BOTUCATU SCHOOL OF MEDICINE, SAO PAULO STATE, BRAZIL

Daniela Ponce

Peritoneal Dialysis:

An Alternate CRRT for AKI?

Faculty Disclosure

X No, nothing to disclose

March 30 - April 2, 2014

Sheraton Sonoma County

Petaluma, California

1- Why to indicate it ?

2- For whom?

3- How to prescribe it?

4- Which complications?

5- Is it better or worse than other methods?

7- Conclusion

Peritoneal Dialysis in AKI

6- PD in AKI: 10 years of Brazilian experience

• simple technique

• no anticoagulation

• low risk of bleeding

• hemodynamically unstable patients

• low risk of electrolyte disorders

• less expensive than CRRT

Advantages of PD

2. Why ?

Disadvantages of PD

Complications related to PD

Low efficiency

UF not controled

Need to peritoneal integrity

Costs of dialysis therapy in AKI

*Canadá

iHD CRRT

0

100

200

300

400

500

US$/dia

CRRT SLED

Manns*

(Crit Care, 2003)

iHD PD

700

600

Berbece*

(Kid Int, 2006)

CRRT

Ponce

(Botucatu, 2010)

iHD PD

Chitalia (Índia)

(Kid Int 2002)

Automatic

Flexible catheter

High volume

40 l/session

Mannual

Rigid Catheter

20 l/session

Manufactured Dialysate

PD in AKI

PubMed: number of studies

0

5

15

25

2 3

7 8

22

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

5

2 2

7

5 5

1 1

2 2 2 2

4

Artículos de Botucatu

10 10

2013 2014

2

3

ISPD Guideline: Peritoneal Dialysis for Acute Kidney Injury Brett Cullis 1,2 Mohamed Abdelraheem 3 Georgi Abrahams 4 Andre Balbi 5

Dinna. N. Cruz 6 Yaakov Frishberg 7 Vera Koch 8 Mignon McCulloch 9

Alp Numanoglu 10 Peter Nourse 9 Roberto Pecoits-Filho 11 Daniela Ponce 5 Bradley Warady 12

Karen Yeates 13 Fredric O Finkelstein 14

1- Why to indicate it ?

2- For whom?

3- How to prescribe it?

4- Wich complications?

5- Is it better or worsen than other methods?

6- PD in AKI: 10 years of Brazilian experience

7- Conclusion

Peritoneal Dialysis in AKI

Choice of dialysis method in AKI

Indications and contra-indications of each method

Hemodinamic stability and hypercatalism

Nephrology team experience

very unstable patients ?

septic patients?

mechanical ventilation?

hypercatabolic patients?

Prospective study to evaluate efficacy of HVPD in AKI and identify risk factors for death

64% septic

patients

55% VAD use

Metabolic and fluid control

Conclusion:

High volume PD is effective treatment for a

selected AKI patients group, allowing adequate

metabolic and fluid control. However, after 3

sessions if UF is low or NB is negative, others

extracorporeal blood purification dialysis methods

should be replaced or associated with high

volume PD.

This was a prospective cohort study that evaluated respiratory mechanics in 44 HVPD sessions

performed in 20 AKI patients undergoing mechanical ventilation

We evaluated IAP, respiratory mechanics (compliance and respiratory resistance and oxygenation.

Respiratory mechanics and IAP were evaluated at 5 moments during 3 days of dialysis

Under

mechanical

ventilation

Conclusions:

Results suggested that PD does not appear to

worse respiratory mechanics despite a modest

increase in IAP.

Peritoneal Dialysis in AKI

1- Why to indicate it ?

2- For whom?

3- How to prescribe it?

4- Which complications?

5- Is it better or worsen than other methods?

6- PD in AKI: 10 years of Brazilian experience

7- Conclusion

For decreasing complications

and improving efficciency

• flexible catheter (1 or 2 cuffs)

• automatic method - cycler

• continuous PD

• high volume of dialysate

Recommendations

No implantation technique was significantly better than other

Choosing the technique should be based on experience and results of each dialysis center

The involvement of nephrologist in implant procedures should always be considered, as it will be directly

responsible for patient care in the long term.

