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ISPDGUIDELINE ON TARGETS FOR SOLUTE AND FLUID REMOVAL IN ADULT PATIENTS ON CHRONIC PERITONEAL DIALYSISKDOQICLINICAL PRACTICE GUIDELINES AND CLINICAL PRACTICE RECOMMENDATIONS 2006 UPDATESERA-EDTAEUROPEAN BEST PRACTICE GUIDELINES FOR PERITONEAL DIALYSISGUIDELINE ON TARGETS FOR SOLUTE AND FLUID REMOVAL IN ADULT PATIENTS ON CHRONIC PERITONEAL DIALYSISISPD GUIDELINES/RECOMMENDATIONSRECOMMENDATIONS 1Adequacy of dialysis should be interpreted clinicallyrather than by targeting only solute and fluid removal.Clinical AssessmentClinical and laboratory resultsPeritoneal and renal clearancesHydration statusAppetite and nutritional statusEnergy levelHemoglobin concentrationResponsiveness to erythropoietin therapyElectrolytes and acidbase balanceCalcium phosphate homeostasisBlood pressure controlRECOMMENDATIONS 2In 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 guidelineGuideline on Targets for Solute and Fluid Removal in Adult Patients on Chronic Peritoneal Dialysis instead of Guideline on Adequacy of Peritoneal Dialysis.RECOMMENDATIONS 3For 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 3In 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 3Knowledge of the transport characteristics of the patients peritoneal membrane by peritoneal equilibration test or other testsmay help to optimize the prescription to meet this target.RECOMMENDATIONS 4A separate target for creatinine clearance is not required in CAPD.In APD, due to a more variable relationship between urea and creatinine clearancean additional target of 45 L/week/1.73 m2 for creatinine clearance is recommended (Evidence level C).RECOMMENDATIONS 5For 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 frequencyso 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 5If 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 6A continuous around-the-clock PD regime is preferred to an intermittent schedule whenever possible (Evidence level B)RECOMMENDATIONS 7Attention should be paid to both urine volume and the amount of ultrafiltration, with the goal of maintaining euvolemia.RECOMMENDATIONS 7A 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 8For 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 9The 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 againstThe potential side effectsEffects on the patients lifestyle Cost consideration (Evidence level C).Peritoneal Dialysis AdequacyClinical Practice Guidelines and Clinical Practice Recommendations2006 UpdatesPERITONEAL DIALYSIS SOLUTE CLEARANCE TARGETS AND MEASUREMENTSGUIDELINE 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) GUIDELINE 2. 2.1 For patients with RKF (considered to be significant when urine volume is 100 mL/d):2.1.3 If the patient has greater than 100 mL/d of residual kidney volume and residual kidney clearance is being considered as part of the patients total weekly solute clearance goal.GUIDELINE 2. 2.1 For patients with RKF (considered to be significant when urine volume is 100 mL/d):2.1.3 A 24-hour urine collection for urine volume and solute clearance determinations should be obtained at a minimum of every 2 months. (B) GUIDELINE 2. 2.2 For patients without RKF (considered insignificant when urine volume is 100 mL/d):2.2.1 The minimal “delivered” dose of total small-solute clearance should be a peritoneal Kt/Vurea of at least 1.7 per week measured within the first month after starting dialysis therapy and at least once every 4 months thereafter. (B)MAINTENANCE OF EUVOLEMIAGUIDELINE 4.GUIDELINE 4. Volume overload is associated with CHF, LVH, and hypertension; therefore, it is important to monitor ultrafiltration volume, dry weight, sodium intake, and other clinical assessments of volume status.GUIDELINE 4.4.1 Each facility should implement a program that monitors and reviews peritoneal dialysate drain volume, RKF, and patient blood pressure on a monthly basis. (B)GUIDELINE 4.4.2 Some of the therapies one should consider to optimize extracellular water and blood volume include, but are not limited to, restricting dietary sodium and water intake, use of diuretics in patients with RKF, and optimization of peritoneal ultrafiltration volume and sodium removal. (B)PERITONEAL DIALYSIS PRESCRIPTION TARGETS AND MEASUREMENTSGUIDELINE 2.GUIDELINE 2.In a PD prescription, there are certain general considerations.GUIDELINE 2.2.1 Regardless of delivered dose, if a patient is not thriving and has no other identifiable cause other than possible kidney failure, consideration should be given to increasing dialysis dose.GUIDELINE 2.GUIDELINE 2.2.2 In a patient with minimal RKF, a continuous (rather than intermittent) 24 h/d of PD dwell PD prescription should be used to maximize middle-molecule clearance.GUIDELINE 2.2.3 If either peritoneal Kt/Vurea is at least 1.7 or 24-hour urine output is less than 100 mL, monitoring of RKF is not required for monitoring the dose of PD. GUIDELINE 2.2.4 All measurements of peritoneal solute clearance should be obtained when the patient is clinically stable and at least 1 month after resolution of an episode of peritonitis.GUIDELINE 2.2.5 More frequent measurements of either peritoneal urea clearance or RKF should be obtained when clinically indicated.GUIDELINE 2.2.6 When calculating Kt/Vurea, one should estimate V from either the Watson or