Quality Improvement on Pediatric Peritoneal Dialysis (PPD) Appropriate organization of PN Center Quality reassurance in PPD (guidelines) Evaluation of

Quality Improvement on Pediatric Peritoneal Dialysis (PPD)

Appropriate organization Appropriate organization of PN Centerof PN Center

Quality reassurance in Quality reassurance in PPD (guidelines)PPD (guidelines)

Evaluation of Evaluation of the clinical outcomethe clinical outcomeModify strategiesModify strategies

Constantinos J. Stefanidis

Advantages of PD in children

The quality of life of children and their family is better during PD

than HD.

The residual renal function is better preserved during PD than HD.

There are logistical advantages of PD.

It requires: a lower staff : patient ratio than HD

a lower dose of rHUEPO

PD is the dialysis of choice :

For children with weight < 15 kg

For children expected to have a prolonged

period of dialysis

For children living too far from a pediatric

hemodialysis unit

Percentage of ESRD children on PD (NAPRTCS and EDTA)

0

10

20

30

40

50

60

70

1982 1989 1993




Quality Improvement on PPD

Paediatric Nephrology Centers

CRICRI TxTx

HDHD

PDPD

PaediatriciansPaediatricians(early referral)(early referral)

Paediatric surgeonsPaediatric surgeons (dialyis access)(dialyis access)

Tx surgeonsTx surgeons

Paediatric Nephrology Centers per million of child population

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

``

Loirat et al. Nephr Dial Transplant 1993Loirat et al. Nephr Dial Transplant 1993

Paediatric Nephrology Centers

HD PD Tx65%

HD PD22%

HD8%Tx

5%

130 centers in 130 centers in 22 European countries22 European countries

Loirat et al. Nephr Dial Transplant 1993Loirat et al. Nephr Dial Transplant 1993

End Stage Renal Disease in Children

5 - 105 - 10 children/year per million of child population (pmcp) children/year per million of child population (pmcp)

Pediatric ESRD is accounting for only 1.8% of all ESRDPediatric ESRD is accounting for only 1.8% of all ESRD United States Renal Data System (USRDS)United States Renal Data System (USRDS)

11 PN center pmcp (per 4-6 m total population)PN center pmcp (per 4-6 m total population) (cp = 25-40% of total population)(cp = 25-40% of total population)

5 - 105 - 10 new children with ESRD / yearnew children with ESRD / year

220 - 440220 - 440 children/yr start dialysis in countries of SEPNWG children/yr start dialysis in countries of SEPNWG

If 50 - 60% of them receive a transplant / year If 50 - 60% of them receive a transplant / year

The number of ESRD children will increase by 100-200/yrThe number of ESRD children will increase by 100-200/yr

Child population per paediatric nephrologist

131131

146146

381381132132 212212

225225

233233 140140

220220

191191

155155623623

353353

547547

317317243243

Child population (x1000) per paediatric nephrologist

467467Child population (millions) 9595 4242 Paediatric nephrologists 500500 120120 Members of ESPN 320320 5050

Multi-disciplinary team

• Structure Structure Doctors, nurses, dietitians, social workers, Doctors, nurses, dietitians, social workers, psychologists, play therapists, teachers. psychologists, play therapists, teachers.

• Goal Goal To deliver to children the care required for To deliver to children the care required for their long-term well being and for their their long-term well being and for their optimal quality of life. optimal quality of life.

• Team meetings Team meetings give the entire team opportunity forgive the entire team opportunity for interaction and collaborative decision interaction and collaborative decision

making. making.

Team working improves patient care and Team working improves patient care and enhances the quality of the working life.enhances the quality of the working life.

• CContinuous education of all health professionals.ontinuous education of all health professionals.

• Each member of the team should have inovative Each member of the team should have inovative approach and the goal to achieve the eapproach and the goal to achieve the excellence.xcellence.