Flexible catheter in AKI patients

can be inserted by nephrologist using percutaneous technique

The aim was to investigate the early catheter complications and catheter survival according to different percutaneous

methods of catheter implantation performed by nephrologist

Fast exchanges h/h,

sessions of 16-20 hs,

2-3xx/weekly

exchanges with dwel

time longer (2-6 hs),

sessions of 24 h

Fast exchanges (30 min)

during 8-10 hs, with

residual volume (0.5-1 l)

HVPD

Fast exchanges

(h/h), sessions of

24 h, 7xx a week

The objective was to explore the role of HVPD in 30 AKI patients,

analyzing the metabolic and fluid control and patients outcome

Dialysate Volume (liters / cycle) 2

Inflow time (min) 10

Dwell Time (min) 35 - 50

Outflow time (min) 20

Duration of cycle (min) 65 - 80

Exchange numbers/session 18-22

Time per session (hours) 24

Total volume (L) 36-44

% glucose 1.5- 4.25

n=14 1.5

n= 6 2.0*

n= 7 2.5

n= 3 3.4**

Prescription

-

Creatinine clearance/session (ml/min) 15.8 ± 4.16

Urea nitrogen clearance/session (ml/min) 17.3 ± 5.01

Prescribed Kt/V

per session 0.65

weekly 4.5

Delivered Kt/V

per session 0.55 ± 0.12a a

weekly 3.85 ± 0.62a a

Solute Reduction Index (%) 41 ± 9.9

a= p>0.05 from prescribed Kt/V

Variable Median ± SD

Dialysis dose parameters

Metabolic and fluid control

• Prospective randomized study HVPD protocol

• 2 groups: prescribed Kt/V= 0.5 vs. 0.8

•Early interrupted

Table 1. Peritoneal Dialysis session characteristics

Characteristics Lower intensity Higher

intensity

Kt/V=0.5 Kt/V=0.8

Dialysate fluid/cycle (l) 2.0 2.0

Inflow time (min) 10 10

Outflow time (min) 20 20

Dwell time (min) 45–60 30-45

Duration /cycle (min) 75-90 60-75

Total exchanges/session 16-19 20-24

Total dialysate volume/session 32-38 40-48

Total duration of session (h) 24 24

Flow rate mL/minute 22-26.5 27.8-33.3

Glucose (%) 1.5-4.25 1.5-4.25

0

20

40

60

80

100

120

140

BUN

(mg/

dl)

a. BUN (mg/dl)

0

1

2

3

4

5

6

7

Cr

(mg

/dl)

0

5

10

15

20

25

0

1

2

3

4

5

6

b. Creatinine (mg/dl)

c. Bicarbonate (mEq/L) d. Potassium (mEq/L)

Figure 3. Comparison of metabolic control in higher and lower-intensity peritoneal dialysis dose. Median serum levels of (a) BUN, (b) creatinine, (c) bicarbonate, (d) potassium, at the beginning of treatment and after each session.

Metabolic Control

Table 4. Outcomes according to treatment group

Higher Lower p value (n=31) (n=30)

Mortality (%) 55 53 0.83

Recovery of kidney function (%)* 86 86 0.97

Duration of treatment (days) 6.1± 2.7 5.7 ± 2.1 0.42

* Recovery and resolution of kidney function of survivors only Fig 2. Comparison patient survival after 30 days treatment

Conclusion

This study showed that increasing the intensity of continuous HVPD does not: :

reduce mortality or dependence on dialysis improve metabolic control

Prescribed Kt/V =0.5 is enough

Peritoneal Dialysis in AKI

1- Why to indicate it ?

2- For whom?

3- How to prescribe it?

4- Which complications?

5- Is it better or worsen than other methods?

