CSN Peritoneal Dialysis Guidelines 2011

The following is an adaptation of the executive summary of the Canadian Society of Nephrology Clinical Practice Guidelines and Recommendations on Peritoneal Dialysis Adequacy 2011 . The original document can accessed separetely at this link. Please feel free to comment on these guidelines in the form below

The original summary is provided by:

Peter G. Blake,¹ Joanne M. Bargman,² K. Scott Brimble,³ Sara N. Davison,⁴ David Hirsch,⁵ Brendan B. McCormick,⁶ Rita S. Suri,¹ Paul Taylor,⁷ Nadia Zalunardo,⁷ and Marcello Tonelli,⁴ the Canadian Society of Nephrology Work Group on Adequacy of Peritoneal Dialysis

¹Division of Nephrology, University of Western Ontario, London, Ontario; ²Division of Nephrology, University of Toronto, Toronto, Ontario; ³Division of Nephrology, McMaster University, Hamilton, Ontario; ⁴Division of Nephrology and Transplant Immunology, University of Alberta, Edmonton, Alberta; ⁵Division of Nephrology, Dalhousie University, Halifax, Nova Scotia; ⁶Division of Nephrology, University of Ottawa, Ottawa, Ontario; ⁷Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada

1: MAINTENANCE OF RRF

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1.1 MEASUREMENT OF RRF

Recommendations:

1.1.1 Residual renal urine volume and residual renal Kt/V (rKt/V) should be measured every 3–6 months in patients with a peritoneal Kt/V (pKt/V) of less than 1.7 weekly, especially if RRF is rapidly declining. In all other PD patients, rKt/V and urinary volume should be measured together with pKt/V when clinically indicated (see Recommendation 2.1.5) (grade D, opinion).

1.1.2 It may help clinical understanding use a mean of 24-hour urine urea and creatinine clearance to express RRF as a glomerular filtration rate (GFR) in milliliters per minute (grade D, opinion).

1.2 USE OF ANTIHYPERTENSIVE AGENTS AND DIURETICS TO PRESERVE RRF

Recommendations:

1.2.1 Per recommendations by the Canadian Hypertension Education Program (CHEP), BP should be controlled to less than 130/80 mmHg provided that this is not associated with signs and symptoms of postural hypotension or volume depletion (grade D, opinion).

1.2.2 Angiotensin converting-enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) should be strongly considered, unless contraindicated, in all PD patients with significant (>100 mL daily) urine output (grade B).

1.2.3 Strong consideration should be given to the use of high-dose oral furosemide (up to 250 mg daily) and oral metolazone (up to 5 mg daily) in all PD patients with significant (>100 mL daily) urine output, provided that this is not associated with signs and symptoms of postural hypotension or volume depletion (grade B).

2: SMALL-SOLUTE CLEARANCE

2.1 PRESCRIPTIONS AND TARGETS

Guideline:

2.1.1 For continuous ambulatory PD (CAPD), the usual starting prescription need not exceed 4×2-L exchanges daily (grade A).

Recommendations:

2.1.2 If patients are experiencing uremic symptoms or are clinically not doing well, and if there is no identifiable cause other than insufficient dialysis, the prescription (that is, the pKt/V) should be increased, especially if the total Kt/V (that is, the pKt/V and rKt/V combined) is less than 1.7 (grade C).

2.1.3 For CAPD, lower volumes or fewer exchanges than 4×2 L daily can be used for smaller individuals or for those with significant RRF, especially if the total Kt/V is greater than 1.7 (opinion).

2.1.4 For APD, the recommended starting prescription (18,34–36) should be designed to achieve a target total Kt/V of 1.7 or more, and should take into account membrane transport characteristics, with the number of nighttime exchanges typically ranging from 3 to 5 (opinion).

2.1.5 A measurement of total Kt/V should be carried out 4 – 6 weeks after initiation of PD (37,38). The measurement of total Kt/V should be repeated if there is an unexplained or unexpected change in the patient's clinical status or a problem with ultrafiltration (UF) (opinion).

2.1.6 Strategies that are effective when attempting to raise clearance in CAPD are increases in dwell volume and addition of extra exchanges (37); however, the small risk of mechanical complications should be considered when dwell volumes are increased, and the substantial risk of noncompliance should be considered when a fifth manual exchange is added (grades A and C).

2.1.7 The most effective strategy when attempting to raise clearance in APD is to ensure that the patient has a day dwell. The next most effective strategies are the introduction of an additional day dwell (that is, 1 daytime exchange) and larger nighttime dwell volumes (37,41). Other options to consider are increasing the cycler time and the frequency of cycles (grade C).

2.1.8 In a patient who is underweight or overweight, the calculation of Kt/V should use the patient's ideal body weight to estimate V (grade C).

3: VOLUME MANAGEMENT

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3.1 MAINTENANCE OF EUVOLEMIA AND DIAGNOSIS OF HYPERVOLEMIA

Recommendations:

3.1.1 All PD patients should have regular clinical assessments of volume control (opinion).

3.1.2 A 2.5% or 4.25% dextrose PET should be carried out no sooner than 4 weeks after initiation of PD. This test should be subsequently repeated if there are unexplained or unexpected changes in volume status or UF (opinion).

