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Peritoneal Dialysis To Treat Acute Kidney Injury

Peritoneal Dialysis To Treat Acute Kidney Injury. Fredric O. Finkelstein Yale University New Haven, CT. Points to be Covered. The increasing frequency of AKI The excellent data for PD use with AKI The dose of dialysis that is reasonable to consider to treat AKI PD AKI guidelines.

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Peritoneal Dialysis To Treat Acute Kidney Injury

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  1. Peritoneal Dialysis To Treat Acute Kidney Injury Fredric O. Finkelstein Yale University New Haven, CT

  2. Points to be Covered • The increasing frequency of AKI • The excellent data for PD use with AKI • The dose of dialysis that is reasonable to consider to treat AKI • PD AKI guidelines

  3. The Increasing Frequency of AKIHsu et al JASN 24:37, 2013

  4. PD and Acute Kidney Injury • 20+ years ago, PD was the standard treatment of AKI • This changed with the introduction of the central venous catheter for hemodialysis and the proliferation of extra-corporeal therapies and devices

  5. 2002 N Engl J Med 2002;347:895-902 • Prospective and randomized study • 70 patients (PD= 36; HF= 34) • Protocol was interrupted: mortality rate 47 vs 15% Survival (RR= 3.2)

  6. 2002 • prospective and randomized study • evaluated two modes of automatic PD (CPD and tidal) in 87 patients with ARF and mild and moderate hypercatabolic state (they excluded severe hypercatabolic and hemodynamically unstable patients) • 118 sessions of dialysis in each treatment arm • by flexible catheter and automated PD with a cycler

  7. Results and conclusions p CPD TPD Pre-dialysis BUN (mg/dL) 77.9 ± 22.1 78.8 ± 8.3 0.67 Post-dialysis BUN (mg/dl) 64.7 ± 12.4 50.8 ± 11.3 0.04 KT/V (session) 0.26 ± 0.07 0.34 ± 0.14 0.001 (week) 1.8 ± 0.32 2.43 ± 0.87 0.001 SRI (%) 20.6 ± 6 28.4 ± 4 0.02 UF (L/session) 2.01 ± 0.28 2.88 ± 0.7 0.03 Total protein loss (g/session) 6.6 ± 1.2 10.5 ± 1.5 0.001 Albumin loss (g/session) 3.48 ± 2.1 6.32 ± 1.03 0.02 “Both CPD and TPD are reasonable options for milD-moderate hypercatabolic ARF. TPD provides better clearences at the same volume. Higher protein loss in TPD was the only limitation to its use in ARF.” Chitalia VC et al. Kidney Int 2002;61:747-757

  8. MGH: 2013 Chennai (Madras General Hospital) • Do 1000 acute PD treatments a year with “old fashioned” trochar technique • Rare bowel perforations • Report excellent outcomes • Have never officially reported their data

  9. 2007

  10. Data • 67% male; 59 ± 7.8 years; 76 % of patients were in ICU; mean APACHE II score (day of the first PD session) : 32.2 ± 8.6; ATN-ISS score: median of 0.68 • Ischaemic ARF (67%) and mixed (33%); sepsis (53%); oliguria (70%) • median number of days of PD: 6 • 23% of patients recovered renal function, 13% remained on dialysis after 30 days, and 57% died. • 36-55 L of dialysate used per day • Weekly KT/V of 3.8 +/- 0.6 Gabriel DP, PDI 2007;27:277-282

  11. Randomized Trial Comparing Mortality Rates with High Volume PD and Daily HD Gabriel DP, KI 2008;72:S87-S93 Weekly delivered Kt/V was 3.6+/-0.6 in HVPD and 4.7+/-0.6 in DHD

  12. Patient Outcomes 5 10 15 20 25 30

  13. none infectious mechanical Complications during the study DHD PD

  14. High vs Lower Dose PDPonce D et al: Adv Perit Dial. 2011;27:118-24 • 61 critically ill patients were randomly assigned to receive higher- or lower-intensity PD therapy (prescribed Kt/Vof 0.8 and 0.5 per day respectively). • Delivered dose was 0.59 in high intensity group and 0.49 in the lower intensity group corresponding to a weekly KT/V of 4.13 and 3.43, assuming daily dialysis • The outcomes were the same in the two groups

