INDIVIDUALIZING THE THERAPY

PD therapy should be based upon patient lifestyle choices, Kt/V_urea (peritoneal and renal) and clinical status. The following pages provide suggested means to achieve clearance and UF targets through sample PD prescriptions based on individual patient membrane transport type, volume of urea distribution and RKF.

Achieving Minimum Recommended Small Solute Clearances³⁰

• The proposed prescriptions will not achieve minimum delivered weekly dialysis clearance goals (Kt/V_urea or creatinine clearance*) for all patients. The peritoneal and kidney clearances must be monitored regularly and the dialysis prescription adjusted using the principles outlined to try to achieve goals. If adequate dialysis cannot be achieved with reasonable alteration in prescription, transfer to HD may be necessary
• Patients with higher V_urea may require a larger fill volume per exchange to enhance clearances (and UF)
• Patients with higher D/P_Cr, in general, require an increased number of exchanges
• Anuric APD patients often require an extra daytime exchange to achieve minimum delivered weekly Kt/V_urea goal and maintain an ideal dry weight. This exchange can either be performed manually or by connecting to the cycler

* Creatinine clearance used in countries outside of the U.S.^6-9

Figure illustrates the need to augment the number of exchanges as D/P creatinine increases and to increase fill volume with increase in V_urea.

Achieving Ultrafiltration Targets

• It is critical to maintain euvolemia in dialysis patients without damaging RKF by too rapid ultrafiltration
• While no recommendation regarding UF target exists in the United States, other countries suggest a UF of 750-1000 mL/day in observational studies^6-10
• Shortening dwell times can result in increased ultrafiltration, especially in patients with high transport characteristics
• Higher glucose concentrations can be used in order to achieve the desired UF target. Clinicians need to be cognizant of the potential negative consequences of glucose exposure on metabolic control and long-term peritoneal membrane function³³
• In high average and high transporters, EXTRANEAL (icodextrin) PD Solution may be preferred to improve (compared to 4.25% dextrose) UF (and clearance) in the long dwell³⁴
• While there is no prospective randomized trial determining what UF targets should be, all work groups suggest that normalization of blood pressure and maintenance of euvolemia are important^4-9