Hume equation in adults.2.6 In the absence of evidence, use of the patients ideal or standard (rather than actual) weight should be considered in the calculation of V.GUIDELINE 2.2.7 The determination of peritoneal CCr is of little added value for predicting risk for death; therefore, for simplicity, adequacy targets are based on urea kinetics only.2.7 Peritoneal creatinine excretion rate may be used to monitor estimates of muscle mass over time.GUIDELINE 2.2.8 During the monthly evaluation of the PD patient, nutritional status should be estimated.2.8 Serum albumin levels should be monitored, and when obtaining 24-hour total solute clearances, estimations of dietary protein intake (DPI; such as nPNA) should be measured.RECOMMENDED LABORATORY MEASUREMENTS FOR PERITONEAL MEMBRANE FUNCTION AND ULTRAFILTRATION VOLUMEGUIDELINE 3.GUIDELINE 3.Total solute clearance and peritoneal effluent volume ultimately are influenced by peritoneal membrane transport characteristics.Multiple tests are documented to be efficacious for determining peritoneal membrane transport.None of these tests has been shown to be clinically superior to the others.GUIDELINE 3.GUIDELINE 3.3.1 Each center should choose one of these tests to use when characterizing peritoneal transport in their patients.3.2 Baseline peritoneal membrane transport characteristics should be established after initiating a daily PD therapy. GUIDELINE 3.3.3 Data suggest that it would be best to wait 4 to 8 weeks after starting dialysis to obtain this baseline measurement.3.4 Peritoneal membrane transport testing should be repeated when clinically indicated. GUIDELINE 3.GUIDELINE 3.3.5 All measurements of peritoneal transport characteristics should be obtained when the patient is clinically stable and at least 1 month after resolution of an episode of peritonitis.WRITING THE PERITONEAL DIALYSIS PRESCRIPTIONGUIDELINE 4.GUIDELINE 4.The PD modality has an impact on adherence and QOL, which are important considerations in writing a PD prescription.GUIDELINE 4.Ultrafiltration, which is important in optimizing volume control and thus patient survival, is dependent on the prescription and peritoneal membrane characteristics.Clearance of middle molecules, while not proved to influence patient survival, should be an important consideration in the prescription.GUIDELINE 4.4.1 The patients schedule and QOL should be taken into account when prescribing PD.GUIDELINE 4.4.2 To optimize middle-molecule clearance in patients who have minimal RKF, the PD prescription should preferentially include dwells for the majority of the 24-hour day.4.2 This is recommended even if small-molecule clearance is above target without the longer dwell.GUIDELINE 4.4.3 As tolerated by the patient, to optimize small-solute clearance and minimize cost, one should first increase instilled volume per exchange before increasing the number of exchanges per day.4.3 The exchange volume of the supine exchange(s) should be increased first because this position has the lowest intra-abdominal pressure.GUIDELINE 4.4.4 The patients record of PD effluent volume should be reviewed monthly, with particular attention to the drain volume from the overnight dwell(s) of CAPD and the daytime dwell(s) of APD.GUIDELINE 4.4.5 A number of techniques can be used to optimize volume and blood pressure control.GUIDELINE 4.4.5.1 To achieve the desired volume status, the lowest possible dialysate dextrose concentration should be used. 4.5.2 When appropriate, implement dietary sodium and fluid restriction.GUIDELINE 4.4.5.3 In patients with RKF, to achieve dry weight, diuretics may be preferred to increasing dialysate dextrose concentration. 4.5.4 Drain volume should be optimized during the overnight dwell(s) of CAPD and the daytime dwell(s) of APD to maximize solute clearance and ultrafiltration volume. GUIDELINE 4.4.5.5 In patients who are hypertensive or who show evidence of volume overload, ultrafiltration generally should not be negative (ie, no absorption) for any daytime or nighttime exchanges.EUROPEAN BEST PRACTICE GUIDELINES FOR PERITONEAL DIALYSISAdequacy of peritoneal dialysisGUIDELINE AAdequacy targets for dialysis should include both urea removal and fluid removal. (Evidence level C)GUIDELINE BThese targets should be based on those achieved by peritoneal dialysis only. Urine production and renal urea clearance can be subtracted from the targets. (Evidence level C)GUIDELINE CThe minimum peritoneal target for Kt/Vurea in anuric patients is a weekly value of 1.7; (Evidence level A)The minimum peritoneal target for net ultrafiltration in anuric patients is 1.0 l/day. (Evidence level B)The presence of residual renal function can compensate when these peritoneal targets are not achieved.(Evidence level C)GUIDELINE DWhen the targets are not achieved, patients should be monitored carefully for signs of overhydration, uraemic complaints and malnutrition. Appropriate therapy changes might be considered. (Evidence level C)GUIDELINE ESome APD patients who use frequent short exchanges and have a slow transport status can fulfil the above targets, but may have a low peritoneal creatinine clearance. In these patients, an additional target of 45 l/week/1.73m2 for peritoneal creatinine clearance should be aimed at in addition to achieving the Kt/Vurea target of 1.7. (Evidence level C)