  15. Review of Brazilian Experience of PD for AKI (Ponce D et al: CJASN 7:887, 2012) • 204 patients with AKI treated with PD • 54 patients withdrawn within 24 hours (34 died, 20 early mechanical complications) • Mean age 64 +/- 16 years • 70% in the ICU • Prescribed KT/V of 0.6 per day and delivered KT/V of 0.5/day (3.5 +/- 0.7/week) • 16-22 exchanges/24 hours (32-44 Liters) • 23% recovery renal function, 7% remained on dialysis after 30 days, 57% died • 12% developed peritonitis and 7.5% mechanical blockage

  16. Chionh et al: Use of peritoneal dialysis in AKI: a systematic review CJASN 8:1649, 2013

  17. Randomized Trial from Saudi ArabiaAbdullah Al-Hwiesh • Presented the Arab Nephrology Meetings 12/14 • Compared acute PD with CVVH-D in critically ill patients in Saudi Arabia • Better survival and shorter duration of dialysis in those patients treated with PD • c. 65 patients in each group

  18. What About the Dose of PD That Provides Acceptable Level of Care?

  19. Dose of Dialysis and Outcomes

  20. Lessons from Hemodialysis and CVVH?

  21. CRRT, HD, AKI and Dose of RRTJun et al: Clin J Am Soc Nephrol. 2010 5:956-63 • Eight trials were identified that provided data on 3841 patients and 1808 deaths. • The prescribed dose of RRT in the lower intensity arms of studies using CRRT ranged between 20 and 25 ml/kg/h and the higher intensity arms ranged between 35 and 48 ml/kg/h. • In the three studies utilizing IHD higher intensity of therapy was achieved by increasing the frequency of treatment. • More intense RRT had no overall effect on the risk of death (RR 0.89, 95% CI 0.76 to 1.04, P = 0.143) or recovery of renal function (RR 1.12, 95% CI 0.95 to 1.31, P = 0.181) compared with less-intensive regimens • Higher intensity RRT does not reduce mortality rates or improve renal recovery among patients with AKI

  22. Risk of mortality for more intensive versus less intensive RRT regimens Jun et al: Clin J Am Soc Nephrol. 2010 5:956-63

  23. CRRT, HD and AKI Vijayan, Palevsky AJKD 59:569, 2012 • “CRRT: effluent rates > 20-25 cc/kg/hr are not warranted for most patients… the floor of the dosing range for CRRT is not well delineated.” • HD: “For IHD, evidence does not support a need to routinely provide dialysis treatments more frequently than every other day as long as KT/V urea of at least 1.2 per rx can be achieved.”

  24. PD Dose Targets for ESRD PatientsK/DOQI/ISPD • Minimal ‘delivered’ dose of a total Kt/Vurea AT LEAST 1.7 per week ( sum of peritoneal and renal urea clearance) • No evidence of improvement in outcomes with higher doses of dialysis: a) WK Lo et al: Kidney Int. 2003 64:649-56 b) ADEMEX trial: Paniagua R et al: J Am Soc Nephrol 2002 13:1307-20 c) Fried et al: AJKD 52:1122-30, 2008 How Then Does this Apply to the Treatment of AKI?

  25. Dose of Dialysis and Outcomes HD Floor is 1.2, qod CVVH: Floor is uncertain

  26. Conversion from Intermittent HD to a Standardized KT/V Brazilian Studies HD 1.2 Every other day

  27. Acute peritoneal dialysis: what is the ‘adequate’ dose for acute kidney injury? Chionh CY, Ronco C, Finkelstein FO, Soni1 SS, Cruz DN NDT 2010 25: 3155 • No data exist on the optimal dose of PD for the treatment of KI • Although the data to support this target are limited, it might be reasonable to suggest a minimum weekly std-Kt/Vurea of 2.1 • A higher clearance should be considered if the patient is markedly catabolic. • In addition, attention needs to be paid to achieving adequate volume control and middle-molecule clearances. • The various techniques of PD should be able to achieve these small-solute clearances • Potential complications such as peritonitis and protein losses need to be considered • Further studies on the use and dose of PD for AKI and its effect on clinical outcomes are necessary.