7- Conclusion

6- PD in AKI: 10 years of Brazilian experience

Mechanical

tip catheter migration leakage

Infectious

peritonitis

Metabolic

hyperglicemia hypokalemia

hypercatabolism

0

10

20

30

40

%

Ponce (adults)

(PDI, 2007)

(PDI 2012)

50

Esezobor (children)

(PDI, 2014)

Kilonzo (adults)

(PDI, 2014)

17% 11.8% 10%

Peritonitis in PD for AKI

12%

0

10

20

30

40

% 50

Esezobor

(PDI, 2012)

Kilonzo

(PDI, 2014)

18% 23.5%

15%

Mechanical complications of PD in AKI

14%

Ponce (adults)

(PDI, 2007)

(PDI 2012)

Main metabolic implications of PD

35%

4g/d

4 mEq/l

1- Why to indicate it ?

2- For whom?

3- How to prescribe it?

4- Complications?

5- Is it better or worse than other methods?

6- PD in AKI: 10 years of Brazilian experience

7- Conclusion

Peritoneal Dialysis in AKI

• prospective and randomized study

• 2 groups: 70 patients (PD = 36 and HF= 34)

• protocol was discontinued: mortality rate > PD (RR=3.2)

rigid catheters

manual exchanges

dwell time < 15 min (70 l/day)

no dialysis dose quantification

Prospective randomized study designed to compare HVPD with IHD

Group HVPD: prescribed Kt/V = 0.65, 7x/week Group IHD= prescribed Kt/V = 1.2/session, 6 x/week

(* p>0.05)

Prospective study performed in India

50 patients (HDF= 25 vs. CPD= 25)

• rigid catheter

• No information about dialysis dose

• High mortality: HDF= 84% vs. DP= 72%

Apoio: FAPESP

Prospective and randomized 143 hemodynamically unstable AKI patients treated with HVPD or EDH and 0.3 <ATN-ISS<0.7 Objectives are to evaluate

death within 60 day

recovery of kidney function

metabolic control

Apoio: FAPESP

Outcome

Sobrevida em 50 dias

11 studies : PD vs. HD methods

7 observational studies (n= 711) and 4 randomized studies (n= 248)

1- Why to indicate it ?

2- For whom?

3- How to prescribe it?

4- Complications?

5- Is it better or worse than other methods?

6- PD in AKI: 10 years of Brazilian experience

7- Conclusion

Peritoneal Dialysis in AKI

Brazilian prospective cohort study

Adult AKI patients on PD were studied from 2004 to 2014 and divided into 2 groups according to the year of treatment:

2004-2008 and 2009-2014

NDT, 2015

NDT, 2015

NDT, 2015

NDT, 2015

NDT, 2015

As conclusion, we observed an improvement in

patient survival and TF along the years

1- Why to indicate it ?

2- For whom?

3- How to prescribe it?

4- Complications?

5- Is it better or worse than other methods?

6- PD in AKI: 10 years of Brazilian experience

7- Conclusion

Peritoneal Dialysis in AKI

There is growing interest in the use of PD in AKI

Because of its simplicity, PD is used in regions with limited resources and sometimes is the only method available

There is no evidence to suggest that the PD is inferior when compared to other methods of dialysis in AKI

However, the success of this method depends on the selection of patients and the team's experience

-

To overcome limitations and if possible, the PD must be performed continuously and automatically, with high volumes

of dialysate and using flexible catheter

The prescription should achieve adequate metabolic and fluid controls

Kt / V of 0.5 per session is enough

Metabolic and mechanical ventilation implications seems to be minimal

It should be discontinued after 3 sessions if no adequate fluid control

We have observed an improvement in patient survival and TF along the years

It is an option to treat AKI patients, mainly in developing countries

• Prof André Luis Balbi

• Nutrit Marina Nogueira Berbel

• Nutrit Cassiana Goes

• Nurse Bianca Albino

• Nurse Mariele Gobo

Thank you very much AKI team

•Tec Enf Elza Maria Januário

• Tec Enf Ana Cristina Paulino Leite

• Tec Enf Vânia Levino

• Tec Tais Pacheco

• Tec Daniele Almeida

Daniela Ponce

dponce@fmb.unesp.br

BOTUCATU SCHOOL OF MEDICINE, SAO PAULO STATE, BRAZIL