• A set of standards of clinical practice and detailed A set of standards of clinical practice and detailed protocols should be available.protocols should be available.

• A detailed registry of patients should be updated.A detailed registry of patients should be updated.

• Networking with other PN centers, multicenter Networking with other PN centers, multicenter studies and global cooperation should be a prioritystudies and global cooperation should be a priority

Quality improvement on the organization of PN centers





Steps for quality reassurance in PPD

• All children on PD should be managed in a All children on PD should be managed in a pediatric nehrology center.pediatric nehrology center.

• Peritoneal catheters should implanted surgically Peritoneal catheters should implanted surgically under general anesthesia. under general anesthesia. A lateral technique through the rectus muscle and two A lateral technique through the rectus muscle and two purse-string sutures around the peritoneum might reduce purse-string sutures around the peritoneum might reduce the risk for leakagethe risk for leakage..

• The training for the parents at the initiating PD The training for the parents at the initiating PD treatment should be detailed and last > 2 weeks.treatment should be detailed and last > 2 weeks.

• A '’closed twin-bag PD system with Y-line'' or A '’closed twin-bag PD system with Y-line'' or automated PD should be preferred. automated PD should be preferred.

Targets for adequacy of peritoneal dialysis

Adequate dose of PD is the amount of PD below Adequate dose of PD is the amount of PD below which there is an increase in morbidity and mortality which there is an increase in morbidity and mortality

Optimal dose of PD is the amount of PD yielding Optimal dose of PD is the amount of PD yielding clinical results which cannot further improveclinical results which cannot further improve

CJ Stefanidis 2001

Adequate doseAdequate dose

Optimal doseOptimal dose

NKF-DOQINKF-DOQI began in March 1995 began in March 1995 Work Groups of 70 professionals reviewed > 11,000 articles.Work Groups of 70 professionals reviewed > 11,000 articles.Only 206 articles were included at the final publication.Only 206 articles were included at the final publication.

In 1997 114 evidence-based clinical practice guidelines were In 1997 114 evidence-based clinical practice guidelines were developeddeveloped. . Am J Kidney Dis 1997 Sep;30 (3 Suppl 2) : S67-136Am J Kidney Dis 1997 Sep;30 (3 Suppl 2) : S67-136

Continuous quality improvement: DOQI becomes K/DOQI and is updated. National Kidney Foundation's Dialysis Outcomes Quality Initiative. Am J Kidney Dis 2001 Jan;37(1):179-194Am J Kidney Dis 2001 Jan;37(1):179-194

Νational Κidney Νational Κidney FoundationFoundation

D O Q ID O Q IDialysis Outcomes Quality InitiativeDialysis Outcomes Quality Initiative

BUN BUN (= Purea / 2)(= Purea / 2)

PNA = 6.25 x UNA (g/kg) + 0.5= 6.25 x UNA (g/kg) + 0.5

Protein intake

ΤΤBWBW

Muscle mass catabolismMuscle mass catabolism

S. creatinineS. creatinine

Creatinine of urine and PDCreatinine of urine and PD

Creatinine clearanceCreatinine clearance

0.660.66 x 12 L x 7 x 1.73 x 12 L x 7 x 1.73mm22

1.6m1.6m22

= = 60 L/1.73m60 L/1.73m22/week/week

== 0.85 0.85 x 12 L x 7 days x 12 L x 7 days

60kg x 0.6 (L/kg) 60kg x 0.6 (L/kg)

= = 22

==

D/PD/Pcreatcreat x V x VPDPD

SS==

D/PD/Pureaurea x V x VPDPD

ΤΤBWBW==

KKtt/Vurea/Vurea

Creatinine and urea adequacy parameters

44 5.75.7 7.17.1

Weight: 70 kg S=1.7m2 ΤΒW =42 L

Weight : 35 kg S=1.2m2 ΤΒW= 21 L

Weight : 14 kg S=0.6m2 ΤΒW: 8.5 L

Creat. clear.Creat. clear. D/P creat x VD/P creat x VPD XPD X 1.73 /S 1.73 /S

D/PD/Pureaurea x V x VPDPD / Τ / ΤBWBWKt/VureaKt/Vurea== ==

D/P creat.D/P creat.