  28. ISPD Guideline: Peritoneal Dialysis for Acute Kidney Injury, Perit Dial Int34:494-517 Brett Cullis 1,2 Mohamed Abdelraheem 3 Georgi Abraham4 Andre Balbi5 Dinna 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 Renal Unit, Greys Hospital, Pietermaritzburg South Africa 2 Renal and Intensive Care Units, Royal Devon and Exeter Hospital, Exeter, United Kingdom 3 Paediatric Nephrology Unit, Soba University Hospital, University of Khartoum, Sudan 4Pondicherry Institute of Medical Sciences and Madras Medical Mission, Chennai, India 5 Department of Medicine, Botucatu School of Medicine, Sao Paulo, Brazil 6Division of Nephrology-Hypertension, University of California, San Diego, USA 7 Division of Paediatric Nephrology, Shaare Zedek Medical Center Jerusalem, Israel 8 Paediatric Nephrology Unit- Instituto da Criança of the Hospital das Clinicas of the University of Sao Paulo Medical School, Sao Paulo, Brazil 9 Paediatric Nephrology Department, Red Cross War Memorial Childrens Hospital, University of Cape Town, Cape Town, South Africa 10 Department of Surgery, Red Cross War Memorial Childrens Hospital, University of Cape Town, Cape Town, South Africa 11 School of Medicine • Pontificia Universidade Catolica do Parana, Curitiba, Brazil 12Division ofPaediatric Nephrology, University of Missouri-Kansas City School of Medicine, Kansas City, USA 13 Division of Nephrology, Queen's University, Kingston, Canada 14 Yale University, New Haven, USA

  29. Adult and Pediatric Guidelines Introduction 1.1 Peritoneal dialysis should be considered as a suitable method of renal replacement therapy in patients with acute kidney injury [1B]

  30. The Sudan: 659 Children with AKIAbdelraheem et al PDI, 2014 34:526-33 • Recovery from AKI: 69% • Death 30% • CKD 6%

  31. 2. Access and fluid delivery for acute PD in adults: 2.1 Flexible peritoneal catheters should be used for acute PD where resources and expertise exist [1C] (Optimal). Itmay be necessary to use rigid stylet catheters or improvised catheters in resource poor environments where they may still be lifesaving.[2D] (Minimum standard) 2.2 We recommend catheters should be tunnelled in order to reduce peritonitis and peri-catheter leaks [1D] 2.3 No method of insertion of PD catheter is superior to any other overall. We recommend that the method of implantation should be based on patient factors and local availability of skills, equipment and consumables.[1D]  2.4. 2.8A closed fluid delivery system with a Y connection should be used [1A] (Optimal).In resource poor areas spiking of bags and makeshift connections may be necessary.[2D] (Minimum standard) It is imperative that strict asepsis is maintained throughout.

  32. A Working Model of PD for AKI • Place flexible, cuffed catheter with surgical technique • Used modified CAPD technique • Target a weekly KT/V of 2.1 (higher if clinically indicated) • Adjust the dose of dialysis per the clinical circumstance of the patient

  33. Urgent Start PD Ghaffari A. Am J Kidney Dis 2012;59:400-408

  34. Survival Curves by Modality and Access TypePerl J et al. J Am Soc Nephrol 2011;22:1113-1121.

  35. Urgent Start Approach Globally • Ontario, Canada Perit Dial Int. 2016 3-4;36(2):171-176 • Saudi ArabiaPerit Dial Int. 2014 34(2):204-11 • USAAdv Perit Dial. 2014;30:36-9. • BrazilInt Urol Nephrol. 2016 Feb 20 • DenmarkPerit Dial Int. 2015 Nov;35(6):622-4 • Saving Young Lives Program Kidney Int. 2016 89:254-6: 10 programs in low resource settings (Africa and SE Asia)

  36. Urgent Start PD • Rapid catheter placement – by surgery, nephrology, or interventional radiology • Nursing staff – in hospital and in dialysis facility • Good treatment algorithms

  37. Summary • PD therapy for patients with AKI needing renal replacement therapy is being utilized and reassessed • There appear to be certain clear advantages to PD over extra-corporeal therapies • PD utilization for urgent start ESRD patients is also getting much attention globally

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