3.2 TREATMENT OF HYPERVOLEMIA

Recommendations:

3.2.1 Sodium intake should be restricted to 65 mmol (1500 mg) or less daily in patients with hypervolemia (grade C).

3.2.2 In patients with RRF, high-dose diuretics (furosemide 250 mg with or without metolazone 5 mg daily) increase sodium excretion and urine volume (grade B).

3.2.3 Hypertonic 4.25% dextrose solution may be required to achieve euvolemia; however, sustained use of such solution is not desirable (grade C).

3.2.4 Icodextrin solution is preferred over glucose-based dialysate for long-duration (>8-hour) dwells (grade C).

3.3 ASSESSMENT AND MANAGEMENT OF BP

Recommendations:

3.3.1 Patients with hypertension should be assessed for hypervolemia and, if appropriate, treated as outlined in the recommendations in "3.2 Treatment of Hypervolemia" (grade C).

3.3.2 Target BP to 130/80 mmHg or lower; optimal BP is uncertain (grade D).

3.3.3 The preferred antihypertensive agents are ACEIs or ARBs; however, comorbid conditions should be taken into account when prescribing antihypertensives (grade B).

4: CV DISEASE IN PD PATIENTS

4.1 DYSLIPIDEMIA

Recommendations:

4.1.1 Statins (3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors), with or without the cholesterol absorption inhibitor ezetimibe, should be considered in all adult PD patients to lower the level of serum low-density lipoprotein cholesterol (LDL-C) (grade B).

4.1.2 Fasting lipid levels—total cholesterol (TC), triglycerides (TGs), LDL-C, and high-density lipoprotein cholesterol (HDL-C)—should be measured annually in PD patients (opinion).

4.1.3 Where possible, dialysate glucose exposure should be minimized by giving priority to other strategies to maintain normovolemia (opinion)

4.1.4 Avoid combination therapy with statins and fibrates (opinion).

5: NUTRITION

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5.1 NUTRITION

Recommendation:

5.1.1 Nutritional status should be monitored at routine clinical visits by the physician and by other members of the health care team, including a registered dietician (opinion).

5.2 NUTRITIONAL SUPPLEMENTS

Recommendations:

5.2.1 Enteral nutritional supplements should be considered for patients with mild-to-severe malnutrition (grade B). However, certain supplements may be poorly tolerated by individual patients, and thus close monitoring is required (grade A).

5.2.2 The use of intraperitoneal amino acid supplements is not recommended in the treatment of malnutrition because of the poor quality of evidence in their favor (grade C) and because of concerns about side effects.

5.2.3 If intraperitoneal amino acids are used, more than 1 daily exchange is not recommended (grade A), and close monitoring for precipitation of acidosis and uremia is required (grade B).

megestrol acetate may also be considered, but supporting evidence is weak. The use of recombinant growth hormone, ghrelin, or insulin-like growth factor 1 is not recommended (grade D).

5.3.2 Serum venous bicarbonate should be maintained in the high-normal range (27 – 28 mmol/L) by using dialysis solutions containing 40 mmol buffer per liter and by prescribing oral sodium bicarbonate as required (grade A).

5.3.3 Prokinetic agents should be considered in PD patients with symptoms that suggest delayed gastric emptying (grade B).

6: HYPERGLYCEMIA

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6.1 GLYCEMIC CONTROL

Guideline:

6.1.1 Patients using icodextrin exchanges must employ a glucometer that uses the glucose oxidase or hexokinase method (grade A).

Recommendations:

6.1.2 Control of hyperglycemia in the PD population should adhere to the recommendations of the Canadian Diabetes Association where possible (hemoglobin A1C < 7.0%, fasting plasma glucose 4–7 mmol/L) (grade B). However, clinicians must take into account the risk of hypoglycemia in individual patients, with particular regard to age, comorbidity, stability, and other circumstances.

6.1.3 The use of metformin should be avoided in dialysis patients (grade C).

6.1.4 Some sulfonylureas and repaglinide can be used to control hyperglycemia in PD patients, provided that the risk of hypoglycemia is appreciated. Thiazolidinediones can also be used, but given possible CV risks, they are not the preferred agents in this population.

6.1.5 Short-acting agents such as gliclazide and repaglinide are preferred in the PD population.

6.2 GLUCOSE-SPARING STRATEGIES

CSN Peritoneal Dialysis Guidelines 2011

1: MAINTENANCE OF RRF

Please select a guideline (click a bar):

1.1 MEASUREMENT OF RRF

Recommendations:

1.2 USE OF ANTIHYPERTENSIVE AGENTS AND DIURETICS TO PRESERVE RRF

Recommendations:

2: SMALL-SOLUTE CLEARANCE

2.1 PRESCRIPTIONS AND TARGETS

Guideline:

Recommendations:

3: VOLUME MANAGEMENT

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3.1 MAINTENANCE OF EUVOLEMIA AND DIAGNOSIS OF HYPERVOLEMIA

Recommendations:

3.2 TREATMENT OF HYPERVOLEMIA

Recommendations:

3.3 ASSESSMENT AND MANAGEMENT OF BP

Recommendations:

4: CV DISEASE IN PD PATIENTS

4.1 DYSLIPIDEMIA

Recommendations:

5: NUTRITION

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5.1 NUTRITION

Recommendation:

5.2 NUTRITIONAL SUPPLEMENTS

Recommendations:

6: HYPERGLYCEMIA

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6.1 GLYCEMIC CONTROL

Guideline:

Recommendations:

6.2 GLUCOSE-SPARING STRATEGIES

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