D/PD/Pureaurea

ΤΤBWBWxx

SS

(x 100)(x 100)

ΤΤBWBW

S S (x 100)(x 100)

60602 x 1002 x 100

70703.1 x 1003.1 x 100

80804 x 1004 x 1003.33.3 4.44.4 5.05.0

Age Years Protein intake0-0.5 2.8-30.5-1 2.3-2.51-6 1.9-27-14 1.7-1.815-18 1.4-1.5

Recommended protein intake for children on PD

Initial prescription 0.6-0.8 L/m²/day, 0.8-1 L/m² overnight Adapted prescription 1-1.2 L/m²/day, up to1.4 L/m² overnight

Recommended volume of PD fluid (VPD )

K/DOQI Guidelines for K/DOQI Guidelines for PD AdequacyPD AdequacyAm J Kidn Dis S94-S99 2001Am J Kidn Dis S94-S99 2001

Guidelines of EPPWG on Adequacy and the dialysis prescriptionGuidelines of EPPWG on Adequacy and the dialysis prescription





• Measurement of PD Patient SurvivalMeasurement of PD Patient Survival• Measurement of PDTechnical SurvivalMeasurement of PDTechnical Survival• Measurement of HospitalizationMeasurement of Hospitalization

• Measurement of Hemoglobin /HematocritMeasurement of Hemoglobin /Hematocrit• Measurement of Albumin ConcentrationMeasurement of Albumin Concentration• Measurement of Normalized PNAMeasurement of Normalized PNA

• Measurement of Patient-Based Assessment of Measurement of Patient-Based Assessment of quality of lifequality of life

• Measurement of Growth, Developmental Progress Measurement of Growth, Developmental Progress and School Attendenceand School Attendence

Am J Kidn Dis S94-S99 2001Am J Kidn Dis S94-S99 2001

Clinical outcome goals of K/DOQI for PD patients


PD Patient Survival PD Patient Survival is dependent uponis dependent upon uncontrollable and uncontrollable and controllable (inadequste dialysis) variablescontrollable (inadequste dialysis) variables

PD Technical Survival PD Technical Survival is dependent uponis dependent upon::

• Complications (peritonitis)Complications (peritonitis)

inadequste dialysis malnutrition peritonitisinadequste dialysis malnutrition peritonitis

` 75% 2-year technique survival rate` 75% 2-year technique survival rate

• Inability to perform PD Inability to perform PD (lack of access, medical contraindications)(lack of access, medical contraindications)

• Patient request/lifestyle issues (burnout) Patient request/lifestyle issues (burnout)

•Measurement of HospitalizationsMeasurement of Hospitalizations1.8 times/year (CANUSA)1.8 times/year (CANUSA)

•Measurement of HemoglobinMeasurement of Hemoglobin Should be 11-13 g/dl in 75% of patients.Should be 11-13 g/dl in 75% of patients.

•Measurement of Albumin Measurement of Albumin ConcentrationConcentration

•Measurement of Normalized PNAMeasurement of Normalized PNAAm J Kidn Dis S94-S99 2001Am J Kidn Dis S94-S99 2001


w h a t S E P N W G s h o u l d d o ? Quality Improvement on PPD

Register the PN centers of the area of SEPNWG.

Enhance the appropriate organization of the PN. centers and

disseminate the use of clinical guidelines.

The clinical outcome of patients should be continuously evaluated.

The problems of children on PD should be discussed and

appropriate solutions should be advised.

Documents

Quality Improvement on Pediatric Peritoneal Dialysis (PPD) Appropriate organization of PN Center Quality reassurance in PPD (guidelines) Evaluation of