targets have been revised as indicated next.,GUIDELINE 2.,2.1 For patients with RKF (considered to be significant when urine volume is 100 mL/d): 2.1.1 The minimal “delivered” dose of total small-solute clearance should be a total (peritoneal and kidney) Kt/Vurea of at least 1.7 per week. (B),GUIDELINE 2.,2.1 For patients with RKF (considered to be significant when urine volume is 100 mL/d): 2.1.2 Total solute clearance (residual kidney and peritoneal, in terms of Kt/Vurea) should be measured within the first month after initiating dialysis therapy and at least once every 4 months thereafter. (B),